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Fujita N, Yasuda I, Endo I, Isayama H, Iwashita T, Ueki T, Uemura K, Umezawa A, Katanuma A, Katayose Y, Suzuki Y, Shoda J, Tsuyuguchi T, Wakai T, Inui K, Unno M, Takeyama Y, Itoi T, Koike K, Mochida S. Evidence-based clinical practice guidelines for cholelithiasis 2021. J Gastroenterol 2023; 58:801-833. [PMID: 37452855 PMCID: PMC10423145 DOI: 10.1007/s00535-023-02014-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.
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Affiliation(s)
- Naotaka Fujita
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Miyagi Medical Check-up Plaza, 1-6-9 Oroshi-machi, Wakabayashi-ku, Sendai, Miyagi, 984-0015, Japan.
| | - Ichiro Yasuda
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Itaru Endo
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroyuki Isayama
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takuji Iwashita
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiharu Ueki
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenichiro Uemura
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Akiko Umezawa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Akio Katanuma
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yu Katayose
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yutaka Suzuki
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junichi Shoda
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshio Tsuyuguchi
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshifumi Wakai
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuo Inui
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Michiaki Unno
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshifumi Takeyama
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takao Itoi
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Satoshi Mochida
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Cholelithiasis'', The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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Masuda S, Koizumi K, Shionoya K, Jinushi R, Makazu M, Nishino T, Kimura K, Sumida C, Kubota J, Ichita C, Sasaki A, Kobayashi M, Kako M, Haruki U. Comprehensive review on small common bile duct stones. World J Gastroenterol 2023; 29:1955-1968. [PMID: 37155530 PMCID: PMC10122794 DOI: 10.3748/wjg.v29.i13.1955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/22/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Kazuya Koizumi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Kento Shionoya
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Makomo Makazu
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Takashi Nishino
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Karen Kimura
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Chihiro Sumida
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Jun Kubota
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Chikamasa Ichita
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Akiko Sasaki
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Masahiro Kobayashi
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Makoto Kako
- Department of Gastroenterology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Uojima Haruki
- Department of Gastroenterology, Kitasato University School of Medicine, Kanagawa 252-0375, Japan
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Ye Q, Zhang J, Ou X, Zhou X, Zhu C, Li W, Yao J, Zhang G. Efficacy and safety of three endoscopic techniques for small common bile duct stones (≤ 10 mm): a multicenter, retrospective, cohort study with propensity score matching. Surg Endosc 2023; 37:1863-1869. [PMID: 36253627 DOI: 10.1007/s00464-022-09436-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a major option for common bile duct (CBD) stones. Endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and endoscopic sphincterotomy plus balloon dilatation (ESBD) are procedures for opening the bile duct orifice to extract CBD stones during ERCP. The optimal method for extracting small CBD stones (≤ 10 mm) has not yet been proposed. We aimed to compare the efficacy and safety of these three techniques in extracting small CBD stones. METHODS ERCP for small stones was performed between January 2009 and November 2020 at three tertiary care centers. The incidence of post-ERCP pancreatitis (PEP) was compared among EST, EPBD, and ESBD groups. First and overall success rates of stone extraction, utilization rate of mechanical lithotripsy, and other ERCP complications such as bleeding, perforation, infection, and hyperamylasemia were compared. RESULTS A total of 2181 patients were enrolled between January 2009 and November 2020. The proportion of young patients (≤ 45 years) in EPBD group was more than those in EST and ESBD group. Stone size in ESBD group was much larger than EST and EPBD group. After propensity score matching, the success rates of first and overall stone extraction in the three groups were high, and the rates of mechanical lithotripsy were low, with no significant difference. The PEP incidences showed no differences among the three groups. The incidence of bleeding complication in EST group was higher than that in EPBD group. No significant differences were observed in other complications between EPBD group and ESBD group. ESBD group had higher incidence of overall, infection, and hyperamylasemia complications than EST group. CONCLUSION EPBD is equivalent to ESBD in stone removal efficiency and complication rate, but brings a lower bleeding risk than EST. Therefore, we recommend EPBD as the first choice for small CBD stones.
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Affiliation(s)
- Qiang Ye
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, No. 300 of Guangzhou Road, Nanjing, 210029, China.,First Clinical Medical College, Nanjing Medical University, Nanjing, 210029, China
| | - Jin Zhang
- Department of Respiratory, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, 212000, China
| | - Xilong Ou
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Xiaoying Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, No. 300 of Guangzhou Road, Nanjing, 210029, China
| | - Chang Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, No. 300 of Guangzhou Road, Nanjing, 210029, China.,First Clinical Medical College, Nanjing Medical University, Nanjing, 210029, China
| | - Wenjie Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, No. 300 of Guangzhou Road, Nanjing, 210029, China.,First Clinical Medical College, Nanjing Medical University, Nanjing, 210029, China
| | - Jun Yao
- Department of Gastroenterology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, 212000, China.
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, No. 300 of Guangzhou Road, Nanjing, 210029, China.
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Bosley ME, Ganapathy AS, Nunn AM, Westcott CJ, Neff LP. Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration. Surg Endosc 2022; 37:3994-3999. [PMID: 36068386 DOI: 10.1007/s00464-022-09571-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway. METHODS We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed. RESULTS Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications. CONCLUSION Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.
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Affiliation(s)
- Maggie E Bosley
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Aravindh S Ganapathy
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Carl J Westcott
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lucas P Neff
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
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Sagami R, Hayasaka K, Ujihara T, Iwaki T, Katsuyama Y, Harada H, Tsuji H, Sato T, Nishikiori H, Murakami K, Amano Y. Accurate Evaluation of Residual Common Bile Duct Stones by Endoscopic Ultrasound: A Two-Step Check Method for Residual Stone Clearance. Digestion 2022; 103:224-231. [PMID: 35124676 DOI: 10.1159/000521925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 01/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Residual common bile duct (CBD) stones occasionally become symptomatic after stone removal with endoscopic retrograde cholangiopancreatography (ERCP) upon removal of the endoscopic biliary stent (EBS). An accurate evaluation of residual stones before stent removal is necessary. This study evaluated a new two-step check method using endoscopic ultrasound (EUS) for the detection of residual stones after ERCP stone removal. METHODS Fifty-six patients who underwent CBD stone removal and EBS placement were prospectively enrolled. Residual stones were evaluated by the check method. EBS was removed at the time of the check method or at a later time of residual stone removal. The primary outcome was to evaluate the efficacy of this check method. RESULTS Residual CBD stone/sludge was detected in 20 of 56 patients (35.7%; stones: 28.6%, sludge: 7.1%) by the check method and removed by the ERCP procedure at a later time. After stent and final stone removal, patients were followed for an average of 211 days; cholangitis recurred in only 1.8% of patients. There were no adverse events associated with the check method. Temporary EBS prevented the recurrence of cholangitis by residual stone and caused no adverse events in the pancreatobiliary tract until the two-step check method (median, 113 days; range, 17-232 days). CONCLUSION The new check method may be ideal and feasible for EBS removal because recurrences are very rare when a clear CBD has been verified, and an additional ERCP procedure is also possibly avoided.
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Affiliation(s)
- Ryota Sagami
- Department of Gastroenterology, Oita San-ai Medical Center, Oita, Japan
| | - Kenji Hayasaka
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Japan
| | - Tetsuro Ujihara
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Japan
| | - Tomoyuki Iwaki
- Department of Gastroenterology, Urawa Kyosai Hospital, Saitama, Japan
| | - Yasushi Katsuyama
- Department of Gastroenterology, Urawa Kyosai Hospital, Saitama, Japan
| | - Hideaki Harada
- Department of Gastroenterology, Urawa Kyosai Hospital, Saitama, Japan
| | - Hiroaki Tsuji
- Department of Gastroenterology, Oita San-ai Medical Center, Oita, Japan
| | - Takao Sato
- Department of Gastroenterology, Oita San-ai Medical Center, Oita, Japan
| | | | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Yufu, Japan
| | - Yuji Amano
- Department of Gastroenterology, Urawa Kyosai Hospital, Saitama, Japan
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Podboy A, Gaddam S, Park K, Gupta K, Liu Q, Lo SK. Management of Difficult Choledocholithiasis. Dig Dis Sci 2022; 67:1613-1623. [PMID: 35348969 DOI: 10.1007/s10620-022-07424-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/13/2022]
Abstract
Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction, and over 10-15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult cases. We describe additional special clinical circumstances in which difficult biliary stones are identified and provide additional management strategies to aid endoscopic stone extraction efforts.
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Affiliation(s)
- Alexander Podboy
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Srinivas Gaddam
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Kenneth Park
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Kapil Gupta
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Quin Liu
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Simon K Lo
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA.
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Zhu KX, Yue P, Wang HP, Meng WB, Liu JK, Zhang L, Zhu XL, Zhang H, Miao L, Wang ZF, Zhou WC, Suzuki A, Tanaka K, Li X. Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto. World J Gastrointest Surg 2022; 14:132-142. [PMID: 35317545 PMCID: PMC8908344 DOI: 10.4240/wjgs.v14.i2.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/24/2021] [Accepted: 01/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.
AIM To compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.
METHODS Patients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.
RESULTS A total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.
CONCLUSION Many clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.
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Affiliation(s)
- Ke-Xiang Zhu
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Ping Yue
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hai-Ping Wang
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Bo Meng
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jian-Kang Liu
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02451, United States
| | - Lei Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiao-Liang Zhu
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Long Miao
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Zheng-Feng Wang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Ce Zhou
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Azumi Suzuki
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Xun Li
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
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8
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Panin SI, Nechaj TV, Sazhin AV, Puzikova AV, Linchenko DV, Chechin ER. [Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]. Khirurgiia (Mosk) 2022:85-93. [PMID: 35775849 DOI: 10.17116/hirurgia202207185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications. MATERIAL AND METHODS We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021. RESULTS There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses. CONCLUSION We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.
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Affiliation(s)
- S I Panin
- Volgograd State Medical University, Volgograd, Russia
| | - T V Nechaj
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Puzikova
- Volgograd State Medical University, Volgograd, Russia
| | - D V Linchenko
- Volgograd State Medical University, Volgograd, Russia
| | - E R Chechin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Park JK, Moon JH, Lee YN, Jo SJ, Choi MH, Lee TH, Cha SW, Cho YD, Park SH. Feasibility study of endoscopic biliary drainage under direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Endosc Int Open 2021; 9:E1447-E1452. [PMID: 34540533 PMCID: PMC8445673 DOI: 10.1055/a-1522-5615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 12/30/2020] [Indexed: 11/09/2022] Open
Abstract
The therapeutic utility of peroral cholangioscopy (POC) is limited. Direct POC using an ultra‑slim upper endoscope expands the therapeutic indications because of its larger working channel, of up to 2.2 mm. We evaluated the feasibility of selective biliary drainage using a plastic stent under direct POC. From April 2015 to March 2019, biliary drainage under endoscopic visualization was performed in the same endoscopic session as direct POC without exchanging the duodenoscope. After guidewire insertion through the stricture or stone, a 5 Fr plastic stent and/or nasobiliary drainage catheter was used for biliary drainage. Selective biliary drainage under direct POC was performed in 32 patients, including 17 with difficult bile duct stones. Biliary drainage was performed with a plastic stent in 29 patients, nasobiliary drainage in one, and combined drainage in two patients. The technical success rate for biliary drainage placement under direct POC was 100 % (32/32). No significant procedure-related complications occurred. In conclusion, biliary drainage with a plastic stent or catheter under direct POC using an ultra-slim upper endoscope is feasible and may be useful for lesions obstructing the bile duct.
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Affiliation(s)
- Jae Keun Park
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Seok jung Jo
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Moon Han Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Tae Hoon Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Sang-Woo Cha
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Young Deok Cho
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Sang-Heum Park
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
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10
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Brewer Gutierrez OI, Godoy Brewer G, Zulli C, Tejaswi S, Pawa R, Jamidar P, Robles-Medranda C, Pawa S, Camilion JV, Oleas R, Parsa N, Runge T, Miaw D, Ichkhanian Y, Khashab MA. Multicenter experience with digital single-operator cholangioscopy in pregnant patients. Endosc Int Open 2021; 9:E116-E121. [PMID: 33532547 PMCID: PMC7834694 DOI: 10.1055/a-1320-0084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background and study aims The use of fluoroscopy during pregnancy should be minimized given that a clear-cut safe radiation dose in pregnancy is unknown. The role of digital single-operator cholangioscopy (D-SOC) as an alternative to standard enodoscopic retrograde cholangiopancreatography (ERCP) in pregnant patients has not been comprehensively studied. This study assessed 1 Technical success defined as performance of ERCP with D-SOC without the use of fluoroscopy in pregnant patients; 2 safety of D-SOC in pregnancy; and 3 maternal and neonatal outcomes after D-SOC during/after pregnancy. Patients and methods This was an international, multicenter, retrospective study at 6 tertiary centers. Pregnant patients who underwent D-SOC for the treatment of bile duct stones and/or strictures were included. Results A total of 10 patients underwent D-SOC. Indications for ERCP were choledocholithiasis, strictures, previous stent removal, and choledocholithiasis/stent removal. Bile duct cannulation without fluoroscopy was achieved in 10 of 10 patients (100 %). Moreover, 50 % of patients (5/10) completed a fluoroless ERCP with D-SOC. Mean fluoroscopy dose and fluoroscopy time were 3.4 ± 7.2 mGy and 0.5 ± 0.8 min, respectively. One case of mild bleeding and one case of moderate post-ERCP pancreatitis occurred. The mean gestational age at delivery was 36.2 ± 2.6 weeks. Median birth weight was 2.5 kg [IQR: 2.2-2.8]. No birth defects were noted. Conclusion ERCP guided by D-SOC appears to be a feasible and effective alternative to standard ERCP in pregnant patients. It enables avoidance of radiation in half of cases.
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Affiliation(s)
- Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Gala Godoy Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Claudio Zulli
- Division of Gastroenterology, University Hospital G. Fucito, Ruggi d’Aragona, Salermo, Italy
| | - Sooraj Tejaswi
- Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento California, United States
| | - Rishi Pawa
- Division of Gastroenterology, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Priya Jamidar
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Carlos Robles-Medranda
- Division of Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Swati Pawa
- Division of Gastroenterology, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Jose V. Camilion
- Nova Southeastern College of Ostheopathic Medicine, Davie, Florida, United States
| | - Roberto Oleas
- Division of Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO
| | - Thomas Runge
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Diana Miaw
- Division of Gynecology & Obstetrics, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, United States
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11
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Sadeghi A, Dooghaie Moghadam A, Jamshidizade S, Norouzinia M, Jamshidfar N, Hosseini P. Comparison of endoscopic balloon dilatation potency using balloons size more or less than 15 mm in the treatment of large bile duct stones: a clinical trial study. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2021; 14:S112-S117. [PMID: 35154610 PMCID: PMC8817744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/02/2021] [Indexed: 11/02/2022]
Abstract
AIM The present study was performed on patients with large bile duct stones to compare clinical outcomes and complications of balloon dilatation treatment between two sizes of balloons, < 15 mm and ≥ 15 mm. BACKGROUND in 1982, the endoscopic papillary balloon dilatation (EPBD) method was presented by Staritz to reduce bleeding and perforation risk of large bile duct stones. METHODS Patients with large bile duct stones admitted to Taleghani hospital from December 2018 to December 2019 who were the candidates for balloon dilation with limited sphincterotomy. Patients were randomly divided into two groups. In group B, a ≥ 15 mm balloon was used, and in group A, a balloon <15 mm was used. The clinical results of balloon dilation and its complications were recorded and compared. RESULTS Most patients had 1 or 2 large bile duct stones, and there was no significant difference in the number of stones. Extraction was successful in 92.8% of group B and 85.7% of group A without significant differences (P = 0.8). Pancreatitis, hemorrhage, cholangitis, and perfusion occurred in 8%, 4.2%, 1.4%, and 2.8% of group B subjects and also in 10%, 2.8%, 0%, and 1.4% of group A subjects, respectively, and the difference between the two groups was not significant. CONCLUSION Generally, this study results showed that balloon size did not have a significant effect on the success rate of bile duct stones. Moreover, considering the lack of significant association between balloon dilatation size and the occurrence of post-endoscopic complications such as pancreatitis, it seems that large-size dilatation has no serious clinical risk.
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Affiliation(s)
- Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Arash Dooghaie Moghadam
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Shaghayegh Jamshidizade
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohsen Norouzinia
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Negin Jamshidfar
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Parna Hosseini
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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12
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Gutt C, Schläfer S, Lammert F. The Treatment of Gallstone Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:148-158. [PMID: 32234195 PMCID: PMC7132079 DOI: 10.3238/arztebl.2020.0148] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 04/25/2019] [Accepted: 12/10/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gallstone disease affects up to 20% of the European population, and cholelithiasis is the most common reason for hospitalization in gastroenterology. METHODS This review is based on pertinent publications retrieved by a selective search of the literature, including the German clinical practice guidelines on the diagnosis and treatment of gallstones and corresponding guidelines from abroad. RESULTS Regular physical activity and an appropriate diet are the most important measures for the prevention of gallstone disease. Transcutaneous ultrasonography is the paramount method of diagnosing gallstones. Endoscopic retrograde cholangiography should only be carried out as part of a planned therapeutic intervention; endosonography beforehand lessens the number of endoscopic retrograde cholangiographies that need to be performed. Cholecystectomy is indicated for patients with symptomatic gallstones or sludge. This should be performed laparoscopically with a four-trocar technique, if possible. Routine perioperative antibiotic prophylaxis is not necessary. Cholecystectomy can be performed in any trimester of pregnancy, if urgently indicated. Acute cholecystitis is an indication for early laparoscopic cholecystectomy within 24 hours of admission to hospital. After successful endoscopic clearance of the biliary pathway, patients who also have cholelithiasis should undergo laparoscopic cholecystectomy within 72 hours. CONCLUSION The timing of treatment for gallstone disease is an essential determinant of therapeutic success.
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Affiliation(s)
- Carsten Gutt
- Department of General, Abdominal, Thoracic, and Vascular Surgery, Memmingen Hospital, Memmingen
| | - Simon Schläfer
- Department of General, Abdominal, Thoracic, and Vascular Surgery, Memmingen Hospital, Memmingen
| | - Frank Lammert
- Department of Internal Medicine II (Gastroenterology, Hepatology, Endocrinology, Diabetology, and Nutritional Medicine), Saarland University Hospital, Homburg
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13
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Yıldırım AE. Optimal dilation time for combined small endoscopic sphincterotomy and balloon dilation for common bile duct stones: A multicentre, single-blinded, randomised controlled trial. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:662-663. [PMID: 31290754 DOI: 10.5152/tjg.2019.240519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- A Emre Yıldırım
- Department of Gastroenterology, Gaziantep University School of Medicine, Gaziantep, Turkey
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14
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length. World J Meta-Anal 2019; 7:259-268. [DOI: 10.13105/wjma.v7.i6.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
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15
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis. World J Meta-Anal 2019; 7:249-258. [DOI: 10.13105/wjma.v7.i5.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the investigation and treatment of pancreaticobiliary diseases. However, post-ERCP pancreatitis (PEP) is a severe adverse effect. Prior meta-analyses have shown that prophylactic PS was useful for preventing PEP. However, abstract reports and patients who underwent endoscopic ampullectomy were included in the previous analyses. In addition, two meta-analyses involved non-randomized controlled trials (RCTs). The efficacy of PS for preventing severe PEP was different in each meta-analysis. Therefore, we performed the current meta-analysis, which included only full-text articles, and added new findings.
AIM To reveal the efficacy of prophylactic pancreatic stent (PS) placement for preventing PEP.
METHODS We searched the MEDLINE, Cochrane Library and PubMed databases for related RCTs. Among the reports retrieved, 11 studies were included in this meta-analysis. All full-text articles were published between 1993 and 2016. A total of 1475 patients were enrolled in the included studies; of these patients, 734 had a PS inserted, and 741 did not have a PS inserted. PEP and severe PEP occurrence were evaluated in this meta-analysis.
RESULTS PEP was observed in all studies and occurred in 39 (5.3%) patients who received a PS. On the other hand, PEP occurred in 141 (19%) patients who did not receive a PS. The occurrence of PEP was significantly lower in the patients who underwent PS placement than in the patients who did not receive a PS (OR = 0.32; 95%CI: 0.23-0.45; P < 0.001). In addition, the occurrence of severe PEP was evaluated. Notably, the occurrence of severe PEP was not observed in the stent group; however, the occurrence of severe PEP was observed in 8 (1.3%) patients who did not have a PS inserted. Severe PEP occurred significantly less often in the stent group than in the no stent group (OR = 0.24; 95%CI: 0.06-0.94; P = 0.04).
CONCLUSION In conclusion, prophylactic PS placement is useful for preventing PEP and severe PEP.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima City, Fukushima Prefecture 960-1295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima City, Fukushima Prefecture 960-1295, Japan
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16
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Haseeb A, Freeman ML. Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones. ACTA ACUST UNITED AC 2019; 17:221-230. [PMID: 30945095 DOI: 10.1007/s11938-019-00234-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To review the current literature focusing on the indications, efficacy, and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) with or without endoscopic sphincterotomy (EST) in the treatment of bile duct stones. • EPBD without EST is associated with a higher risk of post-procedural pancreatitis and lower rate of stone clearance than EST alone. • EPBD without EST should be at least 2 min in duration, and placement of a pancreatic stent and other measures to reduce pancreatitis risk should be considered. • EPBD without EST is most useful to reduce risk of bleeding in patients with coagulopathy. • EPLBD combined with EST can be used as an alternative or adjunct to mechanical lithotripsy in the removal of large or difficult bile duct stones. • EPLBD combined with EST results in fewer complications than EST alone for removal of bile duct stones.
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Affiliation(s)
- Abdul Haseeb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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17
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Liu P, Lin H, Chen Y, Wu YS, Tang M, Lai L. Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis. Ther Clin Risk Manag 2019; 15:91-101. [PMID: 30666119 PMCID: PMC6331186 DOI: 10.2147/tcrm.s182615] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim To compare endoscopic papillary large balloon dilation (EPLBD) alone with EPLBD following endoscopic sphincterotomy (EST) in patients with large and/or multiple common bile duct stones. Methods We conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles until July 19, 2018. Complete common bile duct stone (CBDS) removal rate, frequency of mechanical lithotripsy (ML) usage, total procedure time and intra- and postoperative adverse events were analyzed. We used RevMan 5.3 to perform the pooled analyses. Results Seven RCTs matched the selection criteria. A total of 369 patients underwent EPLBD alone, and 367 patients underwent EPLBD following EST. Our meta-analysis revealed that there were no significant differences in terms of initial success rate (OR =0.69, 95% CI=0.44–1.09, P=0.11), frequency of ML usage (OR =1.18, 95% CI=0.68–2.05, P=0.55), rate of post-endoscopy pancreatitis (PEP) (OR =0.88, 95% CI=0.43–1.78, P=0.72), total procedure time (MD =1.52, 95% CI=-0.13–3.17, P=0.07), or other intra- and postoperative adverse events between the groups for patients with large and/or multiple CBDSs. Conclusions EPLBD alone was comparable to EPLBD with prior EST in patients with large and/or multiple CBDSs. Further studies are required to confirm the mechanisms of PEP in patients who accept EPLBD during endoscopic retrograde cholangiopancreatography (ERCP).
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Affiliation(s)
- Pan Liu
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Sichuan, People's Republic of China,
| | - Huapeng Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, People's Republic of China
| | - Yuanyuan Chen
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yu-Shen Wu
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Maocai Tang
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, People's Republic of China
| | - Liang Lai
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Sichuan, People's Republic of China,
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Terauchi T, Shinozaki H, Shinozaki S, Sasakura Y, Kimata M, Furukawa J, Lefor AK, Ogata Y, Kobayashi K. Single-Stage Endoscopic Stone Extraction and Cholecystectomy during the Same Hospitalization. Clin Endosc 2018; 52:59-64. [PMID: 30300983 PMCID: PMC6370930 DOI: 10.5946/ce.2018.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/27/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS The clinical impact of single-stage endoscopic stone extraction by endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy during the same hospitalization remains elusive. This study aimed to determine the efficacy and safety of single-stage ERCP and cholecystectomy during the same hospitalization in patients with cholangitis. METHODS We retrospectively reviewed the medical records of 166 patients who underwent ERCP for mild to moderate cholangitis due to choledocholithiasis secondary to cholecystolithiasis from 2012 to 2016. RESULTS Complete stone extraction was accomplished in 92% of patients (152/166) at the first ERCP. Among 152 patients who underwent complete stone extraction, cholecystectomy was scheduled for 119 patients (78%). Cholecystectomy was performed during the same hospitalization in 89% of patients (106/119). We compared two groups of patients: those who underwent cholecystectomy during the same hospitalization (n=106) and those who underwent cholecystectomy during a subsequent hospitalization (n=13). In the delayed group, cholecystectomy was performed about three months after the first ERCP. There were no significant differences between the groups in terms of operative time, rate of postoperative complications, and interval from cholecystectomy to discharge. CONCLUSION Single-stage endoscopic stone extraction is recommended in patients with mild to moderate acute cholangitis due to choledocholithiasis. The combination of endoscopic stone extraction and cholecystectomy during the same hospitalization is safe and feasible.
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Affiliation(s)
- Toshiaki Terauchi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Satoshi Shinozaki
- Shinozaki Medical Clinic, Tochigi, Japan.,Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yuichi Sasakura
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Masaru Kimata
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Junji Furukawa
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Yoshiro Ogata
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Kenji Kobayashi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
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Dilation Time in Endoscopic Papillary Balloon Dilation for Common Bile Duct Stones. Surg Laparosc Endosc Percutan Tech 2018; 27:351-355. [PMID: 28737592 PMCID: PMC5633320 DOI: 10.1097/sle.0000000000000431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Supplemental Digital Content is available in the text. Background: To assess the short-term outcomes after endoscopic sphincterotomy (EST) plus endoscopic papillary balloon dilation (EPBD) versus EPBD alone and appropriate balloon dilation time in EPBD alone. Materials and Methods: A total of 413 patients with common bile duct stones (CBDSs) were included in the EST plus EPBD group and 84 were in the EPBD alone group. We retrospectively evaluated the safety and efficacy between EST plus EPBD and EPBD alone group. The patients in EPBD alone group were assigned to dilation time ≥5 minutes group (n=35) and time <5 minutes group (n=49). Further, we preliminarily discussed the influence of balloon dilation time on the procedure-related complications. Results: Compared with EST plus EPBD, the patients in EPBD alone group were younger [56.6 (range: 18 to 95) vs. 65.1 (24 to 92) y; P=0.006], had smaller diameter of the largest stone [10.4 (range: 3 to 20) vs. 12.3 (5 to 30) mm; P<0.001] and were lesser frequently performed with jaundice [22 (26.2%) vs. 189 (45.8%); P=0.001]. The mean duration of postoperative hospital stay in EPBD alone group was significantly shorter than EST plus EPBD group [6.3 (range: 1 to 18) vs. 9.2 (1 to 44) d; P<0.001]. The patients in EPBD alone group had higher risk of post endoscopic retrograde cholangiopancreatography pancreatitis than EST plus EPBD group [11 (13.1%) vs. 22 (5.3%); P=0.009]. Patients in the dilation time <5 minutes group had higher risk to suffer from postoperative pancreatitis than the EST plus EPBD group [9 (18.4%) vs. 22 (5.3%); P=0.002], while patients in the dilation time ≥5 minutes group had less procedure-related hemorrhage than the EST plus EPBD group [0 vs. 36 (8.7%); P=0.047]. Conclusion: Long balloon dilation time in EPBD alone is safe and effective in treating CBDSs.
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Vezakis A, Polydorou A, Kontis E, Pantiora E, Papanikolaou IS, Fragulidis G. Safety and efficacy of extending a previous endoscopic sphincterotomy for the treatment of retained or recurrent common bile duct stones. Ann Gastroenterol 2018; 31:109-114. [PMID: 29333075 PMCID: PMC5759604 DOI: 10.20524/aog.2017.0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/26/2017] [Indexed: 11/28/2022] Open
Abstract
Background: The aim of the study was to evaluate the safety and efficacy of extending a previous endoscopic sphincterotomy (ES) in patients with retained or recurrent common bile duct (CBD) stones. Methods: Between 2001 and 2013, extension of a previous ES, for known or suspected CBD stones, was performed in 118 patients (m/f, 53/65) with a median age of 74 (range: 31-91) years (group A). During the same period, ES was performed in 1064 patients with suspected or known choledocholithiasis (group B). The efficacy and complications of the extension (group A) were analyzed and a comparison was made between groups regarding complications. Results: Bile duct cannulation was straightforward in all patients in group A, while it was considered difficult in 49% of patients in group B. Complete clearance was achieved in 76/97 patients (78%) with CBD stones, after a mean of 1.18 attempts per patient. Mechanical lithotripsy was required in 10% of patients. After extension, immediate bleeding occurred in 24 patients (20%), which stopped spontaneously in 9 (37%) and endoscopic hemostasis was required in the remainder. Complications were more frequent in group B (5.3% vs. 0.8%, P=0.031), but there was no significant difference for any individual complication. Immediate bleeding was more common in group B (29% vs. 20%, P=0.035), but there was no difference in clinical bleeding. Conclusion: Extension of a previous ES seems to be a simple, effective and safe technique, allowing stone clearance in nearly 80% of patients; it is thus recommended in patients with CBD stones after ES.
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Affiliation(s)
- Antonios Vezakis
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Andreas Polydorou
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Elissaios Kontis
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK (Elissaios Kontis)
| | - Eirini Pantiora
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Ioannis S Papanikolaou
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Georgios Fragulidis
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
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Aujla UI, Ladep N, Dwyer L, Hood S, Stern N, Sturgess R. Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy. World J Gastroenterol 2017; 23:8597-8604. [PMID: 29358868 PMCID: PMC5752720 DOI: 10.3748/wjg.v23.i48.8597] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/31/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation (EPLBD) in the management of bile duct stones in a Western population.
METHODS Data was collected from the endoscopic retrograde cholangiopancreatography (ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1st August 2009 to 31st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore, we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.
RESULTS EPLBD was performed in 229 patients (46 females) with mean age of 68 ± 14.3 years. 115/229 (50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP (1st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81 (35.4%). Median balloon size was 13.5 mm (10 - 18). In addition to EPLBD, per-oral cholangioscopy (POC) and electrohydraulic lithotripsy (EHL) was performed in 35 (15%) patients at index* ERCP. 63 (27.5%) required repeat ERCP for stone clearance. 28 (44.5%) required POC and EHL and 11 (17.4%) had repeat EPLBD for complete duct clearance. Larger stone size (12.4 mm vs 17.4 mm, P < 0.000001), multiple stones (2, range (1-13) vs 3, range (1-12), P < 0.006) and dilated common bile duct (CBD) (12.4 mm vs 18.3 mm, P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients (20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis (0.87%) each.
CONCLUSION EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.
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Affiliation(s)
- Usman Iqbal Aujla
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Nimzing Ladep
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Laura Dwyer
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Stephen Hood
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Nicholas Stern
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
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22
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Alberca de Las Parras F, Egea Valenzuela J, Carballo Álvarez F. Bleeding risk in endoscopic retrograde cholangiopancreatography. Impact of the use of antithrombotic drugs. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:202-210. [PMID: 28112960 DOI: 10.17235/reed.2017.4358/2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To analyze the risk factors for hemorrhage during endoscopic retrograde cholangiopancreatography and the impact of antithrombotic drugs. MATERIAL AND METHODS Data sources: papers indexed in PubMed have been reviewed, as well as those found during the analysis of the bibliography of meta-analysis and reviews. SELECTION CRITERIA the references have been firstly evaluated by review of the abstract. After selecting the most significant articles (mainly randomized trials and well-designed case series) these have been deeply analyzed. Evaluation of the studies and synthesis: criteria by the Oxford Centre for Evidence-Based Medicine have been used for the analysis of the references and elaboration of evidence levels. RESULTS Seven hundred and sixty-five references were found, 753 in PubMed and the Cochrane Library. Twelve studies were selected during the analysis of other published articles (systematic reviews, meta-analysis and clinical practice guidelines). After analyzing the title or the abstract, 655 studies were excluded. Finally, 83 high quality trials or descriptive studies have been included in the analysis. CONCLUSION Seven conclusions regarding the risk factors for bleeding and the impact of antithrombotic drugs have been defined.
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Affiliation(s)
| | - Juan Egea Valenzuela
- Unidad de Gestión Clínica digestivo, Hospital Clínico Universitario Virgen de la Arrixaca
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23
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Kuo YT, Wang HP, Chang CY, Leung JW, Chen JH, Tsai MC, Liao WC. Comparable Long-term Outcomes of 1-Minute vs 5-Minute Endoscopic Papillary Balloon Dilation for Bile Duct Stones. Clin Gastroenterol Hepatol 2017; 15:1768-1775. [PMID: 28603054 DOI: 10.1016/j.cgh.2017.05.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic papillary balloon dilation (EPBD) is an alternative to endoscopic sphincterotomy for choledocholithiasis. Unlike endoscopic sphincterotomy, EPBD preserves biliary sphincter function, reducing long-term risk of recurrent choledocholithiasis by 50%. Guidelines recommend that duration of EPBD exceeds 2 minutes, to adequately loosen the sphincter and reduce risks of failed stone extraction and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, it is unclear whether this long duration of EPBD impairs sphincter function and negates the long-term benefit of EPBD. We performed a randomized controlled trial to determine whether long-duration (>1 minute) EPBD increases the risk of subsequent choledocholithiasis and hepatobiliary complications compared with short-duration EPBD (<1 minute). METHODS We performed a prospective study of 170 adult patients who underwent ERCP for suspected choledocholithiasis from April 2007 through October 2008 at 2 centers in Taiwan. Patients were randomly assigned to groups that underwent 1-minute (n = 86) or 5-minute (n = 84) EPBD for choledocholithiasis; patients were followed through June 2015. One month after the initial ERCP, patients were examined and liver function tests and abdominal sonographies were performed. Patients were then examined every 3-6 months over a median follow-up period of approximately 7 years. The primary outcome was recurrent choledocholithiasis or acute cholangitis and the secondary outcome was overall hepatobiliary complications. We assessed the effects of EPBD duration by Cox regression. RESULTS Thirteen patients (15.1%) developed recurrent choledocholithiasis or acute cholangitis after 1-minute EPBD, and 10 patients (11.9%) developed recurrent choledocholithiasis or acute cholangitis after 5-minute EPBD (P = .352). There was no significant difference between groups in number of hepatobiliary complications (P = .154). Compared with 1-minute EPBD, 5-minute EPBD did not increase risk of the primary outcome (adjusted hazard ratio, 0.76; 95% confidence interval, 0.32-1.82) or the secondary outcome (adjusted hazard ratio, 0.65; 95% confidence interval, 0.31-1.40). Mechanical lithotripsy, performed for failed stone extraction with EPBD at initial ERCP, was a risk factor for primary and secondary outcomes. CONCLUSIONS In a randomized controlled trial, we found that the risk of recurrent choledocholithiasis and hepatobiliary complications did not increase with long-duration EPBD (>1 minute), but was increased with mechanical lithotripsy.
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Affiliation(s)
- Yu-Ting Kuo
- Department of Internal Medicine, National Taiwan University Hospital Bei-Hu Branch, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, E-DA Hospital and I-Shou University, Kaohsiung, Taiwan
| | - Joseph W Leung
- Division of Gastroenterology, UC Davis Medical Center and Sacramento VA Medical Center, Sacramento, California
| | - Jiann-Hwa Chen
- Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
| | - Ming-Chang Tsai
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Multiple plastic biliary stent placement in the management of large and multiple choledochal stones: single center experience and review of the literature. Wideochir Inne Tech Maloinwazyjne 2017; 12:231-237. [PMID: 29062442 PMCID: PMC5649504 DOI: 10.5114/wiitm.2017.69107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 06/27/2017] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the first step treatment modality of choledocholithiasis. In spite of an extended sphincterotomy, 10-15% of complex choledochal stones (larger than 15 mm and/or more than 3 stones) cannot be removed and recurrent ERCP procedures may be needed. AIM To evaluate the role and efficiency of multiple biliary stent application in the treatment of large and multiple choledochal stones. MATERIAL AND METHODS Patients with complex choledochal stones and patients with inadequate choledochal clearance during ERCP were included in the study. The study group was divided into 2 groups as the placement of single (n = 27 patients) or multiple stents (n = 58 patients). After a mean time interval of 21 days (10-28), the ERCP procedure was tried for the second time and a stent was placed in case of recurrence. RESULTS Successful biliary drainage was provided in both groups. The decrease in the longitudinal or transverse size of the stones after stent placement was found to be statistically significant in both groups (p = 0.001). Cholestatic enzymes (alkaline phosphatase (ALP), γ-glutamyltransferase (GGT)) and bilirubin levels decreased significantly in both groups following stenting (p = 0.001). Additionally, multiple stents functioned as a bridge starting from the first ERCP to full clearance in patients with large and multiple stones which could not be removed at once and saved them from the possible morbidities of an invasive operation. CONCLUSIONS Endoscopic multiple biliary stent placement should be preferred in the treatment of patients with complex choledochal stones and high rates of co-morbidity, as a safe alternative to surgery.
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol 2017; 52:276-300. [PMID: 27942871 DOI: 10.1007/s00535-016-1289-7] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 02/08/2023]
Abstract
Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.
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Fujisawa T, Kagawa K, Hisatomi K, Kubota K, Nakajima A, Matsuhashi N. Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis? World J Gastroenterol 2016; 22:5909-5916. [PMID: 27468185 PMCID: PMC4948272 DOI: 10.3748/wjg.v22.i26.5909] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/23/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Khan AS, Eloubeidi MA, Khashab MA. Endoscopic management of choledocholithiasis and cholelithiasis in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2016; 10:861-8. [PMID: 26799755 DOI: 10.1586/17474124.2016.1145544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treatment of choledocholithiasis and cholelithiasis in patients with cirrhosis often requires diagnostic and therapeutic endoscopy such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Patients with underlying cirrhosis may have coagulopathy, hepatic encephalopathy, ascites and other comorbidities associated with cirrhosis that can make endoscopic therapy challenging and can be associated with a higher risk of adverse events. Given the unique derangements of physiologic parameters associated with cirrhosis this population requires a truly multifaceted and multidisciplinary understanding between therapeutic endoscopists, hepatologists and anesthesiologists. For therapeutic endoscopists, it is critical to be aware of the specific issues unique to this population of patients to optimize outcomes and avoid adverse events. The epidemiology of gallstone disease, the diagnostic and therapeutic approach to patients with varying degree of hepatic dysfunction, and a review of the available literature in this area are presented.
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Affiliation(s)
- Ali S Khan
- a Digestive and Liver Diseases , Columbia University Medical Center , New York , NY , USA
| | | | - Mouen A Khashab
- c Division of Gastroenterology and Hepatology , The Johns Hopkins University , Baltimore , MD , USA
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Easler JJ, Sherman S. Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:657-75. [PMID: 26431596 DOI: 10.1016/j.giec.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Sphincterotomy with Large Balloon to Extract Common Bile Duct Stones: Sometimes It Is Better to Get an "Incomplete". Dig Dis Sci 2015; 60:1881-2. [PMID: 25963322 DOI: 10.1007/s10620-015-3672-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/16/2015] [Indexed: 12/09/2022]
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Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy. Surg Endosc 2015; 30:222-8. [PMID: 25840897 DOI: 10.1007/s00464-015-4190-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is currently the treatment of choice for symptomatic choledocholithiasis in pregnant patients. We aimed to present our experience with pregnant patients who underwent nonradiation ERCP and to evaluate the safety and efficacy of a new technique. METHODS A retrospective analysis of nonradiation ERCP in 22 pregnant patients with symptomatic choledocholithiasis between January 2002 and December 2013 was performed. The bile aspiration technique with wire-guided sphincterotome was used to confirm selective biliary cannulation. Transpapillary pancreatic septotomy was performed in cases with difficult biliary cannulation (n = 3). After endoscopic biliary sphincterotomy, endoscopic papillary balloon dilation was performed with a 6- or 8-mm dilation balloon in all patients to reduce the risk of recurrent cholangitis because of residual or additional stones. Stones were extracted by balloon sweeping after dilation. All patients were followed for 6 months after the ERCP procedure. RESULTS Biliary cannulation was achieved in all patients. Endoscopic papillary balloon dilation was performed with a 6-mm balloon in 17 patients and an 8-mm balloon in five patients. The stones were extracted in 18 of the 22 patients by balloon sweeping, but no stones were extracted in the remaining four patients. There were two cases of mild post-ERCP pancreatitis. All patients delivered at term, and none experienced recurrence of choledocholithiasis and/or cholangitis during the 6-month follow-up. CONCLUSIONS Endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation in nonradiation ERCP is a safe and effective treatment method for symptomatic choledocholithiasis during pregnancy.
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Xu XD, Dai JJ, Qian JQ, Wang WJ. Prevention of pancreatitis after papillary balloon dilatation by nasobiliary drainage: a randomized controlled trial. Dig Dis Sci 2015; 60:1087-91. [PMID: 25322952 DOI: 10.1007/s10620-014-3400-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic papillary balloon dilation (EPBD) was associated with a higher rate of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). AIM The purpose of this study was to determine whether placement of an endoscopic nasobiliary drainage (ENBD) catheter can also prevent PEP after EPBD. METHODS A total of 93 patients, who with proven common bile duct (CBD) stones, received EPBD were enrolled this trial. They were randomly divided into ENBD group (n = 45) and no-ENBD group (n = 48) according whether undergone an ENBD procedure after EPBD. Their demographics, laboratory, procedural data were collected, and pancreaticobiliary complications were followed. RESULTS The number of patients with serum amylase levels above the normal upper limit (>180 U/L) did not differ between groups. However, compared with ENBD group, more patients in No-ENBD group had levels greater than three times the normal limit (>540 U/L) (11/48 vs 3/45, P = 0.0285), and more patients developed to PEP (7/48 vs 0/45, P = 0.0250). During follow-up, the numbers of patients undergone cholecystectomy, cholangitis and recurrence of CBD stones were similar. There was also no significant difference in the cumulative rate of recurrent pancreaticobiliary complications between the two groups (P = 0.452). CONCLUSIONS EPBD followed by insertion of an ENBD catheter can prevent PEP, and routine ENBD catheter placement is recommended after an EPBD procedure.
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Affiliation(s)
- Xiao-Dan Xu
- Changshu Affiliated Hospital of Suzhou Universit, Changshu, China,
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Kim DU. Is the Balloon Dilation Duration in Endoscopic Papillary Balloon Dilation (EPBD) Related to the Occurrence of Post-EPBD Pancreatitis? Clin Endosc 2015; 48:6-7. [PMID: 25674519 PMCID: PMC4323435 DOI: 10.5946/ce.2015.48.1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 12/24/2014] [Indexed: 12/17/2022] Open
Affiliation(s)
- Dong Uk Kim
- Division of Gastroenterology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Endoscopic sphincterotomy with large balloon dilation versus endoscopic sphincterotomy for bile duct stones: a systematic review and meta-analysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:673103. [PMID: 25756050 PMCID: PMC4338384 DOI: 10.1155/2015/673103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/24/2014] [Accepted: 12/25/2014] [Indexed: 02/06/2023]
Abstract
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.
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Shavakhi A, Minakari M, Ardestani MHS, Sadeghizadeh A, Shavakhi S. A comparative study of one minute versus five seconds endoscopic biliary balloon dilation after small sphincterotomy in choleducolithiasis. Adv Biomed Res 2015; 4:28. [PMID: 25709993 PMCID: PMC4333434 DOI: 10.4103/2277-9175.150421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 08/07/2013] [Indexed: 12/14/2022] Open
Abstract
Background: Limited sphincterotomy and endoscopic papillary balloon dilation (EPBD) is a low-risk method for the treatment of choleducolithiasis. Traditionally one minute ballooning time (BT) is applied; however, the effective BT is not clear. In this study, we compare five seconds and one minute ballooning time. Materials and Methods: In this single-blind, randomized, clinical trial 60 patients with common bile duct (CBD) stones documented in ultrasonography or magnetic resonance cholangiopancreatography (MRCP), with no severe hepatic, biliary or systemic diseases, enrolled in the study. The patients were randomly assigned to receive EPBD with either five seconds (n = 31) or one minute (n = 29) ballooning time (BT) after endoscopic retrograde cholangiopancreatography (ERCP) and small sphincterotomy. Then stones were retrieved with an extractor balloon. The patients were followed for 48 hours to check the possible complications. Results: Successful CBD stone removal was the same in the five-second and one-minute BT groups (93.5% vs. 96.6%; P = 0.594). Pancreatitis occurred in three (9.7%) patients in the five-second BT group and in six (20.7%) patients in the one-minute BT group (P = 0.233). No hemorrhage or perforation was noted. Conclusions: After a small sphincterotomy, EPBD in the five-second and one-minute BT groups had a similar efficacy. Small sphincterotomy combined with very short BT is a safe and effective method for CBD stone removal.
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Affiliation(s)
- Ahmad Shavakhi
- Department of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Minakari
- Department of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Atefeh Sadeghizadeh
- Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sara Shavakhi
- Department of Internal Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:107-21. [PMID: 25442962 DOI: 10.1016/j.giec.2014.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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Guo SB, Meng H, Duan ZJ, Li CY. Small sphincterotomy combined with endoscopic papillary large balloon dilation vs sphincterotomy alone for removal of common bile duct stones. World J Gastroenterol 2014; 20:17962-17969. [PMID: 25548495 PMCID: PMC4273147 DOI: 10.3748/wjg.v20.i47.17962] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/13/2014] [Accepted: 08/28/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of endoscopic papillary large diameter balloon dilation (EPLBD) following limited endoscopic sphincterotomy (EST) and EST alone for removal of large common bile duct (CBD) stones.
METHODS: We retrospectively compared EST + EPLBD (group A, n = 64) with EST alone (group B, n = 89) for the treatment of large or multiple bile duct stones. The success rate of stone clearance, procedure-related complications and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.
RESULTS: There was no statistically significant difference between the two groups regarding periampullary diverticula (35.9% vs 34.8%, P > 0.05), pre-cut sphincterotomy (6.3% vs 6.7%, P > 0.05), size (12.1 ± 2.0 mm vs 12.9 ± 2.6 mm, P > 0.05) and number (2.2 ± 1.9 vs 2.4 ± 2.1, P > 0.05) of stones or the diameters of CBD (15.1 ± 3.3 mm vs 15.4 ± 3.6 mm, P > 0.05). The rates of overall stone removal and stone removal in the first session were not significantly different between the two groups [62/64 (96.9%) vs 84/89 (94.4%), P > 0.05; and 58/64 (90.6%) vs 79/89 (88.8%), P > 0.05, respectively]. The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia were not significantly different between the two groups [3/64 (4.7%) vs 4/89 (4.5%), P > 0.05; 7/64 (10.9%) vs 9/89 (10.1%), P > 0.05, respectively]. There were no cases of perforation, acute cholangitis, or cholecystitis in the two groups. The rate of bleeding and the recurrence of CBD stones were significantly lower in group A than in group B [1/64 (1.6%) vs 5/89 (5.6%), P < 0.05; 1/64 (1.6%) vs 6/89 (6.7%), P < 0.05, respectively].
CONCLUSION: EST + EPLBD is an effective and safe endoscopic approach for removing large or multiple CBD stones.
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Jang SI, Yun GW, Lee DK. Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16913-16924. [PMID: 25493004 PMCID: PMC4258560 DOI: 10.3748/wjg.v20.i45.16913] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/02/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Steed H, Lau K, Glass R, Durkin D, Deakin M, Green JRB. Biliary boulders. Frontline Gastroenterol 2014; 5:161-166. [PMID: 28839765 PMCID: PMC5369731 DOI: 10.1136/flgastro-2013-100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/22/2013] [Accepted: 12/10/2013] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine the outcome of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones. DESIGN A retrospective review of 100 consecutive ERCPs performed for CBD stones. RESULTS 100 ERCPs were performed on 84 patients with a median cohort age of 77. Completion in this cohort, as defined by duct clearance, was achieved in 65% of cases. Completion rates fell rapidly after two ERCPs. 33% of the cohort had small stones <10 mm, and 67% had stones >10 mm. Size, but not number of stones, affected the completion rate and frequency of complications (16%). Presence of periampullary diverticulum did not affect completion or complication rates. MR cholangiopancreatography (MRCP) had a 90% sensitivity for detecting CBD stones compared with 56% for CT. DISCUSSION AND CONCLUSIONS ERCP remains a high-risk procedure with a significant complication rate when performed to deal with CBD stones. MRCP should be the second choice of investigation for CBD stones. This cohort had an unusually high number of larger stones at ERCP of 67% compared with other published UK cohorts of 8%, and this was reflected in the completion and complication rate.
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Affiliation(s)
- H Steed
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - K Lau
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - R Glass
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - D Durkin
- Department of Hepatobiliary Surgery, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - M Deakin
- Department of Hepatobiliary Surgery, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - J R B Green
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
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Jin PP, Cheng JF, Liu D, Mei M, Xu ZQ, Sun LM. Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: A meta-analysis. World J Gastroenterol 2014; 20:5548-5556. [PMID: 24833886 PMCID: PMC4017071 DOI: 10.3748/wjg.v20.i18.5548] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/01/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Comparison of endoscopic papillary balloon dilation and sphincterotomy in young patients with CBD stones and gallstones. Dig Dis Sci 2014; 59:1042-7. [PMID: 24287639 DOI: 10.1007/s10620-013-2949-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 11/11/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Endoscopic biliary sphincterotomy (EBS) results in permanent loss of sphincter function and its long-term complications are unknown. Endoscopic papillary balloon dilation (EPBD) is an alternative procedure that preserves sphincter function, although it is associated with a higher risk of pancreatitis than is EBS. The aim of this study was to evaluate the safety and outcomes of EPBD with limited indications for removal of common bile duct (CBD) stones combined with gallstones in patients younger than 40 years. METHODS Young (age < 40 years) patients who had CBD stones combined with gallstones on imaging studies were enrolled in this study. A total of 132 patients were randomly divided into the EPBD group (n = 62) or the EBS group (n = 70) for extraction of CBD stones. The ballooning size of EPBD ranged from 6 to 10 mm. RESULTS Complete bile duct clearance was achieved in 98.4 % (61/62) of the EPBD group and 100 % (70/70) of the EBS group. Mechanical lithotripsy was required in 8.1 % (5/62) of the EPBD group and 8.6 % (6/70) of the EBS group. The early complication rates were 8.1 % (5/62) (five pancreatitis) in the EPBD group and 11.4 % (8/70) (five [7.1 %] pancreatitis, two bleeding and one perforation) in the EBS group. The recurrence rates of CBD stones were 1.6 % (1/62) in the EPBD group and 5.7 % (4/70) in the EBS group. CONCLUSIONS EPBD with limited indications was safe and effective as EBS for removal of CBD stones combined with gallstones in young patients who had a longer life expectancy.
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Ito K, Masu K, Kanno Y, Ohira T, Noda Y. Ampullary intervention for bile duct stones in patients with surgically altered anatomy. Dig Endosc 2014; 26 Suppl 2:116-21. [PMID: 24750160 DOI: 10.1111/den.12250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 01/12/2014] [Indexed: 12/30/2022]
Abstract
Transpapillary endoscopic treatment is a standard technique for the treatment of bile duct stones. This technique includes biliary cannulation, ampullary interventions such as endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), and stone removal. In patients with Roux-en-Y anastomosis, the transpapillary approach using an ordinary scope has been challenging. A recently developed single-/double-balloon enteroscope enables therapeutic endoscopic retrograde cholangiopancreatography to be carried out in such cases. EST using a balloon enteroscope is often difficult to carry out as a result of restriction of scope maneuverability or inadequate direction of the accessory. Although EPBD is easy to carry out for any anatomy, large or multiple stones are difficult to remove by EPBD only because of insufficient opening of Vater's papilla. Endoscopic papillary large-balloon dilation following EST is reported to be useful for the treatment of large and/or multiple stones. This technique is also useful for the treatment of bile duct stones in patients with Roux-en-Y anastomosis.
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Affiliation(s)
- Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
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Masoni L, Mari FS, Pietropaolo V, Onorato M, Meucci M, Brescia A. Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique. World J Surg 2014; 37:1258-62. [PMID: 23474857 DOI: 10.1007/s00268-013-1992-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. METHODS We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. RESULTS In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days. CONCLUSION Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.
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Affiliation(s)
- Luigi Masoni
- Department of Medical and Surgical Sciences and Translational Medicine, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
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Kim JH, Yang MJ, Hwang JC, Yoo BM. Endoscopic papillary large balloon dilation for the removal of bile duct stones. World J Gastroenterol 2013; 19:8580-8594. [PMID: 24379575 PMCID: PMC3870503 DOI: 10.3748/wjg.v19.i46.8580] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 09/17/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Jeong SU, Moon SH, Kim MH. Endoscopic papillary balloon dilation: Revival of the old technique. World J Gastroenterol 2013; 19:8258-8268. [PMID: 24363517 PMCID: PMC3857449 DOI: 10.3748/wjg.v19.i45.8258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 09/18/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Kubiliun NM, Elmunzer BJ. Preventing pancreatitis after endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23:769-86. [PMID: 24079789 DOI: 10.1016/j.giec.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Gastroenterology, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109, USA
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Itoi T, Tsuyuguchi T, Takada T, Strasberg SM, Pitt HA, Kim MH, Belli G, Mayumi T, Yoshida M, Miura F, Büchler MW, Gouma DJ, Garden OJ, Jagannath P, Gomi H, Kimura Y, Higuchi R. TG13 indications and techniques for biliary drainage in acute cholangitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:71-80. [PMID: 23307008 DOI: 10.1007/s00534-012-0569-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Zhao HC, He L, Zhou DC, Geng XP, Pan FM. Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy. World J Gastroenterol 2013; 19:3883-3891. [PMID: 23840129 PMCID: PMC3699051 DOI: 10.3748/wjg.v19.i24.3883] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis.
METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term complications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyzing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined as P < 0.05. Risk of bias was evaluated using a funnel plot.
RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBD group were younger (OR = -1.16, 95%CI: -1.49 to 0.84, P < 0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Compared with EST, the total stone clearance in the EPBD group decreased (OR = 0.64, 95%CI: 0.42 to 0.96, P = 0.03), the use of stone extraction baskets significantly increased (OR = 1.91, 95%CI: 1.41 to 2.59, P < 0.01), and the incidence of pancreatitis significantly increased (OR = 2.79, 95%CI: 1.74 to 4.45, P < 0.0001). The incidence of bleeding (OR = 0.12, 95%CI: 0.04 to 0.34, P < 0.01) and cholecystitis (OR = 0.41, 95%CI: 0.20 to 0.84, P = 0.02) significantly decreased. The stone recurrence rate also was significantly reduced in EPBD (OR = 0.48, 95%CI: 0.26 to 0.90, P = 0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis.
CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone clearance rate and risk of bleeding was lower with EPBD compared to EST.
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