Pancreatitis induced by endoscopic balloon sphincter dilation and changes in serum amylase levels after the procedure

Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones

BACKGROUND AND AIM

endoscopic papillary large balloon dilatation (EPLBD) is increasingly accepted as an appropriate option for the management of difficult common bile duct stones (CBDS). This study aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) for the extraction of difficult CBDS.

PATIENTS AND METHODS

a total of 40 patients were recruited with obstructive jaundice and dilated CBD (≥ 10 mm) subsequent to a single large CBDS of ≥ 10 mm or multiple stones (≥ 3). All patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) with limited sphincterotomy and large balloon dilatation followed by stone extraction using an extraction balloon or dormia basket, without lithotripsy, stenting or further ERCP sessions.

RESULTS

successful stone extraction was achieved in 34 patients (85%) and stone extraction failure occurred in six patients (15%). Complications included minimal pancreatitis in four cases (10%), mild pancreatitis in two cases (5%), cholangitis in two cases (5%) and bleeding in two cases (5%). There were no recorded cases of perforation or mortality subsequent to the procedure.

CONCLUSION

EPLBD is a safe and efficient procedure for the extraction of difficult CBDS and may be advisable in patients with a bleeding risk or abnormal papillary anatomy.

Complications of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.

Endoscopic papillary balloon dilatation in comparison with endoscopic sphincterotomy for the treatment of large common bile duct stone

BACKGROUND

There are concerns on the efficacy and safety of endoscopic papillary balloon dilatation (EPBD) as an alternative to endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis. We compared the efficacy and safety of EPBD and EST for removing large common bile duct (CBD) stones.

MATERIALS AND METHODS

One hundred sixty patients with CBD stones of 10-20 mm were randomized to undergo EPBD or EST. A 15-mm dilatation balloon was used for EPBD. Cotton's criteria were used to determine the incidence of post-EPBD or post-EST complications. CBD stone removal and complications were compared between the two methods.

RESULTS

CBD stones were completely removed in 97.5% of the EPBD and 96.2% of the EST group (P = 0.5). The incidence of postoperative pancreatitis (11.2% vs 8.7%) and bleeding (1.2% vs 1.2%) were similar between the EPBD and EST groups (P > 0.05). Perforation did not occur in any patient.

CONCLUSIONS

EPBD with 15-mm dilator balloon appears to be equally safe and effective compared with EST for removal of large CBD stones. So because of low complication and high success rate we recommend EPBD as the preferred method for removal of large (10-20 mm) CBD stones.

Prospective comparative study of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for removal of large bile duct stones in patients above 45 years of age

OBJECTIVE

Although endoscopic papillary large balloon dilation (EPLBD) with limited endoscopic sphincterotomy (ES) showed excellent outcomes for treatment of large bile duct stones, hemorrhage and recurrence of stones are problematic complications. Recent studies suggest that EPLBD alone is safe and effective for removal of large bile duct stones. This study aimed to determine the therapeutic outcomes and safety of EPLBD, compared with ES, for removal of large bile duct stones.

MATERIAL AND METHODS

Eighty-three patients above 45 years of age with bile duct stones >1 cm in diameter were randomized to EPLBD and ES groups for removal of common bile duct stones from September 2010 to August 2011. Prophylactic gabexate mesilate was given to all patients.

RESULTS

Baseline characteristics were not significantly different, except diabetes and gallbladder stones between the EPLBD group (n = 40) and ES group (n = 43). The overall complete stone removal rate in each group was 97.5% (39/40) and 95.3% (41/43), respectively (p = 0.600). Requirement of mechanical lithotripsy was not significantly different between the EPLBD and ES group (10% vs. 21%, p = 0.171). Complete ductal clearance in one session was achieved in 82.4% and 81.4% of cases in each group, respectively (p = 0.577). There were no differences in complication rates between the EPLBD and ES group; pancreatitis, 5.0% vs. 7.0%; hemorrhage, 10.0% vs. 16.3%; acute cholangitis, 5.0% vs. 2.3%, and perforation, 2.5% vs. 0%.

CONCLUSIONS

The therapeutic outcomes and complications of EPLBD for removal of large bile duct stones are comparable to those of ES.

The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background/Aims

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP.

Methods

From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia.

Results

PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05).

Conclusions

Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Endoscopic papillary balloon dilation for removal of choledocholithiasis: indications, advantages, complications, and long-term follow-up results

Endoscopic papillary balloon dilation (EPBD) is an alternative method of endoscopic sphincterotomy (EST). Although concerns regarding post-procedure pancreatitis have been expressed, EPBD has come to be recognized as an effective and safe method for stone removal in specific cases. To analyze the proper indications, ideal methods, complications, and long-term follow-up results for EPBD, we reviewed articles about EPBD located through a search of the PubMed data base. We analyzed the ballooning methods, indications, results and complications of EPBD among the articles found and compared the results with those of EST. We considered the authors' own clinical experience and knowledge in developing recommendations for EPBD. EPBD showed similar efficacy and safety for the removal of choledocholithiasis to that of EST. Although large or multiple stones were difficult to remove by EPBD, it was safer and easier to apply in patients with coagulopathy or abnormal anatomy. To prevent severe pancreatitis, excessive ballooning and impractical cannulation should be avoided, and precut sphincterotomy or adjuvant prophylaxis should be considered. Due to its preservation of the sphincter of Oddi, EPBD is expected to have fewer long-term complications, such as stone recurrence, cholangitis and cholecystitis. In conclusion, EPBD appears to be safe and effective for the treatment of choledocholithiasis with proper selection of ballooning methods and patients.

The increase in balloon size to over 15 mm does not affect the development of pancreatitis after endoscopic papillary large balloon dilatation for bile duct stone removal

BACKGROUND

Endoscopic papillary large balloon dilatation (EPLBD) after endoscopic sphincterotomy (EST) has recently become widely used for common bile duct (CBD) stone removal, but many clinicians remain concerned about post-procedural pancreatitis with increasing the balloon size to over 15 mm.

AIMS

We aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) after EST and to evaluate the factors related to post-EPLBD pancreatitis.

METHODS

A retrospective review was undertaken of the endoscopic database of 101 patients with CBD stones who underwent EPLBD using a larger balloon size of over 15 mm (15-20 mm). Clinical parameters, endoscopic data, and outcomes were analyzed.

RESULTS

The mean age of the subjects was 69 years. All patients had a dilated CBD of over 11 mm (mean = 22.6 mm). The mean size of balloon used in EPLBD was 17.1 ± 1.9 mm (range 15-20 mm). Mechanical lithotripsy was required in seven patients (6.9%). The rate of complete stone removal in the first session was 92.1%. Post-procedural pancreatitis developed in five cases (5.4%), but none were graded as severe. The smaller dilatation of the CBD, longer cannulation time, and longer time for stone removal were associated with post-procedural pancreatitis, but larger size of balloon did not affect the development of post-EPLBD pancreatitis.

CONCLUSIONS

EPLBD with a large balloon of over 15 mm with EST is an effective and safe procedure with a very low probability of severe post-procedural pancreatitis. Post-EPLBD pancreatitis was not associated with larger balloon size, but was associated with longer procedure time and smaller dilatation of the CBD.

The ballooning time in endoscopic papillary balloon dilation for the treatment of bile duct stones

BACKGROUND/AIMS

Endoscopic papillary balloon dilation (EPBD) is a safe and effective method for the treatment of choledocholithiasis, but previous studies have rarely reported the appropriate ballooning time (BT). We prospectively evaluated the safety and efficacy of EPBD according to BT in patients undergoing bile duct stone removal.

METHODS

Seventy consecutive patients with bile duct stones were randomly assigned to receive EPBD with either conventional (n = 35, 60 seconds) or short (n = 35, 20 seconds) BT.

RESULTS

EPBD alone achieved complete bile duct clearance in 67 patients (long BT, n = 33, 94.3%; short BT, n = 34, 97.1%; p = 0.808). We also found no significant difference in the rate of complete duct clearance, including procedures that used mechanical lithotripsy, between the long and short BT groups (97.1% vs. 100%; p = 0.811). Mild pancreatitis was noted in four (11.4%) patients in the long BT group and two (5.7%) patients in the short BT group, but this incidence was not significantly different.

CONCLUSIONS

The study showed that EPBD using both 20-sec and 60-sec BTs is safe and effective for the treatment of bile duct stones. Short and long BTs produced comparable outcomes.

Efficacy and safety of low-pressured and short-time dilation in endoscopic papillary balloon dilation for bile duct stone removal

BACKGROUND AND AIM

Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for bile duct stones. However, studies have shown that EPBD may increase the risk for pancreatitis. Pancreatitis after EPBD is believed to be related to papillary damage after balloon dilation. We changed the dilation method to a theoretically less hazardous one. This modified dilation method was compared with the initial method.

METHODS

A total of 324 patients with bile duct stones underwent EPBD by the modified method between June 1999 and June 2003. Three hundred and twenty-four patients undergoing EPBD by the initial method served as a historical control group. The success rate of stone removal and the incidence of procedure-related pancreatitis were compared between the two groups. In the modified method, the balloon was inflated until disappearance of the balloon waist, and the pressure was then maintained for 15 s. In the initial method, the balloon was inflated at 8 atmospheres for 2 min.

RESULTS

Bile duct stones were successfully removed in 313 of 324 patients (96.6%) in the modified group and in 314 of 324 patients (96.9%) in the initial group (not significant). The incidence of post-procedure pancreatitis showed a lower tendency in the modified group (4.0%, 13/324) than in the initial group (7.4%, 24/324) (P-value = 0.0626). The severity of pancreatitis was significantly reduced in the modified group.

CONCLUSION

The modified method of EPBD is feasible for extraction of bile duct stones, and may potentially decrease the incidence of severe post-EPBD pancreatitis.

Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones

BACKGROUND

Endoscopic sphincterotomy (EST) to remove bile-duct stones is the most frequently used endoscopic technique. Few reports exist regarding application of large-balloon dilation (LBD) after EST for treatment of patients with bile-duct stones.

OBJECTIVE

To compare the effect of EST plus LBD with that of EST alone.

DESIGN

A prospective randomized controlled trial.

SETTING

A large tertiary-referral center.

PATIENTS AND INTERVENTIONS

Two hundred consecutive patients with bile-duct stones were randomized in equal numbers to EST plus LBD (12- to 20-mm balloon diameter) or EST alone.

MAIN OUTCOME MEASUREMENTS

Successful stone removal and complications such as pancreatitis and bleeding.

RESULTS

EST plus LBD compared with EST alone resulted in similar outcomes in terms of overall successful stone removal (97.0% vs 98.0%), large size (>15 mm) stone removal (94.4% vs 96.7%), and the use of mechanical lithotripsy (8.0% vs 9.0%). Complications were similar between the 2 groups (5.0% vs 7.0%, P = .767). Complications were as follows for the EST plus LBD group and the EST group: pancreatitis, 4.0% and 4.0%; cholecystitis, 1.0% and 1.0%; and bleeding (delayed), 0% and 2.0%, respectively.

CONCLUSIONS

Based on the similar rates of successful stone removal and complications, EST plus LBD should be an effective alternative to EST. EST plus LBD is a safe and effective treatment for endoscopic removal of common bile duct stones.

Pancreatits after endoscopic retrograde cholangio-pancreatography

Pancreatitis is the most common complication after endoscopic retrograde cholangio-pancreatography (ERCP); the reported incidence of this complication varies from less than 1% to 40%, but a rate of 4%-8% is reported in most prospective studies involving non-selected patients. Differences in criteria for defining pancreatitis, methods of data collection, and patient populations (i.e. number of high-risk patients included in the published series) are factors that are likely to affect the varying rates of post-ERCP pancreatitis. The severity of post-ERCP pancreatitis (PEP) can range from a minor inconvenience with one or two days of added hospitalization with full recovery to a devastating illness with pancreatic necrosis, multiorgan failure, permanent disability, and even death. Although, most episodes of PEP are mild (about 90%), a small percentage of patients (about 10%) develop moderate or severe pancreatitis. In the past, PEP was often viewed as an unpredictable and unavoidable complication, with no realistic strategy for its avoidance. New data have aided in stratification of patients into PEP risk categories and new measures have been introduced to decrease the risk of PEP. As most ERCPs are performed on an outpatient basis, the majority of patients will not develop PEP and can be discharged. Alternatively, early detection of those patients who will go on to develop PEP can guide decisions regarding hospital admission and aggressive management. In the last decade, great efforts have been addressed toward prevention of this complication. Points of emphasis have included technical measures, pharmacological prophylaxis, and patient selection. This review provides a comprehensive, evidence-based assessment of published data on PEP and current suggestions for its avoidance.

Evaluation of serum amylase and gabexate mesilate with endoscopic papillary balloon dilatation

Gabexate mesilate (GM) relaxes the papilla of Vater in addition to inhibiting the several proteases. We evaluated whether prophylactic administration of GM would prevent the occurrence of acute pancreatitis in endoscopic papillary balloon dilation (EPBD). Nineteen patients with common bile duct stones were separated into two groups according to the admission year. The group A has been administered GM intravenously at 2mg/kg/hr after EPBD till six hours later, and the group B has been administered GM before fifteen minutes of EPBD till six hours later. The mean value of sphincter of Oddi (SO) basal and peak pressure in the group B was significantly lower than that in the group A, moreover the mean value of the pancreatic pressure in the group B was significantly lower than that in the group A. However two cases had mild acute pancreatitis in the group B. GM loosened SO and pancreatic duct pressure by direct stimulation of SO, although it could not have enough effect to prevent the acute pancreatitis in EPBD.

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

BACKGROUND

This study was designed to evaluate the therapeutic outcome and early postoperative complications, especially pancreatitis, of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in patients with common bile duct stones in our department.

METHODS

One hundred eighty patients with common bile duct stones were randomized to undergo EPBD or EST. An 8-mm dilatation balloon was used for EPBD. Modified Cotton's criteria, in which relatively mild pancreatitis is also included as a complication, were used to determine the incidence of postoperative complications.

RESULTS

The rate of complete removal of stones was significantly higher in the EST group (95.6%) than in the EPBD group (86.6%); for stones less than 10 mm in diameter, however, the rate with EPBD (93.8%) was almost equivalent to that with EST (98.1%). According to modified Cotton's criteria, the incidence of postoperative pancreatitis was significantly higher in the EPBD group (16.7%) than in the EST group (6.7%). Bleeding was encountered in one patient (1.1%) in the EST group, but in none in the EPBD group. No fatal complication occurred in either the EPBD or the EST group.

CONCLUSIONS

Although EPBD appears to be comparable to EST for removal of small common bile duct stones, mild postoperative pancreatitis is more likely to occur with EPBD than with EST.

Endoscopic papillary balloon dilation for bile duct stone: immediate and long-term outcomes in 1000 patients

BACKGROUND & AIMS

The long-term outcomes of endoscopic papillary balloon dilation (EPBD) for bile duct stone removal are not well known.

METHODS

A total of 1000 patients with bile duct stones were treated with EPBD. After assessing immediate outcomes, patients were followed up for late biliary complications.

RESULTS

Complete bile duct clearance was achieved with EPBD alone in 963 patients (96.3%) in a mean of 1.5 endoscopic sessions. Post-EPBD pancreatitis developed in 48 patients (4.8%), including 1 patient graded as severe. The long-term outcome was evaluated in 837 patients with a mean follow-up period of 4.4 years. Biliary complications were seen in 104 patients (12.4%), and they were less frequent in the cholecystectomy (CCx) after EPBD group than in the gallbladder (GB) left in situ with stones, GB left in situ without stones, and CCx before EPBD groups (2.8% vs 22.6%, 9.2%, and 13.5%, respectively). Stone recurrence was seen in 74 patients (8.8%)--2.4%, 15.6%, 5.9%, and 10.8% in the CCx after EPBD, GB left in situ with stones, GB left in situ without stones, and CCx before EPBD groups, respectively. Lithotripsy and gallbladder status were identified as risk factors for stone recurrence. Cholecystitis occurred in 13 patients (4.5%) in the GB left in situ with stones group.

CONCLUSIONS

EPBD was effective in treating bile duct stones that were not accompanied by an unacceptably high risk of pancreatitis. Patients with calculous gallbladder had the highest risk for late complications, and cholecystectomy is recommended after removal of their bile duct stones.

Efficacy of endoscopic nasobiliary drainage for the prevention of pancreatitis after papillary balloon dilatation: a pilot study

OBJECTIVE

Endoscopic papillary balloon dilatation (EPBD) has been reported to increase the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (4%-11%). Based on the hypothesis that performing endoscopic nasobiliary drainage (ENBD) could prevent this complication, we performed EPBD combined with ENBD (EPBD/ENBD) and analyzed the risk of pancreatitis.

METHODS

Thirty-four patients underwent EPBD followed by ENBD for common bile duct stone(s). Serum amylase levels the following morning and incidence of pancreatitis were compared with those previously reported and with complications of simple diagnostic ERCP performed in our institution.

RESULTS

After EPBD/ENBD, amylase levels the following morning were 214.5 +/- 152.9 U/L, and no cases developed pancreatitis or hyperamylasemia (>3 times normal). These outcomes were favorable compared with previous EPBD reports. Furthermore, despite the stress of EPBD/ENBD after ERCP, these outcomes were better, even compared with simple ERCP performed at our institution [amylase levels: 318.7 +/- 475.2 U/L; hyperamylasemia: 16.5% (P = 0.006); pancreatitis: 7.1%].

CONCLUSION

Although EPBD has been regarded as a risk factor for post-ERCP pancreatitis, our results suggest the possibility that application of ENBD after EPBD decreases the incidence of pancreatitis and should be studied further. We speculate that ENBD itself prevents pancreatic duct obstruction by residual stones or papillary edema.

Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography is commonly performed to remove bile duct stones. The aim of this study was to determine short-term outcomes of endoscopic balloon dilation of the sphincter of Oddi compared with sphincterotomy for stone extraction.

METHODS

A randomized, controlled multicenter study of 117 patients assigned to dilation and 120 to sphincterotomy was performed in a spectrum of clinical and academic practices.

RESULTS

Characteristics of the patients, procedures, and endoscopists were similar except that dilation patients were younger. Procedures were successful in 97.4% and 92.5% of the dilation and sphincterotomy patients, respectively. Overall morbidity occurred in 17.9% and 3.3% ( P < .001; difference, 14.6; 95% confidence interval, 7-22.3) and severe morbidity, including 2 deaths, in 6.8% and 0%( P < .004; difference, 6.8; 95% confidence interval, 2.3-11.4) for dilation and sphincterotomy, respectively. Complications for dilation and sphincterotomy, respectively, included: pancreatitis, 15.4% and .8% ( P < .001; difference, 14.6; 95% confidence interval, 7.8-21.3); cystic duct fistula, 1.7% and 0%; cholangitis, .9% and .8%; perforation, 0% and .8%; and cholecystitis, 0% and .8%. There were 2 deaths (1.7%) due to pancreatitis following dilation and none with sphincterotomy. The study was terminated at the first interim analysis. Dilation patients required significantly more invasive procedures, longer hospital stays, and longer time off from normal activities.

CONCLUSIONS

In a broad spectrum of patients and practices, endoscopic balloon dilation compared with sphincterotomy for biliary stone extraction is associated with increased short-term morbidity rates and death due to pancreatitis. Balloon dilation of the sphincter of Oddi for stone extraction should be avoided in routine practice.

[Dilatation of the papilla of Vater in the treatment of choledocholithiasis in selected patients]

OBJECTIVE

To prospectively analyze the results obtained with papillary balloon dilatation (PBD) in the treatment of common bile duct stones in patients at risk of complications if endoscopic sphincterotomy (ES) were performed.

PATIENTS AND METHOD

Thirty-three patients were included between January 2001 and June 2003 (mean age 76.2 years). The criteria for PBD were: choledocholithiasis < or =10 mm in patients with peripapillary diverticula, hemostatic alterations, Billroth-II, and preservation of Oddi's sphincter. In 79% of the patients sedation was performed by an anesthetist. PBD was performed with a balloon catheter dilator with a diameter of 8 or 10 mm for 2 minutes. The efficacy and duration of the procedure as well as complications at 30 days and patient satisfaction were evaluated.

RESULTS

Stone extraction was achieved in all patients (100%). The mean duration of the procedure was 26 minutes. Two patients (6%) presented mild pancreatitis. Serum amylase was elevated in 16 patients (48%): > or =3 times (post-PBD hyperamylasemia) in 11 (33%). The procedure caused no discomfort in 25/26 (96%) of the patients sedated by an anesthetist vs 2/5 patients (49%) who underwent endoscopic sedation.

CONCLUSIONS

PBD is an effective and simple therapeutic option in the treatment of small common bile duct stones (< or =10 mm) and in patients at high risk. The duration of endoscopic retrograde cholangiopancreatography is not prolonged. Complications are infrequent (6%) and mild. Post-PBD hyperamylasemia is frequent and generally without clinical importance. Sedation by an anesthetist improves patient satisfaction.

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS

Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients.

PATIENTS AND METHODS

A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications.

RESULTS

The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically.

CONCLUSION

Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.

Prognostic factors for recurrence of bile duct stones after endoscopic treatment by sphincter dilation

BACKGROUND

The long-term outcome for patients after endoscopic sphincter of Oddi dilation is poorly documented. This study investigates the recurrence rate for bile duct stones in patients followed for 1 year or more after endoscopic sphincter dilation and stone extraction, and assessed prognostic factors associated with recurrence of ductal calculi.

METHODS

A total of 169 patients with bile duct stones were treated with endoscopic sphincter dilation between July 1998 and August 2001. Follow-up studies consisted of periodic biochemical tests and out-patient evaluations with endoscopic retrograde cholangiography or magnetic resonance cholangiography performed when follow-up exceeded 1 year. Putative risk factors for stone recurrence included gender, age, stone size and number, associated peripapillary diverticulum, gallbladder status, color of bile duct stones, and bile duct diameter. Statistical analysis consisted of both a Kaplan-Meier estimation and a multivariate Cox regression model.

RESULTS

Complete stone clearance was achieved in 162 (95.8%) patients, of whom 151 were followed (13 patients died from unrelated disorders). Mean follow-up was 23 months. Stone recurrence was documented in 13 patients. Patients with dilated bile duct or peripapillary diverticulum were at high risk for recurrence.

CONCLUSIONS

The interval between treatment of bile duct stones by endoscopic sphincter dilation and the recurrence of biliary calculi is relatively short. Bile duct size and peripapillary diverticula are risk factors for early recurrence.

Predictive factors for acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation

BACKGROUND

Although endoscopic papillary balloon dilation may result in acute pancreatitis or hyperamylasemia, the risk factors for these complications have not been well documented. Risk factors predictive of acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation were retrospectively analyzed.

METHODS

In 118 patients who underwent endoscopic papillary balloon dilation for choledocholithiasis, postendoscopic papillary balloon dilation acute pancreatitis and hyperamylasemia (at least 3-fold elevation) were investigated. A multivariate analysis was conducted for 20 potential risk factors related to clinical and procedure characteristics.

RESULTS

Bile duct clearance was achieved in 113 patients. Early complications in the form of mild pancreatitis occurred in 7 patients (6%). Multivariate analysis identified history of acute pancreatitis as the only risk factor for postendoscopic papillary balloon dilation pancreatitis. Postendoscopic papillary balloon dilation hyperamylasemia occurred in 30 patients (25%). Multivariate analysis identified 4 independent risk factors for hyperamylasemia: an age of 60 years or less, previous pancreatitis, bile duct diameter 9 mm or less, and difficult bile duct cannulation.

CONCLUSIONS

Endoscopic papillary balloon dilation is associated with a relatively low occurrence (6%) of pancreatitis but a high frequency (25%) of hyperamylasemia. The latter may represent pancreatic irritation or latent pancreatic injury. Particular care is necessary when endoscopic papillary balloon dilation is performed in younger patients, those with a history of pancreatitis, patients with a nondilated bile duct, and when cannulation is difficult.

Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract

BACKGROUND

Bile duct stones are still present in 10% to 15% of patients after the application of conventional endoscopic extraction techniques and require additional procedures for duct clearance. In the vast majority of these cases, there are 2 main problems: large stone size (>15 mm) and tapering of distal bile duct.

METHODS

Fifty-eight patients in whom endoscopic sphincterotomy and standard basket/balloon extraction were unsuccessful in the removal of bile duct stones underwent dilation with a 10- to 20-mm diameter (esophageal/pyloric type) balloon at the same session. In 18 patients with tapered distal bile ducts (Group 1), 12- to 18-mm diameter balloon catheters were used to enlarge the orifice. In 40 patients with square, barrel shaped and/or large (>15mm) stones (Group 2), the sphincterotomy orifice was enlarged with 15- to 20-mm diameter balloon catheters. After dilatation, standard basket/balloon extraction techniques were used to remove the stone(s).

RESULTS

Stone clearance was successful in 16 patients (89%) in Group 1 and 35 (95%) in Group 2. Complications occurred in 9 (15.5%) patients.

CONCLUSION

Dilation with a large-diameter balloon after endoscopic sphincterotomy is a useful alternative technique in patients with bile duct stones that are difficult to remove with standard methods.

Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones

BACKGROUND

Pancreatitis is the most serious complication of endoscopic sphincter dilation. The aim of this study was to determine whether temporary stent placement in the main pancreatic duct decreases the frequency of pancreatitis and level of hyperamylasemia.

METHODS

Stents were placed in the pancreatic duct after endoscopic sphincter dilation in 40 consecutive patients with bile duct stones. Stents were removed endoscopically 3 days later. Changes in serum amylase and the frequency of pancreatitis for this group were compared with those in 92 patients who underwent sphincter dilation without pancreatic duct stent placement.

RESULTS

Stent placement was successful in 38 of 40 patients. Although the difference in the frequency of pancreatitis was not significantly different between stent and control groups, there was a trend toward a decrease in pancreatitis in the stent group. The level of postprocedure hyperamylasemia was significantly less in the stent group (p < 0.05). There were no procedure-related complications.

CONCLUSIONS

Temporary placement of a stent in the pancreatic duct after sphincter dilation for removal of bile duct stones has a beneficial effect in terms of postprocedure hyperamylasemia and appears to reduce the frequency of postprocedure pancreatitis.

Endoscopic sphincter dilation in patients with bile duct stones: immediate and medium-term results

BACKGROUND

Endoscopic sphincter dilation (ESD) is believed to successfully treat bile duct stones without serious procedure-related complications.

METHODS

We evaluated the efficacy, safety and limitations of this relatively new procedure in a consecutive series of patients to establish the clinical role of this modality for treating bile duct stones. One hundred and forty-three consecutive patients were treated by ESD between July 1995 and March 1998. The balloons used were a Maxforce 5-Fr or Olbert 5-Fr balloon-tipped catheter with a maximal diameter of 8 mm. Mechanical lithotriptor (ML) or extracorporeal shock wave lithotripsy (ESWL) were used when stones were large and/or numerous and a Dormia basket or retrievable balloon catheter was used to extract the stones entirely. Procedure-related symptoms and chemical data after the procedure were monitored during and after ESD at least until the following morning. To diagnose residual stones accurately, intraductal ultrasonography was routinely used.

RESULTS

Although the majority of patients complained of subtle pain during balloon inflation and demonstrated oozing during and after balloon inflation, the procedures were well tolerated. Complete stone extraction was achieved in 139 (97.2%) of the patients. Mechanical lithotriptor and ESWL were used to assist stone clearance in 79 (55.2%) and 23 (16.1%) patients, respectively. Mild pancreatitis occurred in six patients (4.2%). However, there were no other serious complications. Stone recurrence was identified in six patients and these stones were re-extracted by subsequent ESD procedures.

CONCLUSIONS

A high success rate for stone extraction and the relative safety of this procedure was confirmed. However, there was recurrence in a relatively high percentage of patients within a short period and this may be a forthcoming issue in ESD. Long-term follow-up observation and the establishment of countermeasures for stone recurrence seem to be essential.