In the past 2 years, we have carried out 152 consecutive cases of large balloon dilation
of the papilla after full length sphincterotomy in our center. The procedure was undertaken
in patients with normal structural anatomy and large (> 12 mm), unretrieved biliary
duct stones, using balloon catheters (CRE Esophageal/Pyloric, maximum diameter 15,
18, or 20 mm; length 5 cm, Boston Scientific, Natick, Massachusetts, USA). We experienced
three cases of perforation (2 %) related to balloon dilation during this period. All
three cases involved middle-aged women hospitalized for choledocholithiasis.
The first perforation was discovered on cholangiography performed immediately after
the dilation, which showed leakage of the fluorescent contrast medium around the duodenal
wall ([Fig. 1]). A plastic stent was immediately placed to contain the leaking bile and the patient
sent for urgent computed tomography (CT). The other two cases manifested within the
first 24 – 48 hours. There was no sign of perforation on cholangiography and the patients
remained afebrile and haemodynamically stable. However, they complained of a dull
abdominal pain in the epigastrium, and laboratory findings indicated slightly raised
levels of inflammatory markers (C-reactive protein and white blood cell counts). Plain
radiographic examination did not suggest presence of free air and the patients were
referred for CT, which revealed pneumo- and retroperitoneum with no retroperitoneal
fluid collection in both cases. There was only a small amount of contrast leakage
in the first case ([Fig. 2] and [Fig. 3]). All three patients were managed conservatively with antibiotics, placement of
nasogastric tube, and close medical monitoring, and were discharged within 10 days.
There were no medical concerns during the follow-up period.
Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) showing leakage of the fluorescent
medium (arrows) in patient 1.
Fig. 2 Patient 1: computed tomography (CT) scan depicting free air in peritoneal cavity
and retroperitoneum (long white arrows), fluorescent contrast leakage around the duodenal
wall (blue arrow) and a stent in the distal common bile duct (short white arrow).
Fig. 3 Computed tomography (CT) scan depicting free air in the peritoneal cavity and retroperitoneum
(white arrows): a patient 2.
b Patient 3.
To our knowledge, remarkably low rates of perforation (0.2 %) [1] have been observed worldwide in studies using large balloon dilation of the papilla
after sphincterotomy in patients with normal anatomical structures [1]
[2]
[3]
[4]. The rare cases that have been reported until now were treated conservatively [4]
[5]. Of course, large balloon dilation of the papilla after full length sphincterotomy
is a new method, and many related issues are still under evaluation. However, our
data suggest that perforations may be a more frequent complication but are not reported
as such because they may be subclinical or misdiagnosed. Vigilance on the part of
medical staff, appropriate use of radiological imaging, and close monitoring may help
resolve this difficult judgment call, and spare the patient from undergoing unnecessary
and difficult surgical procedures while preventing serious and occasionally fatal
sepsis.
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