Large Balloon Dilation Research Articles

Predictive factors for extraction of common bile duct stones during endoscopic retrograde cholangiopancreatography in Billroth II anatomy patients.

Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in Billroth II anatomy patients is still a technical challenge and factors affecting stone extraction have not yet been clarified. This study aimed to analyze our experience and evaluate potential factors affecting CBD stone extraction. A retrospective analysis of CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from August 1999 to December 2017, was conducted. The outcomes of ERCP and potential factors affecting stone extraction were examined. A total of 227 patients were enrolled, and 176 patients (77.5%) achieved technical success. The success rate of duodenal ampullary access and selective biliary cannulation was 84.1% (191/227) and 92.1% (176/191), respectively. The mean CBD diameter was 15mm (range 6-35mm), and the largest stone size was 13mm (range 4-36mm). CBD stones were ultimately removed in 137 patients (77.8%), and 105 patients (59.7%) for the first session. Mechanical lithotripsy was used in 17 patients (9.7%). The overall ERCP-related complication rate was 6.3% (11/176), including bleeding in 3 patients (1.7%) and mild pancreatitis in 6 patients (3.4%). The multivariate analysis indicated that CBD stone number ≥ 2 (OR 2.171; 95% CI 1.095-4.306; p = 0.027), and the largest CBD stone size ≥ 12mm (OR 3.646; 95% CI 1.833-7.251; p < 0.001) were patient-related risk factors for failed stone removal; while the use of endoscopic papillary (large) balloon dilation (EPBD/EPLBD) (OR 0.291; 95% CI 0.147-0.576; p < 0.001) was a procedure-related protective factor for successful stone extraction. ERCP is safe and effective for extraction of CBD stones in Billroth II anatomy patients. The number and the largest size of CBD stones, and the use of EPBD/EPLBD are predictive factors for CBD stone extraction.

Curative effects and prognosis of endoscopic papillary large balloon dilatation on the treatment of choledocholithiasis

Objective To evaluate the curative effect and prognosis of endoscopic papillary large balloon dilatation (EPLBD) in the treatment of choledocholithiasis. Methods A total of 153 patients with choledocholithiasis (>1.0 cm in stone diameter) admitted and treated in Shanxi People′s Hospital from August 2016 to November 2017 were randomly divided into two groups according to the random number table: the EPLBD group (n=83) and the small endoscopic sphincterotomy plus large balloon dilatation (ESLBD) group (n=70) . The success rate of stone removal, the rate of lithotripsy, and the incidence of short-term and long-term complications were compared between the two groups. Results There were no statistical differences between the EPLBD group and the ESLBD group in total stone removal rate [95.2% (79/83) VS 97.1% (68/70) , χ2=0.388, P=0.533] and one-time stone removal rate [92.8% (77/83) VS 90.0% (63/70) , χ2=0.375, P=0.540]. The lithotripsy rate between the two groups had no statistical difference [25.3% (21/83) VS 35.7% (25/70) , χ2=1.958, P=0.162]. There was no statistical difference in the incidence of recent complications between the two groups [43.4% (36/83) VS 40.0% (28/70) , χ2=0.178, P=0.673]. No postoperative perforation was found in either group. The follow-up time was 22.7±4.3 months in the EPLBD group, and 20.8±6.3 months in the ESLBD group.The cumulative recurrent rate of choledocholithiasis in the two groups were 2.4% (2/83) and 15.7% (11/70) , respectively, and the difference was significant (P=0.003) . Conclusion Simple EPLBD in the treatment of choledocholithiasis is equivalent to ESLBD in the success rate of stone removal, utilization rate of lithotripsy, and incidence of recent complications, but the long-term stone recurrence rate of EPLBD is lower than that of ESLBD. EPLBD is effective and safe on the treatment of choledocholithiasis. Key words: Choledocholithiasis; Cholangiopancreatography, endoscopic retrograde; Endoscopic papillary large balloon dilatation; Small endoscopic sphincterotomy plus large balloon dilatation

The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones

BackgroundThe removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound.MethodsWe enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications.ResultsThe limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12–61) min vs. 23.5 (17–68) min vs. 25.0 (14–60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group.ConclusionsLimited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD.

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.

Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones.

To review the current literature focusing on the indications, efficacy, and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) with or without endoscopic sphincterotomy (EST) in the treatment of bile duct stones. • EPBD without EST is associated with a higher risk of post-procedural pancreatitis and lower rate of stone clearance than EST alone. • EPBD without EST should be at least 2min in duration, and placement of a pancreatic stent and other measures to reduce pancreatitis risk should be considered. • EPBD without EST is most useful to reduce risk of bleeding in patients with coagulopathy. • EPLBD combined with EST can be used as an alternative or adjunct to mechanical lithotripsy in the removal of large or difficult bile duct stones. • EPLBD combined with EST results in fewer complications than EST alone for removal of bile duct stones.

Multiple recurrences after endoscopic removal of common bile duct stones: A retrospective analysis of 976 cases.

Recurrences after endoscopic treatment of common bile duct stones (CBDS) are common. The aims of this study were to identify risk factors for recurrences of CBDS and to evaluate the effect of interventions for prevention of further recurrences. A total of 976 patients who underwent endoscopic treatment of CBDS were retrospectively studied. Risk factors for single and multiple recurrent CBDS were evaluated using a Cox hazard regression model. The incidences of further recurrences were evaluated according to the additional interventions. The mean age was 69.3years, and 39.3% were female. Endoscopic papillary balloon dilation, endoscopic sphincterotomy, and endoscopic papillary large balloon dilation were performed in 858, 77, and 41 patients, respectively. The rates of one or more recurrence and multiple recurrences of CBDS were 12.4% and 2.7%, respectively. In the multivariate analyses, the significant risk factors were the bile duct size (hazard ratio [HR] 1.07, P=0.012), gallbladder left in situ with stones (HR 1.91, P=0.046), and pneumobilia after treatment (HR 2.10, P=0.047) for single recurrence and the number of stones at the first recurrence (HR 1.16, P=0.021) for multiple recurrences. In five out of nine cases with multiple recurrences, further recurrence was not observed after additional sphincteroplasty in addition to cholecystectomy. The incidence of multiple recurrences was not uncommon after the first recurrence of CBDS.

Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care.

The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.

Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study.

Endoscopic papillary large-balloon dilation (EPLBD) allows for the complete removal of large common bile duct (CBD) stones without fragmentation; however, a significant proportion of very large stones and stones floating above a tapering CBD require lithotripsy. Mechanical lithotripsy and cholangioscopy-guided laser lithotripsy are both effective for stone fragmentation. This study aimed to directly compare, for the first time, the efficacy of these two techniques in terms of stone clearance rate, procedure duration, patient radiation exposure, and safety. 32 patients with very large CBD stones or with stones floating above a tapering CBD, and in whom extraction after standard sphincterotomy and/or EPLBD had failed, were randomly assigned to mechanical lithotripsy or cholangioscopy-guided laser lithotripsy at two tertiary referral centers. Crossover was allowed as a rescue treatment if the assigned technique failed. Patients' demographic data were not different between the two groups. Mechanical lithotripsy had a significantly lower stone clearance rate in the first session compared with laser lithotripsy (63% vs. 100%; P < 0.01). Laser lithotripsy rescued 60% of patients with failed mechanical lithotripsy by achieving complete stone clearance within the same session. Radiation exposure of patients was significantly higher in the mechanical lithotripsy group than in the laser lithotripsy group (40 745 vs. 20 989 mGycm2; P = 0.04). Adverse events (13% vs. 6%; P = 0.76) and length of hospital stay (1 vs. 1 day; P = 0.27) were not different. Although mechanical lithotripsy is the standard of care for a very large CBD stone after failed EPLBD, where available, cholangioscopy-guided laser lithotripsy is considered the better option for the treatment of this entity as it provides a higher success rate and lower radiation exposure.

Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study.

With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants). We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively). Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.

Japan Gastroenterological Endoscopy Society (JGES) clinical guidelines for endoscopic papillary large balloon dilation

Japan Gastroenterological Endoscopy Society (JGES) clinical guidelines for endoscopic papillary large balloon dilation

Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis.

AimTo compare endoscopic papillary large balloon dilation (EPLBD) alone with EPLBD following endoscopic sphincterotomy (EST) in patients with large and/or multiple common bile duct stones.MethodsWe conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles until July 19, 2018. Complete common bile duct stone (CBDS) removal rate, frequency of mechanical lithotripsy (ML) usage, total procedure time and intra- and postoperative adverse events were analyzed. We used RevMan 5.3 to perform the pooled analyses.ResultsSeven RCTs matched the selection criteria. A total of 369 patients underwent EPLBD alone, and 367 patients underwent EPLBD following EST. Our meta-analysis revealed that there were no significant differences in terms of initial success rate (OR =0.69, 95% CI=0.44–1.09, P=0.11), frequency of ML usage (OR =1.18, 95% CI=0.68–2.05, P=0.55), rate of post-endoscopy pancreatitis (PEP) (OR =0.88, 95% CI=0.43–1.78, P=0.72), total procedure time (MD =1.52, 95% CI=-0.13–3.17, P=0.07), or other intra- and postoperative adverse events between the groups for patients with large and/or multiple CBDSs.ConclusionsEPLBD alone was comparable to EPLBD with prior EST in patients with large and/or multiple CBDSs. Further studies are required to confirm the mechanisms of PEP in patients who accept EPLBD during endoscopic retrograde cholangiopancreatography (ERCP).

Is it necessary to perform sphincterotomy prior to endoscopic papillary large balloon dilation?

Is it necessary to perform sphincterotomy prior to endoscopic papillary large balloon dilation?

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

Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis.

Endoscopic papillary large balloon dilation (EPLBD) without endoscopic sphincterotomy (EST) may facilitate extraction of large bile duct stones through achieving adequate dilation of the ampulla. However, contrary to favorable long-term outcomes after endoscopic papillary balloon dilation (EPBD), that of EPLBD without EST has been little investigated. Therefore, we conducted the current study to evaluate short- and long-term outcomes of EPLBD without EST and EPBD after removal of large bile duct stones (LBDS; ≥10 mm). This retrospective study included patients without a previous history of EST, EPBD or EPLBD who underwent EPLBD without EST or EPBD for removal of LBDS. Each patient in the EPLBD without EST group was matched to a patient in the EPBD group using propensity scores. Forty-four patients in each group were matched for the analysis. Baseline characteristics were balanced after propensity matching. Rate of complete stone removal in a single session was higher (80% vs 16%, P < 0.001), number of ERCP sessions (1.3 ± 0.7 vs 2.4 ± 1.5, P < 0.001) and rate of lithotripsy use (30% vs 80%, P < 0.001) were smaller in the matched EPLBD without EST group. Contrary to null between-group differences in early adverse events (P = 0.99), a cumulative rate of late biliary complications was higher in the EPLBD without EST group (P = 0.02). EPLBD without EST showed higher efficacy for removal of LBDS but was associated with worse long-term outcomes when compared to EPBD.

Comparison of the Long-Term Outcomes of Endoscopic Papillary Large Balloon Dilation Alone versus Endoscopic Sphincterotomy for Removal of Bile Duct Stones.

Background and Aims Endoscopic papillary large balloon dilation (EPLBD) alone is an alternative to endoscopic sphincterotomy (EST) for treatment of common bile duct (CBD) stones. However, limited data exists regarding comparison of the long-term outcomes for these techniques. In this study, we compared the long-term outcomes after EST with those after EPLBD alone for removal of CBD stones. Methods The records of patients with EST or EPLBD alone referred for CBD stones retrieval between June 2008 and July 2015 were retrospectively reviewed. Complete stone clearance, ERCP-related adverse events, and late biliary complications during long-term follow-up were analyzed. Results Basic patient characteristics were similar between the groups that underwent EST (n = 60) and EPLBD alone (n = 161). EPLBD compared with EST resulted in similar outcomes in terms of complete stone clearance (99.4% versus 100%, P = 0.54) and ERCP-related adverse events (6.8% versus 6.7%, P = 1.00). The mean duration of the follow-up was 74.5 months and 71.6 months who underwent EST and EPLBD alone, respectively (P = 0.42). Late biliary complications were occurred frequently in the EST group than in the EPLBD alone group (11 [18.6%] versus 16 [10.2%]), although the difference did not reach statistical significance (P = 0.11). Multivariate analysis showed that mechanical lithotripsy ([OR], 2.815; 95% CI, 1.148–6.902; P = 0.024) was significantly associated with late biliary complications. Conclusion As an alternative to EST, EPLBD has similar efficacy and safety for managing CBD stones. During long-term follow-up, patients who underwent EPLBD alone may have fewer late biliary complications compared with those after EST. In addition, mechanical lithotripsy may be an independent risk factor for late biliary complications.

Sa1361 CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY IN THE TREATMENT OF DIFFICULT BILE DUCT STONES- A SINGLE CENTER EXPERIENCE

Using standard techniques, the treatment of bile duct stones is highly effective in 85-90% of cases. In 5-15% the stones are classified as “difficult” due to their size, location, form, calcification or altered anatomy. For these situations alternative treatment options are needed. Cholangioscopy- guided laser- or electrohydraulic lithotripsy increases the success rate of the bile duct stones treatment up to 100%. To evaluate the efficacy, safety and cost- effectiveness of the cholangioscopy guided laser lithotripsy for the treatment of difficult bile duct stones in the context of complications, price and mean procedure time. Data was collected retrospectively from January 2016 to September 2017. All the patients had previous single-session ERCP, sphincterotomy with or without large balloon dilation and plastic stenting performed and bile duct stones were characterized as “difficult” after attempts for extraction using standard techniques or after detection of anatomical abnormalities of the biliary system /strictures/. Patients were scheduled for cholangioscopy with the SpyGlass DS system (Boston Scientific, Marlborough, MA, USA). A 200 μm single use laser fiber (Cook Medical, Bloomington, IN, USA) was positioned close to the stone and lithotripsy was performed until complete fragmentation has been achieved (Settings- 1,2 mJ, 8Hz). The procedure was followed by balloon- or basket extraction of fragments. CBD clearance was confirmed by cholangioscopy. Further interventions were rescheduled if needed. For the period a total of 16 cholangioscopy- guided holmium laser lithotripsies were performed in 14 patients. 2 complications were documented- hemobilia caused discontinuation of the procedure in a patient with essential thrombocitopaenia and a case of mild cholangitis treated with i.v. antibiotic for 5 days. Nasobiliary drainage was left for 24 hours in 2 patients, 2 patients received temporary plastic stents for cholangitis- profilaxis due to residual debris . No serious adverse events requiring surgery, blood transfusions or ICU admission were noted. Cholangioscopy guided Holmium laser lithotripsy is a safe and effective option to treat difficult bile duct stones. The early implementation avoids multiple ERCP- sessions, surgery and related complications in patients, unsuitable for standard endoscopic treatment. Carefull patient selection is needed in relation with the cost- effectiveness and procedure duration.Table 1ResultsNumber of patients14Impacted CBD stones6/14 (42,8%)CBD stones8/14 (57%)Stones in the common hepatic duct2/14 (14,2%)Intrahepatic stones3/14 (21,4%)Stones in the cystic duct1/14 (7,1%)Size of the stones10-35 mmNumber of sessions until complete clearance1,14Duration of the procedure90-180 min.Complications2/14 (14,2%) Open table in a new tab

Sa1298 ASSESMENT OF SHORT SINGLE-BALLOON ENTEROSCOPE (SHORT-SBE) FOR THERAPEUTIC ERCP IN PATIENTS WITH SURGICALLY ALTERED ANATOMY

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. We performed ERCP in such patients using a short single-balloon enteroscope (Short-SBE, Olympus), which has a 3.2-mm working channel and a 152-cm working length and for which conventional accessories are available. This study aimed to assess the efficacy and safety of ERCP using a Short-SBE in patients with surgically altered anatomy. The present retrospective study included 101 patients (range, 32-93 years) and 162 procedures comprising Roux-en-Y reconstruction (74 patients and 101 procedures), Billroth II gastrectomy (17 patients and 31 procedures), and reconstruction by the modified Child method (10 patients and 30 procedures) performed using a Short-SBE. The success and complication rates of each procedure were evaluated. The blind end was reached in 93.2% of procedures (151/162). Of the failed procedures, six were caused by jejunum invasion. Among 151 procedures in which the blind end was reached, cholangiography was successfully performed 94% of procedures (142/151). Treatment was successful in 87.7% of procedures (142/162). Successfully performed therapeutic interventions included nasobiliary drainage (n = 2), plastic stent placement (n = 28), self-expandable metallic stent placement (n = 21), tumor biopsy (n = 4), and stone extraction (n = 81) using endoscopic sphincterotomy (n = 2) endoscopic papillary balloon dilation (n = 9), endoscopic papillary large-balloon dilation (n = 28), and choledochojejunostomy dilation (n = 12). Complications that occurred in 9.3% of procedures (15/162) included perforation (n = 3, 2 cases were during scope insertion, and 1 case was during choledochojejunostomy dilation), mild pancreatitis (n = 7), and mild cholangitis (n = 5). ERCP using a short-SBE is effective and safe in patients with surgically altered anatomy.

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 papillary large balloon dilation in patients with large biliary stones and periampullary diverticula: Results of a multicentric series

IntroductionStone extraction represents the most frequent indication for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic papillary large balloon dilation (EPLBD) is a recent introduced approach consisting of an endoscopic papillary large balloon dilation following limited endoscopic sphyncterotomy (ES), which has been proven to be safe and effective for extraction of large common bile duct (CBD) stones. Peri-ampullary diverticula (PAD) are described in 10–20% of patients undergoing ERCP. Aim of our study is to evaluate efficacy and safety of EPLBD for the extraction of large biliary stones in patients with PAD. MethodsThe prospectively collected endoscopy databases of 4 Italian ERCP high-volume centers were reviewed retrospectively, and all consecutive patients with an instrumental diagnosis of large biliary stones and PAD, between September 2014 and October 2016, were included in this study. ResultsEighty-one patients (36 males, median age 75 years) were treated between September 2014 and October 2016. Deep biliary cannulation was reached in 78/80 patients. Successful extraction was achieved in 74/78 patients at the first attempt. AEs occurred in 8 patients (1 severe). Younger age, stone size and incomplete stone extraction were significantly associated with AEs. ConclusionsEPLBD is an effective and safe technique in patients with PAD and large biliary stones, which avoids the need of other techniques, thereby reducing the risks of adverse events.

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.