Endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in a difficult cannulation

Background: When standard methods of biliary cannulation fail, needle-knife fistulotomy may be used. However, large stones cannot be easily extracted through the necessarily smaller opening made when using the fistulotomy technique. Objective: We report the efficacy and safety of endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in patients in whom cannulation is difficult. Design: A case series. Setting: A tertiary referral center. Patients and Interventions: Six patients (6 of 115, 5.2%) with bile duct stones in whom cannulation by the conventional method had failed underwent fistulotomy and large-diameter (12-15 mm) balloon dilation through the fistulotomy tract. Main Outcome Measurements: Successful biliary cannulation, outcome of therapy, and post-ERCP complications including pancreatitis were recorded. Results: Biliary cannulation was successful in 6 of 6 patients (100%) with fistulotomy. After endoscopic large-diameter balloon dialation of fistulotomy tract, stone extraction was successfully performed in 6 of 6 patients. None of the patients developed post-ERCP pancreatitis. One of the 6 patients had minor delayed bleeding, which stopped spontaneously. Limitations: A small case series, retrospective design, and no control group. Conclusions: Endoscopic large-diameter balloon dilation through the fistulotomy tract may be feasible and safe alternative method for the removal of bile duct stones in patients in whom cannulation is difficult.