Lower the complication in Sphincterotomy, you only need progressive dilation balloon

clinical practice. 

Devices chosen in Operation: duodenal endoscope, progressive dilation balloon (balloon diameter 12-13.5-15mm corresponding to pressure 3-4.5-8 ATM), inflation pump, 0.035” guide wire, stone extraction catheter and stone retrieval basket, lithotripter, sphincterotome, nasal biliary drainage tube.

The nursing cooperation from intubation, EST, balloon dilation to drainage tube placement has great influence on the effect and successful rate of operation. 

Cooperation in intubation 

When the duodenal endoscope reaches the papilla, insert sphincterotome loaded with guide wire through the working channel. Protrude the tip of the guide wire from the device and it facilitates the operator to insert it into the papilla. Deliver the guide wire deeper into the bile duct under X ray and reach it to the upper part of common bile duct. Insert the sphincterotome as well. 

Extract the bile and inject the contrast medium. Observe the stone quantity and determine the stone diameter according to the ratio of stone and endoscope. Observe and identify if there is stricture on bile duct and the length of the stricture in order to choose balloons of proper size. 

Cooperation in EST 

Do not over stretch the cutting wire of sphincterotome. Be careful with the cutting degree. Cut the sphincterotome in line with the direction of common bile duct. Be careful not to cut the wrinkle wall.  

Cooperation in balloon dilation 

Leave the guide wire in the bile duct and retreat the sphincterotome. 

Insert the balloon until the balloon tip passes the stricture of the proximal end of bile duct. 

The other end of the balloon is in the visible scope of duodenal endoscope.  Connect with pump and inject contrast medium.  Increase the pressure slowly as abrupt pressure shall tear the sphincter and lead to laceration. When the pressure reaches 3ATM, wait 15 seconds; when the pressure reaches 4.5 ATM, wait another 30 seconds. Extract the contrast agent and release the pressure on the balloons. Then reach 4.5 ATM again, wait 1-2 minutes.  When the stone is large, communicate with the physician and dilate the balloons with 8 ATM pressure which dilates the balloon diameter to 15mm.  

Observe the stone expanding status under X ray. Pay attention that the diameter of balloon cannot be larger than the diameter of common bile duct. 

Extract the contrast medium, retreat balloon catheter and guide wire. 

Cooperation in stone retrieval 

After the dilation of the papilla, the lower end of common bile duct and papilla are in maximum opening status. Perform stone lithotripter and stone retrieval immediately. Enter the stone retrieval catheter above the stone, open the basket, slightly shake it and wrap the stone. 

If lithotripter is used, press the handle with graded pressure to avoid the breaking of wire due to over strength. 

Use stone extraction balloon catheter to clean the stone debris. 

Cooperation in drainage tube placement 

Make contrast medium inspection again and make sure the stones have been cleaned out completely. Insert the guide wire. Prepare the nasal biliary drainage tube with saline filled in the tube. Get the tube through the guide wire and protrude from the channel. The physicians insert the tube into the papilla. At the same time, the nurse holds the guide wire and pushes forward the drainage tube at the same speed with the physician. The position of guide wire keeps still during the operation. 

When the biliary drainage tube is placed in the proper locate, retreat the guide wire and endoscope. Fix the position of nasal biliary drainage tube without migration during the process of retreating endoscope.  

Get the other end of the drainage tube from the nasal cavity. The patient should open the mouth during this process. Fix the tube on the right ear. Finally, inspect the location of the drainage tube under X ray. 

Observe the breathing , blood pressure and oxygen saturation of blood during the operation. Try to console the patients for any discomfort. 

Result

In our research, no bleeding or perforation happen in 105 cases patients. Small bleeding in operation shall not continue or it shall cease immediately after spray of noradrenaline saline. 

4 of 105 patients have mild pancreatitis, and got cured after treatment. Blood amylase in 11 patients elevated after the operation. And all recovered after treatment. 

Only one case could not be treated by ERCP and required open surgery due to stone hardness and size. 

For the papilla with diverticulum besides it, the risk of bleeding and perforation elevated.

In recent years, the researches on the EPBD indicate that EPBD dilates the papilla gradually and therefore reduce rate of bleeding and perforation. EPBD protects the function of sphincterotome to some extent and also reduces the long-term complications. With EPBD, the opening of papilla could be larger than EST. 

Progressive balloon dilation catheter is safe to be used in common bile duct stone diseases with diverticulum besides the papilla. Practice and cooperation makes success. 

Welcome to add your comments for any topics or questions you have in the ERCP operation. As a manufacturer, we are delighted to provide you with possible solutions. 

（J of Wannan Medical College）2016;35(3)