The increase in balloon size to over 15 mm does not affect the development of pancreatitis after endoscopic papillary large balloon dilatation for bile duct stone removal

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Long-term outcomes of endoscopic papillary large-balloon dilation (12-15 mm) with or without limited sphincterotomy for removal of bile duct stones

BACKGROUND

Limited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12-15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones.

METHODS

Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed.

RESULTS

Basic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up was 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357-6.640; P = 0.007) was an independent risk factor for stone recurrence.

CONCLUSIONS

The application of a large balloon (12-15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal

BACKGROUND

Stone removal using endoscopic papillary large balloon dilation (EPLBD) is extremely effective. However, limited research exists regarding the risk factors for perforation of the duodenal papilla and bile duct, which may be fatal.

AIMS

We aimed to investigate the risk factors for perforation during EPLBD + stone removal.

METHODS

We included patients who underwent EPLBD + stone removal at four medical facilities between January 2008 and December 2018. We retrospectively analyzed the risk factors for perforation and their relationship between overdilation and adverse events. Overdilation was defined as a ratio of the balloon diameter to the diameter of the bile duct that exceeded 100%. The diameter of the distal bile duct was measured using the diameter of the intrapancreatic bile duct at a point 10 mm toward the liver from the narrow distal segment on a cholangiogram.

RESULTS

We included 310 patients (177 males; median age: 79 years [range: 46-102 years]). Perforation occurred in five patients (1.6%). Multivariate analysis indicated that no surrounding-pancreas (half or less of the circumference of the intrapancreatic bile duct was surrounded by the pancreatic parenchyma) was a significant risk factor (perforation rate: 8.3%, p = 0.011, odds ratio: 12.7 [95% confidence interval: 1.8-90.5]). No significant difference was found between the overdilation and non-overdilation groups regarding the occurrence of pancreatitis, bleeding, and cholangitis. Perforation rate in patients with no surrounding pancreas + overdilation was 16.7% (2/12). Patients with perforation underwent conservative therapy, which improved their conditions.

CONCLUSIONS

EPLBD + stone removal should be avoided in patients with no surrounding pancreas. Overdilation is not a risk factor for adverse procedural events; however, it should be limited in patients with surrounding pancreas.

Comparison of endoscopic balloon dilatation potency using balloons size more or less than 15 mm in the treatment of large bile duct stones: a clinical trial study

AIM

The present study was performed on patients with large bile duct stones to compare clinical outcomes and complications of balloon dilatation treatment between two sizes of balloons, < 15 mm and ≥ 15 mm.

BACKGROUND

in 1982, the endoscopic papillary balloon dilatation (EPBD) method was presented by Staritz to reduce bleeding and perforation risk of large bile duct stones.

METHODS

Patients with large bile duct stones admitted to Taleghani hospital from December 2018 to December 2019 who were the candidates for balloon dilation with limited sphincterotomy. Patients were randomly divided into two groups. In group B, a ≥ 15 mm balloon was used, and in group A, a balloon <15 mm was used. The clinical results of balloon dilation and its complications were recorded and compared.

RESULTS

Most patients had 1 or 2 large bile duct stones, and there was no significant difference in the number of stones. Extraction was successful in 92.8% of group B and 85.7% of group A without significant differences (P = 0.8). Pancreatitis, hemorrhage, cholangitis, and perfusion occurred in 8%, 4.2%, 1.4%, and 2.8% of group B subjects and also in 10%, 2.8%, 0%, and 1.4% of group A subjects, respectively, and the difference between the two groups was not significant.

CONCLUSION

Generally, this study results showed that balloon size did not have a significant effect on the success rate of bile duct stones. Moreover, considering the lack of significant association between balloon dilatation size and the occurrence of post-endoscopic complications such as pancreatitis, it seems that large-size dilatation has no serious clinical risk.

Acute pancreatitis after percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer

AIM

To investigate the incidence and clinical characteristics of acute pancreatitis following percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer. The clinical efficacy of metallic stent insertion was also evaluated.

MATERIALS AND METHODS

Data from 143 patients (75 men, 68 women; mean age, 65.8 years; range, 35-88 years) with unresectable pancreatic cancer who underwent percutaneous metallic biliary stent insertion between March 2007 and December 2017 were evaluated retrospectively. The incidence and clinical characteristics of acute pancreatitis were analysed. Stent patency and patient survival rates were calculated by Kaplan-Meier analysis.

RESULTS

Technical success was achieved in all patients. Among 31 patients with serum amylase levels above normal values (30-110 U/l), only nine had symptoms of acute pancreatitis (incidence, 6.4%). No statistically significant risk factors were identified. Pancreatitis was successfully managed with conservative treatment at a mean of 2.9 days (range, 1-4 days). The median stent patency and patient survival times were 117 days (95% confidence interval [CI], 87-148 days) and 150 days (95% CI, 125-174.9 days), respectively.

CONCLUSIONS

Acute pancreatitis was a relatively rare complication after percutaneous insertion of metallic biliary stents in patients with unresectable pancreatic cancer, and no significant risk factors were identified. Therefore, insertion of metallic biliary stents was seen to be a feasible and effective treatment approach in this patient group.

Sustained bile drainage decreases the organs injuries via inflammation-associated factors modulation in a severe acute pancreatitis rat model

The timely and effective treatment for severe acute pancreatitis (SAP) is favorable to prognosis. Decompression of the bile duct might be a feasible way to decrease the progression of SAP. The present study investigated the effects of sustained bile external drainage on organs injury caused by SAP in Sprague-Dawley (SD) rats and the mechanisms involved. A total of 72 female SD rats weighting 190-230 g were randomly divided into four groups (n=18): Sham operation group (SOG), SOG + bile drainage group (BDG), SAP group, and SAP + BDG. Sodium taurocholate solution (4%; 1 mg/kg body weight) was used to set up SAP model via injection of retrograde puncture of biliopancreatic duct through the duodenum. A cannula was inserted into the bile duct and fixed externally to establish BDG model. At each time points (t=3, 6, 12; n=6), tissues from the liver, lung, and pancreas, and blood samples were collected. Serum amylase (AMY) was analyzed in all the samples. The levels of tumor necrosis factor-α (TNF-α), heme oxygenase-1 (HO-1), interleukin-10 (IL-10) and high mobility group box 1 (HMGB1) were detected by ELISA. Hematoxylin-eosin staining was performed to observe the histopathological changes, and nuclear transcription factor (NF)-κB-p65 levels in the pancreas were analyzed by western blotting. The data indicated that BDG alleviated the SAP progression and multiple organs injuries. Meanwhile, the histopathological changes of the pancreas, liver, and lungs were improved by BDG. BDG decreased the pathological scores of pancreas significantly (P<0.05). The levels of AMY, TNF-α, HMGB1, and NF-κB-p65 were significantly downregulated by BDG (P<0.05), while the level of HO-1 was upregulated and IL-10 was unchanged. In summary, BDG may attenuate the multiple organs injuries caused by SAP via downregulation of TNF-α, HMGB1, NF-κB-p65 and upregulation of HO-1.

Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones

BACKGROUND AND AIM

endoscopic papillary large balloon dilatation (EPLBD) is increasingly accepted as an appropriate option for the management of difficult common bile duct stones (CBDS). This study aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) for the extraction of difficult CBDS.

PATIENTS AND METHODS

a total of 40 patients were recruited with obstructive jaundice and dilated CBD (≥ 10 mm) subsequent to a single large CBDS of ≥ 10 mm or multiple stones (≥ 3). All patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) with limited sphincterotomy and large balloon dilatation followed by stone extraction using an extraction balloon or dormia basket, without lithotripsy, stenting or further ERCP sessions.

RESULTS

successful stone extraction was achieved in 34 patients (85%) and stone extraction failure occurred in six patients (15%). Complications included minimal pancreatitis in four cases (10%), mild pancreatitis in two cases (5%), cholangitis in two cases (5%) and bleeding in two cases (5%). There were no recorded cases of perforation or mortality subsequent to the procedure.

CONCLUSION

EPLBD is a safe and efficient procedure for the extraction of difficult CBDS and may be advisable in patients with a bleeding risk or abnormal papillary anatomy.

Comparison of the Long-Term Outcomes of Endoscopic Papillary Large Balloon Dilation Alone versus Endoscopic Sphincterotomy for Removal of Bile Duct Stones

BACKGROUND AND AIMS

Endoscopic papillary large balloon dilation (EPLBD) alone is an alternative to endoscopic sphincterotomy (EST) for treatment of common bile duct (CBD) stones. However, limited data exists regarding comparison of the long-term outcomes for these techniques. In this study, we compared the long-term outcomes after EST with those after EPLBD alone for removal of CBD stones.

METHODS

The records of patients with EST or EPLBD alone referred for CBD stones retrieval between June 2008 and July 2015 were retrospectively reviewed. Complete stone clearance, ERCP-related adverse events, and late biliary complications during long-term follow-up were analyzed.

RESULTS

Basic patient characteristics were similar between the groups that underwent EST (n = 60) and EPLBD alone (n = 161). EPLBD compared with EST resulted in similar outcomes in terms of complete stone clearance (99.4% versus 100%, P = 0.54) and ERCP-related adverse events (6.8% versus 6.7%, P = 1.00). The mean duration of the follow-up was 74.5 months and 71.6 months who underwent EST and EPLBD alone, respectively (P = 0.42). Late biliary complications were occurred frequently in the EST group than in the EPLBD alone group (11 [18.6%] versus 16 [10.2%]), although the difference did not reach statistical significance (P = 0.11). Multivariate analysis showed that mechanical lithotripsy ([OR], 2.815; 95% CI, 1.148-6.902; P = 0.024) was significantly associated with late biliary complications.

CONCLUSION

As an alternative to EST, EPLBD has similar efficacy and safety for managing CBD stones. During long-term follow-up, patients who underwent EPLBD alone may have fewer late biliary complications compared with those after EST. In addition, mechanical lithotripsy may be an independent risk factor for late biliary complications.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation

The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.

Clinical utility of 0.025-inch guidewire VisiGlide2TM in the endoscopic retrograde cholangiopancreatography-related procedures

AIM

To examine the result of the use of 0.025-inch guidewire (GW) VisiGlide2^TM as the first choice in the endoscopic retrograde cholangiopancreatography (ERCP)-related procedures without selecting the patient in a multicenter prospective study.

METHODS

ERCP using 0.025-inch GW VisiGlide2^TM as the first choice was conducted in patients who have needed ERCP, and its accomplishment rate of procedure, procedural time, incidence of accidental symptoms were compared with those of ERCP using 0.025-inch GW VisiGlide^TM.

RESULTS

The accomplishment rate of procedure was 97.5% (197/202), and procedural time was 23.930 ± 16.207 min. The accomplishment rate of procedure using 0.025-inch GW VisiGlide^TM was 92.3% (183/195), and procedural time was 31.285 ± 19.122 min, thus the accomplishment rate of procedure was significantly improved and procedural time was significantly shortened (P < 0.05). Accidental symptoms by ERCP-related procedures were observed in 3.0% (6/202), and all were conservatively alleviated.

CONCLUSION

When 0.025-inch GW VisiGlide2^TM was used for ERCP-related procedure as the first choice, it showed high accomplishment rate of procedure and low incidence of accidental symptoms, suggesting it can be used as the universal GW. Clinical Trial Registry (UMIN0000016042).

Efficacy and safety of endoscopic papillary balloon dilation for the removal of bile duct stones: Data from a “real-life” multicenter study on Dilation-Assisted Stone Extraction

AIM

To report data on Dilation-Assisted Stone Extraction (DASE) use in clinical practice and its efficacy and safety trough three Italian referral centers for biliopancreatic diseases treatment.

METHODS

From January 2011 to December 2015 we collected data on 120 patients treated with DASE. Technical success was obtained when the endoscopist was able to place the balloon trough the papilla inflating the balloon until the final diameter for an adequate time (at least 30 s). Clinical success was obtained after complete stone removal (no remaining stones were visible at the cholangiogram).

RESULTS

Forty-nine male (40.8%) and 71 female (59%) were enrolled. The mean age was 67.8 years ± 15.7. The mean common bile duct (CBD) dilation was 19.2 mm ± 3.9 and the mean size of stones 15.8 ± 2.9. DASE was applied as first approach in 38% (62% after initial failure of stones extraction). Technical and clinical success was of 91% and 87% respectively. In those in which DASE failed alternative treatment were adopted. After DASE 18% of patients experienced a complication (bleeding 9%, pancreatitis 8%, perforation 0.8%). At univariable analysis, elective endoscopic retrograde cholangiopancreatography (P = 0.031), DASE as first approach (P = 0.032), and cannulation of major papilla followed by guidewire insertion (P = 0.004) were related to low risk of complications. Pre-cut was related to an increased risk of complications (P = 0.01).

CONCLUSION

DASE allowed a higher first-session success rate and can be consider a valid alternative to endoscopic sphincterotomy not only for bigger CBD stones.

Endoscopic Papillary Large Balloon Dilatation Without Sphincterotomy for the Treatment of Large Common Bile Duct Stone: Long-Term Outcomes at a Single Center

BACKGROUND

Endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy (EST) is an accepted, simplified endoscopic technique for large common bile duct (CBD) stone removal. However, little is known about the long-term outcomes of this technique. The purpose of this study was to evaluate the long-term outcomes of EPLBD without EST for the treatment of large CBD stones.

METHODS

This retrospective study of EPLBD without EST for a large CBD stone was conducted between June 2005 and October 2010. A total of 128 patients with a large CBD stone were included. The primary outcome measurement was complete CBD stone removal after EPLBD. Clinical data obtained from medical records were analyzed.

RESULTS

The overall complete stone removal rate was 94.5 %. Mechanical lithotripsy was needed in 18 (14.1 %) patients. Post-procedural pancreatitis and asymptomatic hyperamylasemia occurred in 1 (0.8 %) and 11 (8.6 %) patients, respectively. One (0.8 %) patient experienced minor bleeding. The rate of stone recurrence was 13.1 %, and median time to stone recurrence was 600 days (range 144-2284 days). Over a half (64.3 %) of stone recurrences occurred during the 2 years following stone removal. Recurrence tended to be more frequent in patients with a large CBD diameter and in patients requiring multiple endoscopic sessions for complete CBD stone retrieval.

CONCLUSION

EPLBD without EST may be safe and effective in patients with a large bile duct stone.

Is endoscopic papillary large balloon dilation safe for treating large CBD stones?

In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. Recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.

Effects Comparison between Endoscopic Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy for Common Bile Duct Stone Removal

Endoscopic sphincterotomy (EST) is a treatment of choice for stone extraction and is now most frequently used. The study was to compare the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and endoscopic sphincterotomy (EST) for common bile duct stone removal. Trials comparing the effects between EPLBD and EST treatment were searched according to the study protocol. Overall stone removal rate, complete removal rate in 1st session, treatment duration, mechanical lithotripsy using rate, and overall complication rate were compared using risk ratio (RR) and mean difference (MD) and their 95% confidence interval (CI) via RevMan 5.2 software. For overall stone removal rate, two therapies showed similar effect, but EPLBD showed better overall stone removal rate for stone >10 mm in diameter. For complete stone removal rate in 1st session, no difference was found, even for those with stone >10 mm in diameter; EPLBD showed longer treatment duration, higher mechanical lithotripsy using rate obvious overall complications rate, and more serious bleeding, whereas there were no significant differences for perforation, hyperamylasemia, pancreatitis, and cholecystitis/cholangitis. EPLBD showed better efficacy in certain conditions compared to EST, however with shortcomings, such as more duration, higher mechanical lithotripsy using rate, more serious overall complications rate, and bleeding.

Is endoscopic papillary large balloon dilatation without endoscopic sphincterotomy effective?

AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy in a prospective study.

METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with naïve papillae prospectively. For sphincteroplasty of EPLBD, endoscopic sphincterotomy (EST) was not performed, and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter (ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.

RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and 16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4 mm, and the mean number of stones was 3.0 ± 2.4. Complete stone removal was achieved in 97.5% (40/41) of cases, and ML was used in 12.2% (5/41) of cases. The mean number of sessions required was 1.2 ± 0.62. Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was 73.1% (30/41). No significant differences were noted in procedure time, rate of complete stone removal (100% vs 100%), number of sessions (1.1 vs 1.3, P = 0.22), application of ML (13% vs 9%, P = 0.71), or occurrence of pancreatitis (3.3% vs 9.1%, P = 0.45) between cases with and without balloon waist disappearance.

CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis. ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation (EPLBD) with a size of 15 mm. Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla. Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis. Therefore, we placed a 10 mm fully covered self-expandable metallic stent (SEMS) across the duodenal papilla, and the hemorrhage stopped immediately. After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct. A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct. We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.

Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial

BACKGROUND/AIMS

Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for the treatment of common bile duct (CBD) stones. However, there is no established consensus on the optimal balloon dilation duration (BDD). We prospectively evaluated the efficacy and post-endoscopic retrograde cholangiopancreatography (ERCP) complications between the 20- and 60-second EPBD groups.

METHODS

A total of 228 patients with small CBD stones (≤12 mm) were randomly assigned to undergo EPBD with a 20- or 60-second duration at six institutions. We evaluated baseline patient characteristics, endoscopic data, clinical outcomes, and procedure-related complications. In addition, we analyzed risk factors for postprocedural pancreatitis.

RESULTS

CBD stones were removed successfully in 107 of 109 patients (98.1%) in the 20-second group and in 112 of 119 patients (94.1%) in the 60-second group (p=0.146). Post-ERCP pancreatitis developed in seven patients (6.4%) in the 20-second group and nine patients (7.5%) in the 60-second group (p=0.408). In multivariate analysis, contrast dye injection into the pancreatic duct is a significant risk factor for post-EPBD pancreatitis.

CONCLUSIONS

Based on the data showing that there were no significant differences in safety and efficacy between the two BDD groups, 20 seconds of BDD may be adequate for treatment of small CBD stones with EPBD.

Mid-term outcome of endoscopic sphincterotomy combined with large balloon dilation

BACKGROUND AND AIM

Endoscopic sphincterotomy (ES) combined with large balloon dilation (ESLBD) can be useful for extracting large and multiple bile duct stones. Although there are many studies on the feasibility and short-term outcome, there are few reports about mid- to long-term outcome after ESLBD. The aim of our study is to prospectively evaluate the mid-term outcome of ESLBD.

METHODS

One hundred eighty-three patients who underwent ESLBD between November 2006 and May 2012 were included. The patients were followed up periodically after the procedure until April 2013. Papillary dilation was performed at the time of initial ES or prior ES. Early and late adverse events and stone recurrence were evaluated in this study.

RESULTS

The patients' mean age was 76.6 ± 10.7 years. Surgically altered anatomy was present: Billroth I gastrectomy (2), Billroth II gastrectomy (13), and gastrectomy with Roux-en Y reconstruction (18). Seventy-eight (42.6%) patients had periampullary diverticulum. Prior ES had been performed in 40 (21.9%) patients. The mean follow-up period was 43.5 ± 19.7 months (range 11-78). Eight (4.4%) patients had stone recurrence. There was rare stone recurrence after initial ESLBD treatment and native gastrointestinal anatomy. Univariate and multivariate analyses showed that prior ES and previous history of stone recurrence were predictive of stone recurrence (P < 0.001).

CONCLUSION

At mid-term outcome, ESLBD is associated with a low rate of recurrent bile duct stones, although long-term follow up is needed.

Small sphincterotomy combined with endoscopic papillary large balloon dilation vs sphincterotomy alone for removal of common bile duct stones

AIM: To evaluate the efficacy and safety of endoscopic papillary large diameter balloon dilation (EPLBD) following limited endoscopic sphincterotomy (EST) and EST alone for removal of large common bile duct (CBD) stones.

METHODS: We retrospectively compared EST + EPLBD (group A, n = 64) with EST alone (group B, n = 89) for the treatment of large or multiple bile duct stones. The success rate of stone clearance, procedure-related complications and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.

RESULTS: There was no statistically significant difference between the two groups regarding periampullary diverticula (35.9% vs 34.8%, P > 0.05), pre-cut sphincterotomy (6.3% vs 6.7%, P > 0.05), size (12.1 ± 2.0 mm vs 12.9 ± 2.6 mm, P > 0.05) and number (2.2 ± 1.9 vs 2.4 ± 2.1, P > 0.05) of stones or the diameters of CBD (15.1 ± 3.3 mm vs 15.4 ± 3.6 mm, P > 0.05). The rates of overall stone removal and stone removal in the first session were not significantly different between the two groups [62/64 (96.9%) vs 84/89 (94.4%), P > 0.05; and 58/64 (90.6%) vs 79/89 (88.8%), P > 0.05, respectively]. The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia were not significantly different between the two groups [3/64 (4.7%) vs 4/89 (4.5%), P > 0.05; 7/64 (10.9%) vs 9/89 (10.1%), P > 0.05, respectively]. There were no cases of perforation, acute cholangitis, or cholecystitis in the two groups. The rate of bleeding and the recurrence of CBD stones were significantly lower in group A than in group B [1/64 (1.6%) vs 5/89 (5.6%), P < 0.05; 1/64 (1.6%) vs 6/89 (6.7%), P < 0.05, respectively].

CONCLUSION: EST + EPLBD is an effective and safe endoscopic approach for removing large or multiple CBD stones.

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

One-step transfistula large versus conventional balloon dilation following precut fistulotomy in difficult biliary cannulation for the removal of biliary stones: a multicenter retrospective study

BACKGROUND AND AIM

After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones.

METHODS

This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications.

RESULTS

A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation (P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation (P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively (P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307).

CONCLUSIONS

One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation.

Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones: A literature review

Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (≥ 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: A meta-analysis

AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm).

METHODS: PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P≤ 0.1 and I² with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias.

RESULTS: Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92).

CONCLUSION: EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone

Background/Aims

Between endoscopic sphincterotomy (ES) alone and combined endoscopic sphincterotomy and large balloon dilation (ES-LBD) groups, efficacy and long-term complications, difference in biliary stone recurrence rate, and risk factors of stone recurrence were compared.

Methods

Medical records of 222 patients who underwent ERCP for biliary stone removal were retrospectively reviewed. Patients with dilated CBD ≥11 mm and follow-up longer than 6 months were included.

Results

There were 101 patients in ES-LBD group and 121 patients in ES group. Mean follow-up duration was 25.0 (6-48) months and 13.0 (6-43) months, respectively (p=0.001). There was no difference in number of ERCP sessions, brown pigment stones, angle between mid and distal common bile duct (CBD angle) <135°, and lithotripsy rate. Complete retrieval success rate was excellent in both groups (100% vs. 99%). Early complication rate of ES-LBD and ES alone group was 4 and 4.1%, respectively (p=1.000). One patient in ES-LBD group died from delayed bleeding. Late complication rate was 5.9 and 3.3%, respectively (p=1.000). Stone recurrence rate was 6.9% and 5.8%, respectively (p=0.984). The only Independent risk factor of stone recurrence was presence of periampullary diverticulum.

Conclusions

Late complication and stone recurrence rates were similar between ES-LBD and ES alone groups.

Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis

OBJECTIVES

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.

METHODS

A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.

RESULTS

A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).

CONCLUSIONS

ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: a single center experience

BACKGROUND

Endoscopic treatment of difficult common bile duct (CBD) stones (diameter ≥ 10 mm, or four or more) is difficult in patients who have undergone Billroth II (B-II) gastrectomy. Endoscopic sphincterotomy (EST) can be particularly troublesome due to anatomical changes effected by the gastrectomy.

AIM

We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with large-diameter dilation balloons in the treatment of difficult CBD stones in patients who have undergone B-II gastrectomy.

MATERIALS AND METHODS

From June 2006 to April 2011, patients with difficult CBD stones and who had undergone B-II gastrectomy previously were included in this study. EPLBD was performed with a 10-18 mm balloon catheter. When selective cannulation through the sphincter was possible, EPLBD was performed without EST. EPLBD was otherwise performed after fistulotomy with needle knife.

RESULTS

A total of 40 patients (32 male) underwent EPLBD for the retrieval of CBD stones, and concurrent fistulotomy was performed in seven patients. The median diameter of CBD was 13 mm (range 10-20 mm) and the balloon was 12 mm (range 10-17 mm). CBD stones were successfully removed in all patients. In only three patients, repeated sessions of ERCP were required for complete removal of CBD stones. Mechanical lithotripsy was required in only one case. Acute complications from EPLBD included mild pancreatitis in two patients (5.0 %). Severe complications, including perforation and bleeding, were not observed. Late complications included stone recurrence in one patient (2.5 %) and cholecystitis in four patients (10.0 %).

CONCLUSIONS

In cases of B-II gastrectomy, EPLBD without EST is a safe and highly effective technique for the retrieval of difficult CBD stones. EPLBD should be considered as an alternative tool to conventional EST.

Endoscopic sphincterotomy plus balloon dilation versus endoscopic sphincterotomy for choledocholithiasis: A meta-analysis

BACKGROUND AND AIM

Endoscopic sphincterotomy (EST) alone and EST combined with balloon dilation (ESBD) are important endoscopic techniques for stone extraction. We were to conduct a meta-analysis to compare the efficacy and safety of ESBD and EST.

METHODS

Meta-analysis was performed respectively on randomized controlled trials (RCTs) and nonrandomized studies comparing the efficacy and safety of ESBD and EST.

RESULTS

The results of three RCTs showed that stone removal in first session (relative risk [RR] 1.01, 0.92-1.11, P=0.85) and the utility of endoscopic mechanical lithotripsy (EML) (RR 0.78, 0.49-1.23, P=0.29) were equivalent between ESBD and EST. ESBD has equivalent complications (RR 0.61, 0.17-2.25, P=0.46) and post-ERCP pancreatitis (Peto odds ratio [OR] 1.11, 0.37-3.35, P=0.86), but less bleeding (Peto OR 0.10, 0.03-0.30, P<0.0001). The analysis of six retrospective studies suggested higher initial success in stone removal (RR 1.11, 1.02-1.20, P=0.01) and less EML (RR 0.32, 0.22-0.46, P<0.00001) in ESBD group. Less complications (RR 0.60, 0.44-0.83, P=0.02) happened in ESBD group, but equivalent post-ERCP pancreatitis (Peto OR 0.65, 0.37-1.15, P=0.14) and bleeding (Peto OR 0.60, 0.29-1.26, P=0.18). For patients with stones ≥ 15 mm, ESBD required less EML (RR 0.35, 0.24-0.51, P<0.00001) and caused fewer complications (RR 0.67, 0.38-0.92, P=0.02).

CONCLUSIONS

ESBD is feasible for the treatment of choledocholithiasis without increased risk of complications, causing less bleeding. However, it warrants more clinical trials to compare the efficacy and safety of ESBD and EST.

Genetics and treatment of bile duct stones: new approaches

PURPOSE OF REVIEW

The global burden of gallstones is increasing. Although the gallbladder is the most common site for gallstone formation, 10-25% of patients display concurrent gallbladder and bile duct stones. Secondary stones are differentiated from primary stones that develop de novo in the biliary tree. Overall, the natural history of bile duct stones is less well defined and their diagnosis and treatment are more complex as compared to gallbladder stones.

RECENT FINDINGS

Elevated liver function tests are not always reflective of bile duct stones, and noninvasive diagnosis by endoscopic ultrasound or MRI should be pursued in ambiguous cases. For treatment, recent studies report endoscopic dilation to result in similar clearance but lower complication and recurrence rates as with sphincterotomy. Pharmacological adjuvants such as ursodeoxycholic acid with sphincterotomy and stenting have been suggested for elderly patients. Indication and timing of cholecystectcomy after endoscopic treatment of bile duct stones is critical, and early cholecystectomy within 3-7 days prevents recurrent biliary events.

SUMMARY

In this review we address the pathophysiology of bile duct stones and present the latest developments in the diagnosis and treatment of this challenging condition, with a consideration of stone recurrence.

Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience

AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.

METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon^®, Cook Ireland Ltd. and CRE^®, Microvasive, Boston Scientific Co., Natick, MA, United States).

RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.

CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.

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.

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 papillary large balloon dilation: guidelines for pursuing zero mortality

Since endoscopic papillary large balloon dilation (EPLBD) is used to treat benign disease and as a substitute for conventional methods, such as endoscopic sphincterotomy plus endoscopic mechanical lithotripsy, we should aim for zero mortality. This review defines EPLBD and suggests guidelines for its use based on a review of published articles and our large-scale multicenter retrospective review.

Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials

BACKGROUND

Endoscopic sphincterotomy (EST) is the most frequently used technique for removal of stones from the bile duct. In recent years, endoscopic papillary large balloon dilation (EPLBD) has been shown to be a safe and effective technique for the removal of large or difficult common bile duct stones. However, comparison of EPLBD and EST for effectiveness in bile duct stone removal has given inconsistent results. The present meta-analysis was carried out to compare the effect of EPLBD and EST in retrieval of choledocholithiasis.

METHODS

A literature search was performed using Medline, PubMed, EMBase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published in English. A meta-analysis was performed on the retrieved studies.

RESULTS

Seven randomized controlled trials and 790 patients were involved. EPLBD compared with EST resulted in similar outcomes for overall successful clearance rates of bile duct stones (97.35 vs. 96.35%, OR 1.28, 95% CI 0.58-2.82, P = 0.54), stone clearance in the first ERCP session (87.87 vs. 84.15%, OR 1.31, 95% CI 0.81-2.11, P = 0.21) and removal of large sized stones (OR 1.08, 95% CI 0.21-5.64, P = 0.49). EPLBD performed with either a short or a long ballooning time did not increase the bile duct stone clearance rate. EPLBD decreased overall usage of mechanical lithotripsy in the bile duct stone removal process (OR 0.51, 95% CI 0.30-0.86, P = 0.01). However, no significant difference was found between EPLBD and EST in the use of mechanical lithotripsy for the removal of large sized stones (OR 0.67, 95% CI 0.34-1.28, P = 0.22). Compared with EST, EPLBD did not show a short ERCP duration (WMD -0.75, 95% CI -1.57 to 0.08, P = 0.08). EPLBD was associated with fewer overall complications than EST (5.8 vs. 13.1%, OR 0.41, 95% CI 0.24-0.68, P = 0.0007). Hemorrhage occurred less frequently with EPLBD than with EST (OR 0.15, 95% CI 0.04-0.50, P = 0.002). There was no significant difference in post-ERCP pancreatitis, perforation and cholangitis.

CONCLUSIONS

EPLBD is an effective and safe method for the removal of large or difficult common bile stones. EPLBD should be considered as an alternative to EST for patients in whom EST could not be routinely performed. Based on EPLBD causing fewer cases of hemorrhaging, EPLBD is also recommended for removal of large or difficult common bile duct stones in patients with an underlying coagulopathy or need for anticoagulation following ERCP. The long-term prognosis of EPLBD need to be further investigated.