Difficulties in endoscopic removal of large bile duct stones. Experience in last 5 years

Background: Large biliary duct stones are difficult to remove endoscopically. Disparity between the lenght of the sphincterotomy and the diameter of the stones mandates large stones to be fragmented before removal to achieve biliary duct clearence.

The aim of this study was to determinate the predictors of success or failure of mechanical lithotripsy in patients with large biliary duct stones.

Methods: A retrospective study was performed in a 5-year period. 118 consecutive patients with large bile duct stones underwent endoscopic retrograde cholangiography, sphyncterotomy, mechanical lithotripsy and basket removal of stones. In cases where the firts interventions were failed, biliary stent implantation was done, and after 6 weeks ursodeoxycholic acid treatment, the endoscopic intervention were repeated.

Results: Between 2000–2004 in total 1345 patients undervent endoscopic retrograde cholangiography. From this choledocholithiasis was found in 315 (23%) patients. In 118 cases the bile duct stones were large (>2cm diameter). In 29 patients the extraction of stones were successful with Dormia basket, in 33 patients by lithotripsy. In 47 cases the first endoscopic stone removal was unsuccessful All of this patient were treated by endoscopic stent implantation, and ursodeoxycholic acid for 6–8 week. After this period the second endoscopic retrograd cholangiography for stone removal was successful in 38 (81%) cases. Only 16 (13%) patient undervent surgical intervention.

Conclusions: The authors propose the second mechanical lithotripsy in cases where the firts endoscopic was unsuccessful. The repeated endoscopic biliary stones removal was successful in about 81% of patients with large bile duct stones after stenting and 6–8 week ursodeoxycholic acid therapy.