Modern Management of Common Bile Duct Stones: Breakthroughs, Challenges, and Future Perspectives

Abstract

Common bile duct (CBD) stone management has evolved significantly with technological advances and an improved understanding of pathophysiology. This comprehensive review examines current evidence and emerging trends in CBD stone management, emphasizing modern diagnostic approaches and treatment paradigms. Recent developments in imaging techniques, including AI-assisted analysis, have enhanced diagnostic accuracy. Treatment strategies now emphasize minimally invasive approaches, with endoscopic techniques showing success rates exceeding 90% in experienced centers. Special considerations for specific populations, including elderly patients and those with altered anatomy, have led to refined management algorithms. Future directions include novel stone fragmentation technologies, biodegradable materials, and personalized medicine approaches. The integration of these advances, combined with a multidisciplinary approach, has improved patient outcomes while presenting new opportunities for enhanced care delivery. Continued technological innovation and refined techniques suggest a promising future for CBD stone management, although challenges remain in optimizing treatment selection and preventing recurrence.

Keywords: biliary stone disease; choledocholithiasis; endoscopic retrograde cholangiopancreatography; laparoscopic common bile duct exploration; minimally invasive surgery; personalized medicine.

Figure 1. Management algorithm for CBD stones: a comprehensive approach

Initial evaluation begins with a clinical assessment of primary symptoms (jaundice, pain, and fever), followed by laboratory tests (bilirubin, ALP, and GGT) and imaging studies (US as first-line, MRCP as gold standard, and EUS for special cases). Treatment selection is primarily based on stone characteristics (size, location, and complexity): endoscopic approaches (ERCP) and laparoscopic surgery serve as the primary intervention and alternative interventional approaches are reserved for special anatomical considerations or complex cases. Special attention should be given to elderly patients (preferring minimally invasive approaches), pregnancy (requiring careful timing), and anatomical variations (potentially needing alternative interventions). A multidisciplinary team approach is essential for complex cases, recurrent stones, and treatment failures. Long-term follow-up focuses on monitoring and preventing recurrence. Treatment decisions should be individualized based on patient characteristics, institutional expertise, and available resources, emphasizing the importance of a comprehensive, patient-centered approach to optimize outcomes. ALP: alkaline phosphatase; CBD: common bile duct; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; GGT: gamma-glutamyl transferase; MRCP: magnetic resonance cholangiopancreatography; US: ultrasound Image credit: Guangbin Chen