M-type dual-channel endoscopy with zebra guidewire lithotripsy for phytobezoars

Abstract

BACKGROUND

Phytobezoars are gastric concretions formed by plant fibers that can cause various gastrointestinal symptoms. Currently, endoscopic mechanical lithotripsy is the primary treatment modality for these masses. However, conventional methods often face challenges, such as low procedural efficiency, incomplete stone clearance, and a relatively high risk of complications when addressing large or hard bezoars. As an emerging technique, M-type dual-channel endoscopy combined with zebra guidewire lithotripsy (M-DCE-ZGL) may theoretically enhance lithotripsy efficacy through dual-channel cooperative manipulation and improved grasping and cutting capability. However, the exact clinical value of this technique compared with that of traditional methods awaits empirical evaluation based on cohort studies.

AIM

To evaluate the stone clearance efficiency and clinical safety of M-DCE-ZGL for treating phytobezoars through a retrospective cohort comparison, thereby providing evidence for optimizing treatment strategies.

METHODS

This retrospective study included 110 patients who underwent gastroscopy between October 2021 and October 2024. Participants were divided into a conventional endoscopy group (polypectomy snare or retrieval basket lithotripsy, n = 67) and a combined endoscopy group (M-DCE-ZGL, n = 43). The indicators assessed included operative duration; time to clinical remission; length of hospital stay; postoperative Visual Analog Scale (VAS) scores at 3 hours, 6 hours, 24 hours, and 72 hours; treatment effectiveness rate at three months; residual stones identified via follow-up endoscopy within two weeks; and complications (gastric perforation, bleeding, mucosal injury, and small bowel obstruction) over three months.

RESULTS

Of the 110 patients (67 conventional and 43 combined), those in the combined group demonstrated significantly shorter lithotripsy durations (45.61 ± 5.94 minutes vs 75.57 ± 6.66 minutes, P < 0.001), fewer lithotripsy sessions (1.22 ± 0.43 vs 1.60 ± 0.87, P = 0.003), and reduced hospital stays (5.89 ± 1.61 days vs 7.14 ± 3.47 days, P = 0.012) than those in the conventional group. The combined group had significantly lower postoperative VAS scores at all time points (all P < 0.05) than the conventional group. The combined group also showed a higher overall efficacy rate (100% vs 80.60%, P = 0.002); lower stone residual rate (4.65% vs 25.37%, P = 0.005); and fewer overall complications (4.65% vs 28.36%, P = 0.002), particularly mucosal injury (4.65% vs 17.91%, P = 0.042), than the conventional group.

CONCLUSION

Compared with conventional endoscopic lithotripsy methods, M-DCE-ZGL is more efficient and safer for treating phytobezoars.

Key Words: Phytobezoars; M-type dual-channel endoscopy; Lithotripsy; Efficacy; Safety; Zebra guidewire

Core Tip: This retrospective study compared M-type dual-channel endoscopy combined with zebra guidewire lithotripsy vs conventional endoscopic methods for phytobezoar treatment. The combined technique significantly reduced procedure time (45.6 minutes vs 75.6 minutes) and hospital stay (5.9 days vs 7.1 days), achieved a 100% complete clearance rate, and lowered the overall complication rate to 4.65%. It demonstrates superior efficiency and safety, offering an optimized approach for endoscopic management of gastric phytobezoars.

INTRODUCTION

Phytobezoars are solid masses formed in the stomach from undigested plant material. They are common in patients with a history of gastrointestinal surgery or those who consume large amounts of persimmons. The East China region, where this study was conducted, has dietary habits that include persimmon and hawthorn consumption, contributing to a high incidence of phytobezoars[1]. As a regional diagnostic and referral center for digestive diseases, our hospital’s gastroenterology department manages a considerable volume of referred phytobezoar cases, enabling the accumulation of a sufficient clinical sample within a limited period. These masses can cause major health issues, including gastric outlet obstruction and mucosal injury. Traditional treatments often involve endoscopic removal but can be time consuming and may not always achieve complete stone clearance[2-4]. Effective treatment is essential to prevent complications and improve patient outcomes.

Patients with phytobezoars typically present with gastrointestinal symptoms, including abdominal pain, bloating, nausea, and vomiting; severe cases may lead to weight loss and malnutrition[5,6]. Over time, endoscopic methods have evolved to address these challenges. Nevertheless, conventional endoscopic approaches frequently require multiple sessions and prolonged hospitalization. Moreover, fragmenting large or hard stones can be technically difficult, often resulting in incomplete clearance and residual fragments[7,8]. This situation underscores the need for additional efficient and effective treatment options. Advances in endoscopic technology now aim to improve stone fragmentation and reduce procedure time, with the potential to translate into improved clinical outcomes.

M-type dual-channel endoscopy represents a notable technological advancement. Its dual working channels allow simultaneous instrument use, supporting cooperative manipulation and countertraction during procedures. This design simplifies workflow, reduces intraoperative instrument exchanges[9,10], and improves maneuverability and torque when handling large or hard stones[11]. By enabling the concurrent use of lithotripsy tools and guidewires, the system streamlines the procedure and enhances efficiency[12-14].

The zebra guidewire, designed specifically for such interventions, provides improved guidance and stability. In contrast to smooth guidewires, it has a textured surface that increases friction and grip, allowing the secure snaring or segmentation of bezoars and reducing slippage risk[11]. Recent clinical experience suggests that this mechanical stability supports controlled, layered fragmentation, which may help minimize mucosal injury[15]. Together, these features contribute to fast and complete stone clearance[16].

Phytobezoars impose a considerable burden on healthcare systems because of prolonged hospital stays and the need for repeated interventions. Efficient treatments that shorten hospitalization and reduce follow-up needs can alleviate this burden. Increased stone clearance rates and decreased complication rates not only improve patient outcomes but also reduce costs. Shortened recovery times further enhance patients’ quality of life[17-19]. Advances in endoscopic techniques thus hold promise not only for individual patient care but also for broad improvements in healthcare delivery.

Theoretically, combining M-type dual-channel endoscopy with the zebra guidewire merges the advantages of coordinated instrument manipulation with enhanced precision and grip. This synergy may improve lithotripsy efficiency and safety, shorten procedure time, and ultimately lead to improved patient outcomes. The further exploration of this integrated approach could markedly advance the management of gastric phytobezoars.

MATERIALS AND METHODS

Case selection

This retrospective study included 110 patients who underwent gastroscopy in the Gastroenterology Department of Zhejiang Provincial People’s Hospital between October 2021 and October 2024. Demographic information was collected through the case system. Given that this retrospective study used deidentified patient data, it posed no potential harm to the patients. Therefore, informed consent was waived. This waiver and the study were approved by our hospital’s ethics review committee, in compliance with relevant regulatory and ethical standards.

Inclusion and exclusion criteria

Inclusion criteria: (1) Patients presenting with nonspecific symptoms, such as upper abdominal pain, nausea/vomiting, upper gastrointestinal bleeding, or gastric discomfort[20]. Upon gastroscopic examination, patients were found to have solid masses of varying sizes in the stomach cavity. These masses appeared grayish-white or yellowish-brown. The surfaces of these masses were often fibrous or resembled remnants of fruits. These masses were confirmed to be plant fiber tissue through biopsy or retrieval, meeting the diagnostic criteria for phytobezoars[21]; (2) Patients aged 18 years or older who were diagnosed with phytobezoars at Zhejiang Provincial People’s Hospital and underwent endoscopic mechanical lithotripsy were included in this study; and (3) Patients who underwent any of the following purely mechanical endoscopic lithotripsy methods were included in this study: Transparent cap combined with zebra guidewire lithotripsy, polypectomy snare lithotripsy, or retrieval basket lithotripsy. All patients’ treatment choices complied with established treatment standards.

Exclusion criteria: (1) Patients with gastric tumors and those in poor general health (such as severe anemia, coagulation disorders, severe infections, severe cardiopulmonary dysfunction, and inability to tolerate general anesthesia); (2) Patients who could not tolerate gastroscopy; (3) Patients with a history of consuming sodium bicarbonate or carbonated beverages prior to stone removal; and (4) Patients who underwent stone fragmentation using two or more combined methods.

Grouping standards and treatment methods

Patients in the combined endoscopy group underwent M-type dual-channel endoscopy combined with zebra guidewire lithotripsy (M-DCE-ZGL), with the specific procedure detailed in the subsection “Transparent Cap Combined with Zebra Guidewire Lithotripsy”. Patients in the conventional endoscopy group subsequently received the outlined traditional lithotripsy methods. Patients who underwent polypectomy snare or retrieval net lithotripsy were defined as the conventional endoscopy group (n = 67), whereas those who underwent M-DCE-ZGL were defined as the combined endoscopy group (n = 43).

Treatment methods: Patients underwent routine preoperative examinations. After local anesthesia with lidocaine gel in the pharynx or intravenous anesthesia with propofol, a gastroscope was inserted into the patient’s stomach. The stomach fluid was aspirated, and an appropriate amount of air was insufflated. By adjusting the bending angle of the endoscope, rotating the scope body, and changing the patient’s position, the gastric stone was positioned optimally within the field of view.

Transparent cap combined with zebra guidewire lithotripsy: The procedure steps are as follows: A long conical transparent cap was attached to the tip of the therapeutic gastroscope. The folded zebra guidewire was inserted through the first biopsy channel of the endoscope, guiding it to the tip of the gastroscope and then into the stomach cavity via the transparent cap. The size and position of the guidewire loop at the front end was adjusted in accordance with the gastric phytobezoar by extending or retracting the guidewire. The guidewire was secured around the widest part of the phytobezoar. The length of the guidewire ends was adjusted to pull the phytobezoar toward the transparent cap. The phytobezoar was mechanically cut by simultaneously retracting both ends of the guidewire, breaking it into two pieces. The above steps were repeated until the maximum diameter of the phytobezoar fragments was approximately 1-2 cm (Figure 1). For fragments generated after cutting, those with a diameter greater than 1 cm were grasped by using a retrieval basket or foreign body forceps inserted through the other working channel and removed by withdrawing them together with the endoscope out of the oral cavity. For fine fragments smaller than 1 cm in diameter, patients were instructed to take a sodium bicarbonate solution orally postoperatively, supplemented with appropriate positional changes, to promote the natural passage of the fragments through the intestinal tract.

Figure 1 Operational procedure of transparent cap combined with zebra guidewire lithotripsy.

Traditional lithotripsy methods: (1) Polypectomy snare lithotripsy: A gastroscope was used to examine the stomach and duodenum thoroughly, exposing the gastric phytobezoar. Before lithotripsy, forceps inserted through the biopsy channel was used to touch and press the phytobezoar to assess its consistency. For medium- or soft-consistency phytobezoars, a polypectomy snare was used to capture the middle portion of the phytobezoar and tighten it. The process to cut the phytobezoar into fragments smaller than 2 cm in diameter was repeated. For hard phytobezoars that cannot be directly cut by the snare, alligator forceps were used to remove the hard parts first, then the snare was employed for soft sections; and (2) Retrieval basket lithotripsy: A gastroscope was used to examine the stomach and duodenum thoroughly, exposing the gastric phytobezoar. After the shape and relationship of the phytobezoar with surrounding tissues were carefully observed, the retrieval basket above the phytobezoar was opened. The wires of the retrieval basket over the phytobezoar were passed and slowly tightened to secure one end of the phytobezoar. They were slowly withdrawn while keeping the long axis of the phytobezoar parallel to the esophagus. During stone retrieval, the retrieval basket must securely hold the phytobezoar close to the front end of the endoscope near the lens, minimizing any gaps to prevent slippage. All patients were administered oral 5% sodium bicarbonate solution postoperatively to prevent the coalescence of small stones (< 0.5 cm) into large masses. Patients were hospitalized for observation and received proton pump inhibitor therapy for gastric protection.

Observation indicators and assessment tools: The patients’ preoperative symptoms, surgery duration, time to clinical remission, hospital stay length, postoperative Visual Analog Scale (VAS) scores, treatment effectiveness rate, follow-up endoscopic examination for residual stones within two weeks, and follow-up for complications (gastric perforation, bleeding, mucosal injury, and small bowel obstruction) over three months were observed and compared. (1) VAS scores: VAS scores were assessed at 3 hours, 6 hours, 24 hours, and 72 hours postoperatively. Scores ranged from 0 to 10, where 0 indicates no pain and 10 indicates unbearable severe pain[22]; (2) Treatment effectiveness rate: Three months postoperatively, effectiveness indicators were established to evaluate the success of the treatment. Complete recovery was defined as no clinical symptoms, disappearance of gastric stones on follow-up gastroscopy, and well-healed ulcers. Effective outcomes included mild clinical symptoms with some residual stone fragments and adequate ulcer healing. Ineffective outcomes indicated persistent significant symptoms, aggregated gastric stones, and poor ulcer healing. The total effectiveness rate was calculated as (number of complete recoveries + number of effective cases)/total number of cases × 100%[23]; and (3) Postoperative complications: Unexpected events occurring after surgery that required additional treatment within three months were collected in this study. They included gastric perforation, bleeding, mucosal injury, and small bowel obstruction[24].

Statistical analysis

Statistical analysis was performed by using SPSS version 29.0 (SPSS Inc., Chicago, IL, United States). Categorical variables were displayed in the format [n (%)]. The χ² test was applied when the sample size was at least 40 and the expected frequency (T) was 5 or greater, with the test statistic represented as χ². When the sample size was at least 40 but T was between 1 and less than 5, a corrected χ² test was used. For small sample sizes (less than 40) or when T was less than 1, Fisher’s exact test was utilized for statistical evaluation. In this study, all patients strictly adhered to the assigned treatment protocols, and no crossover intervention occurred between the two groups. The normality of continuous variables was assessed by using the Shapiro-Wilk test. Continuous variables that conformed to a normal distribution are expressed as mean ± SD and were compared between groups by using the t-test. Variables that did not conform to a normal distribution were expressed as median (interquartile range) and compared between groups by using the Mann-Whitney U test. A P value below 0.05 was deemed statistically significant.

RESULTS

Baseline demographic and clinical characteristics

The baseline demographic and clinical characteristics of the patients are summarized in Table 1. No statistically significant differences were found between the conventional and combined endoscopy groups regarding age, gender distribution, body mass index, social history (alcohol consumption and smoking), comorbidities (including hypertension, diabetes, chronic heart disease, hyperlipidemia, and peptic ulcer), or history of gastrointestinal surgery (all P > 0.05), indicating that the two groups were well matched at baseline (Table 1).

Table 1 Baseline demographic characteristics, n (%)/mean ± SD.

Parameters	Conventional endoscopy group (n = 67)	Combined endoscopy group (n = 43)	t/χ2	P value
Age (years)	48.64 ± 14.21	52.41 ± 13.23	1.395	0.166
Gender			2.037	0.154
Male	36 (53.73)	29 (67.44)
Female	31 (46.27)	14 (32.56)
BMI (kg/m2)	25.33 ± 3.90	25.65 ± 4.25	0.403	0.687
Social history
Alcohol	29 (43.28)	18 (41.86)	0.022	0.883
Smoking	19 (28.36)	12 (27.91)	0.003	0.959
Comorbidities
Hypertension	45 (67.16)	29 (67.44)	0.001	0.976
Diabetes	41 (61.19)	26 (60.47)	0.006	0.939
Chronic heart disease	23 (34.33)	15 (34.88)	0.004	0.952
Hyperlipidemia	36 (53.73)	23 (53.49)	0.001	0.980
Peptic ulcer	27 (40.30)	17 (39.53)	0.006	0.936
Gastrointestinal surgery history
Stomach
Bilroth 2 gastrectomy	9 (13.43)	6 (13.95)	0.006	0.938
Subtotal gastrectomy	4 (5.97)	3 (6.98)	0.000	1.000
Esophagus (Nissen fundoplication)	2 (2.99)	1 (2.33)	0.000	1.000

BMI: Body mass index.

Preoperative clinical and endoscopic characteristics of patients

Preoperative clinical and endoscopic characteristics related to the gastric bezoars are detailed in Table 2. The size, number (single or multiple), and color of stones; distribution of causes (primarily persimmon); and season of onset showed no significant differences between the two groups (all P > 0.05) (Table 2). Furthermore, preoperative clinical manifestations and symptoms, such as abdominal pain, bloating, nausea, vomiting, acid reflux, heartburn, and black stools, were comparable between the groups, without significant disparities observed (all P > 0.05) (Figure 2). Endoscopic findings before surgery, including basal gastric mucosa condition; ulcer characteristics (distribution and sites); and other findings, like erosion, esophagitis, obstruction, and Helicobacter pylori positivity, also demonstrated no significant differences between the groups (all P > 0.05) (Table 3).

Figure 2 Preoperative clinical manifestations and symptoms.

Table 2 Clinical characteristics of gastric bezoars, n (%)/mean ± SD.

Parameters	Conventional endoscopy group (n = 67)	Combined endoscopy group (n = 43)	t/χ2	P value
Stone characteristics
Stone size (cm)	5.63 ± 1.64	5.93 ± 1.74	0.930	0.354
Number of stones			0.002	0.961
Single	59 (88.06)	38 (88.37)
Multiple	8 (11.94)	5 (11.63)
Stone color			0.055	0.973
Blackish-green	28 (41.79)	17 (39.53)
Variegated	18 (26.87)	12 (27.91)
Golden yellow	21 (31.34)	14 (32.56)
Distribution of causes			0.055	0.997
Persimmon	57 (85.07)	37 (86.05)
Hawthorn	5 (7.46)	3 (6.98)
Black Jujube	3 (4.48)	2 (4.65)
Other	2 (2.99)	1 (2.33)
Season of onset			0.102	0.992
Spring	17 (25.37)	11 (25.58)
Summer	7 (10.45)	5 (11.63)
Autumn	9 (13.43)	5 (11.63)
Winter	34 (50.75)	22 (51.16)

Table 3 Endoscopic findings before surgery, n (%).

Parameters	Conventional endoscopy group (n = 67)	Combined endoscopy group (n = 43)	t/χ2	P value
Basal gastric mucosa
Atrophic gastric mucosa	51 (76.12)	33 (76.74)	0.006	0.940
Remnant stomach	7 (10.45)	4 (9.30)	0.000	1.000
Deformation of the pyloric canal or antral chamber	2 (2.99)	1 (2.33)	0.000	1.000
Ulcer condition
Specific distribution of ulcers			0.239	0.887
Single ulcer	45 (67.16)	30 (69.77)
Multiple ulcer	15 (22.39)	8 (18.60)
None	7 (10.45)	5 (11.63)
Distribution of ulcer sites
Gastric angle	44 (65.67)	28 (65.12)	0.004	0.952
Pyloric antrum	13 (19.40)	8 (18.60)	0.011	0.917
Body of stomach	10 (14.93)	6 (13.95)	0.020	0.888
Fundus and cardia of stomach	2 (2.99)	1 (2.33)	0.000	1.000
Anastomotic site	1 (1.49)	1 (2.33)	0.000	1.000
Endoscopic findings
Erosion	61 (91.04)	39 (90.70)	0.000	1.000
Esophagitis	18 (26.87)	11 (25.58)	0.022	0.881
Obstruction	7 (10.45)	5 (11.63)	0.000	1.000
H. pylori positive	38 (56.72)	24 (55.81)	0.009	0.926

H. pylori: Helicobacter pylori.

Perioperative surgical-related indicators of patients

Perioperative surgical-related indicators are shown in Table 4. The combined endoscopy group had a significantly shorter duration of lithotripsy (45.61 ± 5.94 minutes vs 75.57 ± 6.66 minutes, P < 0.001), fewer lithotripsy sessions (1.22 ± 0.43 vs 1.60 ± 0.87, P = 0.003), and a shorter hospital stay (5.89 ± 1.61 days vs 7.14 ± 3.47 days, P = 0.012) than the conventional endoscopy group. The distribution of lithotripsy sessions also differed significantly between the groups (P = 0.001).

Table 4 Perioperative surgical-related indicators, n (%)/mean ± SD.

Parameters	Conventional endoscopy group (n = 67)	Combined endoscopy group (n = 43)	t/χ2	P value
Duration of lithotripsy (minute)	75.57 ± 6.66	45.61 ± 5.94	23.995	< 0.001
Number of lithotripsy sessions	1.60 ± 0.87	1.22 ± 0.43	3.050	0.003
Distribution of lithotripsy sessions			13.056	0.001
1	40 (59.70)	33 (76.74)
2	10 (14.93)	10 (23.26)
3	17 (25.37)	0 (0.00)
Length of hospital stay (day)	7.14 ± 3.47	5.89 ± 1.61	2.556	0.012

Postoperative indicators of patients

Postoperative VAS scores were significantly lower in the combined endoscopy group at all time points: 3 (4.30 ± 0.67 vs 4.82 ± 0.72, P < 0.001), 6 (3.01 ± 0.57 vs 3.35 ± 0.61, P = 0.004), 24 hours (2.35 ± 0.59 vs 2.62 ± 0.58, P = 0.018), and 72 hours (1.02 ± 0.39 vs 1.23 ± 0.45, P = 0.014) (Figure 3). Postoperative efficacy outcomes are summarized in Table 5. Compared with the conventional group, the combined group demonstrated a significantly higher complete recovery rate (79.07% vs 55.22%), leading to a higher overall efficacy rate (100.00% vs 80.60%, P = 0.002) and a lower rate of postoperative residual stones (4.65% vs 25.37%, P = 0.005). However, the time to symptom relief was not significantly different between the groups (60.25 ± 11.32 hours vs 63.21 ± 12.33 hours, P = 0.207). Indicators related to postoperative complications are presented in Figure 4. The combined group had a significantly lower overall rate of postoperative complications (4.65% vs 28.36%, P = 0.002) and a lower rate of mucosal injury (4.65% vs 17.91%, P = 0.042) than the conventional group. No significant differences were observed in bleeding (4.65% vs 10.45%, P = 0.468), gastric perforation (0.00% vs 1.49%, P = 1.000), or small bowel obstruction (0.00% vs 2.99%, P = 0.680).

Figure 3 Comparison of postoperative Visual Analog Scale scores between two groups of patients. A: 3 hours postoperatively; B: 6 hours postoperatively; C: 24 hours postoperatively; D: 72 hours postoperatively. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001.

Figure 4 Indicators related to postoperative complications. ^aP < 0.05, ^bP < 0.01.

Table 5 Postoperative efficacy outcomes, n (%)/mean ± SD.

Parameters	Conventional endoscopy group (n = 67)	Combined endoscopy group (n = 43)	t/χ2	P value
Efficacy rate			10.869	0.004
Complete recovery	37 (55.22)	34 (79.07)
Effective	17 (25.37)	9 (20.93)
Ineffective	13 (19.40)	0 (0.00)
Overall efficacy rate	54 (80.60)	43 (100.00)	9.461	0.002
Postoperative stone residuals	17 (25.37)	2 (4.65)	7.871	0.005
Time to symptom relief (hour)	63.21 ± 12.33	60.25 ± 11.32	1.270	0.207

DISCUSSION

Phytobezoars are solid masses formed in the stomach from indigestible plant material. They are commonly seen in patients with a history of gastrointestinal surgery or those who consume large amounts of persimmons. Effective treatment is crucial to prevent complications, such as gastric outlet obstruction and mucosal injury. In this study, we compared the clinical value of M-DCE-ZGL with that of conventional endoscopic methods in treating phytobezoars. Our findings suggest several advantages associated with the novel approach.

Various lithotripsy techniques, each with distinct success rates and characteristics, are available for treating phytobezoars. Energy-based platforms, such as electrohydraulic lithotripsy and laser lithotripsy (e.g., holmium laser) offer advantages for hard gastric stones, with single-session complete stone clearance rates reported to exceed 90%. However, they are associated with high equipment costs, technical demands, and potential perforation risks[25,26]. Enzymatic dissolution (e.g., using cellulase or papain), as a noninvasive method, shows widely varying reported efficacy rates (50%-90%). Its effectiveness highly depends on the composition and consistency of bezoars and is characterized by a slow onset and prolonged treatment course[27]. Traditional mechanical lithotripsy techniques (e.g., snare and basket) serve as the cornerstone of widespread application, with literature-reported success rates mostly ranging between 80% and 95%. However, their efficiency is often limited by the size and hardness of bezoars, as well as operator experience[28].

In this study, M-DCE-ZGL, an optimized form of mechanical lithotripsy, achieved a 100% total effectiveness rate (43/43). This rate was significantly higher than the 80.60% rate (54/67) observed in the conventional group and ranks at the upper end of the rates reported for other mechanical techniques. The advantages of M-DCE-ZGL likely derive from its dual-channel design, which enables instrument coordination and stable traction, combined with the enhanced grasping and cutting efficiency of the textured zebra guidewire. This approach improves initial treatment success and reduces the number of sessions while maintaining the safety profile of mechanical lithotripsy.

Patients in the combined group experienced shorter lithotripsy durations and required fewer sessions than those in the conventional group. The dual-channel design allows the simultaneous insertion of instruments and guidewires, facilitating precise manipulation and fast fragmentation[29,30]. This situation reduces the need for instrument repositioning and multiple adjustments common in conventional methods. Moreover, the zebra guidewire provides improved stability and control, enabling efficient fragmentation and minimizing the risk of incomplete clearance, which often necessitates repeat procedures. The simplified workflow may also reduce operator fatigue, potentially improving performance in sequential cases[2,3,31].

Shortened hospital stays in the combined group can be attributed to reduced procedure time and required sessions. This reduction not only lowers healthcare costs but also decreases patient discomfort and nosocomial infection risk. Efficient procedures that accelerate recovery contribute to improved patient outcomes and satisfaction[32,33].

The lower postoperative VAS scores at all time points in the combined group than those in the conventional group suggest improved pain management and possibly reduced tissue trauma. The dual-channel system may allow for the gentle manipulation of instruments, reducing mechanical stress on the gastric mucosa. The precision offered by the zebra guidewire might result in the targeted fragmentation of bezoars, minimizing collateral damage to surrounding tissues. The ability to control the movement of instruments with increased accuracy reduces the likelihood of unintended contact with healthy tissue, thereby decreasing inflammation and pain[34,35].

Compared with the conventional group, the combined group showed higher rates of complete recovery and overall efficacy, indicating superior stone clearance. The ability to perform multiple tasks simultaneously using the dual-channel system likely contributes to this enhanced efficacy. The dual-channel setup allows for continuous monitoring and adjustment during the procedure, ensuring that every fragment is addressed. The zebra guidewire provides good guidance and stability during lithotripsy, ensuring the thorough fragmentation of bezoars. This increased precision reduces the likelihood of residual fragments, which could otherwise lead to recurrence[35,36].

While the time to symptom relief did not differ between groups, the combined approach showed high overall efficacy, which underscores its clinical benefit. Comprehensive stone removal reduces the risk of complications, like obstruction or perforation[37,38], and the need for follow-up interventions, alleviating the burden on patients and healthcare systems.

Compared with the conventional group, the combined group had a lower overall postoperative complication rate, particularly for mucosal injuries. This reduction in complications may be ascribed to the controlled and precise nature of the dual-channel system. The ability of the zebra guidewire to stabilize instruments during lithotripsy minimizes unintended movements that could cause mucosal damage. Reduced complications translate to improved patient safety and potentially decreased healthcare costs[38,39].

While no significant differences in bleeding, gastric perforation, or small bowel obstruction rates were observed between the two groups, the overall trend toward fewer complications in the combined group than in the conventional group is promising. These findings highlight the importance of selecting appropriate tools and techniques to minimize risks during endoscopic procedures.

Although the rates of bleeding, gastric perforation, and small bowel obstruction did not differ significantly, the trend toward fewer complications in the combined group than in the conventional group is encouraging. These findings emphasize the importance of selecting appropriate tools and techniques to minimize procedural risks.

This study confirms the efficacy and safety of the combined technique for common phytobezoars. However, for extremely hard or fully calcified stones, mechanical cutting alone may be insufficient. Future strategies could explore combining this technique with energy-based platforms, like laser or electrohydraulic lithotripsy, to broaden its applicability. Furthermore, the principles of cooperative manipulation and stable grasping underlying this technique show potential as a platform for the treatment of other gastric bezoars (e.g., trichobezoars), warranting further study[1].

Several limitations should be noted. The retrospective design of this study limits causal inference between intervention and outcomes. Prospective randomized controlled trials would provide strengthened evidence. Given that cases were sourced from a regional referral center, the included patients may represent a complex or typical subgroup. Therefore, caution is needed when generalizing results to all community hospitals. Future multicenter, prospective studies are required for validation. Additional research should explore long-term outcomes, including recurrence rates and quality of life effects. Understanding how different procedural elements interact will be key to refining diagnostic and therapeutic strategies.

M-DCE-ZGL shows potential for improving perioperative metrics, postoperative pain, efficacy outcomes, and complication rates in phytobezoar treatment. However, further research is necessary to confirm these observations and explore their broad implications. This approach holds promise for enhancing patient care and safety in gastroenterology settings.

CONCLUSION

This study suggests that M-DCE-ZGL may offer potential advantages in the treatment of phytobezoars, particularly in terms of stone clearance efficiency and safety. Compared with conventional methods, the approach appears to facilitate the quick and precise fragmentation of bezoars, potentially leading to shortened procedure times and reduced sessions. Patients treated with this technique may experience reduced postoperative pain and a decreased incidence of complications, such as mucosal injuries. Furthermore, the method holds promise for achieving increased rates of complete recovery and overall efficacy.