Gallstones and Gallbladder Disease - Managing Common Bile Duct Stones

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ERCP with Endoscopic Sphincterotomy (ES)

The ERCP and ES Procedure. A typical ERCP and endoscopy sphincterotomy (ES) procedure includes the following steps:

• The patient is given a sedative and asked to lie on his or her left side.
• An endoscope (a tube containing fiberoptics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a bloating sensation.
• A thin catheter (tubing) is then passed through the endoscope.
• Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows visualization using an x-ray of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area.
• Instruments may also be passed through the endoscope to remove any stones that are detected.
• The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) It serves to widen the junction between the common bile duct and intestine (called the ampulla of Vater) so that the stones can be extracted more easily. With ES a tiny incision is usually made in the orifice of the common bile duct and through the muscles that enclose the lower common bile duct (called the sphincter of Oddi).
• One recent alternative to ES is the use of a small inflatable balloon (called endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass and so avoid cutting the muscles. According to 2003 studies, it is equal in effectiveness to ES but offers no advantage at this time.
• Once the junction has been opened, the stones may pass out on their own or they may be extracted with the use of tiny baskets or balloons.

Complications. Complications of ERCP and ES occur in 5% to 8% of cases, and some can be serious, with mortality rates of 0.2% to 0.5%. They include the following:

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