单纯经内镜乳头球囊扩张术治疗胆总管结石的价值

目的初步研究单纯经内镜乳头球囊扩张术治疗胆总管结石的安全性和有效性。方法根据入选标准和排除标准,共纳入南京鼓楼医院集团宿迁市人民医院2017年1月—2018年12月期间住院的胆总管结石患者60例,按照随机数字表法将患者分为单纯经内镜乳头球囊扩张取石组(EPBP组,n=30)及经内镜乳头括约肌小切开联合球囊扩张取石组(ESBD组,n=30)。比较经内镜取石时间、X线暴露时间、一次性取石率、碎石率及术后急性胰腺炎发生率、术中及术后出血率等指标。结果EPBD组和ESBD组取石时间[（8.5±2.4）min 比（7.8±2.1）min, P=0.14]、X线暴露时间[（21.8±5.2）min 比 （19.7±6.3） min, P=0.11]相比,差异均无统计学意义。两组患者均一次性取完结石,无需要碎石器病例。两组ERCP术后急性胰腺炎发生率均为（6.67%,2/30）。EPBD组和ESBD组术中出血率[3.33%（1/30）比 10.00%（3/30）,P=0.042]、术后出血率[0 比 3.33%（1/30）,P=0.035]相比,差异均有统计学意义。两组均未发生其他近期并发症。结论单纯经内镜乳头球囊扩张术治疗胆总管结石安全、有效。     

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.     

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.     

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 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.     

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.     

十二指肠乳头切开术联合球囊扩张术在肝外胆管结石内镜治疗中的作用

目的 探讨十二指肠乳头切开术(EST)联合十二指肠乳头球囊扩张术(EPBD)在肝外胆管结石内镜治疗中的安全性及其疗效.方法 164例肝外胆管结石患者接受内镜取石治疗,其中78例取石前进行EST联合EPBD治疗(EST+ EPBD组),其余86例取石前进行单一EST治疗(EST组),对比分析2组并发症发生率、结石取净率和碎石发生率.结果 EST+ EPBD组出现高淀粉酶血症3例、轻症急性胰腺炎2例,EST组出现高淀粉酶血症5例、轻症急性胰腺炎3例、出血2例,2组均未出现重症急性胰腺炎、穿孔等严重并发症.EST+ EPBD组并发症发生率为6.4％( 5/78),略低于EST组的11.6％ (10/86)(x2=1.340,P=0.288);结石取净率为100.0％ (78/78),明显高于EST组的93.0％( 80/86)(x2=5.649,P=0.030);碎石发生率为33.3％( 26/78),明显低于EST组的60.5％(52/86)(x2=12.073,P=0.001).结论 EST联合EPBD应用肝外胆管结石内镜治疗中安全、有效,对于结石大、乳头条件差的患者效果尤其明显.     

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.     

Recurrence of bile duct stones after endoscopic papillary large balloon dilation combined with limited sphincterotomy: long-term follow-up study

Background/Aims

Endoscopic papillary large-balloon dilation combined with limited endoscopic sphincterotomy (EPLBD+ES) is promising for the treatment of common bile duct (CBD) stones. The aim of this study was to clarify the recurrence rate and the risk factors for CBD stones after EPLBD+ES.

Methods

In total, 100 patients who underwent EPLBD+ES from 2006 to 2007 were evaluated retrospectively. One hundred and nine patients who were treated with endoscopic sphincterotomy (ES) from 2004 to 2005 were set as the historical control group. Various risk factors for the recurrence of bile duct stones were analyzed.

Results

Of the 209 patients, the duration of follow-up was 32.5±4.5 months in the EPLBD+ES group and 31.8±6.0 months in the ES group. The recurrence rate of CBD stones was 11.0% (11/100) in the EPLBD+ES group and 13.8% (15/109) in the ES group (p=0.546). The cumulative recurrence rate of stones was not significantly different between the EPLBD+ES and ES groups (log rank, p=0.537). Univariate analysis showed that the diameter of the CBD (≥22 mm) was the only predictive variable that could differentiate recurrence from nonrecurrence in the EPLBD+ES group. Multivariate analysis revealed that the diameter of the bile duct was the only risk factor for stone recurrence (p=0.022; odds ratio, 1.175; 95% confidence interval, 1.023 to 1.348).

Conclusions

The recurrence rate of CBD stones after EPLBD+ES is comparable to that of the ES group, and a dilated CBD appears to increase the risk of bile duct stone recurrence.     

EST术联合EPBD术治疗非扩张性肝外胆管结石患者临床研究*

目的 探讨采用十二指肠镜下乳头括约肌切开（EST）联合十二指肠镜下乳头气囊扩张（EPBD）术治疗非扩张性肝外胆管结石患者的临床效果。方法 回顾性分析我院诊治的124例非扩张性肝外胆管结石患者的临床资料,联合组采用EST术联合EPBD术（n=49）、观察组采用单纯EST术（n=31）和对照组采用胆总管切开T管引流术（n=44）治疗。结果 术后48 h时,联合组血清淀粉酶水平为（107.1±34.6） U/L,超敏C-反应蛋白水平为（37.2±8.9） mg/L,观察组分别为（113.9±35.2） U/L和（38.1±9.4） mg/L,均显著低于对照组[分别为（221.5±54.8） U/L和（73.2±16.2） mg/L,P<0.05];联合组手术时间为（95.2±14.8） min,观察组为（113.6±12.7） min,均显著长于对照组[（84.8±12.1）,P<0.05];联合组胰腺炎和反流性胆管炎发生率分别为2.0%和4.1%,显著低于观察组的19.4%和22.6%或对照组的18.2%和22.7%（P<0.05）。结论 采用EST联合EPBD术治疗非扩张性肝外胆管结石患者操作易行,效果好,术后恢复快,近远期并发症发生率低,有较高的临床应用价值。     

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.     

内镜下乳头括约肌小切开术联合球囊扩张术治疗非扩张性肝外胆管结石患者疗效再研究

目的 分析采取内镜下乳头括约肌小切开术(EST)联合球囊扩张术(EPBD)治疗非扩张性肝外胆管结石患者的疗效及其血清淀粉酶(AMS)和环氧合酶-2(COX-2)水平的变化。方法 2017年7月～2019年5月我院肝胆外科收治的120例非扩张性肝外胆管结石患者,其中60例接受EST治疗,另60例接受EST联合EPBD治疗。结果 在术后7 d,联合组外周血白细胞(WBC)计数为(7.8±1.4)×10⁹/L,与对照组的(7.6±1.2)×10⁹/L比,差异无统计学意义(P>0.05),血清COX-2水平为(45.3±11.7)ng/mL,与对照组的(49.6±15.2)ng/mL比,差异无统计学意义(P>0.05),血降钙素原(PCT)水平为(0.4±0.3)μg/L,与对照组的(0.4±0.2)μg/L比,差异无统计学意义(P>0.05),C反应蛋白(CRP)水平为(8.7±2.9)mg/L,与对照组的(8.4±3.2)mg/L比,差异无统计学意义(P>0.05),肿瘤坏死因子-α(TNF-α)水平为(0.5±0.2)ng/mL,与对照组的(0.5±0.2)ng/mL比,差异无统计学意义(P>0.05),血清AMS水平为(60.1±16.7)U/L,与对照组的(58.7±15.3)U/L比,差异无统计学意义(P>0.05);术后,联合组并发症发生率为25.0%,与对照组的31.7%比,差异无统计学意义(P>0.05);联合组一次取石成功率为98.3%,显著高于对照组的86.7%,机械碎石率为5.0%和结石复发率为3.3%, 则均显著低于对照组(分别为16.7%和15.0%,P<0.05)。结论 EST联合EPBD治疗非扩张性肝外胆管结石患者能一次取净结石,而在EPBD的协助下不会加剧机体炎症反应,降低术后结石复发,值得临床进一步研究。     

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。     

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.     

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.     

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 not clear. 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.Methods: The records of patients with previous Billroth Ⅱ gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography(ERCP) between July 1, 2008 and September 1,2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events,and stone recurrence were analyzed.Results: A total of 83 patients with previous Billroth Ⅱ gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth Ⅱ gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients(85.7%). ERCP-related adverse events was in 3 ERCP procedures(5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients(12.2%) had stone recurrence after a median period of22.5 months(range 6–71 months) from the end of stone removal treatment. Female [odds ratio(OR) = 11.352; 95% confidence interval(95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy(OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.Conclusions: At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth Ⅱ gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.     

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.     

内镜下乳头括约肌小切开联合大球囊扩张治疗老年胆总管多发巨大结石的效果及安全性分析

目的评估经内镜下十二指肠乳头括约肌小切开(m EST)联合内镜下乳头大球囊扩张术(EPLBD)在老年患者胆总管多发巨大结石治疗中的安全性和有效性。方法回顾性分析2012年1月-2016年12月安康市中心医院因胆总管多发大结石在内镜中心行ERCP治疗的患者229例,根据患者结石大小及胆总管形态选择手术方式。所有纳入病例按照内镜手术方式不同分为m EST+EPLBD组(治疗组)与EST组(对照组),观察2组首次取石成功率,机械碎石使用率,取石时间及并发症发生率。计量资料组间比较采用t检验,计数资料组间比较采用χ~2检验。结果治疗组(136例)与对照组(93例)比较,2组在一次取石成功率上差异无统计学意义(91.17%vs 87.10%,χ~2=0.980,P>0.05);而在取石时间及机械碎石使用率方面比较差异有统计学意义[(18.2±4.3)min vs(37.4±6.7)min,χ~2=37.1526,P<0.01;6.71%vs 40.00%,t=24.411,P<0.01]。2组在胰腺炎(2.94%vs 6.45%)、出血发生率(2.21%vs 2.15%)方面比较差异无统计学意义(χ~2值分别为1.630、0.001,P值均>0.05),无穿孔及感染等并发症的发生。结论 m EST+EPLBD治疗老年胆总管多发巨大结石,疗效确切,可有效缩短取石时间,有效减少机械碎石的使用率,从而减少结石复发几率,同时该方法不增加ERCP术后并发症,是一种安全、有效的老年胆总管巨大多发结石微创治疗方法。     

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.