Use Of Mechanical Lithotripsy Research Articles

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review.

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow-up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those. A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatographywith clearance, along with an analysis of risk factors. A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2-13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in-situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement. Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow-up in high-risk patients.

Combined endoscopic large balloon dilation with limited sphincterotomy versus sole sphincterotomy for removal of large or multiple common bile duct stones

BackgroundEndoscopic papillary large balloon dilation (EPLBD) after sphincterotomy (EST) was introduced for the removal of large (≥ 10 mm) or multiple bile duct stones. This method combines the advantages of EST and EPLBD by increasing the efficacy of stone extraction while minimizing complications of EST and EPLBD when used alone. This prospective study aimed to compare between EPLBD with prior limited EST and sole sphnicterotomy for extraction of multiple and/or large common bile duct stones.ResultsStatistical analysis revealed insignificant difference between the studied groups as regards the presence of periamullary diverticulum (23% vs. 19%, P > 0.05) and the use of mechanical lithotripsy (4% vs. 9%, P > 0.05). The rates of overall and initial stone clearance were not significantly different between both groups [94% vs. 90%), P > 0.05; and 84% vs. 78%, P > 0.05, respectively]. The procedure-related pancreatitis and bleeding in EST/EPLBD group were lower compared to EST group (3% vs. 5%, P > 0.05; and 2% vs. 6%, P > 0.05, respectively). None of the studied groups’ patients died or developed procedure-related perforation or cholangitis.ConclusionEndoscopic large balloon dilation with prior limited sphincterotomy is an effective and safe endoscopic technique for removing multiple and/or large CBDSs.

Endoscopic papillary large balloon dilation with or without sphincterotomy for extraction of large bile duct stones

ObjectivesThis work aimed to evaluate the safety and efficacy of endoscopic papillary large balloon dilatation (EPLBD) with or without endoscopic sphincterotomy (EST) in extraction of large common bile duct stones (CBDSs).BackgroundEST combined with EPLBD has been proposed as an alternative to manage large bile duct stones. However, recent reports indicate that EPLBD alone may be safe and effective in this setting.Patients and methodsFrom July 2019 to December 2021, we prospectively compared EPLBD alone (group I, n=100) with EST+EPLBD (group II, n=100) for the treatment of large CBDSs. CBDS clearance rate, frequency of mechanical lithotripsy usage, total procedure time, and intraendoscopic and postendoscopic complications were analyzed.ResultsStatistical analysis revealed that there were no significant differences between the studied groups regarding the use of mechanical lithotripsy (6 vs. 8%, P=0.579), overall and initial stone clearance rates (92 vs. 88%, P=0.346; and 81 vs. 76%, P=0.389, respectively), procedure-related pancreatitis (3 vs. 1%, P=0.312), or other intraendoscopic and postendoscopic adverse events, but there was a significant difference in terms of total procedure time (41.23±10.6 vs. 36.87±8.06, P=0.001).ConclusionThe therapeutic outcomes and complications of sole EPLBD for the removal of large CBDSs were comparable to those of EPLBD with prior EST.

Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review.

Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.

Risk factors for adverse events associated with endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a retrospective study

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) is considered to be a challenge in patients with surgically altered anatomy. We aimed to identify the risk factors of ERCP-related adverse events in patients with surgically altered anatomy in our center.MethodsWe included patients with surgically altered anatomy who underwent ERCP between April 2017 and December 2020 at our center. Clinical characteristics and outcomes were analyzed in univariate and multivariate methods to identify the risk factors for adverse events.ResultsA total of 121 ERCP procedures were performed in 93 patients. The papilla or surgical anastomosis was successfully reached in 113 cases (93.4%). Diagnostic success was achieved in 106 cases (93.8%) and subsequent therapeutic success was achieved in 102 cases (96.2%). ERCP-related adverse events occurred in 31 cases (25.6%). In univariate analysis, not first time ERCP attempt, a CBD stone diameter ≥ 15 mm, multiple cannulation attempts, endoscopic papillary balloon dilation, endoscopic papillary large balloon dilation, endoscopic retrograde biliary drainage, biopsy in the bile duct or papilla, mechanical lithotripsy use, and stone retrieval basket were associated with ERCP-related adverse events. In multivariate analysis, multiple cannulation attempts (OR 5.283; 95% CI 1.088–25.659; p = 0.039), endoscopic papillary balloon dilation (OR 4.381; 95% CI 1.191–16.114; p = 0.026), and biopsy in the bile duct or papilla (OR 35.432; 95% CI 2.693–466.104; p = 0.007) were independently associated with ERCP-related adverse events.ConclusionsERCP in patients with surgically altered anatomy was feasible and safe. Interventions including multiple cannulation attempts, endoscopic papillary balloon dilation, and biopsy in the bile duct or papilla were independent risk factors for ERCP-related adverse events.

S2501 Delayed Post Sphincterotomy Bleed and Clot-Induced Cholangitis: A Rare but Life-Threatening Complication of Endoscopic Retrograde Cholangiopancreatography

Introduction: Complication of ERCP are pancreatitis, bleeding and perforation. Post sphincterotomy (PS) bleed, which occurs in about 2% of cases, can be immediate or, very rarely, delayed. This lady had rare, but lethal complications of ERCP such as pancreatitis, severe delayed PS bleed, and clot-induced cholangitis; which was managed endoscopically. Case Description/Methods: A 28-year-old female presented with biliary type of pain abdomen, jaundice and fever. An ultrasonography showed choledocholithiasis, 15mm of size with upstream biliary dilation. Urgent ERCP was done. After biliary cannulation, when sphincterotomy was done, and pus oozed out of the ampulla, suggestive of cholangitis. As attempts to retrieve the calculi failed, mechanical lithotripsy was done and the fragments were removed with the help of basket. After complete CBD clearance, a plastic stent was deployed. There was no immediate PS bleed. But, she developed post ERCP pancreatitis and was managed conservatively. On the 5th day, she complained of melena and syncope. She also developed high-grade fever with chills. She became toxic, with tachycardia and tachypnea. Patient was shifted to ICU, and bedside endoscopy showed bleed in the periampullary area associated with large clots. The patient was intubated because of respiratory distress and started on inotropes and blood transfusion. Again, ERCP was done and blood clots were removed from the periampullary area. The old biliary stent was removed and the CBD was swiped cleared of a large clot that had adhered inside the duct and was causing cholangitis. Multiple aliquots of dilute adrenaline was injected in the peri ampullary area till hemostasis was achieved. A new plastic biliary stent was deployed in the CBD. Post the procedure, the patient began to improve clinically. Discussion: PS bleed can be immediate or very rarely delayed. According to a multivariate analysis, factors for PS bleeding includes coagulopathy, anticoagulation use, cholangitis before ERCP, bleeding during initial sphincterotomy and lower ERCP volume centre. The only risk factor in this patient was cholangitis. There are previously 5 reported cases of delayed PS bleed that has caused clot induced cholangitis. Size of calculus, prior cholangitis, and use of mechanical lithotripsy appear to be the risk factors. Recovery depends on the timing of repeat ERCP.Figure 1.: Endoscopic image showing clot post ERCP.

Cholangioscopy-guided basket retrieval of impacted stones.

ERCP remains the primary method of removing bile duct stones.1Chathadi K.V. Chandrasekhara V. Acosta R.D. et al.The role of ERCP in benign diseases of the biliary tract.Gastrointest Endosc. 2015; 81: 795-803Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Standard ERCP techniques, including endoscopic sphincterotomy with balloon sweeping or basket extraction, carry a >90% success rate in removing stones; however, large or impacted stones may present a particularly challenging scenario for the endoscopist.2Carr-Locke D.L. Therapeutic role of ERCP in the management of suspected common bile duct stones.Gastrointest Endosc. 2002; 56: S170-S174Abstract Full Text Full Text PDF PubMed Google Scholar Alternative solutions include the use of mechanical lithotripsy or cholangioscopy-guided methods, such as electrohydraulic or laser lithotripsy. However, stones may be in a position in which extraction by conventional balloon or basket under fluoroscopic guidance may be difficult (eg, in the intrahepatic ducts). The SpyGlass Retrieval Basket (Boston Scientific, Marlborough, Mass, USA) can be inserted through the SpyGlass cholangioscope (Boston Scientific) to allow for capture and removal of stones under direct visualization.3Fejleh M.P. Thaker A.M. Kim S. et al.Cholangioscopy-guided retrieval basket and snare for the removal of biliary stones and retained prostheses.VideoGIE. 2019; 4: 232-234Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This retrieval basket represents the second iteration of the device; the first iteration was challenging to open adequately. In Video 1 (available online at www.VideoGIE.org), we demonstrate the technique of using this novel device in removing difficult-to-retrieve stones under cholangioscopy guidance. An ERCP is performed using the standard technique with cannulation of the bile duct and cholangiogram, upon which several stones, including 1 in an intrahepatic duct, are visualized. After sphincterotomy, attempts to remove the intrahepatic duct stone with a balloon are unsuccessful because the catheter cannot be advanced past the stone. The cholangioscope is then inserted over the guidewire into the bile duct. Upon visualization of the stone, which appears impacted against upstream ductal mucosa (Fig. 1), the retrieval basket is advanced (exiting at the 5 o’clock position) upstream of the stone (Fig. 2). The basket is then opened with a gentle to-and-fro motion to enclose and dislodge the impacted stone. The basket can then be slightly closed to ensure an adequate hold on the stone (Fig. 3). In this case, some fragmentation of the stone occurs when the basket is closed; once the stone is captured, the cholangioscope is withdrawn transpapillary for stone extraction (Fig. 4). Irrigation through the cholangioscope is then performed to release any debris from the basket before closure and reuse. The cholangioscope is inserted back into the bile duct to ensure all stones have been removed, with complete clearance confirmed on cholangiogram (Fig. 5).Figure 2Retrieval basket positioned inferior to the impacted stone before opening and capture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Stone enveloped within basket.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Stone within retrieval basket withdrawn into the duodenum by withdrawal of the cholangioscope.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Final cholangiogram demonstrating complete clearance of all stones.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We have used the retrieval basket under direct visualization in 5 patients: 3 patients with bile duct stones and 2 patients with pancreatic duct stones. In all 5 patients, use of the retrieval basket was successful in removing stones that were not extracted with a conventional balloon or basket. None of the 5 patients had any adverse events, such as bleeding, perforation, or pancreatitis. No device malfunctions occurred, and there were no instances of inability to release the stone from the basket. Video 1 illustrates the use of a cholangioscopy-guided retrieval basket to remove impacted stones from the bile duct. Use of this device allowed disimpaction of the stones and precise capture under direct visualization, which may be useful in cases in which the wire cannot be advanced upstream of a stone or when the extraction balloon, given the catheter tip distance from the balloon, is ineffective in dislodging the stone. Larger future studies should examine the efficacy of this technique in removing both bile and pancreatic duct stones refractory to conventional extraction techniques.

Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials.

AIMTo compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials.METHODSWe conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis.RESULTSEleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), I2 = 11%, P = 0.31].CONCLUSIONThrough meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.

Sa1276 COMPARISON BETWEEN ENDOSCOPIC SPHINCTEROTOMY VERSUS ENDOSCOPIC SPHINCTEROTOMY ASSOCIATED WITH BALLOON DILATION FOR REMOVAL OF BILE DUCT STONES: A SYSTEMATIC REVIEW AND META-ANALYSIS BASED ON RANDOMIZED CONTROLLED TRIALS.

To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy versus sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. Eligibility criteria: Participants: patients with choledocholithiasis, older than 18 years. Interventions and comparisons: to compare endoscopic isolated sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation. All relevant articles were accessed in full text. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis. We analyzed the data and reported the results in tables and text. Nine RCTs with a total of 1230 patients were included. Data analysis of the included studies showed that there was no statistical difference in safety between the two methods, since the incidence of pancreatitis (FE RD - 0.01, CI [-0.03, 0.02], I2 = 0, p = 0.5), bleeding (FE RD - 0.01, CI [-0.03, 0.01], I2 = 32%, p = 0.25), cholangitis (FE RD 0.00, CI[-0.01, 0.01], I2 =0, p = 0.98) and perforation (FE RD - 0.01, CI [-0.02, 0.01], I2 =0, p = 0.37) was similar between the groups, but it was evident that there was a difference in efficacy, not quantitatively, with similar removal rates of gallstones in general and for subgroups greater than 15mm (FE RD 0.01, CI [-0.02, 0.04], I2 = 0, p = 0.59) and (FE RD 0.02, CI [-0.04, 0.07], I2 = 5%, p = 0.52), respectively, but perhaps qualitative, since there was less need for mechanical lithotripsy in the ESBD group (RE RD - 0.14, CI [-0.25, -0.03], I2 = 91%, p = 0.01), with a consequent theoretical decrease in exposure to adverse events resulting from it. There was no difference in the stone removal rate and incidence of bleeding, pancreatitis, cholangitis and perforation between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones. However, there was less use of mechanical lithotripsy in patients with choledocholithiasis submitted to sphincterotomy associated with balloon dilation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endoscopic papillary large balloon dilation for common bile duct stones

Objective To study the clinical efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) in the treatment of common bile duct (CBD) stones. Methods This retrospective study of EPLBD for CBD stoneswas conducted between May 2015 and March 2017 on 116 patients.The patients were divided into two groups based on the different methods of treatment: group A (the EPLBD group) and B(the EST+ EPBD group). Results Treatment with EPLBD when compared with EST+ EPBD produced similar outcomes with regard to the overall stone removal rates (96.2% vs. 93.5%, P>0.05) and complete ductal clearance in one session (92.6% vs. 92%, P>0.05). There were no significant differences in the rates of overall complication (22.2% vs. 22.2%, P>0.05), hemorrhage (7.4% vs. 11.3%, P>0.05), post-ERCP pancreatitis (9.3% vs. 6.6%, P>0.05) and acute cholangitis (5.6% vs. 8.1%, P>0.05). When compared with EST+ EPBD, mechanical lithotripsy was performed less in the EPLBD group (16.6% vs. 27.4%, P<0.05). Conclusions EPLBD was an effective and safe method to treat CBD stones. EPLBD reduced the use of mechanical lithotripsy when compared with EST+ EPBD. Key words: Endoscopic papillary large balloon dilatation (EPLBD); Endoscopic papillary balloon dilatation (EPBD); Common bile duct stone; Endoscopic retrograde cholangiopancreatography (ERCP); Endoscopic sphincterotomy (EST)

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones.

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease.METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients’ files.RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 ± 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 ± 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 ± 6.9 mm vs 7.2 ± 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 ± 6.3 mm vs 12.0 ± 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence.CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Feasibility of Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Bile Duct Stones without Dilatation of the Lower Part of the Extrahepatic Bile Duct.

Background/AimsThere is no consensus for using endoscopic papillary large balloon dilation (EPLBD) in patients without dilatation of the lower part of the bile duct (DLBD). We evaluated the feasibility and safety of EPLBD for the removal of difficult bile duct stones (diameter ≥10 mm) in patients without DLBD.MethodsWe retrospectively reviewed the records of 209 patients who underwent EPLBD for the removal of bile duct stones from October 2009 to July 2014. Primary outcomes were the clearance rate and additional mechanical lithotripsy. Secondary outcomes were the incidence of complications and recurrence rate.ResultsFifty-seven patients had DLBD (27.3%), and 152 did not have DLBD (72.7%). There were no significant differences in the overall success rate or the use of mechanical lithotripsy. Success rate during the first session and procedure time were better in the DLBD than the without-DLBD group (75.7% vs 66.7%, 48.1±23.0 minutes vs 58.4±31.7 minutes, respectively). As for complications, there were no significant differences in the incidence of pancreatitis, perforation or bleeding after endoscopic retrograde cholangiopancreatography. The recurrence rate did not differ significantly between the two groups.ConclusionsEPLBD is a useful and safe method for common bile duct stone removal in patients without DLBD.

Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation (EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography (ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis (PEP). However, as the efficacy of endoscopic papillary large-balloon dilatation (EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy (EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Risk Factors for the Presence of Residual Bile Duct Stones after Endoscopic Treatment of Stones of the Common Bile Duct

목적: 총담관담석의 내시경 제거술 이후 발생하는 잔여담석은 재발성 총담관담석으로 발현하거나 총담관담석으로자라는데 핵으로 작용할 수 있다. 그러나 관련된 위험인자에관한 연구는 드물다. 본 연구의 목적은 총담관담석의 내시경제거술 후 잔여 담석과 관련이 있는 인자들을 확인하고자하였다. 방법: 2008년 7월부터 2013년 6월까지 부산백병원에서 총담관담석으로 생애 처음 내시경 제거술을 시행 받은 환자중 잔여 담석이 발견된 환자 55명, 잔여 담석이 발견되지 않은 환자 281명을 선정하여 후향적으로 환자 대조군 연구를시행하였다. 두 군 간의 나이, 성별, 총담관담석의 성상, 혈액학적 검사 결과, 유두부 주위 게실의 유무, 기계식 쇄석술시행 유무, 유두부 풍선확장술 단독 사용 유무, 다발성 총담관담석의 동반 유무, 총담관담석의 크기, 총담관의 직경, 담낭 담석의 존재 유무, 이전에 담낭 절제술 시행 유무, 총담관담석의 내시경 제거술 시행 후 담낭 절제술 시행 여부를 비교 분석하였다. 결과: 단변량 분석에서 기계식 쇄석술을 시행 받은 경우,10 mm 이내의 유두부 풍선확장술만을 시행한 경우, 다수의총담관담석을 제거한 경우, 총담관담석의 크기가 1 cm보다큰 경우가 잔여 담석의 위험인자로 확인되었다. 다변량 분석에서 10 mm 이내의 유두부 풍선확장술만을 시행한 경우(OR, 3.174; p = 0.000), 4개 이상의 총담관담석을 제거한 경우(OR, 2.459; p = 0.013)가 잔여 담석의 발생에 관여하는 독립적인 위험인자로 확인되었다. 결론: 10 mm 크기 이내의 유두부 풍선확장술 단독 사용,4개 이상의 총담관담석이 동반된 경우가 총담관담석의 내시경 제거술 후 잔여 담석의 발생과 관련된 독립된 위험인자이고 이런 인자들이 동반된 환자의 시술 시 더욱 주의를 기울임과 동시에 2차 내시경 역행 담췌관조영술을 고려해야하겠다.

Endoscopic sphincterotomy with large balloon dilation versus endoscopic sphincterotomy for bile duct stones: a systematic review and meta-analysis.

The safety and efficacy of endoscopic sphincterotomy with large balloon dilation (EPLBD) are unclear. This study compares the safety and efficacy between EPLBD and endoscopic sphincterotomy (EST). Patients and Methods. Literatures were searched for randomized controlled trials in PUBMED, EMBASE, and Cochrane Library. Outcome measurements included adverse events; stone removal rate; requirement of mechanical lithotripsy. Results. Four RCTs with a total of 596 patients were included. Three RCTs compared EPLBD versus EST alone for stone removal; one RCT compared EPLBD versus EST plus mechanical lithotripsy for stone removal. Pooled data from three RCTs showed that there was no significant difference in the adverse event of ERCP. A significantly higher cholangitis rate was seen in patients who received EST plus mechanical lithotripsy, compared to those treated with EPLBD (13.3% versus 0.0, P = 0.026). No statistical difference was found between EPLBD and EST for stone removal rate. Significant differences in requirement of mechanical lithotripsy were seen with removal of large stones (>15 mm), with EPLBD reducing the use of mechanical lithotripsy (RR: 0.73; 95% CI: 0.54–0.99). Conclusions. EPLBD and EST have similar efficacy and safety for bile duct stones clearance. With larger stones, EPLBD can reduce requirement of mechanical lithotripsy.

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

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

Using cholecystokinin to facilitate endoscopic clearance of large common bile duct stones.

To evaluate the effect of cholecystokinin (CCK) during extracorporeal shockwave lithotripsy (ESWL) in the clearance of common bile duct (CBD) stones in endoscopic retrograde cholangiopancreatography (ERCP). Between January 2007 and September 2012, patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively. Patients were randomized in equal numbers to cholecystokinin (CCK) and no CCK groups. For each CCK case, a dose (3 ng/kg per min for 10 min) of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL. ERCP was performed 4 h after a session of ESWL. The clearance rate of the CBD was assessed between the two groups. A total of 148 consecutive cases (CCK group: 74, no CCK group: 74) were tallied. Overall there were 234 ESWLs and 228 ERCPs in the 148 cases. The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure (71.6% vs 55.4%, P = 0.035), but resulted in similar outcomes in the second (42.8% vs 39.4%) and third (41.7% vs 40.0%) sessions, as well as total stone clearance (90.5% vs 83.8%). The use of mechanical lithotripsy was reduced in the CCK group (6.8% vs 17.6%, P = 0.023), and extremely large stone (≥ 30 mm) removal was higher in the CCK group (72.7% vs 41.7%, P = 0.038). CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session. Mechanical lithotripsy usage was reduced and the extremely large stone (≥ 30 mm) clearance rate can be raised.

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.

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.

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.