A balloon for every stone

This 50 year old lady had undergone cholecystectomy twenty years earlier. She had now been having recurrent bouts of right hypochondrial pain. An ultrasound scan showed a 12mm stone impacted in the distal CBD. We were greeted by a big fat papilla with the orifice at its lower end (A: white arrow). Multiple attempts to cannulate the CBD were unsuccessful. We decided to do a precut with a needle knife (B). It was a textbook precut and the CBD opening was nicely exposed (C: white arrow shows the CBD opening - somehow appearing suspiciously similar to the Superman insignia). Contrast injection showed two stones, one below the scope and another just above it (D: white arrows). The papillotomy was extended (E) , however the size was insufficient considering the size of the stones. Our next step was to do a sphincteroplasty using an 18mm diameter TTS balloon (F: white arrow shows the waist of the inflated balloon at the ampulla). Following this, two stones were successfully extracted (G1 & G2). A final cholangiogram with an inflated balloon just above the ampulla showed a duct clear of stones (H).

Multiple CBD stones requiring different removal techniques

This 40 year old lady had a pre ERCP ultrasound which indicated a single 9mm stone in the distal CBD. Going in, we were encountered by a swollen ampulla (A: green arrow), suggesting an impacted stone. Dye injection showed a grossly dilated CBD (B: green arrows) and negative shadows (B :red arrows). The stones could not be removed even after a wide papillotomy. So we went for a sphincteroplasty with an 18mm TTS (through the scope) wire guided balloon (C1 & C2 and D: green arrow showing the inflated balloon at the ampulla). One stone was retrieved (E: green arrow). Repeat cholangiogram showed more stones in the mid CBD (F: green arrow). The remain stones were removed with an extraction basket (G1: green arrow marks the stone and red arrow indicates the basket wires. G2: red arrow marks the stone trapped in the basket wires)