Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP),with its clinical ad-vantages of less trauma and faster recovery,has become the primary treatment for choledocholithiasis.AIM To investigate the effects of different ERCP procedures on the sphincter of Oddi.METHODS The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively.The patients were divided into endoscopic sphinc-terotomy(EST,n=24)and endoscopic papillary balloon dilation(EPBD,n=67)groups.The duration of operation,pancreatic development,pancreatic sphinc-terotomy,intubation difficulties,stone recurrence,and incidence of reflux cho-langitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction in the EST and EPBD groups.RESULTS Differences in hypertension,diabetes,increased bilirubin,small diameter of the common bile duct,or ampullary diverticulum between the two groups were not significant.Statistically significant differences were observed between the two groups concerning sex and age(<60 years).Patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group.The number of cases of pancreatic development,pancreatic duct sphincterotomy,and difficult intubation were higher in the EST group than in the EPBD group.The number of Oddi’s sphincter manometries,ERCP surgical outcomes,and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group.The numbers of stone recurrences,reflux cholangitis,and cholecystitis were higher in the EST group than in the EPBD group.CONCLUSION In summary,common bile duct stones,pancreatitis history,and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD.Based on this evidence,this study can provide actionable insights for clinicians and researchers.

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 were 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 unnec-essary.A diameter of CBD≥15 mm is a risk factor of stone recurrence.

New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation

AIM： To retrospectively investigate the effect and safety of various new type precut sphincterotomy techniques （VNTPST） in endoscopic retrograde cholangiopancreatography （ERCP） due to difficult biliary duct cannulation （DBC）. METHODS： A plough-like pull-type sphincterotome （PLPTS） or improved short nose sphincterotome or improved needle knife was applied. VNTPST was carried out in 30 of 280 patients, whose biliary tract could not be exposed well or deep cannulation was difficult to perform during ERCP with traditional methods. Patients were followed up for short-term complications and the therapeutic effect of VNTPS was observed and compared with that of traditional endoscopic sphincterotomy （EST）. RESULTS： A total 280 patients underwent ERCP, of which 3 failed in operation because of pathological features in stomch or duodenum, 247 successfully underwent traditional ERCP （89.1%, 247/277）, 30 failed （10.8%, 30/277）. VNTPS technique succeeded in 24 （80%, 24/30） of 30 cases. The successful rate of deep biliary duct cannulation increased 8.6% （24/277）, the total cannulation successful rate following precut was 97.7%. There was a significant difference between the two groups （97.7% vs 89.1%, x^2= 17.1, P 〈 0.01）. The incidence of complications was 9.3% （26/277） for traditional ERCP group and 13.3% （4/30） for VNTPS technique group. Guideline tip was broken in pancreatic duct （KPDGP） of one patient, and there was no pancreatitis, slight or moderate bleeding postoperatively occurred in 2 patients, 1 patient had bleeding during operation （PDWN）. There were no differences between VNTPS technique group and traditional ERCP（TRERCP）group （13.3% vs 9.3%, %2 = 0.478, P 〉 0.05）. CONCLUSION： VNTPS procedure and Deng＇s precut are highly effective methods to get biliary access during ERCP with DBC. With skillful techniques, it can increase the successful rate for deep cannulation of biliary duct and decrease complications. VNTPS technique, especially Deng＇s precut is as effective and safe as EST. This technique can be well performed in hospitals without particular equipments.

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

AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.

Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis

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.

Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND Endoscopic sphincterotomy(EST) for the management of common bile duct stones(CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy(OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.AIM To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.METHODS Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching(1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic(ROC)curve was generated for qualifying independent risk factors.RESULTS In total, 302 patients undergoing successful EST(n = 168) or OCT(n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT(P <0.001). The number of complete stone clearance sessions increased significantly in the EST group(P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in18.8%(33/176) of the patients overall, but no difference was found between the EST(20.5%, 18/88) and OCT(17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct(CBD) diameter > 15 mm(OR =2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS(OR = 5.09; 95%CI: 2.58-10.07; P< 0.001), and distal CBD angle ≤ 145°(OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81(95%CI: 0.76-0.87).CONCLUSION EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

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.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy(EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Minor endoscopic sphincterotomy followed by large balloon dilation for large choledocholith treatment

AIM To evaluate early and late outcomes of endoscopic papillary large balloon dilation(EPLBD) with minor endoscopic sphincterotomy(m EST) for stone removal.METHODS A total of 149 consecutive patients with difficult common bile duct(CBD) stones(diameter ≥ 10 mm or ≥ 3 stones) underwent conventional endoscopic sphincterotomy(EST) or m EST plus EPLBD from May 2012 to April 2016. Their demographic, laboratory and procedural data were collected, and pancreaticobiliary complications were recorded.RESULTS Sixty-nine(94.5%) of the patients in the EPLBD + m EST group and 64(84.2%) in the conventional EST group achieved stone clearance following the first session(P = 0.0421). The procedure time for EPLBD + m EST was shorter than for EST alone(42.1 ± 13.6 min vs 47.3 ± 11.8 min, P = 0.0128). The overall rate of early complications in the EPLBD + m EST group(11%) was lower than in the EST group(21.1%); however, the difference was not significant(P = 0.0938). The cumulative recurrence rate of cholangitis and CBD stones between the two groups was also similar. The procedure time was independently associated with post-endoscopic retrograde cholangiopancreatography pancreatitis(OR = 6.374, 95%CI: 1.193-22.624, P = 0.023), CBD stone diameter ≥ 16 mm(OR = 7.463, 95%CI: 2.705-21.246, P = 0.0452) and use of mechanical lithotripsy(OR = 9.913, 95%CI: 3.446-23.154, P = 0.0133) were independent risk factors for stone recurrence. CONCLUSION EPLBD with m EST is more effective than EST alone for difficult CBD stone removal, with shorter procedure time and fewer early complications.

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 (&#x02265; 10 mm).

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P=0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P=0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P=0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P=0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P=0.00). CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.

Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

AIM： To compare small sphincterotomy combined with endoscopic papillary large balloon dilation （SES ＋ ELBD） and endoscopic sphincterotomy （EST） for large bile duct stones. METHODS： We compared prospectively SES ＋ ELBD （group A, n = 27） with conventional EST （group B, n = 28） for the treatment of large bile duct stones （≥ 15 mm）. When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy. RESULTS： No significant differences were observed in the mean largest stone size （A： 20.8 mm, B： 21.3 mm）, bile duct diameter （A： 21.4 turn, B： 20.5 ram）, number of stones （A： 2.2, B： 2.3）, or procedure time （A： 18 min, B： 19 rain） between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B （P = 0.473）. Mechanical lithotripsy was required for stone removal in nine of 27 patients （33%） in group A and nine of 28 patients （32%, P = 0.527） in group B.CONCLUSION： SES ＋ ELBD did not show significant benefits compared to conventional EST, especially for the removal of large （≥ 15 mm） bile duct stones.

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 (&#x02265; 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.

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 nae 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 and16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4mm, 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 was73.1%(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.

Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones:A systematic review and meta-analysis based on randomized controlled trials

AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials(RCTs) on Med Line, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy(ML), perforation and cholangitis. RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography(ERCP) bleeding [FE RD-0.02, CI(-0.03,-0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI(-0.25,-0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI(-0.38,-0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI(-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI(-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI(-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI(-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI(-0.02, 0.07), I2 = 11%, P = 0.31]. CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy(EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).METHODSThis was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.RESULTSAmong the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.CONCLUSIONLimited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Risk factors for delayed hemorrhage after endoscopic sphincterotomy

Background:Hemorrhage is one of the most serious complications of endoscopic sphincterotomy(EST).The risk factors for delayed hemorrhage are not clear.This study aimed to explore the risk factors for post-EST delayed hemorrhage and suggest some precautionary measures.Methods:This study analyzed 8477 patients who successfully underwent endoscopic retrograde cholangiopancreatography(ERCP)and EST between January 2007 and June 2015 in the First Affiliated Hospital of Nanchang University.Univariate and multivariate analyses were performed to find the risk factors for delayed hemorrhage after EST.Results:Of the 8477 patients screened,137(1.62%)experienced delayed hemorrhage.Univariate analysis showed that male,the severity of jaundice,duodenal papillary adenoma and carcinoma,diabetes,intraoperative bleeding,moderate and large incisions,and directional deviation of incision were risk factors for post-EST delayed hemorrhage(P<0.05).Multivariate analysis showed that intraoperative bleeding[odds ratio(OR)=3.326;95%CI:1.785–6.196;P<0.001]and directional deviation of incision(OR=2.184;95%CI:1.266–3.767;P=0.005)were independent risk factors for post-EST delayed hemorrhage.Conclusions:Delayed hemorrhage is the most common and dangerous complication of EST.Intraoperative bleeding and directional deviation of incision are independent risk factors for post-EST delayed hemorrhage.