Fifty-four patients with common bile duct stones (8-36 mm in diameter) that could not be removed after endoscopic sphincterotomy, even with the use of mechanical lithotripsy, underwent extracorporeal shockwave lithotripsy (ESWL) using a Siemens Lithostar. Their median age was 75.5 (range 34-89) years. Patients received 4000-6000 shocks per session over approximately 60 min. Seventeen underwent two sessions and two patients three or more. Thirty-seven patients had one stone, ten had two, and seven had three or more. Spontaneous clearance of fragments occurred in only three patients before further endoscopic retrograde cholangiopancreatography was performed to remove fragments. Stones were removed and ducts cleared endoscopically in 35 patients, giving a total of 38 of 54 patients (70 per cent) with complete duct clearance. Fragmentation in response to lithotripsy was dependent on stone size; the number of stones had little effect. ESWL was well tolerated without any haematological or biochemical abnormality. Computed tomography in the first 20 patients showed no hepatic or pancreatic change after treatment. ESWL combined with endoscopic extraction of fragments is an alternative to surgery when preliminary endoscopic extraction and mechanical lithotripsy have failed.