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Clinical Spotlight Review: Management of

Choledocholithiasis
sages.o rg/publications/guidelines/clinical-spotlight-review-management-of-choledocholithiasis

By Vimal K. Narula, Eleanor C. Fung, D. Wayne Overby, William Richardson, Dimitrios

Stefanidis and the SAGES Guidelines Committee

Abstract
Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can
result in biliary obstruction, cholangitis, and pancreatitis. A systematic English
literature search was conducted in PubMed to determine the appropriate
management strategies for choledocholithiasis.The following clinical spotlight review
is meant to critically review the available evidence and provide recommendations for
the work-up, investigations as well as the endoscopic, surgical and percutaneous
techniques in the management of choledocholithiasis.

Keywords
Choledocholithiasis, ERCP, Common bile duct exploration, Management, Diagnosis

Choledocholithiasis has a prevalence of approximately 10–15% of patients with

symptomatic cholelithiasis [1]. The clinical presentation of choledocholithiasis can
range from completely asymptomatic to biliary colic and symptoms of obstructive
jaundice, such as pruritus, dark urine and acholic stools. Although up to a third of
patients with common bile duct (CBD) stones will pass them spontaneously without
intervention, the majority of patients will require endoscopic and/or surgical
intervention [2]. The objective of this document was to review best practices in the
diagnosis and management of patients with common bile duct stones.

Methods
The working group first determined questions relevant to the clinical practice of
surgeons treating patients with choledocholithiasis. It then conducted a PubMed
search of all English language articles in October 2019 published using the medical
subject heading (MeSH) search terms “common bile duct stones”,
“choledocholithiasis”, “ERCP/endoscopic retrograde cholangiopancreatography”,
“common bile duct exploration”, “diagnosis” and “management”. A total of 725
articles were found and reviewed by the working group; after exclusion of studies
not relevant to our clinical questions 79 full manuscripts were reviewed in detail.
Articles pertaining to management strategies for choledocholithiasis and best clinical
scenarios for the application of each strategy are summarized below under each
question. Comparative evidence was sought where available.

What investigations should be performed in patients with suspected

choledocholithiasis?
For all patients with suspected choledocholithiasis, obtaining liver transaminases,
bilirubin and a transabdominal ultrasound are recommended as preliminary
investigations to identify patients with high likelihood of common bile duct stones.
Ultrasound findings consistent with choledocholithiasis include visualization of a
common bile duct stone and a dilated common bile duct greater than 8-mm [3]. The
combination of clinical presentation, laboratory results, and imaging findings should
be considered when deciding on next steps of management and investigations.

If the diagnosis of choledocholithiasis is still in question following these tests,

magnetic resonance cholangiopancreatography (MRCP) is a non-invasive option,
which has a sensitivity of > 90% and specificity nearing 100% [4]. However, the main
disadvantage of MRCP is that common bile duct stones identified require intervention
by another method to be removed. Other diagnostic modalities to detect common bile
duct stones include endoscopic ultrasound (EUS) in which an echo endoscope is
positioned in the duodenal bulb in which the average sensitivity and specificity is
approximately 95 and 97%, respectively [5]. Although the interpretation of EUS and
MRCP are both subject to bias, meta-analyses have found an observed superiority in
the sensitivity of EUS as compared to MRCP due to better accuracy of EUS in detection
of small stones and as such, EUS-directed ERCP has been advocated as a cost-effective
method since both EUS and ERCP could be performed in the same session.

What is the pre-test probability of choledocholithiasis in my patient?

Numerous factors have been implicated as prognostic predictors to help stratify
patients into low, intermediate and high probability of choledocholithiasis. The
visualization of a common bile duct stone on abdominal ultrasound carries
approximately a 73% sensitivity and 91% specificity according to a meta-analysis of
five studies [6]. Other strong predictors for choledocholithiasis include clinical
evidence of acute cholangitis, a bilirubin greater than 1.7 mg/dL and a dilated CBD;
the presence of two or more of these factors has a pre-test probability of 50%-94%
for choledocholithiasis (considered high) [7,8]. Patients without evidence of jaundice
and a normal bile duct on ultrasound have a low probability of choledocholithiasis (< 
5%) [9]. Patients that fall between these two spectrums are categorized as having an
intermediate probability of choledocholithiasis. The algorithm presented in
Fig. 1 may be helpful for managing patients with suspected choledocholithiasis
dependent on their risk stratification.

Fig. 1

Management algorithm for patients based on probability of choledocholithiasis

How should patients with documented choledocholithiasis be treated?

The management of choledocholithiasis depends on the timing of common bile duct
stone discovery in relation to the cholecystectomy. The algorithm presented in
Fig. 2 demonstrates the recommended approach to choledocholithiasis dependent on
whether it is discovered pre-operatively, intraoperatively or post-operatively.

Fig. 2

Treatment algorithm for patients with documented choledocholithiasis based on time

of diagnosis

What is the pre-operative management of choledocholithiasis?

If the diagnosis of choledocholithiasis is confirmed pre-operatively, there are options

of clearance of the CBD which include endoscopic retrograde
cholangiopancreatography (ERCP) prior to cholecystectomy or common bile duct
exploration combined with cholecystectomy which is described in the next section.

ERCP is highly sensitive and specific for choledocholithiasis with the added benefit of
being therapeutic to clear stones from the biliary tree in an attempt to avoid common
bile duct exploration and prevent distal obstruction. By directly cannulating the
ampulla to access the biliary tree, a sphincterotomy is often performed with
sweeping and extracting stones from the common bile duct. ERCP has a success rate
of approximately 80–90% for ductal clearance with proper expertise. Reasons for
failure include large or impacted stones, duodenal diverticula, altered gastric or
duodenal anatomy and intrahepatic stones. Risks associated with ERCP include
pancreatitis (1.3–6.7%), infection (0.6–5%), hemorrhage (0.3–2%), perforation (0.1–
1%) and mortality (up to 1%) [10]. Following biliary clearance with ERCP, it is
generally recommended to proceed with subsequent cholecystectomy to prevent the
occurrence of recurrent episodes of symptomatic cholelithiasis which occurs in
approximately 20% of patients. However, in patients with advanced comorbidities
who are at significantly high risk for operative intervention, ERCP with
sphincterotomy without any further subsequent intervention can also be considered
definitive therapy, as there has been no statistical difference in mortality [11,12].

What is the intraoperative management of choledocholithiasis?

The diagnosis of choledocholithiasis can be confirmed intraoperatively during an

intraoperative cholangiogram (IOC) or laparoscopic ultrasound (LUS). The standard
IOC method includes cannulation of the cystic duct or gallbladder with a fine catheter
and direct injection of contrast to visualize the common bile duct and biliary tree
[13]. Laparoscopic IOC has an approximate sensitivity of 75–100% and a specificity of
76–100% [14,15]. When choledocholithiasis is confirmed intraoperatively, a decision
should be made between common bile duct exploration at the time of
cholecystectomy and post-operative ERCP, which is dependent on local availability of
surgical and endoscopic expertise. Both IOC and LUS also allow for evaluation of
biliary anatomy which can aid in determining the optimal approach for biliary
clearance. Furthermore, laparoscopic common bile duct exploration is
contraindicated in the absence of common bile duct pathology, in patients with
hemodynamic instability, or when a hostile porta hepatis is encountered
intraoperatively [16].

Laparoscopic common bile duct exploration combined with cholecystectomy is a

feasible and effective option as a single-stage procedure for the management of
choledocholithiasis. A Cochrane review on the topic has shown that single-stage
laparoscopic common bile duct exploration with cholecystectomy and two-stage ERCP
followed by laparoscopic cholecystectomy have similar efficacy rates in clearing the
CBD with no significant difference in patient morbidity and mortality [17]. Although
the single-stage laparoscopic approach was found to have a longer average operative
time, it was associated with a shorter overall hospital stay and need for fewer
procedures, making it a more cost-effective method for the management of common
bile duct stones in patients undergoing laparoscopic cholecystectomy [18].

Common bile duct exploration was traditionally performed as an open procedure but
can be performed laparoscopically either via a transcystic approach or transductal
approach. Nevertheless, laparoscopic common bile duct exploration has not been
adopted widely as it is technically challenging and strongly dependent on surgeon
experience and equipment availability [19]. However, a simulation-based mastery
learning curriculum has been shown to increase the clinical utilization, skill
acquisition and adoption of laparoscopic common bile duct exploration [20]. While
the results of this study are promising, the most important consideration when
deciding on the treatment of choledocholithiasis for an individual patient are
expertise in the procedure, characteristics of the biliary tree, and local availability of
resources.
For the laparoscopic transcystic approach, a transverse opening is made in the cystic
duct prior to its transection. The common bile duct can then be accessed with a small-
bore catheter for saline flushes, which may be successful in dislodging stones into the
duodenum. 1–2 mg IV glucagon can also be administered to relax the Sphincter of
Oddi to facilitate passage. If this is not successful, stones can be extracted with a wire
basket or Fogarty balloons under fluoroscopic guidance. If the initial ductotomy made
for cholangiogram is too small, the ductotomy can either be extended closer to the
cystic duct-CBD junction or pneumatic cystic duct dilatation can be performed under
fluoroscopy over a guidewire. Alternatively, a small caliber choledochoscope with a
working channel can be passed through the cystic duct into the common bile duct
where a basket stone extractor can then be used to capture the stones under direct
visualization [16].

If the stones cannot be cleared intraoperatively, laparoscopic transcystic biliary stent

placement can be performed under fluoroscopic guidance which can facilitate biliary
drainage and allows for post-operative ERCP to be performed electively and more
successfully. Alternatively, a flexible guidewire can be placed intraoperatively
through a cystic ductotomy into the biliary tree across the ampulla into the
duodenum under fluoroscopy to allow for ERCP via a “rendez-vous” procedure, in
which the duodenoscope can then be inserted per os to capture the guidewire. A
biliary sphincterotome can then be back-loaded over the guidewire to allow for
direct cannulation of the common bile duct followed by stone extraction through a
single-stage laparoscopic-endoscopic approach [21].

Relative contraindications to the transcystic approach include a small, friable cystic

duct, multiple stones in the common bile duct, stones larger than 1 cm or stones in the
proximal duct [16,22]. The success rate of stone clearance via a transcystic approach
can reach up to 71% [23].

A transductal approach can be attempted laparoscopically if the surgeon has the

needed expertise and if the common bile duct is at least 7 mm in diameter to reduce
the risk of post-operative stricture. The anterior surface of the distal CBD is identified
and incised longitudinally to access the common bile duct. Saline flushes, Fogarty
catheters, stone retrieval baskets and the choledochoscope can then be used to
facilitate clearance of the common bile duct. The choledochotomy can then be closed
either primarily using absorbable 4–0 or 5–0 sutures or over a T-tube, an antegrade
biliary stent or with an external biliary drain depending on the surgeon’s discretion
and the clinical situation depending on the potential risk of post-operative CBD
stricture, increased pressure within the CBD leading to bile leak or retained common
bile duct stones [16].
If a T-tube is used, the T-tube is left to gravity drainage post-operatively for 1 week
and imaged with T-tube cholangiography prior to consideration of removal. The T-
tube can also be given a trial of clamping over a 1 week period prior to discharge and
in the absence of jaundice, fevers and elevation of liver transaminases, the tube can
remain clamped over 1 week and subsequently be removed at 2 weeks post-
operatively without cholangiography in the absence of symptoms [24].

Complications of common bile duct exploration include retained stones (0–5%), bile
leak (2.3–26.7%), common bile duct stricture (0–0.8%) and pancreatitis (0–3%). We
suggest that the reader also reviews the SAGES clinical spotlight review on
laparoscopic common bile duct exploration for further details [16].

If plans are made intraoperatively for post-operative ERCP for common bile duct
stone clearance, additional measures, such as endoloops or additional laparoscopic
clips on the cystic duct stump and an external drain in the gallbladder fossa, should
be considered to protect against leakage of the cystic duct stump due to the higher
pressures present in the biliary tree.

What is the post-operative management of choledocholithiasis?

If the patient is found to have a retained stone post-operatively, ERCP is the treatment
of choice for biliary clearance. In the case that endoscopic retrieval is unsuccessful,
percutaneous biliary drainage or less frequently laparoscopic or open common bile
duct exploration may be required.

What are special considerations in the management of

choledocholithiasis?
Patients with choledocholithiasis that present challenges include those with
recurrent CBD stones, large or impacted stones, altered gastric or duodenal anatomy
such as Billroth II or Roux-en-Y gastric bypass and those presenting with sepsis
secondary to acute cholangitis.

What are the approaches to recurrent common bile duct stones?

Patients with recurrent stones pose a challenge in the management of

choledocholithiasis. Risk factors for recurrent stones include multiple common bile
duct stones, biliary dilatation > 13 mm, prior open cholecystectomy, prior gallstone
lithotripsy, hepatolithiasis or factors leading to biliary stasis such as periampullary
diverticula, papillary stenosis, biliary stricture or tumor and angulation of the
common bile duct. Treatment of recurrent common bile duct stones typically includes
repeat endoscopic intervention (i.e., ERCP) but may also be treated surgically in
patients who are at high risk of recurrence. The three main surgical options for re-
establishing biliary drainage include choledochoduodenostomy, hepaticojejunostomy
or transduodenal sphincteroplasty, which should be further pursued with
involvement of a hepatopancreatobiliary surgeon [25].

What techniques can be employed to manage large or impacted

stones?
Traditionally, patients with CBD stones that were unable to be extracted
endoscopically would have to undergo common bile duct exploration. However, there
are a variety of other minimally invasive techniques that can be employed prior to
surgical intervention.

What if the biliary system cannot be cannulated during ERCP or surgery?

If the patient is found to have documented choledocholithiasis pre-operatively and a

pre-operative ERCP is pursued without successful cannulation of the biliary tree, a
pre-cut sphincterotomy can be considered, in which a needle-knife with
electrocautery is used to score the region of the papilla for access. This has been
associated, however, with an increased complication rate of 5–30%, which include
perforation and post-ERCP pancreatitis [18]. Another well-reported method includes
the staged “rendez-vous” procedure in which the interventional radiologist is able to
place a percutaneous transhepatic guidewire that is fed retrograde through the
papilla into the duodenum that can then be accessed by the duodenoscope for
cannulation [26]. Endoscopic ultrasound-guided biliary drainage via
choledochoduodenostomy is also another documented method of accessing the
common bile duct in which the common bile duct is directly punctured via a
transduodenal approach to both clear and stent the common bile duct but this does
require advanced endoscopic expertise [27].

If the patient is found to have choledocholithiasis intraoperatively and the biliary

tree cannot be successfully cannulated for stone extraction, a post-operative ERCP,
further surgical attempts via laparoscopic or open techniques or percutaneous
biliary drainage can be pursued depending on local expertise and resource
availability (Fig. 2). This is described in more detail in the SAGES clinical spotlight
review on laparoscopic common bile duct exploration [16].

What if I am unable to extract the stone during ERCP or surgery?

If the patient is undergoing a pre-operative ERCP and endoscopic attempts with

balloon or basket sweeping are unsuccessful, mechanical lithotripsy by way of
capturing and fragmenting stones with a reinforced basket with a spiral sheath can
be successful in over 80% of cases [28,29]. There are also through the scope
choledochoscopes (e.g., Spyglass) that are now available that can administer
intracorporeal electrohydraulic or laser lithotripsy. In this method, energy is
delivered directly to a large or impacted stone under direct visualization with the aid
of continuous irrigation of the CBD. Electrohydraulic lithotripsy involves shock waves
that are delivered in brief pulses directly at the stone by the probe, which is
optimally located approximately 1–2 mm from the stone. Laser lithotripsy involves
laser light of a high-power density, traditionally Holmium:Yttrium-aluminum-garnet
(YAG) laser, is aimed directly on the surface of a stone, creating a plasma gaseous
collection of ions and free electrons that then induces oscillation and cavitation that
shatter the stone surface [30].

If intraoperative laparoscopic attempts for stone clearance are unsuccessful due to

technical reasons, ampullary edema or distal stricturing, an antegrade ampullary
stent can be inserted laparoscopically under fluoroscopic guidance either through a
transcystic or transcholedochal approach and allows for post-operative ERCP to be
performed (Fig. 3). This laparoscopically deployed stent sits across the ampulla in
which the internal flap is within the common bile duct and the external flap is within
the duodenum with no externalization of drainage; if the stent is deployed
transcystically, the cystic duct stump can then be ligated with either laparoscopic
clips or endoloops. Alternatively, a flexible guidewire can be placed intraoperatively
across the ampulla to allow for concomitant ERCP via a single-stage laparoscopic-
endoscopic “rendez-vous” procedure as described earlier. The SAGES clinical
spotlight review on laparoscopic common bile duct exploration can be referenced for
further discussion [16].

Fig. 3

Example of an antegrade common bile duct stent that can be inserted

laparoscopically under fluoroscopic guidance to allow for biliary drainage, if biliary
clearance cannot be achieved intraoperatively. The stent is deployed across the
ampulla such that the internal flap is within the common bile duct and the external
flap is within the duodenum. Image permissions obtained from Cook Medical and
Boston Scientific

If these methods continue to be unsuccessful and the stone is unable to be retrieved,

the short-term use of a temporary biliary stent either placed endoscopically,
intraoperatively or percutaneously via interventional radiology can be used to ensure
adequate biliary drainage followed by further attempts at ERCP or surgery.

What are non-endoscopic, non-surgical options for achieving biliary decompression?

If endoscopic measures are truly unsuccessful, there are a few options prior to
surgical management, which include percutaneous radiologic treatment,
extracorporeal shock wave lithotripsy and dissolution therapy.
Percutaneous transhepatic biliary drainage (PTBD), although mainly used in cases of
malignancy, can be considered an accepted alternative method for biliary
decompression if the intrahepatic bile ducts are dilated and if other methods of stone
extraction have failed. Either a temporary external drain, an internal/external biliary
drain or an internal stent can be used to achieve biliary drainage (Fig. 4). This
technique is particularly attractive in the setting of sepsis secondary to acute
cholangitis in the patient that is hemodynamically unstable and thus, unfit for
endoscopic or surgical intervention. In addition to percutaneous drainage, the
creation of a transhepatic fistula can then allow for the use of adjuncts via the drain
tract such as basket retrieval, electrohydraulic or laser lithotripsy and the “rendez-
vous procedure” following dilation of the tract (techniques described above) [19].
Although these techniques have high success rates, there is a significant risk of
bleeding via the transhepatic tract and it can also cause patient discomfort as well as
dehydration secondary to fluid losses.

Fig. 4

Percutaneous biliary interventions that can be inserted by interventional

radiology. A Example of a percutaneous transhepatic biliary drain which can either
be an external biliary drain in the intrahepatic ducts or an internal/external biliary
drain that traverses the ampulla into the duodenum. B Example of an internal biliary
stents that can be placed percutaneously under fluoroscopic guidance. Credits to BSIR
and Boston Scientific for permission to use the images of the internal/external biliary
drain and biliary stents

Extracorporeal shockwave lithotripsy (ESWL) involves high-pressure

electrohydraulic or electromagnetic energy that is delivered through a liquid or
tissue medium to the designated target point to fragmenting stones. A naso-biliary
drain is inserted by radiology to allow for fluoroscopic identification and targeting of
the common bile duct stones. The energy setting and number of discharges delivered
is dependent on the device used and patient tolerance as the main adverse effects
include pain, local hematoma formation, cardiac arrhythmias, biliary obstruction,
hemobilia and hematuria [31]. Furthermore, ESWL has particular contraindications,
such as portal thrombosis and varices of the umbilical plexus [32]. Despite a ductal
clearance success rate of approximately 60–90%, it is not considered a first-line
treatment for difficult stones and is uncommonly used.

Lastly, administration of oral ursodeoxycholic acid has been documented to have a

potential role in facilitating stone clearance by reducing the size of common bile duct
stones that are unable to be retrieved endoscopically [33]. The effective dose of
ursodeoxycholic acid is between 8 and 12 mg/kg daily for several months. However,
its role in preventing the formation of common bile duct stones is still unclear.
What techniques can be employed in patients with altered gastric or
duodenal anatomy?
Patients with choledocholithiasis with altered anatomy, particularly with Billroth II
or Roux-en-Y gastric bypass, pose significant challenges for biliary clearance due to
the inability to access the biliary tree in the conventional transoral manner. This has
been increasing in frequency due to the popularity of gastric bypass surgery, and is
also seen in patients following gastric resection surgery, Whipple procedure or liver
transplantation.

Balloon-assisted ERCP or endoscopic ultrasound-directed transgastric ERCP (EDGE

procedure) can be attempted but both require advanced endoscopic expertise. In
balloon-assisted ERCP, the enteroscope has a working length of 200 cm and the 12-
mm diameter Overtube has a length of 140 cm. By alternating inflating and deflating
the balloons and straightening the scope with the Overtube, the endoscope is
progressed stepwise through the small intestine under fluoroscopic guidance and
maneuvered into the biliopancreatic limb to access the ampulla [34]. Due to the
difficulty in navigation and subsequent cannulation, balloon-assisted ERCP is not
always technically feasible for biliary duct clearance in these patients. As such, the
EDGE procedure can be an alternative method of accessing the biliary tree in which
an anastomosis is created typically with a lumen-apposing metal stent between the
gastric pouch or jejunum to the excluded stomach under endoscopic ultrasound
visualization which allows a duodenoscope to be passed to perform a conventional
ERCP [35] (Fig. 5). Although studies show EDGE to be safe and effective, there are
concerns regarding persistent gastrogastric fistula and weight gain following stent
removal in which it is recommended that either an upper endoscopy or upper GI
series be obtained in all patients post-stent removal to determine the presence of
persistent fistula. If present, argon plasma coagulation and over-the-scope clip
placement or revisional surgery with gastrogastric fistula takedown may be required
for fistula closure [36]. Additional data on the long term outcomes of this procedure
(i.e., how many patients develop gastrogastric fistulae?) are needed before it can be
widely endorsed. Alternatively, laparoscopic-assisted transgastric ERCP can be used
to access the biliary tree in gastric bypass patients in which the gastric remnant is
accessed laparoscopically and the duodenoscope is inserted through a gastrotomy
made through the gastric remnant [37] (Fig. 6).

Fig. 5

Depiction of endoscopic ultrasound-directed transgastric ERCP (EDGE) to perform

ERCP following Roux-en-Y gastric bypass. The excluded stomach is located
endosonographically from the gastric pouch or afferent limb and accessed to deploy a
lumen-apposing metal stent into the excluded gastric remnant to allow antegrade
passage of a duodenoscope through the fistula where conventional ERCP can be
performed to access and cannulate the ampulla and biliary tree. Image permissions
obtained from Dr. Prashant Kedia

Fig. 6

Depiction of laparoscopic transgastric access of the gastric remnant to perform ERCP

following Roux-en-Y gastric bypass. A 15 mm port is placed into the greater curvature
of the bypassed gastric remnant where the conventional duodenoscope can then be
inserted and advanced to the duodenum to access and cannulate the ampulla and
biliary tree. Image permission obtained from Gastrointestinal Endoscopy and Elsevier
[41]

If these endoscopic approaches prove unsuccessful, a common bile duct exploration

or PTBD with its associated percutaneous interventions can then be performed for
common bile duct clearance, which have been described earlier in this document.

How should patients presenting with sepsis secondary to cholangitis

be managed?
Once the diagnosis of acute cholangitis has been definitively made in this subset of
patients presenting with sepsis, initial treatment includes IV fluid resuscitation with
careful monitoring of hemodynamic status. Following this, immediate antimicrobial
therapy targeted to the biliary tract and biliary drainage are the key goals of the
treatment of acute cholangitis [38]. The treatment strategy for biliary drainage
should be decided in consideration of the patient’s general status. In patients who do
respond to initial sepsis management, early internal drainage by transpapillary
biliary drainage during ERCP should be considered first-line as it not only achieves
biliary drainage but also allows for stone removal. If the stones cannot be extracted
concurrently with biliary drainage in these critically ill patients, two-session
treatment can be pursued with endoscopic biliary stenting performed as initial
treatment followed by endoscopic stone removal after improvement of cholangitis
[39]. However, in the event of failure of endoscopic techniques or in patients with
rapid deterioration and sepsis-induced organ damage, percutaneous transhepatic
biliary drainage should be considered as described earlier in this review. Surgical
drainage and management is generally rare and not advocated in these critically ill
patients due to the increased morbidity and mortality compared to endoscopic
treatment in this patient population [40].

Conclusion
Choledocholithiasis is a commonly encountered diagnosis for general surgeons.

The subtleties in the management of common bile duct stones relate to the decision
making on the probability of choledocholithiasis based on clinical presentation and
investigations, the timing of presentation in relation to laparoscopic cholecystectomy
in addition to the availability of technology and expertise of the surgeons,
endoscopists and interventional radiologists. Regardless, the surgeon must be
familiar with all possible options at their disposal for managing the patient
presenting with choledocholithiasis which are highlighted in this document.

Disclosures

Eleanor C. Fung is a consultant for Boston Scientific and has received travel
reimbursements from Cook Medical and Fujifilm. Vimal K. Narula, D. Wayne Overby,
William Richardson, and Dimitrios Stefanidis have no conflicts of interest or financial
ties to disclose.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

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