Endoscopic sphincterotomy (ES) has been a useful method in the removal of common bile duct (CBD) stones for some time. However, in certain patients, stone removal by endoscopic sphincterotomy is unsuccessful due to challenging access to the bile duct, stone size exceeding the diameter of ampullary orifice or impacted stones in the bile duct. In the past, such difficult-to-remove stones were extracted by methods like mechanical lithotripsy, intraductal shock-wave lithotripsy, extracorporeal shock-wave lithotripsy, biliary stenting, and chemical dissolution. Biliary sphincterotomy involves making an incision along the ampullary orifice to make it larger. Another method used to enlarge the biliary sphincter opening is Balloon Sphincteroplasty, which in spite of being popular in the Orient, is not widely used in the U.S. because of an associated risk of pancreatitis. Recently, there has been a surge towards combining both sphincterotomy and sphincteroplasty. Endoscopic balloon dilation alone is slightly less successful than endoscopic sphincterotomy in stone extraction. However, in a study by Ersoz et al published in Gastrointestinal Endoscopy in 2003, dilation with a large 10-20 mm balloon after endoscopic sphincterotomy was shown to be a useful alternative technique in patients with difficult-to-remove bile duct stones. Subsequent studies have echoed these findings using 12-15 mm and 15-18 mm diameter balloons.
This patient presented with obstructive jaundice secondary to choledocholithiasis. We began by performing endoscopic retrograde cholangiopancreatography or ERCP under conscious sedation. We used a wire-guided sphincterotome to cannulate the ampulla. A cholangiogram was obtained. Here you can see a dilated common bile duct and a 12 mm common bile duct stone. Then a small sphincterotomy was performed using endocut current. We then used a controlled radial expansion or CRE balloon to perform a biliary sphincteroplasty. We inflated the CRE balloon to 10 mm and kept it in position for approximately 30 seconds. On cholangiogram it can be seen that the CBD stone has now descended slightly. After slowly deflating the balloon, it was removed from the ampullary orifice. Here you can see the dark stone at the orifice. Finally using a balloon sweep, the large CBD stone was gently extracted as if to deliver a baby.
The most common complication of sphincteroplasty after sphincterotomy is bleeding. In this case, the patient had an uneventful procedure and postoperative course. In summary, there are several situations when sphincterotomy is not sufficient in removing large CBD stones. In such situations, it has been our experience that using endoscopic sphincteroplasty after small sphincterotomy is a useful method in the removal of difficult bile duct stones.
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Omkar Dave, B.S., University of Texas Medical Branch
Gottumukkala S. Raju, MD, MD Anderson Cancer Center