Endoscopic management of difficult common bile duct stones.

Widely available endoscopic techniques are successful in clearing the bile duct stones in more than 95% of cases. Both electrohydraulic and laser lithotripsy are effective for fragmenting giant stones; however, these methods are not widely available and require direct visual control. Patients who fail mechanical lithotripsy should be considered for referral to specialized centers for electrohydraulic or laser lithotripsy or surgery. In others, long-term endoscopic stenting is a viable alternative.