To analyze a large series of CBD stones with emphasis on techniques that can be used in difficult stones effectively and how often do we need to resort to cholangioscopy and laser or EHL.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) remains the cornerstone intervention for common bile duct (CBD) stone disease. With the advent of cholangioscopy-guided lithotripsy and laser fragmentation technologies, their increasing availability has prompted debate regarding their necessity in routine practice. This study analyses outcomes from a large series of 3000 biliary ERCPs, evaluating the true requirement for advanced modalities, with a focus on case distribution, anatomical challenges, and treatment success using standard versus advanced techniques.

Methods: A retrospective evaluation was conducted on 3000 consecutive biliary ERCP procedures. Cases were classified into stone disease (n=2410) and other biliary indications (n=590).  Difficult stones were those, that were not amenable to simple balloon or basket extraction and required additional procedures for removal. This included the standard defined criteria of stone size more than 15mm, stone duct ratio > 1, anatomical variations and varied shape of the stones. Procedural outcomes, modalities used, and factors influencing technique selection were analysed. Data are presented as descriptive statistics, with tables included in text format.

Of 3000 ERCPs, 2410 (80.3%) were performed for stone disease and 590 (19.7%) for other biliary conditions. Among stone cases, 1868 (77.5%) were considered easy stones, successfully managed with traditional extraction techniques. A total of 532 cases (22.1%) were classified as difficult stones.

Summary Of Cases: Category — Number — Percentage  

Total ERCP procedures — 3000 (100%),  Stone disease — 2410 (80.3%),  Other biliary disease — 590 (19.7%),  Easy stone cases — 1868 (77.5%),  Difficult stone cases — 532 (22.1%),  Non‑calcified stones retrieved with balloon/basket — 118 (22.2%),  Anatomical abnormalities — 79 (14.8%), Distal CBD narrowing — 29 (5.5%),  Impacted stones requiring cholangioscopy/laser — 10 (1.9%)

Of the 532 difficult stones, non‑calcified stones were 118 (22.2%), all successfully extracted using balloon or basket. Anatomical abnormalities- 79 cases (14.8%), necessitating large balloon sphincteroplasty. 

Breakdown of Anatomical Abnormalities (n=79), Duodenal deformity — 50 (63.3%), Pouch formation above papilla — 20 (25.3%),  Papillary fibrosis — 9 (11.4%)

Distal CBD narrowing -29 cases (5.5%). True narrowing - 9 (31%), 20 (69%) involved faceted or square-shaped stones with normal distal duct calibre.

Distal CBD Narrowing Details (n=29), True distal CBD narrowing — 9 (31%), Faceted/square stones with normal CBD — 20 (69%)

Mechanical lithotripsy was required in 29 cases (5.5%), predominantly in those with distal narrowing or large, faceted stones. Only 10 cases (1.9% of difficult stones; <0.5% of all ERCPs) required cholangioscopy and laser lithotripsy due to severely impacted stones where no space was available for balloon or basket manipulation.

Treatment Modalities for Difficult Cases (n=532), Traditional balloon/basket extraction — 118 (22.2%),  Large balloon sphincteroplasty — 79 (14.8%),  Mechanical lithotripsy — 29 (5.5%),  Cholangioscopy with laser lithotripsy — 10 (1.9%)

This  analysis demonstrates that the majority of difficult CBD stones, can be effectively managed using conventional or standard advanced endoscopic techniques such as balloon/basket extraction, large balloon sphincteroplasty, or mechanical lithotripsy. These findings support a stratified, anatomy- and stone-based approach rather than universal deployment of cholangioscopic laser systems in all ERCP units.