NEW METHOD: Clinical Endoscopy A novel method for estimating the safe margin and the adequate direction of endoscopic biliary sphincterotomy in choledocholithiasis with complications (with videos) Do Hyun Park, MD, Sang-Heum Park, MD, Hyun-Jun Kim, MD, Jeong Hoon Park, MD, Jun-Young Lee, MD, Kyeong-Hee Choi, RN, Jae-Hak Lee, MD, Suck-Ho Lee, MD, Il-Kwun Chung, MD, Hong-Soo Kim, MD, Sun-Joo Kim, MD Cheonan, Korea Background: It is difficult to estimate the safe upper margin and the proper direction of endoscopic biliary sphincterotomy (EBS) in cases of choledocholithiasis complicated by periampullary diverticulum (PAD) or pre- vious EBS. Objective: This study evaluated the clinical usefulness of an inflated-balloon-pulling (IBP) technique for assess- ing 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 choledocholi- thiasis 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 am- pulla 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 choledocholithiasis, 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 ori- ented toward the bile duct in 4 of 12 patients with recurrent choledocholithiasis (33.3%). After EBS extended completely, choledocholithiases 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 choledocholithiasis 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. Endoscopic biliary sphincterotomy (EBS) is a very use- ful technique for pancreaticobiliary diseases, especially in patients with choledocholithiasis. To prevent EBS-related complications, it is recommended that the incision be di- rected along the longitudinal axis of the bile duct but be limited to the length of the intramural bile duct. 1 The crucial step for a safe and effective EBS, especially in patients with choledocholithiasis, is to precisely demar- cate the intramural segment and proper direction of the bile duct, which are endoscopically observable cephalad to the ampulla of Vater (AV) in the majority of cases. 1,2 But this anatomic landmark is not endoscopically evident in some patients with choledocholithiasis, especially when complicated by a periampullary diverticulum (PAD) or previous EBS, because of the distorted anatomy or unclear papillary mound. 3-7 Several techniques have been intro- duced in these patients to delineate endoscopic landmark, Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.06.040 www.giejournal.org Volume 64, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 979