Eastern Chiba Medical Center, Okayamadai, Togane, Japan; Chiba University, Inohana, Chiba, Japan
aDepartment of Gastroenterology, Eastern Chiba Medical Center, Okayamadai, Togane, Japan (Koji Takahashi); bDepartment of General Medical Science, Graduate School of Medicine, Chiba University, Inohana, Chiba, Japan (Koji Takahashi)
Ann Gastroenterol 2026; 39 (2): 277
I read with interest Kogias et al’s article regarding predictors for cholangioscopy-guided electrohydraulic lithotripsy (EHL) in managing difficult common bile duct stones (DBS) [1]. The authors are to be commended for developing a pragmatic classification tree that prioritizes EHL based on specific anatomical markers—namely, the presence of DBS, small papillae, and the absence of wedged stones. Given the expanding role of single-operator cholangioscopy (SOC), such structured approaches are invaluable for reducing futile attempts with conventional techniques.
However, I offer a complementary perspective regarding the preprocedural assessment. While the authors’ model focuses on papillary anatomy and stone impaction, other stone characteristics remain critical variables. Garg et al showed that large stone diameter and impaction degree are well-established predictors of mechanical lithotripsy failure [2]. In cases where stones occupy the majority of the ductal lumen, or exhibit significant surface irregularities, conventional mechanical crushing often fails, potentially leading to ductal injury or “basket impaction.” Integrating these morphological stone properties into the algorithm could further enhance its sensitivity, identifying patients who require first-line EHL to ensure definitive clearance in a single session.
Furthermore, economic implications warrant consideration. High-quality evidence, including systematic reviews and randomized trials, supports early-line EHL’s superior stone clearance rates compared to conventional methods [3,4]. Although the single-use cholangioscope system involves significant upfront instrument costs, cost-utility analyses by Deprez et al suggest that early SOC can be cost-effective by reducing the number of repeat endoscopic retrograde cholangiopancreatography procedures [5]. It would be illuminating to know whether the authors observed reductions in total adverse events or length of hospital stay that specifically offset the higher costs of the EHL equipment in their cohort.
Validating this algorithm in a multicenter setting, incorporating broader stone characteristics and detailed cost-benefit analysis, would further solidify EHL’s position in the therapeutic strategy for difficult biliary stones.
1. Kogias D, Kafalis N, Karapepera V, Papadopoulos V, Kouklakis G. Predictors of a need for cholangioscopy-guided electrohydraulic lithotripsy in the management of difficult common bile duct stones. Ann Gastroenterol 2026;39:32-39.
2. Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc 2004;59:601-605.
3. Galetti F, Moura DTH, Ribeiro IB, et al. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones:a systematic review and meta-analysis. Arq Bras Cir Dig 2020;33:e1491.
4. Bang JY, Sutton B, Navaneethan U, Hawes R, Varadarajulu S. Efficacy of single-operator cholangioscopy-guided lithotripsy compared with large balloon sphincteroplasty in management of difficult bile duct stones in a randomized trial. Clin Gastroenterol Hepatol 2020;18:2349-2356.
5. Deprez PH, Garces Duran R, Moreels T, et al. The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures. Endoscopy 2018;50:109-118.