Balloon dilation of the papilla after sphincterotomy: rescue therapy for difficult bile duct stones

Introduction

Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones was first described in a series of nine patients by Staritz et al. in 1982 [1]. Later on, in the 1990s, with the emerging concept of preservation of the sphincter of Oddi, numerous studies reported on the use of EPBD (mainly using an 8-mm dilation balloon) as an alternative to biliary endoscopic sphincterotomy for the treatment of bile duct stones. More widespread use of EPBD has subsequently been limited, however, because of what appears to be a significant risk of pancreatitis [2] [3] [4]. In addition, it has been shown that more endoscopic retrograde cholangiopancreatography sessions and more frequent use of mechanical lithotripsy are required with EPBD in order to achieve a comparable success rate to that achievable by standard therapy with biliary endoscopic sphincterotomy [5] [6] [7]. One recent series from Japan involving 1000 patients undergoing EPBD (using balloons up to 8 mm in size) showed that lithotripsy was required for complete bile duct clearance in 77 % of the 328 patients who had stones measuring 10 mm or more but in only 6 % of the 672 patients with smaller stones [8].

The standard therapy of biliary endoscopic sphincterotomy with basket or balloon extraction is unsuccessful in 15 % of patients with difficult or larger bile duct stones [9]. Various techniques for stone fragmentation have been used as the ”rescue“ therapy for this subgroup. Among these, mechanical lithotripsy is used most commonly, with a success rate ranging from 79 % to 92 % [9]. However, this procedure can be lengthy, and up to a third of patients require a second procedure [10].

References

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