A novel method for estimating the safe margin and the adequate direction of endoscopic biliary sphincterotomy in choledocholithiasis with complications (with videos).
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 previous EBS.


OBJECTIVE
This study evaluated the clinical usefulness of an inflated-balloon-pulling (IBP) technique for assessing the safe margin and the proper direction of EBS in affected patients.


METHODS
Prospective feasibility study.


METHODS
Academic tertiary center.


METHODS
From March 2003 to November 2003, the IBP technique was applied to patients with choledocholithiasis in whom EBS was difficult because of concomitant PAD or previous EBS.


METHODS
After the endoscopically visible papillary roof of the ampulla 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 oriented 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.
Park
Do Hyun
DH
Division of Gastroenterology and Clinical Research Institute, Soon Chun Hyang University Cheonan Hospital, Cheonan, Korea.
Park
Sang-Heum
SH
Kim
Hyun-Jun
HJ
Park
Jeong Hoon
JH
Lee
Jun-Young
JY
Choi
Kyeong-Hee
KH
Lee
Jae-Hak
JH
Lee
Suck-Ho
SH
Chung
Il-Kwun
IK
Kim
Hong-Soo
HS
Kim
Sun-Joo
SJ
D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery*; D042883:Choledocholithiasis / Q000150:complications / Q000601:surgery*; D004240:Diverticulum / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic / Q000379:methods*; D016896:Treatment Outcome; D014741:Video Recording