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Yabe K, Yamagata W, Satou M, Oka I, Horike H, Namiki S, Hosoi K. Minimal endoscopic sphincterotomy followed by papillary balloon dilation to relieve choledocholithiasis in a 6-year-old girl with hereditary spherocytosis. Clin J Gastroenterol 2024; 17:782-787. [PMID: 38517593 DOI: 10.1007/s12328-024-01960-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024]
Abstract
A 6-year-old girl previously diagnosed with hereditary spherocytosis was admitted to our hospital with gallstones and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and fluoroscopy revealed a dilated common bile duct (CBD) without evident stones, possibly due to spontaneous excretion through the papilla of Vater. A 7-French plastic stent was inserted into the CBD. After the procedure, a marked increase in pancreatic enzyme levels was observed, and she was diagnosed with post-ERCP pancreatitis (PEP). Stent placement could have been a cause of pancreatitis; therefore, we removed the stent. Subsequently, recovery from pancreatitis was confirmed, although she suddenly complained of abdominal pain and was diagnosed with choledocholithiasis recurrence. ERCP was repeated, and fluoroscopy revealed a dilated CBD with a stone. A minimal endoscopic sphincterotomy (EST) was performed to reduce the risk of PEP, and a biliary dilation balloon placed across the papilla was gradually inflated until the waist of the balloon disappeared. Stones were extracted using a retrieval balloon catheter. The abdominal pain resolved immediately, and the patient recovered without developing PEP. To our knowledge, this is the first case report of a pediatric patient treated with minimal EST followed by papillary balloon dilation for choledocholithiasis.
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Affiliation(s)
- Kiyoaki Yabe
- Department of Gastroenterology, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8561, Japan.
| | - Wataru Yamagata
- Department of Gastroenterology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
| | - Masamichi Satou
- Department of Gastroenterology, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8561, Japan
| | - Itsuhiro Oka
- Department of Gastroenterology, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8561, Japan
| | - Hideyuki Horike
- Department of Gastroenterology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
| | - Shin Namiki
- Department of Gastroenterology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8524, Japan
| | - Kenji Hosoi
- Department of Gastroenterology, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, 183-8561, Japan
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Kouchi K, Takenouchi A, Matsuoka A, Yabe K, Yoshizawa H, Nakata C, Fujishiro J, Sugiyama H. Case Series of Endoscopic Papillary Balloon Dilation for Children with Common Bile Duct Stones and a Review of the Literature. J Clin Med 2024; 13:2251. [PMID: 38673524 PMCID: PMC11050672 DOI: 10.3390/jcm13082251] [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: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs) and has been reported to have a high success rate for stone removal. However, EST is associated with a risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years, including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted; pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean 96%). The incidence of pancreatitis was 0-9.6% (mean 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3-5.4% (mean 2.7%). With regards to the grade of bleeding, seven cases were mild (64%) and four were moderate (36%). Compared with adults who underwent EST, the frequencies of pancreatitis and bleeding were almost equal in children; however, in children, once bleeding occurs, it has a higher risk of leading to blood transfusion. Stone removal via EPBD in children has a 100% success rate. Pancreatitis was responsible for all complications were related; its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2-3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal via EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation via EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered to be an effective method for CBDS removal in children.
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Affiliation(s)
- Katsunori Kouchi
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Ayako Takenouchi
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Aki Matsuoka
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Kiyoaki Yabe
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Hiroko Yoshizawa
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Chikako Nakata
- Department of Pediatric Surgery, Tokyo Women's Medical University, Ohwadashinden 477-96, Yachiyo 276-8524, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Tokyo University, Hongou 7-3-1, Bunkyou-ku, Tokyo 113-8655, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Tokyo Women's Medical University, 8-1 Shinjuku-ku, Tokyo 162-8666, Japan
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Park JS, Kim HJ, Seo JH, Youn HS. A Case of Congenital Common Bile Duct Web Treated with Balloon Dilation under Endoscopic Retrograde Cholangiopancreatography in a Young Child. Clin Endosc 2020; 54:285-288. [PMID: 33296955 PMCID: PMC8039748 DOI: 10.5946/ce.2020.167] [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: 06/16/2020] [Accepted: 07/01/2020] [Indexed: 11/24/2022] Open
Abstract
Web in common bile duct (CBD web) is very rare. It is usually asymptomatic and detected incidentally during surgery for other causes in adults. It can be congenital or acquired, however congenital CBD web is extremely rare. Currently, despite its invasiveness and complications, endoscopic retrograde cholangiopancreatography (ERCP) is considered as a useful diagnostic and therapeutic modality in children with hepatobiliary pancreatic diseases as in adults. Herein we report a case of congenital CBD web presenting with acute pancreatitis and choledocholithiasis in a 4-year-old girl which was diagnosed and treated using balloon dilation under ERCP. After balloon dilation of the web, a common pancreatobiliary channel was observed. To the best of our knowledge, a case of congenital CBD web with pancreatobiliary junctional abnormality treated using ERCP in a child has not been reported to date.
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Affiliation(s)
- Ji Sook Park
- Department of Pediatrics, Gyeongsang National University Hospital and Gyeongsang National University School of Medicine, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Hong Jun Kim
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea.,Department of Internal Medicine, Gyeongsang National University Hospital and Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Hyun Seo
- Department of Pediatrics, Gyeongsang National University Hospital and Gyeongsang National University School of Medicine, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Hee-Shang Youn
- Department of Pediatrics, Gyeongsang National University Hospital and Gyeongsang National University School of Medicine, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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Özcan N, Kahrıman G, Görkem SB, Arslan D. Percutaneous management of bile duct stones in children: results of 12 cases. Diagn Interv Radiol 2017; 23:133-136. [PMID: 28082252 DOI: 10.5152/dir.2016.16178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE We aimed to evaluate the effectiveness of percutaneous transhepatic removal of bile duct stones in children. METHODS The study included 12 pediatric patients (4 males, 8 females; age range, 1-16 years; mean age, 6.6 years) who underwent percutaneous transhepatic removal of bile duct stones between September 2007 and December 2015. Demographic data, patient symptoms, indications for interventions, technical and clinical outcomes of the procedure, and complications were retrospectively evaluated. RESULTS Of 12 children, five children with cholelithiasis underwent cholecystectomy subsequently. The overall technical and clinical success rate was 100%. One patient had cholangitis as a complication during the follow-up and was treated medically. CONCLUSION Percutaneous transhepatic removal of bile duct stones is a safe and effective method for the treatment of children with biliary stone disease. It is a feasible alternative when the endoscopic procedure is unavailable or fails.
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Affiliation(s)
- Nevzat Özcan
- Department of Radiology, Erciyes University School of Medicine, Gevher Nesibe Hospital, Kayseri, Turkey.
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Kahriman G, Ozcan N, Gorkem SB. Percutaneous management of benign biliary disorders in children. Diagn Interv Imaging 2017. [PMID: 28645679 DOI: 10.1016/j.diii.2017.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The goal of this study was to analyze the outcomes of percutaneous transhepatic management of benign biliary disorders in pediatric patients. MATERIALS AND METHODS This study included 11 pediatric patients who underwent percutaneous transhepatic biliary interventional procedures between September 2007 and December 2016. There were 3 males and 8 females with a mean age of 9.6±5.4 (SD)years (range: 2-17years). Technical details, complications and outcome of the procedures were evaluated. RESULTS The underlying pathologies were bile duct stones (n=2), bile leakage (n=4), choledochal cyst (n=3) and benign biliary stricture (n=2). The therapeutic interventional procedures were as follows; percutaneous stone removal in patients with bile duct stones, external biliary drainage in patients with choledochal cyst, bile diversion by internal-external percutaneous biliary drainage (IE-PBD) in patients with bile leakage, plastic stent placement, IE-PBD with balloon dilatation in patients with benign biliary stricture. The procedures were successful in all patients technically and clinically. One patient experienced intermittent fever. CONCLUSION Percutaneous transhepatic biliary interventional procedure is an effective and safe approach for the treatment of pediatric patients with bile duct stones, bile leakage, symptomatic choledochal cyst and benign biliary stricture when endoscopic procedure is unavailable or fails.
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Affiliation(s)
- G Kahriman
- Erciyes University, Medical Faculty, Gevher Nesibe Hospital, Department of Radiology, 38039 Kayseri, Turkey.
| | - N Ozcan
- Erciyes University, Medical Faculty, Gevher Nesibe Hospital, Department of Radiology, 38039 Kayseri, Turkey.
| | - S B Gorkem
- Erciyes University, Medical Faculty, Gevher Nesibe Hospital, Department of Radiology, 38039 Kayseri, Turkey.
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Sakai Y, Tsuyuguchi T, Hirata N, Nakaji S, Shimura K, Nishikawa T, Fujimoto T, Hamano T, Nishino T, Yokosuka O. Clinical utility of 0.025-inch guidewire VisiGlide2 TM in the endoscopic retrograde cholangiopancreatography-related procedures. World J Gastrointest Endosc 2017; 9:77-84. [PMID: 28250900 PMCID: PMC5311476 DOI: 10.4253/wjge.v9.i2.77] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/23/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the result of the use of 0.025-inch guidewire (GW) VisiGlide2TM as the first choice in the endoscopic retrograde cholangiopancreatography (ERCP)-related procedures without selecting the patient in a multicenter prospective study.
METHODS ERCP using 0.025-inch GW VisiGlide2TM as the first choice was conducted in patients who have needed ERCP, and its accomplishment rate of procedure, procedural time, incidence of accidental symptoms were compared with those of ERCP using 0.025-inch GW VisiGlideTM.
RESULTS The accomplishment rate of procedure was 97.5% (197/202), and procedural time was 23.930 ± 16.207 min. The accomplishment rate of procedure using 0.025-inch GW VisiGlideTM was 92.3% (183/195), and procedural time was 31.285 ± 19.122 min, thus the accomplishment rate of procedure was significantly improved and procedural time was significantly shortened (P < 0.05). Accidental symptoms by ERCP-related procedures were observed in 3.0% (6/202), and all were conservatively alleviated.
CONCLUSION When 0.025-inch GW VisiGlide2TM was used for ERCP-related procedure as the first choice, it showed high accomplishment rate of procedure and low incidence of accidental symptoms, suggesting it can be used as the universal GW. Clinical Trial Registry (UMIN0000016042).
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Tringali A, Balassone V, De Angelis P, Landi R. Complications in pediatric endoscopy. Best Pract Res Clin Gastroenterol 2016; 30:825-839. [PMID: 27931639 DOI: 10.1016/j.bpg.2016.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/17/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.
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Affiliation(s)
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Rosario Landi
- Digestive Endoscopy Unit, Catholic University, Rome, Italy.
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Sakai Y, Tsuyuguchi T, Sugiyama H, Hayashi M, Senoo JI, Kusakabe Y, Yasui S, Mikata R, Yokosuka O. Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones. World J Gastrointest Endosc 2016; 8:395-401. [PMID: 27247706 PMCID: PMC4877531 DOI: 10.4253/wjge.v8.i10.395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/17/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy (EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.
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Safety and efficacy of one-stage total laparoscopic treatment of common bile duct stones in children. Surg Endosc 2014; 29:1831-6. [PMID: 25318361 DOI: 10.1007/s00464-014-3872-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 09/02/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The purpose of this study is to confirm the effectiveness of total laparoscopic treatment of common bile duct (CBD) stones in children. METHODS All children who were treated in our department for cholelithiasis were reviewed from 1996 to 2013. Data collection focused on children with CBD stones, including age, sex, symptoms at diagnosis, hepatic and pancreatic blood tests results, US scan results, etiology, detailed surgical technique, operative time, length of hospital stay, complications, and stone-free status or not, at last follow-up. RESULTS 551 children were treated for cholelithiasis and had undergone laparoscopic cholecystectomy. Among those, 36 children (6.5%) presented with CBD stones with a mean age at symptom onset of 10.4 years (min-max: 4 months-18 years). A majority of the patients presented with hemolytic disease (61%). In 55% of the cases, cholangiography alone or simple serum saline flush of the biliary tree was sufficient to obtain a stone-free CBD. Additional maneuvers with Dormia basket or Fogarty catheter led to 72% of success rate. In 9 cases (25%) of failure of the procedure, 6 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES), 1 patient was re-operated at day1 for hemorrhage, and 2 patients were followed by US scan with spontaneous evacuation of CBD stones. Mean follow-up was of 2 years (min-max: 1 month-5 years). All patients were stone free at last clinical and radiological evaluation. CONCLUSION A one-stage total laparoscopic treatment of common bile duct stones in children is a safe, feasible, reproducible, and efficient procedure in 72% of the cases. This rate could be upgraded by a combination of laparoscopic and endoscopic technique during the same anesthesia and preserving Oddi sphincter function. These minimal invasive techniques still need to be developed in children.
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10
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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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Sogo T, Kondo T, Tsunoda T, Murayama A, Komatsu H, Inui A, Fujisawa T. Endoscopic papillary balloon dilation for a 7-year-old girl with choledocholithiasis. Pediatr Int 2013; 55:e1-3. [PMID: 23679173 DOI: 10.1111/j.1442-200x.2012.03685.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 7-year-old girl was referred to our hospital for severe abdominal pain and elevated serum levels of amylase and aminotransferase. Radiological examinations revealed choledocholithiasis. EPBD was performed under intravenous anesthesia using midazolam and ketamine chloride. After fluoroscopic confirmation of a bile duct stone, a dilation balloon (30 mm-long, 8 mm-diameter) was passed over the guidewire and placed across the papilla. The balloon was gradually inflated until the notch created by the papillary sphincter disappeared. At 4 atm, the notch disappeared and the pressure was maintained for 15 s. Stone extraction was performed by using a retrieval balloon catheter. Abdominal pain disappeared immediately after EPBD, and she resumed oral intake 2 days after EPBD. In conclusion, EPBD may be a safe and effective technique for the treatment of choledocholithiasis in pediatric patients. EPDB should be selected as a treatment for pediatric choledocholithiasis in view of its advantages of preserving papillary function.
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Affiliation(s)
- Tsuyoshi Sogo
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development Endoscopy Center, Saiseikai Yokohama City Tobu Hospital, Yokohama, Japan.
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