Advances in biliary stone management: Latest-generation extracorporeal shock wave lithotripsy vs laser lithotripsy for difficult bile duct stones

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BACKGROUND Extracorporeal shock wave lithotripsy (ESWL) and laser lithotripsy (LL) are established alternatives for the management of difficult common bile duct (CBD) stones. However, there is limited evidence regarding the efficacy and safety of the latest-generation Dornier Delta III lithotripter. In particular, evidence on the clinical performance of the Dornier Delta III lithotripter is scarce. AIM To evaluate and compare the efficacy and safety of ESWL performed with the Dornier Delta III and of LL using a single-operator cholangioscope with specific focus on stone clearance rates, number of treatment sessions, and procedure-related adverse events in a large patient cohort. METHODS We conducted a retrospective analysis of a prospectively maintained database at AIG Hospitals, Hyderabad, covering the period from January 2019 to December 2022. A total of 458 patients with difficult bile duct stones underwent either ESWL or LL based on clinical discretion. ESWL was performed using the Dornier Delta III lithotripter, whereas LL was carried out with a single-operator cholangioscope in combination with an yttrium-aluminum-garnet laser. RESULTS The 387 patients with difficult bile duct stones (mean age 53.8 ± 15.7 years, 58.7% male) underwent ESWL. A single CBD stone was noted in 46.8% of patients while 53.2% patients had multiple stones. Complete duct clearance was achieved in 95.1% of patients, with 68.7% requiring two or more ESWL sessions. Adverse events included cholangitis in 3 patients and post-sphincterotomy bleeding in 4 patients; All were managed conservatively. Seventy-one patients (mean age 55 ± 15.4 years, 64.8% male) underwent LL. Complete duct clearance was achieved in 97.2% of patients with single-session clearance in 58 (81.7%) patients. The remaining 18.3% of patients required two or three sessions for fragmented stone removal. Adverse events included cholangitis in 2 patients and mild pancreatitis in 1 patient; all were managed conservatively. Patients with incomplete clearance were referred for surgery. There was no significant difference in efficacy between ESWL and LL (95.1% vs 97.2%, P = 0.4). CONCLUSION ESWL using the latest generation lithotripter and LL provide equally effective and safe alternatives for managing difficult CBD stones, minimizing the need for surgery.

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