Endoscopic Large Balloon Sphincteroplasty Along with Endoscopic Sphincterotomy (ELBS-EST) in Patients with Large Extrahepatic Bile Duct Stones

Abstract

Background/Aims: After endoscopic sphincterotomy (EST) had developed, the basket stone removal after EST was the classic treatment modality for the extrahepatic bile duct (EHD) stones. However, for the large EHD stones (usually larger than 15 mm in diameter), endoscopic mechanical lithotripsy (EML) had to be used to break the large stones into small fragments. If there were multiple large EHD stones, repeated EML's were performed to remove the EHD stones. However, if the ampulla could be dilated more wider, such large stones could be removed without EML. The aim of this study was to evaluate the effectiveness of the ELBS-EST to remove the large EHD stones. Method: If the size of the stones were larger than 15 mm, the ampulla was dilated with a balloon (CRETM wire-guided balloon dilator, Boston Scientific, U.S.A) along with EST, with a measurement of 18 mm or 20 mm in diameter. The duration of balloon dilatation times was about 1 min. After dilation of the ampulla, EHD stone removal was tried with a basket. If stone removal failed with the basket, EML was then performed to break the large stones into small pieces. After that the small pieces of stones were removed with the basket. Results: 1) ELBS-EST was performed in 40 patients (M:F = 14:26, mean age: 66.2 yrs). 2) The mean diameter of stones were 19.8 ± 4.6 mm (range, 15∼34 mm). The mean number of stones were 2.3 ±1.4 (range, 1∼6). 3) In 34 (85.0%) patients, the EHD stones were removed without EML. The mean size of stones in these patients was 19.2 mm (range, 15∼34 mm). 4) In 6 (15.0%) patients, failure to remove stones with ELBS-EST alone occurred. The mean size of stones in these patients was 23.5 mm (range, 17∼30 mm). In these patients, only one session of EML was performed to remove the stones. 5) In 5 (12.5%) patients had post-procedure complications (3 cases were minor bleeding, 2 cases were pancreatitis). Conclusion: Endoscopic large balloon sphincteroplasty along with EST is a safe and useful alternative technique in patients with large EHD stones. ELBS-EST could reduce the sessions of EML and substitute the role of EML in some portion. However further study with large scale patients would be needed to evaluate the exact usefulness of ELBS-EST.