Large balloon dilation vs. mechanical lithotripsy for the management of large bile duct stones: a prospective randomized study

Endoscopic Management of the Difficult Bile Duct Stones: A Single Tertiary Center Experience

Background. Most common bile duct (CBD) stones can be removed with standard techniques using endoscopic retrograde cholangiopancreatography (ERCP), but in some cases additional methods are needed. In this study we aimed to investigate the management of patients with difficult stones and the factors that affect the outcome of patients that have undergone periodic endobiliary stenting. Materials and Methods. Data of 1529 patients with naive papilla who had undergone ERCP with an indication of CBD stones was evaluated retrospectively. Stones that could not be removed with standard techniques were defined as “difficult stones.” Cholangiograms of patients who had difficult stones were revised prospectively. Results. Two hundred and eight patients (13.6%) had difficult stones; 150 of these patients were followed up with periodic endobiliary stenting and successful biliary clearance was achieved in 85.3% of them. Both CBD (p < 0.001) and largest stone size (p < 0.001) were observed to be significantly reduced between the first and the last procedure. This difference was even more significant in successfully treated patients. Conclusions. Periodic endobiliary stenting can be used as an effective treatment for patients with difficult stones. Sizes of the CBD and of the largest stone are independent risk factors that affect the success rate.

A review of treatment options for bile duct stones

Approximately 10-15% of bile duct stones cannot be treated using conventional stone removal techniques. For difficult common bile duct stones (CBDS), various endoscopic techniques have been developed. This review covers technical tips and endoscopic treatments including Endoscopic retrograde cholangiopancreatography (ERCP), particularly under Endoscopic ultrasound (EUS) guidance. Areas covered: Literatures about endoscopic treatment for bile duct stone were searched in Pub Med. As novel methods, EUS-guided approaches have also been reported, although long-term results and prospective evaluation are not yet sufficient. Large stones may need fragmentation prior to removal, to prevent stone impaction. To perform fragmentation, mechanical lithotripsy, extracorporeal shock wave lithotripsy or laser lithotripsy techniques are available. Expert commentary: Despite the fact that most bile duct stones can be treated using endoscopic techniques, endoscopists should remind to be able to select the temporary biliary stenting or percutaneous transhepatic cholangiodrainage as an option.

Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques

Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.

Complications of ERCP

Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.

Long-term recurrence of bile duct stones after endoscopic papillary large balloon dilation with sphincterotomy: 4-year extended follow-up of a randomized trial

BACKGROUND

Endoscopic papillary large balloon dilation with biliary sphincterotomy (EPLBD + EBS) is safe and effective in patients with large common bile duct (CBD) stones. However, data on long-term outcomes after EPLBD + EBS remain limited. We sought to prospectively evaluate the long-term recurrence of CBD stones after EPLBD + EBS and to identify the associated factors.

METHODS

We conducted an extended follow-up of a previous randomized trial (2009-2011) comparing the outcomes of 30- versus 60-s large balloon dilation. A total of 106 trial participants undergoing successful CBD stone clearance by EPLBD + EBS were prospectively followed up for up to 4 years (range 19-48 months). Various risk factors were analysed to assess predictors of long-term recurrence of stones.

RESULTS

Recurrent CBD stones appeared in 8/106 (7.5 %) patients during a mean follow-up of 30.5 ± 5.5 months. The mean diameter of CBD was significantly higher in the recurrence versus non-recurrence group (2.0 ± 4.9 vs 1.6 ± 0.9 cm, p = 0.008). Multivariate analysis revealed that CBD diameter was the only predictor significantly associated with the long-term recurrence of stones (odds ratio 1.2, p = 0.01).

CONCLUSIONS

EPLBD + EBS is associated with a low rate of long-term CBD stone recurrence. However, the risk is significantly higher in patients with a more dilated CBD.

Significance of Endoscopic Sphincterotomy Preceding Endoscopic Papillary Large Balloon Dilation in the Management of Bile Duct Stones

BACKGROUND

Endoscopic papillary large balloon dilation (EPLBD) is safe and effective in management of common bile duct stones (CBDS). Endoscopic sphincterotomy (EST) prior to EPLBD has been performed as a standard procedure. However, the significance of EST prior to EPLBD has not been well studied yet.

AIMS

To compare the clinical outcomes of EPLBD with and without EST to evaluate the significance of EST.

METHODS

Between April 2010 and March 2015, a total of 82 patients with naïve papillae underwent EPLBD with or without EST for the management of CBDS. A retrospective analysis compared the efficacy and safety of EPLBD with and without EST.

RESULTS

Basic patient characteristics were not significantly different between the groups that underwent EPLBD with EST (n = 27) and without EST (n = 55). Complete stone removal rates were similar between the groups (100 % in the EST group and 98 % in the non-EST group, p = 1.00). There was no significant difference in the median balloon size (13 mm in both groups, p = 0.445), rate of application of mechanical lithotripsy (26 vs. 35 % in the EST and non-EST groups, respectively, p = 0.463), or the median procedure time (38 vs. 34 min in the EST and non-EST groups, respectively, p = 0.682). The overall adverse event rates were not statistically different (4 vs. 7 % in the EST and non-EST groups, respectively, p = 1.00). Pancreatitis, cholangitis, and hemorrhage rates were also similar in both groups.

CONCLUSIONS

EST prior to EPLBD may be unnecessary since this study did not demonstrate its benefits.

Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis

Biliary disease is a common cause of acute pancreatitis. Risk stratification for persistent pancreatobiliary obstruction is important for selecting a treatment approach. Most common bile duct stones are extracted with standard endoscopic techniques. However, prior foregut surgery, stones with extreme morphologic attributes, and at difficult positions within the biliary system are technically challenging and predict a need for advanced biliary endoscopic techniques. Surgical common bile duct exploration at the time of cholecystectomy is appropriate in centers with experience. We outline the options and approach for the clinician to successfully identify and manage patients with symptomatic choledocholithiasis with or without biliary pancreatitis.

Effects Comparison between Endoscopic Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy for Common Bile Duct Stone Removal

Endoscopic sphincterotomy (EST) is a treatment of choice for stone extraction and is now most frequently used. The study was to compare the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and endoscopic sphincterotomy (EST) for common bile duct stone removal. Trials comparing the effects between EPLBD and EST treatment were searched according to the study protocol. Overall stone removal rate, complete removal rate in 1st session, treatment duration, mechanical lithotripsy using rate, and overall complication rate were compared using risk ratio (RR) and mean difference (MD) and their 95% confidence interval (CI) via RevMan 5.2 software. For overall stone removal rate, two therapies showed similar effect, but EPLBD showed better overall stone removal rate for stone >10 mm in diameter. For complete stone removal rate in 1st session, no difference was found, even for those with stone >10 mm in diameter; EPLBD showed longer treatment duration, higher mechanical lithotripsy using rate obvious overall complications rate, and more serious bleeding, whereas there were no significant differences for perforation, hyperamylasemia, pancreatitis, and cholecystitis/cholangitis. EPLBD showed better efficacy in certain conditions compared to EST, however with shortcomings, such as more duration, higher mechanical lithotripsy using rate, more serious overall complications rate, and bleeding.

Is endoscopic papillary large balloon dilatation without endoscopic sphincterotomy effective?

AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy in a prospective study.

METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with naïve papillae prospectively. For sphincteroplasty of EPLBD, endoscopic sphincterotomy (EST) was not performed, and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter (ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.

RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and 16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4 mm, and the mean number of stones was 3.0 ± 2.4. Complete stone removal was achieved in 97.5% (40/41) of cases, and ML was used in 12.2% (5/41) of cases. The mean number of sessions required was 1.2 ± 0.62. Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was 73.1% (30/41). No significant differences were noted in procedure time, rate of complete stone removal (100% vs 100%), number of sessions (1.1 vs 1.3, P = 0.22), application of ML (13% vs 9%, P = 0.71), or occurrence of pancreatitis (3.3% vs 9.1%, P = 0.45) between cases with and without balloon waist disappearance.

CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.

Comparison of the usefulness of endoscopic papillary large-balloon dilation with endoscopic sphincterotomy for large and multiple common bile duct stones

BACKGROUND

Endoscopic sphincterotomy (EST) is currently recognized as the primary endoscopic treatment for common bile duct stones. However, it is difficult to remove multiple (≥ 3) or large (≥ 15 mm) common bile duct stones with EST alone. Recently, EST plus endoscopic papillary large-balloon dilation (EPLBD) was reported to be an effective treatment for such bile duct stones. We compared the results of EST and EST + EPLBD for multiple (≥ 3) or large (≥ 15 mm) stones that were difficult to treat using EST alone. We also compared the complication rates between the techniques.

METHODS

Seventy patients with large (largest diameter, ≥ 15 mm) or ≥ 3 common bile duct stones treated in our department between April 2010 and March 2013 underwent EST + EPLBD (n = 34) or EST alone (n = 36). We compared final successful stone removal rates, rates of successful stone removal in the first session, procedure times, status of concurrent mechanical lithotripsy (ML), and complications between the EST + EPLBD and EST groups.

RESULTS

The rates of final successful stone removal were similar between the two groups (EST + EPLBD: 100 % vs. EST: 89 %; p = 0.115). The rate of successful stone removal in the first session was significantly higher in the EST + EPLBD group (EST + EPLBD: 88 % vs. EST: 56 %; p = 0.03). Moreover, the procedure time was significantly shorter (EST + EPLBD: 42 min vs. EST: 67 min; p = 0.011) and the rate of ML use was significantly lower in the EST + EPLBD group (EST + EPLBD: 50 % vs. EST: 94 %; p < 0.001). Complications like pancreatitis and bleeding occurred in three patients in the EST + EPLBD group and in 10 patients in the EST group, but the differences were not statistically significant (EST + EPLBD: 9 % vs. EST: 25 %; p = 0.112).

CONCLUSIONS

Our results suggest that EST + EPLBD is an effective therapy for patients with difficult-to-treat multiple or large common bile duct stones, because it requires fewer sessions and shorter operative times than EST alone.

Efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stone removal

BACKGROUND

Endoscopic retrograde cholangiopancreatography is difficult to perform in patients with gastrointestinal tract reconstruction.

AIMS

To evaluate the efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stones in patients with gastrointestinal tract reconstruction.

METHODS

We conducted a retrospective case series with a comparison to historical controls. During the period 2009-2013, 11 postoperative patients underwent endoscopic papillary large-balloon dilatation (Group A). Procedure efficacy and safety were compared with patients who underwent endoscopic sphincterotomy without endoscopic papillary large-balloon dilatation, who served as historical controls (Group B).

RESULTS

Group A consisted of 11 patients (63.6% males, mean age 78±10 years), and Group B consisted of 32 patients (78.1% males, mean age 75±7 years). The stone clearance rate was significantly higher in Group A than in Group B (100% vs. 65.6%, respectively; p<0.05). Median procedure time was significantly shorter in Group A than in Group B (54min vs. 102min, respectively; p<0.05), and the complication rate was not significantly different between groups (18% vs. 15.6%, respectively; p=0.586).

CONCLUSION

Endoscopic papillary large-balloon dilatation may be an effective and safe treatment procedure in patients with gastrointestinal tract reconstruction.

Endoscopic papillary large balloon dilation for bile duct stones in elderly patients

AIM: To investigate whether endoscopic papillary large balloon dilation (EPLBD) can be safety and effectively performed in patients aged ≥ 80 years.

METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A (< 80 years) and group B (≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies (ERCP), and incidence of complications were examined in both groups.

RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent (P < 0.05). The success rate of the initial lithotomy was 88.7 (94/106)%. The final lithotomy rate was 100 (106/106)%. Complications due to treatment procedure occurred in 4.72 (5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.

CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.

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.

Risk factors of open converted cholecystectomy for cholelithiasis after endoscopic removal of choledocholithiasis

BACKGROUND

Open converted cholecystectomy could occur in patients who planned for laparoscopic cholecystectomy after endoscopic removal of choledocholithiasis.

AIM

To evaluate the risk factors associated with open converted cholecystectomy.

PATIENTS AND METHODS

The data for all patients who underwent cholecystectomy after endoscopic removal of choledocholithiasis were retrospectively reviewed. Factors predictive for conversion to open cholecystectomy were analyzed.

RESULTS

The rate of open converted cholecystectomy was 15.7 %. In multivariate analysis, cholecystitis (OR 1.908, 95 % CI 1.390-6.388, p = 0.005), mechanical lithotripsy (OR 6.129, 95 % CI 1.867-20.123, p < 0.005), and two or more choledocholithiases (OR 2.202, 95 % CI 1.097-4.420, p = 0.026) revealed significant risk factors for conversion to open cholecystectomy. Analyzing the risk factors for open converted cholecystectomy according to duration from endoscopic stone removal to cholecystectomy (within 2 weeks, between 2 and 6 weeks, and beyond 6 weeks), acute cholangitis (OR 3.374, 95 % CI 1.267-8.988, p = 0.015), cholecystitis (OR 3.127, 95 % CI 1.100-8.894, p = 0.033), and mechanical lithotripsy (OR 17.504, 95 % CI 3.548-86.355, p < 0.005) were related to open converted cholecystectomy in ≤2 weeks group.

CONCLUSIONS

For patients who need cholecystectomy after endoscopic removal of choledocholithiasis, endoscopic retrograde cholangiography-related factors predictive for open converted cholecystectomy are helpful in planning the appropriate timing of surgery.

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.

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study.

METHODS: Lithotomy by EPLBD was conducted in 124 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. After endoscopic sphincterotomy, the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.

RESULTS: The success rate of first-time lithotomy was 86.3% (107/124) and the final lithotomy success rate was 100% (124/124). Lithotripsy was needed in 10 of the 124 (13.6%) patients. Adverse events due to the treatment procedure occurred in 6 (4.8%) patients, all of which were mild. Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.

CONCLUSION: It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of “risk of carrying CBDS” has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of “under-studying” by poor diagnostic work up or “over-studying” by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. “Low risk” patients do not require further examination before laparoscopic cholecystectomy. Two main “philosophical approaches” face each other for patients with an “intermediate to high risk” of carrying CBDS: on one hand, the “laparoscopy-first” approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the “endoscopy-first” attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Advances in the endoscopic management of common bile duct stones

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

Old age is associated with increased severity of complications in endoscopic biliary stone removal

BACKGROUND AND AIM

Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal.

METHODS

This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications.

RESULTS

Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115).

CONCLUSIONS

Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones: A literature review

Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (≥ 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

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

AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm).

METHODS: PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P≤ 0.1 and I² with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias.

RESULTS: Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92).

CONCLUSION: EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Dilation-assisted stone extraction: an alternative method for removal of common bile duct stones

BACKGROUND

Dilation-assisted stone extraction, also termed small endoscopic sphincterotomy (EST) plus endoscopic papillary balloon dilatation, is more efficient than EST alone for removal of large common bile duct (CBD) stones. However, whether this technique can be used for all stones is unclear.

AIM

This study was designed to evaluate the efficacy and complications of dilation-assisted stone extraction for CBD stones.

METHODS

A total of 462 patients with CBD stones were randomized to undergo either dilation-assisted stone extraction (group A) or EST (group B). The efficacy and complications of the two techniques were compared.

RESULTS

Groups A and B showed similar outcomes in terms of stone removal. The short-term and 1-year complication rates were also similar between the two groups. However, the first-session stone removal rate in group A was significantly higher than that in group B. Mechanical lithotripsy was required significantly more often in group B than in group A. The total procedure time and total fluoroscopy time in group A were significantly shorter than those in group B.

CONCLUSIONS

Dilation-assisted stone extraction and EST are safe and effective techniques for the treatment of CBD stones. Dilation-assisted stone extraction has high efficiency. This technique is an alternative method for removal of CBD stones.

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.

Which is the better treatment for the removal of large biliary stones? Endoscopic papillary large balloon dilation versus endoscopic sphincterotomy

Background/Aims

We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST).

Methods

A total of 1,580 patients who underwent endoscopic CBD stone extraction between January 2001 and July 2010 were reviewed. The following inclusion criteria were applied: choledocholithiasis treated by EPLBD with minor EST or EST with mechanical lithotripsy; and follow-up >9 months after treatment.

Results

Forty-nine patients with EPLBD and 41 with EST were compared. There was no significant difference in the complication rates and stone recurrence rates between the two groups. However, significantly more endoscopic retrograde cholangiopancreatography (ERCP) sessions were required in the EST group to achieve the complete removal of stones (1.7 times vs 1.3 times; p=0.03). The mean cost required for complete stone removal per patient was significantly higher in the EST group compared to the EPLBD group (USD $1,644 vs $1,225, respectively; p=0.04). Dilated CBD was the only significant factor associated with recurrent biliary stones (relative risk, 1.09; 95% confidence interval, 1.02 to 1.17; p=0.02).

Conclusions

EPLBD is the better treatment (compared to EST) for removing large CBD stones because EPLBD requires fewer ERCP sessions and is less expensive.

Clearance of refractory bile duct stones with Extracorporeal Shockwave Lithotripsy: higher failure rate in obese patients

OBJECTIVE

Bile duct stones that cannot be removed endoscopically are still a challenge in interventional gastroenterology. Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option if other endoscopic means are not successful. Our study aimed to investigate the efficacy and safety of ESWL for clearance of refractory bile duct stones.

MATERIAL AND METHODS

A total of 73 consecutive patients treated for refractory choledocholithiasis with ESWL were retrospectively analyzed. Success and complication rates were calculated.

RESULTS

Complete stone clearance was achieved in 66 cases (90%). Patients with complete clearance had a significantly lower body mass index or BMI (25.55 ± 5.01 kg/m² vs. 31.60 ± 6.26 kg/m², p = 0.035) and needed less ESWL treatments (3.61 ± 1.87 vs. 5.00 ± 1.63, p = 0.048). A relevant drop of hemoglobin occurred significantly more often in the group with partial clearance (43% vs. 6%, p = 0.005).

CONCLUSIONS

ESWL proves to be an excellent clearing approach to refractory bile duct stones with high success rates. However, obesity is one risk factor for ESWL failure and higher procedural hazard.

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 sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis: A meta-analysis

AIM: To perform a meta-analysis of large-balloon dilation (LBD) plus endoscopic sphincterotomy (EST) vs EST alone for removal of bile duct stones.

METHODS: 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.

RESULTS: 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.

CONCLUSION: 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 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: Revival of the old technique

Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s. Recently, there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy (EST) in young patients undergoing laparoscopic cholecystectomy. However, there is a disparity in using endoscopic balloon papillary dilation (EPBD) between the East and the West, depending on the origin of the studies. In the early 2000s, EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones. Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method, unlike EPBD. However, fatal complications have occurred in patients with endoscopic papillary large balloon dilation (EPLBD). The safety of endoscopic balloon dilation is still a debatable issue. Moreover, guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon. In this article, we discuss the issue of conventional and large balloon endoscopic dilation. We also suggest the indications and optimal techniques of EPBD and EPLBD.

Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone

BACKGROUND/AIMS

Between endoscopic sphincterotomy (ES) alone and combined endoscopic sphincterotomy and large balloon dilation (ES-LBD) groups, efficacy and long-term complications, difference in biliary stone recurrence rate, and risk factors of stone recurrence were compared.

METHODS

Medical records of 222 patients who underwent ERCP for biliary stone removal were retrospectively reviewed. Patients with dilated CBD ≥11 mm and follow-up longer than 6 months were included.

RESULTS

There were 101 patients in ES-LBD group and 121 patients in ES group. Mean follow-up duration was 25.0 (6-48) months and 13.0 (6-43) months, respectively (p=0.001). There was no difference in number of ERCP sessions, brown pigment stones, angle between mid and distal common bile duct (CBD angle) <135°, and lithotripsy rate. Complete retrieval success rate was excellent in both groups (100% vs. 99%). Early complication rate of ES-LBD and ES alone group was 4 and 4.1%, respectively (p=1.000). One patient in ES-LBD group died from delayed bleeding. Late complication rate was 5.9 and 3.3%, respectively (p=1.000). Stone recurrence rate was 6.9% and 5.8%, respectively (p=0.984). The only Independent risk factor of stone recurrence was presence of periampullary diverticulum.

CONCLUSIONS

Late complication and stone recurrence rates were similar between ES-LBD and ES alone groups.

Endoscopic papillary large-balloon dilation versus endoscopic papillary regular-balloon dilation for removal of large bile-duct stones

BACKGROUND

Endoscopic papillary large-balloon dilation (EPLBD) became popular for the treatment of large common bile-duct stones (CBDS), and its feasibility has been reported in comparison to endoscopic sphincterotomy. However, the comparison between EPLBD and endoscopic papillary regular-balloon dilation (EPBD) has not been reported. In the present study, the efficacy and complications of EPLBD were compared with those of EPBD.

METHODS

We retrospectively assessed 334 consecutive patients with CBDS of any size that were treated by either EPLBD or EPBD between January 2008 and December 2012.

RESULTS

In cases with large CBDS (>10 mm), EPLBD and EPBD had similar results in terms of the success rate of stone removal in the first (65% vs. 84%) and total attempts (100% vs. 95%), use of mechanical lithotripter (64% vs. 80%), and procedure time (48.0 ± 17.8 min vs. 44.1 ± 17.1 min). The necessity for crushing stones with a mechanical lithotripter was significantly decreased in EPLBD compared to EPBD (25% vs. 80%). In all cases with CBDS, there was no significant difference in complication rates between EPLBD and EPBD (3.3% vs. 4.7%).

CONCLUSIONS

Compared to EPBD, EPLBD appears safe and effective for removing large CBDS and decreases the necessity of lithotripsy.

Acute biliary conditions

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.

Efficacy of endoscopic nasobiliary drainage for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis after repeated clearance of common bile duct stones: experience from a Chinese center

BACKGROUND

The aim of the present study was to investigate whether it is reasonable to insert an endoscopic nasobiliary drainage (ENBD) tube in patients with endoscopic sphincterotomy (EST) and repeated clearance of common bile duct (CBD) stones.

PATIENTS AND METHODS

Patients with choledocholithiasis who underwent EST and CBD stone clearance at our center from January 2010 to May 2012 were reviewed. The following parameters were evaluated: (i) serum amylase 2 and 24 h after ERCP; (ii) incidence of endoscopic retrograde cholangiopancreatography (ERCP)-related pancreatitis and cholangitis; (iii) time elapsed to normalization of total serum bilirubin levels for those with jaundice before ERCP; and (iv) length of hospital stay.

RESULTS

Compared with the no-ENBD group, the ENBD group presented a significantly lower postoperative serum amylase of 2 and 24 h (81.3 ± 31.8 U/L vs 90.8 ± 31.2 U/L, 107.0 ± 51.1 U/Lvs 132.3 ± 100.8 U/L, respectively). The incidence of post-ERCP pancreatitis and cholangitis was also lower in the ENBD group, although the differences were not significant (1% vs 4.4%, 0 vs 4.5%, respectively). Time elapsed to normalization of total serum bilirubin levels and length of hospital stay was shorter in the ENBD group (4.3 days ± 0.6 days vs 4.5 days ± 0.7 days, P > 0.05; 4.8 days ± 2.1 days vs 6.3 days ± 2.8 days, respectively, P < 0.01).

CONCLUSIONS

ENBD significantly reduces the incidence of hyperamylasemia and decreases the length of hospital stay in patients with EST and repeated stone extraction. ENBD should be considered for patients with large or multiple CBD stones.

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.

Endoscopic sphincterotomy plus balloon dilation versus endoscopic sphincterotomy for choledocholithiasis: A meta-analysis

BACKGROUND AND AIM

Endoscopic sphincterotomy (EST) alone and EST combined with balloon dilation (ESBD) are important endoscopic techniques for stone extraction. We were to conduct a meta-analysis to compare the efficacy and safety of ESBD and EST.

METHODS

Meta-analysis was performed respectively on randomized controlled trials (RCTs) and nonrandomized studies comparing the efficacy and safety of ESBD and EST.

RESULTS

The results of three RCTs showed that stone removal in first session (relative risk [RR] 1.01, 0.92-1.11, P=0.85) and the utility of endoscopic mechanical lithotripsy (EML) (RR 0.78, 0.49-1.23, P=0.29) were equivalent between ESBD and EST. ESBD has equivalent complications (RR 0.61, 0.17-2.25, P=0.46) and post-ERCP pancreatitis (Peto odds ratio [OR] 1.11, 0.37-3.35, P=0.86), but less bleeding (Peto OR 0.10, 0.03-0.30, P<0.0001). The analysis of six retrospective studies suggested higher initial success in stone removal (RR 1.11, 1.02-1.20, P=0.01) and less EML (RR 0.32, 0.22-0.46, P<0.00001) in ESBD group. Less complications (RR 0.60, 0.44-0.83, P=0.02) happened in ESBD group, but equivalent post-ERCP pancreatitis (Peto OR 0.65, 0.37-1.15, P=0.14) and bleeding (Peto OR 0.60, 0.29-1.26, P=0.18). For patients with stones ≥ 15 mm, ESBD required less EML (RR 0.35, 0.24-0.51, P<0.00001) and caused fewer complications (RR 0.67, 0.38-0.92, P=0.02).

CONCLUSIONS

ESBD is feasible for the treatment of choledocholithiasis without increased risk of complications, causing less bleeding. However, it warrants more clinical trials to compare the efficacy and safety of ESBD and EST.

Genetics and treatment of bile duct stones: new approaches

PURPOSE OF REVIEW

The global burden of gallstones is increasing. Although the gallbladder is the most common site for gallstone formation, 10-25% of patients display concurrent gallbladder and bile duct stones. Secondary stones are differentiated from primary stones that develop de novo in the biliary tree. Overall, the natural history of bile duct stones is less well defined and their diagnosis and treatment are more complex as compared to gallbladder stones.

RECENT FINDINGS

Elevated liver function tests are not always reflective of bile duct stones, and noninvasive diagnosis by endoscopic ultrasound or MRI should be pursued in ambiguous cases. For treatment, recent studies report endoscopic dilation to result in similar clearance but lower complication and recurrence rates as with sphincterotomy. Pharmacological adjuvants such as ursodeoxycholic acid with sphincterotomy and stenting have been suggested for elderly patients. Indication and timing of cholecystectcomy after endoscopic treatment of bile duct stones is critical, and early cholecystectomy within 3-7 days prevents recurrent biliary events.

SUMMARY

In this review we address the pathophysiology of bile duct stones and present the latest developments in the diagnosis and treatment of this challenging condition, with a consideration of stone recurrence.

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones.

METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed.

RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P = 0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P = 0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P = 0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P = 0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P = 0.00).

CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.

Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience

AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.

METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon^®, Cook Ireland Ltd. and CRE^®, Microvasive, Boston Scientific Co., Natick, MA, United States).

RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.

CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.

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

BACKGROUND

Endoscopic 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.

AIMS

To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy.

METHODS

A 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).

RESULTS

The 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.

CONCLUSIONS

30-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.

Modern management of common bile duct stones

It is imperative for gastroenterologists to understand the different formations of bile duct stones and the various medical treatments available. To minimize the complications of endoscopic retrograde cholangiopancreatography (ERCP), it is critical to appropriately assess the risk of bile duct stones before intervention. Biliary endoscopists should be comfortable with the basic techniques of stone removal, including sphincterotomy, mechanical lithotripsy, and stent placement. It is important to be aware of advanced options, including laser and electrohydraulic stone fragmentation, and papillary dilatation for problematic cases. The timing and need for ERCP in those who require a cholecystectomy is also a consideration.

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

OBJECTIVE

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).

METHODS

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.

RESULTS

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).

CONCLUSION

EPLBD following limited EST is an effective and safe approach for the removal of large biliary duct stones, especially for those refractory cases.