1. Biliary stricture with stones
Mathew Philip
PVS Institute of Digestive Diseases
Kochi

2. Standard therapy for CBD stones
ERC with sphincterotomy and stone extraction
85% to 90% of CBD stones can be removed with Dormia basket or balloon catheter

3. Difficult common bile duct stones
Not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon

4. CBD stone removal - Challenges
Large stones (> 15 mm diameter)
Impacted stones
Intra hepatic stones
Bile duct stricture
Narrow distal CBD
Poorly expandable common bile duct
Difficult anatomy

5. Bile duct stricture with stones
True strictures with stones

6. Bile duct stricture with stones
Poorly expandable CBD with stones
Chi-Liang Cheng et al WJG 2012

8. Management
Endoscopic
ESWL
Surgery

9. Endoscopic techniques
ERC/ ES / Mechanical Lithotripsy
Balloon dilatation followed by lithotripsy
Multiple Stents followed by lithotripsy later
Cholangioscopy – Holmium laser lithotripsy/ EHL
Permanent biliary stenting

17. Biliary stenting
Potential definitive treatment in selected elderly patients who are poor candidates for surgery
Endoprosthesis may reduce stone size
May allow later clearance of unextractable stones
Problems - cholangitis

18. ESWL Accepted modality for large CBD stones
NBD and ESWL followed by stone removal and stenting
Tandan M et al J Gastroenterol Hepatol. 2009

19. ESWL
Pre ESWL Post ESWL
Tandan M et al J Gastroenterol Hepatol. 2009

20. Surgery Lap vs. open Definitive treatment for stricture
When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones

21. CBD stricture with stones
Factors influencing treatment
Associated cholangitis
High risk patients
Anatomical abnormality
GB in situ with stones
Intra hepatic stones(RPC)

22. CBD stones with strictures
Cholangitis
Young /stable /GB in situ
Elderly /high risk
patients
ERC /NBD /Stent
Surgery
ERC /ESWL/Lithotripsy/Stent
Surgery
ERC /lithotripsy/Stent

23. Thank you