Endoscopic Papillary Large Balloon Dilation Research Articles

Endoscopic Papillary Large Balloon Dilation for Treatment of Large Bile Duct Stones Does Not Increase the Risk of Post-procedure Pancreatitis

Endoscopic sphincterotomy (ES) and endoscopic papillary large balloon dilation (EPLBD) are well-known procedures for the treatment of common duct stones. There was no statistically significant difference in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis rates between ES and EPLBD in most studies. The aims of this study were to evaluate whether EPLBD increases the risk of post-ERCP pancreatitis and to identify the risk factors influencing post-ERCP pancreatitis. A review of 341 patients who underwent ERCP for treatment of common duct stones larger than 1 cm in diameter from January 2006 to December 2011 was conducted retrospectively. Patients were divided into three groups: ES group (n = 207), EPLBD + ES group (n = 99), and EPLBD with previous history of ES group (n = 35). Of 341 patients, overall incidence of post-ERCP pancreatitis was 2.6% (n = 9). Incidence of post-ERCP pancreatitis was 3.4, 2.0, and 0% in the ES group, EPLBD + ES group, and EPLBD with previous history of ES group, respectively. No significant difference in the incidence of post-ERCP pancreatitis was observed among the three groups (p = 0.47). Endoscopic biliary stenting was the independent risk factor for pancreatitis according to univariate (p = 0.046) and multivariate analyses (p = 0.036, OR 4.211, 95% CI 1.095-16.199). Age, sex, stone size, mechanical lithotripsy, common bile duct diameter, balloon size, and duration of balloon dilation were not significantly related to post-ERCP pancreatitis. EPLBD with antecedent limited ES or previous ES state does not increase the risk of post-ERCP pancreatitis in patients with large bile duct stones. Endoscopic biliary stenting seems to be the independent risk factor of post-ERCP pancreatitis.

Advances in the endoscopic management of common bile duct stones.

Extraction of common bile duct stones by endoscopic retrograde cholangiopancreatography generally involves biliary sphincterotomy, endoscopic papillary balloon dilation or a combination of both. Endoscopic papillary large-balloon dilation after sphincterotomy has increased the safety of large stone extraction. Cholangioscopically directed electrohydraulic and laser lithotripsy using single-operator mother-daughter systems or direct peroral cholangioscopy using ultraslim endoscopes are increasingly utilized for the management of refractory stones. In this Review, we focus on advances in endoscopic approaches and techniques, with a special emphasis on management strategies for 'difficult' common bile duct stones.

Tu1954 Risk Factors of Recurrence of Common Bile Duct Stones After Removing With Endoscopic Papillary Large Balloon Dilatation

Background/Aims: Endoscopic papillary large balloon dilation (EPLBD) can be used as a treatment of removing the difficult common bile duct (CBD) stone. However, we still experience cases of recurrence after an EPLBD. The aim of this study was to evaluate the risk factors of recurrence of CBD stone after an EPLBD. Methods: From March 2004 to October 2010, a total of 262 patients with CBD stones were treated by EPLBD at Gangnam Severance and Daegu Catholic University Hospital. Clinical and endoscopic parameters were analyzed to determine the risk factors of CBD stone recurrence. Results: Of the 262 patients (men 100, women 162, mean age 72.0±11.8 years), the recurrence rate was 19.8% ( 52/ 262). Mean duration between treatment and recurrence was 13.5 months (1.4~64.8 months). In univariate analysis, multiple stones (≥3), large stone (≥14mm), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°) were identified as the significant predictors of recurrence. In multivariate analysis, multiple stones (≥3, P=0.015, OR 2.26, 95% CI 1.174.36), diameter of CBD (≥ 20mm, P < 0.001, OR 4.67, 95% CI 2.23-9.80) and angulated CBD (angle≤145°, P < 0.001, OR 4.98, 95% CI 2.36-10.54) were identified as the significant predictors of recurrence. Gender, age, periampullary diverticulum and previous cholecystectomy did not influence the recurrence rate. Conclusions: The recurrence of CBD stone after EPLBD was strongly associated with multiple stones (≥3), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°). Close and meticulous follow-up may be required in patients with these parameters.

Tu1957 The Association Study Between Histopathologic Features of the Gallbladder Wall and Cholescintigraphy in Patients With Atypical Biliary Pain

Background/Aims: Endoscopic papillary large balloon dilation (EPLBD) can be used as a treatment of removing the difficult common bile duct (CBD) stone. However, we still experience cases of recurrence after an EPLBD. The aim of this study was to evaluate the risk factors of recurrence of CBD stone after an EPLBD. Methods: From March 2004 to October 2010, a total of 262 patients with CBD stones were treated by EPLBD at Gangnam Severance and Daegu Catholic University Hospital. Clinical and endoscopic parameters were analyzed to determine the risk factors of CBD stone recurrence. Results: Of the 262 patients (men 100, women 162, mean age 72.0±11.8 years), the recurrence rate was 19.8% ( 52/ 262). Mean duration between treatment and recurrence was 13.5 months (1.4~64.8 months). In univariate analysis, multiple stones (≥3), large stone (≥14mm), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°) were identified as the significant predictors of recurrence. In multivariate analysis, multiple stones (≥3, P=0.015, OR 2.26, 95% CI 1.174.36), diameter of CBD (≥ 20mm, P < 0.001, OR 4.67, 95% CI 2.23-9.80) and angulated CBD (angle≤145°, P < 0.001, OR 4.98, 95% CI 2.36-10.54) were identified as the significant predictors of recurrence. Gender, age, periampullary diverticulum and previous cholecystectomy did not influence the recurrence rate. Conclusions: The recurrence of CBD stone after EPLBD was strongly associated with multiple stones (≥3), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°). Close and meticulous follow-up may be required in patients with these parameters.

Efficacy and safety of endoscopic papillary large balloon dilation for large bile duct stones in elderly patients.

Minimally invasive interventions for choledocholithiasis are preferable in elderly patients because they tend to have multiple underlying disorders or a decreased activity of daily living. Endoscopic sphincterotomy and endoscopic papillary balloon dilation have been recognized as first-line treatments for choledocholithiasis excluding difficult cases such as large stones or multiple stones. Recently, the safety and efficacy of endoscopic papillary large balloon dilation (EPLBD) for difficult choledocholithiasis cases have been reported, although scarcely in elderly patients. To investigate whether EPLBD can be safety and effectively performed in patients aged 75 years or older. The medical records of 165 patients who underwent EPLBD from November 2006 to August 2013 were analyzed retrospectively. The patients were divided into 2 groups: Group A (≥ 75 years); Group B (<75 years). Some underlying diseases were significantly more common in Group A than in Group B (P < 0.05). However, there was no significant difference in the success rates in the first session (96.2 vs 95.0 %, P = 0.970) and in the final success rates (100 % in both groups) between Group A and Group B. The adverse event rates (2.9 vs 5.0 %, P = 0.783) and recurrence rates of choledocholithiasis (6.7 vs 10.0 %, P = 0.444) were not significantly different. Regarding patients with an altered anatomy, the EPLBD outcome was not significantly different. EPLBD can be safely performed for elderly patients similarly to younger patients.

689 Endoscopic Papillary Large Balloon Dilation With or Without Small Endoscopic Sphincterotomy Do Not Preserve Sphincter of Oddi Function After Large Bile Duct Stones Management: a Prospective Randomized Study

689 Endoscopic Papillary Large Balloon Dilation With or Without Small Endoscopic Sphincterotomy Do Not Preserve Sphincter of Oddi Function After Large Bile Duct Stones Management: a Prospective Randomized Study

Su1670 Efficacy and Safety of Endoscopic Papillary Large-Balloon Dilatation for Postoperative Intestinal Common Bile Duct Stone by Using Double Balloon-ERCP

Endoscopic papillary large balloon dilatation (EPLBD) combined with limited endoscopic sphinteroctomy (EST) have recently been reported to be effective and safe for removal of common bile duct stones. However, there have been few reports of EPLBD treatment using balloon-assisted enteroscopy in patients with post-operative intestine.

Ampullary intervention for bile duct stones in patients with surgically altered anatomy

Transpapillary endoscopic treatment is a standard technique for the treatment of bile duct stones. This technique includes biliary cannulation, ampullary interventions such as endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), and stone removal. In patients with Roux-en-Y anastomosis, the transpapillary approach using an ordinary scope has been challenging. A recently developed single-/double-balloon enteroscope enables therapeutic endoscopic retrograde cholangiopancreatography to be carried out in such cases. EST using a balloon enteroscope is often difficult to carry out as a result of restriction of scope maneuverability or inadequate direction of the accessory. Although EPBD is easy to carry out for any anatomy, large or multiple stones are difficult to remove by EPBD only because of insufficient opening of Vater's papilla. Endoscopic papillary large-balloon dilation following EST is reported to be useful for the treatment of large and/or multiple stones. This technique is also useful for the treatment of bile duct stones in patients with Roux-en-Y anastomosis.

Endoscopic papillary large balloon dilation reduces the need for mechanical lithotripsy in patients with large bile duct stones: a systematic review and meta-analysis.

Background. Removal of large stones can be challenging and frequently requires the use of mechanical lithotripsy (ML). Endoscopic papillary large balloon dilation (EPLBD) following endoscopic sphincterotomy (ES) is a technique that appears to be safe and effective. However, data comparing ES + EPLBD with ES alone have not conclusively shown superiority of either technique. Objective. To assess comparative efficacies and rate of adverse events of these methods. Method. Studies were identified by searching nine medical databases for reports published between 1994 and 2013, using a reproducible search strategy. Only studies comparing ES and ES + EPLBD with regard to large bile duct stone extraction were included. Pooling was conducted by both fixed-effects and random-effects models. Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated. Results. Seven studies (involving 902 patients) met the inclusion criteria; 3 of 7 studies were prospective trials. Of the 902 patients, 463 were in the ES + EPLBD group, whereas 439 underwent ES alone. There were no differences noted between the groups with regard to overall stone clearance (98% versus 95%, RR = 1.01 [0.97, 1.05]; P = 0.60) and stone clearance at the 1st session (87% versus 79%, RR = 1.11 [0.98, 1.25]; P = 0.11). ES + EPLBD was associated with a reduced need for ML compared to ES alone (15% versus 32%; RR = 0.49 [0.32, 0.74]; P = 0.0008) and was also associated with a reduction in the overall rate of adverse events (11% versus 18%; RR = 0.58 [0.41, 0.81]; P = 0.001). Conclusions. ES + EPLBD has similar efficacy to ES alone while significantly reducing the need for ML. Further, ES + EPLBD appears to be safe, with a lower rate of adverse events than traditional ES. ES + EPLBD should be considered as a first-line technique in the management of large bile duct stones.

Direct peroral cholangioscopy using an ultraslim upper endoscope for biliary lesions

The development of direct peroral cholangioscopy (DPOC) using an ultraslim endoscope simplifies biliary cannulation. The conventional techniques are cumbersome to perform and require advanced skills. The recent introduction of the guidewires and balloons has improved the therapeutic outcomes. Here we describe an effective and easier method for performing DPOC using an ultraslim upper endoscope. Indications for DPOC were the presence of stones on follow-up of patients who had previously undergone complete sphincteroplasty, including endoscopic sphincterotomy or endoscopic papillary large balloon dilatation. Fifteen patients underwent DPOC. An ultraslim endoscope was inserted perorally and was advanced into the major papilla. The ampulla of Vater was visualized by retroflexing the endoscope in the distal second portion of the duodenum, and then DPOC was performed using a wire-guided cannulation technique with an anchored intraductal balloon catheter. One patient failed in the treatment due to looping of the endoscope in the fornix of the stomach. Fourteen (93.3%) were successfully treated with our modified DPOC technique. Only one patient (6.7%) experienced an adverse event (pancreatitis) who responded well to conservative management. Residual stones of the common bile duct were completely removed in 3 patients. The modified method of DPOC is simple, safe and easy to access the bile duct.

Delayed Endoscopic Papillary Large Balloon Dilation After Sphincterotomy for Removing Large Bile Duct Stones in Patients with Acute Cholangitis

Endoscopic papillary large balloon dilation (EPLBD) after an endoscopic sphincterotomy (EST) is an option for endoscopic removal of large common bile duct (CBD) stones. However, risks or fear of severe adverse events remain. Our aim was to compare the safety and efficacy of delayed EPLBD after EST with concurrent EST and EPLBD in patients with acute cholangitis by large CBD stones. A total of sixty-eight patients with acute cholangitis from large CBD stones were enrolled in this prospective observational study. Thirty-five patients underwent concurrent EST and EPLBD at the same session (group A). Thirty-three patients underwent only EST at the first session, and EPLBD with stone removal was performed during a second session (group B). The complete stone removal rate and adverse events rate were analyzed. Both groups resulted in similar outcomes in terms of overall successful stone removal (100% in both groups) and the use of additional lithotripsy (22.9% in group A and 24.2% in group B). Six patients (17.1%) in group A had procedural-related adverse events including one patient with death by perforation, one with significant bleeding, and four with pancreatitis, including one moderate grade. However, there was no procedure-related complication in group B (p < 0.05). Delayed EPLBD after EST may reduce complications associated with EPLBD and extraction of large bile duct stones in patients with acute cholangitis.

Endoscopic papillary large balloon dilation for the retrieval of bile duct stones after prior Billroth II gastrectomy

Background/Aims:Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.Materials and Methods:From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.Results:Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.Conclusions:EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: a meta-analysis.

To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm). PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P ≤ 0.1 and I(2) with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias. Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92). EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Endoscopic sphincterotomy plus endoscopic papillary large balloon dilation or endoscopic sphincterotomy extraction of large common bile duct stones: A decision analysis

Abbreviations: EST, endoscopic sphincterotomy; EPBD, endoscopic papillary balloon dilation; EPLBD, endoscopic papillary large balloon dilation; ERCP, endoscopic retrograde cholangiopancreatography; CBD, common bile duct; PEP, post-ERCP pancreatitis; ICER, incremental cost-effectiveness ratio; QALY, Quality adjusted life year; ALOS, Average Length of Stay; NMB, net monetary benefits; WTP, Willingness-to-pay

Feasibility of endoscopic papillary large balloon dilation after prior Billroth II gastrectomy and considerations for endoscopists

Feasibility of endoscopic papillary large balloon dilation after prior Billroth II gastrectomy and considerations for endoscopists

Endoscopic papillary large balloon dilation for large common bile duct stones

Endoscopic papillary large balloon dilation for large common bile duct stones

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

Endoscopic papillary large balloon dilation after endoscopic sphincterotomy for treatment of common bile duct stones: Effects of different dilation durations

Endoscopic papillary large balloon dilation after endoscopic sphincterotomy for treatment of common bile duct stones: Effects of different dilation durations

内視鏡的乳頭大口径バルーン拡張術（EPLBD）における偶発症の検討

内視鏡的乳頭大口径バルーン拡張術（endoscopic papillary lange-balloon dilation : EPLBD）は，径が大きく完全截石困難な総胆管結石に対する内視鏡的治療法として普及してきているが，早期および晩期偶発症については，現段階で評価できていない点が多い。当院においてEPLBDを施行した総胆管結石症の18例をretrospectiveに評価し，偶発症の発生状況について検討を行った。当院では，EPLBDの適応を，75歳以上で下部胆管および胆石径が11mm以上の症例としている。また，実際の手技においては，まず小〜中切開の乳頭切開を付加し，続いて下部胆管・胆石径に合わせてバルーン拡張を行う。さらに，結石嵌頓のリスクも考慮して機械式砕石器を用いて截石を行っている。結果，完全截石は18例中17例（94.4％）で可能であった。結石の破砕を要した例は2例（11.1％）であり，多くの症例で大結石であっても破砕なく結石除去が可能であった。全18例のうち，無症状の高アミラーゼ血症を3例（16.7％）に認めた他は，出血，穿孔，急性膵炎等の重篤な早期偶発症は認めなかった。また，平均11.0カ月（0.5〜17カ月）の観察期間において，1例（5.6％）で12カ月後に結石の再発を認めた。EPLBDは早期偶発症が少なく有用な治療法と考えられるが，一方で依然長期予後が不明瞭な点を考慮し，年齢等の適応基準を厳密にして施行する必要性があると考えられる。

Initial large diameter of common bile duct is associated with long‐term dilatation of bile duct after endoscopic extraction of stones

To investigate the time and extent of recovery of dilated common bile duct (CBD) after the extraction of CBD stones and to identify the factors related to the long-term dilatation of the CBD after stone removal. Data of 329 consecutive patients undergoing endoscopic extraction of CBD stones from January 2008 to December 2012 were retrospectively reviewed. Finally, 44 patients were enrolled in the study. The CBD diameter significantly decreased after stone extraction (P < 0.001). However, the CBD diameter in patients who were followed up for 1 week and longer and <1 week did not differ significantly. The diameter decreased more in patients with an initial CBD diameter ≥ 15 mm than in those with an initial CBD diameter <15 mm before stone extraction (P = 0.007), but the normalization of dilated CBD was less frequent in patients with a large initial CBD diameter. The factors related to the long-term dilatation of CBD (>10 mm for >6 months) were initial CBD diameter, the largest diameter of CBD stone and endoscopic papillary large balloon dilatation. Initial CBD diameter was an independent factor with multivariate analysis (OR 1.754, P = 0.017). The CBD diameter recovers rapidly after the extraction of CBD stones. An initial large CBD diameter before stone extraction is associated with the long-term dilatation of CBD.