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The role of endoscopy in the management of choledocholithiasis

    1. We recommend that CBD stones should be removed if detected unless significant mitigating clinical circumstances are present.
    2. The optimal timing of endoscopic stone management depends on the clinical scenario. We recommend that urgent ERC is indicated for stones associated with severe acute cholangitis that is not responding to medical treatment.
    3. In the setting of symptomatic cholelithiasis, we suggest that preoperative ERC for patients with a high likelihood of choledocholithiasis or intraoperative or postoperative ERC for patients with a positive IOC are all valid and comparable approaches.
    4. If preoperative ERC is undertaken for choledocholithiasis, we recommend subsequent cholecystectomy in most cases. We recommend that cholecystectomy be performed within 2 weeks because longer delays have been associated with increased morbidity from recurrent biliary events.
    5. We suggest that antibiotic prophylaxis is unnecessary in the majority of patients with suspected choledocholithiasis, unless cholangitis or immunosuppression is present or biliary drainage is predicted to be incomplete.
    6. We recommend against routine use of primary EPBD given the reported risks of severe pancreatitis, although it may be considered in select clinical circumstances that increase the risk or difficulty of ES.
    7. We recommend placement of a plastic biliary endoprosthesis to ensure adequate drainage in cases of incomplete stone extraction or severe acute cholangitis.
    8. We recommend against the use of plastic biliary stents as a sole therapy for CBD stones refractory to initial endoscopic extraction, given the high frequency of late biliary complications associated with this strategy.
    9. For large, nonimpacted CBD stones refractory to initial extraction efforts, we suggest that mechanical lithotripsy or EPBD after ES be considered as next steps, given their effectiveness, ease of use, and acceptable safety profiles.
    10. We suggest that in patients with large and/or impacted calculi refractory to mechanical lithotripsy, intraductal lithotripsy (EHL or LL) is preferred over ESWL, given the superior rates of ductal clearance.
    11. Given the increased rate of complications and lower success rate of endoscopic management of CBD stones in patients who have undergone Billroth II or Roux-en-Y reconstructions, we suggest that these patients be referred to biliary centers of excellence.
    12. We recommend that LCBDE is an alternative to ERC as a first-line strategy for CBD stone removal in the setting of symptomatic cholelithiasis in centers where surgical expertise is available.
    13. We recommend against primary percutaneous transhepatic management of CBD stones in patients with native anatomy, given that more expeditious alternatives with similar or better risk profiles exist (eg, ERC, LCBDE).
    14. We suggest that UDCA may be considered as an adjunct to biliary stenting in the management of difficult stones.
    15. We recommend that recurrent CBD stones may be effectively managed with repeat ERC. Limited data guide further decision making in these patients, and the use of UDCA, surveillance ERC, or a biliaryenteric bypass must be individualized.