Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Could saline irrigation clear all residual common bile duct stones after lithotripsy?A self-controlled prospective cohort study

BACKGROUND A previous study showed that irrigation with 100 mL saline reduced residual common bile duct(CBD)stones,which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIM To determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODS This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large(>1.2 cm)CBD stones.After occlusion cholangiography confirmed CBD stone clearance,peroral cholangioscopy(POC)was performed to determine clearance scores based on the number of residual stones.The amounts of residual stones spotted via POC were graded on a 5-point scale(score 1,worst;score 5,best).Scores were documented after only stone removal(control)and after irrigation with 50 mL and 100 mL saline,respectively.The stone composition was analyzed using infrared spectroscopy.RESULTS Between October 2018 and January 2020,47 patients had CBD clearance scores of 2.4±1.1 without saline irrigation,3.5±0.7 with 50 mL irrigation,and 4.6±0.6 with 100 mL irrigation(P<0.001).Multivariate analysis showed that CBD diameter>15 mm[odds ratio(OR)=0.08,95%confidence interval(CI):0.01-0.49;P=0.007]and periampullary diverticula(PAD)(OR=6.51,95%CI:1.08-39.21;P=0.041)were independent risk factors for residual stones.Bilirubin pigment stones constituted the main residual stones found in patients with PAD(P=0.004).CONCLUSION Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy,especially in patients with PAD and/or a dilated(>15 mm)CBD.Pigment residual stones are soft and commonly found in patients with PAD.Additional saline irrigation may be required to remove retained stones.