NOVEL USE OF A BALLOON DILATATION CATHETER TO ENABLE MECHANICAL LITHOTRIPSY OF DIFFICULT COMMON BILE DUCT STONES AFTER INITIAL FAILED ATTEMPT

Aims:

To utilise a through-the-scope (TTS) dilator to increase working space within the common bile duct in the setting of large and multiple stones, to allow for the full deployment of a mechanical lithotriptor.

Methods:

A 7.5Fr CRE™ Wireguided Esophageal/Pyloric Balloon Dilatation Catheter (Boston Scientific, Marlborough, Massachusetts, United States) was chosen. This dilatation catheter has a balloon length of 5.5 cm and a width of 10 – 12 mm depending on insufflation pressure, and can be utilized in a through-the-scope (TTS) method with a minimum working channel of 2.8 mm.

The balloon dilatation catheter was inserted into the CBD over the existing guidewire with the entire length of the balloon portion within the CBD (i.e. no papillary dilatation was performed) and sequentially insufflated. There was initial waisting of the balloon which consequently improved significantly on sustained insufflation at the highest allowed pressure. Total insufflation time was approximately 10 minutes, with the highest insufflation pressure of 8 ATM (balloon diameter 12 mm, 36Fr) held at two minutes.

Results:

The same mechanical lithotripter was re-introduced into the CBD with successful full deployment and trapping of the CBD stones. An additional 20 minutes was spent crushing the stones rather uneventfully and the debris was trawled out in a routine fashion using a balloon catheter. An occlusion cholangiogram confirmed no residual filling defects.

Conclusions:

The ingenious off-label use of an esophageal/pyloric balloon dilatation catheter can be considered by an experienced endoscopist as an additional trick in tackling difficult cases of choledocholithiasis. The main benefit is to increase the success rate of clearance of difficult and multiple large CBD stones, in order to prevent multiple procedures and improve patients’ outcomes.