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 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 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.

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

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

Endoscopic papillary large balloon dilation alone or combined with small or complete sphincterotomy for the removal of large common bile duct stones

Background:Endoscopic papillary large balloon dilation(EPLBD)has been proposed as an alternative to manage large bile duct stones.However,EPLBD alone or combined with sphincterotomy remains controversial.Methods:Between Jan.2014 and Dec.2017,195 consecutive patients with proven large common bile duct stones(size≥10 mm)were retrospectively analyzed.We compared the baseline characteristics,procedure time,success rate of stone removal and morbidity outcomes in different groups.Results:There were no significant difference between baseline characteristics of the groups compared.A total of 89.2%,95.4%,and 93.8% of the patients in the EPLBD,EPLBD+small sphincterotomy(SES),and EPLBD+complete sphincterotomy(CES)groups had stones cleared(P=0.473),respectively.There was no difference in terms of procedure time(33.5±10.2,34.8±9.0,34.9±8.2,in the EPLBD,EPLBD+SES,and EPLBD+CES groups,respectively).However,when assigned to tvvo groups according to bile duct stones diameter(bile duct stones<13 mm,bile duct stones≥13 mm).in the bile duct stones<13 mm group,the procedure time was significantly less in the EPLBD group than the EPLBD+SES group and the EPLBD+CES group(P=0.028).In the bile duct stones≥13 mm group,the mechanical lithotripsy rate of EPLBD was significantly higher compared to EPLBD+SES or EPLBD+CES(P=0.032).The complication rates were similar among all groups.Conclusions:The diameter of bile duct stones should be taken into consideration when choosing EPLBD alone or combined with small sphincterotomy for the removal of common bile duct stones.

Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones:A literature review

Endoscopic sphincterotomy(ES)is the standard therapy in common bile duct(CBD)stones extraction.Large stones(≥12 mm)or multiple stones extraction may be challenging after ES alone.Endoscopic sphincterotomy followed by large balloon dilation(ESLBD)has been described as an alternative to ES in these indications.Efficacy,safety,cost-effectiveness and technical aspects of the procedure have been here reviewed.PubMed and Google Scholar search resulted in fortyone articles dealing with CBD stone extraction with12 mm or more dilation balloons after ES.ESLBD is at least as effective as ES,and reduces the need for additional mechanical lithotripsy.Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis,bleeding and perforation.However,particular attention should be paid in patients with CBD strictures,which is identified as a risk factor of perforation.ESLBD is slightly cost-effective compared to ES.A small sphincterotomy is usually performed,and may reduce bleeding rates compared to full sphincterotomy.Dilation is performed with 12-20 mm enteral balloons.Optimal inflation time is yet to be determined.The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy.ESLBD is effective and safe in the removal of large CBD stones,however,small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

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.

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.

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 papillary large balloon dilation for removal of bile duct stones

AIM:To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation(EPLBD)for bile duct stones in a multicenter prospective study.METHODS:Lithotomy by EPLBD was conducted in 124patients with bile duct stones≥13 mm in size or with three or more bile duct stones≥10 mm.After endoscopic sphincterotomy,the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.RESULTS:The success rate of first-time lithotomy was 86.3%(107/124)and the final lithotomy success rate was 100%(124/124).Lithotripsy was needed in10 of the 124(13.6%)patients.Adverse events due to the treatment procedure occurred in 6(4.8%)patients,all of which were mild.Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.CONCLUSION:It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.

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.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Endoscopic extraction of large common bile duct stones:A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate rapid,safe and effective bile duct stones extraction.Nowadays,endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients.Large common bile duct stones are treated conventionally with mechanical lithotripsy,while the most serious complication of the procedure is "basket and stone impaction" that is predominately resolved surgically.In cases of difficult,impacted,multiple or intrahepatic stones,more sophisticated procedures have been used.Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems,ultra-thin cholangio-scopes,thin endoscopes and ultimately using the novel single use,single operator SpyGlass Direct Visualization System,in order to deliver intracorporeal shock wave energy to fragment the targeted stone,with very good outcomes.Recently,large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials.When compared with mechanical lithotripsy or with balloon dilation alone,it proved to be superior.Moreover,dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic.Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of "impaction" because it seems that is an effective,inexpensive,less traumatic,safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists.When complete extraction of large stones is unsuccessful,the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy.Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective.The great majority of patients with large stones can be treated endoscopically.In cases of unsuccessful stone extraction using balloons,baskets,mechanical lithotripsy,electrohydraulic or laser lithotripsy and large balloon dilation,the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally 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 management of difficult common bile duct stones:Where are we now?A comprehensive review

Endoscopic management for difficult common bile duct(CBD)stones still presents a challenge for several reasons,including anatomic anomalies,patients’individual conditions and stone features.In recent years,variable methods have emerged that have attributed to higher stone removal success rates,reduced cost and lower adverse events.In this review,we outline a stepwise approach in CBD stone management.As first line therapy,endoscopic sphincterotomy and large balloon dilation are recommended,due to a 30%-50%reduction of the use of mechanical lithotripsy.On the other hand,cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence.As discussed,findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions.Furthermore,we evaluate the management of CBD stones in various surgical altered anatomy(Billroth II,Roux-en-Y and Roux-en-Y gastric bypass).Moreover,we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use,rather than following a failed management option.In addition,we discuss the importance of dissecting other techniques,such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed.In conclusion,we recognize that endoscopic sphincterotomy and large balloon dilation,mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones,but emerging techniques are in rapid evolution with encouraging results.

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.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

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.

Endoscopic treatment of difficult extrahepatic bile duct stones, EPBD or EST: An anatomic view

Large bile duct stone(> 10 mm) or multiple stones(≥ 3) are challenging for endoscopists. Endoscopic sphincterotomy(EST) is a routine therapeutic endoscopic retrograde cholangiopancreatography(ERCP) procedure usually used. It is safe and effective, but severe perforation or massive bleeding are the main causes of mortality. Because of the permanent destroy ofOddi sphincter, the use of EST is still controversial. Endoscopic papillary balloon dilation(EPBD) gives another way to open the sphincter. Less incidence of bleeding, perforation and partly preserving the Oddi sphincter's function are the main advantages. But high incidence of post-ERCP pancreatitis becomes a predominant problem. According to the anatomical feature of Oddi sphincter, limited EST + EPBD seems a more reasonable procedure. Compared to the former two procedures, it makes the stone extraction process much easier with lower incidences of short-term and long-term complications.

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.