Small Common Bile Duct Stones Research Articles

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy

IntroductionThe management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients.MethodsPatients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described.ResultsFifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039.ConclusionsThis study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Prospective study on planned biliary stent placement to treat small common bile duct stones.

Small common bile duct stones are known to occasionally clear spontaneously. This study aimed to prospectively assess the role of biliary stent placement in promoting the spontaneous clearance of small common bile duct stones. We analyzed patients presenting with common bile duct stones of ≤5 mm diameter between June 2020 and May 2022. The exclusion criteria included asymptomatic patients, biliary pancreatitis, altered gastrointestinal anatomy, bile duct strictures (malignant or benign), and a history of EST. The biliary stents were inserted without stone removal. Stone clearance was assessed using endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography after 3 months. Our primary endpoint was the clearance rate of common bile duct stones over 6 months, targeting a lower limit for the 95% confidence interval (CI) exceeding 25%. Of the 32 enrolled patients, 18 (56.3%; 95% CI: 37.7-73.6%) exhibited stone clearance. Early complications occurred in 11 patients (34.4%), totaling 12 incidents: acute cholecystitis in four, acute pancreatitis in three, biliary pain in three, and cholangitis in two patients. No severe complications occurred. Six (18.8%) patients experienced asymptomatic stent migration. Following stone clearance, four (12.5%) patients experienced stone recurrence, with an average duration of 256 ± 164 days. Biliary stenting appeared to effectively promote the clearance of small common bile duct stones in approximately half of the patients. However, the potential complications and risks of stone recurrence warrant close monitoring.This trial was registered in the Japan Registry of Clinical Trials (jRCT1042200020).

Treatment efficacy and early complications of Percutaneous Transhepatic Holmium Laser Lithotripsy for biliary stones under Digital Subtraction Angiography guidance

Background: Intrahepatic stones and common bile duct stones are common diseases in Vietnam. Surgical treatments have a high rate of remaining intrahepatic bile duct stones and are ineffective with intrahepatic stones and cases with biliary strictures, while endoscopic retrograde cholangiopancreatography stone removal (ERCP) is usually indicated for small common bile duct stones and has disadvantages such as having to performe sphincterectomie of Oddi, 5% causing acute pancreatitis. Nowadays, minimally invasive treatment techniques are more and more developed. Percutaneous transhepatic lithotripsy under fluoroscopy guidance (TSQD) is an improved method using Holmium laser with small sized trocart (16F) help avoid open surgery and increase the rate of stone clearance, especially with stones located in the intrahepatic duct branches. For that reason, we conducted research to evaluate the treatment effectiveness and early complications of this method. Materials and method: This study was conducted on a group of 38 patients with main biliary tract stones, diagnosed and treated using PTHLL under fluoroscopy guidance at Hanoi Medical University Hospital from July 2018 to December 2019. Results: The PTHLL procedures was performed on patients with main extrahepatic biliary stones (28.9%) and those with intrahepatic stones, either isolated or combined (71.1%). One-step lithotripsy was applied in 26.3% of cases without cholangitis, simple stones. In another hand, Two-steps procedure were indicated in 73.7% of cases with cholangitis, multiple stones, and poor patient health. Stand-alone laser lithotripsy (23.7%) was suitable for simpler cases, while combination with baskets and balloons (76.3%) was used for complex situations. The overall complete stone clearance rate was 84.2%. Complications included septicemie (7.8%) and biloma (2.6%). No major complications like bleeding or deaths were encountered in this study. Conclusion: PTHLL under fluoroscopy guidance is a minimally invasive method that achieves a high rate of complete stone clearance in both intra- and extrahepatic biliary stones, with a low early complication rate. Key words: intervention, biliary stone, percutaneous transhepatic holmium laser lithotripsy.

Endoscopic retrograde cholangiopancreatography versus conservative treatment for patients with symptomatic small common bile duct stones: A randomized controlled trial

Endoscopic retrograde cholangiopancreatography versus conservative treatment for patients with symptomatic small common bile duct stones: A randomized controlled trial

Comprehensive review on small common bile duct stones.

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

Multiple Field-of-View Based Attention Driven Network for Weakly Supervised Common Bile Duct Stone Detection.

Common bile duct (CBD) stones caused diseases are life-threatening. Because CBD stones locate in the distal part of the CBD and have relatively small sizes, detecting CBD stones from CT scans is a challenging issue in the medical domain. We propose a deep learning based weakly-supervised method called multiple field-of-view based attention driven network (MFADNet) to detect CBD stones from CT scans based on image-level labels. Three dominant modules including a multiple field-of-view encoder, an attention driven decoder and a classification network are collaborated in the network. The encoder learns the feature of multi-scale contextual information while the decoder with the classification network is applied to locate the CBD stones based on spatial-channel attentions. To drive the learning of the whole network in a weakly-supervised and end-to-end trainable manner, four losses including the foreground loss, background loss, consistency loss and classification loss are proposed. Compared with state-of-the-art weakly-supervised methods in the experiments, the proposed method can accurately classify and locate CBD stones based on the quantitative and qualitative results. We propose a novel multiple field-of-view based attention driven network for a new medical application of CBD stone detection from CT scans while only image-levels are required to reduce the burdens of labeling and help physicians automatically diagnose CBD stones. The source code is available at https://github.com/nchucvml/MFADNet after acceptance. Our deep learning method can help physicians localize relatively small CBD stones for effectively diagnosing CBD stone caused diseases.

Application and usefulness of a new eight‐wire basket catheter for endoscopic extraction of small common bile duct stones: A retrospective multicenter study

ObjectivesDistally located small common bile duct stones are often difficult to treat or grasp endoscopically. Therefore, multiple devices, such as baskets or balloon catheters, are frequently used in such cases. However, it is desirable to use a single device for stone extraction from the perspective of cost‐effectiveness. In this multicenter study, we evaluated the efficacy of a new eight‐wire basket catheter for extracting small (≤10 mm) common bile duct stones.MethodsWe retrospectively analyzed the records of 144 patients who underwent stone extraction using the eight‐wire basket catheter for common bile duct stones ≤10 mm. The success rate of complete stone extraction and the risk factors for the difficulty in stone extraction with the eight‐wire catheter alone were mainly evaluated.ResultsThe success rate of stone extraction with the eight‐wire catheter alone was 86.1%. The final rate of complete stone extraction was 98.0%. The mean of the maximum diameter of the common bile duct and the largest stone dimension were 10.5 ± 3.5, and 5.1 ± 2.1 mm, respectively. Common bile duct diameter ≥12 mm and stone diameter ≥6 mm were identified as independent risk factors for the difficulty in stone extraction with the eight‐wire catheter alone.ConclusionsThe success rate of the new eight‐wire basket for small common bile duct stone extraction was acceptable. The device is beneficial and could be used from the start for the extraction of small stones < 6 mm.

The high rate of spontaneous migration of small size common bile duct stones may allow a significant reduction in unnecessary ERCP and related complications: results of a retrospective, multicenter study.

Common bile duct stones (CBDS) can spontaneously migrate through the duodenal papilla. In this case, ERCP could be unnecessary and a significant rate of complications could be avoided. In this study, we aim at retrospectively evaluating the rate of spontaneous stone passage in patients with an imaging diagnosis of CBDS and at analysing the factors associated to spontaneous stone migration. We conducted a retrospective multi-centre analysis of patients undergoing ERCP for CBDS in a 12-month period. 1016 patients with CBDS were analysed. In all patients CBDS was diagnosed with adequate imaging methods performed prior to ERCP. ERCPs with failed biliary cannulation were excluded. Data regarding patients' characteristics, imaging findings and ERCP procedure were analysed. 1016 patients with CBDS undergoing ERCP were analysed (male sex 43.3%; mean age 69.9 ± 16.5years). Diagnosis of CBDS was obtained by EUS in 415 patients (40.8%), MR in 343 (33.8%), CT in 220 (21.7%), and US in 38 (3.7%). No stones were found at ERCP in 179 patients (17.6%), in 14 (6.2%) when ERCP was performed within 6h from imaging study, in 114 (18.5%) between 7h and 7days, in 32 (24.6%) between 8 and 29days, and in 19 (43.2%) after 30days. The rate of unnecessary ERCP occurred significantly more frequently in patients in whom imaging methods demonstrated either sludge or ≤ 5mm CBDS (29.9 vs. 8.3%; p < 0.001). Spontaneous migration of small CBDS is a frequent event, and ≤ 5mm size and a delay in ERCP > 7days represent predictive factors for it. We suggest that CBDS ≤ 5mm should not undergo immediate removal and this fact would allow reducing the rate of unnecessary ERCP with their related complications. Prospective studies are needed to confirm these results and demonstrate the safety of a conservative management in this setting.

Best Procedure for the Management of Common Bile Duct Stones via the Papilla: Literature Review and Analysis of Procedural Efficacy and Safety.

Background: Endoscopic management of common bile duct stones (CBDS) is standard; however, various techniques are performed via the papilla, and the best procedure in terms of both efficacy and safety has not been determined. Methods: Endoscopic procedures were classified into five categories according to endoscopic sphincterotomy (EST) and balloon dilation (BD): (1) EST, (2) endoscopic papillary BD (≤10 mm) (EPBD), (3) EST followed by BD (≤10 mm) (ESBD), (4) endoscopic papillary large BD (≥12 mm) (EPLBD), and (5) EST followed by large BD (≥12 mm) (ESLBD). We performed a literature review of prospective and retrospective studies to compare efficacy and adverse events (AEs). Each procedure was associated with different efficacy and AE profiles. Results: In total, 19 prospective and seven retrospective studies with a total of 3930 patients were included in this study. For EST, the complete stone removal rate at the first session, rate of mechanical lithotripsy (ML), and rate of overall AEs in EST were superior to EPBD, but a higher rate of bleeding was found for EST. Based on one retrospective study, complete stone removal rate at the first session, rate of ML, and rate of overall AEs were superior for ESBD vs. EST, and the rate of bleeding for the former was also lower. Complete stone removal rate at the first session and rate of ML for ESLBD were superior to those for EST, with no significant difference in rate of AEs. For EST vs. EPLBD, complete stone removal rate at the first session and rate of ML were superior for the latter. For EPLBD vs. ESLBD, the efficacy and safety were similar. Conclusions: ESBD is considered the best procedure for the management of small CBDS, but strong evidence is lacking. For large CBDS, both ESLBD and EPLBD are similar.

The efficacy and accuracy of endoscopic ultrasound for detecting common bile duct stones in intermediate to high‐risk patients with non‐diagnostic CT or MRCP

AbstractCholedocholithiasis or common bile duct (CBD) stones are found in 15% to 20% of patients with symptomatic gallstone disease. Transabdominal ultrasound (TAUS), computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) are the most commonly used imaging studies for patients with suspected CBD stones. However, the sensitivity of these modalities may decline in patients with microlithiasis (CBD stones smaller than 5 to 6 mm). From literature reviewed, endoscopic ultrasound (EUS) was as effective as MRCP and endoscopic retrograde cholangiopancreatography (ERCP), with higher accuracy in small CBD stones than MRCP and less invasive than ERCP. However, there is not much evidence in the past regarding the diagnostic value of EUS for detecting CBD stones in intermediate to high probability patients based on the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, after non‐diagnostic CT or MRCP. A total of 92 patients with intermediate to high probability of choledocholithiasis based on ASGE guidelines were recruited in this study. We calculated the sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios of EUS for detecting CBD stones after non‐diagnostic CT or MRCP. By using univariate and multivariate analysis, we described the significance of patients' baseline characteristics and predictors that imply for further EUS study after inconclusive CT or MRCP. 35 (38%) out of 92 patients were found to have CBD stones on EUS. Among them, 30 had stones removed by ERCP, and three patients received cholecystectomy and choledocholithotomy with stones removal. Two patients with positive findings of CBD stones on EUS initially, ended up with negative findings on subsequent ERCP procedure. 57 (62%) patients with negative findings of CBD stones on EUS received regular follow‐up with a period of 9 to 24 months and showed no significant change in subsequent imaging and biochemical studies. The diagnostic accuracy of EUS for choledocholithiasis after non‐diagnostic CT or MRCP was 94.3%, with a sensitivity of 100% and specificity of 96.6%. Among all predictors for choledocholithiasis, the presence of clinical cholangitis was the only significant predictor in our multivariate analysis. In patients with intermediate to high probability of choledocholithiasis based on ASGE guidelines, EUS has shown a favorable accuracy and efficacy for detecting CBD stones when CT or MRCP is inconclusive. And the presence of clinical cholangitis is a significant predictor that indicates the necessity for EUS in patients with suspected CBD stones after non‐diagnostic CT or MRCP.

A Case of Post-cholecystectomy Biloma Causing Gastric Outlet Obstruction

A biloma is defined as an encapsulated collection of bile outside the biliary tree. It is mainly caused by iatrogenic injury (surgery, percutaneous transhepatic interventions) or abdominal trauma. We report a case of persistent choledocolithiasis in the distal common bile duct (CBD) causing enlargement of a post surgical biloma with subsequent gastric outlet obstruction. The biloma enlargement was due to the persistent bile leak secondary to blockage of the distal CBD. As a result, the bile was trapped, producing a mass effect on the duodenum as visualized during EGD.A 70 year old female with surgical history of cholecystectomy one month prior was admitted for severe abdominal pain, nausea, and anorexia. On admission, her vital signs and exam were normal except for severe RUQ tenderness and distention. CBC and CMP results were evaluated, which revealed a total bili of 0.98, AST 265, ALT 365, and Alk Phos of 1093. Subsequent workup, including CT abdomen/pelvis and ultrasound, showed choledocholithiasis with a stone measuring 3.8 millimeters in the distal common bile duct with proximal ductal dilatation of 8.5 mm and a large fluid filled structure near the gallbladder fossa concerning for biloma. An EGD was performed and showed extrinsic compression of the antrum and proximal duodenum secondary to the biloma resulting in the patients symptoms of gastric outlet obstruction. ERCP was completed and was significant for a leak of contrast from the CBD into the biloma. A sphincterotomy was performed, the ducts were swept, and a biliary stent was placed with a small CBD stone extracted. The patient's liver enzymes improved. On Day 4, a repeat CT abdomen showed improvement of the biloma post stent placement. Repeat EGD revealed resolution of external compression. The patient's symptoms of nausea and vomiting resolved and she was able to tolerate diet.Biloma formation is encountered mainly after surgical or interventional procedures and trauma involving the biliary system. Disruption of the biliary tree after cholecystectomy has been reported in 0-7% of cases. Postcholecystectomy bilomas are rare with a reported incidence of approximately 2.5%, and most often present with RUQ pain and fever within seven days of procedure. There is only one other reported case of biloma post cholecystectomy leading to gastric outlet obstruction, making this a rare complication. Early diagnosis and intervention is crucial to avoid significant morbidity.1276.tif Figure 1: No Caption available.

Common Bile Duct Stone Size Is an Independent Predictor of Stone Detection by Magnetic Resonance Imaging

Introduction: Endoscopic retrograde pancreatography (ERCP) is now primarily considered a therapeutic modality for management of common bile duct (CBD) stones. Endoscopic ultrasound (EUS) and Magnetic resonance imaging (MRI) are less invasive modalities used in the diagnosis of CBD stones prior to ERCP. The aim of the study is to detect if there is an additional diagnostic yield of EUS over MRI in detecting small common bile stones. Methods: A retrospective cross-sectional study was performed in patients who underwent ERCP between July 2011 and March 2017 for suspected CBD stone. The study included patients with CBD stone confirmed on ERCP and had a MRCP and an EUS within 72 hours from ERCP. Patient's demographic data, medical/surgical history, and imaging findings were collected from electronic health record (EHR). Imaging findings included CBD stone size on ERCP (categorized as small ≤5 mm vs. large >5 mm), CBD diameter (categorized as dilated if CBD diameter >8 mm), and presence or absence of CBD stone on EUS and MRCP. Results: A total of 110 patients were identified to have CBD stone on ERCP. In the final analysis, there were 110 patients with MRCP detecting stone in 66.4% patients. Seventy-two (65.5%) patients had small CBD stone and 38 (34.5%) had large CBD stone. Of this study population, the median age was 53 years, and 61.8% were female. The median BMI was 28.5. A total of 41 (37.3%) had hypertension; 22 (19.8%) had hyperlipidemia and 16 (14.4%) had diabetes. Most patients had cholecystectomy (47.3%) after ERCP and 39.1% before ERCP while the rest still have their gallbladder. Sixty-one (55.4%) had dilated CBD (Table 1). The multivariate logistic regression analysis revealed that larger stone size was associated with a higher likelihood of stone detection by MRCP (adjusted odds ratio: 5.57; 95% confidence interval [CI] 1.66 -18.7; P=0.005) (Table 2).Table: Table. Study population characteristics based on CBD stone size (univariate analysis)Table: Table. Multivariate Logistic Regression Results for the CBD stone detection by MRCPConclusion: MRCP has lower detectability rate for small (≤ 5 mm) common bile duct stone compared to EUS and ERCP. Sensitivity of MRCP for stones larger than 5 mm was satisfactory. Patients with a low or intermediate clinical index of suspicion for choledocholithiasis, further investigation with EUS is recommended despite negative MRCP.

Short-Term Biliary Stent Placement Contributing Common Bile Duct Stone Disappearance with Preservation of Duodenal Papilla Function.

Aims. To investigate the effect of biliary stent placement without endoscopic sphincterotomy (EST) on common bile duct stones (CBDS) disappearance and the contribution of preserving the duodenal papilla function to reduce recurrence of CBDS. Methods. Sixty-six patients admitted for acute obstructive cholangitis due to CBDS who underwent biliary stent placement without EST for 2 years from March 2011 were evaluated retrospectively. The second endoscopic retrograde cholangiopancreatography (ERCP) was performed for treatment of CBDS 3 to 4 months after the first ERCP. We estimated the rate of stone disappearance at the time of second ERCP. Results. CBDS disappearance was observed in 32 (48.5%) of 66 patients. The diameter of the bile ducts and the diameter of CBDS in patients with CBDS disappearance were significantly smaller than in those with CBDS requiring extraction (p = 0.007 and p < 0.001, resp.). Stone disappearance was evident when the diameter of bile ducts and that of CBDS were <10 and 7 mm, respectively (p = 0.002). Conclusions. Short-term stent placement without EST eliminates CBDS while preserving duodenal papilla function and may be suitable for treating CBDS in patients with nondilated bile ducts and small CBDS.

Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial.

Background/AimsEndoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for the treatment of common bile duct (CBD) stones. However, there is no established consensus on the optimal balloon dilation duration (BDD). We prospectively evaluated the efficacy and post-endoscopic retrograde cholangiopancreatography (ERCP) complications between the 20- and 60-second EPBD groups.MethodsA total of 228 patients with small CBD stones (≤12 mm) were randomly assigned to undergo EPBD with a 20- or 60-second duration at six institutions. We evaluated baseline patient characteristics, endoscopic data, clinical outcomes, and procedure-related complications. In addition, we analyzed risk factors for postprocedural pancreatitis.ResultsCBD stones were removed successfully in 107 of 109 patients (98.1%) in the 20-second group and in 112 of 119 patients (94.1%) in the 60-second group (p=0.146). Post-ERCP pancreatitis developed in seven patients (6.4%) in the 20-second group and nine patients (7.5%) in the 60-second group (p=0.408). In multivariate analysis, contrast dye injection into the pancreatic duct is a significant risk factor for post-EPBD pancreatitis.ConclusionsBased on the data showing that there were no significant differences in safety and efficacy between the two BDD groups, 20 seconds of BDD may be adequate for treatment of small CBD stones with EPBD.

Is the Balloon Dilation Duration in Endoscopic Papillary Balloon Dilation (EPBD) Related to the Occurrence of Post-EPBD Pancreatitis?

See Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial by Byoung Wook Bang, Tae Hoon Lee, Tae Jun Song, et al., on page 59-65 Endoscopic papillary balloon dilation (EPBD) was proposed as an alternative to endoscopic sphincterotomy (EST) for opening the bile duct orifice to allow stone extraction with functional preservation of the biliary sphincter. Since its introduction in 1982,1 EPBD has been widely performed because it is associated with lower bleeding and perforation risks compared to EST.2,3,4,5,6 However, EPBD is more likely to cause pancreatitis than EST, resulting in an increased mortality rate.7,8 Therefore, EPBD is reserved for selective patients with a bleeding diathesis or altered anatomy, especially in Western countries. The reported incidence of post-EPBD pancreatitis varies greatly, ranging from 0% to 15.4%.9,10,11,12,13 This disparity may be explained by differences in the stone size, bile duct size, balloon diameter, and balloon dilation duration (BDD). Although the mechanism is unknown, post-EPBD pancreatitis has been associated with papillary edema or spasm resulting from balloon dilation and papillary trauma during stone extraction through an insufficiently dilated sphincter. Therefore, papillary injury resulting in increased post-EPBD pancreatitis may frequently occur in cases with relatively large stones in small bile ducts and balloon diameters larger than the stone size or bile duct diameter. BDD was found to correlate with post-EPBD pancreatitis in previous studies, although the results were conflicting. In a prospective randomized trial,14 the risk of pancreatitis was higher with a 1-minute BDD (15.1%, 13/86) than with a 5-minute BDD (4.8%, 4/84; p=0.038). In a systemic review of randomized trials that compared EPBD and EST,15 short EPBD (≤1 minute) had a higher risk for pancreatitis (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.08 to 13.84) compared to EST, but long EPBD (>1 minute) did not pose a higher risk than EST (OR, 1.14; 95% CI, 0.56 to 2.35). A longer BDD may achieve greater loosening of the sphincter of Oddi and cause less papillary damage during stone extraction, resulting in a lower pancreatitis rate. In contrast, however, an initial 2-minute BDD was modified to 15 seconds during the later period of a retrospective study.16 A lesser tendency toward post-EPBD pancreatitis was observed in the modified group (4%, 13/324) relative to the initial group (7.4%, 24/324; p=0.063). A shorter BDD may be less traumatic to the papilla, thus reducing post-EPBD pancreatitis. Bang et al.17 evaluated the risk of pancreatitis after EPBD with a 20- or 60-second BDD in patients with relatively small bile duct stones (≤12 mm) while using balloon diameters (6 to 10 mm) selected according to the stone size and bile duct diameter. The authors also used a prophylactic pancreatic stent in patients at a high risk of post-ERCP pancreatitis. As a result, all factors that might affect the occurrence of post-EPBD pancreatitis were well controlled except for the BDD. However, they observed no difference in the occurrence of post-ERPD pancreatitis between the 20- and 60-second BDD groups (6.4%, 7/109 vs. 7.5%, 9/119). Bang and colleague17 proposed that EPBD could be adequately performed with a 20-second BDD in carefully selected patients because the BDD had little effect on the incidence of post-EPBD pancreatitis, a difficult finding to accept when compared with previous EPBD studies. Although this study may not appear to make sense, new approaches and data have made us rethink the best approach for bile duct stone removal. Therefore, we continue to seek the safest and most effective bile duct stone removal method.

Endoscopic Papillary Balloon Dilation Versus Sphincterotomy for Removal of Small Common Bile Duct Stones in Young Patients: Unresolved Issues for an Expanding Technique

Endoscopic Papillary Balloon Dilation Versus Sphincterotomy for Removal of Small Common Bile Duct Stones in Young Patients: Unresolved Issues for an Expanding Technique

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

Vascular Biliopathy as a Cause of Common Bile Duct Obstruction Successfully Treated by Mesocaval Shunt and Endoscopic Retrograde Cholangiopancreatography Biliary Stent Placement

Common bile duct stenosis owing to extrahepatic portal varices is termed "portal hypertensive biliopathy" (PHB) and is a rare occurrence. We report a case of PHB owing to portal vein thrombosis with cavernous transformation successfully managed by mesocaval shunt and endoscopic retrograde cholangiopancreatography (ERCP) biliary stent placement. A 44-year-old male, who presented with hematemesis, melena, jaundice, and abdominal pain, underwent gastroscopy, which revealed bleeding gastric varices. Computed tomography with arterial and venous imaging demonstrated portal vein thrombosis with cavernous transformation and extensive extrahepatic varices within the porta hepatis causing common bile duct obstruction from extrinsic compression. Biliary decompression was achieved with ERCP, and a small common bile duct stone was retrieved. A mesocaval shunt with a 16 mm Dacron graft successfully treated the portal hypertension. PHB is rare. We report a case successfully treated by mesocaval shunt and ERCP.

Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones

This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department. One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications. The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group. Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.

Comparison between Endoscopic Pappilary Balloon Dilatation and Endoscopic Sphincterotomy for the Treatment of Common Bile Duct Stones

Purpose: Endoscopic sphincterotomy (EST) has been established as an endoscopic treatment of common bile duct stones, whereas the technique of endoscopic papillary balloon dilatation (EPBD) has recently become widespread. EPBD is simple and preserves the papillary sphincter function. It has been reported that EPBD is associated with a lower risk of bleeding as a complication, but a higher risk of postoperative pancreatitis compared with EST. However, there have been few reports on detailed studies of post-EST and EPBD pancreatitis. Therefore, we conducted a study on the outcomes and early postoperative complications, especially pancreatitis, of EPBD and EST for the treatment of common bile duct stones at our department. Methods: 180 patients with common bile duct stones were randomized to EPBD or EST. For EPBD, an 8-mm dilatation balloon was used. For assessment of postoperative pancreatitis, the Cotton's criteria were modified to include relatively milder pancreatitis. Results: Complete removal rate of stones was significantly higher in EST group (95.6%) than that in EPBD group (86.6%); however, regarding small stones (< 10 mm), complete removal rate of EPBD (93.8%) was similar to that of EST (98.1%). By modified criteria when milder cases were included, postoperative pancreatitis occurred significantly more often in EPBD (16.7%) than in EST (6.7%). Bleeding was encountered in one patient (1.1%) of the EST, while no patients in EPBD. No fatal complication occurred in either the EPBD or EST group. Conclusions: In regard to small common bile duct stones, EPBD achieves appropriate same outcome as EST, while mild postoperative pancreatitis occurrs more often in EPBD.