Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: a meta-analysis

Background and Aim: Endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincterotomy (EST) are two common nonsurgical treatments endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. The aim of this study was to compare the efficacy and safety of EPBD and EST in the treatment for choledocholithiasis, confining the analysis to work reported in the last decade. Methods: The rate of overall postoperative complications was chosen as the primary outcome, and 10 other outcomes were secondary outcomes. Relative risk (RR) or Peto odds ratio (OR) were computed as the measures of pooled effects. We planned sensitivity analyses a priori for examining the change in robustness of the sensitivity to excluding studies with some inappropriate objects, technique defects or without full‐text acquisition. Results: For complete stone removal, EPBD was similar to EST (95% vs. 96%, P = 0.36) and overall postoperative complications (14.0% vs. 11.7%, P = 0.53). The incidence of post‐ERCP cholangitis (2.5% vs. 1.8%, P = 0.40), basket impaction (0.9% vs. 0%, P = 0.16) and perforation (0.0% vs. 0.4%, P = 0.17) were equivalent between EPBD and EST. On the other hand, EPBD caused more post‐ERCP pancreatitis (PEP) (9.4% vs. 3.3%, P < 0.00001), but less hemorrhage (0.1% vs. 4.2%, P < 0.00001). People undergoing EPBD required more use of endoscopic mechanical lithotripsy (35.0% vs. 26.2%, P = 0.0004). The results of sensitivity analyses showed no substantial change. Conclusion: EPBD is comparable to EST for stone extraction, though it requires more endoscopic mechanical lithotripsy (EML). EPBD may outweigh EST for patients with coagulopathy; however, it may cause more PEP.     

单纯经内镜乳头大球囊扩张治疗胆总管大结石的疗效及预后研究

目的 评估单纯经内镜乳头大球囊扩张（EPLBD）治疗胆总管大结石的疗效及预后。方法 山西省人民医院2016年8月至2017年11月收治的153例胆总管大结石（结石直径>1.0 cm）患者按随机数字表法随机分为两组：EPLBD组（n=83例）和经内镜乳头小切开联合大球囊扩张（ESLBD）组（n=70例）,比较两组患者的取石成功率,术中碎石率,术后近期并发症发生率及远期结石复发率。结果 EPLBD组和ESLBD组在总的、一次性结石取尽率方面差异无统计学意义[95.2%（79/83）比97.1%（68/70）,χ2=0.388,P=0.533;92.8%（77/83）比90.0%（63/70）,χ2=0.375,P=0.540]。EPLBD组碎石使用率与ESLBD组比较差异无统计学意义[25.3%（21/83）比35.7%（25/70）,χ2=1.958,P=0.162]。两组近期并发症发生率比较差异无统计学意义[43.4%（36/83）比40.0%（28/70）,χ2=0.178,P=0.673];两组均无术后穿孔病例。EPLBD组随访时间（22.7±4.3）个月,ESLBD组为（20.8±6.3）个月,两组胆总管结石累积复发率差异有统计学意义[2.4%（2/83）比15.7%（11/70）,P=0.003]。结论 EPLBD治疗胆总管大结石在取石成功率、碎石使用率、近期并发症发生率方面与ESLBD相当,远期结石复发率低于后者。单纯EPLBD治疗胆总管大结石安全有效。     

Technique of laparoscopic cholecystectomy combined with percutaneous papillary balloon dilatation under general anesthesia for cholecystocholedocholithiasis

Since the introduction of laparoscopic cholecystectomy (LC), the treatment of cholecystocholedocholithiasis has become a controversial issue among surgeons and endoscopists all over the world. We evaluated the effectiveness of LC combined with percutaneous papillary balloon dilatation (PPBD) under general anesthesia in the treatment of cholecystocholedocholithiasis in 22 patients. All stones in the bile duct were successfully evacuated into the duodenum in all patients. The PPBD was feasible in all patients under general anesthesia. The mean postoperative stay was 9 days. The overall length hospital stay and the duration of PTBD were 19 ± 7 days and 16 ± 8 days, respectively. There were no deaths nor major complications, although a transient hyperamylasemia was found in 10 patients (45%). Cholecystocholedocholithiasis was able to be treated by means of LC combined with PPBD under general anesthesia without laparotomy, sphincterotomy or choledochotomy. This technique can be a choice for the treatment that enables a patient to avoid any discomfort arisen as a result of papillary dilatation.     

Percutaneous transhepatic papillary balloon dilation as a therapeutic option for choledocholithiasis

Background

For choledocholithiasis, endoscopic therapy, including endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD), is now standard. However, the procedure of endoscopic therapy is very complicated and sometimes incomplete for reasons of anatomical anomalies. Therefore, we started performing percutaneous transhepatic papillary balloon dilations (PTPBD) instead of endoscopic therapy for choledocholithiasis 1 year ago for some selected patients. We report our technical methods of PTPBD.

Methods

First, percutaneous transhepatic cholangiodrainage (PTCD) was performed under ultrasound guidance. Via the drainage route, the balloon catheter was inserted until the common bile duct was reached. Then, cholangiography was performed and the stones were identified. The balloon was maintained in the inflated state with 4?ml air at the papilla of Vater for 3?min. Next, the stones were pushed out rapidly into the duodenum with the same balloon catheter. If the stone diameter was larger than 8?mm, then basket lithotripsy was performed before balloon dilation.

Results

Five patients underwent PTPBDs. The bile duct stones were successfully pushed out into the duodenum in all patients. The first three patients required two sessions for complete stone clearance due to technical problems; however, the last two patients needed only one session. There were no deaths and no complications.

Conclusions

We recommend that PTPBD might be a feasible and alternative therapeutic option for choledocholithiasis.

     

内镜下十二指肠乳头括约肌小切开术联合球囊扩张术治疗胆管结石的疗效观察

目的 探讨内镜下乳头括约肌小切开术（smallendoscopicsphincterotomy,SEST）联合球囊扩张术（endo—scopicpapillaryballoondilatation,EPBD）治疗胆管结石的远期疗效和并发症。方法选择青岛市海慈医疗集团消化内科2009年3月至2011年12月住院治疗的127例结石直径〉10mm的胆管结石患者,随机分为4组,SEST＋EPBD组33例,先行乳头括约肌小切开（切开范围小于乳头肌三分之一）,然后球囊扩张,再碎石取石;EPBD＋SEST组32例,先行球囊扩张术,再行乳头括约肌小切开,再碎石取石;EST组32例,仅行十二指肠乳头括约肌大切开（切开范围大于乳头肌三分之二）取石;EPBD组30例,仅行球囊扩张碎石取石。比较4组的疗效和并发症发生率。结果SEST＋EPBD组术后结石取净率为93．93％（31／33）,EPBD＋SEST组为93．75％（30／32）,EST组为96．77％（30／31）,EPBD组为66．67％（20／30）,EPBD组与其他三组比较差异有统计学意义（P〈0．05）;SEST＋EPBD组和EPBD＋SEST组均无远期并发症发生,EST组远期并发症发生率为16．67％,EPBD组为3．57％,EST组与其他三组比较有显著性差异（P〈0．05）。结论SEST与EPBD联合治疗胆管结石安全有效,可有效降低经内镜治疗胆管结石的远期并发症发生率,提高胆管结石患者术后的生活质量。     

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.     

Safeguards against acute pancreatitis associated with endoscopic papillary balloon dilatation

Background/Purpose

Endoscopic papillary balloon dilatation (EPBD) is one of the methods used to remove bile duct stones. EPBD may preserve the function of the sphincter of Oddi in spite of the potential risk of acute pancreatitis caused by the procedure. There are only few reports of attempts to reduce the risk of acute pancreatitis in EPBD.

Methods

We performed EPBD for bile duct stone removal in 201 patients. We used an 8-mm balloon followed by drip infusion of isosorbide dinitrate (ISDN) at a rate of 5?mg/h for low-pressure EPBD. The function of the minor duodenal papilla, the inflation pressure required for the disappearance of the notch sign in the bile duct, and the serum amylase level after EPBD were observed.

Results

The median serum amylase level after the procedure was 367?IU/l. Acute pancreatitis occurred in two patients (1.0%). The two patients with acute pancreatitis had poor function of the minor duodenal papilla, a high inflation pressure (over 5?atm) required for disappearance of the notch, sign, and severe abdominal pain during balloon inflation; as well, the procedure took a long time. The rate of duct clearance was 99.5%.

Conclusions

EPBD with gradual inflation of the balloon at a low pressure, followed by ISDN drip infusion, could decrease the risk of acute pancreatitis associated with the procedure. Poor function of the minor duodenal papilla, high inflation pressure required for disappearance of the notch, sign, severe abdominal pain, and a lengthy procedure increase the risk of acute pancreatitis after EPBD.     

Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy

AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis. METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term com-plications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyz-ing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined asP < 0.05. Risk of bias was evaluated us-ing a funnel plot. RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBDgroup were younger (OR=-1.16, 95%CI:-1.49 to 0.84, P<0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Com-pared with EST, the total stone clearance in the EPBD group decreased (OR=0.64, 95%CI: 0.42 to 0.96,P=0.03), the use of stone extraction baskets significantly increased (OR=1.91, 95%CI: 1.41 to 2.59, P<0.01), and the incidence of pancreatitis significantly increased (OR=2.79, 95%CI: 1.74 to 4.45, P<0.0001). The incidence of bleeding (OR=0.12, 95%CI: 0.04 to 0.34, P<0.01) and cholecystitis (OR=0.41, 95%CI: 0.20 to 0.84, P=0.02) significantly decreased. The stone re-currence rate also was significantly reduced in EPBD (OR=0.48, 95%CI: 0.26 to 0.90, P=0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis. CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone     

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.     

Comparison of endoscopic papillary balloon dilatation and sphincterotomy for lithotripsy in difficult sphincterotomy

BACKGROUND: Endoscopic papillary balloon dilatation is as effective as sphincterotomy for lithotripsy with a lower risk of hemorrhage, but a higher risk of pancreatitis has been reported. It has been suggested as an alternative to sphincterotomy when sphincterotomy is difficult because of periampullary diverticulum or prior sphincterotomy, but comparison with sphincterotomy in these conditions has not been studied. AIM: To compare the efficacy and safety between balloon dilatation and sphincterotomy for lithotripsy when sphincterotomy is difficult because of periampullary diverticulum or prior sphincterotomy. METHODS: Eighty patients with difficult endoscopic sphincterotomy because of periampullary diverticulum or prior sphincterotomy underwent balloon dilatation (n=46) or sphincterotomy (n=34) for lithotripsy. The success of stone clearance and complications were reviewed and compared. RESULTS: In the subgroup of periampullary diverticulum, balloon dilatation was more effective than sphincterotomy in stone clearance (100% vs. 84%, P=0.026). The rate of overall complications and pancreatitis (5.7% and 5.7%) was lower after balloon dilatation than after sphincterotomy (20% and 12%) (P=0.026 and 0.029, respectively). In the subgroup of prior sphincterotomy, no difference in efficacy or safety was noted between balloon dilatation and sphincterotomy. CONCLUSIONS: Balloon dilatation was more effective and safer than sphincterotomy for lithotripsy when sphincterotomy was difficult because of periampullary diverticulum. Balloon dilatation was as effective and safe as sphincterotomy after prior sphincterotomy. As balloon dilatation is easier to perform, it may be the preferred treatment when sphincterotomy is difficult because of periampullary diverticulum or prior sphincterotomy.     

Modified percutaneous transhepatic papillary balloon dilation for patients with refractory hepatolithiasis

BACKGROUND Some patients with hepatolithiasis cannot tolerate surgery due to severe cardiac or pulmonary comorbidities, or cannot be endoscopically treated because of altered gastrointestinal anatomies.AIM To propose a modified percutaneous transhepatic papillary balloon dilation procedure, and evaluate the clinical efficacy and safety of this modality.METHODS Data from 21 consecutive patients who underwent modified percutaneous transhepatic papillary balloon dilation with hepatolithiasis were retrospectively analyzed. Using auxiliary devices, intrahepatic bile duct stones were pushed into the common bile duct and expelled into the duodenum with an inflated balloon catheter. The outcomes recorded included success rate, procedure time, hospital stay, causes of failure, and procedure-related complications. Patients with possible long-term complications were followed up for 2 years.RESULTS Intrahepatic bile duct stones were successfully removed in 20(95.23%) patients. Mean procedure time was 65.8 ± 5.3 min. Mean hospital stay was 10.7 ± 1.5 d. No pancreatitis, gastrointestinal, or biliary duct perforation was observed. All patients were followed up for 2 years, and there was no evidence of reflux cholangitis or calculi recurrence.CONCLUSION Modified percutaneous transhepatic papillary balloon dilation was feasible and safe with a small number of patients with hepatolithiasis, and may be a treatment option in patients with severe comorbidities or in patients in whom endoscopic procedure was not successful.     

改良内镜下乳头气囊扩张术应用的可行性研究

目的探讨改良内镜下乳头气囊扩张术（EPBD）治疗胆管结石的可行性。方法对226例肝外胆管结石的患者应用肠道型柱状气囊行乳头扩张并在此基础上展开治疗，并比较2299例内镜乳头切开术（EST）的治疗效果及术后并发症情况。结果226例患者均顺利完成取石或碎石取石术，术后无胆道感染、穿孔等并发症，发生轻型急性胰腺炎4．7％（10例），与EST（5．2％）比较，差异无统计学意义，术后消化道出血0．47％（1例），与EST（1．2％）比较，差异有统计学意义。结论对EST困难或易发生并发症者用肠道型柱状气囊行EPBD术，能有效地钝性切割乳头，并在此基础上展开较大结石的取石或碎石取石术，同时并发症明显减少。EPBD是内镜下处理胆管结石安全有效的方法之一。     

经内镜乳头气囊扩张术治疗胆总管结石

目的探讨经内镜乳头气囊扩张术（ＥＰＢＤ）治疗胆总管结石的安全性和疗效。方法经内镜乳头气囊扩张术治疗胆总管结石８８例。其中单颗结石４５例,２颗结石３３例,３颗以上结石１０例,最多１例１２颗结石,选择结石直径为２～１２ｍｍ。结果治疗成功８５例,占９６．５％,失败３例。８１例采用网篮或取石气囊取出结石,４例采用金属碎石篮碎石后排出,１例改用内镜乳头括约肌切开术（ＥＳＴ）。７９例病人经ＥＰＢＤ后即取出结石,７例经２～３次再次取石后取净。术后出现胆管炎１例、胰腺炎１例,４４例术后行胃肠钡餐Ｘ线检查,胆道内无钡剂反流。结论经内镜乳头气囊扩张术是一种安全有效的方法,有望替代部分括约肌切开术。     

Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis

AIM:To evaluate the necessity of endoscopic nasobiliary drainage(ENBD)catheter placement after clearance of common bile duct(CBD)stones.METHODS:Patients enrolled in this study were randomly divided into two groups,according to whether or not they received ENBD after the removal of CBD stones.Group 1(ENBD group)was then subdividedinto three groups:G1a patients received an endoscopic papillary balloon dilatation(EPBD),G1b patients received an endoscopic sphincterotomy(EST),and G1c patients received neither.Group 2(non-ENBD group)patients were also subdivided into three groups(G2a,G2b,and G2c),similar to Group 1.The maximum CBD diameter,the time for C-reactive protein(CRP)to normalize,levels of serum amylase,total serum bilirubin(TB)and alanine aminotransferase(ALT),and postoperative hospitalization duration(PHD)were measured.RESULTS:A total of 218 patients(139 males,79females),with an average age of 60.1±10.8 years,were enrolled in this study.One hundred and thirteen patients who received ENBD were included in Group 1,and 105patients who did not receive ENBD were included in Group 2.The baseline clinical characteristics were similar in both groups.There were no significant differences in post-endoscopic retrograde cholangiopancreatography(ERCP)-related complications when Groups 1 and 2 were compared.Seventy-seven patients underwent EPBD,and41 received an ENBD tube(G1a)and 36 did not(G2a).Seventy-three patients underwent EST,and 34 patients received an ENBD tube(G1b)and 39 did not(G2b).The remaining 68 patients underwent neither EPBD nor EST;of these patients,38 received an ENBD tube(G1c)and 30 did not(G2c).For each of the three pairs of subgroups(G1a vs G2a,G1b vs G2b,G1c vs G2c),there were no significant differences detected in the PHD or the time to normalization of CRP,TB and ALT.In the EPBD group,the incidence of post-ERCP pancreatitis,hyperamylasemia and overall patient complications was significantly higher for G2a(post-ERCP pancreatitis:6/36vs 0/41,P=0.0217;hyperamylasemia:11/36 vs 4/41,P=0.0215;overall patient complications:18/36 vs 7/41,P=0.0029).CONCLUSION:After successful CBD stone clearance,ENBD is only beneficial when an EPBD procedure hasbeen performed.