Efficacy and safety of laparoscopic bile duct exploration versus endoscopic sphincterotomy for concomitant gallstones and common bile duct stones: A meta-analysis of randomized controlled trials

A Comparative Analysis of "Surgery First" vs. "Endoscopy First" for Pediatric Choledocholithiasis Presenting at the End of the Week

BACKGROUND

Choledocholithiasis in children is commonly managed with an "endoscopy first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) under a separate anesthetic). Endoscopic Retrograde Cholangiopancreatography is limited at the end of the week (EoW). We hypothesize that a "surgery first" (SF) approach with LC, intraoperative cholangiogram (IOC), and possible laparoscopic common bile duct exploration (LCBDE) can decrease length of stay (LOS) and time to definitive intervention (TTDI).

METHODS

This is a retrospective single-center cohort study conducted between 2018 and 2023 in pediatric patients with suspected choledocholithiasis. Work week (WW) presentation included admission between Monday and Thursday. Time to definitive intervention was defined as time to LC.

RESULTS

88 pediatric patients were identified, 61 managed with SF (33 WW and 28 EoW) and 27 managed with EF (18 WW and 9 EoW). Both SF groups had shorter mean LOS for WW and EoW presentation (64.5 h, 92.4 h, 112.9 h, and 113.0 h; P < .05). There was a downtreading TTDI in the SF groups (SF: WW 24.7 h and EoW 21.7 h; EF: WW 31.7 h and EoW 35.9 h; P = .11). 44 patients underwent LCBDE with similar success rates (91.6% WW and 85% EoW; P = 1.0). All EF patients received 2 procedures; 69% of SF patients were definitively managed with one.

CONCLUSION

Children with choledocholithiasis at the EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF treatment pathway. An SF approach results in shorter LOS with fewer procedures, regardless of the time of presentation.

Curative surgical treatment of common bile duct stones: Retrospective cohort study

BACKGROUND

In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD.

METHODS

This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied.

RESULTS

A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal.

CONCLUSION

This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).

Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis

PURPOSE

The Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI®) are both widely used methods for reporting postoperative complications. Several studies have compared the CCI® with the CDC in evaluating postoperative complications of major abdominal surgery. However, there are no published reports comparing both indexes in single-stage laparoscopic common bile duct exploration with cholecystectomy (LCBDE) for the treatment of common bile duct stones. This study aimed to compare the accuracy of the CCI® and the CDC in evaluating the complications of LCBDE.

METHODS

In total, 249 patients were included. Spearman's rank test was used to calculate the correlation coefficient between CCI® and CDC with length of postoperative stay (LOS), reoperation, readmission, and mortality rates. Student t-test and Fisher's exact test were used to study, if higher ASA, age, larger surgical time, history of previous abdominal surgery, preoperative ERCP, and intraoperative cholangitis finding were associated with higher CDC grade or higher CCI® score.

RESULTS

Mean CCI® was 5.17 ± 12.8. CCI® ranges overlap among three CDC grades: II (20.90-36.20), IIIa (26.20-34.60), and IIIb (33.70-52.10). Age > 60 years, ASA ≥ III, and intraoperative cholangitis finding were associated with higher CCI® (p = 0.010, p = 0.044, and p = 0.031) but not with CDC ≥ IIIa (p = 0.158, p = 0.209, and p = 0.062). In patients with complications, LOS presented a significantly higher correlation with CCI® than with CDC (p = 0.044).

CONCLUSION

In LCBDE, the CCI® assesses better the magnitude of postoperative complications in patients older than 60 years, with a high ASA as well as in those who present intraoperative cholangitis. In addition, the CCI® correlates better with LOS in patients with complications.

Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win

Objectives

Although controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with LC with endoscopic retrograde cholangiopancreatography (ERCP) but increases case complexity/time. The influence of time of day on LCBDE outcomes has not been evaluated. Our aim was to examine outcomes and LOS for nighttime (PM) compared with daytime LC+LCBDE (DAY).

Methods

Consecutive patients who underwent LCBDE were reviewed. Demographics, operative duration, success of LCBDE, time to postoperative ERCP (if required), LOS, and complications were compared. PM procedures were defined as beginning 19:00-07:00 hours.

Results

Between 2018 and 2022, sixty patients underwent LCBDE (PM 42%). Groups had equivalent age/sex and preoperative liver function tests (LFTs). LCBDE success was 69% PM versus 71% DAY (p=0.78). Operative duration did not differ (2.8 IQR: 2.2-3.3 hours vs. 2.8 IQR: 2.3-3.2 hours, p=0.9). LOS was compared, and PM LOS was shorter (p=0.03). Time to ERCP after a failed LCBDE at night was compared with daytime (13.8 IQR: 10.6-29.5 hours vs. 19.9 IQR: 18.7-54.4 hours, p=0.07). LOS for failed PM LCBDE requiring ERCP was similar to successful DAY LCBDE (p=0.29). One complication (transient hyperbilirubinemia) was reported in the DAY group, none in PM.

Conclusion

PM LCBDE cases are equivalent in safety and success rate to DAY cases but have reduced LOS. Widespread adoption of acute care surgery-driven management of choledocholithiasis via LCBDE during cholecystectomy may decrease LOS, especially in PM cases.

Level of evidence

Level IV.

The safety and feasibility of laparoscopic approach for the management of intrahepatic and extrahepatic bile duct stones in patients with prior biliary tract surgical interventions

The purpose of this study was to compare the efficacy and safety of laparoscopic and open reoperation for intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures. The clinical data were retrospectively analyzed of intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures who underwent reoperation in the Second General Surgery Department of China Medical University from January 2012 to February 2018. 44 eligible cases were selected. In accordance with the surgical procedures, they were divided into a laparoscopy group (n = 23) and an open surgery group (n = 21). No statistically significant differences were found in the preoperative general clinical data between the two group. Two patients in the laparoscopy group were converted to open surgery. Comparisons between the two groups showed that the intraoperative blood loss [90.87 ± 62.95 (ml) vs. 152.38 ± 118.82 (ml)], the proportion of postoperative analgesia [10/23 (43.5%) vs. 16/21 (76.2%)], and the length of stay [7.19 ± 5.32 (d) vs. 11.00 ± 4.66 (d)] in the laparoscopy group were significantly lower than those in the open surgery group (P < 0.05). Laparoscopic biliary reoperation for intrahepatic and extrahepatic bile duct stones was feasible. Compared with open surgery, laparoscopic surgery has the advantages of less bleeding, a shorter postoperative length of stay, and a lower rate of additional postoperative analgesia.

Factors predictive of the successful treatment of choledocholithiasis

BACKGROUND

Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP).

METHODS

This was a retrospective, case-control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2).

RESULTS

Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment.

CONCLUSIONS

The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous).

Coledocolitiasis y exploración laparoscópica de la vía biliar. Un estudio de cohorte

Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %. Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.

Preoperative endoscopic treatment for the management of concomitant gallstones and common bile duct stones

BACKGROUND

The combination of gallbladder stone and main biliary stone is seen in 10-25% of cases. Its management with the combination of endoscopic and surgical treatment is increasingly adopted.

AIM

To evaluate the efficacy and safety of preoperative retrograde endoscopic retrograde cholangiopancreatography in the treatment of concomitant gallstones and common bile duct stones.

METHODS

Retrospective study including patients with concomitant gallstones and common bile duct stones and who had preoperative endoscopic retrograde cholangiopancreatography. The rate of clearance from the main bile duct and the rate of complications were evaluated.

RESULTS

One hundred and twenty patients aged 57.4±2.7 years were included on average. The rate of catheterization of the main bile duct was 90%. Endoscopic retrograde cholangiopancreatography was unnecessary in 34.1%. Main bile duct clearance was obtained in 95.5% of patients who presented lithiasis during the procedure. The endoscopic treatment was efficient in 53,3% of cases Post endoscopic retrograde post cholangio-pancreatography acute panreatitis occurred in 1.6% of cases with an overall complication rate of 6.6%.

CONCLUSION

Preoperative endoscopic treatment of concomitant gallstones and common bile duct stones is effective with good safety.

Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases

BACKGROUND

Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases.

METHODS

Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes.

RESULTS

Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group.

CONCLUSION

This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.

Safety and long-term outcomes of endoscopic papillary balloon dilation for removal of common bile duct stones

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) is an effective treatment for common bile duct stones (CBDSs), but there have been few evaluations on its safety and long-term outcomes.

AIM

To assess the safety and long-term outcomes of EPBD in the treatment of CBDSs.

METHODS

The clinical data of patients who underwent CBDSs removal by EPBD from January 2014 to December 2015 at our hospital were reviewed. The main outcomes were stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related complications, and stone recurrence.

RESULTS

A total of 42 patients with CBDSs who underwent EPBD at our hospital were reviewed. The overall successful CBDSs clearance was 100%. ERCP-related complications occurred in four ERCP procedures, all of which were pancreatitis. There was no perforation, bleeding, or cholangitis. Ten (23.8%) of forty-two patients had CBDSs recurrence after a mean period of 51.8 mo (18-66 mo) from the end of EPBD. Female gender (odds ratio = 22.891, 95% confidence interval: 1.544-339.362, P = 0.023) was significantly related to stone recurrence.

CONCLUSION

EPBD is safe and effective in the removal of CBDSs. Female gender may be a risk factor for stone recurrence in a long term.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

Background

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.

Methods

We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.

Results

The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).

Conclusion

LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.

10 years of laparoscopic common bile duct exploration: A single tertiary institution experience

INTRODUCTION

Laparoscopic common bile duct exploration (LCBDE-LC) or ERCP plus laparoscopic cholecystectomy (ERCP-LC) represent minimally invasive choledocholithiasis treatments. We hypothesized that LCBDE-LC has a shorter length of stay (LOS) and lower charges than ERCP-LC.

METHODS

Charts were reviewed for all LCBDE-LC or ERCP-LC for choledocholithiasis from 2007 to 2017. Exclusions included cholangitis, concomitant procedures, or history of Roux-en-Y or biliary surgery. Groups were determined via intention-to-treat with LCBDE-LC or ERCP-LC.

RESULTS

281 subjects were identified; 157 met inclusion criteria. 89 (56%) were in the LCBDE-LC group. There were no differences in age, sex, or ASA. LOS was shorter for LCBDE-LC (3.1 vs 4.4 days, p < 0.01) although total anesthesia time was longer (292 vs 262 min, p = 0.01). There was no difference in total charges ($44,412 vs $51,353, p = 0.08). Thirty (33%) LCBDE-LC were aborted due to challenges passing the dilator or scope (33%) or clearing stones (30%). Two ERCP-LC cases required post-procedure LCBDE.

CONCLUSION

LCBDE-LC resulted in shorter LOS but had a high failure rate. Further research is needed to predict which cases suit each modality.

Novel Technique for Laparoscopic Common Bile Duct Exploration Using Endovascular Instrumentation

Treatment of choledocholithiasis is sometimes a two-step process involving both surgeons and gastroenterologists. Common bile duct (CBD) exploration can be performed at the same time as cholecystectomy but often requires the use of rigid tools, increasing the risk of CBD damage. Here, we report the case of a 64-year-old man who presented with epigastric pain and a positive Murphy's sign. Ultrasonography revealed cholecystitis with cholelithiasis. Gangrenous cholecystitis was visualized upon surgical exploration, and an intraoperative cholangiogram diagnosed likely choledocholithiasis. Cholecystectomy was completed, and CBD exploration was performed by the manipulation of endovascular equipment using a trans-cystic approach through to the ampulla of Vater, and the patient made a complete recovery without complications. The substantial flexibility, gentleness, and durability of endovascular instruments allow for minimal tension on structures during the removal of gallstones from the CBD, providing safe, definitive treatment for choledocholithiasis during cholecystectomy.

Single-stage approach for the management of choledocolithiasis with concomitant cholelithiasis. Implementation of a protocol in a secondary hospital

BACKGROUND

Current evidence shows that single-stage treatment of concomitant choledocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires considerable training. This study aimed to evaluate the implementation of a protocol for managing concomitant choledocholithiasis and cholelithiasis using single-stage treatment.

METHODS

A prospective cohort study of patients diagnosed with cholelithiasis and choledocholithiasis who were treated with the single-stage treatment - transcystic instrumentation, choledocotomy or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) - between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate.

RESULTS

164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after "flushing" in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), choledochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%.

CONCLUSIONS

Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a transcystic approach, with presumable low morbidity and cost-efficiency.

Laparoscopic common bile duct exploration in patients with previous upper abdominal surgery

BACKGROUND

Although patients with previous upper abdominal surgery are no longer considered as a contraindication in laparoscopic surgery, laparoscopic common bile duct exploration (LCBDE) for these patients is still controversial. The aim of this study was to evaluate the safety and effectiveness of LCBDE for patients with previous upper abdominal surgery.

METHODS

Two hundred and seventeen patients with common bile duct stones who underwent LCBDE in our institution from January 2010 to September 2017 were enrolled in the retrospective study. They were divided into two groups: group A, with previous upper abdominal surgery (n = 50) and group B, without previous upper abdominal surgery (n = 167). Patients' demographic, intraoperative, and postoperative outcomes were retrospectively analyzed.

RESULTS

Group A exhibited a longer operative time compared to group B (179.7 ± 61.5 vs. 156.0 ± 46.8 min, p = 0.014). There was no significant difference in intraoperative blood loss (123.9 ± 99.5 vs. 99.5 ± 84.7 mL, p = 0.087), postoperative hospital stay (7.4 ± 2.6 vs. 6.8 ± 2.3 d, p = 0.193), and overall complication rate (8.0 vs. 5.4%, p = 0.732) between the two groups. There was no mortality in both groups. The initial stone clearance rate showed no significant difference between the two groups (98.0 vs. 98.2%, p = 1.000), and the final stone clearance rate was 100% in both groups (p = 1.000). The stone recurrence rate had no significant difference between the two groups (2.0 vs. 2.4%, p = 1.000). The conversion rate was comparable between group A and group B (6.0 vs. 4.8%, p = 0.718).

CONCLUSIONS

LCBDE is a safe and feasible procedure for patients with previous upper abdominal surgery. The keys of this procedure are carefully separating the adhesions and clearly exposing the common bile duct, and using a variety of methods to remove the stones.