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Needle knife sphincterotomy for an impacted ampullary stone with difficult selective biliary cannulation
Hiroshi Kawakami1, Masaki Kuwatani, Manabu Onodera
1Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan. hiropon@med.hokudai.ac.jp
Summary
Endoscopic retrograde cholangiopancreatography (ERCP) effectively removes common bile duct (CBD) stones. A challenging large impacted stone was successfully extracted using balloon extraction after other endoscopic techniques failed.
Area of Science:
- Gastroenterology
- Endoscopic procedures
- Biliary interventions
Background:
- Endoscopic treatment is the primary method for common bile duct (CBD) stone extraction, with high success rates.
- Complete clearance of the biliary duct is the main goal for patients with CBD stones.
- Conventional methods achieve up to 90% success, but resistant stones require advanced techniques.
Observation:
- A patient presented with a large, impacted CBD stone at Vater's ampulla, resistant to standard endoscopic extraction.
- Initial attempts involved needle knife sphincterotomy and forceps (biopsy, alligator grasping) without lithotripsy.
- The impacted stone required multiple endoscopic interventions.
Findings:
- Despite initial challenges with conventional and alternative endoscopic tools, the large impacted CBD stone was ultimately removed.
- Successful extraction was achieved using balloon extraction, demonstrating its utility in difficult cases.
- The case highlights the need for a stepwise approach in managing complex CBD stones.
Implications:
- This case demonstrates the efficacy of balloon extraction as a salvage technique for impacted CBD stones resistant to other endoscopic methods.
- Endoscopic management of complex CBD stones may require a combination of techniques, including less common ones.
- Further research into optimizing techniques for difficult-to-extract CBD stones is warranted.
