Endoscopic Large Balloon Dilation Research Articles

Combined endoscopic large balloon dilation with limited sphincterotomy versus sole sphincterotomy for removal of large or multiple common bile duct stones

BackgroundEndoscopic papillary large balloon dilation (EPLBD) after sphincterotomy (EST) was introduced for the removal of large (≥ 10 mm) or multiple bile duct stones. This method combines the advantages of EST and EPLBD by increasing the efficacy of stone extraction while minimizing complications of EST and EPLBD when used alone. This prospective study aimed to compare between EPLBD with prior limited EST and sole sphnicterotomy for extraction of multiple and/or large common bile duct stones.ResultsStatistical analysis revealed insignificant difference between the studied groups as regards the presence of periamullary diverticulum (23% vs. 19%, P > 0.05) and the use of mechanical lithotripsy (4% vs. 9%, P > 0.05). The rates of overall and initial stone clearance were not significantly different between both groups [94% vs. 90%), P > 0.05; and 84% vs. 78%, P > 0.05, respectively]. The procedure-related pancreatitis and bleeding in EST/EPLBD group were lower compared to EST group (3% vs. 5%, P > 0.05; and 2% vs. 6%, P > 0.05, respectively). None of the studied groups’ patients died or developed procedure-related perforation or cholangitis.ConclusionEndoscopic large balloon dilation with prior limited sphincterotomy is an effective and safe endoscopic technique for removing multiple and/or large CBDSs.

Outcomes of endoscopic papillary large balloon dilatation in comparison to mechanical lithotripsy for large common bile duct stone

Background: The management of common bile duct stone (CBDS) has changed drastically over the past two decades, as open surgery has been supplanted by per-oral endoscopic procedures. Currently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the standard worldwide. After performing an endoscopic biliary sphincterotomy (EBST), endoscopic therapy entails CBDS extraction using conventional procedures. Lithotripsy is an endoscopic procedure used to remove CBDS that are too large to be extracted using conventional techniques.Aim: The aim of the present work is to compare the results of endoscopic large balloon dilatation and mechanical lithotripsy for large CBDS.Subjects and Methods: This prospective cohort study was conducted on 60 cases undergoing endoscopic retrograde cholangial pancreatography for large CBDS who were referred to out-case's clinic and in-case's wards of Gastroenterology, Hepatology and Endoscopy unit of Internal Medicine Department at Tanta University Hospitals December 2019 to February 2021. Cases were divided into two equal groups. Group I included cases undergoing endoscopic papillary large balloon dilatation (EPLBD) and Group II included cases undergoing mechanical lithotripsy (ML).Results: Success of CBDS extraction, Hb, PLT, TLC, albumin, PA, ALT, AST, creatinine and urea and CBDS parameters (diameter, CBDS size, CBDS number) after ERCP were insignificantly different between both groups. Total serum bilirubin, direct serum bilirubin and, Alkaline phosphatase after ERCP were significantly lower in EPLBD. However, Amylase and lipase were significantly higher in EPLBD.Conclusion: Despite that the endoscopic large balloon dilatation caused significantly higher pancreatitis, it showed lower TSB, DSB and ALP. However, both techniques showed no difference regarding the success of CBDS extraction and laboratory investigations.

Efficacy of endoscopic large balloon dilation extended for 2minutes in bile duct stone removal: A multicenter retrospective study.

There is no evidence regarding the optimal balloon dilation time during endoscopic papillary large balloon dilation (EPLBD). The study aim was to evaluate the efficacy of 2-minute extended balloon dilation for EPLBD. Two hundred and five patients who underwent EPLBD during endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones at three tertiary centers were included in the analysis. Clinical outcomes and the adverse events were compared between the 0-minute group (n=94, balloon deflated immediately after waist disappearance) and the 2-minute group (n=111, balloon dilation maintained for 2minutes after waist disappearance). The risk factors of post-ERCP pancreatitis (PEP) after EPLBD were assessed. There were no significant differences in the stone removal rates and hospitalization periods between the two groups. However, the total ERCP procedure time was significantly shorter in the 2-minute group (40.6 vs 48.9min, P=.03). The incidence of PEP was 7.4% in the 0-minute group and significantly lower at 0.9% in the 2-minute group (P=.04). Multivariate analysis identified without 2-minute extended EPLBD as a significant risk factor of PEP (OR: 9.9, P=.045). Extension of EPLBD for 2 minutes helped prevent PEP and shortened the procedure time.

Endoscopic management of difficult common bile duct stones.

Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy and the German Gastroenterological Society. This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones (DCBDS). For the treatment of DCBDS, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangioscopy or endoscopic ultrasound-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialized units.

Safety and Efficacy of Endoscopic Removal of Common Bile Duct Stones in Elderly Patients ≥90 Years of Age.

Objective We examined the safety and efficacy of endoscopic stone removal for choledocholithiasis in elderly patients ≥90 years of age with native papilla and compared the outcomes with those in patients 75-89 years of age. Methods This multicenter retrospective study included 569 patients 75-89 years of age and 126 patients ≥90 years of age who had native papilla and underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at 3 institutions in Japan between April 2012 and March 2018. The main outcomes assessed were the incidence of post-ERCP complications during hospitalization and outcomes of ERCP in patients ≥90 years of age. Results Biliary cannulation and subsequent endoscopic sphincterotomy, endoscopic balloon dilation, and endoscopic large balloon dilation were successful in 97.7% of patients 75-89 years of age and in 98.4% of patients ≥90 years of age. There was no significant difference in the incidence of post-ERCP complications between patients 75-89 years of age and those ≥90 years of age (7.7% vs. 9.5%, respectively; p=0.47). Although the rate of use of mechanical lithotripter was not significantly different, the rate of complete stone removal in patients ≥90 years of age was lower than that in patients 75-89 years of age (81.0% vs. 94.9%, respectively; p<0.001). In all cases with incomplete stone removal in both groups, permanent biliary stent placement was successful. Conclusion ERCP for choledocholithiasis in elderly patients ≥90 years of age is a safe and effective procedure; however, endoscopists should select appropriate strategies after considering each patient's medical condition and background.

Comparison between endoscopic sphincterotomy combined with large-balloon dilation and endoscopic large-balloon dilation alone in removal of large bile duct stones

Objective To compare the efficacy of endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) and that of LBD alone for large bile duct stones. Methods Data of 61 patients who received EST combined with LBD (the combination group) and 48 patients who received LBD alone (the LBD group) from February 2008 to November 2014 were collected. The efficacy and adverse events of two groups were compared. Results The procedure time from successful cannulating to complete stone removal was shorter in the LBD group than that in the combination group [17.3 min (8-35 min) VS 21.5 min (10-42 min), P=0.041]. There were no significant differences in overall complete stone removal rate[90.2% (55/61) VS 91.7% (44/48), P=1.000] and complete stone removal rate without mechanical lithotripsy[78.7% (48/61) VS 83.3% (40/48), P=0.542] in the combination group and the LBD group. Massive bleeding occurred in one patient of the combination group, but was successfully coagulated under endoscopy. There was no significant difference in the incidence of postoperative pancreatitis between the two groups[4.9% (3/61) VS 6.3% (3/48), P=1.000]. Conclusion EST combined with LBD offers no significant advantage over LBD alone for the removal of large bile duct stones. LBD can simplify the procedure compared with EST combined with LBD in terms of shortening the procedure time. Key words: Choledocholithiasis; Endoscopic large-balloon dilation; Endoscopic sphincterotomy

Tu1585 Does Using Balloons Larger Than 15 mm in Size Increase the Risk of Adverse Events in Endoscopic Large Balloon Dilation?

Tu1585 Does Using Balloons Larger Than 15 mm in Size Increase the Risk of Adverse Events in Endoscopic Large Balloon Dilation?

Su1639 Is Endoscopic Sphincterotomy Plus Large-Balloon Dilation a Better Option Than Endoscopic Large-Balloon Dilation Alone in Removal of Large Bile Duct Stones? a Retrospective Comparison Study

Su1639 Is Endoscopic Sphincterotomy Plus Large-Balloon Dilation a Better Option Than Endoscopic Large-Balloon Dilation Alone in Removal of Large Bile Duct Stones? a Retrospective Comparison Study

Su1636 Do Balloons Larger Than 15 mm in Size Increase the Risk of Adverse Events in Endoscopic Large Balloon Dilation?

Su1636 Do Balloons Larger Than 15 mm in Size Increase the Risk of Adverse Events in Endoscopic Large Balloon Dilation?

Endoscopic Large Balloon Dilation After Sphincterotomy: Is Perforation Risk an Alarming Issue?

I read with great interest the report by Park et al. [1] which described a multicenter, retrospective study that included 946 patients who underwent endoscopic papillary large balloon dilation (EPLBD) after sphincterotomy. In this study, 95 (10.0 %) patients exhibited adverse events including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six. Although the rate of duodenal perforation was similar to previous literature [2, 3], it was the most serious adverse event of EPLBD including one mild, four moderate and four severe cases (9.5 %). Three of the four patients with perforations of moderate severity and all four patients with fatal severe lateral wall perforations had underlying distal CBD strictures, a persistent balloon waist in the balloon during dilation, or a longsegment tapering distal CBD. Although distal CBD stricture (OR 17.083; 95 % CI 3.936–74.132, p \ 0.001) was an independent predictor of perforation, they suggested that never fully dilated waist might be one of the factors causing fatal perforation. The rate of distal stricture was 22/755 (2.9 %) in ‘‘patients with no adverse events’’ versus 8/93 (8.6 %) in ‘‘patients with adverse events’’ (Table 1 of mentioned article). To strengthen their conclusion of ‘‘never fully dilated balloon waist’’ as a factor for fatal perforation, I would like to know the procedural details of 22/755 ‘‘patients with no adverse events.’’ What was the rate of occurrence of balloon waist in those cases? Finally, I congratulate the efforts of the authors for detailed description of such a large study, especially with regard to thoughtful analysis of complications of ELBPD.

Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones

BackgroundEndoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) has been proposed as an alternative to manage large bile duct stones. However, recent reports indicate that LBD without EST may be safe and effective in this setting.MethodsOne hundred thirty-one patients with large common bile duct (CBD) stones 12 mm in size or larger underwent LBD alone (n = 62) or EST plus LBD (n = 69) for lithotripsy. The therapeutic outcome and complications were reviewed and compared.ResultsThere were no differences between the two groups with regard to age, size and number of stones, or bile duct diameter. The LBD alone group (mean age, 70.4 years) and the EST plus LBD group (mean age, 68.2 years) had similar outcomes in terms of overall successful stone removal (96.8% vs. 95.7%, P = 0.738) and complete stone removal without the need for mechanical lithotripsy (80.6% vs. 73.9%, P = 0.360). Complications in the LBD alone and EST plus LBD groups were as follows: pancreatitis (6.5% vs. 4.3%, P = 0.593), impaction of basket and stone (0% vs. 1.4%, P = 0.341), and perforation (0% vs. 1.4%, P = 0.341).ConclusionsLBD alone may be a simple, safe, and effective alternative to EST plus LBD in relatively aged patients with large CBD stones, and it can simplify the procedure compared with EST plus LBD.

Endoscopic large balloon dilation versus endoscopic sphincterotomy in patients with choledocholithiasis

We read with interest the article by Feng et al. [1] entitled ‘‘Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials’’, which discussed the efficacy and safety of endoscopic large balloon dilation (EPLBD) and endoscopic sphincterotomy (EST) for the treatment of choledocholithiasis. The authors tried to do a systematic review and metaanalysis of the ‘‘randomized controlled trials (RCT)’’ from several databases, two of which are actually retrospective studies [2, 3]. EST has been a standard endoscopic treatment for the removal of common bile duct (CBD) stones, but it is inclined to cause pancreatitis, bleeding, and perforation. Recently, EPLBD has been advocated as an alternative to EST for the management of CBD stones, though it may have a higher risk of post-ERCP pancreatitis (PEP). It remains controversial whether EPLBD is comparable to EST with regard to the feasibility and safety for the management of CBD stones, especially large or difficult stones. In this review, the authors demonstrated that EPLBD was equivalent to EST for the removal of large stones. However, among the seven included studies, only one compared EPLBD and EST, and the other six compared endoscopic balloon dilation following EST (ESLBD) and EST, which is another serious issue. The combination of these two kinds of studies is not recommended by the Cochrane handbook, because it will cause unknown biases by combining ‘‘apples’’ with ‘‘oranges’’ [4]. Furthermore, ESLBD is a different endoscopic treatment for choledocholithiasis, which can combine the merits of EPLBD and EST. Therefore, it is inappropriate to draw the conclusion by summarizing the results from studies comparing ESLBD versus EST and EPLBD versus EST. Endoscopic mechanical lithotripsy (EML) will be needed as a remedy when stones fail to be removed, a problem which has been found to be reduced in the EPLBD group. However, the enrolled study by Stefanidis [5] applied EML to all the patients of the EST group but none of the EPLBD group, which will probably increase the overall usage of EML in the EST group. Post-ERCP hemorrhage is another serious complication after sphincterotomy or balloon dilation, the risk of which was found to be lower in the EPLBD group. However, nine patients with uncorrected coagulopathy were enrolled in the study by Garcia-Cano [3] and thus it should be excluded from Feng’s study, or sensitivity analysis should be done to explore whether it was biased and able to be included in the meta-analysis.

The Effect of Periampullary Diverticulum on the Outcome of Bile Duct Stone Treatment with Endoscopic Papillary Large Balloon Dilation

Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment. We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed. PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9±11.1 years. Mean diameter of the stones was 14.8±6.0 mm and mean diameter of CBD was 21.6±7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (≥15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups. PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.

Large-diameter balloon sphincteroplasty for removal of bile duct stones： a prospective and randomized study from two endoscopy centers

Objective To investigate the efficiency and safety of endoscopic large balloon dilation following small sphincterotomy （ESBD） for treatment of common bile duct （CBD） stones, and to prospectively compare it with traditional sphincterotomy （ES）. Methods Patients with single or multiple calculi in extra-hepatic bile ducts and with the diameter of CBD larger than 13 mm, were randomized into 2 groups to receive maximal sphincterotomy （ES group）, or partial sphincterotomy plus sphincteroplasty with 15mm-balloon （ESBD group）, respectively, followed by conventional stones removal and/or lithotripsy. The success rate of stone clearance, operation time and related complications were observed. Results A total of 86 patients were enrolled in 2 endoscopy centers, with 2 excluded because of papillary pre-cut in 1 and non-compliance with the protocol in the other, and were randomly divided into groups ES and ESBD, with 42 patients in each. The clinical characteristics, including average diameter of CBD, size and quantity of calculi, and incidences of peri-ampullary diverticulum, of patients in both groups were all similar. Stones clearance with single session in 2 groups were 88% and 93%, respectively （P =0. 531 ）. The operation time were （25.76 ± 12. 74） min and （26. 38 ± 12. 86） min （ P = 0. 825 ）. The rate of mechanical lithotripsy was 36% and 25%, respectively （P=0. 363）. Complications occurred in 5 cases in ES group （3 mild, 2 medium）, and 2 mild complications occurred in ESBD group （no statistical difference）. No death happened in any group.Conclusion ESBD is an effective method for clearance of extra-hepatic bile duct stones with the similar safety, compared with traditional sphincterotomy. It could be an optimal alternative for those with large stones or difficult sphincterotomy. Key words: Common bile duct stone; Sphincterotomy, endoscopic; Balloon dilatation

T1542: Late Complications and Stone Recurrence Rate After Endoscopic Removal of Large Bile Duct Stones by Endoscopic Sphincterotomy and Large Balloon Dilatation Are Similar to Those of Endoscopic Sphincterotomy Alone

Combined endoscopic sphincterotomy and endoscopic large balloon dilatation (EST-LBD) is a safe alternative treatment for removing large bile duct stones that cannot be extracted by endoscopic sphincterotomy (EST) alone. But, long-term complications or stone recurrence rate after EST-LBD is unknown yet.