Endoscopic lithotripsy combined with drug lithotripsy vs. drug lithotripsy for the treatment of phytobezoars: analysis of 165 cases.

AIM: To analyze efficacy of endoscopic lithotripsy combined with drug lithotripsy as compared with drug lithotripsy for the treatment of phytobezoars. METHODS: We collected and evaluated case records of 165 patients with phytobezoars from 2014 to 2023. And we analyzed demographic and clinical characteristics, imaging features, endoscopic features, complications of phytobezoars, and compared efficacy between endoscopic lithotripsy combined with drug lithotripsy (Group A) and drug lithotripsy (sodium bicarbonate combined with proton pump inhibitor) (Group B). RESULTS: The median age of patients with phytobezoars was 67.84 ± 4.286 years old. Abdominal pain was the most common symptom and peptic ulcers (67.5%) were the most common complication. Bezoar-induced ulcers were more frequent in the gastric angle. The success rate of phytobezoars vanishing in Group A and Group B were similar (92.3% vs. 85.1% within 48 h, 98.7% vs. 97.7% within a week), while the average hospitalization period, average hospitalization cost, second endoscopy rate, and average endoscopic operation time were significantly lower in patients in Group B than in Group A. CONCLUSION: Drug lithotripsy is the preferred effective and safe treatment option for phytobezoars. We advise that an endoscopy should be completed after 48 h for drug lithotripsy.

Gallstone Enteropathy: An Unusual Cause of Bowel Obstruction.

Gallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of small bowel obstruction cases. Additionally, it is a rare complication affecting only 0.3% of patients who have gallstones. Fistula formation between the biliary system, most commonly between the gallbladder and duodenum because of their proximity, facilitates the migration of gallstones into the enteric system with subsequent impaction in the small intestine, usually in the distal ileum close to the ileocecal valve, promoting the development of mechanical small bowel obstruction. Computerized tomography of the abdomen and pelvis is a confirmatory and widely used imaging study when there are two signs of Rigler's triad, which includes pneumobilia, evidence of small bowel obstruction and the presence of radiopaque stones. We report a case of a 75-year-old Caucasian man who presented with abdominal distention with signs of severe dehydration secondary to intractable nausea and vomiting complicated with severe acute kidney injury and was found to have a 4.7-centimeter gallstone-induced small intestinal obstruction.

Risk factors for systemic inflammatory response syndrome after endoscopic lithotripsy for upper urinary calculi.

BACKGROUND: To explore the risk factors for systemic inflammatory response syndrome (SIRS) after endoscopic lithotripsy for upper urinary calculi. METHODS: This retrospective study included patients with upper urinary calculi who underwent endoscopic lithotripsy in the First Affiliated Hospital of Zhejiang University between June 2018 and May 2020. RESULTS: A total of 724 patients with upper urinary calculi were included. One hundred and fifty-three patients developed SIRS after the operation. The occurrence of SIRS was higher after percutaneous nephrolithotomy (PCNL) compared with ureteroscopy (URS) (24.6% vs. 8.6%, P < 0.001) and after flexible ureteroscopy compared with ureteroscopy (fURS) (17.9% vs. 8.6%, P = 0.042). In the univariable analyses, preoperative infection history (P < 0.001), positive preoperative urine culture (P < 0.001), history of kidney operation on the affected side (P = 0.049), staghorn calculi (P < 0.001), stone long diameter (P = 0.015), stone limited to the kidney (P = 0.006), PCNL (P = 0.001), operative time (P = 0.020), and percutaneous nephroscope channel (P = 0.015) were associated with SIRS. The multivariable analysis showed that positive preoperative urine culture [odds ratio (OR) = 2.23, 95% confidence interval (CI): 1.18-4.24, P = 0.014] and operative methods (PCNL vs. URS, OR = 2.59, 95% CI: 1.15-5.82, P = 0.012) were independently associated with SIRS. CONCLUSION: Positive preoperative urine culture and PCNL are independent risk factors for SIRS after endoscopic lithotripsy for upper urinary calculi.

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.

Duodenal diverticula perforation caused by an impacted bezoar successfully treated by endoscopic drainage and lithotripsy: A case report and literature review.

Duodenal diverticula perforation due to an impacted bezoar is a rare disease. Surgical treatment is associated with high rates of complications and mortality; therefore, treatment strategies must be carefully decided. Endoscopic treatment offers significant benefits to patients over surgery.

Comparative evaluation of tissue damage induced by ultrasound and impact dual-mode endoscopic lithotripsy versus conventional single-mode ultrasound lithotripsy.

OBJECTIVE: The aim of our study was to perform comparative investigation of the tissue safety of three different endoscopic lithotripter devices including a new single-probe/dual-energy lithotripter in an in vivo animal model. The Swiss LithoClast Trilogy was compared to the Storz Calcuson and the Swiss LithoClast Vario. The safety test simulated the accidental direct contact between lithotripter probes and the urothelium, which can occur when sliding off a stone or drilling through a calculus during lithotripsy. The safety test included a smallest (1.5 mm) and largest (3.3/3.4 mm) probe diameter per device. METHODS: Testing was performed in nine pigs (three animals per device). The bladder tissue was exposed to direct lithotripter probe contact at maximum power for 10 s to produce visible tissue lesions. Acute tissue trauma was evaluated using a simplified scoring model describing the expected bladder wall injuries for histological examination. After 7 days, all animals were killed, necropsied and examined post mortem. For between-group comparisons regarding microscopic histopathologic features, a Chi-square test was used. A p value < 0.05 was considered to be statistically significant. RESULTS: Irrespective of the lithotripter used, no systemic signs of toxicity were observed. Histologically, signs of normal ongoing healing were observed on the bladder mucosa. There were no significant differences in histological findings taking changes of the epithelium (p = 0.360), the leucocyte infiltration (p = 0.123), the vascular congestion (p = 0.929) and the edema (p = 1.0) between the groups into account. CONCLUSIONS: The results of this study demonstrated a comparable safety between all lithotripsy devices.

The value of heparin-binding protein in predicting urosepsis after endoscopic lithotripsy for upper urinary tract stones / 中华泌尿外科杂志

Objective To investigate the value of heparin-binding protein(HBP) in predicting urosepsis after endoscopic lithotripsy for upper urinary tract stones.Methods From January to November 2018,635 cases of upper urinary tract stones treated by endoscopic lithotripsy in our hospital was analyzed.According to the 2014 edition Chinese Guidelines of the diagnosis and treatment of urosepsis,all patients were divided into two groups,the definite urosepsis group (n =53,8.3％) and the no urosepsis group (n =582,91.7％).The serum of HBP level was detected by fluorescence immunoassay technology.The serum of procalcitonin (PCT) level was detected by cyclic enhanced immunofluorescent assay.C-reactive protein (CRP) level was detected by automatic chemiluminescence immunoassay analyzer.White blood cells (WBC) count was performed by hematology analyzer.Receiver operating characteristic(ROC) curves were constructed by SPSS 22 and MedCale,and areas under curves (AUC) were calculated and compared to illustrate the diagnostic power of HBP,PCT,CRP and WBC.The correlation between HBP and WBC was also significant (r =0.68,P ＜ 0.05).Results The level of HBP,PCT,CRP and WBC were significantly higher in the definite urosepsis group compared to the no urosepsis group.AUC of HBP,PCT,CRP and WBC were 0.930,0.878,0.727 and 0.617.When the cutoff of HBP,PCT,CRP and WBC were set as 51.5 ng/ml,0.41 ng/ml,64.2 mg/L and 11.7 × 109/L,the sensitivities were 89.2％,83.3％,83.5％ and 44.7％,and the specificity were 95.9％,75.6％,64.3％ and 77.1％,respectively.Conclusions The value of heparin-binding protein was superior to that of PCT,CRP and WBC in predicting urosepsis after endoscopic lithotripsy for upper urinary tract stones.Heparin-binding protein could be acted as a diagnostic marker for urosepsis.

Uroseptic Shock Can Be Reversed by Early Intervention Based on Leukocyte Count 2 h Post-operation: Animal Model and Multicenter Clinical Cohort Study.

This study investigated whether early intervention based on leukocyte count (WBC) of less than 2.85 × 109/L obtained within 2 h post-operatively may ameliorate the uroseptic shock induced by upper urinary tract endoscopic lithotripsy (UUTEL). Urosepsis was induced in 30 rabbits and assigned to three groups: Control-I, WBC-I, and Shock-I. Control-I: Non-intervention control. WBC-I: Immediate resuscitation when there was a drastic drop of WBC within 2 h post-operatively but without signs or symptoms of shock. Shock-I: Resuscitation only when there were signs or symptoms of shock. In total, 107 patients whose WBC were less than 2.85 × 109/L within 2 h after UUTEL were retrospectively analyzed. Patients were assigned into two groups based on the time of the intervention. Shock-II included 59 patients who were started on the resuscitation bundle when there were signs or symptoms of shock. WBC-II included 48 patients who were started immediately on the resuscitation bundle when the WBC decreased drastically. All Control-I rabbits developed shock within 72 h and died. None of the WBC-I rabbits developed shock and all survived for 72 h. In total, 60% of Shock-I died within 72 h. Overall, 43 patients in Shock-II and six patients in WBC-II experienced uroseptic shock. The average lengths of hospitalization for Shock-II and WBC-II were 17.8 ± 9.7 days and 7 ± 4.2 days, respectively. Six patients in the Shock-II and none in WBC-II died of the uroseptic shock. Early intervention based on WBC measured within 2 h post-operatively might avert the uroseptic shock induced by UUTEL.

Effect of initial intervention based on white blood cell count measured within 2 hours postoperatively to treat uroseptic shock induced by upper urinary tract endoscopic lithotripsy (UUTEL) : animal experiments and clinical study / 中华泌尿外科杂志

Objective To investigate whether initial intervention based on WBC measured within 2 hours postoperatively can reverse the uroseptic shock induced by UUTEL.Methods From May,2015 to July 2015,24 female New Zealand rabbits,weighing 2.0-2.5 kg,born 2-3 months,used as uroseptic shock model.Their ureters were ligated and followed by injection of Escherichia coli solution into the renal pelvis.Then,those animals were randomly assigned into control group(the first group)and experimental groups (the second group,the third group).Each group had 8 rabbits initially.The first group did not receive sensitive antibiotic or fluid resuscitation.The second group received imipenem and cilastatin sodium 15mg/kg and normal saline 5 ml/kg 2 hours postoperatively.The third group received sensitive antibiotic and fluid resuscitation the same dosage as the second group 6 hours postoperatively.Mean arterial pressure(MAP) was recorded for 10 hours and survival rate of all groups for 72h postoperatively was recorded..The clinical data of 46 patients whose WBC count less than 2.85 × 109/L within two hours after UUTEL were analyzed retrospectively.These patients were divided into two groups based on the time of intervention.Group A including 19 patients received routine antibiotic,fluid therapy,low-dose corticosteroids when there was symptom of shock.Group B including 27 patients immediately received resuscitation bundle protocol when there was a drastic decrease in WBC.The incidence of septic shock,the rate of intubation,length of stay in ICU,length of stay in hospital postoperatively,hospitalization cost and survival rate of these two groups were compared.Results All 8 rabbits of the first group died within 72 h,postoperatively and the median time of survival was 11 h.None of the second group rabbits developed shock and all rabbits survived 72 h after operation.6/8 rabbits of the third group survived 72 h after operation.15 patients in Group A and 3 patients in Group B experienced acute uroseptic shock (P ＜ 0.05).11 patients in Group A and one patients in Group B underwent tracheal intubation (P ＜ 0.05).18 patients in Group A and 6 patients in Group B were transferred to ICU(P ＜ 0.05),and their length of stay in ICU was (10.8 ± 5.4) d and (7.5 ± 2.8) d,respectively(P ＞ 0.05).The length of stay in hospital and hospitalization cost of Group A and B were (19 ± 9.8)d vs.(7 ±4.7)d(P ＜0.05),(94 583 ±51 623) RMB vs.(35 389 ± 16 342) RMB respectively (P ＜ 0.05).One patient in Group A died due to acute uroseptic shock and none of Group B died.Conclusions Our animal model and clinical cohort study showed that initial intervention based on WBC mneasured within 2 hours postoperatively can reverse the uroseptic shock induced by UUTEL and improve the prognosis.

Use of XenX™, the latest ureteric occlusion device with guide wire utility: results from a prospective multicentric comparative study.

PURPOSE: This is a prospective multicentric comparative study evaluating the performance of XenX-a new dual-purpose device for the prevention of stone fragments migration during ureteroscopic lithotripsy (URS). METHODS: Between March 2014 and January 2015, 41 patients undertaking URS + XenX were matched with 41 patients undergoing standard URS. Patients included had unilateral ureteric stone(s) of 0.5-1.5 cm in maximum size. Demographics, complication rates and surgical outcomes were recorded for comparison. A Likert-like 5-grade scoring system was used for surgeons' evaluation of XenX properties. Cost analysis was performed by comparing weighted mean costs of the relevant procedures. RESULTS: Patients' characteristics between the two groups were comparable. Lasering time was longer for XenX group (13.59 vs. 5.17 min; p = 0.0001) whilst use of basket and need of JJ stent insertion was more frequent in control group (19.5 vs. 97.6 %; p = 0.0001 and 22 vs. 35 %; p = 0.001, respectively). Intra-operative SFR was significantly higher for XenX group (100 vs. 85.4 %; p = 0.0001), but not at 4-week follow-up, after ancillary procedures were needed in 17.1 % of the control group. Surgeons' evaluations for XenX were suboptimal for "Ease of Basketing" (2/5) and "Advancement of double J stent" (3/5). The use of XenX increased costs of procedures, but spared the costs associated to ancillary procedures and stent removals. CONCLUSIONS: XenX confirmed to be a safe and effective device especially for the treatment of upper ureteric tract stones; moreover, XenX may reduce the risk for the need of auxiliary procedures and for the insertion of a JJ stent.

Impact of using thiocolchicoside during endoscopic ureteral calculi removal: A preliminary study.

OBJECTIVE: To evaluate the effects of thiocolchicoside during endoscopic treatment of ureteral calculus. MATERIAL AND METHODS: Between May 2014 and December 2014, 498 consecutive patients were enrolled. Exclusion criteria were operations under general anaesthesia, chancing laser lithotripter settings, and urinary tract infection. All patients were divided into three groups: Group 1 consisted of patients who were not administered thiocolchicoside, group 2 consisted of patients who were administered 5 mg thiocolchicoside, and group 3 consisted of patients who were administered 10 mg thiocolchicoside. Demographic, perioperative, and postoperative data were recorded. Complications were noted according to Clavien-Dindo classifications. A p value of p ≤ 0.05 was considered statistically significant. RESULTS: A total of 427 patients (319 male and 108 female) with full data were investigated. Mean age was 43.3 ± 13.3 years. There were 157 patients in group 1, 141 patients in group 2, and 129 patients in group 3. Stone migration and operation time were significantly lower in groups 2 and 3 than in group 1 (respectively; p < 0.001, p = 0.03). However, usage of jj stents was significantly lower in group 3 than in the other groups (p < 0.001). CONCLUSION: Stone migration can be decreased by using locally administered thiocolchicoside in irrigation solution during endoscopic treatment of ureteral calculus. Additional doses may decrease usage of jj stents and operation time.

Retrograde endoscopic lithotripsy using the innovative nanosecond electropulse method.

PURPOSE: The purpose of this clinical study is to assess the safety and efficiency of a novel lithotripsy method for endoscopic treatment of urinary stones throughout the urinary tract via semi-rigid and flexible endoscopes. This new method is based on the transfer of nanosecond high voltage electric pulses to the stones through flexible probes of various sizes. METHODS: The study involved 879 patients aged 19-88 with renal, ureter and bladder calculi. Gender distribution: 46.3% female and 53.7% male. The prospective single-arm study took place at three centers. The goal of the clinical study was to evaluate the safety and efficacy of a novel lithotripsy method. All treatments were performed retrograde transurethrally. A variety of probes were used for stone fragmentation at different locations. Auxiliary treatments and adverse events were recorded as per protocol. Statistical analysis was conducted using SPSS software. RESULTS: Nanosecond electropulse lithotripsy (NEPL) was found to be technically feasible for all patients with stones located in the kidney, UPJ, ureter and bladder. It requires only a few dozen pulses to disintegrate stones while causing only minor stone migration. The overall stone-free rate in the study was 96%. The average time required for executing the entire procedure was 45±28 min. The overwhelming majority of intraoperative complications occurred due to endoscopic manipulation when using a rigid ureterorenoscope and not due to lithotripsy impact. CONCLUSIONS: NEPL is a new, efficient and safe method for urinary stone disintegration that can be used throughout the urinary tract using rigid and flexible endoscopes. Intraoperative complications of the NEPL procedure do not exceed the percentage of adverse effects observed in other lithotripsy methods. The main advantages of relatively low-cost NEPL are fast stone fragmentation requiring only a few dozen pulses to disintegrate stones, tissue safety and availability of highly flexible probes for treating stones in the lower pole through a flexible ureterorenoscope.

Recent advances in endoscopic management of difficult bile duct stones.

Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

Endoscopic Removal of Difficult Bile Duct Stones Combined with Extracorporeal Shock Wave Lithotripsy / 대한소화기내시경학회지

BACKGROUND AND AIMS: Nowadays, common bile duct stones are predominantly extracted endoscopically, after endoscopic papillotomy. Nearly 90% of stones can be removed with a Dormia basket or mechanical lithotripter. In the remaining patients several nonoperative procedures serve as alternatives to surgery. Once extracorporeal lithotripsy had been successfully used for gallbladder stones, this technique was extended to bile duct stones. An experience of endoscopic removal of difficult bile duct stones combined with extracorporeal shock wave lithotripsy (ESWL) is reported. METHODS: 82 patients were selected for this treatment because conventional stone extraction had failed. The Biolithos Mark III was used for extracorporeal spark-gap lithotripsy and the shock wave number was 2,000 waves (average) at one session. The stones were detected through a fluoroscopy with dye injection through an endoscopic naso-biliary drainage tube. After the fragmentation of bile duct stones, endoscopic removal of stones was performed for the facilitation of the complete removal of the stones, and to decrease the discomfort of the patients for the duration of their stay. RESULTS: Visualization of the stones using a fluoroscopy with dye injection was possible in all patients. On average, these patients had 3.1 (1-7) sessions of treatment with ESWL. Fragmentation was achieved in 74 (90.2%) patients and complete stone removal occurred in 71 (86.5%) patients. Complete stone clearance was achieved without further intervention in 8 (11.3%) patients, and in 63 (88.7%) patients after endoscopic extraction of the fragments. Thirty-seven (58.7%) patients underwent one endoscopic intervention to extract the remaining fragments. In 54 (81.8%) patients, a balloon catheter or Dormia basket was sufficient to extract the remaining fragments and an additional mechanical lithotripsy was necessary to break down larger fragments in 12 (18.2%) patients. There were no serious adverse effects from ESWL. CONCLUSIONS: Endoscopic removal combined with ESWL is also a useful method for the treatment of difficult bile duct stones to facilitate the complete removal of the stones and to decrease the discomfort of the patients, as well as the duration of their hospitalization.