title: Large size balloon dilation of the ampulla after biliary sphincterotomy can facilitate endoscopic extraction of difficult bile duct stones.
abstract: OBJECTIVE
  Evaluate the efficacy and safety of large size balloon dilation of the biliary orifice after maximal biliary sphincterotomy to facilitate removal of difficult bile duct stones in a Western population.
  
  
  BACKGROUND
  Some bile duct stones may be difficult to remove with standard endoscopic retrograde cholangiopancreatography (ERCP) techniques. Even after multiple procedures, and the use of advanced, labor-intense techniques complete stone clearance may be difficult to achieve.
  
  
  METHODS
  This is retrospective review of prospectively collected data. Patients who had failed stone extraction with standard balloon technique after maximal biliary sphincterotomy at the index ERCP underwent large size balloon dilation of the biliary orifice to facilitate stone removal. The main outcomes were complete stone clearance and complications.
  
  
  RESULTS
  Forty-four patients were evaluated. Thirty-one (70%) had a prior failed ERCP in the past. Periampullary diverticulum was present in 13 patients (30%). Complete stone removal was accomplished in 42 patients (95%). In 37 patients (84%), complete stone clearance was accomplished at the index ERCP without the need for mechanical lithotripsy. Three patients (6%) required an additional ERCP and 2 patients (5%) required 2 additional ERCPs to accomplish complete stone removal. Three mild complications occurred (6.8%). None of the patients developed perforation or pancreatitis.
  
  
  CONCLUSIONS
  Large size balloon dilation after biliary sphincterotomy is simple, safe, and highly effective technique that can greatly assist in the management of difficult to extract bile duct stones.
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, USA. dragapv@medicine.ufl.edu
authors.forename: Peter V
authors.initials: PV
authors.lastname: Draganov
authors.forename: William
authors.initials: W
authors.lastname: Evans
authors.forename: Ali
authors.initials: A
authors.lastname: Fazel
authors.forename: Chris E
authors.initials: CE
authors.lastname: Forsmark