Dilation,discrimination and Uhlmann's theorem of link products of quantum channels

We establish the Stinespring dilation theorem of the link product of quantum channels in two different ways,discuss the discrimination of quantum channels,and show that the distinguishability can be improved by self-linking each quantum channel n times as n grows.We also find that the maximum value of Uhlmann's theorem can be achieved for diagonal channels.

Failure transition of shear-to-dilation band of rock salt under triaxial stresses

Great potential of underground gas/energy storage in salt caverns seems to be a promising solution to support renewable energy.In the underground storage method,the operating cycle unfortunately may reach up to daily or even hourly,which generates complicated pressures on the salt cavern.Furthermore,the mechanical behavior of rock salt may change and present distinct failure characteristics under different stress states,which affects the performance of salt cavern during the time period of full service.To reproduce a similar loading condition on the cavern surrounding rock mass,the cyclic triaxial loading/unloading tests are performed on the rock salt to explore the mechanical transition behavior and failure characteristics under different confinement.Experimental results show that the rock salt samples pre-sent a diffused shear failure band with significant bulges at certain locations in low confining pressure conditions(e.g.5 MPa,10 MPa and 15 MPa),which is closely related to crystal misorientation and grain boundary sliding.Under the elevated confinement(e.g.20 MPa,30 MPa and 40 MPa),the dilation band dominates the failure mechanism,where the large-size halite crystals are crushed to be smaller size and new pores are developing.The failure transition mechanism revealed in the paper provides additional insight into the mechanical performance of salt caverns influenced by complicated stress states.

Time Dilation Cosmology 2

This paper is a further elaboration of the author’s Time Dilation Cosmology (TDC) holographic model that ties gravitation and celestial mechanics and kinematics directly to time dilation, resolving all the major conundrums in astrophysics, and ties astrophysics directly to quantum physics. It begins with a brief summary of the TDC model and contains the new derivation for the time dilation version of the formula for summing relativistic velocities, Einstein’s gravitational constant and the time dilation versions for the Lorentz factor and the Euclidean norm of the 3d velocity vector, the two of which can then be used in the Four-velocity formula. It is demonstrated how orbital curvature is manifested as the resultant of two time dilation-manifested velocities. It also explains why an interferometer cannot distinguish free fall from zero gravity and further elaborates on the author’s previous explanations of how spiral galaxies are formed, and contains mathematical proof that Black Holes are actually Magnetospheric Eternally Collapsing Objects (MECOs) that are massless spacetime vortices.

Advanced Face Mask Detection Model Using Hybrid Dilation Convolution Based Method

A face-mask object detection model incorporating hybrid dilation convolutional network termed ResNet Hybrid-dilation-convolution Face-mask-detector (RHF) is proposed in this paper. Furthermore, a lightweight face-mask dataset named Light Masked Face Dataset (LMFD) and a medium-sized face-mask dataset named Masked Face Dataset (MFD) with data augmentation methods applied is also constructed in this paper. The hybrid dilation convolutional network is able to expand the perception of the convolutional kernel without concern about the discontinuity of image information during the convolution process. For the given two datasets being constructed above, the trained models are significantly optimized in terms of detection performance, training time, and other related metrics. By using the MFD dataset of 55,905 images, the RHF model requires roughly 10 hours less training time compared to ResNet50 with better detection results with mAP of 93.45%.

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.

On Unitary N-Dilations for Tuples of Circulant Contractions and von Neumann’s Inequality

We introduce the spectral mapping factorization of tuples of circulant matrices and its matrix version. We prove that every tuple of circulant contractions has a unitary N-dilation. We show that von Neumann’s inequality holds for tuples of circulant contractions. We construct completely contractive homomorphisms over the algebra of complex polynomials defined on .

Follow-up study on symptom distress in esophageal cancer patients undergoing repeated dilation

BACKGROUND Repeated endoscopic probe dilatation is the most preferred treatment for esophageal stenosis which may cause high levels of symptom distress in the patient’s home rehabilitation stage.AIM To explore the changes in the symptom distress level and its correlation with the dilation effect in patients with esophageal carcinoma undergoing repeated dilations for lumen stenosis.METHODS The difference(R2-R1)between the diameter of the esophageal stenosis opening(R1)of the patients before dilation(R1)and after dilation(R2)was calculated to describe the extent and expansion of the esophageal stenosis before and after dilation.The M.D.Anderson Symptom Inventory was used to describe the symptom distress level of patients with dilation intermittence during their stay at home and to explore the correlation between the dilation effect and symptom distress level.RESULTS The diameter of the esophagus(R1)increased before each dilation in patients undergoing esophageal dilation(P<0.05).The diameter(R2)increased after dilation(P<0.05);the dilation effect(R2-R1)decreased with the number of dilations(P<0.05).The total symptom distress score significantly increased with the number of dilations(P<0.05).The symptom distress scores of the patients were negatively correlated(P<0.05)with the previous dilation effect(R2-R1)and the esophageal diameter(R2)after the previous dilation.After the 1 st to 4 th dilations,the patient’s symptom distress score was negatively correlated with the esophageal diameter(R12)before the next dilation,while there was no significant correlation(P>0.05)with the other dilations.CONCLUSION In patients who have undergone repeated dilations,better effect stands for lower symptom distress level and the increase in symptom distress has a prompt effect on the severity of the next occurrence of restenosis.

Reappraisal of endoscopic papillary balloon dilation for the management of common bile duct stones

Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.

Endoscopic dilation of complete oesophageal obstructionswith a combined antegrade-retrograde rendezvoustechnique

AIM: To investigate the combined antegraderetrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.METHODS: This single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation(CARD) within the last 10 years. The patients' demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy(PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale(FOIS)(≥ level 3).RESULTS: The cohort consisted of six patients [five males; mean age 71 years(range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up(median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing(two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.CONCLUSION: The CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.

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 balloon dilation for management of stricturing Crohn’s disease in children

BACKGROUND Crohn’s disease(CD)has a multitude of complications including intestinal strictures from fibrostenotic disease.Fibrostenotic disease has been reported in 10%-17%of children at presentation and leads to surgery in 20%-50%of cases within ten years of diagnosis.When symptoms develop from these strictures,the treatment in children has primarily been surgical resection.Endoscopic balloon dilation(EBD)has been shown to be a safe and efficacious alternative to surgery in adults,but evidence is poor in the literature regarding its safety and efficacy in children.AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODS In a single-center retrospective study,we looked at pediatric patients(ages 0-18)who carry the diagnosis of CD,who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1,2012 through May 1,2019.We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype.The type of intervention for patients’strictures was then identified through procedural and surgical billing codes.We evaluated their demographics,clinical variables,whether they underwent EBD vs surgery or both,and their clinical outcomes.RESULTS Of the 139 patients with CD,25(18%)developed strictures.The initial intervention for a stricture was surgical resection in 12 patients(48%)and EBD in 13 patients(52%).However,4(33%)patients whom initially had surgical resection required follow up EBD,and thus 17 total patients(68%)underwent EBD at some point in their treatment process.For those 8 patients who underwent successful surgical resection alone,4 of these patients(50%)had a fistula present near the stricture site and 4(50%)had strictures greater than 5 cm in length.All patients who underwent EBD had no procedural complications,such as a perforation.Twenty-two(88%)of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

Dilation assisted stone extraction for complex biliary lithiasis:Technical aspects and practical principles

Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile duct stones for the past 40 years,providing a wide opening to allow extraction.Up to 15%of patients present with complicated choledocholithiasis.In this context,additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy,intraductal or extracorporeal lithotripsy,or endoscopic papillary large balloon dilation(EPLBD).EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter.EPLBD without EST was introduced as a simplified technique in 2009.Dilation-assisted stone extraction(DASE)is the combination of two techniques:EPLBD and sub-maximal EST.Several studies have reported this technique as safe and effective in patients with large bile duct stones,without any increased risk of adverse events such as pancreatitis,bleeding,or perforation.Nevertheless,it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies.The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE,based on current literature and daily clinical experience in biliary referral centers.

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 and95%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 621participants 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%vs25.2%,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 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.

Endoscopic papillary large balloon dilation in patients with periampullary diverticula

AIM:To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation(EPLBD)for bile duct stone extraction in patients with periampullary diverticula.METHODS:The records of 223 patients with large common bile duct stones(≥10 mm)who underwent EPLBD(12-20 mm balloon diameter)with or without limited endoscopic sphincterotomy(ES)from July 2006to April 2011 were retrospectively reviewed.Of these patients,93(41.7%)had periampullary diverticula(PAD),which was categorized into three types.The clinical variables of EPLBD with limited ES(EPLBD+ES)and EPLBD alone were analyzed according to the presence of PAD.RESULTS:Patients with PAD were significantly older than those without(75.2±8.8 years vs 69.7±10.9years,P=0.000).The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and nonPAD groups,however,there was significantly less need for mechanical lithotripsy in the PAD group(3.2%vs 11.5%,P=0.026).Overall stone removal rates,complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD+ES and EPLBD alone in patients with PAD(96.6%vs 97.1%;72.9%vs 88.2%;and 5.1%vs 0%,respectively).No significant differences with respect to the rates of pancreatitis,perforation,and bleeding were observed between EPLBD+ES and EPLBD alone in the PAD group(3.4%vs 14.7%,P=0.095;0%vs 0%;and 3.4%vs 8.8%,P=0.351,respectively).CONCLUSION:EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD,regardless of PAD subtypes.

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.

Endoscopic papillary balloon dilation:Revival of the old technique

Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s.Recently,there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy(EST)in young patients undergoing laparoscopic cholecystectomy.However,there is a disparity in using endoscopic balloon papillary dilation(EPBD)between the East and the West,depending on the origin of the studies.In the early 2000s,EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones.Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method,unlike EPBD.However,fatal complications have occurred in patients with endoscopic papillary large balloon dilation(EPLBD).The safety of endoscopic balloon dilation is still a debatable issue.Moreover,guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon.In this article,we discuss the issue of conventional and large balloon endoscopic dilation.We also suggest the indications and optimal techniques of EPBD and EPLBD.

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 2003and June 2013,where it was performed with largediameter 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 of413 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 and97.2%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.

Endoscopic papillary large balloon dilation after limited sphincterotomy for difficult biliary stones

AIM:To assess the efficacy and safety of endoscopic papillary large balloon dilation after biliary sphincterotomy for difficult bile duct stones retrieval.METHODS:Retrospective review of consecutive patients submitted to the technique during 18 mo.The main outcomes considered were:efficacy of the procedure(complete stone clearance;number of sessions;need of lithotripsy) and complications.RESULTS:A total of 30 patients with a mean age of 68 ± 10 years,23 female(77%) and 7 male(23%) were enrolled.In 10 patients,a single stone was found in the common bile duct(33%) and in 20 patients multiple stones(67%) were found.The median diameter of the stones was 17 mm(12-30 mm).Dilations were performed with progressive diameter Through-TheScope balloons(up to 12,15) or 18 mm.Complete retrieval of stones was achieved in a single session in 25 patients(84%) and in two sessions in 4 patients(13%).Failure occurred in 1 case(6%).Mechanical lithotripsywas performed in 6 cases(20%).No severe complications occurred.One patient(3%) had mild-grade post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.CONCLUSION:Endoscopic balloon dilatation with a large balloon after endoscopic sphincterotomy is a safe and effective technique that could be considered an alternative choice in therapeutic ERCP.