Endoscopic management of bile duct stones

The surgical risk of common duct exploration for the treatment of biliary calculi is considerably higher than that of cholecystectomy. Therefore, introduction of endoscopic sphincterotomy in 1974 was a major advance. It has become the therapy of choice in cholecystectomized patients or in those with an increased operative risk. Endoscopic sphincterotomy has a mortality rate of around 1% and a morbidity rate of 7%. These figures compare favourably with open surgery, especially in old patients. The procedure fails in about 10% of all patients referred for endoscopic removal of their calculi. However, several techniques have been described or are currently under evaluation to overcome these failures: intracorporeal or extracorporeal lithotripsy, long-term stenting of the bile duct, or direct application of solvents. Long-term follow-up studies show that between 2% and 20% of successfully managed patients may develop recurrent stones, mainly caused by bile stasis and infection. Patients with a functioning gall-bladder and no concomitant gall-bladder stones probably do not require cholecystectomy after successful endoscopic treatment of their choledochal stones. While endoscopic stone removal has replaced surgery in the elderly frail patients it has no major advantages in the young and fit patients, especially when the gall-bladder is still in situ.