What are the guidelines for stenting vs stone removal in choledocholithiasis?

Guidelines for Stenting vs Stone Removal in Choledocholithiasis

Primary Recommendation

Stone extraction should be offered to all patients with choledocholithiasis whenever technically possible, with biliary stenting reserved only as a temporary measure or for highly selected patients with prohibitive surgical risk and limited life expectancy. 1

Treatment Algorithm

First-Line: Complete Stone Removal

Endoscopic stone extraction via ERCP with sphincterotomy is the primary treatment approach, achieving 90% success rates in standard cases. 2, 3 The goal is complete duct clearance, not temporary drainage. 1

• For large stones (≥10mm): Endoscopic papillary large balloon dilation (EPLBD) combined with sphincterotomy facilitates removal and achieves 95.6% complete clearance rates. 1, 2, 4
• For difficult stones: Mechanical lithotripsy should be employed when standard basket/balloon extraction fails. 1
• When conventional techniques fail: Cholangioscopy-guided electrohydraulic or laser lithotripsy achieves 73-97% stone clearance rates and should be attempted before abandoning extraction efforts. 1, 2

Surgical Alternative: Laparoscopic Bile Duct Exploration (LBDE)

LBDE is equally valid to ERCP with no difference in efficacy, mortality, or morbidity, but offers shorter hospital stays (approximately 8 days faster return to work). 1, 2 This should be considered an equivalent first-line option when local expertise exists. 1

• Transcystic approach works for small stones with limited common hepatic duct access. 1
• Transductal approach allows retrieval of larger stones and better duct access. 1
• Intraductal lithotripsy (piezoelectric or laser) can increase clearance rates to near 100%. 1

Last Resort Options Before Stenting

Percutaneous radiological stone extraction and open duct exploration should be reserved for patients in whom endoscopic and laparoscopic techniques fail or are not possible. 1, 2 These are preferable to permanent stenting in patients who can tolerate intervention. 2

When Stenting Is Appropriate

Temporary Stenting (Strong Recommendation)

Short-term biliary stent placement is recommended when stones cannot be extracted during the initial procedure, followed by further endoscopy or surgery within 4-6 weeks. 1, 2 This ensures adequate biliary drainage while planning definitive treatment. 1

• Use for acute cholangitis or sepsis to stabilize patients before definitive extraction. 2
• Place when complete clearance cannot be achieved but patient can tolerate future intervention. 1

Permanent Stenting (Restricted Use)

Biliary stenting as sole treatment should be restricted to highly selected patients with limited life expectancy and/or prohibitive surgical risk. 1 This is explicitly a compromise, not standard care. 1

• Consider only when operative risk is deemed prohibitive. 1
• Recognize this leaves stones in situ with ongoing risks. 1

Critical Pitfalls to Avoid

Never proceed directly to permanent stenting without attempting advanced endoscopic techniques including EPLBD, mechanical lithotripsy, and cholangioscopy-guided lithotripsy. 2 The 6-10% complication rate of sphincterotomy is far lower than accepting untreated stone disease. 2

Do not accept incomplete stone clearance as adequate treatment in patients who can tolerate further intervention. 1 Residual stones carry risks of recurrent cholangitis, pancreatitis, and biliary obstruction. 1

Avoid using "difficult anatomy" as justification for stenting alone when percutaneous or surgical options remain available. 1 Expertise should be sought at referral centers for complex cases. 2

Special Populations

Elderly Patients (≥90 years)

ERCP with stone extraction remains safe and effective in patients ≥90 years old, with similar complication rates (9.5% vs 7.7% in younger elderly). 5 However, complete stone removal rates are lower (81.0% vs 94.9%), making permanent stenting more acceptable in this population when extraction fails. 5

Patients with Coagulopathy

EPBD without prior sphincterotomy may be considered as an alternative to sphincterotomy in patients with uncorrected coagulopathy, though this carries increased pancreatitis risk. 1 Anticoagulation should be managed per BSG/ESGE guidelines. 1

Patients with Gallbladder In Situ

After successful duct clearance, prophylactic cholecystectomy significantly reduces mortality (7.9% vs 14.1%) and recurrent biliary events over follow-up periods of 17 months to 5+ years. 1 The gallbladder should not be left in place after stone extraction unless surgical risk is prohibitive. 1