Aims
Endoscopic sphincterotomy with stone extraction is the standard therapy for common bile duct stones (CBDS). However, the presence of large stones (>15 mm) or extensive choledochal lithiasis may compromise technical success and increase the need for additional procedures. Evidence on predictors of endoscopic success remains limited and heterogeneous. This study evaluated the outcomes of ERCP in patients with large versus non-large stones and identified factors associated with treatment success.
Methods
We conducted a monocentric retrospective analytical study over 9 years (2016–2025) at our tertiary center. A total of 867 ERCPs performed for CBDS were included. Large stones were defined as obstructive stones >15 mm; choledochal lithiasis as ≥3 stones.Patients were divided into two groups:
Group I (n = 143): single large obstructive stone >15 mm
Group II (n = 724): one or two stones or choledochal lithiasisPrimary outcomes included success after first attempt, overall endoscopic success, need for reintervention, additional techniques, and early complications. Predictors of success were determined by univariate and multivariate analyses.
Results
Large stones represented 16.5% of the cohort (143/867).
Success after first ERCP: 55.2% in Group I vs. 81% in Group II (p < 0.001).
Reintervention: 14.7% vs. 8% (p = 0.009).
Use of additional techniques: 46.2% vs. 16.1%.
Overall success after adjuncts/reintervention: 88.7% vs. 92.5% (p = 0.125).
Early complications: 10.5% vs. 5.1% (p = 0.017).
Univariate predictors of reduced overall success: older age, acute cholangitis, bile duct strictures, and duct dilation >15 mm.Multivariate analysis showed two independent predictors:
Acute cholangitis (OR 0.295; 95% CI 0.164–0.532; p < 0.001)
Bile duct stricture (OR 0.53; 95% CI 0.922–1.051; p = 0.001)
Conclusions
In this large monocentric 9-year cohort, large stones required more reinterventions and adjunctive procedures but did not significantly reduce the final success rate of ERCP when advanced extraction techniques were available. The main determinants of reduced success were acute cholangitis and bile duct strictures, rather than stone size alone.