What are the treatment options for retained bile duct stones?

Treatment Options for Retained Bile Duct Stones

Patients with retained bile duct stones should be offered endoscopic stone extraction via ERCP with biliary sphincterotomy as the primary treatment approach, as this provides the highest success rates with acceptable morbidity and mortality. 1

Primary Endoscopic Approach

Standard ERCP Technique

• Biliary sphincterotomy with balloon or basket extraction is the first-line treatment for retained common bile duct stones. 1, 2, 3
• Stone extraction should be performed if possible, with evidence of greatest benefit for symptomatic patients. 1
• For optimal outcomes, ERCP should be performed with propofol sedation or general anesthesia in selected patients to improve tolerability and therapeutic success. 1
• Pre-procedure evaluation must include full blood count and INR/PT, with management of any coagulopathy or thrombocytopenia according to local protocols. 1

Management of Large or Difficult Stones

For stones that cannot be removed with standard techniques, endoscopic papillary balloon dilation (EPBD) as an adjunct to biliary sphincterotomy is recommended to facilitate removal of large stones. 1, 2, 3

Additional techniques include:

• Mechanical lithotripsy should be readily available in all ERCP units as a first-line adjunct for large stones (>15mm). 4, 5
• Cholangioscopy-guided electrohydraulic lithotripsy (EHL) or laser lithotripsy should be considered when other endoscopic treatment options fail to achieve duct clearance. 1, 2
• If initial extraction fails, placement of two or more bile duct stents with temporary decompression allows for subsequent attempts at stone removal. 4

Alternative Surgical Approach

Laparoscopic bile duct exploration (LBDE) via transcystic or transductal approach is an equally valid treatment option compared to perioperative ERCP, with no difference in efficacy, mortality, or morbidity, though LBDE is associated with shorter hospital stays. 1, 3

This surgical option should be considered when:

• Local surgical expertise is available 1
• Endoscopic access is challenging 1
• Patient is already undergoing laparoscopic cholecystectomy 1

Special Clinical Scenarios

Patients with Coagulopathy

• EPBD without prior biliary sphincterotomy may be considered in patients with uncorrected coagulopathy, using an 8mm diameter balloon. 1, 2, 3
• This approach carries increased risk of post-ERCP pancreatitis but avoids bleeding complications from sphincterotomy. 1

Altered Anatomy

• For Billroth II anatomy, ERCP can be successfully performed using a forward-viewing endoscope if standard duodenoscope approach is difficult. 1
• Patients with Roux-en-Y gastric bypass and retained stones should be referred to centers offering advanced endoscopic and surgical treatment options. 1
• Limited sphincterotomy supplemented by EPBD is suggested when biliary sphincterotomy cannot be safely completed. 1

Post-Cholecystectomy Patients

• For retained stones discovered after cholecystectomy, ERCP with biliary sphincterotomy and stone extraction remains the primary treatment. 2, 3
• Assessment should include liver function tests and imaging with CT or MRCP to evaluate ductal dilation and stone burden. 2

Urgent Situations

Patients with acute cholangitis who fail to respond to antibiotic therapy or who have signs of septic shock require urgent biliary decompression with endoscopic stone extraction and/or biliary stenting. 1, 2, 3

For biliary pancreatitis:

• Patients with pancreatitis of biliary origin who have associated cholangitis or persistent biliary obstruction should undergo biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation. 1

Common Pitfalls and Caveats

• Do not assume normal ultrasound and liver function tests exclude retained stones if clinical suspicion remains high—proceed with further investigation. 1
• Avoid attempting repeated failed extraction attempts at centers without advanced lithotripsy capabilities; early referral to tertiary centers improves outcomes. 4, 5
• For stones >10mm, expect higher failure rates with sphincterotomy alone—plan for adjunctive techniques from the outset. 6
• Anticoagulation and antiplatelet management must follow BSG and ESGE guidelines to balance bleeding and thrombotic risks. 1
• In patients with repeated pancreatic duct cannulation during ERCP, pancreatic stent insertion in addition to rectal NSAID reduces post-ERCP pancreatitis risk. 1