Supplementary Material for: Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic Stones

<b><i>Background and Aims:</i></b> Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. <b><i>Methods:</i></b> This is a prospective clinical study – conducted at two affiliated university hospitals – of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. <b><i>Results:</i></b> Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (<i>n</i> = 3), pain (<i>n</i> = 1), and mild pancreatitis (<i>n</i> = 1). <b><i>Conclusions:</i></b> Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.

**背景与目的：** 内镜逆行胰胆管造影（Endoscopic retrograde cholangiopancreatography）是治疗胆胰管结石的首选方案。然而临床中仍会遇到难治性结石，液压碎石术（electrohydraulic, EHL）与激光碎石术（laser lithotripsy, LL）已成为实现管腔结石清除的治疗手段。近年来单操作胆道镜的问世，使得此类技术得以常规开展。本研究旨在评估采用激光碎石术或液压碎石术实施胆道镜引导下碎石术，治疗难治性胆胰管结石患者的临床有效性。

**方法：** 本研究为一项前瞻性临床研究，在两所附属大学医院开展，纳入17例连续收治的难治性胆胰管结石患者，所有患者均接受单操作胆道镜引导下碎石术，所用碎石技术包括钬激光碎石术（holmium laser lithotripsy, HL）与双极液压碎石术。本研究分析了完全管腔结石清除率，以及结石位置、数量对临床治疗成功率的影响，并评估了两种胆道镜引导下碎石术的疗效与手术并发症情况。

**结果：** 12例患者（70.6%）的结石位于胆总管/肝总管，2例患者（17.6%）的结石位于胆囊残桩，3例患者（17.6%）的结石位于胰腺。16例患者（94.1%）在单次手术中即成功实现管腔清除，1例患者（5.9%）在接受液压碎石术、激光碎石术与机械碎石术后，经3次手术最终实现管腔清除。11例患者在单次手术中使用单根激光纤维成功完成钬激光碎石术。6例患者接受液压碎石术治疗：其中4例患者使用单根纤维于单次手术中实现管腔清除，1例患者使用两根纤维在单次手术中成功完成碎石，1例患者使用两根纤维后未实现管腔清除，随后在后续手术中采用单根激光纤维成功完成治疗。所有并发症均为轻度，共发生于6/17例患者（35.2%），包括发热（n=3）、疼痛（n=1）与轻度胰腺炎（n=1）。

**结论：** 采用激光碎石术或液压碎石术实施胆道镜引导下碎石术治疗难治性胆胰管结石患者，疗效显著，并发症短暂且轻微。目前仍亟需进一步对比液压碎石术与钬激光碎石术，以明确二者在胆道镜引导下碎石术成功治疗中的作用。