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Shionoya K, Koizumi K, Masuda S, Kubota J, Kimura K, Makazu M. A Case of Spurting Bleeding After Endoscopic Papillary Balloon Dilation. GASTRO HEP ADVANCES 2023; 2:889-892. [PMID: 39130757 PMCID: PMC11308825 DOI: 10.1016/j.gastha.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/06/2023] [Indexed: 08/13/2024]
Abstract
A 58-year-old male with acute cholangitis due to a common bile duct stone underwent endoscopic retrograde cholangiopancreatography for stone removal with endoscopic papillary balloon dilation (EPBD) due to his high bleeding risk owing to maintenance dialysis and antiplatelet and anticoagulant medications. He had a history of stone removal using an EPBD. The stone was removed; however, the patient subsequently developed spurting bleeding and underwent endoscopic hemostasis. Despite the subsequent mild pancreatitis, he recovered with conservative management. While EPBD is considered a low-risk procedure for bleeding, caution should still be exercised due to the possibility of massive postprocedural bleeding.
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Affiliation(s)
- Kento Shionoya
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
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2
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Facciorusso A, Gkolfakis P, Ramai D, Tziatzios G, Lester J, Crinò SF, Frazzoni L, Papanikolaou IS, Arvanitakis M, Blero D, Lemmers A, Eisendrath P, Fuccio L, Triantafyllou K, Gabbrielli A, Devière J. Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis. Clin Gastroenterol Hepatol 2023; 21:33-44.e9. [PMID: 34666153 DOI: 10.1016/j.cgh.2021.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis. METHODS Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence. RESULTS All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03-1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07-1.45], vs S+EPLBD [RR, 1.23; range, 1.06-1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14-1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events. CONCLUSIONS Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy; Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Janice Lester
- Health Science Library, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Aziz M, Khan Z, Haghbin H, Kamal F, Sharma S, Lee-Smith W, Pervez A, Alastal Y, Nawras A, Thosani N. Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis. Endosc Int Open 2022; 10:E1599-E1607. [PMID: 36531684 PMCID: PMC9754880 DOI: 10.1055/a-1958-2348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 10/04/2022] [Indexed: 10/17/2022] Open
Abstract
Background and study aims The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Zubair Khan
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, Houston, Texas
| | - Hossein Haghbin
- Division of Gastroenterology, Ascension providence Hospital, Southfield, Michigan, United States
| | - Faisal Kamal
- Division of Gastroenterology, University of California, San Francisco, California, United States
| | - Sachit Sharma
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, Ohio, United States
| | - Asad Pervez
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia, United States
| | - Yaseen Alastal
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, Houston, Texas
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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Best Procedure for the Management of Common Bile Duct Stones via the Papilla: Literature Review and Analysis of Procedural Efficacy and Safety. J Clin Med 2020; 9:jcm9123808. [PMID: 33255554 PMCID: PMC7760048 DOI: 10.3390/jcm9123808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/10/2020] [Accepted: 11/23/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Endoscopic management of common bile duct stones (CBDS) is standard; however, various techniques are performed via the papilla, and the best procedure in terms of both efficacy and safety has not been determined. Methods: Endoscopic procedures were classified into five categories according to endoscopic sphincterotomy (EST) and balloon dilation (BD): (1) EST, (2) endoscopic papillary BD (≤10 mm) (EPBD), (3) EST followed by BD (≤10 mm) (ESBD), (4) endoscopic papillary large BD (≥12 mm) (EPLBD), and (5) EST followed by large BD (≥12 mm) (ESLBD). We performed a literature review of prospective and retrospective studies to compare efficacy and adverse events (AEs). Each procedure was associated with different efficacy and AE profiles. Results: In total, 19 prospective and seven retrospective studies with a total of 3930 patients were included in this study. For EST, the complete stone removal rate at the first session, rate of mechanical lithotripsy (ML), and rate of overall AEs in EST were superior to EPBD, but a higher rate of bleeding was found for EST. Based on one retrospective study, complete stone removal rate at the first session, rate of ML, and rate of overall AEs were superior for ESBD vs. EST, and the rate of bleeding for the former was also lower. Complete stone removal rate at the first session and rate of ML for ESLBD were superior to those for EST, with no significant difference in rate of AEs. For EST vs. EPLBD, complete stone removal rate at the first session and rate of ML were superior for the latter. For EPLBD vs. ESLBD, the efficacy and safety were similar. Conclusions: ESBD is considered the best procedure for the management of small CBDS, but strong evidence is lacking. For large CBDS, both ESLBD and EPLBD are similar.
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Kogure H, Kawahata S, Mukai T, Doi S, Iwashita T, Ban T, Ito Y, Kawakami H, Hayashi T, Sasahira N, Kubota K, Togawa O, Kato H, Okabe Y, Matsubara S, Yagioka H, Saito T, Nakai Y, Isayama H. Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: MARVELOUS trial. Endoscopy 2020; 52:736-744. [PMID: 32299114 DOI: 10.1055/a-1145-3377] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND : Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. METHODS : This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. RESULTS: 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). CONCLUSION : EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinpei Doi
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.,Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tesshin Ban
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Tokyo Takanawa Hospital of Japan Community Health-care Organization, Tokyo, Japan
| | - Kensuke Kubota
- Division of Gastroenterology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University of Medicine, Kurume, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Lyu Y, Cheng Y, Wang B, Zhao S, Chen L. Comparison of the Efficacy and Safety of Three Endoscopic Methods to Manage Large Common Bile Duct Stones: A Systematic Review and Network Meta-Analysis. J Laparoendosc Adv Surg Tech A 2020; 31:443-454. [PMID: 32762611 DOI: 10.1089/lap.2020.0511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The optimal choice of endoscopic method between endoscopic sphincterotomy (EST), endoscopic papillary large balloon dilation (EPLBD), and EST plus EPLBD (endoscopic sphincterotomy and large balloon dilation [ESLBD]) for patients with large common bile duct stones is unclear. Methods: We systematically searched MEDLINE, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from August 1, 1990 to December 1, 2019. Randomized clinical trials comparing at least two of the following methods EST, ESLBD, or EPLBD were included in this study. The primary outcomes were the overall success rate and initial success rate of common bile duct stone removal. Results: We identified 13 trials comprising 1990 patients. Regarding the overall success rate and initial success rate, EPLBD had the highest probability of being the most successful (surface under the cumulative ranking curve [SUCRA] = 82.8% and 52.9%, respectively) and the lowest probability of bleeding (53.8%). ESLBD had the highest probability (SUCRA) of having the lowest morbidity (88.8%), requiring mechanical lithotripsy (54.9%), perforation (68%), and the lowest mortality (89.3%). EST had the least probability of postendoscopic retrograde cholangiopancreatography pancreatitis and cholangitis (SUCRA: 66.4% and 62.3%, respectively). Conclusions: EPLBD was most successful, and ESLBD was safest for large common bile duct stones. Postendoscopic pancreatitis after EST was less common than that after EPLBD and ESLBD. However, more high-quality trials are required.
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Affiliation(s)
- Yunxiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Yunxiao Cheng
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Sicong Zhao
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Liang Chen
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
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8
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Chou CK, Lee KC, Luo JC, Chen TS, Perng CL, Huang YH, Lin HC, Hou MC. Endoscopic papillary balloon dilatation less than three minutes for biliary stone removal increases the risk of post-ERCP pancreatitis. PLoS One 2020; 15:e0233388. [PMID: 32453738 PMCID: PMC7250446 DOI: 10.1371/journal.pone.0233388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 05/04/2020] [Indexed: 01/22/2023] Open
Abstract
Objectives The adequate duration for EPBD was unclear. Therefore, we aimed to investigate the effect of balloon dilatation duration of EPBD on the occurrence of PEP. Methods One hundred and ninety-eight patients with common bile duct (CBD) stone treated by EPBD were retrospectively recruited. The dilatation duration was determined according to adequate opening of the biliary orifice without bleeding. The clinical outcomes and complications of EPBD were recorded. Results We stratified the patients according to dilatation duration (Group A, <3 minutes; Group B, 3–5 minutes; Group C, ≥5 minutes). The group C patients had a higher proportion of large CBD stones (stones ≥10 mm) (33.3% vs. 26.8% vs. 53.5%, p = 0.01). Patients in group A had a significantly higher PEP rate than patients in group B (13.3 vs. 3.1, p = 0.032). There were no significant differences in perforation and bleeding rate among the three groups. Univariate and multivariate analyses showed that a dilatation duration of <3 minutes, CBD diameter < 10 mm and age ≤ 75 years were independent risk factors of PEP in post-EPBD patients. Conclusions In patients receiving EPBD, dilatation duration <3 minutes, lower CBD diameter, and younger age were independent risk factors of PEP.
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Affiliation(s)
- Chung-Kai Chou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Division of Gastroenterology, Department of Medicine, National Yang-Ming University Hospital, Ilan, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail: (KCL); (JCL)
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail: (KCL); (JCL)
| | - Tseng-Shing Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chin-Lin Perng
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Han-Chien Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans’ General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Is Endoscopic Balloon Dilation Still Associated With Higher Rates of Pancreatitis?: A Systematic Review and Meta-Analysis. Pancreas 2020; 49:158-174. [PMID: 32049951 DOI: 10.1097/mpa.0000000000001489] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The objective of this study was to compare the efficacy and safety of endoscopic papillary balloon dilation (EPBD), endoscopic sphincterotomy (ES), and the combination of large balloon dilation and ES (ES + EPLBD) in the treatment of common bile duct stones, with a special focus on postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials (RCTs) which evaluated at least one of the following outcomes: PEP, complete stone removal in the first ERCP, need for mechanical lithotripsy, recurrence of common bile duct stones, bleeding, and cholangitis. Twenty-five RCTs were selected for analysis. Pancreatitis rates were higher for EPBD than for ES (P = 0.003), as were severe pancreatitis rates (P = 0.04). However, in the 10-mm or greater balloon subgroup analysis, this difference was not shown (P = 0.82). Rates of PEP were higher in the subgroup of non-Asian subjects (P = 0.02), and the results were not robust when RCTs that used endoscopic nasobiliary drainage were omitted. The incidence of pancreatitis was comparable between EPLBD and ES + EPLBD. All 3 approaches were equally efficacious. Nevertheless, the results should be interpreted with caution, because pancreatitis is a multifactorial pathology, and RCTs can have limited generalizability.
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10
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Kuo CM, Chiu YC, Liang CM, Wu CK, Lu LS, Tai WC, Kuo YH, Wu KL, Chuah SK, Kuo CH. The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones. BMC Gastroenterol 2019; 19:93. [PMID: 31215401 PMCID: PMC6582576 DOI: 10.1186/s12876-019-1017-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 06/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound. METHODS We enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications. RESULTS The limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12-61) min vs. 23.5 (17-68) min vs. 25.0 (14-60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group. CONCLUSIONS Limited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD.
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Affiliation(s)
- Chung-Mou Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Chih-Ming Liang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Cheng-Kun Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Lung-Sheng Lu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Yuan-Hung Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Chung-Huang Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan.
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11
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Alsenbesy M, Shahat K, Nawara A, Sallam M, Fakhry M, Shazly M, Moussa M, Tag-Adeen M, El-Amin H, Sobh M. Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:358-363. [PMID: 30810329 DOI: 10.17235/reed.2019.5865/2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
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.
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Affiliation(s)
- Mohamed Alsenbesy
- Department of Internal Medicine, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Khaled Shahat
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdallah Nawara
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, As-Sharquia, Egypt
| | - Mohammad Sallam
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, As-Sharquia, Egypt
| | - Mohamed Fakhry
- Department of Tropical Medicine and Gastroenterology, Al-Azhar University, Assiut, Egypt
| | - Mohamed Shazly
- Department of Diagnostic Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Moussa
- Department of Surgery, Faculty of Medicine, Zagazig University, As-Sharquia, Egypt
| | - Mohammed Tag-Adeen
- Department off Internal Medicine, Faculty of Medicine, South Valley University, Egypt
| | - Hussein El-Amin
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohammed Sobh
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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12
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de Clemente Junior CC, Bernardo WM, Franzini TP, Luz GO, dos Santos MEL, Cohen JM, de Moura DTH, Marinho FRT, Coronel M, Sakai P, de Moura EGH. Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials. World J Gastrointest Endosc 2018; 10:130-144. [PMID: 30147845 PMCID: PMC6107471 DOI: 10.4253/wjge.v10.i8.130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/02/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials.
METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis.
RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), I2 = 11%, P = 0.31].
CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.
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Affiliation(s)
- Cesar Capel de Clemente Junior
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Tomazo Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Gustavo Oliveira Luz
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Jonah Maxwell Cohen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Fábio Ramalho Tavares Marinho
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Martin Coronel
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
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13
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Li T, Wen J, Bie L, Gong B. Comparison of the Long-Term Outcomes of Endoscopic Papillary Large Balloon Dilation Alone versus Endoscopic Sphincterotomy for Removal of Bile Duct Stones. Gastroenterol Res Pract 2018; 2018:6430701. [PMID: 30057600 PMCID: PMC6051268 DOI: 10.1155/2018/6430701] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/31/2018] [Accepted: 04/26/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic papillary large balloon dilation (EPLBD) alone is an alternative to endoscopic sphincterotomy (EST) for treatment of common bile duct (CBD) stones. However, limited data exists regarding comparison of the long-term outcomes for these techniques. In this study, we compared the long-term outcomes after EST with those after EPLBD alone for removal of CBD stones. METHODS The records of patients with EST or EPLBD alone referred for CBD stones retrieval between June 2008 and July 2015 were retrospectively reviewed. Complete stone clearance, ERCP-related adverse events, and late biliary complications during long-term follow-up were analyzed. RESULTS Basic patient characteristics were similar between the groups that underwent EST (n = 60) and EPLBD alone (n = 161). EPLBD compared with EST resulted in similar outcomes in terms of complete stone clearance (99.4% versus 100%, P = 0.54) and ERCP-related adverse events (6.8% versus 6.7%, P = 1.00). The mean duration of the follow-up was 74.5 months and 71.6 months who underwent EST and EPLBD alone, respectively (P = 0.42). Late biliary complications were occurred frequently in the EST group than in the EPLBD alone group (11 [18.6%] versus 16 [10.2%]), although the difference did not reach statistical significance (P = 0.11). Multivariate analysis showed that mechanical lithotripsy ([OR], 2.815; 95% CI, 1.148-6.902; P = 0.024) was significantly associated with late biliary complications. CONCLUSION As an alternative to EST, EPLBD has similar efficacy and safety for managing CBD stones. During long-term follow-up, patients who underwent EPLBD alone may have fewer late biliary complications compared with those after EST. In addition, mechanical lithotripsy may be an independent risk factor for late biliary complications.
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Affiliation(s)
- Tao Li
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Like Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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14
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Itoi T, Ryozawa S, Katanuma A, Okabe Y, Kato H, Horaguchi J, Tsuchiya T, Gotoda T, Fujita N, Yasuda K, Igarashi Y, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation. Dig Endosc 2018; 30:293-309. [PMID: 29411902 DOI: 10.1111/den.13029] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironori Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takuji Gotoda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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15
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Park CH, Jung JH, Nam E, Kim EH, Kim MG, Kim JH, Park SW. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc 2018; 87:43-57.e10. [PMID: 28756105 DOI: 10.1016/j.gie.2017.07.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although various endoscopic techniques have been introduced for successful removal of common bile duct (CBD) stones, the optimal method is not yet clear. We aimed to compare the efficacy of different endoscopic techniques for CBD stone removal. METHODS We searched for all relevant randomized controlled trials published until June 2017, examining the outcomes of endoscopic techniques for CBD stone removal, including endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and EST with balloon dilatation (ESBD). A Bayesian network meta-analysis was performed. RESULTS Twenty-five studies with 3726 patients were included in the meta-analysis. ESBD had a higher successful rate of stone removal in the first endoscopic session than EPBD (odds ratio [OR] [95% credible interval {CrI}], 2.09 [1.07-4.16]). Mechanical lithotripsy was less common in ESBD than in EPBD (OR [95% CrI], .45 [.25-.83]). EPBD revealed a lower risk of bleeding than both EST and ESBD (OR [95% CrI], vs EST, .06 [.008-.23]; vs ESBD, .12 [.01-.64]). The pooled incidences of bleeding were 3.0% (95% confidence interval [CI], 1.8%-5.2%), 1.1% (95% CI, .6%-2.0%), and 2.0% (95% CI, .9%-4.4%) in the EST, EPBD, and ESBD groups, respectively. Pancreatitis tended to be more common in EPBD than in both EST and ESBD (OR [95% CrI]: vs EST, 1.49 [.84-2.59]; vs ESBD, 1.49 [.61-3.57]). CONCLUSION The efficacy of ESBD in stone removal during the first endoscopic session was superior to that of EPBD. Pancreatitis in ESBD and EST tended to be less common than in EPBD, although this difference was not statistically significant. However, ESBD and EST carried a higher risk of bleeding than EPBD.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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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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17
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What Is the Value of the Learning Curve in Endoscopic Balloon Dilatation of the Major Papilla? Gastroenterol Res Pract 2017; 2017:6501485. [PMID: 29093736 PMCID: PMC5603744 DOI: 10.1155/2017/6501485] [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: 02/07/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. Objective To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. Methods We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. Results Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. Conclusions Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.
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Razaghi M, Tajeddin E, Ganji L, Alebouyeh M, Alizadeh AHM, Sadeghi A, Zali MR. Colonization, resistance to bile, and virulence properties of Escherichia coli strains: Unusual characteristics associated with biliary tract diseases. Microb Pathog 2017; 111:262-268. [PMID: 28867623 DOI: 10.1016/j.micpath.2017.08.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/23/2017] [Accepted: 08/30/2017] [Indexed: 12/18/2022]
Abstract
Escherichia coli is the species that is most frequently isolated from bile of patients with biliary tract diseases. This study was aimed to investigate any association between resistance and virulence properties of these isolates with occurrence of the diseases. A total of 102 bile samples were obtained from patients subjected to endoscopic retrograde cholangiopancreatography for different biliary diseases. Clinical data were collected and culture of the bile samples was done on selective media. Resistance of characterized Escherichia coli isolates to deoxycholate sodium (0-7%) and nineteen antibiotics was determined and PCR using 16 pairs of primers targeting stx1, stx2, exhA, eae, bfp, agg, pcvd432, lt, st, ipaH, pic, pet, ast, set, sen, and cdtB genes was done. Our results showed a statistically significant association between E. coli colonization and existence of common bile duct and gallbladder stones (p value 0.028). Out of the 22 E. coli strains (22/102) multidrug resistance phenotype was present in 95.45%. None of the strains belonged to common E. coli pathotypes. However, bfp + EhxA-hly, bfp + astA, bfp + EhxA-hly + pic, and EhxA-hly + pic + astA, bfp, and astA genotypes were detected in these strains. bfp (7/22, 31.8%) and astA (5/22, 22.7%) were among most frequent virulence factors in these strains. Results of this study showed significant association between colonization of E. coli and choledocholithiasis. Unusual existence of virulence gene combinations in these strains and their resistance to DOC and multiple classes of antibiotics could be considered as possible causes of their persistence in this harsh microenvironment.
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Affiliation(s)
- Maryam Razaghi
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elahe Tajeddin
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Ganji
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Alebouyeh
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Science, Tehran, Iran.
| | - Amir Houshang Mohammad Alizadeh
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mohammad Reza Zali
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Science, Tehran, Iran
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Fujita Y, Iwasaki A, Sato T, Fujisawa T, Sekino Y, Hosono K, Matsuhashi N, Sakamaki K, Nakajima A, Kubota K. Feasibility of Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Bile Duct Stones without Dilatation of the Lower Part of the Extrahepatic Bile Duct. Gut Liver 2017; 11:149-155. [PMID: 27538442 PMCID: PMC5221873 DOI: 10.5009/gnl15634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/16/2016] [Accepted: 03/02/2016] [Indexed: 12/18/2022] Open
Abstract
Background/Aims There is no consensus for using endoscopic papillary large balloon dilation (EPLBD) in patients without dilatation of the lower part of the bile duct (DLBD). We evaluated the feasibility and safety of EPLBD for the removal of difficult bile duct stones (diameter ≥10 mm) in patients without DLBD. Methods We retrospectively reviewed the records of 209 patients who underwent EPLBD for the removal of bile duct stones from October 2009 to July 2014. Primary outcomes were the clearance rate and additional mechanical lithotripsy. Secondary outcomes were the incidence of complications and recurrence rate. Results Fifty-seven patients had DLBD (27.3%), and 152 did not have DLBD (72.7%). There were no significant differences in the overall success rate or the use of mechanical lithotripsy. Success rate during the first session and procedure time were better in the DLBD than the without-DLBD group (75.7% vs 66.7%, 48.1±23.0 minutes vs 58.4±31.7 minutes, respectively). As for complications, there were no significant differences in the incidence of pancreatitis, perforation or bleeding after endoscopic retrograde cholangiopancreatography. The recurrence rate did not differ significantly between the two groups. Conclusions EPLBD is a useful and safe method for common bile duct stone removal in patients without DLBD.
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Affiliation(s)
- Yuji Fujita
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Akito Iwasaki
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takamitsu Sato
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, NTT Tokyo Medical Center, Tokyo, Japan
| | - Yusuke Sekino
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kunihiro Hosono
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | | | - Kentaro Sakamaki
- Department of Medical Statistic, Yokohama City University School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kensuke Kubota
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
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Omar MA, Abdelshafy M, Ahmed MY, Rezk AG, Taha AM, Hussein HM. Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Retrieval of Large Choledocholithiasis: A Prospective Randomized Trial. J Laparoendosc Adv Surg Tech A 2017; 27:704-709. [DOI: 10.1089/lap.2016.0601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Mohammed A. Omar
- Department of General Surgery, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Mohamed Abdelshafy
- Department of General Surgery, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Mohamed Yousef Ahmed
- Department of General Surgery, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Asmaa Gaber Rezk
- Department of General Surgery, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Abdallah M. Taha
- Department of General Surgery, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Hamdy M. Hussein
- Department of General Surgery, Qena Faculty of Medicine, South Valley University, Qena, Egypt
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21
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Liu D, Cao F, Liu J, Xu D, Wang Y, Li F. Risk factors for bile leakage after primary closure following laparoscopic common bile duct exploration: a retrospective cohort study. BMC Surg 2017; 17:1. [PMID: 28056934 PMCID: PMC5217550 DOI: 10.1186/s12893-016-0201-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 12/24/2016] [Indexed: 12/11/2022] Open
Abstract
Background Primary closure following laparoscopic common bile duct exploration (LCBDE) has been widely adopted because of the efficacy and safety in treatment of common bile duct (CBD) stones. However, the risk factors for bile leakage, the most common complication after primary closure, has not been clarified yet. Methods A retrospective cohort study of patients who underwent LCBDE with primary closure after choledochotomy between Feb. 2012 and Jun. 2016 was performed. Risk factors for bile leakage were identified by logistic regression inculding demographic factors, preoperative condition and surgical details. Results Between Feb. 2012 and Jun. 2016, a total of 265 LCBDE procedures were applied in our hospital and 141 patients with primary closure were included in this study. Bile leakage occurred in 11.3% (16/141) of these patients, and happened more frequently in patients with slender CBD (<1 vs ≥1 cm, 31.6% vs 7.0%, p = 0.04) and those managed by inexperienced surgeons (initial 70 cases vs later cases, 17.1% vs 5.6%, p = 0.04). After multivariable regression, the diameter of CBD [OR 95% CI, 3.799 (1.081–13.349), p = 0.04] and experience of surgeons [OR 95% CI, 4.228 (1.330–13.438), p = 0.03] were significantly related to bile leakage. Conclusion Slender CBD and inexperienced surgeons were the high risk factors for bile leakage after primary closure following LCBDE.
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Affiliation(s)
- Dongbin Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China.
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Jiafeng Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Dahua Xu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Yuehua Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
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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: 23] [Impact Index Per Article: 2.9] [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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23
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Efficacy and Safety of Endoscopic Papillary Large Balloon Dilation for Removal of Large Bile Duct Stones in Advanced Age. Can J Gastroenterol Hepatol 2016; 2016:6568989. [PMID: 27812520 PMCID: PMC5080473 DOI: 10.1155/2016/6568989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 10/04/2016] [Indexed: 12/16/2022] Open
Abstract
Objective. Bile duct stone-related adverse events can be detrimental in the elderly. However, little is known about clinical outcomes and adverse events following endoscopic papillary large balloon dilation (EPLBD) in the elderly. The aim of this study was to evaluate the safety and feasibility of EPLBD for the removal of CBD stones in patients aged ≥ 80 years. Methods. A total of 204 patients who underwent EPLBD from 2006 to 2012 were retrospectively reviewed. Patients were classified into two groups (148 patients < 80 years old, Group A; 56 patients ≥ 80 years old, Group B). Endoscopic findings, clinical outcomes, and adverse events in two groups were compared. Results. The number of underlying chronic diseases in Group B was significantly higher than in Group A (P = 0.032). The rates of overall stone clearance were similar between two groups (P = 0.145). No significant difference with regard to post-ERCP pancreatitis between two groups was observed (P = 0.687). All episodes of pancreatitis had full recovery with conservative treatment. One major hemorrhage in Group A was successfully controlled endoscopically and one death caused by retroperitoneal perforation occurred in Group A. Conclusions. EPLBD appear to be safe and effective for CBD stone removal in patients aged ≥ 80 years.
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Shim CS, Kim JW, Lee TY, Cheon YK. Is endoscopic papillary large balloon dilation safe for treating large CBD stones? Saudi J Gastroenterol 2016; 22:251-9. [PMID: 27488319 PMCID: PMC4991195 DOI: 10.4103/1319-3767.187599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. 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. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.
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Affiliation(s)
- Chan Sup Shim
- Department of Internal Medicine, School of Medicine, Konkuk University, Seoul, Korea,Address for correspondence: Prof. Chan Sup Shim, Department of Internal Medicine, School of Medicine, Konkuk University, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea. E-mail:
| | - Ji Wan Kim
- Department of Internal Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Tae Yoon Lee
- Department of Internal Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Young Koog Cheon
- Department of Internal Medicine, School of Medicine, Konkuk University, Seoul, Korea
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25
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Kim TH, Kim JH, Seo DW, Lee DK, Reddy ND, Rerknimitr R, Ratanachu-Ek T, Khor CJL, Itoi T, Yasuda I, Isayama H, Lau JYW, Wang HP, Chan HH, Hu B, Kozarek RA, Baron TH. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc 2016; 83:37-47. [PMID: 26232360 DOI: 10.1016/j.gie.2015.06.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/11/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Tae Hyeon Kim
- Department of Gastroenterology, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nageshwar D Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Christopher J L Khor
- Department of Gastroenterology and Hepatology, National University Health System, Tan Tock Seng Hospital, Singapore
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - James Y W Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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26
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Effects Comparison between Endoscopic Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy for Common Bile Duct Stone Removal. Gastroenterol Res Pract 2015; 2015:839346. [PMID: 26351452 PMCID: PMC4553337 DOI: 10.1155/2015/839346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 06/03/2015] [Indexed: 12/23/2022] Open
Abstract
Endoscopic sphincterotomy (EST) is a treatment of choice for stone extraction and is now most frequently used. The study was to compare the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and endoscopic sphincterotomy (EST) for common bile duct stone removal. Trials comparing the effects between EPLBD and EST treatment were searched according to the study protocol. Overall stone removal rate, complete removal rate in 1st session, treatment duration, mechanical lithotripsy using rate, and overall complication rate were compared using risk ratio (RR) and mean difference (MD) and their 95% confidence interval (CI) via RevMan 5.2 software. For overall stone removal rate, two therapies showed similar effect, but EPLBD showed better overall stone removal rate for stone >10 mm in diameter. For complete stone removal rate in 1st session, no difference was found, even for those with stone >10 mm in diameter; EPLBD showed longer treatment duration, higher mechanical lithotripsy using rate obvious overall complications rate, and more serious bleeding, whereas there were no significant differences for perforation, hyperamylasemia, pancreatitis, and cholecystitis/cholangitis. EPLBD showed better efficacy in certain conditions compared to EST, however with shortcomings, such as more duration, higher mechanical lithotripsy using rate, more serious overall complications rate, and bleeding.
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27
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Cheng CL, Liu NJ, Tang JH, Yu MC, Tsui YN, Hsu FY, Lee CS, Lin CH. Double-balloon enteroscopy for ERCP in patients with Billroth II anatomy: results of a large series of papillary large-balloon dilation for biliary stone removal. Endosc Int Open 2015; 3:E216-22. [PMID: 26171434 PMCID: PMC4486040 DOI: 10.1055/s-0034-1391480] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/07/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Data on double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatogrphy (ERCP) in patients with Billroth II gastrectomy and the use of endoscopic papillary large-balloon dilation (EPLBD) for the removal of common bile duct stones in Billroth II anatomy are limited. The aims of the study were to evaluate the success of DBE-assisted ERCP in patients with Billroth II gastrectomy and examine the efficacy of EPLBD ( ≥ 10 mm) for the removal of common bile duct stones. PATIENTS AND METHODS A total of 77 patients with Billroth II gastrectomy in whom standard ERCP had failed underwent DBE-assisted ERCP. DBE success was defined as visualizing the papilla and ERCP success as completing the intended intervention. The clinical results of EPLBD for the removal of common bile duct stones were analyzed. RESULTS DBE was successful in 73 of 77 patients (95 %), and ERCP success was achieved in 67 of these 73 (92 %). Therefore, the rate of successful DBE-assisted ERCP was 87 % (67 of a total of 77 patients). The reasons for ERCP failure (n = 10) included tumor obstruction (n = 2), adhesion obstruction (n = 2), failed cannulation (n = 3), failed stone removal (n = 2), and bowel perforation (n = 1). Overall DBE-assisted ERCP complications occurred in 5 of 77 patients (6.5 %). A total of 48 patients (34 male, mean age 75.5 years) with common bile duct stones underwent EPLBD. Complete stone removal in the first session was accomplished in 36 patients (75 %); mechanical lithotripsy was required in 1 patient. EPLBD-related mild perforation occurred in 2 patients (4 %). No acute pancreatitis occurred. CONCLUSIONS DBE permits therapeutic ERCP in patients who have a difficult Billroth II gastrectomy with a high success rate and acceptable complication rates. EPLBD is effective and safe for the removal of common bile duct stones in patients with Billroth II anatomy.
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Affiliation(s)
- Chi-Liang Cheng
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Nai-Jen Liu
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Jui-Hsiang Tang
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chin Yu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ning Tsui
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Fang-Yu Hsu
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Ching-Song Lee
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hui Lin
- Division of Gastroenterology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan,Corresponding author Cheng-Hui Lin, MD Division of GastroenterologyDepartment of MedicineChang Gung Memorial Hospital5 Fu-Hsin Road, QueishanTaoyuan 333Taiwan+886-3-4630150
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Shimizu S, Naitoh I, Nakazawa T, Hayashi K, Miyabe K, Kondo H, Nishi Y, Umemura S, Hori Y, Kato A, Ohara H, Joh T. Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent. World J Gastroenterol 2015; 21:5090-5095. [PMID: 25945025 PMCID: PMC4408484 DOI: 10.3748/wjg.v21.i16.5090] [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: 10/05/2014] [Revised: 11/11/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
A 78-year-old male was admitted to our hospital because of choledocholithiasis. ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation (EPLBD) with a size of 15 mm. Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla. Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis. Therefore, we placed a 10 mm fully covered self-expandable metallic stent (SEMS) across the duodenal papilla, and the hemorrhage stopped immediately. After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct. A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct. We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.
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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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Endoscopic papillary large balloon dilation for treatment of large bile duct stones does not increase the risk of post-procedure pancreatitis. Dig Dis Sci 2014; 59:3092-8. [PMID: 24996378 DOI: 10.1007/s10620-014-3259-3] [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: 08/29/2013] [Accepted: 06/17/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Endoscopic sphincterotomy (ES) and endoscopic papillary large balloon dilation (EPLBD) are well-known procedures for the treatment of common duct stones. There was no statistically significant difference in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis rates between ES and EPLBD in most studies. The aims of this study were to evaluate whether EPLBD increases the risk of post-ERCP pancreatitis and to identify the risk factors influencing post-ERCP pancreatitis. METHODS A review of 341 patients who underwent ERCP for treatment of common duct stones larger than 1 cm in diameter from January 2006 to December 2011 was conducted retrospectively. Patients were divided into three groups: ES group (n = 207), EPLBD + ES group (n = 99), and EPLBD with previous history of ES group (n = 35). RESULTS Of 341 patients, overall incidence of post-ERCP pancreatitis was 2.6% (n = 9). Incidence of post-ERCP pancreatitis was 3.4, 2.0, and 0% in the ES group, EPLBD + ES group, and EPLBD with previous history of ES group, respectively. No significant difference in the incidence of post-ERCP pancreatitis was observed among the three groups (p = 0.47). Endoscopic biliary stenting was the independent risk factor for pancreatitis according to univariate (p = 0.046) and multivariate analyses (p = 0.036, OR 4.211, 95% CI 1.095-16.199). Age, sex, stone size, mechanical lithotripsy, common bile duct diameter, balloon size, and duration of balloon dilation were not significantly related to post-ERCP pancreatitis. CONCLUSION EPLBD with antecedent limited ES or previous ES state does not increase the risk of post-ERCP pancreatitis in patients with large bile duct stones. Endoscopic biliary stenting seems to be the independent risk factor of post-ERCP pancreatitis.
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Rouquette O, Bommelaer G, Abergel A, Poincloux L. Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones: A literature review. World J Gastroenterol 2014; 20:7760-7766. [PMID: 24976713 PMCID: PMC4069304 DOI: 10.3748/wjg.v20.i24.7760] [Citation(s) in RCA: 16] [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: 10/29/2013] [Revised: 01/17/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (≥ 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.
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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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Lenze F, Heinzow HS, Herrmann E, Berssenbrügge C, Rothenbächer H, Ullerich H, Floer M, Domschke W, Domagk D, Meister T. Clearance of refractory bile duct stones with Extracorporeal Shockwave Lithotripsy: higher failure rate in obese patients. Scand J Gastroenterol 2014; 49:209-14. [PMID: 24256056 DOI: 10.3109/00365521.2013.858767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Bile duct stones that cannot be removed endoscopically are still a challenge in interventional gastroenterology. Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option if other endoscopic means are not successful. Our study aimed to investigate the efficacy and safety of ESWL for clearance of refractory bile duct stones. MATERIAL AND METHODS A total of 73 consecutive patients treated for refractory choledocholithiasis with ESWL were retrospectively analyzed. Success and complication rates were calculated. RESULTS Complete stone clearance was achieved in 66 cases (90%). Patients with complete clearance had a significantly lower body mass index or BMI (25.55 ± 5.01 kg/m² vs. 31.60 ± 6.26 kg/m², p = 0.035) and needed less ESWL treatments (3.61 ± 1.87 vs. 5.00 ± 1.63, p = 0.048). A relevant drop of hemoglobin occurred significantly more often in the group with partial clearance (43% vs. 6%, p = 0.005). CONCLUSIONS ESWL proves to be an excellent clearing approach to refractory bile duct stones with high success rates. However, obesity is one risk factor for ESWL failure and higher procedural hazard.
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Affiliation(s)
- Frank Lenze
- Department of Medicine B, University Hospital Münster , Münster , Germany
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Choi JH, Lee SK. Feasibility of endoscopic papillary large balloon dilation after prior Billroth II gastrectomy and considerations for endoscopists. Saudi J Gastroenterol 2014; 20:79-80. [PMID: 24705145 PMCID: PMC3987156 DOI: 10.4103/1319-3767.129472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Joon-Hyuk Choi
- Department of Internal Medicine, Division of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Zip code: 138-736, Korea E-mail:
| | - Sung-Koo Lee
- Department of Internal Medicine, Division of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Zip code: 138-736, Korea E-mail:
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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: 46] [Impact Index Per Article: 4.2] [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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Kim KH, Kim TN. Endoscopic papillary large balloon dilation in patients with periampullary diverticula. World J Gastroenterol 2013; 19:7168-7176. [PMID: 24222962 PMCID: PMC3819554 DOI: 10.3748/wjg.v19.i41.7168] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/14/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) for bile duct stone extraction in patients with periampullary diverticula.
METHODS: The records of 223 patients with large common bile duct stones (≥ 10 mm) who underwent EPLBD (12-20 mm balloon diameter) with or without limited endoscopic sphincterotomy (ES) from July 2006 to April 2011 were retrospectively reviewed. Of these patients, 93 (41.7%) had periampullary diverticula (PAD), which was categorized into three types. The clinical variables of EPLBD with limited ES (EPLBD + ES) and EPLBD alone were analyzed according to the presence of PAD.
RESULTS: Patients with PAD were significantly older than those without (75.2 ± 8.8 years vs 69.7 ± 10.9 years, P = 0.000). The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and non-PAD groups, however, there was significantly less need for mechanical lithotripsy in the PAD group (3.2% vs 11.5%, P = 0.026). Overall stone removal rates, complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD + ES and EPLBD alone in patients with PAD (96.6% vs 97.1%; 72.9% vs 88.2%; and 5.1% vs 0%, respectively). No significant differences with respect to the rates of pancreatitis, perforation, and bleeding were observed between EPLBD + ES and EPLBD alone in the PAD group (3.4% vs 14.7%, P = 0.095; 0% vs 0%; and 3.4% vs 8.8%, P = 0.351, respectively).
CONCLUSION: EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD, regardless of PAD subtypes.
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Huang SW, Lin CH, Lee MS, Tsou YK, Sung KF. Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope. World J Gastroenterol 2013; 19:4966-4972. [PMID: 23946602 PMCID: PMC3740427 DOI: 10.3748/wjg.v19.i30.4966] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 05/16/2013] [Accepted: 06/20/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To detect and manage residual common bile duct (CBD) stones using ultraslim endoscopic peroral cholangioscopy (POC) after a negative balloon-occluded cholangiography.
METHODS: From March 2011 to December 2011, a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography (ERC) and direct POC were prospectively enrolled in this study. Those patients who were younger than 20 years of age, pregnant, critically ill, or unable to provide informed consent for direct POC, as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded. Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.
RESULTS: The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct (IHD) in 8 patients (36.4%), to the extrahepatic bile duct where the hilum could be visualized in 10 patients (45.5%), and to the distal CBD where the hilum could not be visualized in 4 patients (18.2%). The procedure time of the diagnostic POC was 8.2 ± 2.9 min (range, 5-18 min). Residual CBD stones were found in 5 (22.7%) of the patients. There was one residual stone each in 3 of the patients, three in 1 patient, and more than five in 1 patient. The diameter of the residual stones ranged from 2-5 mm. In 2 of the patients, the residual stones were successfully extracted using either a retrieval balloon catheter (n = 1) or a basket catheter (n = 1) under direct endoscopic control. In the remaining 3 patients, the residual stones were removed using an irrigation and suction method under direct endoscopic visualization. There were no serious procedure-related complications, such as bleeding, pancreatitis, biliary tract infection, or perforation, in this study.
CONCLUSION: Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.
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