We describe here a technique of endoscopy large balloon sphincteroplasty for removing large radiolucent pancreatic stones. A 18Yrs old male patient with symptomatic large radiolucent pancreatic stones underwent a MRCP and then an ERCP for stone extraction.
ERCP was started in left lateral position with a normal cannula for cannulating the pancreatic duct. After turning the patient in the supine position a pancreatogram was obtained which showed large stones occupying the pancreatic duct with a uniformly dilated duct. A sphincterotomy was then carried out of the pancreatic sphincter using a double lumen sphincterotome with the cut being carried some where between 12 to 2'oclock direction. The sphicterotomy was done in a step by step manner using a blended endocut current and as the cut was being progressed there was a flow of pancreatic juice with some floating whitish pancreatic stones coming out from the pancreatic duct. The cut was extended until the entire bulging position of the ampulla was cut and until the biliary and duodenal junction was reached. After making a complete cut a controlled radial expansion (CRE) balloon of 12-15mms was inserted by the side of the guide wire inside the dilated pancreatic duct an the pancreatic sphincter was dilated up to 13mm.
After dilation once the balloon removed there was a gush of pelt up pancreatic juice and some floating stones after which a stone extraction balloon was inserted right till the tail of the pancreas and some of the stones which were in the head and body of the pancreas were removed by gentle sweep of the balloon in the axis of the pancreatic duct. Two or three times the balloon had to be passed inside and pulled out for achieving complete ductal clearance. As the stoned were large inspite of the large balloon sphincteroplasty a gentle but firm push of the endoscope with the balloon inside was required to pull some of the stones out an there by the achieve a complete ductal clearance. Because of large balloon sphincteroplasty even the big stones which were located inside the pancreatic duct could be taken out by repeated sweeps of the stone extraction balloon catheter without the need of performing a intraductal lithotripsy. A pancreaotography done after the stone removal showed that most of the large stones were removed in a single sitting of balloon sphincteroplasty after which a temporary 7 Fr. Stent was placed inside for continued and enhanced pancreatic ductal drainage. The patients was followed up after three months and the stent was removed and the duct checked and the patient had been completely asymptomatic at six months follow up after stent removal.
Amit P. Maydeo, MD, Institute of Advanced Endoscopy