Sequential Endoscopic Papillary Balloon Dilatation Following Limited Sphincterotomy for Common Bile Duct Stones

Abstract

Endoscopic papillary balloon dilatation (EPBD) has been recently used in conjunction with endoscopic sphincterotomy (EST) for the removal of common bile duct (CBD) stones. The present study was aimed at assessing the safety and outcome of sequential EPBD following EST for CBD stones. A total of 74 patients (43 females, mean age 41 years) with > or = 10-mm stone(s) in the CBD were selected for the procedure, which included limited EST followed by EPBD with balloon dilators of 10-18 mm in size. Eleven patients had undergone EST and unsuccessful stone removal earlier. Forty-nine patients had symptoms of CBD stones, while 25 were detected on imaging. Eleven patients had previous CBD stent in situ and four had T-tube in situ. The stone size was 10-12 mm in 34, 13-14 mm in 26, and > or = 15 mm in 14 patients. Thirty-one patients had a single stone, while 43 had > or = 2 stones. The successful removal of stones was achieved in 68 (91.9%) patients; 62 in the first attempt, five in the second, and one in the third. Six patients were deemed to be "failures." In two of them, the stones could be removed after mechanical lithotripsy. Complications were seen in 16 patients, with self-limiting pain in 13, self-limiting ooze in five, melaena in one, and mild pancreatitis in two. One patient had impaction of the dormia basket. We conclude that EPBD following EST is safe and effective in removing stones > or = 10 mm in size in over 90% of patients.

Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

“…In contrast, we had a 33% mechanical lithotripsy rate in group A and a 32% rate in group B. Compared to previous reports, the frequency of mechanical lithotripsy was markedly higher [24][25][26][27]39] , which might be attributable to the large stones (≥ 15 mm).…”

“…They reported an 83% success rate in the first session with a 7% rate of mechanical lithotripsy in 58 patients in whom endoscopic removal of bile duct stones using standard EST and balloon/ basket extraction had failed. Recently, multiple published series have shown that the overall first session success rates of stone removal with EBD following EST ranged from 80% to 100% [24,25,27,38] , and these success rates were similar to those of EST. Although some recent studies have reported that the stone clearance rate for the initial session of EBD following EST is high, the outcome for large stone removal by ELBD following EST remains controversial.…”

“…A previous series of EST + ELBD gave first session success rates of 70%-99% and mechanical lithotripsy rates of 1%-11% [24][25][26][27]39] . In contrast, we had a 33% mechanical lithotripsy rate in group A and a 32% rate in group B.…”

“…They have reported that EBD with conventional EST is more effective for the retrieval of large stones and shortens the procedure time. Recently, this technique has been modified slightly to endoscopic papillary large balloon dilatation (ELBD) with small incision EST, and many studies have reported on the outcome of stone removal and complication rate [25][26][27] . However, these studies on the efficacy of ELBD with SES have concentrated on small stones, of which the majority are ≤ 1 cm [25,26] .…”

Small sphincterotomy combined with endoscopic papillary large balloon dilationvssphincterotomy alone for removal of common bile duct stones

“…Another disadvantage of conventional EPBD is that it is difficult to remove larger stones because the biliary opening is not enlarged to the same degree as with EST [6,7] ; therefore, the application of EPBD is restricted to patients with small stones less than 10 mm in diameter [9] . EPLBD combined with limited EST, which was first proposed to facilitate the removal of large or multiple bile duct stones, has been proven safe and effective in patients with large bile duct stones [27] . EPLBD combined with limited EST enlarged the biliary orifice enough to remove multiple or larger bile duct stones, resulting in an increased success rate of stone removal [28,29] and in decreased use of mechanical lithotripsy [9,12,13,[30][31][32][33] .…”