Endoscopic Papillary Large Balloon Dilation Research Articles

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Common Bile Duct Stones: Endoscopic Management of Difficult Common Bile Duct Stones

Difficult common bile duct (CBD) stones are difficult to remove using conventional stone clearance methods such as endoscopic papillary sphincterotomy. In this guideline, we present several recommendations and relevant information on the endoscopic treatment of difficult CBD stones. For the primary treatment of large CBD stones in patients without distal bile duct stricture, we recommend limited endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation. For large CBD stones that are difficult to remove with conventional endoscopic treatment methods, we recommend electrohydraulic or laser lithotripsy under cholangioscopy. Short-term biliary stenting is recommended in patients with CBD stones that are difficult to remove by these methods. Finally, endoscopic treatment via small bowel enteroscopy or percutaneous transhepatic cholangioscopy may be an option in patients with surgically altered anatomy.

The value of endoscopic duodenal papilloplasty with titanium clip in improving post-operative complications of choledocholithiasis.

To investigate the value of endoscopic duodenal papillary sphincterotomy combined with balloon dilatation in the treatment of duodenal papilloplasty with titanium clip after choledocholithiasis in post-operative complications. One hundred and twenty-five patients (69 males and 56 females) with a median age of 65 (32-81) years were included. The treatment plan was randomly divided into Group A (n = 59) and Group B (n = 66) according to the random number table. Patients in Group A were treated with endoscopic sphincterotomy (EST) combined with endoscopic papillary large balloon dilation (EPLBD), followed by a titanium clip for duodenal papilloplasty and then indwelling nasobiliary drainage, whereas those in Group B were treated with EST combined EPLBD to remove stones and then indwelling nasobiliary drainage. In patients with choledocholithiasis or with anatomical changes that make stone extraction difficult, this prospective study attempted to perform duodenal papilloplasty with titanium clips after EST and EPLBD lithotripsy to compare and observe post-operative papillary healing, biliary reflux, and complication rates. The use of endoscopic duodenal papilloplasty with a titanium clip can improve biliary reflux after lithotripsy and reduce the incidence of post-operative cholangitis complications.

Addition of Mechanical Lithotripsy to Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Common Bile Duct Stones: A Retrospective Single-Center Study.

Introduction: This study aimed to compare the treatment outcomes of endoscopic papillary large-balloon dilation (EPLBD) with and without mechanical lithotripsy (ML) in removing difficult common bile duct stones. Methods: Patients with difficult common bile duct stones treated with EPLBD, with or without ML, at the Eastern Chiba Medical Center between April 2014 and March 2020, were retrospectively evaluated. The rates of cumulative recurrence and complications were compared between the two groups. Results: Overall, 122 patients (n = 44, EPLBD + ML and n = 78, EPLBD) treated by 12 gastroenterologists were included. Patients in the EPLBD + ML group were older (85 years versus 81.5 years) and had larger maximum stone diameter (15 mm versus 12.5 mm) than those in the EPLBD group. Compared with the EPLBD group, the EPLBD + ML group required more endoscopic retrograde cholangiopancreatography (ERCP) procedures (≥2) (86% versus 67%) and longer total ERCP time after reaching the papilla (78.5 minutes versus 25 minutes). Complication rates were not significantly different (9.1% versus 12.8%); however, the cumulative recurrence rates were higher in the EPLBD + ML group than in the EPLBD group (69.4% versus 23.5% at 4 years). Conclusion: Although there were no differences in complication rates, the long-term recurrence rate was higher in the EPLBD + ML group than in the EPLBD group. This study emphasizes the added burden imposed by performing ML during ERCP and suggests that by appropriate case selection, it is possible to treat cases of difficult biliary stones using EPLBD without ML.

Endoscopic papillary large balloon dilation with wide sphincterotomy and brief balloon expansion is safe and leads rarely in recurrence in large common bile duct stones

Endoscopic papillary large balloon dilation with wide sphincterotomy and brief balloon expansion is safe and leads rarely in recurrence in large common bile duct stones

Successful Endoscopic Treatment of Difficult Common Bile Duct Stones Using Various Interventional Techniques: A Case Report

Clearance of a difficult biliary stone can be obtained using various interventional techniques such as endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation, mechanical lithotripsy, peroral cholangioscopy-assisted intraductal electrohydraulic/laser lithotripsy, temporary plastic stent insertion, percutaneous transhepatic cholangioscopy-guided lithotripsy, and extracorporeal shock wave lithotripsy. We hereby describe the successful endoscopic treatment using various currently available interventional techniques in a case with multiple difficult common bile duct stones. Furthermore, we discuss the countermeasures to overcome the hurdles of each procedure.

Successful hemostasis using a self-assembling peptide hydrogel for bleeding after endoscopic papillary large-balloon dilation.

Adverse bleeding events can occur after endoscopic papillary large-balloon dilation (EPLBD) [1], though not as frequently as after endoscopic sphincterotomy. Post-EPLBD bleeding often originates from sites deeper than the bile duct orifice, such as lacerations of the bile duct wall, and the origin of bleeding may not be identified; therefore, it is often difficult to stop the bleeding. A novel self-assembling peptide hydrogel (PuraStat; 3-D Matrix, Tokyo, Japan) was recently developed as a hemostatic agent [2] [3] [4]. We present a case of hemostasis of massive post-EPLBD bleeding achieved with this hydrogel.

Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance.

To develop a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions. This study included patients with CBD stones who underwent ERCP at Pattani Hospital between August 2017 and December 2021. Retrospective cohort data was collected and patients were categorized into two groups: bile duct stones successfully treated by endoscopic biliary sphincterotomy and extraction compared to the former method combined with EPLBD. We explored potential predictors using multivariable logistic regression. The chosen logistic coefficients were transformed into a scoring system based on risk with internal validation via bootstrapping procedure. Among the 155 patients who had successful endoscopic therapy for bile duct stones, there were 79 (50.97%) cases of endoscopic biliary sphincterotomy, EPLBD and extraction versus 76 (49.03%) cases without EPLBD. The factors used to derive a scoring system included the size of CBD stones >15 mm, the difference between the stone and distal CBD diameter >2mm, distal CBD arm length <36 mm and stone shape. The score-based model's area under ROC was 0.88 (95% CI: 0.83, 0.93). For clinical use, the range of scores from 0 to 16, was divided into two subcategories based on CBD stone removal difficulty requiring EPLBD to derive the PPV. For scores <5 and ≥ 5, the PPV was 23.40 (p <0.001) and 93.44 (p <0.001) respectively. The Bootstrap sampling method indicated a prediction ability of 0.88 (AuROC, 95% CI: 0.83, 0.94). This scoring system has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

Current management of concomitant cholelithiasis and common bile duct stones.

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

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.

Endoscopic papillary large-balloon dilation with sphincterotomy for difficult common bile duct stones ≤12 mm: a prospective study.

Stone recurrence is a significant complication following endoscopic bile duct clearance. Endoscopic papillary large-balloon dilation (EPLBD) with biliary sphincterotomy (EBS) has shown satisfactory results in preventing recurrence of "large" common bile duct stones (CBDS). However, data on outcomes after EPLBD+EBS for CBDS ≤12 mm remain scarce. The present study prospectively evaluated the mid- and long-term efficacy of EPLBD+EBS for CBDS recurrence among this group of patients. Consecutive patients with CBDS ranging from 8-12 mm, treated with EPLBD+EBS from June 2018 through June 2020, were prospectively followed-up for at least 36 months. CBDS recurrence was defined as recurrent stones confirmed by endoscopic retrograde cholangiopancreatography (ERCP) during the follow-up period. Overall, 72 patients (mean age: 67 years, 52.8% male) were included, of whom 22 (30.5%) had multiple (≥3) CBDS, 23 (31.9%) had a history of cholecystectomy, 13 (18.1%) had a periampullary diverticulum and 22 (30.5%) had a previous EBS. The mean CBD diameter was 11.6±1 mm, while a tapered duct was noted in 7 (9.7%). Post-procedural bleeding and cholangitis occurred in 1 and 2 cases respectively. No cases of perforation and post-ERCP pancreatitis were observed. During a mean follow up of 46.4±6.2 months (range 37-60), no mid-term recurrence was observed, whereas CBDS recurred in 2/72 (2.7%) in the long term. EPLBD+EBS in patients with CBDS ≤12 mm was associated with a very low rate of mid- and long-term CBDS recurrence. Our results need to be further investigated with randomized controlled trials.

Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis.

Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).

Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis.

Background and study aims The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.

Common bile duct stone-related parameters and their potential prognostic values for stone extraction requiring endoscopic papillary large balloon dilation.

For difficult common bile duct (CBD) stones, endoscopic sphincterotomy accompanied by endoscopic papillary large balloon dilatation (EPLBD) may be the preferred initial procedure according to the selection criteria. The purpose of this study was to determine the association between CBD stone-related parameters and their potential prognostic values for technically difficult CBD stone extraction requiring EPLBD. We retrospectively analyzed the data of 80 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary sphincterotomy, or the aforementioned procedures combined with EPLBD, resulting in successful CBD stone extraction in the first session from January 2018 and December 2021. The association between CBD stone-related parameters and stone extraction requiring EPLBD was analyzed by multivariable risk regression analysis. In multivariable analysis, the independent predictors of CBD stone extraction that required EPLBD were CBD stones larger than distal CBD diameterby >2 mm (risk ratio [RR] 2.34, 95% CI 1.30-4.19) and the presence of shaped stones (round shape RR 1.69 [95% CI 1.05-2.73]; square shape RR 2.34 [95% CI 1.24, 4.44] vs oval shape). Endoscopic CBD stone removal is technically difficult in patients with stones larger than 2 mm in diameter in comparison to the distal CBD diameter or round or square-shaped stones.

Single-operator Cholangioscopy Guided Lithotripsy

ERCP is the standard treatment for common bile duct stones (CBD stones). On the other hand, in approximately 10% of patients with CBD stones, the complete removal of the stones cannot be achieved by conventional ERCP, which performs endoscopic sphincterotomy followed by stone extraction. Additional advanced and complex procedures are often necessary to remove these "difficult bile duct stones", including endoscopic papillary large balloon dilatation or mechanical lithotripsy. Advances in cholangioscopy have made electrohydraulic or laser lithotripsy under direct endoscopic visualization possible during ERCP. Cholangioscopy-guided lithotripsy using the SpyGlass DS system could be a better treatment tool for removing difficult stones. The focus of this review was to describe single-operator cholangioscopy in the management of difficult CBD stones.

National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea.

This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea. The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021. The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively. Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones.

Long-term outcomes of endoscopic papillary large-balloon dilation (12–15 mm) with or without limited sphincterotomy for removal of bile duct stones

BackgroundLimited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12–15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones. MethodsPatients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed. ResultsBasic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357–6.640; P = 0.007) was an independent risk factor for stone recurrence. ConclusionsThe application of a large balloon (12–15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.

Comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy in clearing large common bile duct stones: A systematic review and meta‐analysis of randomized controlled trials

AbstractThere are three methods to retrieve large common bile duct stones, the first is endoscopic sphincterotomy (EST), the second is endoscopic papillary large‐balloon dilatation (EPLBD), and the third is limited EST plus EPLBD. Although EST is the most popularly used method, it has higher risk of bleeding complication and basket stuck. EPLBD alone without EST demonstrated safe and quick in the clinical practice, but there were only few studies focused on comparing EST or EPLBD alone. Thus, this study aims to compare the efficacy and safety of EPLBD with EST. We searched for PubMed, Embase, and Cochrane Library databases to collect relevant articles until August 31st, 2019. We included randomized controlled trials, common bile duct stones &gt; 10 mm, comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy, and patients older than 18. We compare endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy on the clearance of large common bile duct stones, the adverse events, and the need for mechanical lithotripsy. This systematic review and meta‐analysis was registered on PROSPERO and the registration number is CRD42020150485. Total six studies met inclusion criteria and 762 participants were enrolled. The data revealed that endoscopic papillary large‐balloon dilatation alone was comparable to endoscopic sphincterotomy on the clearance of large common bile duct stones (RR = 1.02, 95% CI: 0.93‐1.12), the adverse events (RR = 1.01, 95% CI: 0.71‐1.43) and the need for mechanical lithotripsy. In the subgroup analysis, the requirement of mechanical lithotripsy decreased in the non‐Chinese group (RR = 0.58, 95% CI: 0.41‐0.84). The efficacy and safety to clean large common bile duct stones are comparable in either EPLBD or EST. In addition, EPLBD alone not only saves the operation time but also reduces the chance of mechanical lithotripsy in the subgroup analysis.

Endoscopic Papillary Large Balloon Dilation Reduces Further Recurrence in Patients With Recurrent Common Bile Duct Stones: A Randomized Controlled Trial.

Up to 60% of patients with common bile duct stone (CBDS) recurrence suffer from further recurrence after endoscopic retrograde cholangiopancreatography (ERCP). There are no effective methods to prevent recurrence in most patients. In this study, we aimed to assess the short-term and long-term efficacies of endoscopic papillary large balloon dilation (EPLBD) for the management of recurrent CBDS in a randomized controlled trial. Consecutive patients with recurrent CBDS were eligible and randomly assigned in a 1:1 ratio to the EPLBD group or the control group. The primary outcome was the CBDS recurrence rate within 2 years after ERCP. The analysis followed the intention-to-treat principle. From 2014 to 2021, 180 patients with recurrent CBDS were included, with 90 in each group. All patients underwent complete CBDS clearance by 1 or several sessions of ERCP. The rate of complete clearance in 1 session was significantly higher with EPLBD treatment (95.6% vs 85.6%, P = 0.017). During the follow-up, the CBDS recurrence rate within 2 years was significantly lower in the EPLBD group than in the control group (21.1% [19/90] vs 36.7% [33/90], relative risk 0.58, 95% confidence interval 0.36-0.93, P = 0.021). At a median follow-up of approximately 56 months, CBDS recurrence was found in 34.4% of the patients (31/90) in the EPLBD group and 51.1% (46/90) in the control group (hazard ratio 0.57, 95% confidence interval 0.36-0.89, P = 0.012). Multiple recurrences (≥2) were also decreased in the EPLBD group (4.4% vs 18.9%, P = 0.020). During the long-term follow-up, nearly half of the patients with recurrent CBDS experienced stone recurrence after traditional ERCP. Our study was the first to show that EPLBD effectively reduced the recurrence of CBDS.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences.

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938–3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques.

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.