Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Abstract

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient's needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.

Keywords: ERCP; ESWL; cholangioscopy; choledocholithiasis; electro-hydraulic lithotripsy; endoscopic retrograde cholangiopancreatography; hepatolithiasis; laser lithotripsy; spyglass.

Figure 1

Cases of difficult biliary stones not amenable to conventional ERCP treatment. (A,B) Magnetic Resonance Images showing complex bile duct stones with large signal defects extending to the hilum and intrahepatics; (C) cholangiogram showing a very large common bile duct stone. All cases were successfully managed with single-operator cholangioscopy-assisted electrohydraulic lithotripsy.

Figure 2

(A,B) cholangiograms showing multiple and large common bile duct stones; (C,D) fluoroscopy showing mechanical lithotripsy with basket of the largest stones; (E,F) final occlusive cholangiograms showing complete clearance of the bile duct after lithotripsy and extraction of fragments.

Figure 3

(A) cholangiogram showing a large common bile duct stone; (B) fluoroscopic image of the cholangioscope in the common bile duct during lithotripsy; (C) cholangioscopic view of intraductal lithotripsy with electro-hydraulic probe; (D) final cholangiogram showing clearance of the bile duct after lithotripsy and extraction of fragments; (E) cholangioscopy showing clearance of the bile duct.

Figure 4

(A) cholangiogram showing a large stone impacted at the cystic duct insertion, obstructing the common bile duct; (B) fluoroscopic image of the cholangioscope approaching the impacted stone; (C) direct visualization of the impacted stone and inflamed biliary mucosa during cholangioscopy; (D) fluoroscopic image of the fragmented stone after electrohydraulic lithotripsy.

Figure 5

Flowchart for management of biliary stones. EPLBD, Endoscopic Papillary Large Balloon Dilation. * risk factors for failure of EPLBD or mechanical lithotripsy: stone impaction, size above 30 mm, stone size/extrahepatic bile duct ratio > 1, tapered bile duct.