Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract Galip Ersoz, MD, Oktay Tekesm, MD, Ahmet Omer Ozutemiz, MD, Fulya Gunsar, MD Izmir, Turkey Background: Bile duct stones are still present in 10% to 15% of patients after the application of conventional endoscopic extraction techniques and require additional procedures for duct clear- ance. In the vast majority of these cases, there are 2 main problems: large stone size (>15 mm) and tapering of distal bile duct. Methods: Fifty-eight patients in whom endoscopic sphincterotomy and standard basket/balloon extraction were unsuccessful in the removal of bile duct stones underwent dilation with a 10- to 20-mm diameter (esophageal/pyloric type) balloon at the same session. In 18 patients with tapered distal bile ducts (Group 1), 12- to 18-mm diameter balloon catheters were used to enlarge the ori- fice. In 40 patients with square, barrel shaped and/or large (>15mm) stones (Group 2), the sphinc- terotomy orifice was enlarged with 15- to 20-mm diameterballoon catheters. After dilatation, stan- dard basket/balloon extraction techniques were used to remove the stone(s). Results: Stone clearance was successful in 16 patients (89%) in Group 1 and 35 (95%) in Group 2. Complications occurred in 9 (15.5%) patients. Conclusion: Dilation with a large-diameter balloon after endoscopic sphincterotomy is a useful alternative technique in patients with bile duct stones that are difficult to remove with standard methods. (Gastrointest Endosc 2003;57:156-9.) Endoscopic sphincterotomy (ES) is the most fre- quently used endoscopic technique for clearance of stones from the bile duct, although balloon dilation of the papillary sphincter has also been used for this purpose.i, 2 Both procedures are performed in 3 stages; deep cannulation of common bile duct, ES or balloon dilatation, and extraction of stones. ES is successful in 90% to 98% of patients and 86% to 91% of all bile duct stones can be extracted with a Dormia basket after ES. 3-5 The major factors that restrict the ability to remove stones include large size (>15 mm), barrel shaped stones, and tapering of the distal common bile duct. In such cases, additional procedures, main- ly mechanical lithotripsy, may be needed for stone clearance. The reported success rate of mechanical lithotripsy is 80% to 98%. 6-9 The main factor that influences success is stone diameter; in one study, the success rate was only 68% for stones larger than 28 mm. 9 Alternatives to mechanical lithotripsy are dissolution of stones with solvents, extracorporeal shock, wave lithotripsy (ESWL) and laser or electro- Received April 30, 2002. For revision August 6, 2002. Accepted October 16, 2002. Current affiliations: Ege University School of Medicine, Department of Gastroenterology, Izmir, Turkey. Reprint requests: Fulya Gunsar, Ege Universitesi Tip Faki~ltesi, Gastroenteroloji Bilim Dali, Bornova, Izmir, Turkey. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.106 7 / mge.2003.52 hydraulic lithotripsy. However, none of these are used commonly, and thus there are few data pertain- ing to their efficacy and safety. 10-14 Balloon catheters are used frequently for dilatation of strictures of the esophagus, pylorus, and colon. In the past, large-diameter balloons were used for dila- tion of the papillary orifice, but balloons with smaller diameters are currently preferred for this purposeJ 5-1s There are no reports of the application of large- diameter balloons for dilatation after standard ES for treatment of patients with bile duct stones. The removal of bile duct stones by dilatation with a large- diameter balloon after adequate ES in patients in whom standard basket and balloon extraction tech- niques failed was retrospectively reviewed. PATIENTS AND METHODS Endoscopic interventions for removal of bile duct stones were retrospectively evaluated in 942 patients treated between February 1998 and October 2001. In 854 (91%), the stones were successfully removed by standard ES and balloon or basket extraction techniques:. In 4 patients, stents were placed in the bile duct. Sixteen patients in whom bile duct cannulation was unsuccessful and 10 who refused balloon dilatation underwent surgery. Dilatation with a large balloon was performed after ES in the remaining 58 patients in whom endoscopic removal of bile stones by standard ES and balloon/basket extraction techniques had failed. Informed consent was obtained from all patients before the procedure. Tests to evaluate coagulation were performed in all patients before ES. Antibiotics were administered prophylactically before the 156 GASTROINTESTINAL ENDOSCOPY VOLUME 57, NO. 2, 2003