Digestive Diseases and Sciences (2022) 67:1613–1623

https://doi.org/10.1007/s10620-022-07424-9

REVIEW

Management of Difficult Choledocholithiasis

Alexander Podboy1 · Srinivas Gaddam1 · Kenneth Park1 · Kapil Gupta1 · Quin Liu1 · Simon K. Lo1

Accepted: 21 January 2022 / Published online: 29 March 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction,
and over 10–15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics
of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult cases. We describe
additional special clinical circumstances in which difficult biliary stones are identified and provide additional management
strategies to aid endoscopic stone extraction efforts.

Keywords  Gallstones · Endoscopic retrograde cholangioscopy (ERC) · Lithotripsy

Alexander Podboy  Srinivas Gaddam  Kenneth Park  Kapil Gupta

Simon K. Lo is the article guarantor, who accepts full

responsibility for the conduct of the study.

* Simon K. Lo
Simon.Lo@cshs.org
1
Pancreatic and Biliary Disease Program, Department Quin Liu Simon K. Lo 
of Digestive Diseases, Cedars Sinai Medical Center, 8700
Beverly Boulevard, South Tower, Suite 7511, Los Angeles,
CA 90048, USA

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1614 Digestive Diseases and Sciences (2022) 67:1613–1623

Introduction Extension of the Biliary Orifice: The Knife,

Approximately 20 million Americans are afflicted with gall-
stones, with an estimated health care impact of 6.5 billion
dollars per year in the US [1]. While the true prevalence of
common bile duct stones is unknown, 10–20% of individuals
with symptomatic gallstones also possess concurrent com-
mon bile duct (CBD) stones, suggesting a substantial bur-
den of undiagnosed asymptomatic CBD stone disease within
the US [2]. Owing to the significant risk of morbidity and
potential mortality from obstructive common bile duct stone
induced cholangitis or pancreatitis, many current societal
guidelines recommend biliary stone extraction for all iden-
tified bile duct stones regardless of symptoms [3, 4]. Since
the first description in the 1970s, the first-line treatment for
biliary stone extraction in the US is endoscopic retrograde
cholangiography (ERC) [5].
While initial ERC-based therapies are effective in
85–90% of cases [3, 4, 6], 10–15% of stone cases cannot be
treated with standard ERC-based practices, and these “dif-
ficult biliary stones” can represent a significant therapeu-
tic challenge [6]. Once biliary access is established, stone
characteristics such as large stones (> 1.5 cm in diameter),
numerous stones, unusually shaped (i.e., barrel-shaped)
stones, or stones in difficult to access locations (impacted
stones at the ampulla, cystic duct, or intrahepatic stones) can
all contribute to failure of traditional stone extraction meth-
ods [4, 6]. Additionally, biliary anatomical factors such as
downstream biliary ductal narrowing, sigmoid ductal shape,
bile duct diverticulum, short ductal length, or hyper-acute
biliary ductal angulation [4] have also been linked to failure
of traditional ERC stone extraction methods. Table 1 lists
common causes of difficult biliary stones. The goal of this
review is to provide an overview of current management
strategies for difficult or complex common bile duct stones.
the Balloon or Both?
Following biliary cannulation, a critical step to successful
biliary stone extraction is the creation of an adequate exit
for the stones via enlarging the biliary orifice. This is largely
performed by two methods, endoscopic sphincterotomy (ES)
or endoscopic papillary balloon dilatation (EPBD). The
practice of endoscopic sphincterotomy utilizes a bowed
sphincterotome fitted with a metal wire to facilitate passage
of a blended high cutting current and low coagulation cur-
rent to the roof of the papillary hood to enlarge the orifice
[4, 7].
Balloon dilatation enlarges the papillary orifice by utiliz-
ing a catheter-based balloon to stretch the elastic wall of the
papillary sphincter. Theoretically, EPBD is thought to better
preserve the architecture of the papillary sphincter, allow-
ing it to maintain its usual function and is associated with
lower rate of postprocedural bleeding [7, 8]. More recently,
endoscopic sphincterotomy + endoscopic papillary dilatation
(ES + EPBD) has been advocated to facilitate passage of dif-
ficult or complex stones. Direct comparison on the impact
of stone extraction between all three modalities has not been
evaluated in a single study [4, 5]. However, in a recent net-
work meta-analysis comparison of the efficacy of the three
techniques (ES, EPBD, and ES + EPBD) on stone extraction,
ES was noted to be superior to EPBD in facilitating same
session stone clearance (EPBD vs. ES 0.59 odds ratio (OR)
[0.36–0.94, 95% confidence interval (CI)]). While no sig-
nificant difference was noted between ES and ES + EPBS in
same session stone clearance (1.71 vs. 1.70 OR [0.92–3.17,
95% CI]) there was significantly less use of mechanical
lithotripsy with combination therapy compared to ES alone
(0.49 OR [0.29–0.83, 95% CI] [9]. While there was an
increased risk in sphincterotomy related bleeding in combi-
nation therapy, the overall increase in post sphincterotomy
bleeding was relatively low (3.0% [1.8–5.2%, 95% CI]) in
ES, 1.1% (0.6–2.0%, 95% CI) in EPBD, and 2.0% (0.9–4.4%,
95% CI) in ES + EPBS. The pooled incidences of perforation
were also similar among the groups 1.2% (0.7–2.0%, 95%
CI), 1.1% (0.6–2.1%, 95% CI), and 0.9% (95% CI 0.3–2.1%)

Table 1  Etiologies of difficult biliary stone extraction

Stone characteristics Papillary access issues Bile duct characteristics Stone location

Etiologies for difficult biliary stone extraction

Large stones > 1.5 cm
Numerous stones
Barrel-shaped stones
Stones with unusual hardness
Surgically altered anatomy
Luminal narrowing (intrinsic or
extrinsic)
Duodenal/biliary diverticula
Papillary stenosis
Redundant papillary tissue
Recessed or obscured papilla
Sigmoid ductal shape Intrahepatic stones
Short ductal length Cystic duct stones
Hyper-acute biliary ductal angulation Impacted ampullary stones
Downstream biliary stricture Mirizzi’s
Bile duct diverticulum

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Digestive Diseases and Sciences (2022) 67:1613–1623 1615
Fig. 1  Mechanical lithotripsy of
a large common bile duct stone.
(A) Cholangiogram depicting a
large intrabiliary stone within
the mid common bile duct. (B)
Depicts basket envelopment
of the stone in anticipation of
mechanical lithotripsy
for ES, EPBD, and ES + EPBD, respectively [9]. There was
no significant difference in rate of post-ERCP related pan-
creatitis between EPBD and ES. [0.80–2.54 (95% CI)].
Based on this analysis [9] and similar results from other
systematic reviews [10], the current international consen-
sus recommendation is to use combination ES + EPBD as
a first-line adjunctive approach to facilitate difficult biliary
stone removal for stones that are smaller than 1.5 cm [4,
5]. The size of sphincterotomy and balloon dilatation in
ES + EPBD has not been formally evaluated in prospective
studies as the determination of ultimate balloon diameter is
largely predicated on the diameter of the distal CBD, as risk
of perforation increases when the diameter of the balloon
exceeds the CBD ductal diameter [5]. A recent literature
review suggested performing a limited endoscopic sphinc-
terotomy (approximately 1/2 of the distance to the papillary
roof) rather than full sphincterotomy prior to EPBD to help
minimize the risk of potential complications [6]. However,
this recommendation has not be validated prospectively.
In our practice, we typically perform a sphincterotomy
without reaching the “maximum cut”, followed by balloon
dilatation sized to the diameter of the distal common bile
duct as our first-line therapy for most large gallstones.
Mechanical Lithotripsy
First introduced for endoscopic use in 1982, mechanical
lithotripsy utilizes the compressive force generated from
mechanical retraction of a wire basket into a metal sheath to
fragment/crush biliary stones captured within the basket and
is generally considered a first-line device for management of
large stones (> 1.5 cm) (Fig. 1). There are largely two major
designs of mechanical lithotripters, integrated, and salvage
devices. Integrated devices are designed for use through the
operating channel of the duodenoscope. Salvage devices
consist of only the metal sheath and handle and are typically
used when a non–lithotripsy-compatible basket containing a
stone becomes impacted and is unable to be removed during
attempted stone extraction [7].
In a retrospective analysis of mechanical lithotripsy on
difficult biliary stones (> 1.5 cm or failed previous tradi-
tional stone removal), Chang et al. found mechanical litho-
tripsy initially successful for stone extraction in 77.5% of
patients, with an additional 22% cumulative success rate
with multiple sessions [11].
Predictors for mechanical lithotripsy failure were ana-
lyzed by Lee et al. [12] that noted increased rates of failure
for impacted stones (OR 17.83), large stones (≥ 30 mm;
OR 4.32), and stones with high size to bile duct diameter
ratio (> 1.0; OR 5.47). There was no difference in compli-
cation rates between the successful and failed mechanical
lithotripsy groups. When mechanical lithotripsy failed, all
patients were successfully treated using various modalities,
including surgery, without mortality.
The most identified complications related to mechani-
cal lithotripsy include basket failure (1.7%), wire fracture
(1.2%), broken basket handle (1.1%), and ductal injury/per-
foration (0.5%) [13].
In our experience, mechanical lithotripsy is a highly suc-
cessful strategy for very large (> 1.5 cm) stones or large
stones that have failed extraction attempts post sphincter-
otomy and papillary dilatation. While providers and cent-
ers may have wide variations in mechanical lithotripsy
techniques, we employ several techniques that we believe
amplify facilitation of successful stone extraction and mini-
mize potential failure. Minimizing basket angulation helps
trap stones for fragmentation and we often will maneuver the
basket to keep the basket as straight as possible. Orienting
the duodenoscope in order to approach the papilla in as a
much a retrograde position as possible either in the long or
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Fig. 2  Direct cholangioscopy of large intrahepatic duct stone. (A)
Endoscopic image of direct cholangioscopy bile duct cannulation. (B)
Cholangiogram depicting intrahepatic duct stone. (C) Direct cholan-
exaggerated long position can be advantageous in achiev-
ing the optimal positioning. Once the basket is in position,
utilization of contrast is important to confirm stone position
and location in order to guide optimal basket manipulation
and ensure that all the wires have fully encircled the stone
(Fig. 2). It is important to be cognizant of the fact that bas-
ket wires can often become misshapen and that reshaping
the wires can help enhance the capture and crushing, espe-
cially after two or three attempts at mechanical lithotripsy.
It is important to avoid opening or closing the basket across
the elevator, as that may lead to entanglement of the wires
around the elevator. Finally, stone fragments often find their
way under the elevator and lead to failure of the elevator to
lower or difficulty to extend the basket outside of the instru-
ment channel. Whenever this problem occurs, the only way
to remedy the situation is to remove the endoscope from the
patient and clear the space under the elevator.
Lithotripsy: Electrohydraulic or Laser?
Alternative advanced stone fragmentation maneuvers
include electrohydraulic lithotripsy, laser lithotripsy, or
extracorporal shock wave (ESWL) therapy. Electrohydrau-
lic Lithotripsy (EHL) promotes stone fragmentation via
probe-based delivery of short electrical charges into an aque-
ous medium. These shocks stimulate the creation of high
frequency hydraulic pressure waves that can oscillate into
nearby biliary stones, resulting in concussive fragmentation
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Digestive Diseases and Sciences (2022) 67:1613–1623
gioscopy-mediated electrohydraulic lithotripsy (EHL), note progres-
sive stone fracturing between the images related to EHL-mediated
effect (left to right)
[7, 14]. Laser lithotripsy (LL) utilizes pulsed laser light to
create high energy plasma at the stone surface/adjacent fluid.
The rapid expansion and subsequent collapse of this plasma
creates spherical mechanical shock waves between the laser
fiber and stone, inducing stone fragmentation [15].
In both methods, the desired pressure waves need to be
in close proximity to the stones in order to be effective and
to limit the potential for inadvertent ductal injury, direct
cholangioscopy is typically employed [16]. Several meth-
ods including dual-operator cholangioscopy, single-operator
cholangioscopy, and direct cholangioscopy with an ultrathin
endoscope have all been utilized [4]. However, widespread
use of these modalities have been blunted either by operating
difficulty (ultrathin), cumbersome operating requirements
(2-operator system) or suboptimal image quality (single-
operator cholangioscopy) [17]. More recently, a single-oper-
ator cholangioscopy system with new digital video inputs
(SpyGlass DS; Boston Scientific, Marlborough, MA) has
been introduced and is now the most widely utilized tool to
facilitate EHL or LL therapy in tertiary biliary centers [15].
ESWL or Extracorporeal shockwave lithotripsy utilizes
the creation of high pressure shock waves generated by
piezoelectric crystals or electromagnetic membrane tech-
nology, however unlike EHL or LL, close proximity to the
biliary stone is not required as acoustic focusing allows for
the shock waves to originate outside the body [7, 18]. Typi-
cally, external ultrasound or fluoroscopy is utilized to help
localize the stone noninvasively.
Digestive Diseases and Sciences (2022) 67:1613–1623 1617

Comparisons between the three modalities are limited and

Sphincterotomy + Papilary
currently the ASGE recommends the decision largely on a Balloon Dilaon
local level in conjunction with local expertise, cost, patient,
and physician preference [19].
In a multicenter comparison of single-operator direct
Mechanical Lithotripsy
cholangioscopy, EHL and LL performed similarly with
excellent clinical success rates with 97% technical success in
306 patients treated with EHL versus 99% clearance in 101
patients with LL. Complication rates between the techniques Endoprosthesis Placement
were also similar with cholangitis (n = 6) and abdominal
pain (n = 5) reportedly in only a minority of patients. How-
ever, EHL was associated with longer procedure times [20]. Repeat Mechanical
In a randomized trial comparing fluoroscopic guided Lithotripsy
ESWL and LL for choledocholithiasis, LL was preferred, with
higher stone free rates (73% vs. 97%), and decreased number
of required sessions and duration of treatment [21]. Another Electrohydraulic or Laser
Lithotripsy
randomized trial comparing ultrasound guided ESWL and
laser lithotripsy in the treatment of CBD stones refractory
to conventional treatment also demonstrated superior stone
clearance rate for laser lithotripsy (52.4% vs. 82%) [22]. Endoprosthesis Placement
In a systematic review of the treatment of difficult bil-
iary choledocholithiasis, similar efficacy was seen in
conventional (ES, EBPD, and ML) versus intraductal Extracorporeal shockwave
lithotripsy
approaches (EHL/LL) (92% for both) [14]. However, in a
RCT of patients that had previously failed attempts at stone
removal, increased efficacy for intraductal versus conven- Post ESWL Mechanical
tional therapy was noted (90% vs. 54%), while no difference Lithotripsy
in efficacy was noted in patients that had not undergone a
prior procedure, highlighting that conventional therapy with
ES + EPBD coupled with ML is a highly successful initial Endoprosthesis Placement
strategy and intraductal therapy should be considered as
an adjunctive therapy for difficult to treat stones [14]. Sev-
eral prospective clinical trials are underway to investigate
potential differences between EHL and LL on difficult stone
extraction. (ClinicalTrials.gov Identifier: NCT03244163).
At our institution we utilize either EHL or LL utilizing
the single-operator cholangioscopy system following unsuc-
cessful attempts at mechanical lithotripsy (Fig. 2). The
decisions regarding EHL or LL are predicated on operator
experience. We utilize ESWL for stones in which EHL or
LL have failed, or as rescue therapy for failed mechanical
lithotripsy cases with simultaneous trapped basket and stone
impaction.
The Role of Endoprosthesis for Biliary Stones
Reestablishing antegrade biliary flow in the setting of
obstructive biliary lithiasis is paramount in any success-
ful treatment for choledocholithiasis. When bile duct stone
removal is not possible, stent placement is recommended [4].
This is particularly pertinent in difficult stones associated
with acute cholangitis. The frictional force of the indwelling
and Surgical Evaluaon
Fig. 3  An algorithmic approach to the management of difficult chole-
docholithiasis
stent on any remaining intraductal stone has been associated
with stone fracturing, reduction in stone size, and improve-
ment in future stone removal attempts [14, 23]. In a study of
60 patients with difficult bile duct stones, pre-treatment with
plastic biliary stenting was associated with decreased pro-
cedural times. The authors concluded that the plastic stent
appeared to change the character of the indwelling stones,
making them more conducive to mechanical lithotripsy
by increasing the friability of the stones [16]. However,
the required size and duration of stent placement prior to
enhanced facilitation of stone removal is unknown with sev-
eral studies demonstrating no difference with various stent
sizes and a range of several weeks to several months prior
to enhanced stone retrieval [4].
In the community clinical practice setting, many physi-
cians choose to use straight plastic stents designed to treat
biliary obstruction. The anchoring ability of these stents
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is often inadequate to ensure proper stability of the stents
within the bile duct. Modifying the stents by adding extra
flaps in the lower portion of the stents often reduces the
chance of distal migration. It is our standard clinical practice
to utilize a surgical scalpel to cut extra flaps into the plas-
tic stent to aid stent anchoring. Alternatively, double pigtail
stents may be used to provide the needed stability.
The use of fully covered metal stent placement for diffi-
cult to treat biliary stones which failed plastic stent drainage
has also been reported [23]. However, widespread adoption
of FCEMS has been limited secondary to cost concerns.
Medical stone dissolution therapy with ursodeoxycholic
acid (UDCA) with or without terpene preparation (Rowa-
chol) in conjunction with biliary endoprosthesis is not cur-
rently recommended as two RCTs failed to demonstrate a
reduction in biliary stone size or successful duct clearance
[19, 24].
Several porcine studies have demonstrated preliminary
success of either coated or impregnated plastic and FCSEMS
with sodium cholate (SC) and disodium ethylene diamine
tetraacetic acid (EDTA) compounds linked to stone dissolu-
tion, however their clinical use has not yet been evaluated
[25, 26].
Algorithmic Approach to Difficult
Choledocholithiasis
So when faced with difficult biliary stones, what is the
preferred treatment method? Figure  3 demonstrates our
institution’s approach to difficult biliary stones that mimics
Fig. 4  Cholangiogram depicting a large amount of intrahepatic duct
stones secondary to recurrent pyogenic cholangitis
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Digestive Diseases and Sciences (2022) 67:1613–1623
previously published algorithms [27]. Once biliary access
is established, we utilize the combination of sphincterot-
omy + EPBD when possible. Our practice utilizes a lim-
ited sphincterotomy with balloon dilatation sized to the
diameter of the distal bile duct. If balloon sweeping fol-
lowing combined ES + EPBD is not efficacious, we uti-
lize basket retrieval attempts. If mechanical lithotripsy
fails, we then establish continuity of biliary drainage with
plastic endoprosthesis with plan for repeat ERC typically
within 4–6 weeks. Our anecdotal experience mimics previ-
ous reports that note easier stone fracturing secondary to
indwelling stenting. During the follow-up ERC, mechani-
cal lithotripsy is again attempted with plans for intraductal
therapy if mechanical therapy is not successful. At our center
EHL is employed secondary to provider experience. If EHL
fails, we then repeat endoprosthesis and plan for ESWL
therapy. If the above algorithm is unsuccessful, we recom-
mend surgical extraction. Cost-effective analyses and formal
prospective analyses of this ‘graded’ approach to difficult
biliary stones are needed.
Special Situations
Recurrent Pyogenic Cholangitis
Recurrent pyogenic cholangitis (RPC), a disease predomi-
nately found in East Asian countries, often represents a chal-
lenging cause of biliary stone disease (Fig. 4). RPC patho-
logically is characterized by the development of pigmented
calcium bilirubinate stones within dilated strictured intrahe-
patic ducts although in 60% of cases stones are also identi-
fied in the common hepatic and common bile duct [27].
Etiology for these stones is unknown although smolder-
ing bacterial infection, concurrent or remote parasitic infec-
tion, or mucus hyperproduction have all been postulated as
potential etiologies.
Because of occurrence of both intrahepatic strictures
and stones, biliary stone disease in RPC can be incredibly
challenging to manage endoscopically. Our approach to the
difficult biliary stone disease in RPC is targeted removal of
stones that are considered the source of cholangitis or jaun-
dice, without aiming to remove all the intrahepatic stones.
Liver abscess or unrelenting biliary sepsis are often due to
overzealous endoscopic attempts to achieve the improb-
able by disrupting an otherwise chronically stable condi-
tion. Many patients may experience an occasional episode
of mild pain or transient fever that may be easily controlled
by a short course of oral antibiotic. If extrahepatic stones
or stones within the left or right hepatic duct have been
removed and the patient remains symptomatic, then a par-
tial hepatectomy to remove the liver segment with a heavy
stone burden or combined approach with percutaneous
Digestive Diseases and Sciences (2022) 67:1613–1623 1619
transhepatic manipulations should be considered. In clini-
cal scenarios that demand more aggressive endoscopic
treatment, a progressive systematic strategy to clear each
intrahepatic ductal system with dilatation and mechanical
or intraductal lithotripsy is recommended. When one of
the systems is cleared, we then schedule a repeat ERC in
4–6 weeks for evaluation and clearance of a subsequent duct.
Mirizzi Syndrome
Gallstone trapped in the cystic duct with compression and
obstruction of the common hepatic duct, Mirizzi’s syn-
drome, is often a challenging clinical entity to manage as
it challenges the typical “cholecystectomy-first” paradigm,
as often the bile duct obstruction may not be resolved with
surgical cholecystectomy. Likewise, an ERC-first approach
may only allow insertion of a stent into the common hepatic
duct to decompress the ductal obstruction if it is even tech-
nically feasible. Mirizzi syndrome may also be mimicked
by cholangiocarcinoma or cystic duct cancer, which further
complicates the diagnostic and therapeutic approach to the
condition. In patients unsuitable for surgical intervention,
therapeutic decompression via ERC with papillotomy, fol-
lowed by stent placement or naso-biliary tube drainage
(NBD), and direct cholangioscopy with LL or EHL have all
been utilized successfully [28, 29].
Our practice for all potential Mirizzi’s syndrome cases
is to first investigate the condition with a cholangiographic
Fig. 5  Biliary stone extraction in Roux-En-Y anatomy via use of double balloon enteroscopy device. (A) Depicts cholangiogram demonstrating
large common bile duct stone. (B) Endoscopic mechanical lithotripsy and basket retrieval
examination and attempt to remove the impacting stone if it
happens to reside mostly within the common bile duct. Once
it is determined that the stone is within the cystic duct, we
would place a stent to bypass the point of obstruction and
await the surgical outcome. Occasionally, we may have to
re-investigate the bile duct and perform further ductal clear-
ance or manage surgery related complications such as bile
duct leakage or postoperative stricture.
Cystic Duct Stones
While post-cholecystectomy retained cystic duct stone is not
technically a bile duct stone condition, it may cause similar
RUQ symptoms and pose similar challenges to problematic
choledocholithiasis. Diagnosing this condition is often dif-
ficult as it is rarely on the initial differential diagnosis and
confirmed radiographically. Even when it is found, there
is always some doubt as to its relationship to the patient’s
complaints.
Whenever it is discovered during an ERC, we prefer to
pass a guidewire around the duct and to dilate the cystic
duct with a small caliber balloon. This may free up suffi-
cient space to allow a small basket or extraction balloon to
remove a small stone. When that is not possible, we would
leave a plastic stent alongside the stone and return later with
a single-operator cholangioscope to deliver EHL to break
down the stone for extraction.
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Fig. 6  Biliary stone extraction in hepaticojejunostomy anatomy via use of double balloon enteroscopy device. (A) Depicts endoscopic balloon
retrieval. (B) Cholangiography depicting intrahepatic duct stone
Altered Anatomy
Accessing the papillary orifice in which intestinal continuity
has been altered or disrupted can be challenging, especially
when the afferent limb is very long (> 50 cm) and prevents
biliary stone removal via a traditional duodenoscope. Pedi-
atric colonoscope, enteroscopy-assisted ERC, and radiology-
assisted rendezvous have all be utilized to aid in establishing
papillary access and stone removal. Performing ERC with a
duodenoscope through a surgically placed laparoscopic port
or large gastrostomy, or through a lumen-apposing metal
stent (LAMS) with the endosonographic directed stent
placement (EDGE) have also been done with success.
The choice of the specific intervention is often predicated
on provider experience and the availability of specialized
equipment and is beyond the scope of this review. A retro-
spective analysis of enteroscopy-assisted ERCP (e-ERCP)
compared to EUS-guided biliary drainage (EUS-BD) dem-
onstrated higher rates of technical and clinical success with
lower procedural duration of EUS-BD compared to e-ERCP,
however higher rates of complications were noted in EUS-
BD (20% vs. 4% in e-ERCP) and follow-up was too brief
for detailed assessment of long-term adverse events [30]. A
multicenter retrospective series for Roux-en-Y gastric bypass
patients comparing EUS-guided gastrogastric fistula crea-
tion with LAMS to e-ERCP noted higher technical success
rate for the EUS group (100% vs. 60%) and shorter proce-
dure length (49.8 min vs. 90.7 min) with similar adverse
events (10% vs. 6.7%) [31]. A recent meta-analysis of
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Digestive Diseases and Sciences (2022) 67:1613–1623
laparoscopy-assisted ERCP compared with e-ERCP noted
higher success rates with laparoscopic-assisted ERCP, but
higher complication rates and procedure length as well [32].
Figures 5 and 6 depict utilization of enteroscopy-assisted
biliary stone removal in Roux-en-Y and hepaticojejunostomy
anatomy.
Our clinical practice for these altered anatomy cases is
to utilize enteroscopy-assisted ERC first, and only offer
EUS, transhepatic- or laparoscopy-assisted techniques fol-
lowing enteroscopy failure. When ERC attempts fail, we
employ radiology-assisted rendezvous attempt for the sim-
ple stone disease. In the event that repeated manipulations
are expected such as in malignant stricture, we favor the
performance of duodenoscopy after an EDGE procedure.
CBD Stones Within a Choledochal Cyst
Another special consideration for difficult stone extraction
is CBD stones within Types I, II, or IV choledochal cysts.
While found in up to 70% of type I or type II choledochal
cysts, the configuration of the bile duct with downstream
narrowing and shared channel with the pancreatic duct make
stone extraction incredibly difficult [33]. Additionally, forc-
ing a stone through a common channel carries a high risk
for inducing acute pancreatitis.
For these special circumstances we typically avoid per-
forming an ERC and direct patients to a surgical solution. On
occasion when the pre-procedure diagnosis was uncertain
and an ERC must be performed, we prefer to place a small
Digestive Diseases and Sciences (2022) 67:1613–1623 1621
caliber, mostly 7 French, biliary endoprosthesis to prevent
cholangitis or temporarily alleviate the biliary obstruction
while awaiting surgical evaluations.
CBD Stones and Pregnancy
Pregnancy is an especially high-risk time for the develop-
ment of gallstone pathology. Thought to be secondary to a
combination of gallbladder dysmotility and maternal hor-
monal alterations, an estimated 7–10% of pregnant females
will develop some form of new onset biliary sludge or stones
during their pregnancy term with over 1% noting symptoms
related to this new stone pathology.
The traditional ERCP adverse events coupled with the
additional special risks including the risk of radiation and
electrocautery to the fetus, sedation concerns to mother and
fetus, and technical difficulties related to the changing mater-
nal anatomy make CBD stones in pregnancy an especially
difficult clinical scenario [34, 35].
Fetal radiation exposure depends on multiple factors such
as position, size, body composition of the mother and fetus,
and fetal gestational age [36]. Risks of fetal growth restric-
tion, genetic anomalies, or intrauterine demise have not been
reported with radiation exposure of less than 50 mGy, and
several studies have estimated fetal radiation exposure via
ERC to be relatively minimal at less than 0.1–5.8 mGy [36].
However, despite this, radiation exposure remains a signifi-
cant concern for patient and provider alike.
We routinely perform ERC in pregnancy utilizing a
radiation free approach. We advocate performance of the
procedure by an experienced endoscopist without trainee
involvement to limit procedural time and potential procedure
related complications. We also start the procedure with an
EUS to determine the size of the common bile duct and the
number of CBD stones. Once these parameters are iden-
tified we typically perform ERC with sphincterotomy and
papillary balloon dilatation without fluoroscopic guidance.
Confirmation of biliary cannulation is performed via gentle
bile aspiration. For numerous stones (> 3) or stones that are
very large, we may choose to perform biliary stenting or
direct cholangioscopy without radiation to confirm complete
stone removal prior to procedure completion.
Conclusion
Over 30% of all ERCs in the US are associated with bil-
iary stone extraction, making complex or difficult to remove
choledocholithiasis a commonly encountered clinical entity
[1, 2, 37]. An algorithmic approach to these stones increases
the chances of successful stone extraction ultimately limiting
unnecessary morbidity, improving patient and provider satis-
faction, and limiting the potential need for surgical interven-
tion of these complex biliary stones.
Key Findings
• Overview and algorithmic management strategies for dif-
ficult common bile duct stones.
• Overview and management strategies for CBD stones in
special clinical circumstances including:
• Recurrent Pyogenic Cholangitis
• Mirizzi’s syndrome
• Cystic duct stones
• Altered anatomy
• CBD stones within a Choledochal cyst
• CBD stones in pregnant patients
Future Unmet Needs
• Prospective comparison of EHL and LL for difficult stone
extraction
• Evaluation of coated or impregnated plastic and
FCSEMS for CBD stone dissolution
• Optimal approach to management of bile duct stones in
surgical anatomy, recurrent pyogenic cholangitis and
pregnancy
• Cost-effective analyses and formal prospective analy-
ses of ‘graded’ algorithmic approach to difficult biliary
stones.
Implications for the Clinician
• An algorithmic approach to difficult common bile duct
stones increases the chances of successful stone extraction.
• Several special difficult clinical circumstances are identi-
fied and additional management strategies to aid endo-
scopic stone extraction efforts are provided.
Author's contribution  Dr. Podboy is currently an Interventional Gas-
troenterology and Hepatology fellow at Cedars Sinai Medical Center.
He was instrumental in the design and conduct of the study, data col-
lection, analysis and writing of the manuscript. Drs. Park, Gaddam,
and Gupta are gastroenterologists in the Pancreatic and Biliary Dis-
ease Department of Cedars Sinai. They were instrumental in critical
appraisal of the manuscript. Simon K. Lo is a Gastroenterologist in the
Pancreatic and Biliary Disease Department of Cedars Sinai Medical
Center. He was instrumental in the design and conduct of the study,
data collection, critical appraisal and writing of the manuscript.
13

1622
Declarations  18. Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treat-
Conflict of interest  The authors declare that they have no conflict of
interest.
19. Katsinelos P, Kountouras J, Paroutoglou G et al. Combination of
Informed consent  Informed consent was obtained from the patient for
publication of the case details.
20. Buxbaum J et al. Randomized Trial of Cholangioscopy-Guided
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