Bile duct stone management has greatly changed in the past 2 decades. Open surgical techniques have mostly been replaced by transoral endoscopic techniques. Routine common bile duct stones can be managed by standard biliary endoscopic sphincterotomy and extraction. Various advanced transoral techniques can also manage most difficult ductal stones. In skilled centers, laparoscopic ductal stone management has assumed a back-up role.
In Western countries, most stones in the common bile duct (CBD) result from passage of gallbladder stones into the CBD. Stones in the common duct are found in 8% to 18% of patients with symptomatic gallbladder stones. At least 3% to 10% of patients undergoing cholecystectomy have CBD stones. Patients with symptomatic bile duct stones are at high risk of experiencing further symptoms or complications if left untreated. Given the potential serious complications of bile duct stones, specific therapy generally is indicated regardless of symptoms.
Introduction of endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy in 1974 opened a new era in the nonsurgical treatment of CBD stones. Such endoscopic management is now the mainstay in the management of bile duct stones. Multiple supplemental techniques are now available.
This article discusses the current state of endoscopic treatment of extrahepatic bile duct stones. This includes conventional endoscopic management of CBD stones and alternative strategies for stones that are more difficult to remove. Gallstone pancreatitis, intrahepatic stones (mostly seen in Asians), and postliver transplant problems are not discussed.
Routine common bile duct stones
Stones less than 1 cm in diameter with normal terminal CBD/sphincter anatomy are considered routine because more than 85% can be managed by standard biliary endoscopic sphincterotomy (BES) and extraction ( Fig. 1 ).
