title: A novel method for estimating the safe margin and the adequate direction of endoscopic biliary sphincterotomy in choledocholithiasis with complications (with videos).
abstract: 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.
authors.affiliation: Division of Gastroenterology and Clinical Research Institute, Soon Chun Hyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Do Hyun
authors.initials: DH
authors.lastname: Park
authors.forename: Sang-Heum
authors.initials: SH
authors.lastname: Park
authors.forename: Hyun-Jun
authors.initials: HJ
authors.lastname: Kim
authors.forename: Jeong Hoon
authors.initials: JH
authors.lastname: Park
authors.forename: Jun-Young
authors.initials: JY
authors.lastname: Lee
authors.forename: Kyeong-Hee
authors.initials: KH
authors.lastname: Choi
authors.forename: Jae-Hak
authors.initials: JH
authors.lastname: Lee
authors.forename: Suck-Ho
authors.initials: SH
authors.lastname: Lee
authors.forename: Il-Kwun
authors.initials: IK
authors.lastname: Chung
authors.forename: Hong-Soo
authors.initials: HS
authors.lastname: Kim
authors.forename: Sun-Joo
authors.initials: SJ
authors.lastname: Kim
mesh_terms: 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