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In 10–15 % of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for the indication of suspected choledocholithiasis, identified stones can be difficult to remove [1]. Common factors associated with failure include stones[1 cm, numerous stones, and altered biliary anatomy. There are several techniques for removing these ‘‘difficult CBD stones’’. Leaving a plastic biliary stent in place with or without ursodeoxycholic acid therapy with subsequent ERCP is often successful [2]. Mechanical lithotripsy (ML) fragmentation combined with biliary sphincterotomy (EST) successfully removes many large stones [3, 4]. Complications following biliary sphincterotomy and ML include bleeding, pancreatitis, and perforation and are usually mild and self-limited but on rare occasions can cause short-term morbidity or even death [5]. Electrohydraulic lithotripsy can be useful for disintegrating stones prior to removal, but requires direct visualization of the stone with cholangioscopy with attendant risks such as hemobilia, cholangitis, and ductal perforation [6]. Endoscopic papillary balloon dilation (EPBD), or balloon sphincteroplasty, has evolved as another technique for removing large bile duct stones. Controlled radial expansion (CRE) balloons 6–10 mm in diameter stretch the intact sphincter of Oddi to facilitate stone removal. Though early experience with balloon sphincteroplasty was promising, subsequent multicenter, randomized controlled trials reported overall higher rates of pancreatitis including severe pancreatitis leading to death in some patients treated with balloon sphincteroplasty [7, 8]. While balloon sphincteroplasty remains an accepted practice in some parts of the world, the American Society for Gastrointestinal Endoscopy only recommends EPBD for patients in whom sphincterotomy is considered too risky or difficult such as patients medically anticoagulated or those with post-surgical anatomy or a periampullary diverticulum [1]. Endoscopic papillary large-balloon dilation (EPLBD) is a technique introduced in 2003 that dilates with a 12 to 20-mm CRE balloon following biliary sphincterotomy [9]. Balloon size is chosen to be at least the same diameter as the stone but no larger than the diameter of the bile duct. The initial published retrospective series reported that biliary stones too large to be removed despite a complete sphincterotomy and use of an extraction balloon or basket could be successfully removed in most cases without the use of ML [9]. Furthermore, the overall complication rate was an acceptable 15.5 %, consisting of mild-to-moderate cholangitis, pancreatitis, and bleeding, with no deaths [9]. Several retrospective studies, prospective series, and randomized controlled studies have reported that EPLBD is an effective and mostly safe method for the removal of large CBD stones [10–16]. A recent systematic review of R. Daniel Lawson: A military service member (or employee of the U.S. Government).

Safely Stretching Our Options for Removing Large CBD Stones