Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation (EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography (ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis (PEP). However, as the efficacy of endoscopic papillary large-balloon dilatation (EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy (EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stone removal

BACKGROUND

Endoscopic retrograde cholangiopancreatography is difficult to perform in patients with gastrointestinal tract reconstruction.

AIMS

To evaluate the efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stones in patients with gastrointestinal tract reconstruction.

METHODS

We conducted a retrospective case series with a comparison to historical controls. During the period 2009-2013, 11 postoperative patients underwent endoscopic papillary large-balloon dilatation (Group A). Procedure efficacy and safety were compared with patients who underwent endoscopic sphincterotomy without endoscopic papillary large-balloon dilatation, who served as historical controls (Group B).

RESULTS

Group A consisted of 11 patients (63.6% males, mean age 78±10 years), and Group B consisted of 32 patients (78.1% males, mean age 75±7 years). The stone clearance rate was significantly higher in Group A than in Group B (100% vs. 65.6%, respectively; p<0.05). Median procedure time was significantly shorter in Group A than in Group B (54min vs. 102min, respectively; p<0.05), and the complication rate was not significantly different between groups (18% vs. 15.6%, respectively; p=0.586).

CONCLUSION

Endoscopic papillary large-balloon dilatation may be an effective and safe treatment procedure in patients with gastrointestinal tract reconstruction.