A novel method for estimating the safe margin and the adequate direction of endoscopic biliary sphincterotomy in choledocholithiasis with complications (with videos)

Abstract

Background: it is difficult to estimate the safe upper margin and the proper direction of endoscopic biliary sphincterotomy (EBS) in cases of choleclocholithiasis complicated by periampullaty diverticulum (PAD) or previous EBS. Objective: This study evaluated the clinical usefulness of an inflated-balloon-pulling (IBP) technique for assessing the safe margin and the proper direction of EBS in affected patients. Design: Prospective feasibility study. Setting: Academic tertiary center. Patients: From March 2003 to November 2003, the IBP technique was applied to patients with choledocholithiasis in whom EBS was difficult because of concomitant PAD or previous EBS. Interventions and Main Outcome Measurements: After the endoscopically visible papillary roof of the ampulla of Vater was fully dissected, an inflated 11.5- or 15-mm retrieval balloon was inserted in the bile duct and was pulled toward the duodenal lumen, creating an artificial bulge. This bulge was considered an endoscopic landmark to indicate the residual intramural portion and the direction of the bile duct. Results: A total of 19 patients (12 men, 7 women), with a mean age of 61.5 years, were consecutively enrolled. Of these patients, 7 had PAD, 7 had recurrent choleclocholithiasis, and 5 had both conditions. The mean length of the IBP-induced residual intramural bile duct was 6.6 mm (range, 3-15 mm). The previous EBS was not oriented toward the bile duct in 4 of 12 patients with recurrent choleclocholithiasis (33.3%). After EBS extended completely, choleclocholithiases were successfully removed in all patients (1 by mechanical lithotripsy). Of the 19 patients, 2 had complications (11%; 1 mild hemorrhage, 1 mild pancreatitis), which were managed medically. There was no case of perforation. Conclusions: The IBP technique is a feasible and a reliable method for safe and effective EBS in patients with choleclocholithiasis in whom EBS is difficult because of PAD or/and previous EBS. The clinical significance of the direction of previous EBS needs to be defined.