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Given lack of efficacy relative to endoscopic retrograde cholangiography (ERCP), pharmacologic therapy for bile duct stones should be reserved for patients who are not candidates for therapeutic procedures.
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ERCP should be performed only if there is a high suspicion of bile duct stones; imaging studies for confirmation should be performed if there is intermediate suspicion, to minimize complications associated with ERCP.
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ERCP with sphincterotomy, mechanical lithotripsy, and stent placement may be
Modern Management of Common Bile Duct Stones
Section snippets
Key points
Genesis and pharmacologic therapy for bile duct stones
Medical therapy for gallstone disease was championed particularly in the 1970s and early 1980s. Interest has waned since the introduction of laparoscopic cholecystectomy and ERCP, whereby stones in the gallbladder and bile duct may be removed with low morbidity. Medical therapy aims to correct the biochemical anomalies that cause cholesterol and pigment stone formation. More recently, there has been keen interest in addressing and treating stone disease as part of the metabolic syndrome.
Clinical approach to bile duct stones
In the contemporary era, most bile duct stones are removed by ERCP and concomitant gallbladder stones are removed by laparoscopic cholecystectomy. Although it is the least invasive approach, ERCP for the removal of bile duct stones is associated with complications in 8% to 10% of patients.25 Thus it is critical that ERCP be used only for therapy and not diagnosis, which necessitates accurately assessing probability of bile duct stones.
Endoscopic removal of bile duct stones
In the era of laparoscopic cholecystectomy, ERCP with sphincterotomy has achieved primacy in the management of bile duct stones. Sphincterotomy, mechanical lithotripsy, and stent placement are the fundamental techniques. If used appropriately, the biliary endoscopist may remove 80% to 90% of stones and may expect complications in fewer than 10% of cases.
Advanced endoscopic techniques for challenging bile duct stones
The management of difficult bile duct stones is a formidable challenge for the biliary endoscopist and has been the subject of extensive contemporary endoscopic research. Stone fragmentation may be accomplished by ESWL and intraductal methods of fragmentation, including electrohydraulic and laser lithotripsy. Intraductal treatment may be guided by fluoroscopy or choledochoscopy. Over the past decade, papillary balloon dilatation after endoscopic sphincterotomy has been introduced as a technique
Approach to bile duct stones in the patient with an intact gallbladder
The widespread introduction of ERCP and laparoscopic cholecystectomy has generated controversy regarding the best approach to patients with symptomatic bile duct stones and an intact gallbladder. Laparoscopic approaches to the bile duct are challenging and time consuming. Comparing the 2-stage approaches of ERCP along with laparoscopic cholecystectomy (Fig. 12) with laparoscopic cholecystectomy and laparoscopic common duct exploration (LCBDE) has been the subject of ongoing study and debate.
Summary
Bile duct stones are a source of significant morbidity, given their association with pancreatitis and cholangitis. Medical therapy for cholesterol and pigment bile duct stones aims to correct the biochemical aberrancies that lead to their formation. Hydrophilic bile salts and Rowachol decrease the biliary cholesterol supersaturation that underlies the formation of cholesterol stones. However, the modest efficacy of these agents relative to minimally invasive endoscopic and surgical
Acknowledgments
Special thanks are extended to Richard Molina, Kelvin Yeh, MD, and Arthur Yan, MD for assisting with figures.
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Cited by (31)
Dormia basket impacted during ERCP, resolved by laparoscopic bile duct approach: Case report
2021, International Journal of Surgery Case ReportsCitation Excerpt :Prospective population data reveal that 10% of adults will develop symptomatic gallstones within a decade. Those with 10%–20% symptomatic cholelithiasis have concomitant choledocholithiasis [1,2]. Since its introduction in 1974, ERCP has become the standard method for removing bile duct stones, which involves endoscopic sphincterotomy with balloon or basket for removal of stones.
Holmium Intraductal Laser Lithotripsy of Biliary Stones in Liver Grafts
2016, Transplantation ProceedingsCitation Excerpt :Therefore, once urologists gave us the option to use the HILL, we explored the efficacy of this device. Salvage treatment of biliary calculi include extracorporeal shockwave lithotripsy (SWL), actually an abandoned procedure, and intracorporeal lithotripsy [4] with electrohydraulic (EHL), or intraductal laser lithotripsy (ILL) under direct visualization through flexible choledochoscopy [5] inserted by way of a percutaneous access sheath [6]; therefore, due to direct visualization, collateral damages to surrounding tissues are minimal. Both EHL and HILL have been previously used for urinary calculi [7,8] through cystoscopy or ureteroscopy.
Rare and underappreciated complications of endoscopic retrograde cholangiopancreatography
2014, Techniques in Gastrointestinal EndoscopyCitation Excerpt :Few events during ERCP are as disheartening as impacting a retrieval basket around a large common bile duct stone. With electrohydraulic lithotripsy (EHL) [32-34] and balloon orifice dilation [33,35,36] techniques to facilitate large stone retrieval, impacted baskets are probably on the decline. Nonetheless, the incidence may be as high as 6% for cases involving a lithotripsy-compatible basket [37,38].
Endoscopic Retrograde Cholangiopancreatography
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth EditionRetained stone retrieval basket causing chronic pancreatitis: a case report
2023, Frontiers in Surgery
Conflicts of interest: The author has nothing to disclose.