Large CBD Stones and its Impact on Successful Stone Extraction and the Possible Adverse Events During Ercp Procedure

Abstract

Choledocholithiasis is the presence of stones within the common bile duct (CBD). It is estimated that common bile duct stones are present in anywhere from 1-15% of patients with cholelithiasis. The present-day treatment of bile duct stones is endoscopic retrograde cholangiopancreatography (ERCP), or in some cases, laparoscopic cholecystectomy with bile duct exploration. In most US centers, when bile duct stones present, ERCP is usually followed by laparoscopic cholecystectomy). Bile duct stone management has changed dramatically in the last two decades when open surgery has been replaced by per-oral endoscopic procedures. Nowadays, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is performed worldwide as the first approach in the management of extrahepatic bile duct stones and is superior to surgical or percutaneous approaches, although it can be challenging in some cases. The main problem that has to be solved regarding endoscopic extraction of large bile duct stones is extraction of something larger than the orifice through which access has been achieved. This is obtained by either enlarging the ampulla of Vater (cutting, dilation) or reducing the size of the stone that has to be extracted (fragmentation, crushing) using adequate devices and second problem is the size of the stone itself. For large stones in the CBD (single stone diameter ≥ 1.5 cm or ≥ 3 stones with diameters ≥ 1.0 cm), it is difficult to completely remove the stones by conventional EST or EPBD procedure. And then, endoscopic papillary large balloon dilation (EPLBD), mechanical lithotripsy (ML), or other lithotripsy methods such as electrohydraulic lithotripsy (EHL), laser lithotripsy (LL), and extracorporeal shock wave lithotripsy (ESWL) are often required to achieve complete stones removal. However, these methods increase the time and complexity of the ERCP procedure, thereby increasing the risk of complications