Khizar H. et al., 2025: A comparative study of extracorporeal shock wave lithotripsy and cholangioscopy-guided lithotripsy in the management of complex biliary stones: A randomized trial.
Hayat Khizar 1, Weigang Gu, Haibin Zhou, Jing Yang, Hangbin Jin, Xiayin He, Xiaofeng Zhang, Jianfeng Yang
1From the Department of Gastroenterology (H.K., W.G., H.Z., J.Y., H.J., X.H., X.Z., J.Y.), Hangzhou First People's Hospital, Hangzhou, Zhejiang; Department of Surgery (H.K.), The Fourth Affiliated Hospital, International Institute of Medicine, Zhejiang University School of Medicine, Hangzhou; Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province (J.Y.); Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province (J.Y.); and Hangzhou Institute of Digestive Diseases (J.Y.), Hangzhou, Zhejiang, China.
Abstract
Background: Large and impacted common bile duct stones (CBDSs) cannot be removed by conventional endoscopic retrograde cholangiopancreatography (ERCP), and extracorporeal shock wave lithotripsy (ESWL) or cholangioscopy-guided lithotripsy is recommended as a second-line treatment. The aim of this study is to compare safety and efficacy of ESWL for difficult CBDS.
Methods: Patients at our hospital diagnosed with complex large CBDS between January 2021 and June 2022 were randomly assigned to the ESWL group or the cholangioscopy group for lithotripsy. Our results include clinical and technical success, the mean number of ERCP sessions, and any complications from the procedure.
Results: A total of 84 patients were included assigned to two groups (the ESWL group [42 patients] and the cholangioscopy group [42 patients]). Technical success was 92.85% for the ESWL group and 100% for the cholangioscopy group ( p = 0.19), whereas clinical success was 69% and 88%, respectively ( p = 0.01). The ESWL group had 2.32 ± 0.98 ERCPs, and the cholangioscopy group had 1.13 ± 0.36 ( p < 0.001). The mean lithotripsy sessions were 2.3 ± 0.63 for ESWL and 1.13 ± 0.36 for cholangioscopy ( p < 0.001). Both groups had similar adverse events, except for cutaneous petechiae.
Conclusion: Compared with ESWL, cholangioscopy-guided lithotripsy is a safe and effective treatment for large and complex CBDSs.
J Trauma Acute Care Surg. 2025 Oct 1;99(4):628-634. doi: 10.1097/TA.0000000000004693. Epub 2025 Aug 13. PMID: 40811584
Comments 1
The authors compared SWL and cholangioscopic lithotripsy of common bile duct stones, The conclusion of this randomized study was that cholangioscopy-guided lithotripsy was superior to SWL. The bottom-line was that more RCT-studies are necessary. I doubt, however, that such a step will add more valuable information to this procedure.
Common bile-duct stones present special treatment problems particularly because the stones are radiolucent. Accordingly, an endoscopic procedure for insertion of a nasobiliary catheter is necessary to enable contrast infusion.
Although disintegration of the stone(s) can be achieved a follow-up ERCP usually will be necessary to eliminate fragments. Therefore, the mean numbers of ERCP-procedures were 2.32(0.98) in the SWL patients and 1.13(0.36) in the cholangioscopy-patients. The clinical success rates were 69% and 88%, respectively. Although SWL apparently was an attractive approach for removing large common bile duct stones the conclusion was that with modern lithotripters stones >3 cm is not an indication for SWL.
Several years ago, we used SWL for treating bile duct stones, mainly with the Dornier HM3 lithotripter [1]. The stone-free rate after one session was 38% and the overall success rate was 86%. All patients were treated without anesthesia.
Reference
1.Lindström E, Borch K, Kullman EP, Tiselius HG and Ihse I. Extracorporeal shockwave lithotripsy bile duct stones: a single institution experience. Gut 1992;33: 1416-1420
Hans-Göran Tiselius