Nonoperative management of bile duct stones.

The treatment of choice for most retained bile duct stones is by nonoperative means. If a T-tube is in place, percutaneous techniques via the T-tract are indicated. Percutaneous access via puncture of a Roux-en-Y loop is also practical. In the absence of a T-tube, retrograde endoscopic techniques should be used. Both techniques are very effective and safe. Stones in the intrahepatic and extrahepatic ducts also can be treated nonoperatively. Endoscopic sphincterotomy has a role in the treatment of selected patients with gallstone pancreatitis, acute cholangitis, and choledocholithiasis with in situ gallbladders. In difficult cases, endoscopic and percutaneous techniques are employed in combination.