Endoscopic treatment of bile duct stones

Approximately fifteen per cent of patients who undergo gallstones also have concomitant common bile duct stones. Endoscopic papillosphincterotomy (EPS) is the treatment of choice for common bile duct stones in cholecystectomized patients as well as in patients with gallbladder in situ but at high operative risk. Endoscopic papillosphincterotomy is a highly effective technique and able to remove stones from choledochus in 85-90% of cases. The failure of EPS is mainly related to the size of stones (greater than 15 mm). However, recently introduced sophisticated techniques, such as extraluminal (extracorporeal shock wave lithotripsy) or intraluminal lithotripsy (mechanical, electro-hydraulical or laser) now allow to fragment and remove also "large" stones. Should EPS fail to remove stones, a naso-biliary tube can be endoscopically positioned and attempts made to dissolve the stone by infusing chemical solvents. However, until now the chemical dissolution has only a marginal efficacy in the treatment of common bile duct stones. If all these techniques fail, good operative risk patients can be treated by surgical choledochotomy, while high operative risk patients can be treated by permanent biliary endoprosthesis or percutaneous techniques.