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Large-balloon dilation of the biliary orifice for the management of basket impaction: a case series of 6 patients
Large-balloon dilation of the biliary orifice for the management of basket impaction: a case series of 6 patients Panagiotis Katsinelos, MD, PhD, Kostas Fasoulas, MD, Athanasios Beltsis, MD, Grigoris Chatzimavroudis, MD, PhD, Christos Zavos, MD, PhD, Sotiris Terzoudis, MD, Jannis Kountouras, MD, PhD Thessaloniki, Greece
ERCP with endoscopic sphincterotomy (ES) and stone extraction remains the treatment of choice for bile duct stones1,2; 85% to 90% of all CBD stones can be effectively treated by ES and stone extraction by using balloon catheters or baskets.3 Regarding the latter devices, impaction of a Dormia basket or fracture of the basket’s traction wires during endoscopic mechanical lithotripsy with an entrapped stone in the distal CBD is an uncommon but well-known complication,4-6 presenting a challenge to most endoscopists. Reported management strategies include the use of a mechanical lithotriptor to capture the impacted basket and crush the stone, extracorporeal shock-wave lithotripsy, endoscopic laser lithotripsy, or other sophisticated methods.7-12 This case series describes, for the first time, the safe and effective use of large-diameter balloon dilation of the biliary orifice in the management of impacted baskets in the distal CBD.
PATIENTS AND METHODS Patients In this retrospective, observational study carried out between June 2007 and August 2010, 6 consecutive patients with basket impaction in the distal CBD were treated with large-diameter balloon dilation of the postsphincterotomy papilla and subsequent retrieval of the impacted basket and entrapped stone. In all cases, the intervention was performed during the same session of CBD stone extraction. The median age of our patients was 81.5 years (range 68-92 years). Five patients had a previous cholecystectomy; periampullary diverticulum was present in 3
Abbreviations: CBD, common bile duct; ES, endoscopic sphincterotomy. DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.01.034 Received October 5, 2010. Accepted January 17, 2011. Current affiliations: Department of Endoscopy and Motility Unit (P.K., K.F., A.B., G.C., S.T.), Central Hospital, Thessaloniki, Greece, Department of Gastroenterology (C.Z., J.K.), Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece. Reprint requests: Jannis Kountouras, MD, PhD, Department of Gastroenterology, 8 Fanariou Street, Byzantio, 551 33, Thessaloniki, Macedonia, Greece.
1298 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 6 : 2011
cases (in 2 patients the papilla was at the edge of the diverticulum, and in the other patient, it was intradiverticular). In 1 patient, the major papilla was ectopic, located in the beginning of the second part of the duodenum. Patients 2, 3, and 6 were considered at a high risk of open surgery because of severe comorbid disease (stroke, heart and respiratory failure). In 4 patients, the impacted basket was a Dormia (Fig. 1), and in 2 the impaction occurred when the wires leading to the basket were broken during mechanical lithotripsy (BAL-Q3; Olympus, Athens, Greece). Patient clinical data are summarized in Table 1. Written informed consent for ERCP and balloon dilation was obtained from the patients and their relatives. The study was approved for publication by the Institutional Review Board of Central Hospital.
Endoscopic procedure The Dormia basket impaction was confirmed when forceful traction was applied to the basket catheter steadily while the endoscope was pushed further into the second and third parts of duodenum to straighten the axis of the basket and the bile duct, but extraction of entrapped stone was impossible. The plastic handle of the basket was cut off with a wire cutter, and the duodenoscope was removed. In 2 cases with fracture of the lithotriptor’s wires, the crank handle disconnected from its metal sheath and the metal sheath and endoscope were removed, respectively. The procedure was performed using a large working channel (4.2 mm) therapeutic duodenoscope for easier passage of the devices used in the management of basket impaction. The diameter of the distal CBD and of the entrapped stone was measured after correction for the magnification by using the known diameter of the duodenoscope on the same radiograph as a reference. A 0.0035inch hydrophilic stiff guidewire (Jagwire; Boston Scientific, Athens, Greece) was placed high in the biliary tract (Fig. 2). Balloon dilation was performed with a largeballoon catheter (CRE; Boston Scientific). The choice of the balloon’s diameter was determined by the diameter of the terminal CBD, and that of the entrapped stone. Care was taken not to exceed the terminal CBD diameter to minimize the risk of bile duct perforation. The balloon catheter was passed over the stiff hydrophilic guidewire, which positioned the deflated balloon across the postsphincterotomy main papilla with the middle portion of the balloon located at the biliary sphincter. www.giejournal.org
Katsinelos et al
Large-balloon dilation of the biliary orifice for the management of basket impaction
and midazolam, but no additional sedation was required for the disimpaction procedure. No complications were encountered after papillary dilation, except in 1 patient who presented minor bleeding (oozing). He was successfully treated with an 3-mL injection of epinephrine (1: 10,000) into the upper edge of the dilated papilla using a 23-gauge sclerotherapy needle. The details of the procedures are summarized in Table 2. All of the dilations were performed by an experienced pancreaticobiliary endoscopist (P.K.) on an outpatient basis, and patients were observed for 6 hours before discharge. The patients were all asymptomatic at follow-up, and no patient required further interventions.
DISCUSSION Figure 1. Endoscopic view of an impacted basket (arrow).
The balloon was then gradually filled with diluted contrast medium (1:1 with sterile water) under endoscopic and fluoroscopic guidance to observe the gradual disappearance of the waist in the balloon (Fig. 3). Once the waist disappeared, the balloon remained inflated for 60 seconds and then was deflated and retracted. The fractured lithotriptor’s wires or the basket catheter were grasped by alligator forceps (FG-7L-1; Olympus) near the level of the papilla and steady traction was applied, resulting in the simultaneous release of the impacted basket and entrapped stone (Fig. 4). The procedure time was recorded, according to the screen recording time, starting with the cutting of the plastic handle of the basket or disconnection of the crank handle of the lithotriptor until the release of the impacted basket.
RESULTS A total of 937 ESs for choledocholithiasis were performed from June 2007 to August 2010 at our institution. Basket impaction with an entrapped stone in the CBD occurred in 6 patients (0.64%). In 2 cases of Dormia basket impaction, the ESs and removal of CBD stones were performed by a trainee under the supervision of a consultant. In the remaining 2 cases of Dormia basket impaction, as well as in the 2 cases of rupture of the basket traction wire during mechanical lithotripsy, the ESs and basket impactions were done by a consultant. The median terminal CBD diameter was 15.35 mm (range 12.7-20 mm). The median diameter of the entrapped stone was 11.5 mm (range 10.4-14.5 mm). The biliary orifice was dilated with a 12-mm balloon in 4 patients, and 15- and 18-mm diameters in 2 patients, respectively. The median time required for an impacted basket’s removal was 10.5 minutes (range 9-12 minutes). Retrieval of the impacted basket and the entrapped stone was achieved in all patients on the first attempt. All patients were under sedation with meperidine www.giejournal.org
Although the incidence of a basket impaction with an entrapped stone was reported in 5.9% patients7,13; because of the developments in the therapeutic techniques for CBD stones, this incidence has been decreased to 0.8%,14 comparable to the rate observed in our case series (0.65%). Despite its low incidence, impaction of a basket with an entrapped stone in the distal CBD may cause cholestatic jaundice accompanied by acute suppurative cholangitis, acute pancreatitis, sepsis,15 and even death, particularly in patients with comorbid diseases, thereby usually requiring open surgery or specialized endoscopic interventions.7-12 However, some of those “rescue” procedures are not widely available in many parts of the world, and most require considerable expertise to achieve a successful outcome. Moreover, as in our case series, patients with severe comorbid diseases are considered at a high risk of open surgery. Based on the experience that large-balloon dilation of the postsphincterotomy biliary orifice is a safe and effective technique for the extraction of large or difficult CBD stones,16-21 we hypothesized that a similar method will facilitate the release of an impacted basket. Indeed, the introduction of this technique was successful in all our patients. The simplicity of this technique makes it worth attempting it as a first-line salvage treatment for distal CBD basket impaction, particularly in patients with severe comorbid diseases, before proceeding to high-risk open surgery or more complicated methods. The advantage of this method is that it can be performed with equipment found in the armamentarium of every pancreaticobiliary endoscopist and during the same session with few adverse events and no excessive hospitalization, as demonstrated by this study; therefore, it appears to be a cost-effective technique. Regarding the postprocedure complications, we observed only slight bleeding, and none of our patients experienced pancreatitis or perforation. Postprocedure hemorrhage seemed to be an uncommon complication in patients undergoing large-diameter balloon dilation after ES for removal of large CBD stones, with rates ranging from 0% to 2% in most series,16-19 with the exception of 2 Volume 73, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1299
Large-balloon dilation of the biliary orifice for the management of basket impaction
Katsinelos et al
TABLE 1. Patients’ characteristics
Case
Age, y
Sex
Comorbid disease
Cholecystectomy
Periampullary diverticula
1
68
Female
Hypertension
⫹
⫹
2
84
Male
Heart failure
⫹
⫺
3
69
Male
Diabetes mellitus, hypertension
⫹
⫺
4
79
Male
Cardiorespiratory failure
⫺
⫺
5
85
Female
Heart failure, hypertension
⫺
⫹
6
92
Female
Stroke, dementia
⫺
⫹
Figure 2. A stiff hydrophilic guidewire is passed into the common bile duct.
Figure 3. The balloon is advanced over the stiff guidewire and inflated once it is located across the biliary orifice.
case series reporting bleeding in 9%20 and 12%,21 respectively. In both of these studies with a high rate of postdilation bleeding, the duration of the balloon’s maximum dilation was less than 60 seconds. We believe that a dila1300 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 6 : 2011
Figure 4. Retrieval of the impacted basket with an entrapped stone.
tion time less than 60 seconds may actually induce bleeding, which may be attributed to insufficient compression time by the balloon. Despite the fact that an increased risk of post-ERCP pancreatitis has been associated with balloon dilation of the native biliary sphincter,22 most data suggest that when ES precedes balloon dilation, the risk of post-ERCP pancreatitis is low.16-21 The explanation is that performing ES before large-balloon dilation creates a pathway of less resistance, along which the expanding balloon tracks, limiting the pressure applied in the direction of the pancreatic duct and subsequently its mechanical injury and the development of post-ERCP pancreatitis. It must be emphasized that caution is required in the selection of a suitable balloon diameter, which must not exceed the CBD diameter beyond the CBD/duodenal junction. Any extension beyond this junction could lead to retroduodenal perforation. Therefore, when papillary balloon dilation at this junction dilates both the distal CBD and the papillary orifice together in 1 direction, the potential for perforation is minimized. Two important limitations of our study are the small number of patients and that it was based on the experience of a single endoscopist. It is obvious that the results www.giejournal.org
Katsinelos et al
Large-balloon dilation of the biliary orifice for the management of basket impaction
TABLE 2. Details of large-size balloon dilation of biliary orifice for the treatment of impacted baskets
Case
Type of impacted basket
Terminal CBD diameter, mm
Size of entrapped stone, mm
CRE balloon diameter, mm
Duration of procedure, min
Complications
1
Dormia
20
14.5
18
11
None
2
Dormia
14.5
11
12
12
None
3
Lithotripter
13.2
10.4
12
10.5
None
4
Lithotripter
16.4
12
12
9
None
5
Dormia
12.7
11
12
10.5
Mild bleeding
6
Dormia
16.2
12.5
15
10
None
CBD, Common bile duct.
achieved with a single pair of expert hands in a tertiarycare institution cannot always be extrapolated to the general practice of endoscopy, particularly in ERCP. In conclusion, this case series shows for the first time that the technique of large-size balloon dilation of the postsphincterotomy biliary orifice is a simple, safe, and effective therapeutic maneuver for basket impaction in the distal CBD and mainly that the equipment used is part of the standard armamentarium of all endoscopists. REFERENCES 1. Venu RP, Geenen JE. Overview of endoscopic sphincterotomy for common bile duct stones. Gastrointest Endosc Clin N Am 1991;1:3-26. 2. Binmoeller KF, Shafer TW. Endoscopic management of bile duct stones. J Clin Gastroenterol 2001;32:106-18. 3. Hochberger J, Tex S, Maiss J, et al. Management of difficult common bile duct stones. Gastrointest Endosc Clin N Am 2003;13:623-34. 4. Payne WG, Norman JG, Pinkas H. Endoscopic basket impaction. Am Surg 1995;61:464-7. 5. Hintze RE, Adler A, Veltzke W, et al. Management of traction wire fracture complicating mechanical basket lithotripsy. Endoscopy 1997;29: 883-5. 6. Fukino N, Oida T, Kawasaki A, et al. Impaction of a lithotripsy basket during endoscopic lithotomy of a common bile duct stone. World J Gastroenterol 2010;16:2832-4. 7. Sauter G, Sackmann M, Holl J, et al. Dormia baskets impacted in the bile duct: release by extracorporeal shock-wave lithotripsy. Endoscopy 1995;27:384-7. 8. Neuhaus H, Hoffmann W, Classen M. Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct. Endoscopy 1992;24:596-9. 9. Merrett M, Desmond P. Removal of impacted endoscopic basket and stone from the common bile duct by extracorporeal shock waves. Endoscopy 1990;22:92. 10. Ranjeev P, Goh K. Retrieval of an impacted Dormia basket and stone in situ using a novel method. Gastrointest Endosc 2000;51:504-6.
www.giejournal.org
11. Draganov P, Cunningham JT. Novel “through-the-endoscope” technique for removing biliary stones trapped in a retrieval basket. Endoscopy 2002;34:176. 12. Maple JT, Baron TH. Biliary-basket impaction complicated by in vivo traction-wire fracture: report of a novel management approach. Gastrointest Endosc 2006;64:1031-3. 13. Attila T, May GR, Kortan P. Nonsurgical management of an impacted mechanical lithotriptor with fractured traction wires: endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extraendoscopic mechanical lithotripsy. Can J Gastroenterol 2008;22:699702. 14. Schreurs WH, Juttmann JR, Stuifbergen WN, et al. Management of common bile duct stones: selective endoscopic retrograde cholangiography and endoscopic sphincterotomy: short- and long-term results. Surg Endosc 2002;16:1068-72. 15. Nuehaus B, Safrany L. Complications of endoscopic sphincterotomy and their treatment. Endoscopy 1981;13:197-9. 16. Misra SP, Dwivedi M. Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones. Endoscopy 2008;40:209-13. 17. Draganov PV, Evans W, Fazel A, et al. Large size balloon dilation of the ampulla after biliary sphincterotomy can facilitate endoscopic extraction of difficult bile duct stones. J Clin Gastroenterol 2009;43:782-6. 18. Itoi T, Itokawa F, Sofuni A, et al. Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones. Am J Gastroenterol 2009;104:560-5. 19. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008;67:1046-52. 20. Ersoz G, Tekesin O, Ozutemiz AO, et al. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc 2003;57:156-9. 21. Koruk I, Parlak E, Secilmis S, et al. Endoscopic sphincteroplasty with large balloon dilation for extraction of difficult common bile duct stones. Dig Dis Sci 2008;53:1737-8. 22. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001;54:425-34.
Volume 73, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1301
ERCP with endoscopic sphincterotomy (ES) and stone extraction remains the treatment of choice for bile duct stones1,2; 85% to 90% of all CBD stones can be effectively treated by ES and stone extraction by using balloon catheters or baskets.3 Regarding the latter devices, impaction of a Dormia basket or fracture of the basket’s traction wires during endoscopic mechanical lithotripsy with an entrapped stone in the distal CBD is an uncommon but well-known complication,4-6 presenting a challenge to most endoscopists. Reported management strategies include the use of a mechanical lithotriptor to capture the impacted basket and crush the stone, extracorporeal shock-wave lithotripsy, endoscopic laser lithotripsy, or other sophisticated methods.7-12 This case series describes, for the first time, the safe and effective use of large-diameter balloon dilation of the biliary orifice in the management of impacted baskets in the distal CBD.
PATIENTS AND METHODS Patients In this retrospective, observational study carried out between June 2007 and August 2010, 6 consecutive patients with basket impaction in the distal CBD were treated with large-diameter balloon dilation of the postsphincterotomy papilla and subsequent retrieval of the impacted basket and entrapped stone. In all cases, the intervention was performed during the same session of CBD stone extraction. The median age of our patients was 81.5 years (range 68-92 years). Five patients had a previous cholecystectomy; periampullary diverticulum was present in 3
Abbreviations: CBD, common bile duct; ES, endoscopic sphincterotomy. DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.01.034 Received October 5, 2010. Accepted January 17, 2011. Current affiliations: Department of Endoscopy and Motility Unit (P.K., K.F., A.B., G.C., S.T.), Central Hospital, Thessaloniki, Greece, Department of Gastroenterology (C.Z., J.K.), Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece. Reprint requests: Jannis Kountouras, MD, PhD, Department of Gastroenterology, 8 Fanariou Street, Byzantio, 551 33, Thessaloniki, Macedonia, Greece.
1298 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 6 : 2011
cases (in 2 patients the papilla was at the edge of the diverticulum, and in the other patient, it was intradiverticular). In 1 patient, the major papilla was ectopic, located in the beginning of the second part of the duodenum. Patients 2, 3, and 6 were considered at a high risk of open surgery because of severe comorbid disease (stroke, heart and respiratory failure). In 4 patients, the impacted basket was a Dormia (Fig. 1), and in 2 the impaction occurred when the wires leading to the basket were broken during mechanical lithotripsy (BAL-Q3; Olympus, Athens, Greece). Patient clinical data are summarized in Table 1. Written informed consent for ERCP and balloon dilation was obtained from the patients and their relatives. The study was approved for publication by the Institutional Review Board of Central Hospital.
Endoscopic procedure The Dormia basket impaction was confirmed when forceful traction was applied to the basket catheter steadily while the endoscope was pushed further into the second and third parts of duodenum to straighten the axis of the basket and the bile duct, but extraction of entrapped stone was impossible. The plastic handle of the basket was cut off with a wire cutter, and the duodenoscope was removed. In 2 cases with fracture of the lithotriptor’s wires, the crank handle disconnected from its metal sheath and the metal sheath and endoscope were removed, respectively. The procedure was performed using a large working channel (4.2 mm) therapeutic duodenoscope for easier passage of the devices used in the management of basket impaction. The diameter of the distal CBD and of the entrapped stone was measured after correction for the magnification by using the known diameter of the duodenoscope on the same radiograph as a reference. A 0.0035inch hydrophilic stiff guidewire (Jagwire; Boston Scientific, Athens, Greece) was placed high in the biliary tract (Fig. 2). Balloon dilation was performed with a largeballoon catheter (CRE; Boston Scientific). The choice of the balloon’s diameter was determined by the diameter of the terminal CBD, and that of the entrapped stone. Care was taken not to exceed the terminal CBD diameter to minimize the risk of bile duct perforation. The balloon catheter was passed over the stiff hydrophilic guidewire, which positioned the deflated balloon across the postsphincterotomy main papilla with the middle portion of the balloon located at the biliary sphincter. www.giejournal.org
Katsinelos et al
Large-balloon dilation of the biliary orifice for the management of basket impaction
and midazolam, but no additional sedation was required for the disimpaction procedure. No complications were encountered after papillary dilation, except in 1 patient who presented minor bleeding (oozing). He was successfully treated with an 3-mL injection of epinephrine (1: 10,000) into the upper edge of the dilated papilla using a 23-gauge sclerotherapy needle. The details of the procedures are summarized in Table 2. All of the dilations were performed by an experienced pancreaticobiliary endoscopist (P.K.) on an outpatient basis, and patients were observed for 6 hours before discharge. The patients were all asymptomatic at follow-up, and no patient required further interventions.
DISCUSSION Figure 1. Endoscopic view of an impacted basket (arrow).
The balloon was then gradually filled with diluted contrast medium (1:1 with sterile water) under endoscopic and fluoroscopic guidance to observe the gradual disappearance of the waist in the balloon (Fig. 3). Once the waist disappeared, the balloon remained inflated for 60 seconds and then was deflated and retracted. The fractured lithotriptor’s wires or the basket catheter were grasped by alligator forceps (FG-7L-1; Olympus) near the level of the papilla and steady traction was applied, resulting in the simultaneous release of the impacted basket and entrapped stone (Fig. 4). The procedure time was recorded, according to the screen recording time, starting with the cutting of the plastic handle of the basket or disconnection of the crank handle of the lithotriptor until the release of the impacted basket.
RESULTS A total of 937 ESs for choledocholithiasis were performed from June 2007 to August 2010 at our institution. Basket impaction with an entrapped stone in the CBD occurred in 6 patients (0.64%). In 2 cases of Dormia basket impaction, the ESs and removal of CBD stones were performed by a trainee under the supervision of a consultant. In the remaining 2 cases of Dormia basket impaction, as well as in the 2 cases of rupture of the basket traction wire during mechanical lithotripsy, the ESs and basket impactions were done by a consultant. The median terminal CBD diameter was 15.35 mm (range 12.7-20 mm). The median diameter of the entrapped stone was 11.5 mm (range 10.4-14.5 mm). The biliary orifice was dilated with a 12-mm balloon in 4 patients, and 15- and 18-mm diameters in 2 patients, respectively. The median time required for an impacted basket’s removal was 10.5 minutes (range 9-12 minutes). Retrieval of the impacted basket and the entrapped stone was achieved in all patients on the first attempt. All patients were under sedation with meperidine www.giejournal.org
Although the incidence of a basket impaction with an entrapped stone was reported in 5.9% patients7,13; because of the developments in the therapeutic techniques for CBD stones, this incidence has been decreased to 0.8%,14 comparable to the rate observed in our case series (0.65%). Despite its low incidence, impaction of a basket with an entrapped stone in the distal CBD may cause cholestatic jaundice accompanied by acute suppurative cholangitis, acute pancreatitis, sepsis,15 and even death, particularly in patients with comorbid diseases, thereby usually requiring open surgery or specialized endoscopic interventions.7-12 However, some of those “rescue” procedures are not widely available in many parts of the world, and most require considerable expertise to achieve a successful outcome. Moreover, as in our case series, patients with severe comorbid diseases are considered at a high risk of open surgery. Based on the experience that large-balloon dilation of the postsphincterotomy biliary orifice is a safe and effective technique for the extraction of large or difficult CBD stones,16-21 we hypothesized that a similar method will facilitate the release of an impacted basket. Indeed, the introduction of this technique was successful in all our patients. The simplicity of this technique makes it worth attempting it as a first-line salvage treatment for distal CBD basket impaction, particularly in patients with severe comorbid diseases, before proceeding to high-risk open surgery or more complicated methods. The advantage of this method is that it can be performed with equipment found in the armamentarium of every pancreaticobiliary endoscopist and during the same session with few adverse events and no excessive hospitalization, as demonstrated by this study; therefore, it appears to be a cost-effective technique. Regarding the postprocedure complications, we observed only slight bleeding, and none of our patients experienced pancreatitis or perforation. Postprocedure hemorrhage seemed to be an uncommon complication in patients undergoing large-diameter balloon dilation after ES for removal of large CBD stones, with rates ranging from 0% to 2% in most series,16-19 with the exception of 2 Volume 73, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1299
Large-balloon dilation of the biliary orifice for the management of basket impaction
Katsinelos et al
TABLE 1. Patients’ characteristics
Case
Age, y
Sex
Comorbid disease
Cholecystectomy
Periampullary diverticula
1
68
Female
Hypertension
⫹
⫹
2
84
Male
Heart failure
⫹
⫺
3
69
Male
Diabetes mellitus, hypertension
⫹
⫺
4
79
Male
Cardiorespiratory failure
⫺
⫺
5
85
Female
Heart failure, hypertension
⫺
⫹
6
92
Female
Stroke, dementia
⫺
⫹
Figure 2. A stiff hydrophilic guidewire is passed into the common bile duct.
Figure 3. The balloon is advanced over the stiff guidewire and inflated once it is located across the biliary orifice.
case series reporting bleeding in 9%20 and 12%,21 respectively. In both of these studies with a high rate of postdilation bleeding, the duration of the balloon’s maximum dilation was less than 60 seconds. We believe that a dila1300 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 6 : 2011
Figure 4. Retrieval of the impacted basket with an entrapped stone.
tion time less than 60 seconds may actually induce bleeding, which may be attributed to insufficient compression time by the balloon. Despite the fact that an increased risk of post-ERCP pancreatitis has been associated with balloon dilation of the native biliary sphincter,22 most data suggest that when ES precedes balloon dilation, the risk of post-ERCP pancreatitis is low.16-21 The explanation is that performing ES before large-balloon dilation creates a pathway of less resistance, along which the expanding balloon tracks, limiting the pressure applied in the direction of the pancreatic duct and subsequently its mechanical injury and the development of post-ERCP pancreatitis. It must be emphasized that caution is required in the selection of a suitable balloon diameter, which must not exceed the CBD diameter beyond the CBD/duodenal junction. Any extension beyond this junction could lead to retroduodenal perforation. Therefore, when papillary balloon dilation at this junction dilates both the distal CBD and the papillary orifice together in 1 direction, the potential for perforation is minimized. Two important limitations of our study are the small number of patients and that it was based on the experience of a single endoscopist. It is obvious that the results www.giejournal.org
Katsinelos et al
Large-balloon dilation of the biliary orifice for the management of basket impaction
TABLE 2. Details of large-size balloon dilation of biliary orifice for the treatment of impacted baskets
Case
Type of impacted basket
Terminal CBD diameter, mm
Size of entrapped stone, mm
CRE balloon diameter, mm
Duration of procedure, min
Complications
1
Dormia
20
14.5
18
11
None
2
Dormia
14.5
11
12
12
None
3
Lithotripter
13.2
10.4
12
10.5
None
4
Lithotripter
16.4
12
12
9
None
5
Dormia
12.7
11
12
10.5
Mild bleeding
6
Dormia
16.2
12.5
15
10
None
CBD, Common bile duct.
achieved with a single pair of expert hands in a tertiarycare institution cannot always be extrapolated to the general practice of endoscopy, particularly in ERCP. In conclusion, this case series shows for the first time that the technique of large-size balloon dilation of the postsphincterotomy biliary orifice is a simple, safe, and effective therapeutic maneuver for basket impaction in the distal CBD and mainly that the equipment used is part of the standard armamentarium of all endoscopists. REFERENCES 1. Venu RP, Geenen JE. Overview of endoscopic sphincterotomy for common bile duct stones. Gastrointest Endosc Clin N Am 1991;1:3-26. 2. Binmoeller KF, Shafer TW. Endoscopic management of bile duct stones. J Clin Gastroenterol 2001;32:106-18. 3. Hochberger J, Tex S, Maiss J, et al. Management of difficult common bile duct stones. Gastrointest Endosc Clin N Am 2003;13:623-34. 4. Payne WG, Norman JG, Pinkas H. Endoscopic basket impaction. Am Surg 1995;61:464-7. 5. Hintze RE, Adler A, Veltzke W, et al. Management of traction wire fracture complicating mechanical basket lithotripsy. Endoscopy 1997;29: 883-5. 6. Fukino N, Oida T, Kawasaki A, et al. Impaction of a lithotripsy basket during endoscopic lithotomy of a common bile duct stone. World J Gastroenterol 2010;16:2832-4. 7. Sauter G, Sackmann M, Holl J, et al. Dormia baskets impacted in the bile duct: release by extracorporeal shock-wave lithotripsy. Endoscopy 1995;27:384-7. 8. Neuhaus H, Hoffmann W, Classen M. Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct. Endoscopy 1992;24:596-9. 9. Merrett M, Desmond P. Removal of impacted endoscopic basket and stone from the common bile duct by extracorporeal shock waves. Endoscopy 1990;22:92. 10. Ranjeev P, Goh K. Retrieval of an impacted Dormia basket and stone in situ using a novel method. Gastrointest Endosc 2000;51:504-6.
www.giejournal.org
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