Video
Selective biliary cannulation was difficult, and the catheter tended to be cannulated into the pancreatic duct. We applied a double-wire technique to achieve biliary cannulation. Finally, selective biliary cannulation was achieved. Cholangiography revealed a small stone of approximately 5 mm in the common bile duct (red arrow). Subsequently, endoscopic papillary balloon dilation (EPBD) was performed using a new EPBD catheter with a diameter of 8 mm. This new EPBD catheter was inserted. We inflated this EPBD catheter slightly while observing both endoscopy and fluoroscopy monitors to confirm its dilation process. EPBD was easily and effectively performed without slipping in or out of the papilla. The orifice of the papilla was dilated. Stone extraction was completely achieved.
Introduction
Endoscopic stone extraction in patients with surgically altered anatomy (SAA) using balloon enteroscopy is considered challenging.1, 2, 3 Endoscopic sphincterotomy or endoscopic papillary balloon dilation (EPBD) is necessary.4,5 EPBD can help maintain the biliary sphincter function when the stone size is small.6 However, securing the stable scope positioning in patients with SAA is more challenging. Furthermore, balloon enteroscopy lacks a channel elevator like a duodenoscope. Consequently, the EPBD catheter is prone to slipping in or out of the papilla during balloon inflation, which is time consuming and may increase adverse events.
This report was approved by the research ethics committee (approval number 2023-015) of Saitama Medical University International Medical Center.
A Novel Balloon Dilation Catheter
A new EPBD catheter (RIGEL; Japan Lifeline, Shinagawa, Japan) with a length and diameter of 220 cm and 2.37 mm, respectively, was developed (Fig. 1). The balloon length is 20 mm, which is shorter than other balloon catheters currently available. It facilitates dilation of the papilla or anastomotic strictures, such as hepaticojejunal anastomosis, more selectively and does not increase the distance between the papilla and the scope during the balloon inflation. The distal and proximal ends of the balloon inflate first, and then the middle inflates to prevent the catheter from slipping in or out of the papilla. Moreover, a black elastic band is attached in the middle of the balloon to facilitate confirming the center of the balloon endoscopically. The balloon's maximal filling pressure is 6 atm, and the delayed expansion of the central portion of the balloon owing to the band is accounted for when determining the maximum filling pressure. We report a case of successful EPBD using this novel balloon dilation catheter in a patient with SAA.
Figure 1.
A new endoscopic papillary balloon dilation catheter (RIGEL; Japan Lifeline, Japan) with a length of 20 mm and a diameter of 8 mm. The distal and proximal ends of the balloon initially inflate to prevent the catheter from slipping in or out of the papilla.
Case Presentation
A 77-year-old man with choledocholithiasis was referred to our facility. He had undergone distal gastrectomy with Roux-en-Y for gastric cancer. A CT scan revealed a stone of approximately 5 mm in the common bile duct. Therefore, ERCP was performed using a short-type single-balloon enteroscopy7 (SIF-H290; Olympus Marketing, Shinjuku, Japan) with a working length of 152 cm and a working channel of 3.2 mm in diameter (Video 1, available online at www.videogie.org). As selective biliary cannulation was difficult and the catheter tended to be cannulated into the pancreatic duct in this case, we applied a double-wire technique to achieve biliary cannulation.8 Cholangiography revealed a small stone of approximately 5 mm in the common bile duct (Fig. 2). We chose EPBD for stone extraction. The new EPBD catheter with a diameter of 8 mm was inserted. EPBD was performed effortlessly and effectively without slipping in or out of the papilla, and the orifice of the papilla was dilated (Fig. 3). As the result, the stone was extracted smoothly using a basket catheter (Fig. 4). After this procedure, the patient developed mild post-ERCP pancreatitis. Fortunately, the patient was cured using conservative treatment. There has been no recurrence of choledocholithiasis as of 8 months postoperatively.
Figure 2.
Cholangiography revealing a small stone of approximately 5 mm in the common bile duct (red arrow).
Figure 3.
A, Balloon is inflated without slipping in or out of the papilla. B and C, Endoscopic papillary balloon dilation is performed effectively. D, The orifice of the papilla is dilated.
Figure 4.
Stone extraction is completely achieved.
This novel balloon dilation catheter can help achieve effective EPBD without catheter slippage in or out of the papilla, facilitating stone extraction in patients with SAA, especially with a small stone, thus preserving the biliary sphincter function. It would be a good selection for stone extraction and aid in standardization of stone extraction in patients with SAA. Conversely, EPBD for a native papilla has been reported as a risk factor for post-ERCP pancreatitis.9, 10, 11 Furthermore, we applied a double-wire technique to achieve biliary cannulation and performed pancreatic duct injection. The entire process carries the risk of post-ERCP pancreatitis. It would have been better to place prophylactic pancreatic stent for the prevention of post-ERCP pancreatitis. Additionally, performing a sphincterotomy before EPBD would have been a preferable approach. This balloon should be studied further to truly evaluate its clinical utility and safety.
Disclosure
The authors disclosed no financial relationships relevant to this publication.
Acknowledgment
The authors thank Editage (www.editage.com) for English-language editing.
Supplementary data
Selective biliary cannulation was difficult, and the catheter tended to be cannulated into the pancreatic duct. We applied a double-wire technique to achieve biliary cannulation. Finally, selective biliary cannulation was achieved. Cholangiography revealed a small stone of approximately 5 mm in the common bile duct (red arrow). Subsequently, endoscopic papillary balloon dilation (EPBD) was performed using a new EPBD catheter with a diameter of 8 mm. This new EPBD catheter was inserted. We inflated this EPBD catheter slightly while observing both endoscopy and fluoroscopy monitors to confirm its dilation process. EPBD was easily and effectively performed without slipping in or out of the papilla. The orifice of the papilla was dilated. Stone extraction was completely achieved.
References
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Associated Data
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Supplementary Materials
Selective biliary cannulation was difficult, and the catheter tended to be cannulated into the pancreatic duct. We applied a double-wire technique to achieve biliary cannulation. Finally, selective biliary cannulation was achieved. Cholangiography revealed a small stone of approximately 5 mm in the common bile duct (red arrow). Subsequently, endoscopic papillary balloon dilation (EPBD) was performed using a new EPBD catheter with a diameter of 8 mm. This new EPBD catheter was inserted. We inflated this EPBD catheter slightly while observing both endoscopy and fluoroscopy monitors to confirm its dilation process. EPBD was easily and effectively performed without slipping in or out of the papilla. The orifice of the papilla was dilated. Stone extraction was completely achieved.
Selective biliary cannulation was difficult, and the catheter tended to be cannulated into the pancreatic duct. We applied a double-wire technique to achieve biliary cannulation. Finally, selective biliary cannulation was achieved. Cholangiography revealed a small stone of approximately 5 mm in the common bile duct (red arrow). Subsequently, endoscopic papillary balloon dilation (EPBD) was performed using a new EPBD catheter with a diameter of 8 mm. This new EPBD catheter was inserted. We inflated this EPBD catheter slightly while observing both endoscopy and fluoroscopy monitors to confirm its dilation process. EPBD was easily and effectively performed without slipping in or out of the papilla. The orifice of the papilla was dilated. Stone extraction was completely achieved.