Percutaneous transhepatic extraction and balloon dilation for simultaneous gallbladder stones and common bile duct stones:A novel technique

AIM To evaluate the clinical efficacy and safety of an innovative percutaneous transhepatic extraction and balloon dilation(PTEBD) technique for clearance of gallbladder stones in patients with concomitant stones in the common bile duct(CBD).METHODS The data from 17 consecutive patients who underwent PTEBD for clearance of gallbladder stones were retrospectively analyzed. After removal of the CBD stones by percutaneous transhepatic balloon dilation(PTBD), the gallbladder stones were extracted to the CBD and pushed into the duodenum with a balloon after dilation of the sphincter of Oddi. Large stones were fragmented using a metallic basket. The patients were monitored for immediate adverse events including hemorrhage, perforation, pancreatitis, and cholangitis. During the two-year follow-up, they were monitored for stone recurrence, reflux cholangitis, and other longterm adverse events.RESULTS Gallbladder stones were successfully removed in 16(94.1%) patients. PTEBD was repeated in one patient. The mean hospitalization duration was 15.9 ± 2.2 d. Biliary duct infection and hemorrhage occurred in one(5.9%) patient. No severe adverse events, including pancreatitis or perforation of the gastrointestinal or biliary tract occurred. Neither gallbladder stone recurrence nor refluxing cholangitis had occurred two years after the procedure.CONCLUSION Sequential PTBD and PTEBD are safe and effective for patients with simultaneous gallbladder and CBD stones. These techniques provide a new therapeutic approach for certain subgroups of patients in whom endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy or surgery is not appropriate.

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.

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.

Safety and efficacy of percutaneous transhepatic balloon dilation in removing common bile duct stones:A systematic review

BACKGROUND Endoscopic sphincterotomy(EST) is widely regarded as the first choice in the management of common bile duct(CBD) stones. However, for some patients, this treatment is not possible. The percutaneous transhepatic balloon dilation(PTBD)technique has been suggested as an alternative but has yet to gain wide acceptance.AIM To review cases of PTBD for removing CBD stones and explore the safety and efficacy of this treatment.METHODS We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched EMBASE,PubMed, and Web of Science for cases of PTBD that underwent CBD stone removal from 1981 to January 2019. We analyzed all relevant articles available in full text. We extracted data on patient's age, gender, overall technique success rate, reasons for technique failure, and the presence and type of major and minor complications. We analyzed the data and reported the results in a table and text.Altogether, we retrieved 12 case series and 6 case reports, for a total of 1347 patients. Thirty cases were excluded due to a lack of patient data.RESULTS The overall technique success rate for removing a CBD stone was 98.5%(1327/1347) and 98.1%(109/111) for removing concurrent CBD and gallbladder stones. Based on available data(n = 1312), mean age of all patients(687 males and625 females) was 68.9 years. The total number of procedures in the remaining 1317 patients(after exclusion) was 3237(average 2.4 procedures per patient). The total number of failures for eliminating a CBD stone was 20, and the reasons for failure included: Stone impaction(n = 10), intrahepatic bile duct stricture(n = 5),large stone(n = 2), severe CBD dilation(n = 1), multiple stones(n = 1), and duodenal perforation(n = 1). Various major complications related to the procedure were reported, but the incidence rate was low(1.4%). No pancreatitis or procedure related mortality was reported. Minor complications including transient hyperamylasemia, nausea, vomiting, abdominal pain, fever, and mild hemobilia were reported. For 218 patients(88 patients with unsuccessful endoscopic removal due to anatomical change and large or impacted stone and130 cases who refused endoscopic procedure due to poor general condition or other additional disease), the CBD stones were successfully pushed into the duodenum by performing the PTBD procedure.CONCLUSION PTBD is a safe and effective approach in the nonoperative management of CBD stones. PTBD provides an alternative treatment when endoscopic procedures fail or are unsuitable for the patient.

内镜下十二指肠乳头括约肌小切开联合大球囊扩张术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石的远期疗效分析

目的 比较内镜下十二指肠乳头括约肌小切开联合大球囊扩张术(ESLBD)(12~15 mm)与内镜下十二指肠乳头括约肌切开术(EST)治疗难治性胆总管结石的远期疗效。方法 选择2009年1月至2020年1月在上海交通大学医学院附属瑞金医院和上海中医药大学附属曙光医院消化内镜中心采用EST或ESLBD(12~15 mm)治疗的131例难治性胆总管结石患者,分为EST组(n=70)和ESLBD组(n=61),比较2组的完全取石成功率、经内镜逆行胰胆管造影术(ERCP)相关术后近期并发症及远期并发症发生率等指标。结果 EST组和ESLBD组的取石成功率和机械碎石率差异均无统计学意义(98.6%比100.0%,24.3%比18.0%,P均>0.05)。EST组的ERCP术后近期并发症发生率高于ESLBD组(8.6%比3.3%),但差异无统计学意义(P>0.05)。长期随访结果显示,EST组和ESLBD组的ERCP术后远期并发症发生率差异无统计学意义(11.9%比8.6%,P>0.05)。结论 与EST相比,ESLBD(12~15 mm)用于治疗难治性胆总管结石是安全有效的,尤其是对于合并十二指肠乳头旁憩室、凝血功能障碍等患者,ESLBD可作为首选治疗方法。EST与ESLBD的术后远期并发症发生率相似,ESLBD也会造成十二指肠乳头括约肌功能损伤。

内镜下乳头括约肌球囊扩张术治疗胆总管结石的安全性和有效性分析

目的评价内镜下乳头括约肌球囊扩张术治疗胆总管结石的安全性和有效性。方法回顾性选取2015年1月—2022年10月在徐州医科大学附属宿迁医院接受内镜治疗胆总管结石的284例患者,术中的球囊扩张时间均为5 min,依手术方式分为内镜下乳头括约肌切开术(37例)、内镜下乳头括约肌球囊扩张术(49例)及内镜下乳头括约肌小切开联合球囊扩张术(198例)3组,收集患者的人口学特征、临床特征及短期并发症等资料并分析安全性和有效性。结果安全性方面,内镜下乳头括约肌球囊扩张术组术中出血发生率(6.1%)明显低于内镜下乳头括约肌切开术组(29.7%)以及内镜下乳头括约肌小切开联合球囊扩张术(26.3%)组,差异有统计学意义(P=0.003)。3组患者间的其他短期并发症发生率差异无统计学意义。有效性方面,3组患者的首次结石清除率和机械碎石率差异无统计学意义。结论内镜下乳头括约肌球囊扩张术手术安全有效,且术中出血风险更低,临床应用具有价值。

乳头柱状球囊扩张术时间的选择及其对胆总管结石疗效的影响

目的 探讨乳头柱状球囊扩张术(EPBD)治疗时间的选择及其对内镜逆行胰胆管造影(ERCP)治疗胆总管结石疗效的影响。方法 选取2017年1月至2022年12月于青岛市胶州中心医院住院治疗的108例胆总管结石患者作为研究对象,将EPBD持续时间为30 s的患者列入30 s组,将EPBD持续时间为60 s的患者列入60 s组,两组各54例。两组均行ERCP取石,记录两组性别、年龄、憩室旁乳头比率、结石直径、胆管直径等一般资料,一次净石率、机械碎石率、术中活动性出血率、手术时间、住院时间等取石情况,穿孔、术后出血、急性胰腺炎、高淀粉酶血症等术后并发症发生情况。比较两组患者的临床资料,建立不同EPBD持续时间ERCP治疗胆总管结石的多准则决策模型。结果 60 s组患者的一次净石率高于30 s组(P<0.05),机械碎石率、住院时间、住院费用、术后并发症的发生率均低于30 s组(P<0.05)。应用Meta分析方法分别合并两组患者的风险-效益值发现,60 s组的效益平均值、风险平均值均高于30 s组,且效益-风险总值68高于30 s组的58;60 s组优于30 s组的概率为100%。结论 选择EPBD时间维持在60 s可有效提高一次净石率,降低机械碎石率、住院时间及住院费用,减少急性胰腺炎和高淀粉酶血症的发生。

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.

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.

Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy

AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis. METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term com-plications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyz-ing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined asP < 0.05. Risk of bias was evaluated us-ing a funnel plot. RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBDgroup were younger (OR=-1.16, 95%CI:-1.49 to 0.84, P<0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Com-pared with EST, the total stone clearance in the EPBD group decreased (OR=0.64, 95%CI: 0.42 to 0.96,P=0.03), the use of stone extraction baskets significantly increased (OR=1.91, 95%CI: 1.41 to 2.59, P<0.01), and the incidence of pancreatitis significantly increased (OR=2.79, 95%CI: 1.74 to 4.45, P<0.0001). The incidence of bleeding (OR=0.12, 95%CI: 0.04 to 0.34, P<0.01) and cholecystitis (OR=0.41, 95%CI: 0.20 to 0.84, P=0.02) significantly decreased. The stone re-currence rate also was significantly reduced in EPBD (OR=0.48, 95%CI: 0.26 to 0.90, P=0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis. CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone clearance rate and risk of bleeding was lower with EPBD compared to EST.

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

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 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.

Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy

AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation(EPLBD) in the management of bile duct stones in a Western population. METHODS Data was collected from the endoscopic retrograde cholangiopancreatography(ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1 st August 2009 to 31 st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using Med Calc for Windows,version 12.5(Med Calc Software,Ostend,Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore,we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.RESULTS EPLBD was performed in 229 patients(46 females) with mean age of 68 ± 14.3 years. 115/229(50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP(1 st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81(35.4%). Median balloon size was 13.5 mm(10-18). In addition to EPLBD,per-oral cholangioscopy(POC) and electrohydraulic lithotripsy(EHL) was performed in 35(15%) patients at index* ERCP. 63(27.5%) required repeat ERCP for stone clearance. 28(44.5%) required POC and EHL and 11(17.4%) had repeat EPLBD for complete duct clearance. Larger stone size(12.4 mm vs 17.4 mm,P < 0.000001),multiple stones(2,range(1-13) vs 3,range(1-12),P < 0.006) and dilated common bile duct(CBD)(12.4 mm vs 18.3 mm,P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients(20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis(0.87%) each.CONCLUSION EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.

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.

内镜下乳头球囊扩张术和乳头括约肌切开术治疗胆总管结石的有效性和安全性

目的:内镜下乳头括约肌切开术(endoscopic sphincterotomy,EST)是胆总管结石的经典治疗方法,但存在一些并发症。内镜下乳头球囊扩张术(endoscopic papillary balloon dilatation,EPBD)创伤小、并发症少、对乳头括约肌有保护作用,被认为是EST取石最有价值的替代方法。本研究旨在对比2种术式治疗胆总管结石的疗效和并发症,为个体化选择提供依据。方法:回顾性收集2021年1月1日至12月31日在内蒙古医科大学附属医院消化内科住院治疗的164胆总管结石患者的临床资料,按术式分为EPBD组(79例)和EST组(85例)。比较2组的有效性和近期及远期并发症。结果:与EST组相比,EPBD组的机械碎石率高(35.44%vs 20.00%);随访1年的远期并发症结石复发率低(2.53%vs 11.76%),差异均有统计学意义(均P<0.05);近期并发症中出血发生率低(1.26%vs 7.05%),但差异无统计学意义(P>0.05)。结论:与EST相比,EPBD术后出血发生率和结石复发率降低,结石清除率相近,提示EPBD可以作为胆总管结石患者的治疗选择,特别是对不适于EST的患者。

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.

449例内镜下不同取石方式去除10mm以内胆总管结石的疗效分析

目的比较经内镜逆行胰胆管造影术(ERCP)中不同取石方式去除10 mm以内胆总管结石的效果及安全性,为临床选用不同的取石方式提供依据。方法回顾性分析2017年4月-2020年4月在我院行ERCP去除10 mm以内胆总管结石的449例患者临床资料,根据术中取石方式不同,分为网篮联合球囊组(161例)、单纯球囊组(94例)和单纯网篮组(194例),比较三组在一次性结石清除率、近期并发症发生率以及远期结石复发率等方面的差别。结果网篮联合球囊组、单纯球囊组和单纯网篮组一次性结石清除率分别为97.5%、94.7%和91.2%,网篮联合球囊组和单纯球囊组的一次性结石清除率均高于单纯网篮组,差异有统计学意义(P<0.05)。网篮联合球囊组、单纯球囊组和单纯网篮组内镜取石术后高淀粉酶血症发生率分别为14.9%、19.1%和9.8%,术后胰腺炎发生率分别为4.3%、6.4%和3.1%,出血发生率分别为0.6%、2.1%和2.6%,差异均无统计学意义(P>0.05)。网篮联合球囊组、单纯球囊组和单纯网篮组其胆总管结石复发率分别为1.9%、4.3%和7.7%,网篮联合球囊组和单纯球囊组的胆总管结石复发率均低于单纯网篮组,差异有统计学意义(P<0.05)。单独比较网篮联合球囊组和单纯球囊组其胆总管结石的一次清除率(97.5%vs.94.7%),术后高淀粉酶血症(14.9%vs.19.1%),胰腺炎发生率(4.3%vs.6.4%),出血发生率(0.6%vs.2.1%),胆总管结石复发率(1.9%vs.4.3%),网篮联合球囊组的一次性结石清除率稍高于单纯球囊组,近期并发症发生率和远期结石复发率稍低于单纯球囊组,但差异均无统计学意义(P>0.05)。结论对于内镜下去除10 mm以内胆总管结石时,选用网篮取石联合球囊廓清胆道对比单纯网篮或球囊治疗增加了一种取石器械,增加了手术步骤和时间,也增加了手术费用,但其具有较高的一次性结石清除率、较低的近期并发症发生率以及较低的远期结石复发率,从患者的疾病治愈和获益角度出发,在临床实际操作中建议选用网篮联合球囊取石的方式。

LC联合ESBD对胆囊结石合并胆总管结石的临床疗效分析

目的 探讨腹腔镜胆囊切除术(LC)联合内镜下十二指肠乳头括约肌小切开加球囊扩张术(ESBD)治疗胆囊结石(GS)合并胆总管结石(CBDS)对结石清除率及血清天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)、总胆红素(TBIL)的影响。方法 对内蒙古自治区人民医院2020年3月至2022年3月123例GS合并CBDS患者的临床资料进行回顾性分析,根据手术方法分为LC联合腹腔镜胆总管探查术(LCBDE)组(n=65)及LC联合ESBD组(n=58),比较两组结石清除率、术中及术后情况、手术前后肝功能指标、术后并发症及结石复发情况。结果 LC联合ESBD、LC联合LCBDE两组结石清除率分别为100.00%、95.38%,差异无统计学意义(P>0.05)。LC联合ESBD组术中出血量、腹腔引流管应用比例、下床活动时间均低于LC联合LCBDE组(均P<0.05),术后AST、ALT及TBIL均低于LC联合LCBDE组(均P<0.05);LC联合ESBD、LC联合LCBDE两组并发症发生率分别为8.62%、6.16%,差异无统计学意义(P>0.05);随访6个月,两组术后结石复发率分别为0和3.08%,差异无统计学意义(P>0.05)。结论 在GS合并CBDS的治疗中,LC联合LCBDE、LC联合ESBD均具有良好的结石清除效果,但LC联合ESBD的手术时间较短,能减少术中出血量,改善患者肝功能。