Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Abstract

Common bile duct (CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone (larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation (EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Keywords: Difficult common bile duct stones, Endoscopic sphincterotomy, Endoscopic papillary large balloon dilatation, Mechanical lithotripsy, Cholangioscopy, Laparoscopic surgery

Core Tip: Difficult common bile duct stone is defined based on the characteristics of the stone, accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation (EPLBD) of a previous sphincterotomy or EPLBD combined with limited sphincterotomy performed on the same session is still recommended as the main approach in difficult common bile duct stone with history of failed sphincterotomy and balloon and/or basket attempts. No significant difference has been observed in mortality and morbidity rates, as well as conversion to open surgery between groups treated with a single-stage laparoscopic procedure and two-stage endoscopic and laparoscopic procedures.