Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

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.

Surgical procedure for unexpected balloon burst complication during endoscopic balloon dilatation in a patient with common bile duct stones

“…The high success rate and safety of this modality have been well established by a number of studies [1][2][3]. Complications of EBD, such as pancreatitis, hemorrhage, perforation, and infection have been reported [4][5][6][7][8][9]. In the current case, we demonstrated balloon burst of an EBD catheter as a rare complication of EBD.…”

Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis

“…Nevertheless, current studies suggested that EPLBD alone is safe and effective to treat large CBDSs without increasing the rate of PEP 26. Fujisawa et al27 reviewed studies of balloon dilation and reevaluated the incidence of PEP, and concluded that PEP may not be caused by papillary damage, suggesting that the catheterization of the EPLBD was not the main reason for PEP, whereas the frequency of ML usage and total procedure time may be the main reasons for patients suffering from PEP. In addition, Park et al28 performed a multicenter retrospective study with 946 patients who underwent EPLBD (balloon size 12–20 mm), and their results suggested that balloons $14 mm in diameter were associated with a lower risk of pancreatitis (OR =0.27, P =0.015).…”

Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study

“…In our cohort, the rate of EPBD for Type 2 papilla was 12%, which was much higher than that for the other types of papilla (p = 0.003). It is well known that EPBD with small-caliber (diameter = 8-10 mm) balloons increase PEP rate [14]. In our hospital, we preferred sphincterotomy over EPBD (diameter 8-10 mm was typically used) for most cases.…”