Mechanical Lithotripsy (ML) of Pancreatic Biliary Stones: Complications and Available Treatment Options Collected from Expert Centers

Abstract

Large and/or impacted PD and CBD stones often require ML at ERCP for successful endoscopic extraction. Many have reported on the outcome of refractory pancreatic-biliary stones. Rate and spectrum of complications is not well described. Complications are varied and include failure of basket to open in confined space, trapped basket surrounding a stone, fracture of basket wires, malfunction of ML crank handle, and ductal injury. METHODS: 6 tertiary referral centers participated in this comprehensive review. All centers identified the total # of cases requiring ML of large or resistant PD and CBD stones. Centers reviewed each case for type(s) of complication, Rx attempted, and success of Rx. A 56 data point questionnaire was filled by all investigators for each complication. Completed forms were returned for data analysis at the host institution. RESULTS: 695 ML cases were identified. 628 were biliary (90.4%) while 67 were pancreatic (9.6%). Complications were distributed at follows: 21 of 628 biliary (3.3%) and 7 of 67 pancreatic (10.5%). Of the 28 complications, 19 were single complications, 9 cases were multiple. Complications in the biliary group included: trapped (TR)/broken (BR) basket (n=10), wire fracture (FX) (n=8), failure to open (n=4), broken (BR) handle (n=4), perforation/duct injury (n=3). Complications in the pancreatic group included: TR/BR basket (n=6), wire FX (n=3), failure to open (n=1), BR handle (n=3). Rx of complications in the biliary group included: sphincterotomy (ES) extension (n=7), electrohydraulic lithotripsy (EHL) (n=11), stent (n=3), per-oral Soehendra lithotripsy (n=8), surgery (n=1). Rx of complications in the pancreatic group included: ES extension (n=2), EHL (n=2), stent (n=3), Soehendra (n=4), extracorporeal lithotripsy (ECL) (n=1), surgery (n=1). Pt with perforated viscus died at 30d. CONCLUSIONS: The vast majority of ML in expert centers involve the bile duct. The complication rate of pancreatic ML is 3 fold greater than biliary ML. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most useful treatment options.