Endoscopic treatment outcomes in difficult bile duct stones: A single-center experience with pre-cut sphincterotomy and mechanical lithotripsy

INTRODUCTION: Endoscopic treatment success rates and complication profiles in difficult bile duct stones may differ compared to standard cases. This study aimed to evaluate the clinical outcomes and the impact of pre-cut sphincterotomy and mechanical lithotripsy on complications in patients with difficult bile duct stones.
METHODS: A total of 343 adult patients who underwent ERCP for difficult bile duct stones between March 2024 and December 2025 were retrospectively analyzed. Difficult stones were defined as stones ≥15 mm in diameter, the presence of multiple stones, distal bile duct stricture, or stones not removable with standard techniques. Demographic data, procedural characteristics, complications, and clinical outcomes were evaluated. Factors associated with the development of complications were analyzed using univariate and multivariate logistic regression analyses.
RESULTS: At least one complication developed in 43 of 343 patients (12.5%). The most common complication was post-ERCP pancreatitis (7.9%). Pre-cut sphincterotomy was performed in 54 patients (15.7%), and mechanical lithotripsy in 41 patients (12.0%). The overall complete stone clearance rate was 83.4%. Although pre-cut appeared to be associated with complications in univariate analysis, it was not identified as an independent risk factor in multivariate analysis. ASA≥3, stone diameter, difficult cannulation, and procedure duration were found to be independent predictors of complications.
DISCUSSION AND CONCLUSION: In difficult bile duct stones, pre-cut sphincterotomy and mechanical lithotripsy can be safely performed with appropriate patient selection and in experienced centers. These findings support the effective use of advanced endoscopic techniques in difficult stone cases with an acceptable safety profile.

Keywords: ERCP, difficult bile duct stone, mechanical lithotripsy, post-ERCP pancreatitis, pre-cut sphincterotomy

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