Common bile duct stones complicate 10–20% of gallstone disease. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon or basket extraction is standard treatment, but 10–15% of stones resist conventional techniques. In such cases, cholangioscopy-guided intraductal laser lithotripsy (LL) or electrohydraulic lithotripsy (EHL) achieves high success rates with low morbidity. We aimed to evaluate the efficacy and safety of cholangioscopy-guided LL and EHL for complex common bile duct stones in our center.

We conducted a retrospective single-center study from January 2023 to October 2025, including patients with complex bile duct stones defined by failed conventional ERCP extraction. Complexity criteria included stone >15 mm, multiple stones, impacted stones, hard consistency, "packed" choledocholithiasis, or difficult location (intrahepatic or cystic duct). The primary endpoint was complete bile duct clearance, analyzed per patient and per procedure. Proportions were reported with 95% confidence intervals (Clopper–Pearson method), with comparisons using Fisher's exact test.

Twenty patients (10 men, 10 women; mean age 57 years [16–85]) underwent 22 procedures (19 LL, 3 EHL). Stone complexity related to size in 16 patients (mean 18.1 mm [15–40]), multiplicity (n=12), impaction (n=5), hard consistency (n=1), or difficult location (n=6). Packed stones were present in the common bile duct in 7 cases and cystic duct stump in 2 cases.

Complete duct clearance was achieved in 12/20 patients (60%, 95% CI 38–80) and 12/22 procedures (54.5%, 95% CI 34–74). Eleven patients were successfully treated in a single session and one after three sessions. Ten patients had unsuccessful LL/EHL. Three failures were technical: one referred for surgery, one ultimately cleared after three sessions, and one failed probe advancement due to duodenal diverticulum (not reattempted). In two patients, extraction was impossible: one persistent large stone awaiting second session and one suspicious papilla case (macrodilatation not performed, papillary biopsies revealing ductal adenocarcinoma, referred for surgery). Five additional patients had difficult extraction; all were scheduled for second sessions, but two were lost to follow-up.

The procedure demonstrated excellent safety with only one minor adverse event (self-limited mild bleeding), representing 1/22 procedures (4.5%). Mean hospital stay was 1.3 days [1–3]. No significant association was found between extraction failure and sex (p=1), stone size >15 mm (p=0.5), multiplicity (p=0.6), impaction (p=0.4), difficult location (p=0.5), packed choledocholithiasis (p=0.13), or cystic stump stones (p=1).

Cholangioscopy-guided intraductal EHL and LL is an effective and safe option for complex common bile duct stones. In this first Tunisian series, we observed 60% patient success rate with minimal morbidity. This technique represents a valuable alternative in high-risk surgical candidates and elderly, comorbid patients, reducing the need for surgery and repeated ERCP with prolonged biliary stenting.