Endoscopic Mechanical Lithotripsy Research Articles

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial.

Mechanical lithotripsy produces stone fragments that are not easily detected by cholangiography and is a potential cause of recurrence of common bile duct stones (CBDS). This study aims to clarify whether 100ml saline irrigation after mechanical lithotripsy reduces the recurrent rate of CBDS. In this randomized controlled trial performed at the Surgical Endoscopy Center, the First Hospital of Lanzhou University between May 10, 2019, and Dec 31, 2020, patients undergoing endoscopic mechanical lithotripsy were randomly assigned to receive saline irrigation (study group) or no irrigation (control group). The saline irrigation was given 100ml saline pulse irrigation after cholangiography showed no residual stones. Patients were followed up for at least 24 months after endoscopic stone removal to assess the recurrence of CBDS. This study was registered with ClinicalTrials.gov (NCT03937037). During the median follow-up period of 35.6 months (interquartile range, 26.0-40.7), 43 of the 180 patients had stone recurrence (24%). The frequency of recurrence of CBD stones was 12.22% in the saline irrigation group and 35.56% in the control group, with a difference of 23.33% between the two groups (95% confidence interval [CI], 11.35%-35.32%, p<0.001). Multivariable Cox proportional hazards analyses showed that constipation (hazard risk [HR] 2.42; 95% CI, 1.22-4.80, p=0.012), periampullary diverticulum (PAD) (HR 3.06; 95% CI, 1.62-5.79, p<0.001), and total to direct bilirubin ratio (HR 1.48; 95% CI, 1.21-1.81, p<0.001) were independent risk factors for the recurrence of CBDS. Saline irrigation was the only preventive factor for the recurrence of CBDS (HR 0.22; 95% CI, 0.11-0.44, p<0.001). For patients with CBDS requiring mechanical lithotripsy, 100ml saline irrigation effectively reduces the recurrent rate of CBDS after endoscopic stone removal. This work was supported by National Natural Science Foundation of China (32160255); Natural Science Foundation of Gansu Province (22JR5RA898, 20JR10RA676); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043).

Immediate or Interval Endoscopic Papillary Large-balloon Dilation after Limited Endoscopic Sphincterotomy for Bile Duct Stone Removal.

Objective Endoscopic papillary large-balloon dilation (EPLBD) with limited endoscopic sphincterotomy (EST) is widely used for removing multiple large common bile duct (CBD) stones. However, the safety and effectiveness of immediate EPLBD after limited EST and EPLBD at an interval after limited EST is unclear. Thus, this multicenter retrospective study was conducted to examine this matter. Methods Propensity score-matching was performed to adjust the baseline characteristics between the immediate and interval EPLBD groups. We compared the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications and the early outcomes of ERCP between the 2 matched groups, which comprised 66 patients each. Results The complete stone clearance rate in each study group was 100%. The overall incidence of post-ERCP complications in the propensity score-matched interval and immediate EPLBD groups was 3/33 (9.1%) and 1/33 (3.0%), respectively (p=0.61). The immediate EPLBD group had significantly fewer mean ERCP sessions for complete stone removal and a significantly lower rate of endoscopic mechanical lithotripsy (EML) usage than the interval EPLBD group [1.6 vs. 2.4 sessions, p<0.001; and 4/33 (12.1%) vs. 12/33 (36.4%), p=0.042, respectively]. Conclusion The incidence of post-ERCP complications in the immediate EPLBD group was not significantly different from that in the interval EPLBD group. Compared with interval EPLBD, immediate EPLBD may result in a reduced number of ERCP sessions for complete stone clearance and reduce the rate of EML usage.

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.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10mm, cholesterol stone, maximum diameter of CBD >15mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10mm, and EML were related to postoperative CBD stones after cholecystectomy. Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique.

ABSTRACTMechanical lithotripsy is one of the well-known rescue methods for impacted common bile duct (CBD) stones. A fractured Dormia basket with a captured stone is an unusual complication and poses a special management problem. In the past, surgical intervention was the standard method. Various nonsurgical techniques have been reported. If the impaction is at the level of the papilla, extending the sphincterotomy might be sufficient. Stent insertion, endoscopic mechanical lithotripsy, extracorporeal shock wave lithotripsy, endoscopic laser lithotripsy, and transhepatic choledochoscopic lithotripsy have all been reported. In this case, we used a second basket, which is readily available and less expensive, as a rescue technique.How to cite this articleKhamaysi I, Hajj E. Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique. Euroasian J Hepato-Gastroenterol 2020;10(1):45–46.

Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography.

Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papil-lary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increas-ingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enter-oscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disad-vantages of each technique for better management of bile duct stones.

2170 Endoscopic Management of Gastric Outlet Obstruction Due to a Large Gallstone ("Bouveret's Syndrome")

INTRODUCTION: Bouveret's syndrome is referred to a gastric outlet obstruction due to an impacted gallstone in the duodenum following cholecystoduodenal fistula. Surgery is required in certain cases, but the mortality rate is up to 30 %. Endoscopic management has been reported with a low success rate. We demonstrate a successful endoscopic mechanical and electrohydraulic lithotripsy of a large gallstone causing gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 88 years old female presented with a three-day history of right upper quadrant abdominal pain (RUQ), nausea, and non-bilious vomiting. Past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes. Vital signs were normal. Pertinent findings included tenderness to palpation in the epigastric and RUQ regions, normal bowel sounds, and a loud succession splash. Labs revealed Hgb 10.2 g/dl, WBC 7k/mm3, platelets 289k/mm3, BUN 13 mg/dl, creatinine 0.6 mg/dl. Plain abdominal X-ray showed round calcified structure in the right mid abdomen (Figure 1). CT scan of the abdomen showed 4 cm × 3.5 cm gallstone causing complete obstruction of the duodenum, cholecystoduodenal fistula, pneumoperitoneum, and distended stomach (Figure 2). Upper endoscopy revealed a large gallstone impacted in the first part of the duodenum, extensive ulceration of the duodenal wall with a small perforation at the site of stone impaction (Figure 3). Mechanical and electrohydraulic lithotripsy was performed, and the stone was fragmented into small pieces in the duodenum. There was spontaneously sealed duodenal perforation with fat and omental plug. The endoscopic lithotripsy was performed without difficulty. The patient was improved, tolerated an oral diet, and discharged home in a stable condition. DISCUSSION: Bouveret’s syndrome is a rare cause of gastric outlet obstruction and characterized by impaction of a gallstone within the pylorus or duodenum. It occurs mostly in elderly, female patients with an average age of 70 years. Given that most patients are elderly with multiple comorbidities, they are poor surgical candidates. The endoscopic approach is considering to be a good alternative. As we demonstrated in our case, these patients can be successfully managed endoscopically with lithotripsy despite the low success rate that was reported in the literature. Endoscopic treatment is effective and safer and should be considered as a first line option.

Treatment of acute cholangitis caused by benign processes in the major duodenal papilla

Objective: to improve the surgical treatment of acute cholangitis caused by benign tumors in the area of the major duodenal papilla.Material and methods. Analysis of the surgical treatment of 83 patients with acute cholangitis arising from benign diseases in the area of the major duodenal papilla was made. Among them, there were 49 men and 34 women. The average age of patients was 49.7 ± 6.9 years. According to the nosological forms, it looked as follows: papillary stenosis — 51, adenomas of the major duodenal papilla — 13, parapapillary duodenal polyps — 12, diverticulum of the duodenum in the area of the major duodenal papilla — 5, peptic duodenal ulcer — 2.Results. Acute cholangitis in papillary stenosis, adenoma of the major duodenal papilla, parapapillary polyps was eliminated using endoscopic transduodenal techniques with the removal of the immediate cause of acute cholangitis. For this used endoscopic papillo-sphincterotomy, endoscopic mechanical lithotripsy, lithoextraction, electroexcision of polyps and adenomas. Among 83 patients, 19 (22,9%) patients had to perform 2 or more endoscopic transpapillary interventions. The greatest difficulties were in the cannulation of the major duodenal papilla in patients with parapapillary ulcers and duodenal diverticulum. Two patients underwent laparoscopic and two patients underwent open surgical interventions. Among 83 patients treated with acute cholangitis on the background of benign pathology of the major duodenal papilla, 11 (13,3%) had different complications. Conclusions. Acute cholangitis in papillary stenosis, adenoma of the major duodenal papilla and parapapillary polyps with concomitant choledocholithiasis can be completely treated exclusively with endoscopic interventions (if necessary — multiple) with a small number of complications (13,3%). Treatment of acute cholangitis on the background of parapapillary ulcers and duodenal diverticulum in most cases requires the use not only endoscopic transduodenal techniques, but also the use of laparoscopic biliary and open resection surgical interventions.

A cumulative meta-analysis of endoscopic papillary balloon dilation versus endoscopic sphincterotomy for removal of common bile duct stones

Endoscopic papillary balloon dilation (EPBD) was introduced to overcome the risk of adverse events associated with endoscopic sphincterotomy in the removal of common bile duct (CBD) stones. We performed a meta-analysis of randomized controlled trials (RCTs) comparing efficacy and safety of EPBD vs. endoscopic sphincterotomy, focusing on stone size, balloon diameter, and balloon dilation time. A multiple database search was performed, including MEDLINE, EMBASE and Cochrane Library, from their inception date until October 2017. RCTs comparing the efficacy and safety of EPBD vs. endoscopic sphincterotomy in the removal of CBD stones were included. Cumulative meta-analyses over time, and subgroup analyses according to stone size, and balloon diameter and dilation time were carried out. 25 RCTs met the inclusion criteria. Despite the cumulative meta-analysis showing a trend over time in favor of endoscopic sphincterotomy in studies published up to 2004, the conventional meta-analysis revealed that EPBD was equally efficacious compared with endoscopic sphincterotomy in stone removal at first attempt (odds ratio [OR] 0.95, 95 % confidence interval [CI] 0.65 - 1.38). Endoscopic sphincterotomy was superior to EPBD in terms of overall stone clearance (OR 0.65, 95 %CI 0.43 - 0.99) in studies published since 2002, but no differences emerged in studies using large ( ≥ 10 mm) balloons (OR 1.37, 95 %CI 0.72 - 2.62). No statistically significant difference in pancreatitis occurrence emerged between EPBD and endoscopic sphincterotomy (OR 1.35, 95 %CI 0.90 - 2.03). Pancreatitis was more common with EPBD than with endoscopic sphincterotomy in studies using balloons < 10 mm (OR 1.78, 95 %CI 1.07 - 2.97), whereas no difference emerged in studies using large balloons (OR 0.84, 95 %CI 0.46 - 1.53). EPBD had lower rates of bleeding and cholecystitis. Our latest data confirm that EPBD is currently inferior to endoscopic sphincterotomy in terms of overall stone clearance. However, EPBD using large balloons (≥ 10 mm) was as effective as endoscopic sphincterotomy, both in stone clearance and the need for endoscopic mechanical lithotripsy, without carrying an increased risk of pancreatitis.

Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center’s 12-year experience

Objectives: Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs.Methods: A retrospective query for AETs. Primary outcome: Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC).Results: From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET’s. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1–20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The ‘Combination’ and ‘POC’ groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p < .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%).Conclusions: AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs.

Endoscopic management of bile duct stones in patients with surgically altered anatomy.

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.

RETROGRADE ENDOSCOPIC INTERVENTIONS IN OBSTRUCTIVE JAUNDICE MANAGEMENT

Aim. To determine the effectiveness of endoscopic transpapillary techniques in diagnosis and treatment of patients with obstructive jaundice of various origin. Materials and Methods. We analyzed the effectiveness of endoscopic diagnosis and treatment of patients with obstructive jaundice for the period 2008–2012. The total number of patients was 900. Patients with mechanical obstacle for bile outflow and bilirubin level over 20 mmol/l were included. We used retrograde cholangiopancreatography (ERCP), endoscopic papillotomy (EPT), endoscopic mechanical lithotripsy and lithoextraction (EMLE, EMLT), nasobiliary drainage (NBD), probing and stenting of bile ducts, endoscopic contact electrohydraulic lithotripsy, balloon dilatation of the common bile duct. Results. Interventions were effective in 874 patients (97.11%). Complications occurred in 31 patients (3.44%). Mortality was absent. Conclusion. Endoscopic transpapillary interventions are highly effective in patients with obstructive jaundice. Instrumental hardware equipment and complex application have a great importance in this case.

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

Objectives: Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.Materials and methods: Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.Results: The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344–7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175–6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062–5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy.Conclusions: CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.

Large Bowel Obstruction Due to a Big Gallstone Successfully Treated with Endoscopic Mechanical Lithotripsy.

Colonic gallstone ileus in an uncommon mechanical bowel obstruction caused by intraluminal impaction of one or more gallstones. The surgical management of gallstone ileus is complex and is potentially of high risk. There have been reports of gallstone extractions using various endoscopic modalities to relieve the obstruction. In this report we present the technique employed to successfully perform a mechanical lithotripsy and extraction of a large gallstone embedded in a sigmoid colon affected by diverticular stenosis. We passed through the stenosis with a 11.3 mm videoscope with 3.7 mm channel. A large lithotripsy extraction basket was used to catch and break up the stone and fragments were removed using the same basket. The patient was discharged asymptomatic three days after the procedure. Using appropriate devices mechanical lithotripsy is a safe and effective method to treat colonic obstruction and avoid surgery in the setting of gallstone ileus even in case of big stones.

Endoscopic transpapillary interventions in diagnostics and treatment of patients with diseases of the pancreatobiliary area

It was performed analysis of efficiency of endoscopic retrograde transpapillary interventions in diagnostics and treatment of 1513 patients with diseases of the pancreatobiliary area for the period 2008--2012. About half of patients had choledocholithiasis. There were tumors in 9.5% of patients. Associated diseases confirmed or first identified during transpapillary intervention (stricture + choledocholithiasis, cancer + choledocholithiasis, etc.) were revealed in 6.8% of patients. We used almost all types of endoscopic transpapillary techniques which are applies for biliary hypertension including retrograde cholangiopancreatography, endoscopic papillotomy, endoscopic mechanical lithoextraction and lithotripsy, nasobiliary drainage, bougienage, balloon dilatation, stenting and endoscopic contact electrohydraulic lithotripsy of calculus of common bile duct. Efficiency of endoscopic transpapillary interventions was 96.5%. Complications were observed in 4.3% of patients. Mortality rate was 0.06%.

A rare complication of forming a stent-stone complex after short-term endoscopic biliary plastic stenting in a giant impacted common bile duct stone

Abbreviations: CBD, common bile duct; EPLBD, endoscopic papillary large balloon dilatation; EML, endoscopic mechanical lithotripsy; ESWL, extracorporeal shock wave lithotripsy; LL, laser lithotripsy; EHL, electrohydraulic lithotripsy; ERCP, endoscopic retrograde cholangio-pancreatography; CT, computed tomography; PTCSL, percutaneous transhepatic cholangioscopic lithotripsy; PTBD, percutaneous transhepatic biliary drainage

Old age is associated with increased severity of complications in endoscopic biliary stone removal.

Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Endoscopic sphincterotomy plus balloon dilation versus endoscopic sphincterotomy for choledocholithiasis: A meta‐analysis

Endoscopic sphincterotomy (EST) alone and EST combined with balloon dilation (ESBD) are important endoscopic techniques for stone extraction. We were to conduct a meta-analysis to compare the efficacy and safety of ESBD and EST. Meta-analysis was performed respectively on randomized controlled trials (RCTs) and nonrandomized studies comparing the efficacy and safety of ESBD and EST. The results of three RCTs showed that stone removal in first session (relative risk [RR] 1.01, 0.92-1.11, P=0.85) and the utility of endoscopic mechanical lithotripsy (EML) (RR 0.78, 0.49-1.23, P=0.29) were equivalent between ESBD and EST. ESBD has equivalent complications (RR 0.61, 0.17-2.25, P=0.46) and post-ERCP pancreatitis (Peto odds ratio [OR] 1.11, 0.37-3.35, P=0.86), but less bleeding (Peto OR 0.10, 0.03-0.30, P<0.0001). The analysis of six retrospective studies suggested higher initial success in stone removal (RR 1.11, 1.02-1.20, P=0.01) and less EML (RR 0.32, 0.22-0.46, P<0.00001) in ESBD group. Less complications (RR 0.60, 0.44-0.83, P=0.02) happened in ESBD group, but equivalent post-ERCP pancreatitis (Peto OR 0.65, 0.37-1.15, P=0.14) and bleeding (Peto OR 0.60, 0.29-1.26, P=0.18). For patients with stones ≥ 15 mm, ESBD required less EML (RR 0.35, 0.24-0.51, P<0.00001) and caused fewer complications (RR 0.67, 0.38-0.92, P=0.02). ESBD is feasible for the treatment of choledocholithiasis without increased risk of complications, causing less bleeding. However, it warrants more clinical trials to compare the efficacy and safety of ESBD and EST.

Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: "EPLBD with EST" and "EPLBD without EST". A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

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.