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©The Author(s) 2026. Published by Baishideng Publishing Group Inc. All rights reserved.
Advances in biliary stone management: Latest-generation extracorporeal shock wave lithotripsy vs laser lithotripsy for difficult bile duct stones
Neeraj Singla, Katrevula Anudeep Venkata, Pradev Inavolu, Sana Fathima Memon, Krithi Krishna Koduri, Aniruddha Pratap Singh, Thejesh Katamareddy, Santosh Darisetty, Vinod Koppoju, Nitin Jagtap, Rakesh Kalpala, Sundeep Lakhtakia, Mohan Ramchandani, Manu Tandan, Duvvur Nageshwar Reddy
Neeraj Singla, Katrevula Anudeep Venkata, Pradev Inavolu, Krithi Krishna Koduri, Aniruddha Pratap Singh, Nitin Jagtap, Rakesh Kalpala, Sundeep Lakhtakia, Mohan Ramchandani, Manu Tandan, Duvvur Nageshwar Reddy, Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangāna, India
Sana Fathima Memon, Vinod Koppoju, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangāna, India
Thejesh Katamareddy, Santosh Darisetty, Department of Anesthesia, Asian Institute of Gastroenterology, Hyderabad 500032, Telangāna, India
Co-first authors: Neeraj Singla and Katrevula Anudeep Venkata.
Author contributions: Singla N, Venkata KA, and Inavolu P contributed to conceptualization, writing the original draft, and revision; Memon SF and Kodure KK contributed to methodology, to the images, and to the references; Singh AP, Katamareddy T, Darisetty S, Koppoju V, Jagtap N, Kalapala R, Lakhtakia S, Ramchandani M, Tandan M, and Reddy DN assisted in the conceptualization; Singla N and Venkata KA contributed equally to this manuscript and are co-first authors; All authors read and approved the final manuscript.
Institutional review board statement: This study was conducted in accordance with ethical principles that have their origin in the provisions of the Declaration of Helsinki. This study was approved by the Ethics Committee of Asian Institute of Gastroenterology (Approval No. AIG/IEC-Post BH&R 46/05.2023-01).
Informed consent statement: The requirement for participants to consent to participate was waived by the Institutional Ethics Committee, as the study was retrospective.
Conflict-of-interest statement: All authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The dataset supporting the conclusions of this article is available from the corresponding author upon reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Pradev Inavolu, DM, MD, MRCP, Senior Researcher, Medical Gas
troenterology, Asian Institute of Gastroenterology, 1-66/AIG/2 to 5, Mindspace Road, Gachibowli, Hyderabad 500032, Telangāna, India.
dr.inavolup@aighospitals.com
Received: September 3, 2025
Revised: October 13, 2025
Accepted: December 9, 2025
Published online: February 27, 2026
Processing time: 166 Days and 6.4 Hours
BACKGROUND
Extracorporeal shock wave lithotripsy (ESWL) and laser lithotripsy (LL) are established alternatives for the management of difficult common bile duct (CBD) stones. However, there is limited evidence regarding the efficacy and safety of the latest-generation Dornier Delta III lithotripter. In particular, evidence on the clinical performance of the Dornier Delta III lithotripter is scarce.
AIM
To evaluate and compare the efficacy and safety of ESWL performed with the Dornier Delta III and of LL using a single-operator cholangioscope with specific focus on stone clearance rates, number of treatment sessions, and procedure-related adverse events in a large patient cohort.
METHODS
We conducted a retrospective analysis of a prospectively maintained database at AIG Hospitals, Hyderabad, covering the period from January 2019 to December 2022. A total of 458 patients with difficult bile duct stones underwent either ESWL or LL based on clinical discretion. ESWL was performed using the Dornier Delta III lithotripter, whereas LL was carried out with a single-operator cholangioscope in combination with an yttrium-aluminum-garnet laser.
RESULTS
The 387 patients with difficult bile duct stones (mean age 53.8 ± 15.7 years, 58.7% male) underwent ESWL. A single CBD stone was noted in 46.8% of patients while 53.2% patients had multiple stones. Complete duct clearance was achieved in 95.1% of patients, with 68.7% requiring two or more ESWL sessions. Adverse events included cholangitis in 3 patients and post-sphincterotomy bleeding in 4 patients; All were managed conservatively. Seventy-one patients (mean age 55 ± 15.4 years, 64.8% male) underwent LL. Complete duct clearance was achieved in 97.2% of patients with single-session clearance in 58 (81.7%) patients. The remaining 18.3% of patients required two or three sessions for fragmented stone removal. Adverse events included cholangitis in 2 patients and mild pancreatitis in 1 patient; all were managed conservatively. Patients with incomplete clearance were referred for surgery. There was no significant difference in efficacy between ESWL and LL (95.1% vs 97.2%, P = 0.4).
CONCLUSION
ESWL using the latest generation lithotripter and LL provide equally effective and safe alternatives for managing difficult CBD stones, minimizing the need for surgery.
Core Tip: Difficult common bile duct stones pose a significant clinical challenge when standard endoscopic techniques fail. Previous studies have shown significantly better efficacy of laser lithotripsy in managing difficult common bile duct stones as they were compared with the previous generation Dornier delta II system. This study highlighted the role of the latest Dornier Delta III extracorporeal shock wave lithotripsy system in improving treatment outcomes, establishing it as a viable, noninvasive alternative to laser lithotripsy.
