The Recalcitrant Bile Duct Stone

Endoscopic management of choledocholithiasis by the gastroenterologist at endoscopic retrograde cholangiopancreatography has become the standard of care and, to a large degree, routine in most endoscopic units. Large common bile duct (CBD) stones or CBD stones in patients with altered anatomy still pose a challenge above and beyond the routine skills and techniques needed to perform endoscopic retrograde cholangiopancreatography. In this article, we review the features that may make stone removal difficult, including size and number of stones as well as various anatomical challenges, including postsurgical anatomy. Approaches to lithotripsy are discussed including mechanical and nonmechanical and a description of routinely available accessories and more novel equipment that may be found in tertiary centers. Stenting and other alternatives for management, including perctutaneous approach, are discussed as well.