Cholangioscopy-first lithotripsy linked to higher initial stone clearance after gastrectomy

Large common bile duct stones can be difficult to treat during balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy. A retrospective registry study from seven Japanese institutions compared peroral cholangioscopy-guided lithotripsy (POCL)-first with mechanical lithotripsy (ML)-first strategies in 104 postgastrectomy patients with an accessible native papilla. The primary outcome was complete stone clearance during the initial session; 39 patients received POCL-first and 65 received ML-first treatment.

Initial-session complete clearance occurred in 95% versus 62%, respectively, an absolute risk difference of 33.3 percentage points (95% CI, 17.3–46.0). After adjustment, POCL-first remained associated with greater initial-session clearance (adjusted risk ratio, 1.40; 95% CI, 1.08–1.83). Among patients achieving final clearance, 5% in the POCL-first group required at least two sessions, compared with 32% in the ML-first group. Adverse event rates did not differ significantly.

These findings suggest POCL-first may reduce repeat procedures in this technically challenging population. However, the retrospective, nonrandomized comparison cannot establish causality, and the absence of a significant adverse-event difference does not establish equivalent safety. The authors support prospective evaluation; applicability beyond postgastrectomy patients with an accessible native papilla remains uncertain.