Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy
- Isaac Raijman, MD
Isaac Raijman, MD
- Clinical Associate Professor of Medicine
- Baylor College of Medicine, Houston, TX
- Digestive Associates of Houston, PA
Choledocholithiasis (a gallstone in the common bile duct) occurs in 15 to 20 percent of patients with cholelithiasis. The majority of gallstones form in the gallbladder and then pass into the common bile duct via the cystic duct. Common bile duct stones can also develop in patients who have an apparently normal gallbladder; such patients represent about 10 percent of those with choledocholithiasis. In addition, approximately 5 percent of patients who have undergone a cholecystectomy have a retained or recurrent stone .
The introduction of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy in the late 1970s has virtually supplanted surgery for the treatment of this condition [2,3]. This topic will review the most frequently used endoscopic techniques for common bile duct stone clearance (including sphincterotomy and/or balloon dilation of the ampulla followed by stone extraction using baskets and extraction balloons) and mechanical lithotripsy. Other issues related to gallstones and their complications are presented separately. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Endoscopic ultrasound in patients with suspected choledocholithiasis" and "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications" and "Endoscopic balloon dilatation for removal of bile duct stones" and "Common bile duct exploration".)
The term sphincterotomy refers to severing of the deep muscle layers of the sphincter of Oddi. In contrast, papillotomy suggests cutting of the superficial papillary sphincter of the main duodenal papilla. However, in practice, these terms are used interchangeably.
Sphincterotomy is the most commonly used therapy for treatment of choledocholithiasis. The goal of the sphincterotomy is to cut the biliary sphincter (figure 1), thereby eliminating the principal anatomic barrier impeding stone passage and facilitating stone extraction.
Technique — Standard sphincterotomy involves the application of electrocautery to create an incision through the musculature of the biliary portion of the sphincter of Oddi. A number of different devices are available with that vary in design to facilitate the procedure depending upon specific anatomic considerations. In expert hands, a sphincterotomy is possible in 95 to 100 percent of patients. (See "Standard biliary sphincterotomy technique: The cutting edge".)
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- - Short-term complications
- - Long-term complications
- - High-risk patients
- - Safety of outpatient sphincterotomy
- - Cholecystectomy following sphincterotomy
- PAPILLARY BALLOON DILATION
- BASKETS AND EXTRACTING BALLOONS
- MECHANICAL LITHOTRIPSY
- EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
- ELECTROHYDRAULIC LITHOTRIPSY
- LASER LITHOTRIPSY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS