Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.     

Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones

AIM: The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good. However, the degree of difficulty is increased when stones are larger. Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g. electrohydraulic lithotripsy (EHL), where stones are crushed using baby-mother scope electric shock. The extracorporeal shock-wave lithotripsy (ESWL) or laser lithotripsy also yields an excellent success rate of greater than 90%. However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance. METHODS: During the period from August 1996 to December 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone>1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter). These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy. A follow-up was conducted on the post-treatment conditions and complications of the patients. RESULTS: Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%. The procedure failed in 32 patients, for whom surgery was needed. Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis, and 10 patients had delayed bleeding, and no patient died. Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy. As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%) had pancreatitis, and 9 patients (14.7%) had delayed bleeding. Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%) had cholangitis, 1 (0.4%) had delayed bleeding, and 7 patients (3.3%) had pancreatitis. Statistical deviation was present in post-procedure cholangitis, delayed bleeding, and pancreatitis of both groups. CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate. Moreover, complications are minimal. This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.     

Should we redefine large common bile duct stone？

The definition of large stones is not clear ranging from 10 mm to 15 mm and does not include the lower common bile duct （CBD） diameter. Three hundred and four patients who underwent endoscopic retrograde cholangiopancreatography and stone extraction were retrospectively analyzed over a 1-year period, Sixteen patients were different from others in that 10 patients with large stones had stone extraction with a wire basket or a balloon catheter and 6 patients with small stones had stone extraction with mechanical lithotripsy. The definition of large stones should include diameter of the lower CBD and any stone in lower CBD with its diameter greater than 2 mm,     

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM:To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation(EPLBD)for bile duct stones in a multicenter prospective study.METHODS:Lithotomy by EPLBD was conducted in 124patients with bile duct stones≥13 mm in size or with three or more bile duct stones≥10 mm.After endoscopic sphincterotomy,the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.RESULTS:The success rate of first-time lithotomy was 86.3%(107/124)and the final lithotomy success rate was 100%(124/124).Lithotripsy was needed in10 of the 124(13.6%)patients.Adverse events due to the treatment procedure occurred in 6(4.8%)patients,all of which were mild.Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.CONCLUSION:It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.     

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate rapid,safe and effective bile duct stones extraction.Nowadays,endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients.Large common bile duct stones are treated conventionally with mechanical lithotripsy,while the most serious complication of the procedure is "basket and stone impaction" that is predominately resolved surgically.In cases of difficult,impacted,multiple or intrahepatic stones,more sophisticated procedures have been used.Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems,ultra-thin cholangio-scopes,thin endoscopes and ultimately using the novel single use,single operator SpyGlass Direct Visualization System,in order to deliver intracorporeal shock wave energy to fragment the targeted stone,with very good outcomes.Recently,large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials.When compared with mechanical lithotripsy or with balloon dilation alone,it proved to be superior.Moreover,dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic.Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of "impaction" because it seems that is an effective,inexpensive,less traumatic,safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists.When complete extraction of large stones is unsuccessful,the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy.Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective.The great majority of patients with large stones can be treated endoscopically.In cases of unsuccessful stone extraction using balloons,baskets,mechanical lithotripsy,electrohydraulic or laser lithotripsy and large balloon dilation,the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.     

Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy

AIM： TO introduce a new method： small endoscopic sphincterotomy （ES） combined with endoscopic papillary large balloon dilation （SES ＋ EPLBD） to treat patients with large biliary stones.
METHODS： Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 ± 3 mm and mean number of stones was 2.5 ± 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket.
RESULTS： Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 ± 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis （1%） occurred.
CONCLUSION： SES ＋ EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.     

Modified percutaneous transhepatic papillary balloon dilation for patients with refractory hepatolithiasis

BACKGROUND Some patients with hepatolithiasis cannot tolerate surgery due to severe cardiac or pulmonary comorbidities, or cannot be endoscopically treated because of altered gastrointestinal anatomies.AIM To propose a modified percutaneous transhepatic papillary balloon dilation procedure, and evaluate the clinical efficacy and safety of this modality.METHODS Data from 21 consecutive patients who underwent modified percutaneous transhepatic papillary balloon dilation with hepatolithiasis were retrospectively analyzed. Using auxiliary devices, intrahepatic bile duct stones were pushed into the common bile duct and expelled into the duodenum with an inflated balloon catheter. The outcomes recorded included success rate, procedure time, hospital stay, causes of failure, and procedure-related complications. Patients with possible long-term complications were followed up for 2 years.RESULTS Intrahepatic bile duct stones were successfully removed in 20(95.23%) patients. Mean procedure time was 65.8 ± 5.3 min. Mean hospital stay was 10.7 ± 1.5 d. No pancreatitis, gastrointestinal, or biliary duct perforation was observed. All patients were followed up for 2 years, and there was no evidence of reflux cholangitis or calculi recurrence.CONCLUSION Modified percutaneous transhepatic papillary balloon dilation was feasible and safe with a small number of patients with hepatolithiasis, and may be a treatment option in patients with severe comorbidities or in patients in whom endoscopic procedure was not successful.     

Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

AIM： To compare small sphincterotomy combined with endoscopic papillary large balloon dilation （SES ＋ ELBD） and endoscopic sphincterotomy （EST） for large bile duct stones. METHODS： We compared prospectively SES ＋ ELBD （group A, n = 27） with conventional EST （group B, n = 28） for the treatment of large bile duct stones （≥ 15 mm）. When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy. RESULTS： No significant differences were observed in the mean largest stone size （A： 20.8 mm, B： 21.3 mm）, bile duct diameter （A： 21.4 turn, B： 20.5 ram）, number of stones （A： 2.2, B： 2.3）, or procedure time （A： 18 min, B： 19 rain） between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B （P = 0.473）. Mechanical lithotripsy was required for stone removal in nine of 27 patients （33%） in group A and nine of 28 patients （32%, P = 0.527） in group B.CONCLUSION： SES ＋ ELBD did not show significant benefits compared to conventional EST, especially for the removal of large （≥ 15 mm） bile duct stones.     

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones？

AIM： To investigate the usefulness of magnetic resonance cholangiopancreatography （MRCP） and the need for endoscopic retrograde cholangiopancreatography （ERCP） in cases of suspected spontaneous passage of stones into the common bile duct.
METHODS： Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever, and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes. These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP. All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.
RESULTS： No stones were detected by ERCP in any patient, confirming the results of MRCP.
CONCLUSION： When clinical symptoms improve, blood biochemical parameters have normalized, and MRCP shows there are no stones in the common bile duct, it can be considered the stone has spontaneously passed and thus ERCP is not necessary.     

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth Ⅱ gastrectomy patients

Background: Endoscopic papillary balloon dilation(EPBD) for common bile duct(CBD) stones removal in Billroth Ⅱ gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth Ⅱ gastrectomy patients.Methods: The records of patients with previous Billroth Ⅱ gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography(ERCP) between July 1, 2008 and September 1,2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events,and stone recurrence were analyzed.Results: A total of 83 patients with previous Billroth Ⅱ gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth Ⅱ gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients(85.7%). ERCP-related adverse events was in 3 ERCP procedures(5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients(12.2%) had stone recurrence after a median period of22.5 months(range 6–71 months) from the end of stone removal treatment. Female [odds ratio(OR) = 11.352; 95% confidence interval(95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy(OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.Conclusions: At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth Ⅱ gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.     

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND: Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35% and 26% of the cases, respectively. RESULTS: Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. 31.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.     

Endoscopic papillary large balloon dilation in Billroth II gastrectomy patients with bile duct stones

Background and Aims: Patients with Billroth II (B‐II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B‐II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B‐II gastrectomy. Methods: Twenty‐six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B‐II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10–15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated. Results: In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1–3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation. Conclusions: Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B‐II gastrectomy.     

Recent advances in endoscopic management of difficult bile duct stones

Endoscopic treatment is now recognized worldwide as the first‐line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother‐baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single‐use cholangioscope system – the SpyGlass direct visualization system – are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound‐guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.     

ANALYSIS OF PLASTIC STENTS IN THE TREATMENT OF LARGE COMMON BILE DUCT STONES IN 45 PATIENTS

Background: Although endoscopic plastic biliary stenting is a clinical procedure routinely carried out in patients with common bile duct stones, the effects of stenting on the sizes or fragmentation of large common bile duct stones have not been formally established and the mechanism of this condition is controversial. We compared the stone sizes of common bile duct stones after biliary stenting in order to develop the mechanism. Patients and Methods: Endoscopic plastic biliary stenting was performed in 45 patients with large common bile duct stones or those difficult to extract with conventional endoscopic therapy, including mechanical lithotripsy. The stone diameter was ≥16 mm in all patients. Bile duct drainage and endoscopic placement of 7–8.5 Fr plastic biliary stents were established in all patients. Differences of stone sizes and fragmentations after biliary stenting were compared. The complete stone clearance rate after treatment was obtained. Results: After biliary stenting for 3–6 months, the bile stones disappeared or changed to sludge in 10 (10/45) patients, and fragmentation of the stones or decreased stone sizes were seen in 33 patients, whose stone median size was significantly decreased from 23.1 mm to 15.4 mm in 33 patients (P < 0.05). The stones were removed successfully with basket, balloon, mechanical lithotripsy or a combination in 43 (43/45) patients. The remaining two patients (2/45) demonstrated no significant changes in stone sizes. Conclusion: Plastic biliary stenting may fragment common bile duct stones and decrease stone sizes. This is an effective and feasible method to clear large or difficult common bile duct stones.     

The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy

BACKGROUND: When choledochoscopic lithotomy with basket and electrohydraulic lithotripsy is used to remove intrahepatic duct stones, fragments or small stones usually remain in the bile duct that are too small to be captured with a basket. METHODS: An attempt was made to remove stone fragments in 16 patients with intrahepatic duct stones by antegrade balloon dilation of the sphincter of Oddi with a conventional balloon catheter. After balloon dilation, remnant stones and sludge were pushed through the papilla with the choledochoscope. RESULTS: Bile duct stones were completely removed in 12 of 16 patients (75%); stones were removed in 1 session. There was no clinical evidence of procedure-related pancreatitis or fatal complications. CONCLUSIONS: Percutaneous transhepatic papillary balloon dilation of the sphincter of Oddi and clearance of remnant bile duct stones and stone fragments with the tip of choledochoscope is simple and effective in patients undergoing percutaneous transhepatic choledochoscopic lithotomy.     

Endoscopic treatment of retained bile-duct stones by using a balloon catheter for electrohydraulic lithotripsy without cholangioscopy

BACKGROUND: Electrohydraulic lithotripsy is a highly effective method for fragmenting biliary stones, but direct visual control is required. The efficacy and the safety of electrohydraulic lithotripsy without cholangioscopy by using a balloon catheter were evaluated in patients with bile-duct stones that could not be extracted by using standard techniques. METHODS: Nineteen patients with extrahepatic bile-duct stones that could not be extracted by using conventional endoscopic methods, e.g., mechanical lithotripsy, were selected to undergo electrohydraulic lithotripsy without peroral cholangioscopy. An electrohydraulic lithotripsy probe with a 3.0 F radio-opaque tip was inserted through a balloon catheter. Electrohydraulic lithotripsy was performed under fluoroscopy until the fragmented stone could be captured in a large basket for mechanical lithotripsy. Endoscopic removal of the fragments was attempted during the electrohydraulic lithotripsy session. RESULTS: Stones were successfully fragmented in 17 of 19 patients. In 16 patients (84.2%), the bile duct was cleared of all stones. A mean of 1.8 endoscopic sessions was required for complete removal. Additional mechanical lithotripsy was performed in 9 (56.2%) of the 16 patients. Minor complications were noted in 4 patients (2 hemobilia, 1 pancreatitis, 1 cholangitis). There was no 30-day mortality. CONCLUSIONS: For a selected group of patients with bile-duct stones not extractable by using standard techniques, fluoroscopically controlled electrohydraulic lithotripsy with a balloon catheter seems to be an effective method of fragmentation.     

柱状大水囊扩张术治疗合并十二指肠乳头旁憩室者胆总管较大结石的初步探讨

目的初步探讨内镜下十二指肠乳头柱状大水囊扩张术对合并十二指肠乳头旁憩室胆总管较大结石患者的安全性和治疗价值。方法对21例合并十二指肠乳头旁憩室且胆总管结石直径较大的患者先行EST,切开3～6mm,用直径10mm的球囊扩张,再根据胆总管直径以及结石大小分别应用直径16～20mm的柱状水囊扩张器行乳头扩张,随后予以取石网篮和（或）取石气囊将结石完整取出。结果所有患者均经一次操作取出结石,均未使用碎石器碎石。取出结石直径1．3～2．0cm,平均1．6cm,单发结石患者15例,2枚结石患者4例,3枚结石患者2例。2例患者术后并发轻型急性胰腺炎,2例术后有一过性血淀粉酶升高,但均低于正常值上限3倍;未发生穿孔、明显出血、感染等并发症。结论对于合并十二指肠乳头旁憩室且胆总管结石较大的患者,十二指肠乳头柱状大水囊扩张术是一种安全有效的治疗方法。     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.