Balloon sphincteroplasty for removing difficult
bile duct stones

Background and study aims: Extraction of common bile duct stones at endoscopic retrograde cholangiopancreatography can be technically challenging when the size of the stone exceeds that of an endoscopic sphincterotomy. The aim of this study was to evaluate the efficacy and safety of papillary balloon dilation after sphincterotomy for extraction of these difficult-to-remove bile duct stones.

Patients and methods: This was a prospective study of all patients with large common bile duct stones that could not be extracted using a stone retrieval balloon and basket after endoscopic sphincterotomy. These patients underwent papillary dilation using a radial expansion balloon after maximum sphincterotomy. Biliary ductal clearance was then reattempted using a stone retrieval balloon and/or basket. The success rate and the complication rate for the papillary balloon dilation technique were assessed.

Results: A total of 60 patients (16 men, 44 women; mean age 58, range 28 - 73) were enrolled in this study. The mean stone size was 16 mm (range 12 - 20 mm). After maximum sphincterotomy and papillary balloon dilation, ductal clearance was achieved in 57/60 patients (95 %); three patients required adjunctive mechanical lithotripsy for stone extraction. Bleeding occurred in five patients (8.3 %) and was managed conservatively in all cases.

Conclusions: Papillary balloon dilation after endoscopic sphincterotomy is an effective and safe technique for retrieval of difficult common bile duct stones. The procedure is technically safe and obviates the need for mechanical lithotripsy in a majority of patients.

References

• 1 Carr-Locke D L. Therapeutic role of ERCP in management of suspected common bile duct stones.  Gastrointest Endosc. 2002;  56 (6 Suppl) S170-S174
• 2 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy complications and their management: an attempt at consensus.  Gastrointest Endosc. 1991;  37 383-393
• 3 Lauri A, Horton R C, Davidson B R. et al . Endoscopic extraction of bile duct stones: management related to stone size.  Gut. 1993;  34 1718-1721
• 4 Baron T H, Harewood G C. Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of bile duct stones during ERCP: a meta-analysis of randomized controlled trials.  Am J Gastroenterol. 2004;  99 1455-1460
• 5 Weinberg B M, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones.  Cochrane Database Syst Rev. 2006;  Oct 18 (4) CD004890
• 6 Ersoz G, Tekesin O, Ozutemiz A O. et al . Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract.  Gastrointest Endosc. 2003;  57 156-159
• 7 Seitz U, Bapaye A, Bohnacker S. et al . Advances in therapeutic endoscopic treatment of common bile duct stones.  World J Surg. 1998;  22 1133-1144
• 8 Shaw M J, Mackie R D, Moore J P. et al . Results of a multicenter trial using a mechanical lithotriptor for treatment of large common bile duct stones.  Am J Gastroenterol. 1993;  88 730-733
• 9 Hintze R E, Adler A, Veltzke W. Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients.  Hepatogastroenterology. 1996;  43 473-476
• 10 Cohello R, Bordas J M, Guevera M C. et al . Mechanical lithotripsy during retrograde cholangiography in choledocholithiasis untreatable by conventional endoscopic sphincterotomy.  Gastroeterol Hepatol. 1997;  20 124-127
• 11 Cipolletta L, Costamagna G, Bianco M A. et al . Endoscopic mechanical lithotripsy of difficult bile duct stones.  Br J Surg. 1997;  84 1407-1409
• 12 Garg P K, Tandon R K, Ahuja V. et al . Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones.  Gastrointest Endosc. 2004;  59 601-605
• 13 Chang W H, Chu C H, Wang T. et al . Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones.  World J Gastroenterol. 2005;  11 593-596
• 14 Bergman J J, Rauws E A, Fockens P. et al . Randomized trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bile duct stones.  Lancet. 1997;  349 1124-1129
• 15 Tanaka S, Sawayama T, Yoshioka T. Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial.  Gastrointest Endosc. 2004;  59 614-618
• 16 Arnold J C, Benz C, Martin W R. et al . Endoscopic papillary balloon dilation vs. spincterotomy for removal of common bile duct stones: a prospective randomized pilot study.  Endoscopy. 2001;  33 563-567