891 Efficacy and Safety of Per-Oral Cholangioscopy With Lithotripsy for Difficult Biliary Stones: A Cumulative Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Per-oral cholangioscopy with intraductal electrohydraulic lithotripsy (EHL) or laser lithotripsy facilitates optically-guided biliary stone fragmentation in cases refractory to conventional endoscopic therapy. The primary aim of this study was to evaluate the efficacy and safety of per-oral cholangioscopy with intraductal lithotripsy for difficult biliary stones. METHODS: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed in accordance with PRISMA and MOOSE guidelines. Measured outcomes included overall fragmentation success, single session fragmentation and duct clearance rate, and rate of adverse events. Sensitivity and subgroup analysis was performed based upon cholangioscopy technique and type of lithotripsy. Pooled rates were estimated using random effects modelswith 95% prediction interval calculated to simulate clinical practice. Heterogeneity was assessed with Cochran Q test and I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. RESULTS: Thirty-two studies (n = 1513; 43.87% male) were included. Mean age was 60.87 ± 11.83 years. Prior cholecystectomy occurred in 23% of patients with an average number of 1.56 ± 0.49 prior ERCPs performed. Mean stone size was 2.15 ± 2.8 cm. Per-oral cholangioscopy with intraductal lithotripsy achieved an overall stone fragmentation successof 91.29% (95% CI 87.78 to 93.86) with an average of 1.35 ± 0.67 lithotripsy sessions performed. Mean procedure time was 68.32 ± 20.99 minutes. Complete fragmentation success and duct clearance with a single lithotripsy session was 75.71% (95% CI 69.69 to 80.86). Rate of adverse events was 9.72% (95% CI 6.98 to 13.38). Cumulative and sensitivity analyses limited to prospective and randomized controlled trials as well as studies limited to the second generation, digital cholangioscope device are shown in Table 1. Subgroup analyses based upon EHL versus laser lithotripsy demonstrated laser therapy to be more effective – though this was not statistically significant [overall fragmentation 90.14% versus 91.79%, P = 0.384; single session success rate 70.47% versus 82.10%, P = 0.058; and adverse event rate 11.85% versus 11.30%, P = 0.810] – Table 2. CONCLUSION: Per-oral cholangioscopy with intraductal lithotripsy appears to be a relatively safe and highly effective modality for difficult biliary stones. Laser lithotripsy outperformed EHL treatment; however, this difference was not statistically significant.