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Endoscopic Therapies for Management of Complex Choledocholithiasis

by Sâmara Martins

Choledocholithiasis is a complication of gallbladder stone disease that affects 10 to 20% of this population. The vast majority of cases (90%) are resolved with conventional endoscopic treatment techniques, however, the remaining 10% make up a population group that has a condition entitled complex choledocholithiasis [1].


Complex choledocholithiasis, also known as “difficult stone” or “stone of difficult management,” is defined according to some criteria that depend on the characteristics of the stone, location of the stone, patient anatomy, and factors associated with the patients.

  • Regarding the characteristics of the stones: Large stones (>15mm), multiple stones (> 3 stones larger than 10mm), hard stones, and those with unusual shapes (square or barrel) present difficulty in capture by the basket and generally require lithotripsy;
  • Regarding the location of the stones: Intrahepatic stones, above strictures, impacted in the common bile duct, or associated with Mirizzi syndrome offer difficulty in access;
  • Regarding the anatomical situation: Congenital or surgical alteration of the biliary tract (Billroth II/gastric bypass with Roux-en-Y) and duodenal diverticulum with peri/intradiverticular papilla that hinder access and limit the endoscope and accessory management;
  • Regarding the patient: Advanced age, poor clinical conditions, hemodynamic instability, tendency to bleed, and paradoxical responses that favor the occurrence of adverse effects;


Choledocholithiasis with non-complex stones generally achieves high rates of therapeutic success with the conventional technique of access and exploration of the biliary tract, usually with sphincterotomy and removal with an extraction balloon. In the case of complex stones, additional techniques are required for the complete resolution of the condition, such as papilla dilation with a balloon, use of a basket with a mechanical lithotripsy system, or even the use of cholangioscopy with laser lithotripsy.

Papilla dilation with balloon

Papilla dilation with a balloon is a method that can be used in association or not with endoscopic sphincterotomy and has the potential to reduce the use of mechanical lithotripsy by 30 to 50% [2].

Balloon dilation of a larger duodenal papilla with a hydrostatic balloon via ERCP.

Papilla dilation can assist in the resolution of stones in patients who have increased chances of post-sphincterotomy bleeding and those for whom complete sphincterotomy is not technically possible (intradiverticular, papilla with a small infundibulum). A careful selection of patients is suggested, avoiding forced procedures, ideal duration of dilation, and immediate conversion to alternative procedures.

Mechanical lithotripsy

Mechanical lithotripsy (ML) is a technique generally used after failure in the attempt to remove the stone after sphincterotomy and papilla dilation with a balloon, usually caused by a disproportion of the stone in relation to the distal biliary tract. It has a reported success rate between 79 to 96% and low mortality rates, as well as adverse effects (3.5%) [3].

The basket is used for stone capture and can also be an instrument for performing mechanical breaking of the stone in an integrated manner or with the use of an emergency lithotriptor.

Despite this, ML may require multiple sessions and still not be effective in the complete elimination of stones, therefore, requiring additional procedures with the use of more robust accessories such as cholangioscopy with electro-hydraulic or laser lithotripsy.
The success rate is inversely proportional to the diameter of the stone, with a 68% chance of resolution in stones larger than 28 mm and reaching 90% in stones less than 10mm in diameter [2]. Another factor that reduces the chances of resolution is the impaction of the stone in the biliary tract, shape molded by the biliary tract, and hardened stones.

Endoscopic biliary stent

The insertion of a biliary stent is a therapeutic option for patients with unsuccessful stone removal and the need for biliary drainage, thus avoiding cholangitis. The friction of the stent on the stones promotes their fragmentation and increases the chances of resolution in a subsequent approach.
Fully covered self-expanding metal stents can also be used to drain the biliary tract after an unsuccessful stone removal, however, with still questionable cost-effectiveness.

Cholangioscopy-guided lithotripsy

Cholangioscopy is a procedure that allows the visualization of the interior of the biliary tract and is performed through the use of a cholangioscope, an instrument that is inserted through the channel of the duodenoscope so that it can be introduced into the biliary tract visualizing its ducts and walls. This is a procedure ideally performed by experienced endoscopists and a trained team for the management of the accessory, reaching success rates of over 90% in clearing the biliary tract [1].
Cholangioscopy-guided lithotripsy can be performed through two modalities: laser (LL) or electro-hydraulic (LEH).

An important meta-analysis compared the success rate of extracorporeal lithotripsy (ECL), LL, and LEH in clearing the biliary tract, being 84.5%, 95.1%, and 88.4%, respectively, as well as higher complication rates in LEH procedures (13.8%), followed by LL (9.6%) and ECL (8.4%) [4]. However, another more recent meta-analysis compares LL vs. LEH showing superiority of success in the latter with therapeutic success rates of 88.6% and 91.4%, respectively [5].

It is recommended that such a procedure should be reserved for use in selected cases of failure with conventional ERCP, preferably being performed in a reference center, due to its complexity, cost, and adverse events, although some authors already defer its indication as first-line therapy for patients with complex choledocholithiasis in order to reduce the number of interventions and increase cost-effectiveness.


ERCP is a therapeutic procedure intended for the management of biliopancreatic tract diseases, including the management of stones in the biliary tracts. Complex choledocholithiasis, although infrequent, is still a condition that requires not only expertise in its management but also knowledge and skill of endoscopists. Today, we have a vast arsenal for resolving these cases, such as the use of a dilating balloon to correct the stone-papilla disproportion and lithotripsy instruments (mechanical, extracorporeal, and guided by cholangioscopy, whether laser or electrohydraulic) and it is of fundamental importance the training of teams for their correct use in such situations.


  1. Trikudanathan G, Navaneethan U, Parsi MA. Endoscopic management of difficult common bile duct stones. World J Gastroenterol. 2013 Jan 14;19(2):165-73. doi: 10.3748/wjg.v19.i2.165. PMID: 23345939; PMCID: PMC3547556.
  2. Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol. 2021 Nov 28;27(44):7597-7611. doi: 10.3748/wjg.v27.i44.7597. PMID: 34908801; PMCID: PMC8641054.
  3. Thomas M, Howell DA, Carr-Locke D, Mel Wilcox C, Chak A, Raijman I, Watkins JL, Schmalz MJ, Geenen JE, Catalano MF. Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers. Am J Gastroenterol. 2007 Sep;102(9):1896-902. doi: 10.1111/j.1572-0241.2007.01350.x. Epub 2007 Jun 15. PMID: 17573790.
  4. Veld JV, van Huijgevoort NCM, Boermeester MA, Besselink MG, van Delden OM, Fockens P, van Hooft JE. A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave. Endoscopy. 2018 Sep;50(9):896-909. doi: 10.1055/a-0637-8806. Epub 2018 Jul 10. PMID: 29991072.
  5. Galetti F, Moura DTH, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGH. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. Arq Bras Cir Dig. 2020 Jun 26;33(1):e1491. doi: 10.1590/0102-672020190001e1491. PMID: 32609255; PMCID: PMC7325696.

How to cite this article

Martins S. Endoscopic therapeutics for management of complex choledocholithiasis. Endoscopia Terapeutica, 2024, vol 1. Available at: https://endoscopy.news/general-topics/endoscopic-therapies-for-management-of-complex-choledocholithiasis/

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Cirurgiã Geral SES-SP;
Médica Endoscopista FMABC;
Título de especialista SOBED;
Mestranda em Ciências da Saúde da Faculdade de Medicina do ABC de Santo André;
Hospita Geral Prado Valadares.


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