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ENDOSCOPIC TECHNIQUES OF
SPHINCTEROTOMY AND
REMOVING COMMON BILE DUCT
STONES

NOI SOI
MEDIC
NGUYEN PHUC BAO HUNG - MD
Endoscopist - MEDIC

MEDIC 254 Hoa Hao Q. 10 TP. Ho Ch Minh

T: 8357284 8355 136 fax: 8488352543 email: medic@hcm. vnn. vn

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ENDOSCOPIC SPHINCTEROMY (ES) is a unique

therapeutic modality that has revolutionized the
non operative treatment of various biliary and
pancreatic disorders.
In 1974, endoscopic sphincterotomy for
common bile duct stone was first reported by
classen and demlling in Germany and by KAWAI
and al in Japan. Nowadays, endoscopic
sphincterotomy is routinely carried out for
diagnosis and treatment of pancreatic and
biliary diseases.

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I/- INDICATIONS:
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1. Benign diseases of the biliary and pancreatic

ducts:

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- Common bile duct stone.

- Ascending cholangitis.
- Sphincter of Oddi dysfunction.
- Benign stricture of either the papilla of Vater or
the distal common bile duct.
- Benign stricture of the pancreatic duct.
- Pancreatic duct stones.

2. Obtructive jaundice in malignant diseases of

pancreas and bile duct.
3. Removing parasites in the bile duct or
pancreatic duct.

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II/- CONTRAINDICATIONS:
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- Recent myocardial infarction.

- Bleeding disorders.
-Acute pancreatitis not due to common bile duct
stones.
- Stenosis of esophagus, cardia orifice and
pylorus.

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III/- TECHNIQUES AND METHODS:
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1. Anatomic consideration:

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The distal end of the common bile duct course

downward and medially through the duodenal
wall beforeits intestinal exit at the papilla of
Vater, a smooth, nipple-like elevation at the
posteromedial wall of the descending duodenum
(fig-1).
The intramural segment of the bile duct is
invested with a bundle of smooth muscle fibers
that interdigitate with each other and with the
duodenal musculature constituting the sphincter
of Oddi (fig-2).

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Figure 1 : The anatomy of the descending uodenum, with the
intramural segment of the distal common bile duct
cephalad to the papilla of Vater. Folds of the plicae duodeni
longitudinalis run cephalad and end at the papilla.

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Figure 2 : Normal papilla is seen on the medial
duodenal wall, with longitudinal folds just below
it. The configuration is papillary or protruding.

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2. Equipment: Lateral viewingendoscope (fig-3).
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Figure 3 : These are side-viewing duodenoscopes.

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Figure 4a : A double-channel. sphincterotome allows"over-awire" placement and is useful in achieving difficult

cannulations because its tip may be manipulates to seek an
orifice and a wire can be passed through it.
Figure 4b : (A) A 20-mm papillotome(B) A 30-mm papillotome.

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- Dormia basket (fig-5).
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Figure 5 :
(A) Dormia basket catheter.
(B) Close-up of Dormia
basket.

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- Balloon catheters (fig-6).
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Figure 6 :
(A)
Balloon
catheter
(American
Edwards Co) for
extraction of bile
duct stones.
(B) Fully inflated
1-cm
diameter
balloon
of
balloon
extraction
catheter.

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- Mechanichal lithotriptor (fig-7).
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Figure 7 : A mechanical lithotriptor can be used
to surround large or difficult stones and crush
them.

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Biopsy forceps.
X- ray machine with monitor.
Suction machine.
Medicine:

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Sedation : hypnovel, seduxen.
Antispasm: buscopan, glucagon.

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3. Techniques of endoscopic
sphincterrotomy for common bile
(A) Patient preparation : duct stones :

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- Fasting for a minimum of 8 hours before the

procedure.
- Antibiotic are given 2 hours prior to the
procedure and continueed for two doses 8 and
16 hours after the procedure.
- Intravenous infusion.
- Medicine: sedation, antispasm.
- Preoperative findings.

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(B) Technique :

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- The patient lies in a semiprone position with the

right side up and the left arm behind him.
- Checking the esophagus, stomach and
duodenum by an end-viewing upper endoscope.
- Lateral-viewing scope is inserted and advanced
into the stomach, pylorus and duodenum. After
reaching the second portion of duodenum and
straightening out the scope, the papilla is
brought to an en face position. Cannulation is
performed with regular cannula, documenting
the presence of the stones or any other
pathologic condition of the common bile duct.

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Once
the
endoscopic
retrograde
cholangio-pancreatography (ERCP) is completed,
the cannula is removed and if there is a need for
papillotomy, a proper papillotome is reintroduced
through the biopsy channel and advanced into the
common bile duct.
Proper placement of the papillotome in the
common bile duct should be permanently
documented by fluoroscopy or a radiograph. If
access to the common bile duct is difficult, the
endoscopist should leave the cannula in place and
insert a long wire through the cannula into the
common bile duct and then remove the cannula.
This will allow the use of the wire -guided
papillotome and easier access for insertion of the
papillotome into the common bile duct and then
remove
a
long
wire
and
withdraw
the
sphincterotome from the common bile duct until a
small portion of the papillome is visible in the
duodenum.

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The gastrointestinal surgical assitant will pull

the handle of the papillotome slowly to the
cutting position. when the papillotome is in the
cutting position, an incision is made in the
papilla of vater, starting from the center and
continouing to the 11-12 oclock position. The
length of the cut should be between 10-15 mm.
Extending the incision beyond the transverse
duodenal fold will increase the chance of
perforation. this incision should be made slowly
and deliberately in step wire fashion with small
bursts of cutting current.

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The important points are:

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The endoscopist should not proceed if the direction

of the incision is incorrect.
The papilla must always remain in view while an
incision is being made.

In difficult cases, the following techniques are

available remedies this situation :
Over -the wire papillotomy.
Precut papilotomy.

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Endoscopic sphicterotomy:
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The sphicterome is placed in the duct and
cutting will be proced

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The sphincterotomy is complete and sphincterotome will be
pulled off the bile duct.

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Endosopic sphincterotomy is accomplished

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Fig- 8 : Cholelithiasis with multiple gallstones
and a single common bile duct stone (arrow).

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Figure 8: Technique of endoscopic retrograde

sphincterotomy.
(A) A papilla is located in the descending duodenum.
Note the longitudinal fold just below the pappila.
(B) The pappila is cannulated for diagnosis.
(C) The cannula is replacedwith a papillotome. After
the position in the common bile duct is confirmed,
the papillotome is bowed in preparation for
endoscopic retrograde sphincterotomy.

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Fig-8 (cont) :

(D) A cutting current is passed through the wire

and partial incision is made.
(E) The incision is extended.
(F) Endoscopic retrograde sphincterotomy is
completed.

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Figure 9 : A balloon
catheter is placed
and inflated (arrow)
after
papillotomy
and
is
used
to
extract the calculus.

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REMOVING STONE FROM THE
COMMON BILE DUCT:
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Once the papilotomy is completed, the

endoscopist should evaluate the situation and if
no complications are present, proceed with the
removal of the stone.
By balloon (size of the stone 10 mm) :

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The extraction balloon catheter is inserted through

the biopsy channel and under fluorosopic
observation is advanced past the stone in the
proximal common bile duct. After that, balloon is
inflated, the endosopist slowly pulls it back toward
the duodenum. One may observe the delivery of
the stone into the duodenum through the scope or
the monitor.

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Figure 10 : (A) A balloon with a 1cm diameter is passed,

inflated, and withdrawn to calibrate the papillotomy orifice.
(B) The ballon has been passed above the retained stone,
inflated, and pulled down to bring out the stone. The stone
can be seen exiting the papilla.

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By basket ( size of the stone 10 mm

):
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The basket should be primed with contrast

material. After insertion of its tip above the
stone is in the basket. At this time, the
gastrointestinal surgical assistant closes the
handle of the basket until the stone is trapped
inside it and then endoscopist will pull back into
the duodenum. If size of stone in large,
mechanical lithotriptor is used to break stone
into multiple small stones.

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Figure 11 : Stages of removing common bile
duct stones by basket.

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ERCP:
stones
in
commo
n
bile
duct
and
commo
n
hepatic
duct

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Stones are pulled from common bile duct into the
duodenum.

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V/- COMPLICATIONS OF ENDOSCOPIC
SPHINCTEROTOMY :
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Bleeding : 2%-- 3%.

Perforation : 0, 8%.
Panceatitis : 5%- 10%.
Cholangititis.
Basket impaction.

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VI/- CONCLUSION :
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Endoscopic
sphincterotomy
has
helped
treatment of biliary and pancreatic diseases
easier and simpler.
Today
with
the
advent
of
endoscopic
sphincterotomy, the morbidity and mortality of
stone extraction is possibly less than with
surgical removal.
The hospital stay is shorter, revovery and return
to work is much quicker and the most important,
the patients feel less painful.
In MEDIC center, patient can be removed
common bile duct stones and come back their
home in 24 hour after the procedure.

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References:
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1. Jeffrey L, Ponsky. Endoscopic retrograde

cholangiopancreatography and the management of
common bile duct stones. Frederick L. G ; Jeffrey L. P;
eds. Endoscopic surgery. Ehiladelphia : Saunders,
1994: 185-- 191.
2. Fred E. S, Guido N, J, T. endoscopic retograde
cholangiopancreatography. Fred E,S ; Guido N, J, T, eds.
gastrointestinal endoscopy. Barcelona: Mosby-wolfe;
1997: 68-- 90.
3. Ira m. Jacobson. ERCP dianostic and therapeutic
applications. Elsevier science publishing co. inc. 1989
4. Michael V. Sivak, JR. ERCP. Benjamin H. Sullivan, JR.
Gastroenterology endoscopy. 1987: 502-- 735.
5. Le Quang Quoc Anh. Luan an tien s y khoa. Tp
Ho Ch Minh. 1998

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