内镜下乳头球囊扩张术对比乳头括约肌切开术治疗胆总管结石的Meta分析

目的 对比内镜下乳头球囊扩张术(EPBD)与内镜乳头括约肌切开术(EST)治疗胆总管结石的利与弊.方法 检索Cochrane Library、Embase、Medline、Pubmed、CBM、CNKI、VIP和万方数据库,没有语言限制.纳入从1983年1月到2012年9月间发表的比较EPBD与EST治疗胆总管结石的临床随机对照实验,并对其进行了质量学评价,最后用RevMan 5.1软件进行Meta分析.结果 18个临床随机对照实验符合研究标准(2385个研究对象).在第一次成功取石率、总成功取石率、穿孔、长期胆管炎发生率等方面EPBD与EST结果类似.EPBD有更高的危险发生胰腺炎(RR=1.99,95％ CI:1.41 ～2.81)和重症胰腺炎(RR =4.68,95％ CI:1.36～ 16.11),需要机械碎石的概率更高(RR=1.31,95％CI:1.14～ 1.50).相反的是,EPBD不但有明显低的出血率(RR=0.14,95％ CI:0.06 ～0.34),而且长期结石复发(RR =0.67,95％ CI:0.47～0.96),长期胆囊炎(RR =0.38,95％ CI:0.19 ～0.76)和总的长期并发症(RR =0.52,95％ CI:0.40 ～0.67)发生率更低.结论 考虑出血、结石复发或长期并发症的话,相对于EST,EPBD治疗胆总管结石是更好的选择;但后者胰腺炎尤其是重症胰腺炎的发生率更高.     

Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography is commonly performed to remove bile duct stones. The aim of this study was to determine short-term outcomes of endoscopic balloon dilation of the sphincter of Oddi compared with sphincterotomy for stone extraction. METHODS: A randomized, controlled multicenter study of 117 patients assigned to dilation and 120 to sphincterotomy was performed in a spectrum of clinical and academic practices. RESULTS: Characteristics of the patients, procedures, and endoscopists were similar except that dilation patients were younger. Procedures were successful in 97.4% and 92.5% of the dilation and sphincterotomy patients, respectively. Overall morbidity occurred in 17.9% and 3.3% ( P < .001; difference, 14.6; 95% confidence interval, 7-22.3) and severe morbidity, including 2 deaths, in 6.8% and 0%( P < .004; difference, 6.8; 95% confidence interval, 2.3-11.4) for dilation and sphincterotomy, respectively. Complications for dilation and sphincterotomy, respectively, included: pancreatitis, 15.4% and .8% ( P < .001; difference, 14.6; 95% confidence interval, 7.8-21.3); cystic duct fistula, 1.7% and 0%; cholangitis, .9% and .8%; perforation, 0% and .8%; and cholecystitis, 0% and .8%. There were 2 deaths (1.7%) due to pancreatitis following dilation and none with sphincterotomy. The study was terminated at the first interim analysis. Dilation patients required significantly more invasive procedures, longer hospital stays, and longer time off from normal activities. CONCLUSIONS: In a broad spectrum of patients and practices, endoscopic balloon dilation compared with sphincterotomy for biliary stone extraction is associated with increased short-term morbidity rates and death due to pancreatitis. Balloon dilation of the sphincter of Oddi for stone extraction should be avoided in routine practice.     

Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial

BACKGROUND: Little is known about the long-term outcome of endoscopic papillary balloon dilation for removal of bile duct stones. A randomized trial that compared long-term outcomes after endoscopic papillary balloon dilation and endoscopic sphincterotomy was conducted. METHODS: Thirty-two patients with bile duct stones were randomized to endoscopic papillary balloon dilation or endoscopic sphincterotomy, with 16 patients in each group. Endoscopic papillary balloon dilation was performed by using an 8-mm-diameter balloon; endoscopic sphincterotomy was performed in the standard manner. The success rates for stone removal, as well as the frequency and types of early (<15 days), mid-term (<1 year), and long-term (1-6 years) post-procedure complications were evaluated. RESULTS: The success rates for stone removal and early complication rates were similar for both groups. The frequency of stone recurrence was approximately 4-fold higher in the endoscopic papillary balloon dilation group (25%) vs. the endoscopic sphincterotomy group (6.3%) at mid-term evaluation. However, over the long term, Kaplan-Meier estimated probability of stone recurrence tended to be higher in the endoscopic sphincterotomy group vs. the endoscopic papillary balloon dilation group; recurrent stones were found in, respectively, 26.7% vs. 6.3%. Complications occurred in 7 patients in each group. CONCLUSIONS: Long-term outcome of endoscopic papillary balloon dilation for bile duct stone removal is satisfactory, provided that consideration is given to recurrence of stones by early follow-up evaluation.     

经内镜乳头括约肌切开术与气囊扩张术治疗胆总管结石临床评价

目的:评价经内镜乳头括约肌切开术(EST)和气囊扩张术(EPBD)联合机械碎石(EML)治疗胆总管结石的临床疗效．方法:选取我院住院胆总管结石患者60例,随机分成EST组(n=30)和EPBD组(n=30),分别采用EST和EPBD联合机械碎石进行内镜下取石．观察二组的治愈率,近期并发症、远期并发症．结果:正结果EST组与EPBD组的取石成功率为93．3％和90％．无显著性差异(P>0．05): 两组近期并发症发生率(包括胰腺炎、胆道感染、出血)为30％和13．3％,无显著性差异 (P>0．05);而远期并发症(包括胆道感染、结石复发)26．7％和3.3％,有显著性差异(P<0．05)．结论:EST和EPBD的结石清除率及近期并发症相似,但EPBD远期并发症的发病率较低, 表明EPBD能够在一定程度上保护Oddi括约肌功能。     

十二指肠乳头括约肌小切开联合气囊扩张治疗难治性胆总管结石的疗效评价

目的 探讨乳头括约肌小切开联合气囊扩张治疗难治性胆总管结石的效果和安全性.方法 将2008年3月至2009年12月收治的难治性胆总管结石患者随机分为两组,分别为乳头括约肌切开组及乳头括约肌小切开联合气囊扩张组,比较两组间结石取净率、取石次数、机械碎石使用率、并发症发生率.结果 两组间结石取净率、早期并发症发生率,差异无统计学意义（2/61比2/62,6/61比4/62;P＞0.05）;乳头括约肌切开组需多次及需要使用机械碎石才能取净结石的比例以高于乳头括约肌小切开联合气囊扩张组,率差异有统计学意义（15/61比5/62,12/6l比4/62;P＜0.05）.结论 乳头括约肌小切开联合气囊扩张与乳头括约肌切开两种方法同样安全有效;乳头括约肌小切开联合气囊扩张操作更简便.     

Endoscopic sphincterotomy and papillary balloon dilation for bile duct stones

BACKGROUND/AIMS: There are many reports of the results of endoscopic sphincterotomy (EST) for common bile duct stones. Recently, there were several reports on the results of endoscopic papillary balloon dilation (EPBD) for this condition. However, there have been few reports about a comparison between EST and EPBD. METHODOLOGY: Between Oct. 1994 and Dec. 1998, 196 consecutive patients underwent 102 EST or 94 EPBD. RESULTS: EST and EPBD were successful in 100 of 102 (98.0%), and all 94 patients. Bile duct clearance was achieved in 88 (88.0%) in the EST group and 88 (95.7%) in the EPBD group. Early complications occurred in 13 (13.0%: 3 acute pancreatitis, 4 cholangitis, 2 cholecystitis, 2 bleeding, 2 perforation) in the EST group and 16 (17.0%: 7 acute pancreatitis, 4 cholangitis, 4 cholecystitis, 1 basket impaction) in the EPBD group. Three patients (1 bleeding, 2 perforations) underwent emergent surgery after EST. CONCLUSIONS: The rate of bile duct clearance with EPBD was comparable to that with EST. Early complications did not differ between EST and EPBD. The use of EST tended to be associated with a lower incidence of acute pancreatitis, a higher incidence of bleeding, and a higher rate of perforation.     

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.     

Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials

AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials(RCTs) on Med Line, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy(ML), perforation and cholangitis. RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography(ERCP) bleeding [FE RD-0.02, CI(-0.03,-0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI(-0.25,-0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI(-0.38,-0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI(-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI(-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI(-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI(-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI(-0.02, 0.07), I2 = 11%, P = 0.31]. CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.     

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.     

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.     

内镜下十二指肠乳头小切开后球囊扩张术治疗胆总管结石的临床研究

目的探讨内镜下十二指肠乳头括约肌小切开后球囊扩张术在胆总管结石治疗中的有效性和安全性。方法将150例临床确诊为胆总管结石的患者随机分为乳头括约肌切开组(EST组)和乳头括约肌小切开后球囊扩张术组(SEST+EPBD组),比较两组疗效及并发症的发生率。结果 EST组和SEST+EPBD组取石成功率分别为92%和97%(χ2=1.19,P0.05)。EST组术后出现急性胰腺炎2例,出血4例,结石复发11例,逆行性胆道感染15例。SEST+EPBD组术后出现急性胰腺炎1例,出血1例,结石复发2例,逆行性胆道感染6例。两组取石成功率及近期并发症比较差异无统计学意义(P0.05),远期并发症比较差异有统计学意义(P0.05)。结论内镜下乳头括约肌小切开后球囊扩张术治疗胆总管结石安全、有效,并发症少,并且尽可能的保留了十二指肠乳头括约肌的功能,值得临床推广。     

乳头括约肌小切开联合大气囊扩张术在胆总管结石内镜治疗中的作用研究

目的 探讨乳头括约肌小切开联合大气囊扩张术在胆总管结石内镜治疗中的安全性和有效性.方法 83例胆总管结石行ERCP治疗患者采用随机数字表法随机分成2组,观察组42例接受乳头括约肌小切开联合大气囊扩张,对照组41例接受传统乳头括约肌切开,比较2组间结石取净率、取石次数、机械碎石率、操作时间及早期并发症发生情况.结果 观察组无一例穿孔,发生出血2例(4.8％)、胰腺炎5例(11.9％),总体并发症发生率为16.7％ (7/42);对照组发生穿孔1例(2.4％)、出血5例(12.2％)、胰腺炎3例(7.3％),总体并发症发生率为22.0％ (9/41);2组总的并发症发生率及每种并发症发生率比较差异均无统计学意义(P＞0.05).2组共有3例取石失败,其中观察组1例,对照组2例,其余患者均经1～2次ERCP取净结石,观察组结石取净率、机械碎石率、2次取石率、操作时间分别为97.6％ (41/42)、4.8％ (2/42)、2.4％( 1/42)和(29.2 ±5.3)min,对照组分别为95.1％ (39/41)、22.0％( 9/41)、19.5％( 8/41)和(38.8±4.3) min,2组结石取净率比较差异无统计学意义(P＞0.05),其他3项比较差异均有统计学意义(P＜0.05).结论 乳头括约肌小切开联合大气囊扩张术与传统乳头括约肌切开同样安全有效,但操作更为简便.     

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 sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: A prospective randomized controlled multicenter trial

BACKGROUND: Endoscopic papillary balloon dilatation may be an alternative to endoscopic sphincterotomy in the treatment of bile duct stones. However, there is a controversy as to the effectiveness and safety of endoscopic papillary balloon dilatation. METHODS: Two hundred eighty-two patients with bile duct stones were enrolled and randomized to an endoscopic sphincterotomy or endoscopic papillary balloon dilatation group. The success rate for duct clearance as well as the frequency and types of complications were evaluated prospectively. Endoscopic sphincterotomy was performed in a standard manner. Endoscopic papillary balloon dilatation was carried out with gradual inflation of a 4-, 6-, or 8-mm diameter balloon. RESULTS: Complete duct clearance was achieved in 100% in the endoscopic sphincterotomy group and 99.3% in the endoscopic papillary balloon dilatation group (not significant). Complications occurred in 11.8% of patients in the endoscopic sphincterotomy group and 14.5% of those in the endoscopic papillary balloon dilatation group (not significant). No complication was severe; there was no mortality. The frequency of acute pancreatitis was higher in the endoscopic papillary balloon dilatation group than the endoscopic sphincterotomy group (respectively, 10.9% vs. 2.8%; p < 0.045). Hemorrhage occurred only in the endoscopic sphincterotomy group. CONCLUSIONS: Endoscopic sphincterotomy and endoscopic papillary balloon dilatation were approximately equal in terms of successful clearance of bile duct stones. They were also similar with respect to overall complications. Endoscopic papillary balloon dilatation is an alternative to endoscopic sphincterotomy as a treatment of bile duct stones.     

Endoscopic biliary large-balloon dilation after endoscopic sphincterotomy for the treatment of large common bile duct stones. Case Report

Common bile duct (CBD) stones extraction is usually performed by endoscopic sphincterotomy followed by removal by either a Dormia basket or extraction balloon catheter. However, some stones due to their size are not amenable to these procedures and extracorporeal or mechanical lithotripsy devices need to be used. Mechanical lithotripsy involves usage of a basket that will be inevitably destroyed which increases cost to the patient and endoscopy unit. The use of extracorporeal wave shock lithotripsy is an alternative; however it is not available widely. Reports about the use of hydrostatic large caliber balloon dilator (HLCBD) aiding in the extraction of large caliber CBD stones have concluded that is a safe and feasible therapeutic alternative. We present the case of a 25 mm x 30 mm CBD stone that could not be extracted using conventional methods. CBD dilation using HLCBD was performed after endoscopic sphincterotomy in an attempt to avoid mechanical lithotripsy.     

Endoscopic papillary balloon dilation for treatment of common bile duct stones

BACKGROUND/AIMS: Use of endoscopic papillary balloon dilation (EPBD) for the treatment of common bile duct stones has increased in recent years, owing to its simplicity and its advantage of preserving sphincter function. It has been reported that EPBD is associated with a lower risk of bleeding, but a higher risk of pancreatitis than endoscopic sphincterotomy. However, there have been few reports on studies of post-EPBD pancreatitis. This report concerns the use of EPBD at our department for the treatment of common bile duct stones and early postoperative complications, with a focus on pancreatitis. METHODOLOGY: The study was conducted in 63 patients with choledocholithiasis, including 4 patients with cirrhosis and 21 patients with periampullary diverticula. The stones were extracted after EPBD conducted with an 8-mm dilatation balloon. RESULTS: Complete removal of stones was achieved in 53 out of 63 patients (84.1%). Pancreatitis meeting the criteria of Cotton et al. occurred in 7 of the 63 patients (11.1%), while 12 patients (19.5%) were affected when milder cases of pancreatitis were included. Severe pancreatitis occurred in 1 patient only. Cholangitis occurred in 3 patients (4.8%) and basket impaction occurred in 1 patient (1.6%), but no serious complications such as bleeding or perforation were encountered. CONCLUSIONS: These results suggest that EPBD is an effective procedure for the treatment of common bile duct stones, with a low risk of serious complications.     

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.     

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.