Balloon dilation of congenital perforated duodenal web in newborns: Evaluation of short and long-term results

BACKGROUND Incomplete congenital duodenal obstruction(ICDO)is caused by a congenitally perforated duodenal web(CPDW).Currently,only six cases of balloon dilatation of the PDW in newborns have been described.AIM To present our experience of balloon dilatation of a perforated duodenal memb-rane in newborns with ICDO.METHODS Five newborns who underwent balloon dilatation of the CPDW along a prein-stalled guidewire between 2021 and 2023 were included.Nineteen newborns diagnosed with ICDO who underwent laparotomy were included in the control group.RESULTS In all cases,good anatomical and clinical results were obtained.In three cases,a follow-up study was conducted after 1 year.The average time to start enteral feeding per os was significantly earlier in the study group(4.4 d)than in the laparotomic group(21.2 days;P<0.0001).The time spent by patients in the intensive care unit and hospital after balloon dilatation was also significantly shorter.We determined the selection criteria for possible and effective CPDW balloon dilatation in newborns as follows:(1)Presence of dynamic radiographic signs of the passage of a radiopaque substance beyond the zone of narrowing or radiographic signs of pneumatisation of the duodenum and small bowel distal to the web;(2)presence of endoscopic signs of CPDW;(3)successful cannulation with a guidewire performed parallel to the endoscope,with holes in the congenital duodenal web;and(4)successful positioning of the balloon performed along a freestanding guidewire on the web.CONCLUSION Strictly following selection criteria for newborns with ICDO caused by CPDW ensures that endoscopic balloon dilatation using a pre-installed guidewire is safe and effective and shows good 1-year follow-up results.

Immediate balloon deflation method in endoscopic papillary large balloon dilation for extraction of difficult bile duct stones

Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outcomes. However, there is no consensus with regard to the ballooning time. The aim of our study was to evaluate the efficacy and safety of immediate balloon deflation in EPLBD for the treatment of difficult bile duct stone. Methods: This was a retrospective study of 80 consecutive patients with bile duct stones who were treated with an immediate balloon deflation method in EPLBD combined with endoscopic sphincterotomy (EST) between January 2010 and December 2012. Overall success rate, success rate at first ERCP, and the frequency of mechanical lithotripsy for complete stone removal were assessed for efficacy and safety was evaluated by assessing major complications. Results: Overall success rate for complete stone removal was high (78/80, 97.5%) and success rate for complete stone removal at first ERCP was 86.3% (69/80). The use of mechanical lithotripsy was 0% (0/80). The overall complication rate was favorable (5/80, 6.3%). PostERCP pancreatitis was observed in 3 patients (two: mild, one: moderate). In subgroup analysis, the presence of periampullary diverticulum was the only factor affecting the success rate at first ERCP. Conclusion: This study demonstrated the favorable outcome of immediate balloon deflation for treatment of difficult CBD stones and can be considered for clinical application.

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.

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 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.

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.

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 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.

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.

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 balloon dilation for benign gastric outlet obstruction in adults

Gastric outlet obstruction(GOO) includes obstruction in the antropyloric area or in the bulbar or post bulbar duodenal segments.Though malignancy remains the most common cause of GOO in adults,a significant number of patients have benign disease.The latter include peptic ulcer disease,caustic ingestion,post-operative anastomotic state and inflammatory causes like Crohn's disease and tuberculosis.Peptic ulcer remains the most common benign cause of GOO.Management of benign GOO revolves around confirmation of the etiology,removing the offending agent Helicobacter pylori(H.pylori),non-steroidal anti-inflammatory drugs,etc.and definitive therapy.Traditionally,surgery has been the standard mode of treatment for benign GOO.However,after the advent of through-the-scope balloon dilators,endoscopic balloon dilation(EBD) has emerged as an effective alternative to surgery in selected groups of patients.So far,this form of therapy has been shown to be effective in causticinduced GOO with short segment cicatrization and ulcer related GOO.In the latter,EBD must be combined with eradication of H.pylori.Dilation is preferably done with wire-guided balloon catheters of incremental diameter with the aim to reach the end-point of 15 mm.While it is recommended that fluoroscopic control be used for EBD,this is not used by most endoscopists.Frequency of dilation has varied from once a week to once in three weeks.Complications are uncommon with perforation occurring more often with balloons larger than 15 mm.Attempts to augment efficacy of EBD include intralesional steroids and endoscopic incision.

Balloon dilation of Eustachian tube combined with tympanostomy tube insertion and middle ear pressure equalization therapy for recurrent secretory otitis media

Objective: To report outcomes of balloon dilation Eustachian tuboplasty combined with tympanostomy tube insertion and middle ear pressure equalization therapy in treatment of recurrent secretory otitis media. Methods: Fifty one patients with recurrent secretory otitis media (62 ears) underwent balloon dilation of Eustachian tube and tympanic tube insertion under general anesthesia, followed by long term middle ear pressure equalization therapies. The Eustachian tube score (ETS) and Eustachian tube function questionnaire (ETDQ-7) were used for pre- and postoperative (up to 12 months) evaluation of Eustachian tube functions. Results: The mean ETS score was 2.34 ± 0.97 preoperatively, and 6.17 ± 1.54, 7.23 ± 1.62, 8.24 ± 1.97, and 7.63 ± 1.86 at 1, 3, 6 and 12 months postoperatively, respectively (P < 0.05). The ETDQ-7 score was 4.82 ± 1.07 preoperatively, and 2.20 ± 0.54, 2.32 ± 0.68, 2.53 ± 0.79, and 2.67 ± 0.76 at 1, 3, 6 and 12 months postoperatively, respectively (P < 0.05). Conclusion: Balloon dilation of Eustachian tube combined with tympanostomy and catheterization resulted in significant improvement of subjective symptoms and objective evaluation of Eustachian tube functions in most patients with recurrent secretory otitis media, as indicated by the ETS and ETDQ-7 scores, demonstrating high levels of efficacy and patient satisfaction.

Short- and long-term efficacy of endoscopic balloon dilation in Crohn's disease strictures

AIM:To evaluate short- and long-term efficacy of endoscopic balloon dilation in a cohort of consecutive patients with symptomatic Crohn's disease (CD)-related strictures. METHODS:Twenty-six CD patients (11 men; median age 36.8 year, range 11-65 years) with 27 symptomatic strictures underwent endoscopic balloon dilation (EBD).Both naive and post-operative strictures, of any length and diameter, with or without associated fistula were included. After a clinical and radiological assessment, EBD was performed with a Microvasive Rigiflex through the scope balloon system. The procedure was considered successful if no symptom reoccurred in the following 6 mo. The long-term clinical outcome was to avoid surgery. RESULTS:The mean follow-up time was 40.7 ± 5.7 mo (range 10-94 mo). In this period, forty-six EBD were performed with a technical success of 100%. No procedure-related complication was reported. Surgery was avoided in 92.6% of the patients during the entire follow-up. Two patients, both presenting ileocecal strictures associated with fistula, failed to respond to the treatment and underwent surgical strictures resection. Of the 24 patients who did not undergo surgery, 11 patients received 1 EBD, and 13 required further dilations over time for the treatment of relapsing strictures (7 patients underwent 2 dilations, 5 patients 3 dilations, and 1 patient 4 dilations). Overall, the EBD success rate after the first dilation was 81.5%. No difference was observed between the EBD success rate for naive (n = 12) and post-operative (n = 15) CD related strictures (P > 0.05). CONCLUSION:EBD appears to be a safe and effective procedure in the therapeutic management of CD-related strictures of any origin and dimension in order to prevent surgery.

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM:To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.METHODS:Patients (n=208) were divided into five groups based on the largest CBD stone size of < 5,6-8,8-12,12-14,and > 14 mm.Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8,10,12 and 14 mm balloons,such that the size of each balloon did not exceed the size of the CBD.Short-and long-term outcomes,such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis,perforation,bleeding,and pneumobilia were compared among the five groups.RESULTS:The overall rate of successful stone removal in all groups was 100%,and all patients were cured.Eight (3.85%) patients had post-ERCP pancreatitis,none had perforations,and 6 (2.9%) had bleeding re-quiring transfusion.There were no significant differences in early complication rates among the five groups.We observed significant correlations between increased balloon size and the short-and long-term rates of postERCP pneumobilia.Post-ERCP pancreatitis and bleeding correlated significantly with age,with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years,and bleeding occurring more frequently in patients aged > 70 years.We observed a significant correlation between patient age and the diameter of the largest CBD stone,with stones > 12 mm occurring more frequently in patients > 60 years old.CONCLUSION:Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones.Balloon size should not exceed 15 mm.

Endoscopic papillary balloon dilation for diffi cult common bile duct stones:Our experience

AIM: To evaluate the eff icacy and safety of endoscopic balloon dilation(EBD) performed for common bile duct(CBD) stones.METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome(small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography(ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN cholangiography and, when necessary, with computed tomography of the abdomen(for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic(ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBDof the ampulla was performed under endoscopic and f luoroscopic guidance with a balloon through the scope(Hercules, wireguided balloon, Cook Ireland Ltd. and CRE, Microvasive, Boston Scientific Co., Natick, MA, United States). RESULTS: A total of 14 patients(9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy(ES) prior to the EBD. The size of balloon insuff lation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and f luoroscopic guidance. The balloon was gradually f illed with diluted contrast agent and was maintained inf lated in position for 45 to 60 s before def lation and removal. The need for precutting the major papilla was 21.4%. In one patient(an 81-year-old), EBD was performed in a Billroth Ⅱ. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures(ERCP + ES) was only an intra procedural bleeding(6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an eff icacious and safe procedure.

Modified percutaneous transhepatic papillary balloon dilation for patients with refractory hepatolithiasis

BACKGROUND Some patients with hepatolithiasis cannot tolerate surgery due to severe cardiac or pulmonary comorbidities,or cannot be endoscopically treated because of altered gastrointestinal anatomies.AIM To propose a modified percutaneous transhepatic papillary balloon dilation procedure,and evaluate the clinical efficacy and safety of this modality.METHODS Data from 21 consecutive patients who underwent modified percutaneous transhepatic papillary balloon dilation with hepatolithiasis were retrospectively analyzed.Using auxiliary devices,intrahepatic bile duct stones were pushed into the common bile duct and expelled into the duodenum with an inflated balloon catheter.The outcomes recorded included success rate,procedure time,hospital stay,causes of failure,and procedure-related complications.Patients with possible long-term complications were followed up for 2 years.RESULTS Intrahepatic bile duct stones were successfully removed in 20(95.23%)patients.Mean procedure time was 65.8±5.3 min.Mean hospital stay was 10.7±1.5 d.No pancreatitis,gastrointestinal,or biliary duct perforation was observed.All patients were followed up for 2 years,and there was no evidence of reflux cholangitis or calculi recurrence.CONCLUSION Modified percutaneous transhepatic papillary balloon dilation was feasible and safe with a small number of patients with hepatolithiasis,and may be a treatment option in patients with severe comorbidities or in patients in whom endoscopic procedure was not successful.

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth Ⅱ gastrectomy patients

Background： Endoscopic papillary balloon dilation （EPBD） for common bile duct （CBD） stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are notclear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients.

Endoscopic papillary large balloon dilation for bile duct stones in elderly patients

AIM: To investigate whether endoscopic papillary large balloon dilation(EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A(< 80 years) and group B(≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies(ERCP), and incidence of complications were examined in both groups.RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent(P < 0.05). The success rate of the initial lithotomy was 88.7(94/106)%. The final lithotomy rate was 100(106/106)%. Complications due to treatment procedure occurred in 4.72(5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.

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 mm,B:20.5 mm),number of stones(A:2.2,B:2.3),or procedure time(A:18 min, B:19 min)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.