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 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.     

Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation(EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography(ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis(PEP). However, as the efficacy of endoscopic papillary largeballoon dilatation(EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy(EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.     

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.     

Which Is the Better Treatment for the Removal of Large Biliary Stones? Endoscopic Papillary Large Balloon Dilation versus Endoscopic Sphincterotomy

Background/Aims

We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST).

Methods

A total of 1,580 patients who underwent endoscopic CBD stone extraction between January 2001 and July 2010 were reviewed. The following inclusion criteria were applied: choledocholithiasis treated by EPLBD with minor EST or EST with mechanical lithotripsy; and follow-up >9 months after treatment.

Results

Forty-nine patients with EPLBD and 41 with EST were compared. There was no significant difference in the complication rates and stone recurrence rates between the two groups. However, significantly more endoscopic retrograde cholangiopancreatography (ERCP) sessions were required in the EST group to achieve the complete removal of stones (1.7 times vs 1.3 times; p=0.03). The mean cost required for complete stone removal per patient was significantly higher in the EST group compared to the EPLBD group (USD $1,644 vs $1,225, respectively; p=0.04). Dilated CBD was the only significant factor associated with recurrent biliary stones (relative risk, 1.09; 95% confidence interval, 1.02 to 1.17; p=0.02).

Conclusions

EPLBD is the better treatment (compared to EST) for removing large CBD stones because EPLBD requires fewer ERCP sessions and is less expensive.     

不同内镜术式治疗胆总管结石青年患者的长期随访研究

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者,按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组,进行随访,统计近期（≤3年）及远期（〉3年）结石复发率,并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月,54例（16．5％）结石复发,其中近期复发35例（10．7％）,远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％）,但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％）,差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明,胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05）,而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者,单纯EPBD取石固然可保留乳头括约肌功能,但增加了结石的远期复发风险,而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。     

ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION AFTER ENDOSCOPIC SPHINCTEROTOMY FOR TREATMENT OF LARGE COMMON BILE DUCT STONE

The extraction of large common bile duct (CBD) stones after an endoscopic sphincterotomy is successful in most cases. However, the procedure often requires a prolonged time and repeated trials, therefore, subsequent occurrence of procedure‐related complications are not uncommon. The purpose of the present paper was to investigate the utility of a combined endoscopic papillary large balloon dilation (EPLBD) preceded by a mid‐incision endoscopic sphincterotomy for the removal of large CBD stones. Stone removal was surprisingly effective with EPLBD in patients with large CBD stones. Occurrence of major complication, such as pancreatitis, bleeding, and perforation, was not observed in any patients who were treated with EPLBD. EPLBD also can be safely carried out on patients with anatomic alteration, such as a periampullary diverticulum, and on patients who have undergone a Billroth II operation. EPLBD is a landmark method of removing a large CBD stone, the impact of which is comparable to that of the introduction of endoscopic mechanical lithotripsy. However, further investigation is required to address the applications and potential outcomes of this procedure. Also, procedure guidelines should be established to avoid major complications.     

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.     

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 Dilation for the Retrieval of Bile Duct Stones After Prior Billroth II Gastrectomy

Background/Aims:

Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.

Materials and Methods:

From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.

Results:

Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.

Conclusions:

EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.     

Endoscopic papillary large balloon dilation in Billroth II gastrectomy patients with bile duct stones

Background and Aims: Patients with Billroth II (B‐II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B‐II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B‐II gastrectomy. Methods: Twenty‐six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B‐II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10–15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated. Results: In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1–3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation. Conclusions: Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B‐II gastrectomy.     

Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy

AIM： TO introduce a new method： small endoscopic sphincterotomy （ES） combined with endoscopic papillary large balloon dilation （SES ＋ EPLBD） to treat patients with large biliary stones.
METHODS： Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 ± 3 mm and mean number of stones was 2.5 ± 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket.
RESULTS： Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 ± 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis （1%） occurred.
CONCLUSION： SES ＋ EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.     

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比较

目的 探讨内镜下乳头球囊扩张术(EPBD)治疗胆总管结石的有效性和安全性.方法 2005年6月至2007年5月山东大学齐鲁医院320例拟行内镜下取石的胆总管结石患者,随机分为EPBD组及内镜下乳头括约肌切开术(EST)组,每组160例.EPBD组在乳头球囊扩张后用取石网篮或气囊取石,当结石较大时先行机械碎石网篮碎石后再取石;EST组按常规操作.两组术后均常规鼻胆管引流3 d,并造影复查.结果 EST组及EPBD组分别有156例(97.5%)及157例(98.1%)成功取净结石,其中各有112例(70.0%)及104例(65.0%)一次完成;机械碎石网篮应用比例分别为20.0%(32/160)和22.5%(36/160);术后早期并发症的总发生率分别为5.6%及8.1%,无死亡病例.随访3年,EST组胆管结石复发率(7.5%)高于EPBD组(2.5%),P＜0.05.结论 EPBD取石具有与EST取石相近的成功率,经术后常规鼻胆管引流处理后,胰腺炎发生率无明显升高.EPBD可以作为胆总管结石的备选治疗措施,尤其是对不适于EST的患者.

Abstract：

Objective To explore the effectiveness and safety of endoscopic papillary balloon dilation( EPBD ) for the removal of common bile duct stones. Methods Three hundred and twenty consecutive patients with common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP) who met all eligibility criteria were randomly assigned endoscopic sphincterotomy (EST) or EPBD.Complications were classified by an expert panel unaware of treatment allocation and outcome. Results After a single ERCP, all stones were removed from 112 patients ( 70% ) assigned EST and 104 ( 65% )assigned EPBD. Mechanical lithotripsy was used to fragment stones in 36 (22. 5% ) EPBD procedures and 32 ( 20. 0% ) EST procedures. Early complications occurred in 5.6% EST patients and 8.1% EPBD patients. No patient died. Gallstone disease recurrence, which is a long-term complication, is 7. 5% ( 12/160) in EST patients and 2.5% (4/160) in EPBD patients, P ＜0. 05. Conclusions The success rate of EPBD was similar to that of EST. We found no evidence of previously suggested higher risk of pancreatitis with EPBD, and suggest that EPBD is preferred in patients who are not suitable for EST, such as those with high risk of bleeding. This procedure is a valuable alternative to EST in patients with bile duct stones.     

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.     

Small sphincterotomy combined with endoscopic papillary large balloon dilation vs sphincterotomy alone for removal of common bile duct stones

AIM: To evaluate the efficacy and safety of endoscopic papillary large diameter balloon dilation (EPLBD) following limited endoscopic sphincterotomy (EST) and EST alone for removal of large common bile duct (CBD) stones.METHODS: We retrospectively compared EST + EPLBD (group A, n = 64) with EST alone (group B, n = 89) for the treatment of large or multiple bile duct stones. The success rate of stone clearance, procedure-related complications and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.RESULTS: There was no statistically significant difference between the two groups regarding periampullary diverticula (35.9% vs 34.8%, P > 0.05), pre-cut sphincterotomy (6.3% vs 6.7%, P > 0.05), size (12.1 ± 2.0 mm vs 12.9 ± 2.6 mm, P > 0.05) and number (2.2 ± 1.9 vs 2.4 ± 2.1, P > 0.05) of stones or the diameters of CBD (15.1 ± 3.3 mm vs 15.4 ± 3.6 mm, P > 0.05). The rates of overall stone removal and stone removal in the first session were not significantly different between the two groups [62/64 (96.9%) vs 84/89 (94.4%), P > 0.05; and 58/64 (90.6%) vs 79/89 (88.8%), P > 0.05, respectively]. The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia were not significantly different between the two groups [3/64 (4.7%) vs 4/89 (4.5%), P > 0.05; 7/64 (10.9%) vs 9/89 (10.1%), P > 0.05, respectively]. There were no cases of perforation, acute cholangitis, or cholecystitis in the two groups. The rate of bleeding and the recurrence of CBD stones were significantly lower in group A than in group B [1/64 (1.6%) vs 5/89 (5.6%), P < 0.05; 1/64 (1.6%) vs 6/89 (6.7%), P < 0.05, respectively].CONCLUSION: EST + EPLBD is an effective and safe endoscopic approach for removing large or multiple CBD stones.     

Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones

Background This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department. Methods One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications. Results The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group. Conclusions Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.     

Efficacy and safety of low-pressured and short-time dilation in endoscopic papillary balloon dilation for bile duct stone removal

Background and Aim:  Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for bile duct stones. However, studies have shown that EPBD may increase the risk for pancreatitis. Pancreatitis after EPBD is believed to be related to papillary damage after balloon dilation. We changed the dilation method to a theoretically less hazardous one. This modified dilation method was compared with the initial method.
Methods:  A total of 324 patients with bile duct stones underwent EPBD by the modified method between June 1999 and June 2003. Three hundred and twenty-four patients undergoing EPBD by the initial method served as a historical control group. The success rate of stone removal and the incidence of procedure-related pancreatitis were compared between the two groups. In the modified method, the balloon was inflated until disappearance of the balloon waist, and the pressure was then maintained for 15 s. In the initial method, the balloon was inflated at 8 atmospheres for 2 min.
Results:  Bile duct stones were successfully removed in 313 of 324 patients (96.6%) in the modified group and in 314 of 324 patients (96.9%) in the initial group (not significant). The incidence of postprocedure pancreatitis showed a lower tendency in the modified group (4.0%, 13/324) than in the initial group (7.4%, 24/324) ( P -value = 0.0626). The severity of pancreatitis was significantly reduced in the modified group.
Conclusion:  The modified method of EPBD is feasible for extraction of bile duct stones, and may potentially decrease the incidence of severe post-EPBD pancreatitis.     

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.     

两种胆总管结石手术的临床疗效比较

目的观察内镜下乳头小切开术(EST)联合球囊扩张术(EPBD)治疗胆总管结石的效果。方法选取192例胆总管结石患者随机分为EST组和EST+EPBD手术组各96例。对这两种手术的疗效进行评价。结果两组间平均手术时间、住院时间比较,EST+EPBD组均明显减少;一次性取石成功率及总取石成功率比较,EST+EPBD组均明显高于EST组。两组出血、胰腺炎、胆管内钡剂反流、结石复发等多项并发症比较,差异均有统计学意义(P0.05),EST+EPBD组术中、术后并发症显著减少。结论EST联合EPBD可极大地提高胆总管结石取石成功率和减少术后并发症,安全且疗效满意。     

内镜下乳头球囊扩张术治疗胆总管结石的安全性和长期疗效

背景内镜下乳头球囊扩张术(endoscopic papillary balloon dilation,EPBD)是治疗胆总管结石(common bile duct stones,CBDSs)-种有效方法,但其安全性及长期疗效却缺乏评价.本研究拟分析EPBD治疗CBDSs的安全性和长期疗效.目的评估EPBD治疗CBDSs的安全性和长期疗效.方法分析我院2014-01/2015-12期间收治的CBDSs患者行EPBD的资料.主要观察指标为CBDSs清除率、内镜下逆行性胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)相关并发症和CBDSs复发率.结果42例CBDSs患者进行了EPBD,全部患者均完成了结石清除(100%).ERCP相关并发症发生4例(4/45,8.8%),均为术后胰腺炎,没有穿孔、出血及胆管炎的发生.在随后进行平均时间为51.8 mo(18-66 mo)随访中,10例(10/42,23.8%)患者CBDSs复发.单因素分析提示女性(比值比=22.891,95%可信区间:1.544-339.362,P=0.023)是结石复发的危险因素.结论EPBD治疗CBDSs是安全和有效的.长期随访发现,女性可能是结石复发的危险因素.