Not all common bile duct stones can be removed with standard sphincterotomy and basket or balloon extraction. Certain stone characteristics and anatomical features predict extraction failure and require a distinct management approach.
This protocol applies when one or more difficult-stone criteria are present: CBD stone diameter greater than 1.5 cm, barrel-shaped stone morphology, sigmoid or angulated common bile duct, stone positioned in the cystic or intrahepatic ducts, stone impaction, multiple CBD stones, or a narrow distal CBD. These features predict failure of standard sphincterotomy combined with balloon and/or basket extraction.
Management centres on a lithotripsy-based strategy to reduce stone size before or during extraction. The complete protocol specifies which modalities apply, how they are selected, and the full clinical decision sequence.
The criteria for difficult gallstones are as follows: diameter over 1.5 cm, barrel-shaped, sigmoid or located in the cystic and intrahepatic ducts, and stone impaction, as shown in Figure 8.
Predicted failed extraction by sphincterotomy + balloon and/or basket (stone size >1.5 cm, multiple stones, narrow distal CBD, angled CBD)
mechanical lithotripsy, using the method of stone destruction with baskets, then altering the basket's size to be smaller to create relatively high pressure to make the stone's size smaller.
electrohydraulic lithotripsy, which runs electrical pulses through an intermediary liquid medium, which produces shockwaves that can fracture gallstones into relatively smaller ones.
Lithotripsy (as shown in Figure 9) using lasers to make the gallstone size smaller.
extracorporeal shock wave lithotripsy (ESWL) uses electromagnetic waves from outside the body to the target organ, which in this case is the stone in the bile duct, to reduce its size.
Consider mechanical lithotripsy or cholangioscopy-associated lithotripsy or ESWL
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