Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones

TG13 indications and techniques for biliary drainage in acute cholangitis (with videos)

The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy

AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis.

METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term complications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyzing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined as P < 0.05. Risk of bias was evaluated using a funnel plot.

RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBD group were younger (OR = -1.16, 95%CI: -1.49 to 0.84, P < 0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Compared with EST, the total stone clearance in the EPBD group decreased (OR = 0.64, 95%CI: 0.42 to 0.96, P = 0.03), the use of stone extraction baskets significantly increased (OR = 1.91, 95%CI: 1.41 to 2.59, P < 0.01), and the incidence of pancreatitis significantly increased (OR = 2.79, 95%CI: 1.74 to 4.45, P < 0.0001). The incidence of bleeding (OR = 0.12, 95%CI: 0.04 to 0.34, P < 0.01) and cholecystitis (OR = 0.41, 95%CI: 0.20 to 0.84, P = 0.02) significantly decreased. The stone recurrence rate also was significantly reduced in EPBD (OR = 0.48, 95%CI: 0.26 to 0.90, P = 0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis.

CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone clearance rate and risk of bleeding was lower with EPBD compared to EST.

Long-term outcomes of endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones

AIM

We recently reported that endoscopic papillary balloon dilation (EPBD) might suppress biliary bacterial contamination better than endoscopic sphincterotomy (EST) in patients with small bile duct stones (diameter ≤8 mm). In the present study, we evaluated immediate and long-term outcomes of endoscopic papillary balloon dilation with regard to stone size.

METHODS

We allocated 474 patients alternately to the two procedures. The patients were classified according to stone diameter (≤8 mm or >8 mm) and outcomes (i.e. complete stone removal, early complications, and late complications) were compared. The predictive risk factors for late complications were also investigated.

RESULTS

In patients with small stones, complete stone removal rate and early complication rate were similar between the two procedures; the incidence of pancreatitis was higher after EPBD, although the difference was not significant. Late complication rate and stone recurrence rate were significantly lower after EPBD than after EST (5.3% vs 17.3%, P = 0.009; 4.4% vs 12.7%; P = 0.048, respectively). In patients with large stones who underwent EPBD complete stone removal rate and late complication rate were lower, but the incidence of pancreatitis was higher. However, these differences were not statistically significant. Multivariate analysis showed that the increased risk of bactobilia following EPBD for large stones or EST, and the gallbladder with stones in situ were independent risk factors for late complications.

CONCLUSIONS

EPBD produced significantly better long-term outcomes than EST in patients with small bile duct stones.

Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series

BACKGROUND

Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones.

AIMS

We sought to identify factors predictive of adverse events (AEs) following EPLBD.

METHODS

This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12-20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan.

RESULTS

Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015).

CONCLUSIONS

EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Endoscopic papillary large-balloon dilation following limited sphincterotomy for the removal of refractory bile duct stones: experience of 169 cases in a single Chinese center

OBJECTIVE

To evaluate the efficacy and safety of endoscopic papillary large-balloon dilation (EPLBD) combined with limited endoscopic sphincterotomy (EST) for the removal of large biliary duct stones (≥10 mm).

METHODS

Data of patients who underwent an attempted removal of large bile duct stones by limited EST followed by EPLBD (≥12 mm in diameter) from April 2006 to October 2011 in our center were reviewed. Clinical characteristics, endoscopic methods and outcomes of the patients were collected and analyzed.

RESULTS

A total of 169 patients with a mean age of 69.3 years (range 19-97 years) underwent 171 procedures. Median stone size and balloon diameter was 15 mm and 13 mm, respectively. Complete stone removal in a single session was achieved in 163 procedures (95.3%) with mechanical lithotripsy (ML) used in 66 (38.6%). Patients with a larger stone size required more frequent use of ML with a comparable success rate (P < 0.01). There were no significant differences between patients with and without periampullary diverticula in stone clearance (97.3% vs 93.8%), ML requirement (36.5% vs 40.2%) and complications (2.7% vs 6.2%) (all P > 0.05). Seven patients had eight procedure-related complications including moderate or mild bleeding (n = 4), minor perforation (n = 1), mild pancreatitis (n = 2) and cholangitis (n = 1).

CONCLUSION

EPLBD following limited EST is an effective and safe approach for the removal of large biliary duct stones, especially for those refractory cases.

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM: To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.

METHODS: Patients (n = 208) were divided into five groups based on the largest CBD stone size of < 5, 6-8, 8-12, 12-14, and > 14 mm. Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8, 10, 12 and 14 mm balloons, such that the size of each balloon did not exceed the size of the CBD. Short- and long-term outcomes, such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, perforation, bleeding, and pneumobilia were compared among the five groups.

RESULTS: The overall rate of successful stone removal in all groups was 100%, and all patients were cured. Eight (3.85%) patients had post-ERCP pancreatitis, none had perforations, and 6 (2.9%) had bleeding requiring transfusion. There were no significant differences in early complication rates among the five groups. We observed significant correlations between increased balloon size and the short- and long-term rates of post-ERCP pneumobilia. Post-ERCP pancreatitis and bleeding correlated significantly with age, with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years, and bleeding occurring more frequently in patients aged > 70 years. We observed a significant correlation between patient age and the diameter of the largest CBD stone, with stones > 12 mm occurring more frequently in patients > 60 years old.

CONCLUSION: Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones. Balloon size should not exceed 15 mm.

Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones

Background

Endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) has been proposed as an alternative to manage large bile duct stones. However, recent reports indicate that LBD without EST may be safe and effective in this setting.

Methods

One hundred thirty-one patients with large common bile duct (CBD) stones 12 mm in size or larger underwent LBD alone (n = 62) or EST plus LBD (n = 69) for lithotripsy. The therapeutic outcome and complications were reviewed and compared.

Results

There were no differences between the two groups with regard to age, size and number of stones, or bile duct diameter. The LBD alone group (mean age, 70.4 years) and the EST plus LBD group (mean age, 68.2 years) had similar outcomes in terms of overall successful stone removal (96.8% vs. 95.7%, P = 0.738) and complete stone removal without the need for mechanical lithotripsy (80.6% vs. 73.9%, P = 0.360). Complications in the LBD alone and EST plus LBD groups were as follows: pancreatitis (6.5% vs. 4.3%, P = 0.593), impaction of basket and stone (0% vs. 1.4%, P = 0.341), and perforation (0% vs. 1.4%, P = 0.341).

Conclusions

LBD alone may be a simple, safe, and effective alternative to EST plus LBD in relatively aged patients with large CBD stones, and it can simplify the procedure compared with EST plus LBD.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses

BACKGROUND & AIMS

Endoscopic sphincterotomy (EST) is the standard treatment for choledocholithiasis. Endoscopic papillary balloon dilation (EPBD) has a lower risk for bleeding than EST, but EPBD is reserved for patients with bleeding diathesis because some studies reported that it increases the risk for pancreatitis. A short dilation time (≤1 minute) is therefore recommended to reduce pancreatitis. However, there is evidence for an inverse relationship between EPBD duration and pancreatitis, prompting reevaluation of the optimal duration and relative safety of EPBD vs EST.

METHODS

We systematically reviewed randomized controlled trials to compare long EPBD (>1 minute), short EPBD (≤1 minute), and EST regarding pancreatitis and overall complications. In addition to pairwise meta-analyses, Bayesian network meta-analysis was undertaken to compare the 3 procedures together. Relation between duration and outcome was also analyzed by meta-regression.

RESULTS

Compared with EST, short EPBD had a higher risk for pancreatitis (odds ratio [OR] by traditional analysis, 3.87; 95% confidence interval, 1.08-13.84 and OR by network meta-analysis, 4.14; 95% credible interval, 1.58-12.56), but long EPBD did not pose a higher risk than EST (1.14, 0.56-2.35 and 1.07, 0.38-2.76). Long EPBD had a lower overall rate of complications than EST (0.61, 0.36-1.04 and 0.54, 0.20-1.36). In network meta-analysis, probabilities of being the safest treatment for long EPBD/short EPBD/EST regarding pancreatitis and overall complications were 43.9%/0.2%/55.9% and 90.3%/1.3%/8.4%, respectively.

CONCLUSIONS

Duration of EPBD is inversely associated with pancreatitis risk. Currently recommended ≤1-minute dilation actually increases pancreatitis. EPBD with adequate duration may be preferred over EST because of comparable pancreatitis but lower overall complication rates.

Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts

Stones in biliary and pancreatic ducts are entities that plague hundreds of thousands of patients worldwide every year. Symptoms can be mild (pain) to life threatening (cholangitis, severe acute pancreatitis). In the last few decades, management of these stones has transitioned from exclusively surgical to now predominantly endoscopic techniques. This article reviews the evolution of endoscopic techniques used in the management of stones in the common bile duct and pancreatic duct.

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.

Endoscopic papillary large balloon dilation in Billroth II gastrectomy patients with bile duct stones

BACKGROUND AND AIMS

Patients with Billroth II (B-II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B-II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B-II gastrectomy.

METHODS

Twenty-six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B-II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10-15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated.

RESULTS

In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1-3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation.

CONCLUSIONS

Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B-II gastrectomy.

Current status of endoscopic papillary balloon dilation for the treatment of bile duct stones

Background/purpose

While endoscopic sphincterotomy (EST) is performed worldwide for the removal of common bile duct stones, many biliary endoscopists hesitate to regard endoscopic papillary balloon dilation (EPBD) as a standard procedure for treatment. Therefore, the aim of this review is to re-evaluate the status of EPBD for the treatment of common bile duct stones.

Results

A major benefit of EPBD is preservation of papillary function, which is not complete but may be greater than that after EST. The disadvantages of EPBD compared with EST are that EPBD is difficult to use for the removal of larger stones because of the smaller biliary opening, it requires more frequent use of mechanical lithotripsy, and it is associated with a higher incidence of pancreatitis, although the risks of bleeding and perforation are low. Since the biliary sphincter is easily dilated with a balloon catheter, EPBD may be effective for patients with anatomic anomalies, such as after gastric bypass surgery or in the presence of a periampullary diverticulum. No standard procedure exists to reduce the risk of acute pancreatitis with EPBD.

Conclusion

EPBD is feasible, however, we must pursue less hazardous techniques of papillary balloon dilation. Furthermore, we must understand the benefits and limitations of EPBD and determine whether it could provide clinical benefits for long-term complications.

Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones

BACKGROUND

Lethal pancreatitis has been reported after treatment for common bile duct stones using small endoscopic papillary balloon dilation.

METHODS

We retrospectively evaluated the safety and efficacy of using large balloon dilation alone without the use of sphincterotomy for the treatment of large common bile duct stones in Kaohsiung Veterans General Hospital. Success rate of stone clearance, procedure-related adverse events and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.

RESULTS

A total of 247 patients were reviewed in the current study. The mean age of the patients was 71.2 years. Most of them had comorbidities. Mean stone size was 16.4 mm. Among the patients, 132 (53.4%) had an intact gallbladder and 121 (49%) had a juxtapapillary diverticulum. The mean size of dilating balloon used was 13.2 mm. The mean duration of the dilating procedure was 4.7 min. There were 39 (15.8%) patients required the help of mechanical lithotripsy while retrieving the stones. The final success rate of complete retrieval of stones was 92.7%. The rate of pancreatic duct enhancement was 26.7% (66/247). There were 3 (1.2%) adverse events and 6 (2.4%) intra-procedure bleeding incidents. All patients recovered completely after conservative and endoscopic treatment respectively, and no procedure-related mortality was noted. 172 patients had a follow-up duration of more than 6 months and among these, 25 patients had recurrent common bile duct stones. It was significantly correlated to the common bile duct size (p = 0.036)

CONCLUSIONS

Endoscopic papillary large balloon dilation alone is simple, safe, and effective in dealing with large common bile duct stones in relatively aged and debilitated patients.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients

PURPOSE

To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients.

MATERIALS AND METHODS

During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated.

RESULTS

Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed.

CONCLUSIONS

Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Endoscopic management of biliary ductal stones

Bile duct stone management has greatly changed in the past 2 decades. Open surgical techniques have mostly been replaced by transoral endoscopic techniques. Routine common bile duct stones can be managed by standard biliary endoscopic sphincterotomy and extraction. Various advanced transoral techniques can also manage most difficult ductal stones. In skilled centers, laparoscopic ductal stone management has assumed a back-up role.

Risk factors for recurrent symptomatic pigmented biliary stones after percutaneous transhepatic biliary extraction

PURPOSE

To evaluate risk factors for the recurrence of biliary stones after a percutaneous transhepatic biliary stone extraction.

MATERIALS AND METHODS

The procedures were performed on 339 patients between July 2004 and December 2008 (54 months). Medical records and images were retrospectively reviewed for 135 patients (mean age, 66.4 years; 83 men and 52 women) who had undergone follow-up for a mean of 13.2 months (range, 3-37 months). To evaluate risk factors for the recurrence of biliary stones, variables were evaluated with univariate and multivariate analyses. Variables included sex, age, stone location, number of stones, stone size, presence of a peripapillary diverticulum, application of antegrade sphincteroplasty, presence of a biliary stricture, largest biliary diameter before the procedure, and gallbladder status.

RESULTS

Thirty-three of the 135 patients (24%) had recurrent symptomatic biliary stones and underwent an additional extraction. The mean time to recurrence was 17.2 months +/- 8.7. Univariate analysis of risk factors for recurrence of biliary stones demonstrated that location, number of stones, stone size, application of antegrade sphincteroplasty, presence of a biliary stricture, and biliary diameter were significant factors (P < .05). With use of multivariate analysis, the number of stones (> or =6; relative risk, 64.8; 95% confidence interval: 5.8, 717.6) and stone size (> or =14 mm; relative risk, 3.8; 95% confidence interval: 1.138, 13.231) were determined to be significant risk factors.

CONCLUSIONS

The independent risk factors for recurrence of symptomatic biliary stones after percutaneous transhepatic biliary stone extraction were a stone size of at least 14 mm and the presence of at least six stones.

Sphincter of Oddi laxity: An important factor in hepatolithiasis

AIM: To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).

METHODS: Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups: Group I included 45 patients with SOL, and Group II included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.

RESULTS: The recurrence index was 0.135 in Group I and 0.018 in Group II (P < 0.001). The reoperation index was 0.070 in Group I and 0.010 in Group II (P < 0.001). The mean frequency of biliary operation was 2.07 in Group I and 1.21 in Group II (P = 0.001). Differences between the two groups are significant.

CONCLUSION: HL patients with SOL tend to have a higher risk of recurrence and a larger demand for reoperation than those without this condition.

Efficacy and safety of therapeutic ERCP for the elderly with choledocholithiasis: comparison with younger patients

OBJECTIVE

To clarify the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography for the elderly with choledocholithiasis compared with younger patients.

METHODS

Consecutive therapeutic ERCPs performed between 2005 and 2007 at our institution for 118 patients aged 80 years or older (group A) and 205 patients younger than 80 years old (group B) were retrospectively reviewed. Successful cannulation rate, complete stone clearance rate, complications and prognosis were compared between the two groups.

RESULTS

Successful cannulation was achieved in 99.2% in group A versus 99.5% in group B. The complete stone clearance rate was significantly lower in group A than in group B (92.4% versus 99.0%, p<0.01). Plastic stent placement was performed for patients with incomplete duct clearance. There was no significant difference in the early complication rate between group A (5.5%) and group B (6.6%). Procedure-related mortality did not occur. Cholangitis-free survival was similar between the two groups. The short-term prognosis was comparable between those with complete duct clearance and those with biliary stent placement.

CONCLUSION

With a duct clearance rate of more than 90% and plastic stent placement for patients with poor general condition, therapeutic ERCP for choledocholithiasis in patients 80 years of age or older is comparable in safety and effectiveness to that in younger patients.

Various techniques for the surgical treatment of common bile duct stones: a meta review

Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.

Sequential endoscopic papillary balloon dilatation following limited sphincterotomy for common bile duct stones

Endoscopic papillary balloon dilatation (EPBD) has been recently used in conjunction with endoscopic sphincterotomy (EST) for the removal of common bile duct (CBD) stones. The present study was aimed at assessing the safety and outcome of sequential EPBD following EST for CBD stones. A total of 74 patients (43 females, mean age 41 years) with > or = 10-mm stone(s) in the CBD were selected for the procedure, which included limited EST followed by EPBD with balloon dilators of 10-18 mm in size. Eleven patients had undergone EST and unsuccessful stone removal earlier. Forty-nine patients had symptoms of CBD stones, while 25 were detected on imaging. Eleven patients had previous CBD stent in situ and four had T-tube in situ. The stone size was 10-12 mm in 34, 13-14 mm in 26, and > or = 15 mm in 14 patients. Thirty-one patients had a single stone, while 43 had > or = 2 stones. The successful removal of stones was achieved in 68 (91.9%) patients; 62 in the first attempt, five in the second, and one in the third. Six patients were deemed to be "failures." In two of them, the stones could be removed after mechanical lithotripsy. Complications were seen in 16 patients, with self-limiting pain in 13, self-limiting ooze in five, melaena in one, and mild pancreatitis in two. One patient had impaction of the dormia basket. We conclude that EPBD following EST is safe and effective in removing stones > or = 10 mm in size in over 90% of patients.

Post-sphincterotomy transampullary balloon dilation is a safe and effective technique

PURPOSE

To evaluate the safety and efficacy of performing ampullary balloon dilation (ABD) following endoscopic sphincterotomy (ES).

METHODS

Retrospective review of patients that underwent ABD at Thomas Jefferson University from 2000 to 2007. In all cases, dilation was performed with Hurricane RX hydrostatic balloons (Boston Scientific, Natick MA) or CRE esophageal dilating balloons (Boston Scientific, Natick MA).

RESULTS

ABD following ES was performed in 69 patients. The procedure was performed for choledocholithiasis in 58%, abnormal imaging in 26%, and abnormal liver enzymes in 23% of patients. ABD following ES was 86% successful in achieving the intended therapeutic goal of the procedure. Pancreatitis (2.9%) post endoscopic retrograde cholangiopancreatography (ERCP) occurred in two individuals, with one case of hemorrhage (1.5%) and one perforation (1.5%).

CONCLUSION

ABD following ES is a safe and effective alternative to ES alone, particularly for the extraction of large common bile duct (CBD) stones.

[Common bile duct stones. Diagnostic and therapeutic management]

The best predictors for the presence of common bile duct stones (CBDS) are cholangitis, jaundice, and direct visualization of stones with ultrasound. In the setting of high suspicion of choledocholithiasis, endoscopic retrograde cholangiography (ERC) is indicated because when CBDS are identified, it allows immediate therapy in the same sitting. If there is a moderate probability of choledocholithiasis, endosonography or magnetic resonance cholangiopancreatography are the first-line options. In patients with gallbladder stones and CBDS, preoperative ERC with or without endoscopic sphincterotomy (ES) is widely recommended as a standard approach. The interval between that and laparoscopic cholecystectomy (LC) should be at least 24 h (<6 weeks) to exclude possible complications due to the ERC/ES. In the setting of open cholecystectomy, open bile duct surgery is significantly superior to ERC with sphincterotomy in achieving common bile duct clearance and is the method of choice. Only in centres with advanced laparoscopic expertise is the laparoscopic removal of CBDS an equivalent treatment option.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

Gallstone disease: from genes to evidence-based therapy

The number of gallstone patients is increasing in ageing populations with a high prevalence of metabolic syndrome and obesity. Recently variants of hepatic ATP binding cassette transporters have been identified as genetic susceptibility factors for gallstone disease, pointing to novel means for risk assessment and prevention. Although laparoscopic cholecystectomy is the mainstay of therapy for symptomatic gallbladder stones, the clinical management of gallstone disease is changing rapidly, with an increase in day case surgery and the advent of transluminal endoscopic surgery. Here, we summarize the molecular and genetic mechanisms of gallstone formation as well as the current evidence-based algorithms for diagnosis and therapy of gallbladder and bile duct stones.

Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series

BACKGROUND

The utility and safety of endoscopic biliary orifice balloon dilation (EBD) for bile duct stone removal (with use of large-diameter balloons) after biliary endoscopic sphincterotomy (BES) is currently not well established.

OBJECTIVE

Our purpose was to evaluate the efficacy and complications of BES followed by > or = 12 mm diameter EBD for bile duct stone removal.

DESIGN

Retrospective, multicenter series.

SETTING

Five ERCP referral centers in the United States.

PATIENTS AND INTERVENTIONS

Patients who underwent attempted removal of bile duct stones by BES followed by EBD with > or = 12 mm diameter dilating balloons were identified by searching the prospectively recorded endoscopic databases from 1999 to 2007. Clinical parameters, endoscopic data, and outcomes were collected and analyzed.

RESULTS

One hundred three patients, mean age 70 +/- 17 years (range 23-98 years), with 56 (54%) women, underwent 107 procedures. Eleven patients (11%) had a prior history of acute pancreatitis. Pancreatogram was performed in 15 (14%) patients. Median stone size and median balloon diameter used was 13 mm. Complete stone removal in the first session of EBD was accomplished in 102 (95%) procedures, and mechanical lithotripsy was required in 29 (27%). Six patients (5.4%) had documented procedure-related complications including one patient with severe bleeding and one with severe cystic duct perforation. No acute pancreatitis occurred.

CONCLUSION

EBD with a large-diameter balloon in conjunction with BES for bile duct stone removal is effective and relatively safe. This technique appears to be a reasonable alternative option when standard BES and basket or balloon sweep are inadequate to remove bile duct stones.

Endoscopy in the management of choledocholithiasis

Choledocholithiasis (bile duct stones) occurs in 10% to 15% of patients with cholelithiasis. Endoscopic retrograde cholangiopancreatography and biliary sphincterotomy, combined with the use of a variety of available accessories (eg, mechanical lithotriptors), are highly effective in managing most common bile duct stones. The combination of biliary sphincterotomy and papillary balloon dilation allows removal of many stones without the need for mechanical lithotripsy. Large stones may require additional expertise and the use of cholangioscopy with intraductal lithotripsy. Some patients, especially those with intrahepatic stones, require the help of an interventional radiologist or a biliary surgeon. The availability of endoscopists, radiologists, and surgeons interested in and experienced with biliary diseases will allow successful and safe therapy to be tailored to the individual patient.