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).

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.

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 (&#x02265; 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (&#x0003c; 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

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

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

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.