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Percutaneous Balloon Sphincterotomy May Be Good Choice for Biliary Stone Removal

February 10, 2009
Written by: , Filed in: Interventional Radiology
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Endoscopic sphincterotomy followed by use of a balloon to pull stones from the common bile duct is standard therapy in patients with normal anatomy. In surgically altered biliary systems found after Billroth II or Whipple procedures, there is no easy way to gain access to the biliary system endoscopically.

To report the authors’ use of a cutting balloon for a transhepatic papillary balloon dilatation used to treat bile duct stones.

The author’s results have shown that transhepatic cutting balloons have been used to dilate the papilla with good initial success.

Case Report
A 66-year-old female with a history of a Billroth II procedure to treat gallbladder cancer presents with high bilirubin. CT showed bile duct stones and recurrent cancer in the hilum of the liver.

After access was obtained into the biliary system percutaneously, an 8-mm cutting balloon was used under low pressure and inflated several times, at different angles. Stones were then flushed with a push of saline from the biliary tree to the duodenum. No complications were noted on follow-up.

Reviewer’s Comments
Use of a cutting balloon for transhepatic dilatation of the ampulla was used in this instance because researchers thought it would be less traumatic than using a balloon to open the ampulla, thus hopefully decreasing the chances that the patient would develop pancreatitis. In the endoscopic literature, balloon papillotomy, rather than sphincterotomy, is associated with a high frequency of pancreatitis, which is the most feared complication of papillary intervention. It is also less successful for stone removal, requiring a higher rate of mechanical lithotripsy.

Sphincterotomy is associated with a high stone retrieval rate and a morbidity of 2% to 10%, with a mortality rate of <2%. Via the endoscopic route, sphincterotomy is associated with higher rates of bleeding and higher short- and long-term infection rates. Endoscopic papillary balloon dilatation and sphincterotomy are both associated with the same rates of mortality, perforation, and short-term complications. The cutting balloon that was used here has also been used in the peripheral and coronary vascular system, in the ureters, and in the biliary system, but not the ampulla. The advantage the cutting balloon offers is a controlled, shallow cut in several locations and less trauma because of the low pressure of the balloon. The decreased trauma is what the authors believe will decrease the risk of developing pancreatitis when compared to balloon papillotomy, which is currently the method being used to dilate the ampulla from the transhepatic approach in cases where endoscopic access is not feasible or possible. Large-scale studies using this method are needed to establish the effectiveness and morbidity and mortality rates of this method, but it seems that this may be a good alternative to either transhepatic or endoscopic balloon dilatation. Author: Sharon Gonzales, MD

Oguzkurt L, Ozkan U, Gumus B. Percutaneous Transhepatic Cutting Balloon Papillotomy for Removal of Common Bile Duct Stones.
Cardiovasc Intervent Radiol; 2008; December 18 (epub ahead of print).

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 University of California San Francisco Department of Radiology
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