Clinical Evaluation of the Effectiveness of Digital Peroral Cholangioscopy‐Guided Lithotripsy for Difficult Bile Duct Stones

BACKGROUND AND AIMS: Peroral cholangioscopy-guided lithotripsy (POCS-L) has emerged as a treatment option for difficult bile duct stones (DBDSs), but detailed evidence remains limited. This study evaluated its effectiveness, safety, and risk factors for adverse events (AEs). METHODS: We retrospectively analyzed 132 consecutive patients who underwent POCS-L for DBDSs between December 2014 and July 2023 at Tokyo Medical University Hospital. Electrohydraulic lithotripsy or holmium: yttrium-aluminum-garnet laser lithotripsy was performed under cholangioscopic guidance. The primary outcomes were technical and clinical success, and secondary outcomes included procedure-associated AEs and risk factors for cholangitis. RESULTS: The technical and clinical success rates were 98.5% and 94.7%, respectively, with a median procedure time of 56 min. Clinical success was higher for common bile duct stones than intrahepatic bile duct stones (98.0% vs. 83.9%). Procedure-associated AEs occurred in 29.5% of patients, most commonly transient fever (16.7%) and cholangitis (11.4%). Multivariable analysis identified a stone diameter > 20 mm (odds ratio [OR]: 4.79; p = 0.016) and absence of postprocedural biliary drainage (OR: 3.73; p = 0.048) as independent predictors of cholangitis. CONCLUSIONS: POCS-L is an effective and safe treatment for DBDSs. Postprocedural biliary drainage may reduce the risk of cholangitis, particularly in patients with large stones.