Balloon Sphincteroplasty for Extraction of Difficult Bile Duct Stones

Abstract

Background: Endoscopic stone retrieval becomes a therapeutic challenge when the diameter of the CBD stone exceeds that of the distal bile duct at the ampulla. As further extension of biliary sphincterotomy and use of conventional stone retrieval balloon/basket is unlikely to be helpful in this scenario, additional maneuvers such as use of mechanical lithotripsy may be required to achieve ductal clearance. We propose balloon sphincteroplasty as a technique for endoscopic management of these patients. Methods: This is a prospective study of 62 patients (16 men, 46 women; median age 58, range 28-73 years) with CBD stones that could not be extracted by standard maneuvers (biliary sphincterotomy followed by use of balloon/basket) as the diameter of the CBD stone exceeded that of the distal bile duct at the ampullary orifice. The mean stone size was 16 mm (range, 12-25 mm). Balloon sphincteroplasty was undertaken to facilitate stone extraction in these patients. Complications were assessed per consensus criteria. Local bleeding was managed by injection of epinephrine or placement of hemoclips. Procedural technique: The biliary orifice at the ampulla was subjected to balloon dilation using a CRE balloon (diameter, 12-15 mm; Microvasive Inc.,). Prior to dilation, all patients had undergone maximal biliary sphicterotomy followed by attempts at stone extraction using standard stone retrieval balloon/basket. Following balloon dilation, a reattempt was made using standard stone retrieval balloon/basket for extraction of the residual CBD stones. Results: Balloon sphincteroplasty facilitated successful stone extraction in 57 of 62 (92%) patients. In 5 others in whom the stones could not be retrieved by balloon sphincteroplasty technique, mechanical lithotripsy aided clearance in 3 patients and surgery in 2. Failures were encountered when stones were large (>15 mm) and multiple. Minor bleeding was encountered following CRE balloon dilation in 5 (8.3%) patients that was managed endoscopically. No long-term complications were encountered. Conclusions: Balloon sphincteroplasty augments the biliary orifice opening at the ampulla and facilitates extraction of difficult stones when the diameter of the CBD stone exceeds that of the distal bile duct. The requirement for additional maneuvers like mechanical lithotripsy and risks associated with extended sphincterotomy can be minimized by this technique.