Endoscopic papillary large balloon dilation for large common bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) involves endoscopic biliary sphincterotomy (EBS) followed by balloon dilation using a 12–20-mm balloon to remove large or difficult stones from the common bile duct. The complications and limitations of endoscopic biliary sphincterotomy (EBS) are well known. Endoscopic papillary balloon dilation (EPBD) with a smaller diameter balloon but without sphincterotomy is widely used in a number of regions of the world for removal of routine bile duct stones and has been investigated as an alternative to EBS. EPBD, however, appears to be associated with an increased risk of pancreatitis. EPLBD differs from EPBD as it involves EBS followed by large balloon dilation. EPLBD would theoretically combine advantages of sphincterotomy and balloon dilation by increasing efficacy at stone extraction while minimizing complications of both EBS and EBD. A review of the available literature for EPBLD shows that it is relatively safe and effective. A high success rate (up to 95%) has been described for stone removal using EPLBD, with a low complication rate. Unlike EPBD, EBLBD does not appear to be associated with a higher risk of post-ERCP pancreatitis, probably because of separation of the biliary and pancreatic sphincters after EBS. EPLBD appears to be a reasonable option for removal of large or difficult common bile duct stones. This technique may be especially helpful in patients with difficult papillary anatomy, such as those with small papillae, intra- or peri-diverticular papilla. Its role in patients with coagulopathy or other risks for bleeding remains to be investigated.