Flexible Percutaneous Laser Lithotripsy for Intrahepatic Stones: A Multicenter Study in Western Patients

Abstract

Introduction: Intrahepatic lithiasis (IHL) remains a challenging condition in populations, particularly in patients with surgically altered biliary anatomy or failed endoscopic interventions. Percutaneous laser lithotripsy (PLL) under flexible cholangioscopic guidance has emerged as a minimally invasive alternative for managing complex intrahepatic stones. Purpose: To evaluate the efficacy and safety of flexible PLL for the treatment of intrahepatic stones in a multicenter Brazilian cohort with altered anatomy or failed ERCP. Materials and Methods: The primary outcome was technical success, defined as complete ductal clearance confirmed by cholangioscopy or MRI at 1-month follow-up. Clinical success was defined as resolution of biliary symptoms without recurrence or need for additional intervention during follow-up. Secondary outcomes included the number of lithotripsy sessions, complication rates, and symptomatic stone recurrence. Results: Complete ductal clearance was achieved in 100% of patients, with a mean of 1.29 lithotripsy sessions per patient. Minor complications occurred in 11.4% of cases, with no major adverse events, bile duct injuries, or procedure-related deaths. No symptomatic recurrence was observed during a mean follow-up of 14.7 months. Notably, five incidental biliary polyps were identified under direct cholangioscopic visualization; one was confirmed as low-grade dysplasia. These lesions were not detected on preprocedural imaging, highlighting the added diagnostic value of cholangioscopy. Conclusion: Flexible PLL is a safe, effective, and reproducible technique for managing complex intrahepatic lithiasis, especially in patients with altered anatomy or failed endoscopic treatment. The added diagnostic yield and potential for outpatient protocols using disposable cholangioscopes support broader adoption of this approach in interventional radiology.