Common bile duct (CBD) stones are a frequent cause of biliary pathology, with clinical presentations ranging from incidental findings to life-threatening cholangitis and pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the standard technique for removing CBD stones; however, it carries significant risks and is subject to considerable variation in practice. This review outlines strategies to optimise ERCP utilisation and outcomes through improved patient selection, procedural planning and postprocedure management. Preprocedural optimisation begins with careful risk stratification using established guidelines to minimise unnecessary ERCP. The use of adjunctive imaging modalities such as magnetic resonance cholangiopancreatography, endoscopic ultrasound (EUS) or, where available, same-session EUS-ERCP can significantly reduce negative procedures. Anticipation of procedural difficulty based on stone size, number and anatomical factors enables appropriate triage to specialist centres, improving first-session clearance rates. Advances in endoscopic techniques including endoscopic papillary large balloon dilatation, mechanical lithotripsy and cholangioscopy-guided lithotripsy have enhanced the management of large and complex stones. These techniques can lead to increased single-session success and reduce the need for repeat interventions. Optimising ERCP practice requires a patient-centred, guideline-driven approach supported by service-level improvements such as regional networks and multidisciplinary collaboration. By integrating careful triage with advanced endoscopic techniques, clinicians can reduce unnecessary procedures, minimise complications and achieve successful bile duct clearance.
Mirzaali et al. (Thu,) studied this question.