Endoscopic Management of Large and Difficult Common Bile duct Stones

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) assisted removal of small stones is easily accomplished with standard biliary sphincterotomy and balloon and basket extraction. Common bile duct stones greater than 15 mm are difficult to remove with standard techniques. Besides large stones, impacted and adherent bile duct stones, intrahepatic stones, stones proximal to stricture, Mirizzi syndrome, and stones associated with postsurgical biliary anatomy are often challenging and constitute difficult bile duct stones. Patients with difficult and large bile duct stones are managed best at tertiary academic centers with therapeutic pancreaticobiliary endoscopy expertise. Dedicated techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laser lithotripsy (LL), and endoscopic papillary balloon dilation (ELPBD) either used alone or in combination are helpful in the treatment of patients with large and difficult CBD stones. Enteroscopy-assisted ERCP, EUS-guided biliary access, offers helpful alternative in difficult to access papillas. The majority of patients with large and difficult bile duct stone can be successfully treated with these endoscopic modalities. Despite widespread use and success in endoscopic management of patients with large and difficult bile duct stones, a small percentage of patients fail these treatment options and can benefit from surgery or percutaneous approach for stone removal. Identification of large and difficult to treat bile duct stone patients and referral to places with available expertise, equipment, and multidisciplinary teams are helpful in successful treatment and better patient outcomes.