Evolving Strategies for the Optimal Management of Common Bile Duct Stones

Management of common bile duct (CBD) stones has evolved substantially with the advent of endoscopic techniques and dedicated high-end devices. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widespread essential technique for managing CBD stones, with high success rates in standard cases. However, for patients with large stones, stones in an impacted state, and stones in anatomically challenging regions, advanced strategies using various dedicated devices may be needed. Although mechanical lithotripsy and endoscopic papillary large balloon dilation are effective techniques for managing giant stones, temporary biliary stenting with interval stone extraction, commonly referred to as two-stage ERCP, is a valuable approach, particularly in patients with sepsis or significant comorbidities. Digital single-operator cholangioscopy (DSOC) combined with electrohydraulic or laser lithotripsy has significantly transformed the endoscopic treatment strategy for managing difficult-to-extract stones by enabling direct visualization of stones and real-time targeted fragmentation. In very difficult situations where conventional ERCP is unsuccessful, percutaneous transhepatic cholangioscopy may be an effective solution, with DSOC enhancing both efficacy and safety. Advances in endoscopic technology, including integrated laser systems and next-generation retrieval devices, are expected to further improve procedural outcomes. Artificial intelligence is also gaining traction, with potential applications in diagnostic imaging interpretation, intraprocedural decision support, and prediction of stone recurrence. In conclusion, optimal management of CBD stones requires a patient specific, resource-sensitive approach. The integration of cutting-edge technologies and data-driven strategies is expected to improve the precision, efficiency, and overall quality of endoscopic CBD stone management.