Endoscopic Papillary Large Balloon Dilation with Minor Endoscopic Sphincterotomy in the Management of Difficult Bile Duct Stones

Abstract

Background/Aims: Endoscopic sphincterotomy (ES) followed by extraction using a basket or a retrieval extraction balloon is the procedure that is generally used for the removal of extrahepatic bile duct (EHD) stones. However, for the large EHD stones (more than 15 mm in diameter), major ES is needed to remove the stones and moreover endoscopic mechanical lithotripsy (EML) is usually needed to crush the large stone. These procedures may result in prolonged procedure time, increased complication rates, and repeated procedure for complete removal of stones. Additionally, the patients with periampullary diverticulum (PAD) may have a higher risk of complications such as bleeding or perforation during a major ES. The aim of this study was to investigate the effectiveness and the safety of endoscopic papillary large balloon dilation (EPLBD) with minor ES for the removal of large EHD stones. Methods: 44 patients (20 men, 24 women; mean age 72.0±11.2 years) with large EHD stones were enrolled for this study. Among them, 20 patients had PAD (45.5%). Major papilla was dilated with 10-mm to 15-mm-diameter balloon (CRETM wireguided balloon dilator, Boston Scientific, U.S.A.) after minor ES. The duration of balloon dilation was 30 to 120 seconds. The stones were then retrieved from the bile duct with a conventional basket or a retrieval balloon. When conventional methods with basket or balloon failed to removed the stones, EML was then performed to break the large stone into small fragments. Results: All patients underwent EPLBD with minor ES. The mean diameter of EHD stones was 18.3 mm (range, 10.9-43.9 mm). In 42 patients (95.5%), EHD stones were completely removed by only one session of the procedure. EML was carried out in two patients for impacted stones in distal EHD. Serum amylase or lipase levels were elevated in 17 patients (38.6%) after the procedure. However, mild pancreatitis developed in only 2 patients (4.5%) of them, and was self limiting. Minor bleeding occurred in 3 patients (6.8%), but they were easily controlled by spraying of epinephrine or balloon compression. No procedure related cholangitis, perforation or mortality was observed. Conclusions: EPLBD with minor ES is safe and effective treatment modality for the retrieval of large EHD stones even in the patients with PAD, and EML could be avoided in the majority of these patients using this approach.