Radial sphincterotomy in endoscopic retrograde cholangiopancreatography due to extrahepatic obstructions by large stones in the common bile duct

Abstract

Objectives: The most common method of removal of calculi (“stones”) from the common bile duct (CBD) is an endoscopic sphincterotomy. We wished to determine the role of an improved method of sphincterotomy in choledocholithiasis: “radial sphincterotomy”. Methods: From 2017 to 2018, 54 endoscopic retrograde cholangiopancreatography (ERCP) procedures were undertaken in patients diagnosed with choledocholithiasis. Group 1 (23 patients) received a standard “pull type” sphincterotomy. The sphincterotomy incision in group 1 was made at the 11, 12 or 1 ‘O’ clock directions of a conventional clock depending on the anatomy of the papilla and stone size. Group 2 (31 patients) received a radial sphincterotomy. In this case, several incisions were made in the 11, 12 or 1 ‘O’ clock directions. The main incision was applied to the transverse fold, and other radial incisions were made below the transverse fold, without going beyond the boundaries of the proposed course of the intramural part of the CBD. Results: Stone size (mm) was classified as ≤5, 5–10, 10–15, 15–20 and >20. In group 1, the stone size was 20 mm in two patients. In group 2, stones >20 mm were detected in seven patients, and in other cases the size was 15–20 mm. In patients who underwent radial sphincterotomy, post-ERCP pancreatitis was noted in one patient, and bleeding and perforations were not observed . Conclusions: Our method showed promising results, and deserves more extensive research and worldwide application. We recommend that only experienced endoscopists should undertake this novel procedure.

Keywords

• ercp
• radial sphincterotomy
• choledocholithiasis
• extra-biliary disease