Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study

Abstract

Background and Aim With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure‐related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. Methods In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non‐users of antithrombotic agents (antiplatelet agents and anticoagulants). Results We analyzed a total of 144 patients (47 users and 97 non‐users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non‐users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non‐users, respectively). Conclusions Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure‐related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.

Percutaneous Transhepatic Flexible Ureteroscope-Guided Frequency-Doubled Dual Pulse ND:YAG Laser Lithotripsy for Refractory Choledocholithiasis

“…Although several studies have shown that endoscopic sphincterotomy plus balloon dilation was safe and effective for large CBDS removal, owing to the improvements of laser technology, more and more endoscopists preferred lithotripsy plus balloon dilation. [26][27][28] Peroral cholangioscopy-guided lithotripsy achieved a technical success rate of 80%-86% in a single procedure, and was signi cantly more likely indicated for stones ≤30 mm in size than for stones with >30 mm in size. 29,30 In the present study, no CBDS had a size of 30 mm, and the technical success rate was 100%.…”

International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy

“…To update the evidence for the previous KSGE guidelines, we performed a literature search and identified eight retrospective and prospective cohort studies. 53,59,[73][74][75][76][77][78] Various low-risk endoscopic procedures, such as double-balloon enteroscopy, 73,78 diagnostic endoscopy, 53,75 endoscopic papillary large balloon dilatation, 76 or endoscopic biopsy, 59,77 were evaluated to determine whether warfarin could be continued or discontinued before the procedures. All included studies indicated that the overall rate of early or delayed hemorrhage did not differ between the warfarin interruption and non-interruption groups.…”

Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review

“…However, balloon dilation is contraindicated in cases with distal biliary strictures, due to the increased risk of perforation[ 21 ], whereas EST increases the risk of bleeding in patients on antithrombotic agents[ 22 ]. A recently published systematic review and metanalysis including 13 randomized controlled trials conducted on 1990 patients[ 23 ] focused on the treatment of large CBD stones using the three techniques.…”