Large Balloon-Lithotripsy (LB-L) 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 classical 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 so widely, such large stones could be removed without EML. The aim of this study was evaluate the effectiveness of large balloon dilatation of ampulla to remove the large extrahepatic bile duct stones. Method: If the size of the stones were larger than 15 mm, dilate the ampulla with a balloon (CRETM wireguided balloon dilator, Boston Scientific, U.S.A), with a measurement of 18 mm or 20 mm in diameter. the duration of balloon dilatation were 1 min × 3 times (7 patients), 1 min (16 patients), and 30 sec (1 patient). After dilate the ampulla, EHD stone removal was tried with basket. If stone removal failed with the basket, EML was then performed to break the large stone to small pieces. After that the small pieces of stones were removed with the basket. Results: 1) In 24 patients (M:F = 7;17, mean age: 65 yrs), the ampulla was dilated with balloon dilator. 2) The mean diameter of stones were 20.4'6.1 mm. And the mean number of stones were 2.2 (1.6). 3) Among the 24 patients, in 19 patients, the EHD stones were removed without EML after dilated the ampulla without EML. The mean size of stones in these patients was 19.4 mm. 4) In 5 patients, failed to remove stones with ampulla dilatation alone. The mean size of stones in these patients was 28.7 mm. In these patients, EML was performed to remove the stones. 5) In 1 patient, pancreatitis happened after dilated the ampulla with balloon. In this patient, the duration of balloon dilatation was 1 min × 3 times. Bleeding was happened in 1 patient. In this patient, the duration of balloon dilatation was 30 sec. Conclusion: Large balloon-lithotripsy could reduce the sessions of EML and substitute the role of EML in some portion. Therefore, the large balloon-lithotripsy could be an effective treatment modality in patients with large EHD stones.