Endoscopic Sphincterotomy with Large Balloon Dilation versus Endoscopic Sphincterotomy for Bile Duct Stones: A Systematic Review and Meta-Analysis

Abstract

The safety and efficacy of endoscopic sphincterotomy with large balloon dilation (EPLBD) are unclear. This study compares the safety and efficacy between EPLBD and endoscopic sphincterotomy (EST). Patients and Methods. Literatures were searched for randomized controlled trials in PUBMED, EMBASE, and Cochrane Library. Outcome measurements included adverse events; stone removal rate; requirement of mechanical lithotripsy. Results. Four RCTs with a total of 596 patients were included. Three RCTs compared EPLBD versus EST alone for stone removal; one RCT compared EPLBD versus EST plus mechanical lithotripsy for stone removal. Pooled data from three RCTs showed that there was no significant difference in the adverse event of ERCP. A significantly higher cholangitis rate was seen in patients who received EST plus mechanical lithotripsy, compared to those treated with EPLBD (13.3% versus 0.0, P = 0.026). No statistical difference was found between EPLBD and EST for stone removal rate. Significant differences in requirement of mechanical lithotripsy were seen with removal of large stones (>15 mm), with EPLBD reducing the use of mechanical lithotripsy (RR: 0.73; 95% CI: 0.54–0.99). Conclusions. EPLBD and EST have similar efficacy and safety for bile duct stones clearance. With larger stones, EPLBD can reduce requirement of mechanical lithotripsy.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation

“…With regard to the use of ML for patients with large bile duct stones, three RCTs revealed a significantly lower rate of usage in the EPLBD group . Furthermore, a previous meta‐analysis found that the rate of ML usage was significantly lower, particularly in patients with large stones exceeding 15 mm in diameter . In the case of relatively large stones, enlarging the bile duct aperture widely by EPLBD enables lithotomy without breaking the stone, which may result in a shorter procedure and fluoroscopic duration …”

“…15,41,82,89 Similarly, in a meta-analysis of RCTs that involved bile duct diameter and stone diameter of 12 mm or greater, the stone removal rate was 85.5% in the EPLBD group and 86.9% in the EST group in the initial treatment (RR: 0.98, 95%CI: 0.91-1.06), whereas the stone removal rates were 97.5% and 99.0%, respectively, in the ultimate treatment (RR: 0.98, 95% CI: 0.91-1.01), with no significant difference found between the two treatments. 123 With regard to the use of ML for patients with large bile duct stones, three RCTs revealed a significantly lower rate of usage in the EPLBD group. 89,91,96 Furthermore, a previous meta-analysis found that the rate of ML usage was significantly lower, particularly in patients with large stones exceeding 15 mm in diameter.…”

“…89,91,96 Furthermore, a previous meta-analysis found that the rate of ML usage was significantly lower, particularly in patients with large stones exceeding 15 mm in diameter. 123,124 In the case of relatively large stones, enlarging the bile duct aperture widely by EPLBD enables lithotomy without breaking the stone, which may result in a shorter procedure and fluoroscopic duration. 96 Although there are few reports of the stone removal rate in EPLBD with or without EST, a systematic review has compared EPLBD with EST and EPLBD without EST.…”

Current endoscopic strategies for managing large bile duct stones

“…A meta-analysis comparing EPLBD versus ES looked at three randomized controlled trials (RCT) with 496 cases from which pooled data showed no significant difference in adverse events. 32 Balloon dilatation size varied from 12 mm to 20 mm, and stone or CBD size was greater than 12 mm. The study concluded that EPLBD and ES have similar efficacy and safety for bile duct stones clearance.…”

Difficult Biliary Access

“…Recent studies and meta-analyses have shown balloon dilation after initial sphincterotomy to be as effective as sphincterotomy alone and to decrease the need for mechanical lithotripsy. [31][32][33][34][35] The balloon dilation technique is discussed further in the article by Dr Sherman elsewhere in this issue.…”