Balloon Sphincteroplasty and Transpapillary Elimination of Bile Duct Stones:10 Years' Experience

Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study

Objectives

Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues.

Methods

All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated.

Results

A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively.

Conclusions

Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively.

Percutaneous removal of common bile duct stones using a modified balloon technique

To evaluate the effectiveness of percutaneous removal of common bile duct (CBD) stones using a modified balloon technique (balloon catheter sphincteroplasty and expulsion of the stones using half-captured balloons within the sheath) in patients difficult to treat with endoscopy.Fifty patients underwent a modified balloon technique (balloon group), and 53 patients underwent CBD stone removal by the basket method (stone basket group) between 2016 and 2019. We compared the balloon and stone basket groups to evaluate the effectiveness of the modified balloon technique. Outcome variables such as demographics, technical success rates, procedural details, and complications were analyzed. Statistical analysis was performed using Student t test, Fisher exact test, or the χ2 test.The technical success rate in the balloon group was 66% (33/50) in 1 session, 32% (16/50) in 2 sessions, and 2% (1/50) in 3 sessions. That of the stone basket group was 45% (24/53) in 1 session, 38% (20/53) in 2 sessions, and 17% (9/53) in 3 sessions.The total procedure time was significantly shorter in the balloon group (29.5 ± 15.1 minutes) than in the stone basket group (41.7 ± 20.2 minutes) (P < .01), whereas the number of stones was higher in the balloon group than in the stone basket group (P = .03). Maximal stone size, balloon size, pancreatitis, and hospitalization stay did not show statistical differences between the 2 groups. Most complications (9 patients, balloon group; 8 patients, stone basket group) were mild and transient. Major complications occurred in one patient in the stone basket group, who experienced hemobilia due to arterial injury caused by percutaneous transhepatic biliary drainage, which was treated by endovascular embolization without mortality.The modified balloon technique is an effective and safe treatment method for CBD stone removal in patients presenting difficulties in the endoscopic approach.

Percutaneous stone removal using a compliant balloon after papillary balloon dilatation

PURPOSE

To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation.

MATERIAL AND METHODS

Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attempted via a pushing maneuver using an endoscopic stone extraction balloon. Clinical and technical success rates, complications, and risk factors for failure and complications were evaluated.

RESULTS

Biliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure.

CONCLUSION

Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible. Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; PTBD: percutaneous transhepatic biliary drainage.

Outcomes following percutaneous treatment of biliary stones

BACKGROUND

The percutaneous approach (PA) for management of biliary stones (BS) with or without an underlying biliary stenosis is an option for patients in whom an endoscopic approach (EA) is not possible. The aim of this study was to evaluate the efficacy of a PA in patients with BS unsuitable for an EA.

METHODS

A retrospective review of a database was performed. Inclusion criteria included patients with benign disease, BS who had undergone a PA. The outcomes were technical success rate, short (≤90 days) and long-term (>90 days) efficacy and safety.

RESULTS

A total of 91 patients enrolled were divided into those with (n = 38) or without (n = 53) a biliary stenosis. A median of 5 (IQR:3-7) treatments/patient were performed. During a median follow-up of 23 months (IQR:3-52), the median time free from recurrence was 21 months (CI:14-29). In the long term, the PA was most efficacious in those patients without a biliary stenosis with long term success in 68% of patients as compared to 36% of patients with a biliary stenosis (p = 0.003).

CONCLUSION

A PA is an effective procedure with high initial success rate, however the coexistence of stenosis affects long-term efficacy, especially in patients with chronic biliary disease.

Percutaneous Transcholecystic Removal of Common Bile Duct Stones: Case Series in 114 Patients

Purpose To evaluate the safety and effectiveness of percutaneous transcholecystic removal of common bile duct (CBD) stones in 114 patients. Materials and Methods This retrospective study was approved by the institutional review board. From September 2011 through February 2017, 114 consecutive patients (68 men, 46 women; mean age, 73 years) underwent percutaneous transcholecystic removal of CBD stones. All patients had acute cholangitis or cholecystitis. Stones were extracted through a 12-F sheath by using a Wittich nitinol stone basket uder fluoroscopic guidance. Technical success rates, complications, and long-term follow-up were evaluated. Results Technical success was achieved in 96 of 114 (84.2%) patients. In 18 patients, stone removal was unsuccessful due to failure of cystic duct cannulation (n = 11), proximal migration of the CBD stone (n = 3), multiple CBD stones (n = 3), and low insertion of the cystic duct (n = 1). No major procedure-related complications were seen. During the mean follow-up of 644 days (range, 11-2206 days), CBD stones recurred in 12 patients after a mean of 884 days (range, 439-1799 days) after the procedure. Conclusion Percutaneous transcholecystic removal of common bile duct stones seems to be a safe and effective method. © RSNA, 2018 Online supplemental material is available for this article . See also the editorial by vanSonnenberg and Panchanathan in this issue.

Percutaneous transcystic balloon dilation for common bile duct stone removal in high-surgical-risk patients with acute cholecystitis and co-existing choledocholithiasis

BACKGROUND

Percutaneous procedures to treat common bile duct (CBD) stones typically require access via intrahepatic bile ducts. This study aimed to describe the outcomes of a percutaneous transcystic approach that expelled the CBD stones into the duodenum after percutaneous transcystic balloon dilation of the ampulla (PTCBDA) for high-risk patients who present with acute cholecystitis and CBD stones.

METHODS

Patients diagnosed with acute cholecystitis and CBD stones who were deemed too high-risk for surgery or general anesthesia and were treated with PTCBDA and CBD stone removal between March 2010 and November 2015 were included for further analysis. Patients underwent emergency percutaneous transhepatic gallbladder drainage under ultrasound. Staged PTCBDA and CBD stone expulsion were performed. Outcomes evaluated included the success rate, causes of failure, and complications.

RESULTS

Eighteen patients met the inclusion criteria. CBD stones were successfully expelled in 16 patients. A second procedure was performed in one patient because of residual stones. The procedure failed in two patients because their stones were large. One patient developed bile peritonitis and underwent percutaneous catheter drainage.

DISCUSSION

Percutaneous transcystic anterograde expulsion of CBD stones may be a feasible and effective method for treating high-risk surgical patients with acute cholecystitis and co-existing CBD stones.

Biliary stone removal through the percutaneous transhepatic biliary drainage route, focusing on the balloon sphincteroplasty flushing technique: a single center study with 916 patients

PURPOSE

To present our experience in biliary stone removal (BSR) through the percutaneous transhepatic biliary drainage (PTBD) route in 916 patients, and discuss its clinical usefulness.

MATERIALS AND METHODS

From 2001 to 2015, 916 patients (479 male patients and 437 female patients; age range, 22-92 years; mean age, 67 years) with 52 recurring cases, so a total of 968 cases, were enrolled in this study and retrospectively reviewed. PTBD was performed in all patients. BSR was performed using a combination of a balloon sphincteroplasty flushing technique, a pushing technique after sphincteroplasty, and classical extraction technique, decided case by case.

RESULTS

A complete removal was achieved in 893 cases (92.3%) and the overall clinical success rate was 99.3%. Failure occurred in 7 cases (0.7%), and the causes of failure were stone impaction (n = 5) and intrahepatic bile duct stricture (n = 2). Sphincteroplasty was performed in 902 cases (93.2%). Balloon sphincteroplasty flushing technique was used in 829 (85.6%) cases. There was no major complication. Transient minor complications were seen in 86 cases (8.9%).

CONCLUSIONS

BSR through the PTBD route using a combination of techniques, including balloon sphincteroplasty flushing, is a safe and effective treatment modality to remove biliary stones.

Choledocholithiasis: Evaluation, Treatment, and Outcomes

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

Percutaneous management of residual bile duct stones through T-tube tract after cholecystectomy: A retrospective analysis of 89 patients

PURPOSE

The purpose of this study was to analyze the outcome of percutaneous management of residual common bile duct (CBD) stones in patients with surgically inserted T-tube in CBD after cholecystectomy.

MATERIAL AND METHODS

Between April 2001 and August 2015, 89 patients (52 women, 37 men) with a mean age of 55.7 years±18 (SD) (range, 22-88 years) underwent percutaneous sphincteroplasty and stone expulsion into the duodenum with a Fogarty balloon catheter through the T-tube tract for residual CBD stones. All patients had previously undergone open cholecystectomy with CBD exploration and T-tube insertion 7 to 60 days (mean, 14.4 days) before the procedure. Results of the procedure and complications were evaluated by a review of clinical notes, imaging and laboratory findings.

RESULTS

The procedure was successful in 87/89 patients (97.7%). Complete CBD clearance was achieved in a first session in 86 patients (96.6%). One patient (1.1%) needed a second session. The procedure was unsuccessful in 2 patients (2.2%) due to inappropriate position of T-tube and stone impaction into the cystic duct remnant. Two complications (2.2%) including intra-abdominal bile collection and distal CBD stricture were observed after the procedure.

CONCLUSION

Percutaneous CBD expulsion into the duodenum through the T-tube tract is a non-traumatic, effective and safe method for the treatment of residual CBD stones in patients who had cholecystectomy and T-tube insertion.

Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience

OBJECTIVES

Clinical evidence regarding radiological-endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological-endoscopic management of intrahepatic difficult bile duct stones.

METHODS

From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3-7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological-endoscopic approach and reported our technical and clinical outcomes.

RESULTS

Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention.

CONCLUSION

After 18 years of experience we demonstrated that our combined radiological-endoscopic approach to 'difficult bile duct stones' may result in both immediate and long-term clearance of stones with a low rate of adverse events.

Innovative percutaneous antegrade clearance of intrahepatic and extrahepatic biliary stones with the use of a hysterosalpingography catheter

OBJECTIVES

We present a novel modified technique of percutaneous antegrade clearance of intrahepatic and common bile duct stones with the use of a hysterosalpingography balloon (HSG) catheter.

METHODS

Technical tips and techniques used, along with the clinical results obtained in six patients whom we treated over a 6-month period have been described.

RESULTS

The HSG balloon catheter is shown to demonstrate superior pushability, flexibility, and maneuverability in comparison with other previously described compliant balloons.

CONCLUSIONS

The HSG balloon catheter is shown to be a really good device to remove intrahepatic and common bile duct stones percutaneously, allowing, where required, access to both the right and the left intrahepatic biliary systems from a single and smaller Fr hepatic bile duct access.

Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients

BACKGROUND/AIMS

Choledocholithiasis is a common complication of cholecystolithiasis, occurring in 15-20% of patients who have gallbladder stones. Endoscopic retrograde cholangio-pancreatography is the standard treatment. When this is not possible or not feasible, percutaneous transhepatic stone removal is an alternative treatment. In this retrospective study, we analyze 110 patients who were treated with percutaneous transhepatic removal of Common Bile Duct (CBD) stones.

PATIENTS AND METHODS

Between March 1998 and September 2013 110 patients (61 men, 49 women; aged 14-96, mean age 69.7 years) with confirmed bile duct stones were included. PTC was done using ultrasound and fluoroscopy. Balloon dilatation of the papilla was done with 8-12 mm balloons. If stone size exceeded 10 mm, mechanical lithotripsy was performed. Stones were then removed by percutaneous extraction or evacuation into the duodenum.

RESULTS

In 104 patients (104/110; 94.5%) total stone clearance of the CBD was achieved. A total of 12 complications occurred (10.9%), graded with the Clavien-Dindo scale as IVa, IVb, and V, respectively; hypoxia requiring resuscitation, sepsis and death due to ongoing cholangiosepsis (n = 1, 4, 1). Minor complications I, II, and IIIa included: small liver abscess, pleural empyema, transient hemobilia and mild fever (n = 1, 1, 2, 2).

CONCLUSION

Percutaneous removal of CBD stones is an effective alternative treatment, when endoscopic treatment is contra-indicated, fails or is not feasible. It is effective, has a low complication rate and using deep sedation potentially requires only a very limited number of treatment sessions.

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients

PURPOSE

To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients.

MATERIALS AND METHODS

During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated.

RESULTS

Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed.

CONCLUSIONS

Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Tissue harmonic sonography in the diagnosis of common bile duct stones: a comparison with endoscopic retrograde cholangiography

PURPOSE

To revisit the diagnostic accuracy of sonography in the detection of choledocholithiasis using modern equipment with tissue harmonic imaging (THI) and endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy as the gold standard.

METHODS

A total of 107 patients with clinically suspected choledocholithiasis were examined with THI before undergoing ERCP. The sonographic findings that were prospectively evaluated included the presence of choledocholithiasis, size of common bile duct, sonographic view and patient position that best visualized the stone(s), visualization of the distal common duct, and duration of examination. The accuracy of sonography compared with ERCP and sphincterotomy was calculated.

RESULTS

Sonography correctly detected stones in 65 of 76 patients (sensitivity of 86%). The specificity and the overall accuracy were 87% and 86%, respectively. The sensitivity of sonography was higher with dilated extrahepatic duct (44% in patients with common bile duct measuring less than 6 mm in diameter, 82% between 6 and 10 mm, and 100% with common bile duct larger than 10 mm). The lateral approach with the patient in left lateral decubitus position of the patient was the most effective in 47% of the cases.

CONCLUSION

Sonography with THI is an accurate technique for the detection of choledocholithiasis that may be used as the first-choice technique to avoid unnecessary procedures in a high percentage of patients, especially those with dilated biliary tree.

[Functional recovery of Oddi's sphincter after balloon dilatation of the papilla of Vater. An experimental study in rabbits]

INTRODUCTION

Balloon dilatation of the papilla of Vater is used to treat biliary lithiasis. The results and complications rate of this technique are excellent. Published data indicate that this procedure does not significantly alter the physiology of the sphincter of Oddi and that normal function is maintained. Papillary balloon dilatation would therefore provide an advantage over other techniques in which sphincteric function is abolished. The objective of this study was to evaluate the functional status of the sphincter of Oddi after balloon dilatation of the papilla of Vater.

MATERIAL AND METHODS

Twenty-four New Zealand albino rabbits were used. All animals underwent laparotomy and duodenotomy with balloon dilatation of the papilla of Vater. Manometric study of the biliary tract and of the sphincter of Oddi was also performed before, shortly after, and 21 days after dilatation. Biliary and sphincter of Oddi pressures and phasic activity of the sphincter (frequency, amplitude and duration of waves) were used as measuring variables for each of the stages of the experiment.

RESULTS

Papillary balloon dilatation immediately provoked substantial sphincter relaxation. Comparison of the values of basal biliary and sphincter of Oddi pressures with those found 21 days after dilatation showed no statistically significant differences. No significant differences were found when the variables related to phasic activity of the sphincter (frequency, amplitude and duration) were compared between the distinct phases of the experiment.

CONCLUSIONS

The results of the present study suggest complete recovery of sphincter function 21 days after balloon dilatation.

Operative cholangiography in two-port needlescopic cholecystectomy

We report the use of operative cholangiography in two-port needlescopic (minilaparoscopic) cholecystectomy. A prospective series of 11 patients underwent two-port needlescopic cholecystectomy with operative cholangiography. In ten cases, operative cholangiography was successfully performed. There were no conversions. No additional ports were required. No related complications were noted. Two cases positive for common bile duct stones were identified. The median operative time was 92.5 minutes. Operative cholangiography in two-port needlescopic cholecystectomy is safe and feasible.

[Diagnosis and interventional therapy for ductal gallstones]

Different imaging modalities recently underwent considerable improvements for the visualization of ductal gallstones. The declining significance of endoscopic retrograde cholangiopancreatography (ERCP) has been accepted unanimously. This paradigm shift is mostly due to improvements in transabdominal ultrasound, the increased availability of endoscopic ultrasound, and the use of magnetic resonance cholangiopancreatography (MRCP). In particular, MRCP is limited only in visualizing very small intraductal gallstones due to spatial resolution restrictions, whereas the detection rate of larger concretions is comparable to that with ERCP and endoscopic ultrasound. Patients with biliary pancreatitis benefit greatly from noninvasive MRCP visualization, establishing it as the preferred imaging modality. Particularly if ductal gallstones requiring further intervention are highly suspected, ERCP is preferable to other imaging modalities. If that suspicion is moderate, MRCP would be the imaging modality of choice, and transabdominal ultrasound would be performed if ductal gallstones are considered improbable. In up to 90% of cases, removal can be achieved endoscopically. Using a percutaneous approach smaller concretions can be extracted directly. However, larger gallstones need to be broken down into smaller fragments. For lithotripsy, either cholangioscopically-guided laser or electrohydraulic procedures are easy and effective. In case of strictures due to biliodigestive anastomoses, additional papillary balloon dilatation may be required.

Percutaneous treatment of extrahepatic bile duct stones assisted by balloon sphincteroplasty and occlusion balloon

Objective

To describe the technical feasibility and usefulness of extrahepatic biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing.

Materials and Methods

Fifteen patients with extrahepatic bile duct stones were included in this study. Endoscopic stone removal was not successful in 13 patients, and two patients refused the procedure due to endoscopy phobia. At first, all patients underwent percutaneous transhepatic biliary drainage (PTBD). A few days later, through the PTBD route, balloon assisted dilatation for common bile duct (CBD) sphincter was performed, and then the stones were pushed into the duodenum using an 11.5 mm occlusion balloon. Success rate, reason for failure, and complications associated with the procedure were evaluated.

Results

Eight patients had one stone, five patients had two stones, and two patients had more than five stones. The procedure was successful in 13 patients (13/15). In 12 of the patients, all stones were removed in the first trial. In one patient, residual stones were discovered on follow-up cholangiography, and were subsequently removed in the second trial. Technical failure occurred in two patients. Both of these patients had severely dilated CBD and multiple stones with various sizes. Ten patients complained of pain in the right upper quadrant and epigastrium of the abdomen immediately following the procedure, but there were no significant procedure-related complications such as bleeding or pancreatitis.

Conclusion

Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an effective, safe, and technically feasible procedure which can be used as an alternative method in patients when endoscopic extrahepatic biliary stone removal was not successful.