Endoscopic management of difficult common bile duct stones

Abstract

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Keywords: Choledocholithiasis; Difficult to remove biliary stones; Electrohydra-ulic lithotripsy; Endoscopic large balloon papillary dilation; Laser lithotripsy; Mechanical lithotripsy; Peroral cholangioscopy.

Figure 1

Example of a three-layered mechanical lithotripsy device with the basket, inner plastic sheath and an outer metal sheath. The stone is captured by the basket and crushed against the outer metal sheath.

Figure 2

Image of a mechanical lithotripter which can be used as a “salvage device” for removal of impacted baskets.

Figure 3

Laser lithotripsy of a bile duct stone under cholangioscopic guidance.

Figure 4

Direct peroral cholangioscopy guided laser lithotripsy of a bile duct stone. The red laser light makes targeting of the stone easier).

Figure 5

Large diameter papillary balloon dilatation to remove bile duct stone.