Endoscopic Retrograde Cholangiopancreatography Techniques Research Articles

Optimization of ERCP Technique to Improve the Sensitivity of Biliary Brushing: A Systematic Review and Meta-analysis

Optimization of ERCP Technique to Improve the Sensitivity of Biliary Brushing: A Systematic Review and Meta-analysis

EVALUATING ERCP OUTCOMES: GENERAL ANESTHESIA VS. CONSCIOUS SEDATION IN A TERTIARY CARE SETTING

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a critical technique for diagnosing and treating conditions affecting the biliary and pancreatic ducts. Recently, there has been a shift towards employing general anesthesia instead of conscious sedation for these interventions to enhance comfort and efficiency, particularly in intricate cases. This investigation evaluates the decision-making process behind general anesthesia over conscious sedation and assesses their comparative effectiveness and associated complication rates. Methods: Conducted as a retrospective cohort study at Akhtar Saeed Medical and Dental College Lahore, Pakistan, in the period from November 2023 to April 2024, this research involved 380 ERCP patients equally divided into two groups: one administered general anesthesia and the other, conscious sedation. Comprehensive data collection included patient demographics, specific criteria before the procedure, procedural details, and outcomes. The analysis utilized SPSS version 26.0, applying independent t-tests and chi-square tests for continuous and categorical variables, respectively, alongside logistic regression to pinpoint procedural outcomes and complications predictors. Results: Both the general anesthesia and conscious sedation groups, averaging ages of 55.2 and 54.8 years, respectively, showed no significant disparity in BMI, ASA scores, or reasons for ERCP. Success rates of the procedures did not significantly differ, standing at 85% for general anesthesia and 83% for conscious sedation, with complication rates at 20% and 18%, respectively. Metrics such as post-procedure pain, hospitalization duration, and patient satisfaction remained statistically similar across both groups. Conclusions: The study concludes that general anesthesia for ERCP is just as effective and safe as conscious sedation, with both methods showing equivalent success and complication rates. These results advocate for a tailored, patient-centric approach in selecting anesthesia techniques for ERCP, ensuring no procedural effectiveness or patient safety compromise.

Practical application of the modification in endoscopic retrograde cholangiopancreatography treated common bile duct stones in patients with Billroth II gastroenterostomy in Vietnam.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Billroth II gastroenterostomy (B-II GE) has been challenging, requiring flexibility in technical approaches during execution. The study aims to assess the effectiveness of enhanced techniques in performing ERCP on this patient group in Vietnam. A total of 42 Vietnamese patients with B-II GE performed an ERCP using a duodenoscope or a modification of ERCP equipment (a cap-fitted regular forward-viewing endoscope) if the former failed. The effectiveness and safety of the ERCP technique were assessed, particularly in patients who underwent the forward-viewing endoscope method. A total of 39 out of 42 patients had the Vater's papilla identified, among whom 12 patients (30.8%) achieved successful cannulation into the bile duct using a side-viewing endoscope, significantly lower than the success rate using a forward-viewing endoscope (25/27, counted 92.6%, with p < 0.001). After successful cannulation, the rate of stone clearance, the procedural time, and the hospitalization duration of the patients were equivalent between the two methods and were not dependent on the number or size of the stones. On the other hand, post-ERCP complications in patients utilizing forward-viewing endoscopy included acute pancreatitis (22.2%), post-sphincterotomy bleeding (3.7%), septicemia (4.8%), and perforation (0%). These complications were mild and amenable to conservative endoscopic and medical management, and no mortality was observed. The rates of complications and adverse events after ERCP are comparable between the two treatment methods, even though the end-viewing endoscope is used after the failure of the side-viewing endoscope. Alter ERCP utilizing a cap-fitted forward-viewing endoscope can be a primary choice for treating common bile duct stones in patients with a Billroth II gastric resection history because of high efficacy and acceptable complications. It requires a high level of procedural expertise that requires multiple training sessions.

Endoscopic retrograde cholangiopancreatography (ERCP) approach for patients with Roux-en-Y gastric bypass: a comparative study between four ERCP techniques with proposed management algorithm

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) due to altered anatomy. ObjectiveTo compare the procedural and clinical outcomes of 4 different ERCP techniques in RYGB patients. SettingAcademic tertiary referral center in the United States. MethodsA retrospective cohort study including patients with RYGB anatomy who underwent an ERCP between January 2015 and September 2020. We compared procedural success and adverse events (AEs) rates of balloon-assisted enteroscopy (BAE), gastrostomy-assisted ERCP (GAE), endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE), and rendezvous guidewire-assisted ERCP (RGA). ResultsSeventy-eight RYGB patients underwent a total of 132 ERCPs. The mean age was 60 ± 11.8 years, with female predominance (85.7%). The ERCP procedures performed were BAE (n = 64; 48.5%), GAE (n = 18; 13.7%), EDGE (n = 25; 18.9%), and RGA (n = 25; 18.9%), with overall procedure success rates of 64.1%, 100%, 89.5%, and 91.7%, respectively. All approaches were superior to BAE (GAE versus BAE, P = .003; EDGE versus BAE, P = .034; RGA versus BAE, P = .011). The overall AE rates were 10.9%, 11.1%, 15.8 %, and 25.0%, respectively. There was no statistical difference in AEs. There were also no differences in bleeding, post-ERCP pancreatitis, and perforation rates between the 4 approaches. ConclusionProcedure success was similar between GAE, RGA, and EDGE, but superior to BAE. AE rates were similar between approaches.

Comparison of diagnostic usefulness of magnetic resonance cholangiopancreatography (MRCP) with endoscopic retrograde cholangiopancreatography (ERCP) in evaluation of patients with obstructive jaundice.

Objective: To determine the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography in diagnosis of obstructive jaundice taking Endoscopic Retrograde Cholangiopancreatography as gold standard. Study Design: Cross-sectional study. Setting: Department of Radiology, Aziz Fatima Medical and Dental Hospital, Faisalabad. Period: 1st October 2022 to 31st March 2023. Material &amp; Methods: A total number of 108 patients reported at the OPD with the obstructive jaundice confirmed with liver function tests and having indication for conducting ERCP was included in this study. MRCP was done by radiologist with a torso phased-array coil. Sequence of MRCP was planned with use of 3 plane gradient-echo localizing images. By using Single–shot fast spine echo axial slices were taken. ERCP was carried out by gastroenterologist under local or general anesthesia. Assessment was done on the basis of pathology and results were compared between the two techniques where results of ERCP were taken as reference. The primary outcomes were sensitivity, specificity and negative &amp; positive predictive values for obstructive jaundice. Results: In this study age range was 18 to 50 years with mean age of 40.805±5.98 years and mean duration of complain was 7.259±1.72months. Female gender was dominant in this study (50.9%) followed by male (49.1%). MRCP diagnosed 58(53.7%) patients while ERCP diagnosed 55(50.9%) patients with obstructive jaundice. MRCP has shown sensitivity of 85.46%, specificity 79.24% and diagnostic accuracy by 82%, PPV 81% and NPV 84% in diagnosis of obstructive jaundice (p &lt; 0.000). Conclusion: The non-invasive technique of MRCP provides a good and reliable diagnostic option in patients with obstructive jaundice which is comparable with invasive technique of ERCP.

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Endoscopic Retrograde Cholangiopancreatography during Pregnancy

Physiological changes caused by pregnancy promote the formation of gallstones, increasing the risk of acute cholecystitis, cholangitis, and cholelithiasis that occur during pregnancy. Since these diseases can be fatal to both mother and fetus, active treatment is critical. Biliary gallstones are preferably treated using endoscopic retrograde cholangiopancreatography (ERCP), even during pregnancy. While there is no alternative, safer and easier treatment method, complications from ERCP are lethal; therefore, several risks and benefits must be considered. First, various tests should be conducted and considered to determine whether ERCP is necessary. The risk of congenital disabilities from radiation exposure to the fetus during ERCP should be considered and minimized. Furthermore, clinicians should be aware of and use safe anesthetic agents and antibiotics that are safe to use during pregnancy. Finally, ERCPists should be familiar with various technical methods, such as the recently introduced ERCP technique without radiation exposure, stent drainage without complete removal of gallstones in the case of large biliary stones, and removal of biliary stones after childbirth. Pregnancy is not a contraindication for ERCP; as a lifesaving procedure, it should be performed when necessary. Even though the safety of ERCP is considered an acceptable risk in pregnancy, clinicians should continue to try and find safer ways for pregnant women and fetuses being treated for cholelithiasis.

Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Intrahepatic Stone in Post Liver Transplanted Patient

BACKGROUND: The complication of the bile duct is quite a typical case of indisposition after liver transplant from a deceased or a live donor. The morbidity rates of the patients that underwent orthotopic liver transplantation were reported. In this case report, the intrahepatic stone formation was studied in post liver transplanted patients. CASE REPORT: This report presents a sporadic case of 53-year-old male patient in post-operative liver transplant. The initial post-transplant course of the patient was quite favorable, but after a week post-surgery, the patient developed the case of jaundice and came on with yellow discoloration in the skin. The endoscopic retrograde cholangiopancreatography (ERCP) was initially performed and the common bile duct (CBD) stent was inserted. Routine post-operative examination and follow-ups showed that the onset of jaundice. Further investigations with ERCP and the magnetic resonance cholangiopancreatography (MRCP) to determine the complete mapping of the biliary region showed the presence the presence of biliary stones in the CBD. In short, this is a rare finding that presents a sporadic case of post-operative liver transplant complications of biliary stones. The patient underwent a liver transplant but came back with post-surgery complications. MRCP and ERCP techniques were used for the imaging and providing an accurate diagnosis, indicating the presence of biliary stones in the CBD. CONCLUSION: Intrahepatic stone was found in patients with post liver transplanted patient.

Outcome of Digital Cholangioscopy and Laser Lithotripsy for Impacted Biliary Stones

Abstract Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct. Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications. Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient. Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Management of difficult bile duct stones with temporary plastic stent and ursodeoxycholic acid treatment: 5 years of experience

Aim: The aim of the study was to investigate the effect of temporary plastic stenting and ursodeoxycholic acid (UDCA) treatment on difficult choledochal stones that cannot be removed by basic ERCP techniques in patients who applied to our clinic with occlusion and underwent endoscopic retrograde cholangiopancreatography (ERCP).&#x0D; Material and Method: Patients were scanned retrospectively using the hospital database. Patients who underwent ERCP due to malignancy, biliary tract injury and benign strictures were excluded from the study. 61 patients who were not successful with basic ERCP techniques such as endoscopic sphincterotomy (EST) and mechanical lithotripsy (ML) were included in the study. 750 mg/day UDCA was given to the patients for three months and plastic stent was applied. After the treatment, ERCP was tried again.&#x0D; Results: Among the patients who underwent stent+UDCA, three (4.9%) patients had perioperative bleeding, one (1.6%) patient had peroperative perforation, four (6.6%) patients had postoperative pancreatitis, and one (1.6%) patient had mortality. The mean hospital stay was 1.96±2.1 days. Post-procedure total bilirubin and direct bilirubin values were observed to be lower than before the procedure (respectively, p

ID: 3526790 ERCP APPROACH FOR PATIENTS WITH A RYGB: A COMPARATIVE RETROSPECTIVE STUDY BETWEEN FOUR ERCP TECHNIQUES WITH PROPOSED MANAGEMENT APPROACH

Endoscopic Retrograde Cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en y gastric bypass (RYGB) due to altered anatomy. Current techniques either have a low success rate, are invasive, associated with high cost, or have an unclear long-term safety profile. The main aim of our study is to compare the procedural and clinical outcomes of four ERCP techniques in RYGB patients.

Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience.

Background and objectiveFluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff. MethodsWe conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups.ResultsThe median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001).ConclusionThe ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) can safely and effectively manage postsurgical or traumatic bile duct leaks (BDLs). Standardized guidelines are lacking regarding effective management of BDLs. Our aim was to evaluate the efficacy, clinical outcomes, and complications of different ERCP techniques and intervention timing using a nationwide database. Patients and methods We performed a retrospective analysis of the IBM Explorys database (1999–2019), a pooled, national, de-identified clinical database of over 64 million unique patients across the United States. ERCP timing after BDL was classified as emergent (< 1 day), urgent (1–3 days) or expectant (> 3 days). ERCP technique was classified into sphincterotomy, stent or combination therapy. ERCP complications were defined as pancreatitis, duodenal perforation, duodenal hemorrhage, and ascending cholangitis within 7 days of the procedure. Results Expectant ERCP had a decreased risk of adverse events (AEs) compared to emergent and urgent ERCP ( P = 0.004). Rehospitalization rates also were lower in expectant ERCP ( P < 0.001). Patients with COPD were more likely to have an AE if the ERCP was performed emergently compared to expectantly ( P = 0.002). Combination therapy had a lower rate of ERCP failure compared to placement of a biliary stent ( P = 0.02). There was no statistically significant difference in rates of ERCP failure between biliary stent and sphincterotomy ( P = 0.06) or sphincterotomy and combination therapy ( P = 0.74). Conclusion Our study suggests that ERCP does not need to be performed emergently or urgently for management of BDLs. Combination therapy is superior to stenting but not sphincterotomy; however, future prospective studies are needed to validate these findings.

A novel endoscopic retrograde cholangiopancreatography technique to reduce stone size in type IV Mirizzi syndrome: avoiding cholangiojejunostomy.

A novel endoscopic retrograde cholangiopancreatography technique to reduce stone size in type IV Mirizzi syndrome: avoiding cholangiojejunostomy.

Advances in Biliary Access.

Bile duct cannulation using conventional techniques fails in up to 16% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Advanced techniques to gain biliary access include ERCP-based maneuvers, and newer endoscopic ultrasound (EUS)-guided interventions. In this article, we review the evidence supporting the use of various ERCP and EUS techniques for biliary access, as well as studies comparing these different techniques. In comparative studies, biliary access after failed conventional cannulation was more successful with EUS-rendezvous compared to precut papillotomy. EUS-guided drainage compares favorably with percutaneous drainage with respect to clinical success, safety profile, and cost-efficiency. Recent randomized trials comparing EUS to ERCP drainage in malignant obstruction have found similar success rates between these techniques. EUS-guided techniques compare favorably to ERCP-based methods for biliary access and drainage. The advent of newer technologies to facilitate interventional EUS may further change current treatment approaches.

Pancreatic Duct Variations and the Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic procedure in the management of biliary and pancreatic disorders. Despite advances in ERCP facilities and techniques, pancreatitis remains the most common and feared complication of this procedure. The technical challenges of ERCP could be further compounded by variations in the configuration of the pancreatic ductal system. As a result, the knowledge of these variations and their potential role in the development of post-ERCP pancreatitis (PEP) is essential to any successful risk reduction strategy. This review provides an overview of the anatomy and embryological basis of pancreatic duct variations, as well as explore the different types and prevalence of these variations. Also, we discuss the mechanisms of PEP and provide evidence supporting a link between the variations and PEP using published data

Su1436 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A TERTIARY CANADIAN HOSPITAL: OPTIMIZING TISSUE SAMPLING TECHNIQUES

Pancreatic and biliary cancer can be difficult to diagnose definitively, and tissue diagnosis defines clinical management in both early and late disease. The majority of patients diagnosed with pancreaticobiliary malignancy present with advanced disease, and only 30% have resectable tumors. This lag contributes to poor prognosis and outcome. Endoscopic retrograde cholangiopancreatography (ERCP) is a mainstay for diagnosing and treating conditions of the bile and pancreatic duct. This study aimed to provide data on the diagnostic performance of ERCP utilizing conventional methods for tissue acquisition, particularly in the setting of an indeterminate stricture. In particular, this was a quality assurance review to determine our center’s baseline performance as a reference benchmark, so new methods of tissue acquisition, such as the SpyglassTM can be better compared. In a tertiary care hospital, 3723 ERCP procedures were performed between 2013 and 2017. Demographic and clinical information was retrospectively collected. Demographic and clinical information was collected. Three ERCP techniques of tissue sampling were analyzed: brushing alone (BiA), biopsy (BrA), and brushing and biopsy dual-modality approach (BrBi). The diagnostic performances (sensitivity, specificity, and accuracy) were analyzed with data from post-sampling clinical reports, surgical pathological reports, and diagnostic imaging reports. 222 patients (285 ERCP procedure) met the study criteria and received fluoroscopy-guided ERCP sampling with cytology brushing and/or tissue biopsies. 36 (13%) patients had BiA, 85 (29%) patients had BrA, and 164 (58%) patients had BrBi (Table 1). The sensitivities, specificities, and accuracies of the three sampling techniques respectively were: 56%, 93%, and 85% for BiA; 73%, 96%, and 83% for BrA; and 79%, 94%, and 86% for BrBi (Table 1). Our retrospective analysis of fluoroscopic-guided tissue acquisition shows accuracy as high as current published data on direct visualization cholangioscopy guided techniques. A prospective study looking not only at clinical yield but a cost analysis should be implemented before a commitment to purchase new technology (i.e. SpyglassTM).

Factors Associated with the Success Rate of Endoscopic Retrograde Cholangiopancreatography with Standard Technique followed by Laparoscopic Cholecystectomy in the Management of Choledocholithiasis: A Single-Center Experience

Abstract Background Choledocholithiasis is the most common benign biliary disease. Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) has been the first-line therapy in recent years, although laparoscopic common bile duct exploration has promising results. This retrospective study aimed to define the factors associated with biliary clearance by standard ERCP technique and conversion rate of LC. Materials and Methods We retrospectively evaluated the records of 217 choledocholithiasis patients who had undergone ERCP with stone removal by the standard technique from 2010 to 2018. A failed ERCP was defined when the first ERCP session could not remove the stones . The number of patients who later underwent open cholecystectomy or LC was also recorded. Conversion was defined when LC had to be converted OC. Statistical Analysis Student’s t-test was used for the comparison of continuous variables. Nominal variables were analyzed using Pearson’s chi-square test or Fisher’s exact test. Binary logistic regression was performed for multivariate analysis. Results The rate of successful biliary clearance was 81.1%. Of the patients, 109 (50.2%) had difficult stones. Increasing age (p = 0.004), increasing number (p = 0.001), and increasing size of stone (p &lt; 0.001) were the three significant factors that were associated with the failure of biliary clearance. The difficult stone group had a higher failure rate of ERCP and a higher conversion rate of LC compared with the easy stone group (p = 0.001 and p = 0.027, respectively). Conclusions ERCP with the standard technique is a highly effective and safe management option for patients with common bile duct (CBD) stones. The difficult stone group was found to be an independent risk factor that affected the success rate of both ERCP and the following LC. Difficult stone criteria should be assessed to identify a patient who might benefit from laparoscopic CBD exploration.