Endoscopic Removal of Large Common Bile Duct Stones: Time to Arm the Laser?

Excerpt

Since its inception nearly 40 years ago, endoscopic retrograde cholangiopancreatography (ERCP) has become the therapeutic cornerstone for removal of common bile duct (CBD) stones. Removal of the vast majority of stones with endoscopic sphincterotomy (EST), followed by sweeping the duct with either balloon or basket is successful in most cases, with an acceptable safety profile. Nevertheless, despite considerable refinements in ERCP over the last four decades, management of large, “difficult” CBD stones remains a therapeutic challenge. The definition of “large” CBD stones varies, ranging from >1 to >2 cm in diameter. Although the size of a stone is a prime determinant of its resistance to extraction, factors other than size are important. In a multivariate analysis, acute angulation of the distalmost aspect of the CBD and a shorter length of this distal CBD “arm” were associated with difficulty of ductal clearance [1]. Other factors inversely associated with stone clearance include very large stones such as those >3 cm, surgically altered anatomy, and firmness of the stones. The endoscopist must also consider not only the absolute stone size, but its diameter relative to the width of the distal duct through which it must be removed. …