DOWNERS GROVE, Ill. – November 22, 2018 – A growing body of scientific literature on biliary and pancreatic lithotripsy devices prompted the American Society for Gastrointestinal Endoscopy to update its 2007 technology status evaluation report on these types of devices. The updated report appears in the November issue of VideoGIE, ASGE’s official video journal.
Lithotripsy is a procedure that breaks up or destroys difficult pancreaticobiliary stones, allowing them to be extracted or passed from the biliary or pancreatic ducts. Clearing difficult stones, such as those that are large, impacted, irregularly shaped or refractory to standard endoscopic approaches, is a common challenge faced by gastroenterology endoscopists. However, several therapeutic technologies and techniques are available with mechanical, laser, electrohydraulic and extracorporeal shock-wave lithotripsy devices.
“Understanding the evidence behind these technologies and techniques is critical to providing the best care to these challenging patients, and this updated document will provide an accessible, valuable resource to endoscopists encountering difficult biliopancreatic stones in their practice,” said Rabindra Watson, MD, FASGE, lead author of the report and a member of the ASGE Technology Committee, which was charged with updating the report.
Recent literature suggests that the majority of difficult stones may be managed using one or more of the lithotripsy strategies, depending on local expertise. However, notable among the report updates, endoscopic papillary balloon dilation has emerged as an effective and safe alternative to mechanical lithotripsy. This technique may lessen the need for advanced lithotripsy techniques and lower adverse event rates and should be considered as an alternative or adjunct to traditional lithotripsy, according to the report.
Among the evidence-based findings on lithotripsy included in the report:
- Stones smaller than 10 mm had more than a 90 percent cumulative probability of bile duct clearance with mechanical lithotripsy. In addition, stones with a median diameter of 18 mm had an 87.6 percent clearance rate, and stones larger than 25 mm had a 67.6 percent clearance rate with this technique.
- Fragmentation and clearance rates using electrohydraulic lithotripsy ranged from 77 percent to 100 percent for patients with bile duct stones that were refractory to standard endoscopic therapy.
- The holmium:YAG laser lithotripter achieved total clearance of intrahepatic and extrahepatic bile duct stones in 85% to 100% of patients.
- Extracorporeal shock-wave lithotripsy for bile duct stones unsuccessfully removed with standard endoscopy had a complete clearance rate of 78% to 90%.
- Obesity was found to be a potential risk factor for extracorporeal shock-wave lithotripsy failure and adverse events.
- Intravenous administration of cholecystokinin during extracorporeal shock-wave lithotripsy was associated with a higher rate of complete stone clearance.
- Laser lithotripsy was more effective at complete stone clearance (82.4%) than extracorporeal shock-wave lithotripsy (52.4%). Another study also reported superior complete stone clearance with laser lithotripsy (97%) compared to extracorporeal shock-wave lithotripsy (73%).
- Mechanical, electrohydraulic and extracorporeal shock-wave lithotripsy procedures performed on biliary stone extractions that failed using standard methods had an overall success rate of 95%.
- Holmium:YAG laser lithotripsy of pancreatic stones resulted in complete duct clearance in 79% of patients as well as improvements in pain and a reduction in the use of narcotics in 89% of patients.
- Extracorporeal shock-wave lithotripsy for chronic calcific pancreatitis was associated with a complete ductal clearance rate of 71% and a partial ductal clearance rate of 22%.
- Extracorporeal shock-wave lithotripsy was effective at preventing recurrent attacks of acute pancreatitis in patients with obstructive pancreatic duct stones.
The report concludes that lithotripsy is safe and effective for treating difficult biliary and pancreatic duct stones.
In addition to lithotripsy technology descriptions, efficacy data and financial considerations, as well as information on ease of use, limitations and safety, the online report includes videos of cholangioscopy-guided electrohydraulic and laser lithotripsy.
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