Large-balloon technique for one-step endoscopic biliary stenting in patients with an inaccessible major papilla owing to difficult duodenal stricture (with video)

Background Marked duodenal stenosis makes endoscopic biliary stenting (EBS) impossible, although it is the most common method for treating obstructive jaundice in patients with benign or malignant biliary strictures. Large-balloon dilation can be used to enable endoscope passage in the GI tract. Objective We describe 4 cases of successful EBS combined with the use of a large balloon for the treatment of difficult duodenal strictures in patients with benign and malignant biliary strictures. Design A retrospective case series. Setting Two tertiary referral centers. Patients Four patients: 1 with hilar carcinoma, 1 with gallbladder carcinoma, and 2 with chronic pancreatitis. Interventions After duodenal dilation, the slightly deflated balloon was pushed with the endoscope into the major papilla through the duodenal stricture (pushing method used in 2 patients). In the cases in which the major papilla was not accessible with the pushing method, a large dilation balloon was deflated completely after dilation, advanced beyond the stricture into the third portion of the duodenum, and reinflated to the maximum size. Pulling the dilation balloon catheter into the working channel while hooking the inflated balloon as the anchor at the anal side of the duodenal stricture, the endoscope was straightened to advance to the major papilla (hooking method used in 2 patients). Main Outcome Measurement Successful EBS. Results Reaching the major papilla and EBS was accomplished in all 4 patients. Limitation Small number of cases. Conclusions Use of large-balloon dilation can contribute to successful ERCP in patients with difficult duodenal strictures.