Endoscopic Papillary Large Balloon Dilatation Alone Is Safe and Effective for the Treatment of Difficult Choledocholithiasis in Cases of Billroth II Gastrectomy: A Single Center Experience

Abstract

Endoscopic treatment of difficult common bile duct (CBD) stones (diameter ≥ 10 mm, or four or more) is difficult in patients who have undergone Billroth II (B-II) gastrectomy. Endoscopic sphincterotomy (EST) can be particularly troublesome due to anatomical changes effected by the gastrectomy. We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with large-diameter dilation balloons in the treatment of difficult CBD stones in patients who have undergone B-II gastrectomy. From June 2006 to April 2011, patients with difficult CBD stones and who had undergone B-II gastrectomy previously were included in this study. EPLBD was performed with a 10-18 mm balloon catheter. When selective cannulation through the sphincter was possible, EPLBD was performed without EST. EPLBD was otherwise performed after fistulotomy with needle knife. A total of 40 patients (32 male) underwent EPLBD for the retrieval of CBD stones, and concurrent fistulotomy was performed in seven patients. The median diameter of CBD was 13 mm (range 10-20 mm) and the balloon was 12 mm (range 10-17 mm). CBD stones were successfully removed in all patients. In only three patients, repeated sessions of ERCP were required for complete removal of CBD stones. Mechanical lithotripsy was required in only one case. Acute complications from EPLBD included mild pancreatitis in two patients (5.0 %). Severe complications, including perforation and bleeding, were not observed. Late complications included stone recurrence in one patient (2.5 %) and cholecystitis in four patients (10.0 %). In cases of B-II gastrectomy, EPLBD without EST is a safe and highly effective technique for the retrieval of difficult CBD stones. EPLBD should be considered as an alternative tool to conventional EST.