Biliary and pancreatic lithotripsy devices

Abstract

Background and aims: Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL).

Methods: In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations.

Results: Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs.

Conclusions: Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Keywords: ASGE, American Society for Gastrointestinal Endoscopy; C-APCS, Comprehensive Ambulatory Payment Classification; CMS, Centers for Medicare and Medicaid Services; CPT, Current Procedural Terminology (https://www.asge.org/docs/default-source/education/Technology_Reviews/doc-enteral-nutrition-access-devices.pdf?sfvrsn=4); EHL, electrohydraulic lithotripsy; EPBD, endoscopic papillary balloon dilation; ERCP, endoscopic retrograde cholangiopancreatography; ES, endoscopic sphincterotomy; ESWL, extracorporeal shock wave lithotripsy; FDA, U.S. Food and Drug Administration; FREDDY, frequency-doubled, double-pulse neodymium; HCPCS, Healthcare Common Procedure Coding System; MAUDE, Manufacturer and User Facility Device Experience; ML, mechanical lithotripsy; RCT, randomized controlled trial; YAG, yttrium aluminum garnet.

Figure 1

Example of an integrated mechanical lithotripter basket with a plastic inner sheath and metal outer sheath (A) and handle (B).

Figure 2

Salvage lithotripter consisting of (A) a metal sheath and (B) a handle.

Figure 3

Example of an ESWL system including the generator and imaging apparatus with a patient in position. ESWL, Extracorporeal shock-wave lithotripsy.