Management of giant common bile duct stones in high-risk patients using a combined transhepatic and endoscopic approach

Background Endoscopic sphincterotomy (EST) for removing common bile duct stones is regarded as the safest and most successful method, particularly in patients with a high surgical risk. However, giant immobile stones still continue to present a therapeutic problem. Methods In our 12 patients, when endoscopic sphincterotomy and lithotomy proved to be unsuccessful a transhepatic choledochoscopic lithotomy was attempted. Results The stones were fragmented using choledochoscopic electrohydraulic lithotripsy and then were completely removed through both the transhepatic route and an EST opening in all 12 patients. The number of sessions required for these choledochoscopic procedures combined with EST was fewer than that required for only a transhepatic approach (2.5 ±1.3 versus 3.2 .2), which thus resulted in a shorter hospital stay. Minor complications occurred in three patients with bleeding (two from the bile duct, one from the EST opening) and in two with postprocedure chills and fever. Conclusions A combined lithotomy through duodenoscopic and choledochoscopic approaches is considered to be an efficient method for removing giant biliary calculi in patients who are not successfully treated by an ordinary duodenoscopic lithotomy.