Sphincterotomy plus balloon dilation versus sphincterotomy alone for choledocholithiasis: a meta-analysis

Background and Aims: Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. Methods: A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. Results: The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. Conclusions: Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

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“…A total of 24 articles were used in the analysis with data abstracted from their full text. 10 , 23 – 45 …”

Section: Resultsmentioning

confidence: 99%

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

Alrajhi

Barkun

Adam

et al. 2021

Therap Adv Gastroenterol

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“…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%.…”

Section: Discussionmentioning

confidence: 99%

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

Wang

Jia

Chen

et al. 2021

Preprint

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ObjectivesTo evaluate the safety and efficiency of percutaneous transhepatic flexible ureteroscope-guided frequency-doubled dual pulse ND:YAG laser lithotripsy (PTFU-FREDDY) for refractory choledocholithiasis.MethodsFrom December 2017 to October 2018, 24 refractory choledocholithiasis patients with large common bile duct stones, anatomic variations, multiple stones or stones at difficult locations (impacted, above a biliary stricture) were admitted to two centers. Four patients were considered intolerant to surgery or endoscopic retrograde cholangiopancreatography (ERCP), and 2 had ERCP failure, the others refused. All patients underwent PTFU-FREDDY. Clinical success rate, recurrence of calculus, laser safety, and related complications, such as fever, haematoma, and local thermal damage were recorded. ResultsPatients’ mean age was 66.0±12.1 (43-89) years. Sex ratio was 1:1.2 (male: female). The mean diameter of stones was 21.8±2.4 mm. All stones were successfully broken and pushed into the duodenum. The mean lithotripsy frequency and procedure time of Bilirubin stones was higher than cholesterol stones, and the mixed were in middle，P<0.01. One patient（4.2%）had haemobilia, requiring immediate transarterial embolisation with 100mg 300-500um gelatin sponge particles. No pancreatitis, sepsis, or serious local thermal damage, such as bile duct perforation, was observed. The rates of Grade A/B of fever, abdominal pain, nausea, and vomiting were 12.5%, 12.5%, 8.3%, and 4.2% during follow-up, respectively. The recurrence was none at the endpoint of 12 months.Conclusion PTFU-FREDDY is a safe and effective alternative treatment for refractory choledocholithiasis, especially when traditional treatments fail or are difficult to perform.

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“…Following a 2003 report on endoscopic papillary large balloon dilation (EPLBD) [4], major changes have been made to refine the technique used to remove difficult stones. The improved approach increases the success rate of initial complete stone removal, decreases the treatment duration, and reduces the need for lithotripsy [5][6][7][8][9].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal

et al. 2021

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Background Stone removal using endoscopic papillary large balloon dilation (EPLBD) is extremely effective. However, limited research exists regarding the risk factors for perforation of the duodenal papilla and bile duct, which may be fatal. Aims We aimed to investigate the risk factors for perforation during EPLBD + stone removal. Methods We included patients who underwent EPLBD + stone removal at four medical facilities between January 2008 and December 2018. We retrospectively analyzed the risk factors for perforation and their relationship between overdilation and adverse events. Overdilation was defined as a ratio of the balloon diameter to the diameter of the bile duct that exceeded 100%. The diameter of the distal bile duct was measured using the diameter of the intrapancreatic bile duct at a point 10 mm toward the liver from the narrow distal segment on a cholangiogram. ResultsWe included 310 patients (177 males; median age: 79 years [range: 46-102 years]). Perforation occurred in five patients (1.6%). Multivariate analysis indicated that no surrounding-pancreas (half or less of the circumference of the intrapancreatic bile duct was surrounded by the pancreatic parenchyma) was a significant risk factor (perforation rate: 8.3%, p = 0.011, odds ratio: 12.7 [95% confidence interval: 1.8-90.5]). No significant difference was found between the overdilation and non-overdilation groups regarding the occurrence of pancreatitis, bleeding, and cholangitis. Perforation rate in patients with no surrounding pancreas + overdilation was 16.7% (2/12). Patients with perforation underwent conservative therapy, which improved their conditions. Conclusions EPLBD + stone removal should be avoided in patients with no surrounding pancreas. Overdilation is not a risk factor for adverse procedural events; however, it should be limited in patients with surrounding pancreas.

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Sphincterotomy plus balloon dilation versus sphincterotomy alone for choledocholithiasis: a meta-analysis

Cited by 21 publications

References 37 publications

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

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

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal

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Sphincterotomy plus balloon dilation versus sphincterotomy alone for choledocholithiasis: a meta-analysis

Cited by 21 publications

References 37 publications

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

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

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal

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