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 fortyone articles dealing with CBD stone extraction with12 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.

Usefulness of the Hook knife in flexible endoscopic myotomy for Zenker's diverticulum

AIM To investigate the outcome of flexible endoscopic myotomy performed with the Hook knife in patients with symptomatic Zenker's diverticulum(ZD).METHODS All consecutive patients treated for ZD at our institution between 7/2012 and 12/2016 were included.The flexible endoscopic soft diverticuloscope-assisted technique with endoclips placement and Hook knife myotomy were performed in all patients.Here we report a retrospective review of prospectively collected data.Demographics,dysphagia score(Dakkak and Bennett),associated symptoms and adverse events were collected pre-procedure,at 2 and 6 mo post-procedure,and at the end of the follow-up period.Clinical success was defined as at least 1-point improvement in dysphagia score and a residual dysphagia score≤1,with no need for reintervention.Dysphagia scores were compared before treatment and at end-of-follow-up using the Wilcoxon test.RESULTS Twenty-four patients were included.Mean size of ZD was 3.0 cm(range 2-8 cm).Mean number of sessions was 1.17/patient(range 1-3 sessions).Overall clinical success was 91.7%.Two adverse events(8.3%) occurred,and both were managed conservatively.No bleeding or perforation was reported.Mild pain was reported by 9 patients(37.5%).Median hospital stay was 1 d(range 1-6).Median follow-up was 19.5 mo(range 6-53).Mean ± SD dysphagia score was 2.25±0.89 before treatment and decreased to 0.41 ± 0.92 at end-of-follow-up(P<0.001).Regurgitation and cough dropped from 91.7% and 50% to 12.5% and 0% at the end of follow-up,respectively.Recurrence was observed in 3 patients,and all 3 were symptom-free after one more session.CONCLUSION The Hook knife,used in the soft diverticuloscope-assisted technique setting,is efficient and safe for treatment of ZD.