Balloon Sphincteroplasty Procedural Steps
Balloon sphincteroplasty (endoscopic papillary balloon dilation) should be performed as an adjunct to biliary sphincterotomy for large common bile duct stones >10mm, or as a standalone procedure only in patients with uncorrected coagulopathy where sphincterotomy carries prohibitive bleeding risk. 1, 2
Pre-Procedural Preparation
Obtain brush cytology and/or endoscopic biopsy before any therapeutic intervention to exclude superimposed malignancy, particularly in patients with strictures or unexplained biliary obstruction 1, 3
Administer prophylactic antibiotics before the procedure because injecting contrast into obstructed ducts may precipitate cholangitis 4, 1, 3
Perform MRCP or contrast-enhanced CT in patients with suspected hilar obstruction prior to intervention to map the biliary anatomy and identify drainable segments 4
Verify coagulation parameters if considering balloon dilation without sphincterotomy, as this is the primary indication for avoiding sphincterotomy 2
Step-by-Step Procedural Technique
1. Biliary Access and Cholangiography
Perform endoscopic retrograde cholangiography (ERC) to visualize the biliary tree and confirm stone size, number, and location 5
Use a 19-gauge EUS-FNA needle for duct puncture if standard ERCP access fails 4
2. Guidewire Placement
Insert a 0.035 inch or 0.025 inch guidewire with floppy tip through the papilla and advance it into the bile duct under fluoroscopic guidance 4, 5
Position the guidewire well above the obstruction to maintain stable access throughout the procedure 5
3. Sphincterotomy (When Indicated)
Perform biliary sphincterotomy first in all cases except those with uncorrected coagulopathy, as balloon dilation without sphincterotomy carries 7.3-20% risk of post-ERCP pancreatitis 1, 2
Complete a limited sphincterotomy if full sphincterotomy cannot be safely performed, then supplement with balloon dilation 4
4. Balloon Catheter Selection and Positioning
Select an 8mm diameter balloon catheter (3cm in width) for standard sphincteroplasty; this is the maximum safe diameter when performing dilation without prior sphincterotomy 2, 5
Insert the balloon catheter over the guidewire and position it precisely at the sphincter of Oddi under fluoroscopic visualization 5, 6
5. Balloon Inflation
Inflate the balloon gradually until the waist (indentation at the sphincter level) disappears under fluoroscopic monitoring 6
Maintain balloon inflation for ≥1 minute after waist disappearance to reduce post-ERCP pancreatitis risk to levels comparable with sphincterotomy alone 2
Use prolonged inflation (>1 minute) as network meta-analysis demonstrates 90.3% probability of being the safest approach regarding overall complications 2
6. Stone Extraction
Remove stones using mechanical lithotripsy for stones >12mm, a basket catheter for medium-sized stones, or a balloon extraction catheter for smaller stones 5, 6
Expect to achieve complete duct clearance in 78% of cases during a single session with sphincteroplasty alone for stones up to 20mm diameter 6
Plan for mechanical lithotripsy in approximately 10% of cases when stones exceed 12mm in diameter 6
7. Stent Placement (If Needed)
Use fully or partially covered metal stents for transluminal stenting if drainage is required 4
Reserve biliary stenting only for strictures refractory to dilation alone, as stenting increases complications compared to dilation alone 1, 3
Critical Contraindications
Do not perform balloon sphincteroplasty in the following circumstances: 2
- Biliary strictures (unless treating dominant strictures in primary sclerosing cholangitis)
- Ampullary, pancreatic, or biliary malignancies
- Prior biliary surgery (except cholecystectomy)
- Acute pancreatitis
- Precut sphincterotomy already performed for biliary access
Complication Management
Recognize that post-ERCP pancreatitis occurs in 5% of cases with balloon sphincteroplasty, typically mild and resolving within 48 hours 5, 6
Expect significantly lower hemorrhage rates (0.1-2%) compared to sphincterotomy alone, particularly when balloon dilation is used without sphincterotomy in coagulopathic patients 2
Ensure multidisciplinary support including interventional radiologists, surgeons, and anesthesiologists is available to prevent and manage complications 4
Post-Procedural Follow-Up
Perform repeat ERCP if incomplete duct clearance is achieved (occurs in approximately 4% of cases), with successful clearance typically achieved without sphincterotomy 6
Monitor for recurrent symptomatic bile duct stones during median 16-month follow-up, which occur in approximately 2% of patients and can be managed with repeat sphincteroplasty 6
Do not expect clinical evidence of papillary stenosis during long-term follow-up when proper technique is used 6