Small sphincterotomy and balloon sphincteroplasty for extraction of a common bile duct stone in a patient with juxtapapillary diverticulum
Epublication WebSurg.com, Mar 2010;10(03). URL: http://websurg.com/doi/vd01en2917
Duodenal diverticula have a prevalence of 9 to 32%. Usually, they are within 2cm of the major duodenal papilla and for that are called juxtapapillary diverticula. They are acquired and their incidence increases with age. Biliary and pancreatic disease is often associated with juxtapapillary diverticula, in particular common bile duct stones. They are directly associated with the outcome of Endoscopic Retrograde Cholangio-Pancreatography (due to the complexity of cannulation) and with an increased rate of complications, in particular bleeding. Various techniques are described to increase the success rate, such as clip-assisted biliary cannulation, endoscopic ultrasound-guided bile duct access, main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. The success rate, independently of these techniques, varies from 61% to 95%. In this video, we show a case of a patient with angiocholitis secondary to choledocholithiasis, and several cardiovascular co-morbidities, having the papilla of Vater on the edge of a diverticulum. A small sphincterotomy was performed as shown and then bleeding risk was evaluated (the patient being on anticoagulants) and because of the important size of the impacted stone, a sphincteroplasty with dilatation of the papilla with a balloon expanded to 15mm was performed, along with stone extraction using a Dormia basket. The patient was discharged on postoperative day 2 with normal liver function tests and no inflammation.