Difficult bile duct stones |
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Authors: | Lee McHenry MD Glen Lehman MD |
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Institution: | (1) Indiana University Medical Center, 550 North University Boulevard, Suite 4100, 46202 Indianapolis, IN, USA |
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Abstract: | Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy
with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones
may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y
gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct
or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter
orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a
readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction
fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression,
stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed
locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal
fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can
be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical
bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the
patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult
bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient
outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary. |
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