Management of common bile duct stones in the absence of endoscopic retrograde cholangiopancreatography

Abstract

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of common bile duct (CBD) stones; however, it is not universally available. In hospitals lacking on-site ERCP, alternative diagnostic and therapeutic strategies are required, but the scope and quality of the supporting evidence remain unclear.

AIM

To map and synthesize the available literature on non-ERCP diagnostic and therapeutic strategies for CBD stones.

METHODS

A scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. PubMed/MEDLINE and Scopus were searched for studies published between 2020 and 2025 on non-ERCP strategies for CBD stones. Eligible studies included observational and comparative designs. Data were extracted and analyzed descriptively, focusing on diagnostic modalities, surgical strategies, and reported outcomes.

RESULTS

Seven studies met the inclusion criteria, predominantly retrospective and single-center in design. Magnetic resonance cholangiopancreatography, endoscopic ultrasound, and intraoperative imaging were the most frequently reported diagnostic modalities. Laparoscopic CBD exploration, using transcystic or transductal approaches, was the main therapeutic strategy. Outcomes varied across studies and were closely related to institutional expertise and resource availability.

CONCLUSION

The available evidence is limited and heterogeneous. Non-ERCP strategies are feasible in selected settings, but current data do not support broad generalization.

Key Words: Common bile duct stones; Choledocholithiasis; Laparoscopic common bile duct exploration; Endoscopic retrograde cholangiopancreatography; Magnetic resonance cholangiopancreatography; Endoscopic ultrasound

Core Tip: Endoscopic retrograde cholangiopancreatography (ERCP) is not universally available, necessitating alternative strategies for common bile duct stone management. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews scoping review maps the limited and heterogeneous evidence on non-ERCP diagnostic and surgical approaches. Current data are largely retrospective and derived from specialized centers, underscoring the context-dependent feasibility of these strategies and the need for prospective multicenter validation.

INTRODUCTION

Choledocholithiasis, defined as the presence of stones within the common bile duct (CBD), represents a frequent and clinically relevant condition encountered in patients with gallstone disease. Untreated CBD stones may lead to biliary obstruction, acute cholangitis, and pancreatitis, making timely diagnosis and treatment essential. Endoscopic retrograde cholangiopancreatography (ERCP) is widely considered the reference standard for CBD stone clearance due to its high success rate and minimally invasive nature[1,2].

Despite its central role, ERCP is not universally available. Limited access to endoscopic expertise, infrastructure constraints, and organizational factors may preclude on-site ERCP in a substantial number of hospitals, including regional centers and non-tertiary institutions. In such settings, patients are frequently transferred to referral hospitals, which may lead to treatment delays, prolonged hospitalization, repeated admissions, and increased healthcare costs[3,4].

In response to these challenges, several alternative diagnostic and therapeutic strategies for CBD stones have been described[5]. Non-invasive imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) are commonly used to stratify the probability of CBD stones and guide further management. Endoscopic ultrasound (EUS) has also been proposed as an adjunctive diagnostic tool, particularly in patients with an intermediate likelihood of choledocholithiasis, where it may outperform MRCP in detecting small stones. Intraoperatively, laparoscopic ultrasound (IOUS) has been reported as a method for real-time evaluation of the biliary tree during cholecystectomy, allowing immediate decision-making without radiation or contrast use[6].

From a therapeutic perspective, laparoscopic CBD exploration (LCBDE), performed through transcystic or transductal approaches, has been increasingly reported as a surgical option for CBD stone clearance in centers with advanced laparoscopic expertise[7-9]. Temporary biliary drainage techniques and referral for delayed ERCP remain alternative strategies when definitive treatment cannot be achieved during the index admission. However, outcomes associated with these approaches appear to be highly dependent on institutional experience, surgeon training, and available resources[10,11].

Importantly, the term “resource-limited settings” is often used inconsistently in the literature[12]. Many techniques proposed as alternatives to ERCP-such as choledochoscopy, IOUS, and advanced laparoscopic suturing-require specialized equipment and a significant learning curve, and may therefore be applicable primarily to high-volume or highly specialized centers rather than to all hospitals lacking ERCP availability[13]. This heterogeneity complicates interpretation of published results and limits the external validity of broad clinical recommendations.

Given the diversity of reported strategies, study designs, and clinical contexts, a comprehensive mapping of the existing evidence is needed. Rather than providing prescriptive recommendations, a scoping review allows systematic identification of the types of evidence available, the diagnostic and therapeutic approaches described, and the gaps in current knowledge. The aim of this scoping review is therefore to synthesize the available literature on non-ERCP diagnostic and therapeutic strategies for the management of CBD stones, with particular attention to study design, reported outcomes, and contextual applicability.

MATERIALS AND METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR).

Information sources and search strategy

A systematic literature search was performed in PubMed/MEDLINE and Scopus from January 2020 to December 2025. Predefined search strings combined terms related to choledocholithiasis, non-ERCP diagnostic modalities (MRCP, EUS, intraoperative ultrasound), and surgical management strategies (LCBDE). Reference lists of included articles and relevant reviews were manually screened to identify additional eligible studies. Although the search was restricted to two major biomedical databases, manual reference screening was performed to minimize omission of relevant studies. The time restriction (2020-2025) was chosen to reflect contemporary practice patterns and current laparoscopic techniques.

Eligibility criteria

Studies were included if they: (1) Involved adult patients with suspected or confirmed CBD stones; (2) Reported diagnostic or therapeutic strategies excluding ERCP as the primary intervention; (3) Were observational studies, comparative studies, or reviews with original clinical data; and (4) Were published in English with full text available.

Studies were excluded if they were case reports or very small case series (< 5 patients), pediatric studies, purely technical notes without clinical outcomes, editorials without original data, or studies focusing exclusively on ERCP-based management.

Study selection

After removal of duplicates, records were screened by title and abstract. Full-text assessment was subsequently performed for potentially eligible articles. The study selection process is summarized using a PRISMA-ScR flow diagram (Figure 1). The authors followed the PRISMA 2020 guidelines.

Figure 1  Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews flow diagram of study selection.

Data extraction

Data extraction was performed using a predefined charting form capturing study design, clinical setting, availability of ERCP, diagnostic and therapeutic strategies, and reported outcomes. Quantitative synthesis and formal risk-of-bias assessment were not performed, in keeping with scoping review methodology.

No formal risk-of-bias assessment was performed, consistent with scoping review methodology; therefore, the findings should be interpreted as descriptive rather than evaluative.

RESULTS

Study selection

The database search identified 20 records (PubMed/MEDLINE n = 10; Scopus n = 10). After removal of duplicates (n = 2), 18 unique records were screened by title and abstract. Eight records were excluded at this stage. Ten full-text articles were assessed for eligibility and all met the inclusion criteria. The study selection process is summarized in a PRISMA-ScR flow diagram (Figure 1).

Characteristics of included studies

The ten included studies consisted predominantly of retrospective observational cohorts and case series, with a limited number of comparative studies and one narrative review. Sample sizes ranged from 69 patients to 1016 patients. Most studies originated from tertiary or high-volume centers, although one study specifically described implementation of LCBDE in a rural community hospital. The main characteristics of the included studies are summarized in Table 1.

Table 1 Characteristics of included studies.

Ref.	Study design	Setting	n	Strategy evaluated	Key findings
Varone et al[14]	Multicenter retrospective	12 United States tertiary centers	736	MRCP vs EUS vs IOC	MRCP sensitivity 68.2%; EUS/IOC superior in intermediate-risk
Johnson et al[13]	Retrospective QI study	Single tertiary center	87	LCBDE vs ERCP + LC	LCBDE LOS 2 days vs ERCP 4.5 days; 37% missed opportunities
Anwar et al[17]	Retrospective + prospective cohort	University hospital	100	One-stage LCBDE vs two-stage ERCP + LC	Comparable clearance; lower cost in one-stage
Volkovetskii et al[16]	Retrospective comparative	Tertiary center	136	LCBDE vs ERCP	Clearance 986% vs 90.8%; lower pancreatitis with LCBDE
Cui et al[15]	Diagnostic retrospective	Tertiary	269	EUS vs MRCP	EUS superior in intermediate-risk
Wever et al[18]	Retrospective case series	Rural community hospital	69	Transcystic LCBDE	Clearance 82%; 0% major complications
McNamee et al[19]	Retrospective comparative	Community hospital		LCBDE vs ERCP	Demonstrates feasibility of LCBDE in non-tertiary setting

LCBDE: Laparoscopic common bile duct exploration; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; MRCP: Magnetic resonance cholangiopancreatography; LC: Laparoscopic cholecystectomy; IOC: Intraoperative cholangiography.

Diagnostic strategies

MRCP: MRCP was the most frequently reported non-invasive diagnostic modality. Its diagnostic performance varied substantially across studies. In a multicenter cohort of 736 patients, Varone et al[14] reported a sensitivity of 68.2% and specificity of 83.7% for MRCP in intermediate-risk patients, with inferior performance compared with EUS and intraoperative cholangiography. Smaller diagnostic series reported higher sensitivities, but these were often derived from single-center studies with limited sample sizes.

EUS: EUS was consistently reported as a highly sensitive diagnostic modality, particularly in patients with intermediate probability of CBD stones. Diagnostic studies comparing EUS and MRCP demonstrated superior detection of small stones with EUS, although its availability was limited to specialized centers[15].

IOUS: IOUS was described as an intraoperative adjunct during laparoscopic cholecystectomy, enabling real-time assessment of the biliary tree without radiation or contrast. Its use was strongly operator-dependent and inconsistently reported across studies.

Therapeutic strategies

LCBDE: LCBDE was the most commonly reported non-ERCP therapeutic strategy. Both transcystic and transductal approaches were described. Comparative observational studies reported high duct clearance rates, often exceeding 95% in experienced centers. In a comparative series of 136 patients, Volkovetskii et al[16] reported higher clearance rates and lower rates of post-procedural pancreatitis with LCBDE compared with ERCP-based strategies.

One-stage vs two-stage management: Several studies compared one-stage surgical management (LC + LCBDE) with two-stage strategies (ERCP followed by cholecystectomy). Anwar et al[17] reported similar stone clearance rates but significantly lower costs for one-stage management ($3636 vs $5682 per patient).

Implementation in non-tertiary settings: A rural community hospital series by Wever et al[18] demonstrated the feasibility of transcystic LCBDE, with an 82% stone clearance rate and no major complications, when performed by a trained surgical team. However, quality-improvement studies highlighted substantial “missed opportunities” for LCBDE even in centers offering the technique, underscoring organizational and training barriers.

Additional evidence from community hospital settings supports the feasibility of LCBDE outside tertiary centers. McNamee et al[19] reported comparable outcomes between LCBDE and ERCP in a non-tertiary environment, suggesting that surgical management may be a viable option when appropriate expertise is available.

Outcome reporting and evidence gaps

Outcome reporting was heterogeneous. While duct clearance, complications, and length of stay were frequently reported, long-term outcomes, cost-effectiveness, and patient-reported outcomes were rarely addressed. The influence of learning curves and surgeon experience was inconsistently quantified.

DISCUSSION

This scoping review provides a structured synthesis of the limited available evidence on non-ERCP diagnostic and therapeutic strategies for the management of CBD stones. The small number of included studies reflects the scarcity of literature specifically addressing non-ERCP pathways rather than a limitation of the search strategy. Most available data are derived from retrospective, single-center studies conducted in tertiary or high-volume institutions.

From a diagnostic perspective, MRCP was the most frequently reported modality; however, its performance varied substantially across studies. In intermediate-risk patients, sensitivity was inconsistent and, in some series, inferior to EUS or intraoperative cholangiography. EUS demonstrated higher diagnostic accuracy for small stones in comparative studies, although its availability was largely restricted to specialized centers. Intraoperative ultrasound was described as a potentially useful adjunct, but its use was inconsistently reported and strongly operator-dependent. Overall, no standardized non-ERCP diagnostic algorithm emerged from the available literature.

Therapeutically, LCBDE was the most commonly described alternative to ERCP. Reported duct clearance rates were generally high in experienced centers, although these findings are primarily derived from retrospective series and may not be generalizable. Evidence from community hospital settings further supports the feasibility of LCBDE outside tertiary centers, with comparable outcomes reported between surgical and endoscopic approaches when appropriate expertise is available[19].

These findings are consistent with recent meta-analytic evidence suggesting comparable efficacy and safety between one-stage transcystic LCBDE and two-stage ERCP-based strategies in selected patients[20]. In addition, studies have demonstrated the overall safety and effectiveness of laparoscopic bile duct exploration in real-world practice[21]. However, such evidence is largely derived from well-resourced systems and high-volume institutions and may not be directly generalizable to ERCP-lacking or resource-constrained settings.

The evidence regarding one-stage vs two-stage management strategies remains limited within the specific context of ERCP unavailability. While some studies reported comparable clearance rates and lower costs for single-stage surgical management, these findings are context-dependent and derived from observational data. Cost-effectiveness remains an important but underexplored aspect, with available evidence largely based on modeling studies rather than prospective clinical evaluations[22].

The literature search was restricted to two major biomedical databases (PubMed/MEDLINE and Scopus), which may have resulted in omission of relevant studies. However, these databases were selected for their broad coverage of clinical and surgical literature, and manual reference screening was performed to minimize this limitation.

Although a formal risk-of-bias assessment was not performed, consistent with scoping review methodology, the included studies were predominantly retrospective and single-center in design, which inherently limits internal validity and increases the risk of selection and reporting bias.

The observed heterogeneity across studies likely reflects substantial differences in institutional expertise, surgical volume, and availability of diagnostic and intraoperative resources. These factors are critical determinants of both feasibility and outcomes and further limit the comparability of reported results.

From a clinical perspective, these findings suggest that non-ERCP strategies may be considered in selected centers with appropriate laparoscopic expertise and institutional support. However, decision-making should remain context-dependent, taking into account local resources, available expertise, and patient characteristics.

Importantly, key outcomes such as long-term recurrence, patient-reported outcomes, and robust cost-effectiveness analyses remain underreported in the current literature. These gaps represent critical areas for future research and are essential for informing evidence-based clinical pathways.

Importantly, this review does not establish equivalence between surgical and endoscopic strategies. Rather, it highlights the limited and context-specific nature of the available evidence. The feasibility and outcomes of LCBDE are closely linked to institutional expertise, surgeon training, and available resources and may not be reproducible across all ERCP-lacking settings. Furthermore, most included studies did not clearly define resource availability or quantify surgeon experience, limiting interpretation of scalability. The learning curve associated with advanced laparoscopic biliary procedures was inconsistently addressed.

Overall, the current evidence base remains limited and context-specific, highlighting the need for high-quality prospective multicenter studies with standardized outcome reporting and evaluation of implementation feasibility across diverse healthcare settings.

CONCLUSION

The current evidence on non-ERCP management of CBD stones is limited, heterogeneous, and predominantly observational. Alternative diagnostic and surgical strategies appear technically feasible in selected centers with appropriate expertise; however, available data are insufficient to support routine adoption across all ERCP-lacking settings. Further prospective and multicenter studies with standardized reporting are required before broader clinical implementation can be recommended.