Postgraduate Course at DDW: Complete Clinical Updates for Today's Practice | May 2025-Sunday May 4_12_Baron_Endoscopic Management of difficult CBD stones

Sunday May 4_12_Baron_Endoscopic Management of difficult CBD stones

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The document is a presentation by Dr. Todd H. Baron from May 2025, focusing on the endoscopic management of difficult bile duct stones and strategies for treating obstructive jaundice. Dr. Baron outlines several advanced techniques for removing difficult stones and emphasizes the importance of drainage in cases where stones cannot be extracted.<br /><br />Difficult stones are characterized by factors such as their size, location, or impact on bile ducts. They may be impacted in the ampulla or main duct, large (over 15mm in diameter), multiple, or present post-surgical challenges. Management techniques discussed include mechanical lithotripsy, balloon sphincteroplasty, combined endoscopic techniques (like sphincterotomy with papillary large-balloon dilation), and several types of lithotripsy including electrohydraulic and laser approaches.<br /><br />For large bile duct stones, balloon sphincteroplasty can be beneficial, as it is less invasive than lithotripsy and reduces complications like post-ERCP pancreatitis when combined with biliary sphincterotomy. Intraductal lithotripsy is performed under direct vision to avoid bile duct injury and is particularly useful when conventional therapies fail.<br /><br />Extracorporeal shock wave lithotripsy (ESWL) is suggested as a last resort for the removal of large bile duct stones. Special cases such as cystic duct and intrahepatic stones often require cholangioscopic-guided fragmentation and multiple procedures for complete clearance. For anatomically altered patients, technical adaptations in ERCP and EUS-guided approaches are necessary.<br /><br />Dr. Baron concludes that most difficult stones can be managed endoscopically with the mentioned techniques, with drainage being critical to preventing complications. These methods enhance the success rate of stone removals and reduce the need for surgical interventions.

Keywords

endoscopic management

bile duct stones

obstructive jaundice

mechanical lithotripsy

balloon sphincteroplasty

extracorporeal shock wave lithotripsy

intraductal lithotripsy

cholangioscopic-guided fragmentation

ERCP

EUS-guided approaches