Endoscopic and Surgical Approaches for Bile Duct Stone Management

The management of bile duct stones encompasses a spectrum of endoscopic and surgical strategies designed to achieve reliable stone clearance while minimising patient morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and adjunctive balloon or basket extraction remains first‐line for common bile duct stones. For large or impacted calculi, advanced lithotripsy modalities—including mechanical, electrohydraulic or laser techniques delivered via single‐operator cholangioscopy—have expanded the therapeutic arsenal. Endoscopic papillary large‐balloon dilation, with or without limited sphincterotomy, has further optimised extraction of difficult stones. When endoscopic clearance is not feasible or in cases of recurrent or complex disease, laparoscopic common bile duct exploration (LCBDE) offers a single‐stage surgical alternative, employing transcystic or choledochotomy routes. LCBDE achieves high clearance rates and may reduce overall hospital stay and costs, dependent on local expertise. Open exploration remains a reserved option for anatomically challenging cases or failed minimally invasive attempts. Integration of tri‐endoscopic approaches, combining laparoscopy, duodenoscopy and choledochoscopy in a single session, is emerging as a cost‐effective strategy. Selection of the optimal approach requires consideration of stone characteristics, patient comorbidities and institutional resources.

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Endoscopic and Surgical Approaches for Bile Duct Stone Management publication trend

The graph below shows the total number of articles in endoscopic and surgical approaches for bile duct stone management across all publications each year (not limited to Nature Index journals).

Technical terms

Choledocholithiasis: Presence of stones within the common bile duct.

Endoscopic retrograde cholangiopancreatography (ERCP): Endoscopic technique to visualise and treat biliary and pancreatic ducts.

Endoscopic sphincterotomy (ES): Division of the biliary sphincter to facilitate stone extraction.

Laparoscopic common bile duct exploration (LCBDE): Minimally invasive surgical removal of bile duct stones via laparoscopy.

Choledochotomy: Surgical incision into the common bile duct to access and remove stones.

Transcystic approach: Stone extraction via the cystic duct without direct choledochotomy.

Lithotripsy: Fragmentation of stones using mechanical, electrohydraulic or laser energy.

References

1. Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback. World Journal of Emergency Surgery (2023).
2. Recurrent common bile duct stones as a late complication of endoscopic sphincterotomy. BMC Gastroenterology (2018).
3. Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study. BMC Surgery (2017).
4. Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones. BMC Gastroenterology (2013).
5. Single-stage management with combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis. Surgical Endoscopy (2016).
6. Laparoscopic Transcystic Common Bile Duct Exploration: Advantages over Laparoscopic Choledochotomy. PLOS ONE (2016).
7. Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (2022).