Introduction

Difficult biliary stones and complex bile duct anatomy often limit the efficacy of endoscopic sphincterotomy (EST) alone. Dilation-Assisted Stone Extraction (DASE), involving large balloon dilation following EST, has emerged as a complementary technique to improve stone clearance. This study aimed to evaluate the safety and effectiveness of DASE performed either after primary EST in patients with naïve papilla or as a rescue strategy following prior EST.

Aims & Methods

A retrospective review was conducted on all patients who underwent DASE between January 2018 and December 2024 at the Department of Gastroenterology and Digestive Endoscopy, Mohammed VI University Hospital, Marrakech, Morocco. Inclusion criteria comprised patients with naïve or previously treated papilla undergoing DASE for bile duct clearance. Technical success was defined as successful balloon placement across the papilla, full inflation to target diameter for >30 seconds, followed by complete stone extraction. Complications were categorized as intraprocedural, early (<24 hours), or delayed (>24 hours).

Results

A total of 57 patients were included (mean age 72.5 ± 12.1 years; 30 females [52.6%], 27 males [47.4%]). Thirty-five patients (61.4%) had a naïve papilla, and 22 (38.6%) had prior EST. Main indications for DASE included large or impacted CBD stones (63.2%), periampullary diverticulum (15.8%), difficult cannulation (12.3%), altered anatomy (5.3%), and other causes (3.5%).
Technical success was achieved in 55 patients (96.5%). Thirteen patients (22.8%) experienced complications: 7 (53.8%) intraprocedural, 4 (30.8%) early, and 2 (15.4%) delayed.
Adverse events included:

• Bleeding in 8 patients (61.5% of all complications): 4 self-limited (50%), 3 endoscopically managed (37.5%), and 1 required radiological embolization (12.5%).
• Post-ERCP pancreatitis (PEP) in 4 patients (30.8%): all mild, resolved with conservative management.
• Perforation in 1 patient (7.7%): managed successfully with endoscopic clipping and supportive care.

Conclusion

DASE following EST is a highly effective and relatively safe approach for managing difficult CBD stones, with a high technical success rate and acceptable complication profile. The results support its routine use in therapeutic endoscopy, particularly for cases refractory to EST alone. Prior EST may be associated with a higher risk of adverse events and should prompt careful intra- and post-procedural monitoring.

References

- Zhang Q, Shen H, Zhang Y, Ding Y, Zhang X, Wang L.
Dilation-assisted stone extraction versus mechanical lithotripsy for large bile duct stones: a systematic review and meta-analysis. Endoscopy. 2021;53(5):454–463.
- Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, et al.
International consensus recommendations for difficult biliary access.
Gastrointest Endosc. 2017;85(2):295–304.
- Tringali A, Familiari P, Perri V, Boskoski I, Mutignani M, Costamagna G.
Endoscopic papillary large balloon dilation with sphincterotomy for the treatment of difficult common bile duct stones: outcomes, complications, and rates of stone recurrence.
Surg Endosc. 2020;34(11):4912–4920.