Endoscopic management of difficult common bile duct stones

We have studied 45 patients with difficult common bile duct (CBD) stones which could not be removed with endoscopic sphincterotomy combined with stone removal using a Dormia basket. These 45 patients underwent additional endoscopic procedures: mechanical lithotripsy (ML) in 22 (49%), electrohydraulic (EHL) or pulse dye laser lithotripsy via peroral choledochoscopy in 7 (15%). and biliary stenting in the remaining 16 (36%). The latter group consisted of elderly patients with an average age of 79 years (range 72-85) who had cholangitis and surgical risk. Duct clearance was achieved in all 22 patients undergoing ML. Fragmentation and stone extraction were successful in all 7 patients with EHL or laser lithotripsy. One patient developed recurrent stone two years later after EHL which required surgery. Resolution of cholangitis and cholestasis indicating successful bile drainage was achieved in all 16 stented patients. However. 5 patients developed stent-clogging during 24 month follow-up: three of these subsequently underwent successful ML and the other two received new-stent. No complications were noted in this study. Additional endoscopic procedures are beneficial in treating difficult CBD stones.