Mechanical Lithotripsy Research Articles

Combined endoscopic large balloon dilation with limited sphincterotomy versus sole sphincterotomy for removal of large or multiple common bile duct stones

BackgroundEndoscopic papillary large balloon dilation (EPLBD) after sphincterotomy (EST) was introduced for the removal of large (≥ 10 mm) or multiple bile duct stones. This method combines the advantages of EST and EPLBD by increasing the efficacy of stone extraction while minimizing complications of EST and EPLBD when used alone. This prospective study aimed to compare between EPLBD with prior limited EST and sole sphnicterotomy for extraction of multiple and/or large common bile duct stones.ResultsStatistical analysis revealed insignificant difference between the studied groups as regards the presence of periamullary diverticulum (23% vs. 19%, P > 0.05) and the use of mechanical lithotripsy (4% vs. 9%, P > 0.05). The rates of overall and initial stone clearance were not significantly different between both groups [94% vs. 90%), P > 0.05; and 84% vs. 78%, P > 0.05, respectively]. The procedure-related pancreatitis and bleeding in EST/EPLBD group were lower compared to EST group (3% vs. 5%, P > 0.05; and 2% vs. 6%, P > 0.05, respectively). None of the studied groups’ patients died or developed procedure-related perforation or cholangitis.ConclusionEndoscopic large balloon dilation with prior limited sphincterotomy is an effective and safe endoscopic technique for removing multiple and/or large CBDSs.

Outcomes of endoscopic papillary large balloon dilatation in comparison to mechanical lithotripsy for large common bile duct stone

Background: The management of common bile duct stone (CBDS) has changed drastically over the past two decades, as open surgery has been supplanted by per-oral endoscopic procedures. Currently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the standard worldwide. After performing an endoscopic biliary sphincterotomy (EBST), endoscopic therapy entails CBDS extraction using conventional procedures. Lithotripsy is an endoscopic procedure used to remove CBDS that are too large to be extracted using conventional techniques.Aim: The aim of the present work is to compare the results of endoscopic large balloon dilatation and mechanical lithotripsy for large CBDS.Subjects and Methods: This prospective cohort study was conducted on 60 cases undergoing endoscopic retrograde cholangial pancreatography for large CBDS who were referred to out-case's clinic and in-case's wards of Gastroenterology, Hepatology and Endoscopy unit of Internal Medicine Department at Tanta University Hospitals December 2019 to February 2021. Cases were divided into two equal groups. Group I included cases undergoing endoscopic papillary large balloon dilatation (EPLBD) and Group II included cases undergoing mechanical lithotripsy (ML).Results: Success of CBDS extraction, Hb, PLT, TLC, albumin, PA, ALT, AST, creatinine and urea and CBDS parameters (diameter, CBDS size, CBDS number) after ERCP were insignificantly different between both groups. Total serum bilirubin, direct serum bilirubin and, Alkaline phosphatase after ERCP were significantly lower in EPLBD. However, Amylase and lipase were significantly higher in EPLBD.Conclusion: Despite that the endoscopic large balloon dilatation caused significantly higher pancreatitis, it showed lower TSB, DSB and ALP. However, both techniques showed no difference regarding the success of CBDS extraction and laboratory investigations.

Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis.

Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).

Antegrade minimally invasive technologies in treatment of complicated cholelithiasis

Aim. To evaluate the potential and effectiveness of antegrade X-ray surgical interventions as treatment choice to eliminate the cholecysto- and choledocholithiasis in the complicated cholelithiasis.Materials and methods. We carried out an analysis of the results of staged X-ray surgical treatment of 29 patients with cholecysto- and/or choledocholithiasis having relative or absolute counterindications to the implementation of laparoscopy, open surgery or endoscopy. Thirteen patients (44.8%) were revealed to have diverticulum of the major duodenal papilla; seven (24.1%) – coronary heart disease with chronic heart failure. Five patients (17.2%) had previously undergone gastrectomy. Severe diseases of the respiratory organs were detected in four cases (13.7%). The primary intervention included percutaneous microcholecystostomy and percutaneous transhepatic cholangiostomy. The drainage channel formation was followed by cholecysto- and choledocholangioscopy, mechanical and pneumatic lithotripsy, lithoextraction.Results. A total of 34 percutaneous minimally invasive interventions were performed. Percutaneous transhepatic biliary drainage was performed in 23 cases (67.6%), percutaneous microcholecystostomy – in seven (20.5%), and percutaneous drainage of peri- and intrahepatic abscesses was additionally carried out in four cases (11.9%). At the second stage, seven patients (24.4%) underwent cholecystoscopy and 20 (68.8%) – choledocholangioscopy. Both interventions were used in two cases (6.8%). In all cases, the work resulted in eliminating the complications of cholelithiasis, cholecystosis and/or choledocholithiasis with restorating the bile passage by means of percutaneous minimally invasive technologies. No fatal outcomes or complications were recorded.Conclusion. Antegrade X-ray surgical technologies are effective minimally invasive choice treatment to eliminate the cholecysto- and choledocholithiasis with counterindications to other surgical treatments in the complicated cholelithiasis.

OGBN P13 Management of Bouveret Syndrome: an endoscopic approach

Abstract Background Bouveret syndrome is rare complication of gallstones with 600 reported cases since 1950. The syndrome occurs when adhesions develop between the gallbladder to surrounding hollow viscera leading to fistula formation. Large gallstones migrate into the enteric system and become impacted in the stomach or duodenum causing gastric outflow obstruction. Bouveret syndrome accounts for 1–4% of gallstone ileus cases. It is more common in co-morbid women in their 7th and 8th decades. Most common symptoms are vomiting and abdominal pain. Upper gastrointestinal bleeding is reported in 15% of cases. CT scan has the highest sensitivity at 79–93% to make the diagnosis. Of note 15–25% of gallstones are isoattenuating. Riglers triad is a diagnostic marker and consists of aerobilia, a gastric outflow obstruction or dilated bowel and the presence of a calculus outside of the biliary tree. The diagnosis was associated with mortality rates as high as 30% but with modern advances mortality has decreased to approximately 12%. Treatment options are surgical or endoscopic retrieval. Endoscopic management carries less risk especially in the frail elderly patient. This approach has low success rates. We present a case of successful endoscopic management of Bouveret syndrome and discuss surgical and endoscopic management strategies. Methods A frail 83 year old female attended ED with epigastric pain, vomiting and signs of sepsis. She had a recent diagnosis of severe cholecystitis that was managed conservatively. On examination she had tenderness in the right upper quadrant. Bloods revealed an AKI, a CRP 189 and normal liver function tests. Axial imaging showed aerobilia with a CBD dilated at 14mm and there was a 3.5cm calculus impacted in the duodenum with a cholecysto-duodenal fistula. Her medical history included diabetes mellitus, atrial fibrillation, hypertension, primary hyperparathyroidism, reflux and cauda equina (operated). On OGD there was a large stone which had eroded into the first part of the duodenum. A combination of mechanical lithotripsy and the Kudo snare were used to fragment the stone. 2 large fragments were retrieved using a bag to avoid gallstone ileus. Results The patient had an uneventful but slow recovery. She re-established oral intake on the second post-operative day. She was discharged 2 weeks later without complication. Conclusions The success of endoscopic management is reported as low as 10%. Endoscopic intervention is attempted in 61% of cases. Success is more likely with stones <4cm and if the site of impaction is the stomach or D1/D2. Surgical management is associated with a morbidity rate of 26% but was successful in 78%. Laparoscopic surgery is possible but less successful in stones >5cm. Endoscopic techniques have evolved and should be considered for extraction of stones in the first instance. If not feasible surgery can be considered. The literature shows that success is more likely when various endoscopic techniques are utilized including mechanical lithotripsy, nets and baskets, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, laser lithotripsy and duodenal stenting. There is a risk of distal migration of stone fragments causing gallstone ileus in the more distal small bowel. Bouveret syndrome can be resolved with endoscopy in expert hands.

Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis.

Background and study aims The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.

Single-operator Cholangioscopy Guided Lithotripsy

ERCP is the standard treatment for common bile duct stones (CBD stones). On the other hand, in approximately 10% of patients with CBD stones, the complete removal of the stones cannot be achieved by conventional ERCP, which performs endoscopic sphincterotomy followed by stone extraction. Additional advanced and complex procedures are often necessary to remove these "difficult bile duct stones", including endoscopic papillary large balloon dilatation or mechanical lithotripsy. Advances in cholangioscopy have made electrohydraulic or laser lithotripsy under direct endoscopic visualization possible during ERCP. Cholangioscopy-guided lithotripsy using the SpyGlass DS system could be a better treatment tool for removing difficult stones. The focus of this review was to describe single-operator cholangioscopy in the management of difficult CBD stones.

S1162 A Comparison of Technical Failures and Patient-Related Adverse Events Associated With Three Widely Used Mechanical Lithotripters for ERCP: Insights From the FDA MAUDE Database

Introduction: Mechanical lithotripsy is a commonly used, effective method for fragmenting large biliary or pancreatic duct stones. Real-world data on the most commonly reported complications and modes of failure associated with mechanical lithotripters are limited. We analyzed the post-marketing surveillance data from the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database for three commercially available mechanical lithotripters for use during ERCP. Methods: A search of the FDA MAUDE database from January 2010 to October 2021 was conducted for the the following mechanical lithotripters: Trapezoid RX (Boston Scientific, Natick, MA), LithoCrush (Olympus Endoscopy, Center Valley, PA), and the Fusion Lithotripsy Extraction Basket (Cook Endoscopy, Winston Salem NC). Results were compiled and reviewed. Results: 1,128 medical device reports with 2,129 device malfunctions and 205 patient complications were identified. Most device malfunctions were due to guidewire port or sheath failure (n=379, 17.8%), basket entrapment (n=357, 16.8%), and basket tip separation failure (n=315, 14.8%). The most commonly reported adverse events to patients were an additional procedure to remove an entrapped basket (n=170/205, 82.9%), bleeding (n=15/205, 7.3%), and bowel perforation (n=5/205, 2.4%). Conclusion: Findings from the MAUDE database highlight device and patient-related adverse outcomes that should be recognized to improve clinical success and reduce patient risk.

S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis

Introduction: Biliary complications, like anastomotic stricture and cholangitis, are seen in 10-15% of orthotopic liver transplants (OLT). OLTs often require multiple endoscopic retrograde cholangiopancreatoscopy (ERCP) for recurrent disease. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CD) has been effective in treatment of malignant distal biliary obstruction after failed ERCP; however, there are limited reports regarding EUS-CD in OLTs. We present a case of successful EUS-CD with lumen apposing metal stents (LAMS) in an OLT with recurrent cholangitis secondary to benign anastomotic stricture refractory to management with ERCP. Case Description/Methods: A 61-year old female with 3 OLTs (1996 and twice in 2008) for autoimmune hepatitis presented with recurrent cholangitis secondary to anastomotic biliary stricture in the setting of duct mismatch with a dilated common hepatic bile duct to 3 cm. She had recurrent choledocholithiasis measuring 3 cm despite prior mechanical and electrohydraulic lithotripsy with cholangioscopy confirmed clearance. As a result, she had undergone a total of 26 prior ERCP treatments (2012-2021). She underwent an EUS-CD with LAMS for definitive treatment. 2-weeks later, an upper endoscope was traversed through the LAMS to perform lithotripsy of remaining choledocholithiasis. At this time, the patient remains free of cholangitis for the past 8 months. (Figure) Discussion: Biliary complications, like anastomotic stricture and recurrent cholangitis, are a common occurrence in OLTs. With use of various ERCP techniques, obstructions can be removed or ameliorated. Timely treatment of cholangitis is imperative as the mortality rate is high (10-30%). With each cholangitis episode and subsequent ERCP, the cumulative procedural risk and mortality increases. EUS-CD has been demonstrated to be effective in treatment for malignant distal biliary obstruction after failed ERCP. Our patient had previously undergone 26 ERCPs and additionally was on Warfarin for pulmonary embolism putting her at very high risk for complications with additional future endoscopic procedures. This represents a case of successful use of EUS-CD with LAMS in a patient post-OLT with a significant distal common bile duct stricture which had been refractory to traditional management via ERCP. Long term studies are indicated to see if this can provide durable benefit.Figure 1.: 1A. MRI imaging demonstrating a large 3 cm choledocholithiasis within the dilated CBD, which formed as a result of bile stasis. 1B. CT coronal view demonstrating successful deployment of LAMS to complete EUS-CD. 1C. Fluoroscopic view of the standard upper scope traversing through the LAMS for definitive lithotripsy and dredging of remaining choledocholithiasis. 1D. Endoscopic view of the final LAMS placement with double pigtail plastic stents.

Outcome of Digital Cholangioscopy and Laser Lithotripsy for Impacted Biliary Stones

Abstract Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct. Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications. Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient. Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Endoscopic treatment of Bouveret syndrome with Holmium laser lithotripsy.

Gallstone ileus is a rare condition that is seen in about 0.5 % of all cases of mechanical intestinal obstruction [1]. Furthermore, only 1 %–3 % of these patients have Bouveret syndrome, which is defined as the impaction of a large gallstone within the duodenum as a result of a cholecystoduodenal fistula [2]. Endoscopic baskets, mechanical lithotripsy, electrohydraulic lithotripsy, laser lithotripsy, and extracorporeal shockwave lithotripsy are the endoscopic treatment modalities used in Bouveret syndrome [3].

Direct cholangioscopy using a standard-size gastroscope to guide mechanical lithotripsy after failed ERCP-based basket capture

Direct cholangioscopy using a standard-size gastroscope to guide mechanical lithotripsy after failed ERCP-based basket capture

Management of difficult bile duct stones with temporary plastic stent and ursodeoxycholic acid treatment: 5 years of experience

Aim: The aim of the study was to investigate the effect of temporary plastic stenting and ursodeoxycholic acid (UDCA) treatment on difficult choledochal stones that cannot be removed by basic ERCP techniques in patients who applied to our clinic with occlusion and underwent endoscopic retrograde cholangiopancreatography (ERCP).
 Material and Method: Patients were scanned retrospectively using the hospital database. Patients who underwent ERCP due to malignancy, biliary tract injury and benign strictures were excluded from the study. 61 patients who were not successful with basic ERCP techniques such as endoscopic sphincterotomy (EST) and mechanical lithotripsy (ML) were included in the study. 750 mg/day UDCA was given to the patients for three months and plastic stent was applied. After the treatment, ERCP was tried again.
 Results: Among the patients who underwent stent+UDCA, three (4.9%) patients had perioperative bleeding, one (1.6%) patient had peroperative perforation, four (6.6%) patients had postoperative pancreatitis, and one (1.6%) patient had mortality. The mean hospital stay was 1.96±2.1 days. Post-procedure total bilirubin and direct bilirubin values were observed to be lower than before the procedure (respectively, p

Minimally invasive treatment of duodenal obstruction with acute pancreatitis caused by two large bezoars.

Bezoar without gastrointestinal surgical history occurring simultaneously in the gastric and duodenal lumen is very rare. We report a case of acute pancreatitis due to duodenal obstruction caused by two large bezoars. Two large bezoars were detected in the gastric and duodenal lumen, respectively, on abdominal computed tomography (CT) scan and oesophagogastroduodenoscopy images. Bezoars were crushed and removed using endoscopic devices such as trapezoid basket and lithotripsy handle. After removal of bezoars, blood tests and CT follow-up tests confirmed improvement. In the case of bezoar, which causes duodenal obstruction, it is difficult to administer coke for dissolution, and if it is difficult to perform surgical approach due to old age, an endoscopic treatment using mechanical lithotripsy devices can be an alternative option.

Comparison of technical failures and patient-related adverse events associated with 3 widely used mechanical lithotripters for ERCP: insights from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database

Mechanical lithotripsy is a commonly used, effective method for fragmenting large biliary or pancreatic duct stones. Real-world data on the most commonly reported adverse events and modes of failure associated with mechanical lithotripters are limited. We analyzed the postmarketing surveillance data from the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for 3 commercially available mechanical lithotripters for use during ERCP. A search of the MAUDE database from January 2010 to October 2021 was conducted for the following mechanical lithotripters: Trapezoid RX (Boston Scientific, Natick, Mass, USA), LithoCrush (Olympus Endoscopy, Center Valley, Pa, USA), and the Fusion Lithotripsy Extraction Basket (Cook Endoscopy, Winston Salem, NC, USA). Results were compiled and reviewed. In total, 1128 medical device reports with 2129 device malfunctions and 205 patient adverse events were identified. Most device malfunctions were because of guidewire port or sheath failure (n= 379, 17.8%), basket entrapment (n= 357, 16.8%), and basket tip separation failure (n= 315, 14.8%). The most commonly reported adverse events to patients were an additional procedure to remove an entrapped basket (170/205, 82.9%), bleeding (15/205, 7.3%), and bowel perforation (5/205, 2.4%). Findings from the MAUDE database highlight device- and patient-related adverse outcomes that should be recognized to improve clinical success and reduce patient risk.

Novel elbow basket mechanical lithotripter for large common bile duct stone removal

ABSTRACT Background Large common bile duct (CBD) stones often require lithotripsy. In this study, we aimed to introduce a novel device-elbow basket catheter for mechanical lithotripsy (ML) of CBD stones and assess the efficacy and safety of the novel device. Methods This was a retrospective study. A total of 139 patients with large CBD stones who underwent lithotripsy using the elbow basket mechanical lithotripter (EBML) or conventional basket mechanical lithotripter (CBML) during endoscopic retrograde cholangiopancreatography (ERCP) from June 2016 to September 2021 in our center were enrolled in the study. The stone clearance rate, intubation time, overall procedure time, and adverse event rate were compared between the two groups. Results The stone clearance rate in the first ERCP program in the EBML (n = 71) group was significantly higher than that in the CBML (n = 68) group (98.6% vs. 88.2%; P< 0.05). The intubation time in the EBML group was significantly shorter than that in the CBML group (median time; 12s vs. 78s; P< 0.001). The overall procedure time in the EBML group was significantly shorter than that in the CBML group (median time; 51 min vs. 63 min; P< 0.001). The adverse event rate (7.4% vs. 1.4%: P> 0.05) was similar between the two groups. Conclusions ML using EBML in patients with large CBD stones is feasible and safe. Compared with the CBML, the stone clearance rate of the EBML is higher in a single procedure and decreases the time of intubation and the overall procedure.

A novel machine learning model and a public online prediction platform for prediction of post-ERCP-cholecystitis (PEC)

SummaryBackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an established treatment for common bile duct (CBD) stones. Post- ERCP cholecystitis (PEC) is a known complication of such procedure and there are no effective models and clinical applicable tools for PEC prediction.MethodsA random forest (RF) machine learning model was developed to predict PEC. Eligible patients at The First Hospital of Lanzhou University in China with common bile duct (CBD) stones and gallbladders in-situ were enrolled from 2010 to 2019. Logistic regression analysis was used to compare the predictive discrimination and accuracy values based on receiver operation characteristics (ROC) curve and decision and clinical impact curve. The RF model was further validated by another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126.FindingsA total of 1117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy as the top six predictive factors and has a sensitivity of 0.822, specificity of 0.853 and accuracy of 0.855, with the area under curve (AUC) value of 0.890. A separate logistic regression prediction model was built with sensitivity, specificity, and AUC of 0.811, 0.791, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model.InterpretationThe results suggest that the proposed RF model based on the top six PEC risk factors could be a promising tool to predict the occurrence of PEC.

V03-10 THULIUM LASER VS DUAL ACTION ULTRASONIC/BALLISTIC CYSTOLITHOLAPAXY

You have accessJournal of UrologyCME1 May 2022V03-10 THULIUM LASER VS DUAL ACTION ULTRASONIC/BALLISTIC CYSTOLITHOLAPAXY Matthew Beamer, and Scott Weiner Matthew BeamerMatthew Beamer More articles by this author , and Scott WeinerScott Weiner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002539.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There are many options available to perform a transurethral cystolitholapaxy including ultrasonic, ballistic, pneumonic, laser, and mechanical lithotripsy. Both holmium laser lithotripsy and ultrasonic lithotripsy are commonly used for the treatment of bladder stones. Both have been deemed safe and have been shown to produce less mucosal bleeding when compared to other methods. Recently the thulium laser has been used for the treatment of nephrolithiasis. Proponents suggest that this laser creates smaller stone fragments with greater stone ablation, allowing for shorter operative times and higher stone free rates when compared to the holmium laser. Here we compare the thulium laser and dual action ultrasonic/ballistic lithotripsy for the treatment of bladder stones in a single patient. METHODS: A 76-year-old male presented with two bladder stones of equal size (1.6cm) and Hounsfield units (1300). Both stones were treated transurethrally during a single procedure. The first stone was treated with the thulium laser where a 550-micron fiber was placed through a 28 French resectoscope. A frequency of 8Hz and energy of 18.8kJ was used. The second stone was treated with an Olympus ShockPulse (dual action ultrasonic/ballistic) lithotripter placed through a 24 French nephroscope. The two procedures were evaluated objectively based on time to completion and subjectively based on visualization, mucosal bleeding, and stone retropulsion. RESULTS: The thulium laser cystolitholapaxy was completed in 29 minutes and 10 seconds, while the ultrasonic/ballistic lithotripsy was completed in 36 minutes and 6 seconds. Both were effective at clearing the stone burden. Subjectively, the thulium laser allowed for less stone retropulsion and greater stone ablation. There was minimal mucosal damage and excellent visualization. The ultrasonic/ballistic lithotripter produced larger stone fragments and significant stone movement, leading to mucosal bleeding with decreased visualization. CONCLUSIONS: A thulium laser cystolitholapaxy may provide shorter operative times, minimal stone movement, decreased mucosal bleeding, and improve visualization when compared to ultrasound/ballistic cytsolitholapaxy. Future prospective or retrospective analysis is needed to make a definitive assessment. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e204 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Beamer More articles by this author Scott Weiner More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP32-05 BENCHTOP EVALUATION OF MINIATURE PERCUTANEOUS NEPHROLITHITOMY LITHOTRITES

You have accessJournal of UrologyCME1 May 2022MP32-05 BENCHTOP EVALUATION OF MINIATURE PERCUTANEOUS NEPHROLITHITOMY LITHOTRITES Patrick Whelan, Christopher Kim, Christian Tabib, Russell Terry, Glenn Preminger, and Michael Lipkin Patrick WhelanPatrick Whelan More articles by this author , Christopher KimChristopher Kim More articles by this author , Christian TabibChristian Tabib More articles by this author , Russell TerryRussell Terry More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , and Michael LipkinMichael Lipkin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002581.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the preferred surgical treatment for kidney stones >2cm. While PCNL has traditionally been performed using access sheaths from 24-30Fr in size, there is presently a trend toward using increasingly smaller sheaths (<20Fr) and scopes to perform what has been termed “mini-PCNL.” Smaller mechanical lithotripsy instruments have therefore been developed for this purpose, but are limited in comparative effectiveness. We performed benchtop assessment of multiple mini-PCNL lithotrites. METHODS: One 1cm3, hard Begostone phantom, mimicking a calcium oxalate monohydrate stone, was placed in a cylinder with four 5.5mm cylindrical openings to simulate size of a 16.5Fr mini-PCNL sheath to drain via Venturi effect. Lithotripsy was then performed with either the 1.9mm Trilogy (EMS), 1.83mm ShockPulse (SP, Olympus) and 200mm Holmium:YAG laser. Suction was used for the mechanical lithotrites. The Trilogy probes were used at 50% impact, 6Hz, 80% ultrasound and 10% suction. The ShockPulse was used at high-power setting. The 1.9mm probe was used with a 15Fr mini nephroscope (Olympus). The ShockPulse, 1.5mm Trilogy and laser fiber were used with a 12Fr mini nephroscope (Karl-Storz). The laser was set at 0.5J/70Hz Moses-Distance (MD) (Lumenis). 10 independent runs were performed with each probe. Time to complete stone clearance was recorded and mass stone clearance rates were calculated. RESULTS: The Trilogy 1.9mm probe showed superior stone clearance rate (11.69±3.68 mg/s) vs the SP 1.83mm probe (6.29±1.37 mg/s, p=0.003) and the laser fiber (4.73 ± 0.61 mg/s, p <0.0005), respectively (Figure 1). The SP was also superior to the laser (p=0.016). This translates to 4.6 and 7.9 minutes less treatment time vs the SP and laser, respectively, for a spherical 1.5cm diameter calcium oxalate monohydrate stone. CONCLUSIONS: Among these three commonly used mini-PCNL probes, the Trilogy 1.9 demonstrated clearly superior stone clearance rates in this benchtop model. This could be due to improved lithotrite properties and use of suction evacuation, especially compared to the laser. Future clinical testing is warranted to evaluate optimal lithotrite for miniPCNL. Source of Funding: Boston Scientific provided funding for this study through an educational grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e533 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick Whelan More articles by this author Christopher Kim More articles by this author Christian Tabib More articles by this author Russell Terry More articles by this author Glenn Preminger More articles by this author Michael Lipkin More articles by this author Expand All Advertisement PDF DownloadLoading ...

Comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy in clearing large common bile duct stones: A systematic review and meta‐analysis of randomized controlled trials

AbstractThere are three methods to retrieve large common bile duct stones, the first is endoscopic sphincterotomy (EST), the second is endoscopic papillary large‐balloon dilatation (EPLBD), and the third is limited EST plus EPLBD. Although EST is the most popularly used method, it has higher risk of bleeding complication and basket stuck. EPLBD alone without EST demonstrated safe and quick in the clinical practice, but there were only few studies focused on comparing EST or EPLBD alone. Thus, this study aims to compare the efficacy and safety of EPLBD with EST. We searched for PubMed, Embase, and Cochrane Library databases to collect relevant articles until August 31st, 2019. We included randomized controlled trials, common bile duct stones &gt; 10 mm, comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy, and patients older than 18. We compare endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy on the clearance of large common bile duct stones, the adverse events, and the need for mechanical lithotripsy. This systematic review and meta‐analysis was registered on PROSPERO and the registration number is CRD42020150485. Total six studies met inclusion criteria and 762 participants were enrolled. The data revealed that endoscopic papillary large‐balloon dilatation alone was comparable to endoscopic sphincterotomy on the clearance of large common bile duct stones (RR = 1.02, 95% CI: 0.93‐1.12), the adverse events (RR = 1.01, 95% CI: 0.71‐1.43) and the need for mechanical lithotripsy. In the subgroup analysis, the requirement of mechanical lithotripsy decreased in the non‐Chinese group (RR = 0.58, 95% CI: 0.41‐0.84). The efficacy and safety to clean large common bile duct stones are comparable in either EPLBD or EST. In addition, EPLBD alone not only saves the operation time but also reduces the chance of mechanical lithotripsy in the subgroup analysis.