Efficacy and safety of sphincterotomy with sphincteroplasty using large caliber balloons in the treatment of choledocholithiasis with extraction difficulties


Introduction: Endoscopic retrograde cholangiopan-creatography (ERCP) with endoscopic sphincterotomy (ES) is the most widely used technique for treating choledocholithiasis. In some cases, due to anomalies of the papilla or the presence of large or multiple calculi, additional maneuvers are needed to remove the stones. The present study investigates the efficacy and safety of ES with sphincteroplasty (SP) in the management of choledocholithiasis with extraction difficulties. Patients and Methods: A prospective study was made of 153 patients with choledocholithiasis subjected to ERCP. Fifty-two patients underwent ES with SP, while 101 were subjected only to ES. The two groups were compared in terms of age, gender, percentage cannulation, presence of papilla alterations, large or multiple stones, success in stone removal and complications (acute pancreatitis, bleeding and perforation). In the ES with SP group, we moreover recorded the diameters of the balloons employed (10-18 mm). Results: There were no significant differences between the groups in the stone extraction success rate (94.23% in the ES with SP group versus 97.03% in the ES group) or in the appearance of complications (3.8% in the ES with SP group versus 2.7% in the ES group). The presence of difficult papillae, and of multiple or large stones was significantly greater in the ES with SP group. The diameter of the balloon was not associated with the appearance of complications. Conclusion: Endoscopic sphincterotomy with sphincteroplasty is effective and safe in the treatment of choledocholithiasis with extraction difficulties.

Share and Cite:

Uribarrena-Amezaga, R. , Serna, I. , Calvo-Morillas, I. , Sebastián-Domingo, J. , Cabrera-Chaves, T. , Teodoro, M. and Uribarrena-Echebarría, R. (2013) Efficacy and safety of sphincterotomy with sphincteroplasty using large caliber balloons in the treatment of choledocholithiasis with extraction difficulties. Open Journal of Gastroenterology, 3, 241-248. doi: 10.4236/ojgas.2013.34041.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Kawai, K., Akasaka, Y., Murakami, K., Tada, M. and Koli, Y. (1974) Endoscopic sphincterotomy of the ampula of water. Gastrointestinal Endoscopy, 20, 148-151. doi:10.1016/S0016-5107(74)73914-1
[2] Classen, M. and Demling, L. (1974) Endoscopic sphincterotomy of the papilla of water and extraction of stones from the choledochal duct. Dutch Med Wochenschr, 99, 496-497. doi:10.1055/s-0028-1107790
[3] Henry, L. and Lehman, G. (2006) Difficult bile duct stones. Current Treatment Options in Gastroenterology, 9, 123-132. doi:10.1007/s11938-006-0031-6
[4] Hochberger, J., Tex, S., Maiss, J. and Hahn, E.G. (2003) Management of difficult common bile duct stones. Gastrointestinal Endoscopy Clinics of North America, 13, 623-634. doi:10.1016/S1052-5157(03)00102-8
[5] Stefanidis, G., Viazis, N., Pleskow, D., Manolakopoulos, S., Theokaris, L. and Cristodolou, C. (2011) Large baloon vs mechanical lithotripsy for the management of large bile duct stones: A prospective randomized study. American Journal of Gastroenterology, 106, 278-285. doi:10.1038/ajg.2010.421
[6] Ersoz, G., Tekesin, O., Osutemiz, A.O. and Gunsar, F. (2003) Biliary sphincterothomy plus dilation with large baloon for bile duct stones that are difficult to extract. Gastrointestinal Endoscopy, 57, 156-159. doi:10.1067/mge.2003.52
[7] Cotton, P.B. (1972) Cannulation of the papila of vater by endoscopic and retrograde cholangiopancreatography (ERCP). Gut, 13, 1014-1025. doi:10.1136/gut.13.12.1014
[8] Cotton, P.B. (1977) ERCP. Gut, 18, 316-341. doi:10.1136/gut.18.4.316
[9] Martín-Arranz, E., Rey-Sanz, R., Martín Arranz, M.D., Gea-Rodríguez, F., Mora-Sanz, P. and Segura-Cabral, J.M. (2012) Safety and efficacy of large baloon sphincteroplasty in a third care hospital. Revista Espanola de Enfermedades Digestivas, 102, 355-359. doi:10.4321/S1130-01082012000700004
[10] Wang, W.H., Chu, C.H., Wang, T.E., Chen, M.J. and Lin, C.C. (2005) Outcome of simple use of mchanical lithotripsy of difficult common bile duct stones. World Journal of Gastroenterology, 11, 593-596.
[11] Attam, R. and Freeman, M.L. (2009) Endoscopic papillary large baloon dilation for large common bile duct stones. Journal of Hepato-Biliary-Pancreatic Surgery, 16, 618-623. doi:10.1007/s00534-009-0134-2
[12] Itoi, T. and Wang, H.P. (2010) Endoscopic management of bile duct stones. Digestive Endoscopy, 22, 69-75. doi:10.1111/j.1443-1661.2010.00953.x
[13] Itoi, T., Itokawa, F., Sofuni, A., Kurihara, T., Tsuchiya, T., Ishii, K., et al. (2009) Endoscopic sphincterothomy combined with large baloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones. American Journal of Gastroenterology, 104, 560-565. doi:10.1038/ajg.2008.67
[14] Shim, C.S. (2010) How should biliary Stone be managed? Gut and Liver, 4, 161-172. doi:10.5009/gnl.2010.4.2.161
[15] Nakayama, H.A., Kajiyama, M., Kato, N., Kamijima, T., Graham, D.Y. and Tanaka, N. (2010) Biliary stenting and the management of large or multiple common bile duct stones. Gastrointestinal Endoscopy, 71, 1200-1203. doi:10.1016/j.gie.2009.12.055
[16] Maydeo, A. and Bhandari, S. (2007) Baloon sphincterothomy for removing difficult bile duct sotones. Endoscopy, 11, 956-961.
[17] Kim, T.H., Oh, H.S., Lee, J.Y. and Sohn, Y. (2011) Can endoscopic sphincterothomy plus a large baloon dilation reduce the use of mechanical lithotripsy in patients winth large bile duct stones? Surgical Endoscopy, 25, 3330-3337. doi:10.1007/s00464-011-1720-3
[18] Espinel, J., Pinedo, E. and Olcoz, J.L. (2007) Large hydrostatic baloon for choledocholitiasis. Revista Espanola de Enfermedades Digestivas, 99, 33-38.
[19] Misra, S.L. and Dwivedi, M. (2008) Large-diameter baloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones. Endoscopy, 40, 209-213. doi:10.1055/s-2007-967040
[20] Mirami, A., Shinji, H., Mamoto, T. and Hayakwa, S. (2007) Small sphincterotomy combined with paillary dilation with large baloon permits retrieval of large stones without mechanical lithotripsy. World Journal of Gastroenterology, 13, 2172-2182.
[21] Draganov, P.V., Evans, W., Fazel, A. and Forsmark, C.E. (2009) Large size baloon dilation of the ampula after biliary sphincteotomy can facilitate endoscopic extraction of difficult bile duct stones. Journal of Clinical Gastroenterology, 43, 782-786. doi:10.1097/MCG.0b013e31818f50a2
[22] Kurita, A., Maguchi, H., Takahashi, K., Katamura, A. and Osonai, M. (2010) Large baloon dilation for the treatment of recurrent bile duct stones in patients with previous sphincterotomy. Preliminary results. Scandinavian Journal of Gastroenterology, 45, 1242-1247. doi:10.3109/00365521.2010.495420
[23] Freeman, M.L., Di Sario, J.A., Nelson, D.B., et al. (2001) Risk factors for post ERCP pancreatitis: A prospective multicenter study. Gastrointestinal Endoscopy, 54, 425-434. doi:10.1067/mge.2001.117550
[24] Freeman, M.L., Nelson, D.B., Sherman, S., et al. (1996) Complications of endoscopic biliary sphincterotomy. New England Journal of Medicine, 335, 909-918. doi:10.1056/NEJM199609263351301
[25] Fujita, N., Maguchi, H., Komatsu, Y., et al. (2003) Endoscopic sphincterotomy and endoscopic baloon dilation for bile duct stones: A prospective randomized controlled multicenter trial. Gastrointestinal Endoscopy, 57, 151-155. doi:10.1067/mge.2003.56
[26] Di Sario, J.A., Freeman, M.L., Bjorkman, D.J., et al. (2004) Endoscopic baloon dilation compared winth sphincterotomy for extraction of bile duct stones. Gastroenterology, 127, 1291-1299. doi:10.1053/j.gastro.2004.07.017
[27] Chien, K.L., Tu, Y.K., Wu, M.S., Wang, H.P., Lin, J.T., Leung, J.W. and Chien, K.L. (2012) Baloon dilation with adequate duration is safer tan sphincterotomy for extracting bile duct stones: A sistematic review and meta-analyses. Clinical Gastroenterology and Hepatology, 10, 1009-1011.
[28] Machado, N.O. (2012) Management of duodenal perforation post-endoscopic retrograde cholangiopancreatography. When and whom to operate and what factors determine the outcome. A review article. Journal of the Pancreas, 13, 18-25.

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.