Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review

Abstract

Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.

Current management of concomitant cholelithiasis and common bile duct stones

“…ES and large balloon dilation is the initial approach. Mechanical lithotripsy or preferably cholangioscopy-assisted lithotripsy are alternative options, but the latter may be used as the initial step[ 54 , 55 ]. Additionally, fully covered metal stents are safe and may be useful when they remain for more than 1 mo, especially in males and stone sizes less than 2 cm[ 56 ].…”

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“…About 8-20% of patients with gallbladder stones evolve with the migration of these stones to the common bile duct. Thus, cholelithiasis is the main risk factor for the development of choledocholithiasis [14,27]. In this context, the risk factors for the development of cholelithiasis are female gender, age around 60 years, obesity/dyslipidemia, cirrhosis, and infections, among others, which are essential for the development of secondary choledocholithiasis [13,28].…”

“…This is because the stone moves in the common bile duct, temporarily clearing the bile flow (with an improvement in jaundice) until it impacts a new, more distal location of the chimney [11,26]. In addition, the typical picture of these patients may include pain in the right hypochondrium of the abdomen (similar to the pain found in patients with acute cholecystitis, however, of a transient nature) and other signs of cholestasis, such as jaundice, choluria (urine stained dark) and acholia fecal (light stool) [26][27][28]. Once the diagnosis is made based on the clinical picture, laboratory tests detecting direct hyperbilirubinemia (conjugated bilirubin) in periods when there is obstruction of the biliary tract, in addition to an increase in alkaline phosphatase and gamma-GT (canalicular enzymes which, when increased, suggest obstruction of the biliary tract.…”

“…In cases that are not urgent, there is some time to investigate and schedule the unblocking procedure on an elective basis. The second step in defining the treatment is to discern the origin of the calculus impacted in the biliary tract [24][25][26][27]. The secondary origin choledocholithiasis must undergo cholecystectomy and treatment to clear the biliary tract.…”

“…The optimal time for BTI repair is still controversial and depends on several factors, including the patient's general condition, favorable local abdominal factors for a successful repair, and the surgeon's experience. [27][28][29][30][31][32] Performing the definitive operation early (within the first 72 hours), in the period, or in the late period (after 1.5 months) of the injury significantly affects the morbidity of patients [27][28][29][30].…”