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Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (<jats:styled-content style=\"fixed-case\">EHL<\/jats:styled-content>) is carried out under the guidance of conventional mother\u2010baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single\u2010use cholangioscope system \u2013 the <jats:styled-content style=\"fixed-case\">S<\/jats:styled-content>py<jats:styled-content style=\"fixed-case\">G<\/jats:styled-content>lass direct visualization system \u2013 are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including <jats:styled-content style=\"fixed-case\">M<\/jats:styled-content>irizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as <jats:styled-content style=\"fixed-case\">EHL<\/jats:styled-content> or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound\u2010guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.<\/jats:p>","DOI":"10.1111\/den.12118","type":"journal-article","created":{"date-parts":[[2013,5,8]],"date-time":"2013-05-08T09:49:09Z","timestamp":1368006549000},"page":"376-385","source":"Crossref","is-referenced-by-count":108,"title":["Recent advances in endoscopic management of difficult bile duct stones"],"prefix":"10.1111","volume":"25","author":[{"given":"Ichiro","family":"Yasuda","sequence":"first","affiliation":[{"name":"First Department of Internal Medicine Gifu University Hospital  Gifu"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Takao","family":"Itoi","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology Tokyo Medical University  Tokyo 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