Predictors of a need for cholangioscopy-guided electrohydraulic lithotripsy in the management of difficult common bile duct stones

Abstract

Background While standard endoscopic methods effectively clear most common bile duct stones, complex cases require specialized management. This study compared the effectiveness of cholangioscopy-guided electrohydraulic lithotripsy (EHL) against conventional techniques for treating difficult common bile duct stones (DBS).

Methods This retrospective study included 436 patients who underwent endoscopic retrograde cholangiopancreatography between April 2020 and April 2024. Demographic, laboratory and procedural data were recorded. Categorical regression identified predictors for EHL, and classification tree analysis was used to develop a prioritization algorithm.

Results Among patients with DBS (305/436, 70%), conventional methods succeeded in 28.9% (88/305). Endoscopic papillary large balloon dilation followed failed first-line techniques in 115 cases, with a 21.7% success rate. EHL was used in 192 patients, achieving a 98.4% success rate. Multivariate analysis showed that DBS (P<0.001), absence of wedged stones in the ampulla of Vater (P<0.001), and small papillae (P=0.002) were strong independent predictors for EHL use, with DBS being the most significant.

Conclusions DBS, absence of wedged stones in Vater and small papillae are key predictors of the need for cholangioscopy-guided EHL. Given its high success rate and comparable safety profile, EHL should be considered an early-line treatment in selected cases.

Keywords Electrohydraulic, lithotripsy, endoscopic retrograde cholangiopancreatography, choledocholithiasis, common bile duct stone

Ann Gastroenterol 2026; 39 (1): 32-39