Small sphincterotomy combined with endoscopic papillary large balloon dilation in patients with Billroth II gastrectomy

Background: The difficulty in orienting a duodenoscope or sphincterotome in Billroth II gastrectomy patients with an afferent loop is well known to experienced biliary endoscopists. In patients who have large biliary stones, stone retrieval is technically difficult, particularly when a mechanical lithotriptor is required. To address this issue a new technique was developed to gain greater access to the common bile duct. Methods: This new technique, small endoscopic sphincterotomy combined with endoscopic papillary large balloon dilation (SES + EPLD), was carried out in eight cases with Billroth II reconstruction. First, endoscopic sphincterotomy (ES) with a small incision was performed with a capped forward-viewing endoscope. Then, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. Results: Stone retrieval was successful in all cases. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations near the papilla. Conclusions: SES + EPLD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy for B-II reconstruction cases. This new method, incorporating a slow dilation of the papilla up to a large diameter, could provide a larger opening than a large ES. This method of stone retrieval is easy to perform and may be able to play a role in the treatment of large and multiple bile duct stones with B-II gastrectomy.