Large Bile Duct Stones Research Articles

Mechanical Lithotripsy of an Impacted, Large Bile Duct Stone

Choledocholithiasis is usually treated by endoscopic retrograde cholangiography (ERC) and stone extraction with the help of a stone extraction basket or balloon. In cases of giant or incarcerated stones, a normal stone extraction is not always successful. In these cases, it can be necessary to perform a stone fragmentation to remove the stone. Stone fragmentation can be performed mechanically with a stone fragmentation basket, with extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, or laser lithotripsy. The performance of a mechanical lithotripsy is widely spread, it is easy to perform and cost effective.1The authors present a case of a patient who underwent an ERC procedure for mechanical lithotripsy of a giant stone that could not be retrieved in the traditional way. This article is part of an expert video encyclopedia.

Direct Cholangioscopy with Standard Ultraslim Endoscopes for Electrohydraulic Lithotripsy of an Incarcerated Large Bile Duct Stone

Ninety percent of patients with intraductal biliary stones are successfully treated with sphincterotomy and subsequent stone extraction. However, technical difficulty increases with stone size and giant stones require fragmentation to facilitate endoscopic removal. For stones too large to be engaged in a basket for mechanical lithotripsy, laser and electrohydraulic lithotripsy have been proposed for stone fragmentation. Application of electrohydraulic lithotripsy (EHL) is best achieved under direct visualization during cholangioscopy, because shock waves can also injure normal tissue. We present the case of a patient who underwent direct cholangioscopy for EHL of a giant stone that could not be retrieved by endoscopic retrograde cholangiopancreatography (ERCP). This article is part of an expert video encyclopedia.

Small endoscopic sphincterotomy plus large-balloon dilation for removal of large common bile duct stones during ERCP

This study compared the therapeutic benefits and complication rates of small endoscopic sphincterotomy plus large-balloon dilation (ESLBD) with those of endoscopic sphincterotomy (EST) alone for large bile duct stones. We compared prospectively ESLBD group (n=63) with conventional EST group (n=69) for the treatment of large bile duct stones (≥15mm). Mechanical lithotripsy was performed when the stone could not be removed using a normal basket. We compared the rates of stone removal, frequency of mechanical lithotripsy use, procedure-related complications, and recurrent stones. A total of 132 patients were reviewed in the study. The mean age of the patients was 67.9 years. The two groups showed significant differences in complete stone removal during the first session (80.9 vs. 60.8%; P = 0.046), the use of mechanical lithotripsy (7.94 vs. 24.6%; P = 0.041), and less duration of admission (P =0.045). After ERCP, there were some instances of oozing in both groups, All patients recovered completely, 14 patients had recurrent common bile duct stones among the follow-up duration. The ESLBD technique seems to be a feasible and safe alternative technique for conventional EST and EBD and has no more Post-ERCP complications.

Recent advances in endoscopic management of difficult bile duct stones

Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

Su1407 Safety and Effectiveness of Endoscopic Sphincterotmy Plus Large Balloon Dilation: Single Center Mid-Term Outcome

Safety and Effectiveness of Endoscopic Sphincterotmy Plus Large Balloon Dilation: Single Center Mid-Term Outcome Fumihide Itokawa*, Takao Itoi, Atsushi Sofuni, Takayoshi Tsuchiya, Nobuhito Ikeuchi, Reina Tanaka Tokyo Medical University, Tokyo, Japan Background: Endoscopic sphincterotmy plus large balloon dilation (ESLBD) would theoretically favorable for extracting large bile duct stones. Although there are many studies on the feasibility and short-term outcome, there is no midto long-term outcome after ESLBD. The aim of our study is to evaluate the mid-term outcome of ESLBD. Methods: 168 patients with large bile duct stones who underwent ESLBD from November 2006 through December 2011 were retrospectively reviewed. The patients were observed till November 2012. In the present study, inclusion criteria were used to select patients with large and/or multiple bile-duct stones: 1) bile duct stone, 13 mm or more in shortest dimensionor 2) multiple ( 3) bile-duct stones, with the smallest more than 10 mm in shortest dimension. Exclusion criteria included coagulopathy, marked thrombocytopenia, anticoagulation therapy, acute pancreatitis, septic shock. After endoscopic sphincterotomy or prior sphincterotomy, the papillary balloon catheter (maximum diameter 15 mm, 18 mm, or 20 mm) was passed over the guidewire and positioned across the main duodenal papilla. The size of balloon was matched to the diameters of the bile duct and the stones. Results: The patients mean age were 76.8 9.8years. The history of gastric operation was 140 with none (normal), 2 with Billroth 1, 11 with Billroth 2 and 15 with Rouxen Y. 70 patients (41.7%) had periampullary diverticulum. The presence of Gallstone was 65 (38.7%), the history of cholecystectomy was 42(25%), the previous sphincterotomy was 33 (19.6%). The mean follow up period were 39.85 13.7 months (range 11-69). 7 patients (4.2%) occurred stone recurrence (Mean age 72.8 7.8, surgically altered anatomy: none 6, Billroth 2 1, Gallstone 3, Periampullary diverticulum 1, History of sphincterotomy 6 (85.7%), History of stone recurrence 6 (85.7%)). There were no recurrence who had first ESLBD treatment. Conclusions: ESLBD can be safely and effectively performed. Furthermore, our mid-term outcome revealed that ESLBD is low risk of recurrence of bile duct stones. Thus, although further lon-term outcome seems to be mandatory, it will be promising treatment in patients with difficult bile duct stones.

Sa1531 Endoscopic Papillary Large Balloon Dilation or Endoscopic Sphincterotomy in Extraction of Large Common Bile Duct Stones: Optimal Management Strategy Using Decision Analysis Techniques

Sa1531 Endoscopic Papillary Large Balloon Dilation or Endoscopic Sphincterotomy in Extraction of Large Common Bile Duct Stones: Optimal Management Strategy Using Decision Analysis Techniques

Author reply: Comment to “Sixty versus thirty seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial”

Author reply: Comment to “Sixty versus thirty seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial”

Comment to “Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial”

Comment to “Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial”

Safely Stretching Our Options for Removing Large CBD Stones

In 10–15 % of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for the indication of suspected choledocholithiasis, identified stones can be difficult to remove [1]. Common factors associated with failure include stones[1 cm, numerous stones, and altered biliary anatomy. There are several techniques for removing these ‘‘difficult CBD stones’’. Leaving a plastic biliary stent in place with or without ursodeoxycholic acid therapy with subsequent ERCP is often successful [2]. Mechanical lithotripsy (ML) fragmentation combined with biliary sphincterotomy (EST) successfully removes many large stones [3, 4]. Complications following biliary sphincterotomy and ML include bleeding, pancreatitis, and perforation and are usually mild and self-limited but on rare occasions can cause short-term morbidity or even death [5]. Electrohydraulic lithotripsy can be useful for disintegrating stones prior to removal, but requires direct visualization of the stone with cholangioscopy with attendant risks such as hemobilia, cholangitis, and ductal perforation [6]. Endoscopic papillary balloon dilation (EPBD), or balloon sphincteroplasty, has evolved as another technique for removing large bile duct stones. Controlled radial expansion (CRE) balloons 6–10 mm in diameter stretch the intact sphincter of Oddi to facilitate stone removal. Though early experience with balloon sphincteroplasty was promising, subsequent multicenter, randomized controlled trials reported overall higher rates of pancreatitis including severe pancreatitis leading to death in some patients treated with balloon sphincteroplasty [7, 8]. While balloon sphincteroplasty remains an accepted practice in some parts of the world, the American Society for Gastrointestinal Endoscopy only recommends EPBD for patients in whom sphincterotomy is considered too risky or difficult such as patients medically anticoagulated or those with post-surgical anatomy or a periampullary diverticulum [1]. Endoscopic papillary large-balloon dilation (EPLBD) is a technique introduced in 2003 that dilates with a 12 to 20-mm CRE balloon following biliary sphincterotomy [9]. Balloon size is chosen to be at least the same diameter as the stone but no larger than the diameter of the bile duct. The initial published retrospective series reported that biliary stones too large to be removed despite a complete sphincterotomy and use of an extraction balloon or basket could be successfully removed in most cases without the use of ML [9]. Furthermore, the overall complication rate was an acceptable 15.5 %, consisting of mild-to-moderate cholangitis, pancreatitis, and bleeding, with no deaths [9]. Several retrospective studies, prospective series, and randomized controlled studies have reported that EPLBD is an effective and mostly safe method for the removal of large CBD stones [10–16]. A recent systematic review of R. Daniel Lawson: A military service member (or employee of the U.S. Government).

Endoscopic papillary large‐balloon dilation following limited sphincterotomy for the removal of refractory bile duct stones: Experience of 169 cases in a single Chinese center

To evaluate the efficacy and safety of endoscopic papillary large-balloon dilation (EPLBD) combined with limited endoscopic sphincterotomy (EST) for the removal of large biliary duct stones (≥10 mm). Data of patients who underwent an attempted removal of large bile duct stones by limited EST followed by EPLBD (≥12 mm in diameter) from April 2006 to October 2011 in our center were reviewed. Clinical characteristics, endoscopic methods and outcomes of the patients were collected and analyzed. A total of 169 patients with a mean age of 69.3 years (range 19-97 years) underwent 171 procedures. Median stone size and balloon diameter was 15 mm and 13 mm, respectively. Complete stone removal in a single session was achieved in 163 procedures (95.3%) with mechanical lithotripsy (ML) used in 66 (38.6%). Patients with a larger stone size required more frequent use of ML with a comparable success rate (P < 0.01). There were no significant differences between patients with and without periampullary diverticula in stone clearance (97.3% vs 93.8%), ML requirement (36.5% vs 40.2%) and complications (2.7% vs 6.2%) (all P > 0.05). Seven patients had eight procedure-related complications including moderate or mild bleeding (n = 4), minor perforation (n = 1), mild pancreatitis (n = 2) and cholangitis (n = 1). EPLBD following limited EST is an effective and safe approach for the removal of large biliary duct stones, especially for those refractory cases.

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

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

Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones

Objective. Removal of large bile duct stones by endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been proven safe and effective. Little evidence supports the benefits of a preceding EST in reducing complications. Recent studies suggest that large bile duct stone removal by EPLBD alone may be safe and effective. Material and methods. We removed large bile duct stones by EPLBD with EST from March 2008 to February 2010 and without EST from March 2010 to October 2011. Efficacy and safety of EPLBD with or without EST and late biliary complication outcomes were assessed. Results. Forty-two patients (men/women, 27/15; mean age, 76 years) underwent EPLBD: 14 underwent EPLBD with EST and 28 underwent EPLBD without EST. The mean stone size was 14 mm (9–30 mm). Overall complete stone removal rate was 98%, with 83% achieved in 1 session. Complete duct clearance by EPLBD alone was achieved in 79%. Mechanical lithotripsy was required in 4 (10%) patients. Extracorporeal shock wave lithotripsy and electrohydraulic lithotripsy were required in 4 (10%) and 1 (2%) patients, respectively. Pancreatitis and perforation occurred in 2 (5%) and 1 (2%) patients, respectively. Patients treated by EPLBD with EST and by EPLBD alone did not differ in complication outcomes. Six (14%) patients had recurrent bile duct stones, with a significant correlation to dilated common bile duct (p = 0.0351). Conclusions.EPLBD is safe and effective in patients with large bile duct stones. Preceding EST may be unnecessary.

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 papillary balloon dilation after sphincterotomy for difficult choledocholithiasis: A case-controlled study

To evaluate the efficacy and safety of endoscopic sphincterotomy (EST) + endoscopic papillary large balloon dilation (EPLBD) vs isolated EST. We conducted a retrospective single center study over two years, from February 2010 to January 2012. Patients with large (≥ 10 mm), single or multiple bile duct stones (BDS), submitted to endoscopic retrograde cholangio-pancreatography (ERCP) were included. Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy (EST+EPLBD), using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram. Patients in Group B (control group) underwent isolated sphincterotomy. Stones were removed using a retrieval balloon catheter and/or a dormia basket. When necessary, mechanical lithotripsy was performed. Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure. In case of residual lithiasis, a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk. Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP. Outcomes of EST+EPLBD (Group A) vs isolated EST (Group B) were compared regarding efficacy (complete stone clearance, number of therapeutic sessions, mechanical and/or extracorporeal lithotripsy, biliary stent placement) and safety (frequency, type and grade of complications). Statistical analysis was performed using χ(2) or Fisher's exact tests for the analysis of categorical parameters and Student's t test for continuous variables. A P-value of less than 0.05 was considered statistically significant. One hundred and eleven patients were included, 68 (61.3%) in Group A and 43 (38.7%) in Group B. The mean diameter of the stones was similar in the two groups (16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B, respectively). Forty-eight (70.6%) patients in Group A and 21 (48.8%) in Group B had multiple BDS (P = 0.005). Overall, balloon dilation was performed up to 12 mm in 10 (14.7%) patients, 13.5 mm in 17 (25.0%), 15 mm in 33 (48.6%), 16.5 mm in 2 (2.9%) and 18 mm in 6 (8.8%) patients, taking into account the diameter of the largest stone and that of the bile duct. Complete stone clearance was achieved in sixty-five (95.6%) patients in Group A vs 30 (69.8%) patients in Group B, and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B (P < 0.001). Patients submitted to EST+EPLBD underwent fewer therapeutic sessions (1.1 ± 0.3 vs 1.8 ± 1.1, P < 0.001), and fewer required mechanical (14.7% vs 37.2%, P = 0.007) or extracorporeal (0 vs 18.6%, P < 0.001) lithotripsy, as well as biliary stenting (17.6% vs 60.5%, P < 0.001). The rate of complications was not significantly different between the two groups. EST+EPLBD is a safe and effective technique for treatment of difficult BDS, leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.

Endoscopic papillary large balloon dilation in patients with periampullary diverticula

To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) for bile duct stone extraction in patients with periampullary diverticula. The records of 223 patients with large common bile duct stones (≥ 10 mm) who underwent EPLBD (12-20 mm balloon diameter) with or without limited endoscopic sphincterotomy (ES) from July 2006 to April 2011 were retrospectively reviewed. Of these patients, 93 (41.7%) had periampullary diverticula (PAD), which was categorized into three types. The clinical variables of EPLBD with limited ES (EPLBD + ES) and EPLBD alone were analyzed according to the presence of PAD. Patients with PAD were significantly older than those without (75.2 ± 8.8 years vs 69.7 ± 10.9 years, P = 0.000). The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and non-PAD groups, however, there was significantly less need for mechanical lithotripsy in the PAD group (3.2% vs 11.5%, P = 0.026). Overall stone removal rates, complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD + ES and EPLBD alone in patients with PAD (96.6% vs 97.1%; 72.9% vs 88.2%; and 5.1% vs 0%, respectively). No significant differences with respect to the rates of pancreatitis, perforation, and bleeding were observed between EPLBD + ES and EPLBD alone in the PAD group (3.4% vs 14.7%, P = 0.095; 0% vs 0%; and 3.4% vs 8.8%, P = 0.351, respectively). EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD, regardless of PAD subtypes.

Endoscopic papillary balloon dilatation in comparison with endoscopic sphincterotomy for the treatment of large common bile duct stone

Background:There are concerns on the efficacy and safety of endoscopic papillary balloon dilatation (EPBD) as an alternative to endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis. We compared the efficacy and safety of EPBD and EST for removing large common bile duct (CBD) stones.Materials and Methods:One hundred sixty patients with CBD stones of 10-20 mm were randomized to undergo EPBD or EST. A 15-mm dilatation balloon was used for EPBD. Cotton's criteria were used to determine the incidence of post-EPBD or post-EST complications. CBD stone removal and complications were compared between the two methods.Results:CBD stones were completely removed in 97.5% of the EPBD and 96.2% of the EST group (P = 0.5). The incidence of postoperative pancreatitis (11.2% vs 8.7%) and bleeding (1.2% vs 1.2%) were similar between the EPBD and EST groups (P > 0.05). Perforation did not occur in any patient.Conclusions:EPBD with 15-mm dilator balloon appears to be equally safe and effective compared with EST for removal of large CBD stones. So because of low complication and high success rate we recommend EPBD as the preferred method for removal of large (10-20 mm) CBD stones.

Electrohydraulic lithotripsy as an highly effective method for complete large common bile duct stone clearance

The removal of common bile duct (cBD) stones is commonly performed by endoscopic retrograde cholangiography (eRc), which has an 85-90% success rate. Thus, 10-15% of cBD stones, specifically large ones, cannot be completely removed using standard techniques and are therefore managed conservatively by sequential biliary stenting or using other techniques such as electrohydraulic lithotripsy (ehL). The aim of the present paper was to determine the outcomes of these different methods for the removal of large cBD stones in the patients who failed to clear the cBD after initial attempt and to identify the factors which might associated with patients who would fail for sequential biliary stenting. We retrospectively reviewed 439 patients who underwent eRc for stone removal in our institute. In this study, 36 cases and 7 cases were included in the sequential biliary stenting and intraductal ehL groups, respectively, with rates of complete cBD clearance of 86.1% and 100%, respectively. On average, 2.8 and 1.3 sessions were required before complete stone removal in the biliary stenting and ehL groups, respectively. The number of complications during follow-up was higher in biliary stenting than in intraductal ehL patients. The factors associated with failure to complete cBD stone clearance in the biliary stenting group were no change in cBD stone size 9 weeks after the first biliary stenting attempt and failure of balloon sphincteroplasty. ehL was an effective and safe procedure for acheivement of complete cBD clearance especially for large cBD stone.

Endoscopic sphincterotomy plus large-balloon dilationvsendoscopic sphincterotomy for choledocholithiasis: A meta-analysis

To perform a meta-analysis of large-balloon dilation (LBD) plus endoscopic sphincterotomy (EST) vs EST alone for removal of bile duct stones. Databases including PubMed, EMBASE, the Cochrane Library, the Science Citation Index, and important meeting abstracts were searched and evaluated by two reviewers independently. The main outcome measures included: complete stone removal, stone removal in the first session, use of mechanical lithotripsy, procedure time, and procedure-related complications. A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio (OR) when heterogeneity was not significant among the studies. When a Q test or I² statistic indicated substantial heterogeneity, a random-effects model weighted by the DerSimonian-Laird method was used. Six randomized controlled trials involving 835 patients were analyzed. There was no significant heterogeneity for most results; we analyzed these using a fixed-effects model. Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone (OR = 0.53, 95%CI: 0.33-0.85, P = 0.008); subcategory analysis indicated a significantly lower risk of perforation in the EST plus LBD group (Peto OR = 0.14, 95%CI: 0.20-0.98, P = 0.05). Use of mechanical lithotripsy in the EST plus LBD group decreased significantly (OR = 0.26, 95%CI: 0.08-0.82, P = 0.02), especially in patients with a stone size larger than 15 mm (OR = 0.15, 95%CI: 0.03-0.68, P = 0.01). There were no significant differences between the two groups regarding complete stone removal, stone removal in the first session, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, infection of biliary tract, and procedure time. EST plus LBD is an effective approach for the removal of large bile duct stones, causing fewer complications than EST alone.

Factors Predictive of Adverse Events Following Endoscopic Papillary Large Balloon Dilation: Results from a Multicenter Series

Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones. We sought to identify factors predictive of adverse events (AEs) following EPLBD. This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12-20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan. Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015). EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial

BackgroundEndoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy. AimsTo compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy. MethodsA total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n=60) or the 30-s dilation group (G30, n=64). ResultsThe complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p=0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p=0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p=0.17). Two perforations of moderate severity were observed, one in each group. Conclusions30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.