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Hasegawa S, Kurita Y, Yamazaki Y, Nihei S, Iizuka T, Misawa N, Hosono K, Endo I, Kobayashi N, Kubota K, Nakajima A. Post-endoscopic sphincterotomy delayed bleeding occurs in patients with just 1-day interruption of direct oral anticoagulants or hemodialysis. DEN OPEN 2025; 5:e70060. [PMID: 39822950 PMCID: PMC11736286 DOI: 10.1002/deo2.70060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Revised: 12/10/2024] [Accepted: 12/31/2024] [Indexed: 01/19/2025]
Abstract
Objective Endoscopic sphincterotomy (EST), especially when anticoagulants are used, carries a significant risk of delayed bleeding. However, the relationship between the use of antithrombotic agents, including direct oral anticoagulants, and post-EST bleeding remains unclear. This study aimed to identify the risk factors for post-EST delayed bleeding when antithrombotic agents were administered according to the guidelines. Methods We analyzed cases of patients who underwent endoscopic retrograde cholangiopancreatography and EST between January 2018 and August 2022, focusing on those with normal anatomy and naïve papillae. We examined the incidence of post-EST bleeding, endoscopic retrograde cholangiopancreatography procedure details, severity and timing of post-EST delayed bleeding, hemostatic interventions, and factors related to post-EST delayed bleeding. Results Among the 502 patients included, 76 (15%) were taking antithrombotic agents. Post-endoscopic retrograde cholangiopancreatography delayed bleeding was noted in seven patients (1.4%). Mild, moderate, and severe delayed bleeding occurred in four, one, and two cases, respectively. Hemostatic injection completely controlled cases of delayed bleeding. Multivariate analysis identified a 1-day direct oral anticoagulants interruption (odds ratio: 20.5, 95% confidence interval: 3.33-125, p = 0.0011) and dialysis (odds ratio: 38.7, 95% confidence interval: 2.4-624, p = 0.0099) as significant risk factors for delayed bleeding. No thromboembolic events related to the discontinuation of antithrombotic drugs were observed. Conclusion A 1-day direct oral anticoagulants interruption and dialysis are independent risk factors for post-EST delayed bleeding, necessitating careful consideration.
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Affiliation(s)
- Sho Hasegawa
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Yusuke Kurita
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Yuma Yamazaki
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Shinichi Nihei
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Takeshi Iizuka
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Noboru Misawa
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Kunihiro Hosono
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineKanagawaJapan
| | - Noritoshi Kobayashi
- Department of OncologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Kensuke Kubota
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
| | - Atsushi Nakajima
- Department of Gastroenterology and HepatologyYokohama City University Graduate School of MedicineKanagawaJapan
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Wang J, Cao L, Xue K, Qi P, Mao Q, Cui M, Ju H, He B, Cao B. Endoscopic Papillary Large Balloon Dilatation With or Without Endoscopic Sphincterotomy in the Treatment of Common Bile Duct Stones. Dig Dis Sci 2025; 70:478-493. [PMID: 39708261 DOI: 10.1007/s10620-024-08797-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Accepted: 12/09/2024] [Indexed: 12/23/2024]
Abstract
PURPOSE OF REVIEW Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS. FINDINGS EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Jia Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Lichao Cao
- Health Care Management Master of Science, Johns Hopkins University, Baltimore, MD, USA
| | - Kuijin Xue
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Peng Qi
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Qingdong Mao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Mingjuan Cui
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Hui Ju
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Baoguo He
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Bin Cao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China.
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Wang Z, Yuan H, Lin K, Zhang Y, Xue Y, Liu P, Chen Z, Wu M. Artificial intelligence-empowered assessment of bile duct stone removal challenges. EXPERT SYSTEMS WITH APPLICATIONS 2024; 258:125146. [DOI: 10.1016/j.eswa.2024.125146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Ahmed J, Prakash P, Mehta G, Davies T, Lim YY, Cross ND, Czajkowski MA, Allison MC. Outcome of long-term biliary stenting for stones in the 2010s: beware the cholecystectomised! Frontline Gastroenterol 2024; 15:99-103. [PMID: 38486672 PMCID: PMC10935539 DOI: 10.1136/flgastro-2023-102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/12/2023] [Indexed: 03/17/2024] Open
Abstract
Objective Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for most patients with common bile duct stones (CBDS). Duct clearance at initial ERCP may not be achieved in a third of patients, many of whom may be elderly with multiple comorbidities rendering them at potentially high risk for further procedures. We aimed to quantify the rate of biliary sequelae and mortality among a large cohort undergoing a single ERCP with sphincterotomy and stent insertion without having undergone complete ductal clearance (permanent stent insertion, PSI), and to examine factors that may predispose to adverse outcomes. Design/method Outcomes of all ERCPs undertaken on the intact papilla between February 2010 and January 2020 were distilled to identify a cohort who had undergone PSI for initially irretrievable CBDS. These were subjected to retrospective follow-up until the development of biliary sequelae, death or survival into 2023. Results There were 2175 index ERCPs for CBDS, of whom 114 met the PSI criteria. Eleven did not survive their index hospitalisation, leaving 103 for follow-up. Of these, 25 (24%) developed late biliary sequelae, 19 (18%) required at least one further ERCP and 8 (8%) died from biliary sequelae. Adverse outcomes were found to be more common among those who had undergone cholecystectomy prior to ERCP, and those with periampullary diverticula. Conclusions Long-term biliary stenting following sphincterotomy remains a valid option for selected patients with initially irretrievable bile duct stones who could be at high risk from repeat procedures.
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Affiliation(s)
| | - Priyanka Prakash
- Department of Gastroenterology and Hepatology, Royal Gwent Hopsital, Newport, UK
| | - Gney Mehta
- Department of Gastroenterology and Hepatology, Royal Gwent Hopsital, Newport, UK
| | - Tessa Davies
- Department of Gastroenterology and Hepatology, Royal Gwent Hopsital, Newport, UK
| | - Yin Yin Lim
- Department of Gastroenterology and Hepatology, Royal Gwent Hopsital, Newport, UK
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Patel S, Kiker D, Mondal U, Sayana H, Saligram S, Rosenkranz L, Han S. Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:346. [PMID: 38399633 PMCID: PMC10889936 DOI: 10.3390/medicina60020346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.
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Affiliation(s)
- Sandeep Patel
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Dustin Kiker
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Utpal Mondal
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Laura Rosenkranz
- Division of Gastroenterology and Nutrition, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Li YY, Miao YS, Wang CF, Yan J, Zhou XJ, Chen YX, Li GH, Zhu L. Optimal dilation duration of 10 mm diameter balloons after limited endoscopic sphincterotomy for common bile duct stones: a randomized controlled trial. Sci Rep 2024; 14:971. [PMID: 38200057 PMCID: PMC10782008 DOI: 10.1038/s41598-023-50949-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Limited endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) is widely used. However, the optimal duration of small balloon dilation in choledocholithiasis remains controversial. We aimed to determine the optimal duration for 10 mm diameter balloon dilation after limited EST in choledocholithiasis. In this randomized controlled clinical trial, 320 patients were randomly assigned to receive small balloon dilation (10 mm in diameter) for 1 min (n = 160) or 3 min (n = 160) after deep bile duct cannulation. No significant difference in success rate of stone extraction between the two groups was observed. The incidence of post-ERCP pancreatitis (PEP) was higher in the 1 min group (10.6%) than in the 3 min group (4.4%) (P = 0.034). The logistic regression analysis showed that guidewire into the pancreatic duct, cannulation time > 5 min and 1 min balloon dilation were independent risk factors for PEP. There were no significant differences in other post-ERCP adverse events such as acute cholangitis, bleeding, perforation, etc. between the two groups. In conclusion, 3 min in duration was determined to be the optimal dilation condition for the removal of common bile duct stones.
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Affiliation(s)
- Yuan-Yuan Li
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yin-Shui Miao
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Cai-Feng Wang
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Jing Yan
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Xiao-Jiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Guo-Hua Li
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
| | - Liang Zhu
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
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Kamezaki H, Iwanaga T, Tokunaga M, Maeda T, Senoo JI, Ohyama H, Kato N. Addition of Mechanical Lithotripsy to Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Common Bile Duct Stones: A Retrospective Single-Center Study. J Laparoendosc Adv Surg Tech A 2023; 33:1162-1166. [PMID: 37856153 DOI: 10.1089/lap.2023.0274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Introduction: This study aimed to compare the treatment outcomes of endoscopic papillary large-balloon dilation (EPLBD) with and without mechanical lithotripsy (ML) in removing difficult common bile duct stones. Methods: Patients with difficult common bile duct stones treated with EPLBD, with or without ML, at the Eastern Chiba Medical Center between April 2014 and March 2020, were retrospectively evaluated. The rates of cumulative recurrence and complications were compared between the two groups. Results: Overall, 122 patients (n = 44, EPLBD + ML and n = 78, EPLBD) treated by 12 gastroenterologists were included. Patients in the EPLBD + ML group were older (85 years versus 81.5 years) and had larger maximum stone diameter (15 mm versus 12.5 mm) than those in the EPLBD group. Compared with the EPLBD group, the EPLBD + ML group required more endoscopic retrograde cholangiopancreatography (ERCP) procedures (≥2) (86% versus 67%) and longer total ERCP time after reaching the papilla (78.5 minutes versus 25 minutes). Complication rates were not significantly different (9.1% versus 12.8%); however, the cumulative recurrence rates were higher in the EPLBD + ML group than in the EPLBD group (69.4% versus 23.5% at 4 years). Conclusion: Although there were no differences in complication rates, the long-term recurrence rate was higher in the EPLBD + ML group than in the EPLBD group. This study emphasizes the added burden imposed by performing ML during ERCP and suggests that by appropriate case selection, it is possible to treat cases of difficult biliary stones using EPLBD without ML.
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Affiliation(s)
- Hidehiro Kamezaki
- Department of Gastroenterology, Eastern Chiba Medical Center, Togane City, Japan
| | - Terunao Iwanaga
- Department of Gastroenterology, Eastern Chiba Medical Center, Togane City, Japan
| | - Mamoru Tokunaga
- Department of Gastroenterology, Eastern Chiba Medical Center, Togane City, Japan
| | - Takahiro Maeda
- Department of Gastroenterology, Eastern Chiba Medical Center, Togane City, Japan
| | - Jun-Ichi Senoo
- Department of Gastroenterology, Eastern Chiba Medical Center, Togane City, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba City, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba City, Japan
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Mohammed HI, Nada ASE, Seddik RM, ElGazara AR. Combined endoscopic large balloon dilation with limited sphincterotomy versus sole sphincterotomy for removal of large or multiple common bile duct stones. EGYPTIAN LIVER JOURNAL 2023. [DOI: 10.1186/s43066-023-00235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Abstract
Background
Endoscopic papillary large balloon dilation (EPLBD) after sphincterotomy (EST) was introduced for the removal of large (≥ 10 mm) or multiple bile duct stones. This method combines the advantages of EST and EPLBD by increasing the efficacy of stone extraction while minimizing complications of EST and EPLBD when used alone. This prospective study aimed to compare between EPLBD with prior limited EST and sole sphnicterotomy for extraction of multiple and/or large common bile duct stones.
Results
Statistical analysis revealed insignificant difference between the studied groups as regards the presence of periamullary diverticulum (23% vs. 19%, P > 0.05) and the use of mechanical lithotripsy (4% vs. 9%, P > 0.05). The rates of overall and initial stone clearance were not significantly different between both groups [94% vs. 90%), P > 0.05; and 84% vs. 78%, P > 0.05, respectively]. The procedure-related pancreatitis and bleeding in EST/EPLBD group were lower compared to EST group (3% vs. 5%, P > 0.05; and 2% vs. 6%, P > 0.05, respectively). None of the studied groups’ patients died or developed procedure-related perforation or cholangitis.
Conclusion
Endoscopic large balloon dilation with prior limited sphincterotomy is an effective and safe endoscopic technique for removing multiple and/or large CBDSs.
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Facciorusso A, Gkolfakis P, Ramai D, Tziatzios G, Lester J, Crinò SF, Frazzoni L, Papanikolaou IS, Arvanitakis M, Blero D, Lemmers A, Eisendrath P, Fuccio L, Triantafyllou K, Gabbrielli A, Devière J. Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis. Clin Gastroenterol Hepatol 2023; 21:33-44.e9. [PMID: 34666153 DOI: 10.1016/j.cgh.2021.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis. METHODS Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence. RESULTS All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03-1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07-1.45], vs S+EPLBD [RR, 1.23; range, 1.06-1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14-1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events. CONCLUSIONS Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy; Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Janice Lester
- Health Science Library, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Chuang TW, Leung J, Chen JJ, Lee PL, Tung HD, Fang ML, Ou-Yang MC, Chen JL. Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis. J Laparoendosc Adv Surg Tech A 2022; 33:355-369. [PMID: 36576861 DOI: 10.1089/lap.2022.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).
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Affiliation(s)
- Tang-Wei Chuang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - Joseph Leung
- Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and UC Davis Medical Center, Sacramento, California, USA
| | - Jyh-Jou Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - Pei-Lun Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - Hung-Da Tung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - Min-Lin Fang
- Medicine Library and Center for Knowledge Management, University of California, San Francisco, California, USA
| | - Mei-Chen Ou-Yang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Jyu-Lin Chen
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California, USA
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11
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Aziz M, Khan Z, Haghbin H, Kamal F, Sharma S, Lee-Smith W, Pervez A, Alastal Y, Nawras A, Thosani N. Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis. Endosc Int Open 2022; 10:E1599-E1607. [PMID: 36531684 PMCID: PMC9754880 DOI: 10.1055/a-1958-2348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 10/04/2022] [Indexed: 10/17/2022] Open
Abstract
Background and study aims The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Zubair Khan
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, Houston, Texas
| | - Hossein Haghbin
- Division of Gastroenterology, Ascension providence Hospital, Southfield, Michigan, United States
| | - Faisal Kamal
- Division of Gastroenterology, University of California, San Francisco, California, United States
| | - Sachit Sharma
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, Ohio, United States
| | - Asad Pervez
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia, United States
| | - Yaseen Alastal
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, Houston, Texas
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12
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Guo JY, Zhu JH, Pan J, Wang YC, Qian YY, Hu LH, He CH, Zou WB. Increased severity of complications after therapeutic ERCP in geriatric patients with chronic pancreatitis: An observational study. Medicine (Baltimore) 2022; 101:e29753. [PMID: 35801792 PMCID: PMC9259179 DOI: 10.1097/md.0000000000029753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 04/29/2022] [Accepted: 05/20/2022] [Indexed: 01/04/2023] Open
Abstract
Studies of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in geriatric patients have mainly examined patients with biliary diseases, rather than chronic pancreatitis (CP). This study aimed to evaluate the safety and success rate of therapeutic ERCP in geriatric patients with CP. The medical records of patients with CP aged over 65 years (group A) were retrospectively collected in a tertiary hospital from January 2013 to December 2018. Sex-matched CP patients under 65 years (group B) were randomly selected into the control group (matching ratio = 1:2). The success rate and the complication rate of therapeutic ERCP in 2 groups were compared. The risk factors for post-ERCP pancreatitis were investigated by univariate and multivariate analyses. A total of 268 ERCPs were performed in 179 patients of group A and 612 ERCPs in 358 patients of group B. The success rate of ERCP in group A was similar to that of group B (92.16% vs 92.32%; P = .936). The overall incidence of post-ERCP complications was 7.09% (19/268) and 5.72% (35/612) in group A and B, respectively (P = .436). However, geriatric patients had a significantly increased occurrence of moderate to severe complications (2.61% vs 0.16%; P = .002). Female gender (odds ratio [OR] = 3.40; P = .046), pancreas divisum (OR = 7.15; P = .049), dorsal pancreatogram (OR = 7.40; P = .010), and lithotripsy (OR = 0.15; P = .016) were significantly associated with risk of post-ERCP pancreatitis in geriatric patients. Therapeutic ERCP is safe and feasible in elderly patients with CP. However, occurrence of moderate to severe complications after ERCP increased in geriatric patients.
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Affiliation(s)
- Ji-Yao Guo
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Jia-Hui Zhu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Jun Pan
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Yuan-Chen Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Yang-Yang Qian
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
| | - Chao-Hui He
- Department of Gastroenterology, the Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
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13
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Phillpotts S, Webster G, Arvanitakis M. Endoscopic Management of Complex Biliary Stones. Gastrointest Endosc Clin N Am 2022; 32:477-492. [PMID: 35691692 DOI: 10.1016/j.giec.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.
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Affiliation(s)
- Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England.
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, Brussels 1070, Belgium
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14
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Zhang H, Fang Y, Huang J, Li F, Qin X, Huang J. Novel elbow basket mechanical lithotripter for large common bile duct stone removal. Postgrad Med 2022; 134:622-626. [PMID: 35603726 DOI: 10.1080/00325481.2022.2081418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Large common bile duct (CBD) stones often require lithotripsy. In this study, we aimed to introduce a novel device-elbow basket catheter for mechanical lithotripsy (ML) of CBD stones and assess the efficacy and safety of the novel device. METHODS This was a retrospective study. A total of 139 patients with large CBD stones who underwent lithotripsy using the elbow basket mechanical lithotripter (EBML) or conventional basket mechanical lithotripter (CBML) during endoscopic retrograde cholangiopancreatography (ERCP) from June 2016 to September 2021 in our center were enrolled in the study. The stone clearance rate, intubation time, overall procedure time, and adverse event rate were compared between the two groups. RESULTS The stone clearance rate in the first ERCP program in the EBML (n = 71) group was significantly higher than that in the CBML (n = 68) group (98.6% vs. 88.2%; P< 0.05). The intubation time in the EBML group was significantly shorter than that in the CBML group (median time; 12s vs. 78s; P< 0.001). The overall procedure time in the EBML group was significantly shorter than that in the CBML group (median time; 51 min vs. 63 min; P< 0.001). The adverse event rate (7.4% vs. 1.4%: P> 0.05) was similar between the two groups. CONCLUSIONS ML using EBML in patients with large CBD stones is feasible and safe. Compared with the CBML, the stone clearance rate of the EBML is higher in a single procedure and decreases the time of intubation and the overall procedure.
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Affiliation(s)
- Huahui Zhang
- Graduate School, Dalian Medical University, Dalian, Liaoning, China
| | - Ying Fang
- Graduate School, Dalian Medical University, Dalian, Liaoning, China
| | - Jian Huang
- Department of Gastroenterology, Nanjing Medical University, Changzhou, Jiangsu, China
| | - Fengdong Li
- Department of Gastroenterology, Nanjing Medical University, Changzhou, Jiangsu, China
| | - Xiangrong Qin
- Department of Gastroenterology, Nanjing Medical University, Changzhou, Jiangsu, China
| | - Jin Huang
- Department of Gastroenterology, Nanjing Medical University, Changzhou, Jiangsu, China
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15
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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16
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Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol 2021; 27:7597-7611. [PMID: 34908801 PMCID: PMC8641054 DOI: 10.3748/wjg.v27.i44.7597] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/23/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.
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Affiliation(s)
- Alberto Tringali
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Deborah Costa
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
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17
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May SA, Korotkevich AG, Leontiev AS, Shestak IS, Savostyanov IV. Tactics and techniques of choledochal sanation after papillotomy. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2021. [DOI: 10.31146/1682-8658-ecg-189-5-49-56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Сholelithiasis ranks third in terms of the prevalence of diseases among the adult population. A complication such as choledocholithiasis occurs in up to 33% of patients with gallstone disease. Despite the improvement in treatment methods and the use of “gold” standards, the number of complicated forms of cholelithiasis has no tendency to decrease. Timely resolution of choledocholithiasis by a correctly chosen technique helps to reduce complications and increases the frequency of favorable outcomes of the disease, returning patients to social activity.That is why it is important to know and, if possible, to use various methods of rehabilitation of the common bile duct when performing modern endoscopic transpapillary interventions.
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Affiliation(s)
- S. A. May
- “Novokuznetskaya City Clinical Hospital № 29”
| | - A. G. Korotkevich
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
| | - A. S. Leontiev
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
| | | | - I. V. Savostyanov
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
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18
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Dollhopf M, Schmetkamp H. Endoscopic management of difficult common bile duct stones. Minerva Gastroenterol (Torino) 2021; 68:144-153. [PMID: 34142521 DOI: 10.23736/s2724-5985.21.02876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. EVIDENCE ACQUISITION A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS). EVIDENCE SYNTHESIS This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones. CONLCLUSIONS For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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Affiliation(s)
- Markus Dollhopf
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany
| | - Henning Schmetkamp
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -
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19
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Huang L, Lu X, Huang X, Zou X, Wu L, Zhou Z, Wu D, Tang D, Chen D, Wan X, Zhu Z, Deng T, Shen L, Liu J, Zhu Y, Gong D, Chen D, Zhong Y, Liu F, Yu H. Intelligent difficulty scoring and assistance system for endoscopic extraction of common bile duct stones based on deep learning: multicenter study. Endoscopy 2021; 53:491-498. [PMID: 32838430 DOI: 10.1055/a-1244-5698] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The study aimed to construct an intelligent difficulty scoring and assistance system (DSAS) for endoscopic retrograde cholangiopancreatography (ERCP) treatment of common bile duct (CBD) stones. METHODS 1954 cholangiograms were collected from three hospitals for training and testing the DSAS. The D-LinkNet34 and U-Net were adopted to segment the CBD, stones, and duodenoscope. Based on the segmentation results, the stone size, distal CBD diameter, distal CBD arm, and distal CBD angulation were estimated. The performance of segmentation and estimation was assessed by mean intersection over union (mIoU) and average relative error. A technical difficulty scoring scale, which was used for assessing the technical difficulty of CBD stone removal, was developed and validated. We also analyzed the relationship between scores evaluated by the DSAS and clinical indicators including stone clearance rate and need for endoscopic papillary large-balloon dilation (EPLBD) and lithotripsy. RESULTS The mIoU values of the stone, CBD, and duodenoscope segmentation were 68.35 %, 86.42 %, and 95.85 %, respectively. The estimation performance of the DSAS was superior to nonexpert endoscopists. In addition, the technical difficulty scoring performance of the DSAS was more consistent with expert endoscopists than two nonexpert endoscopists. A DSAS assessment score ≥ 2 was correlated with lower stone clearance rates and more frequent EPLBD. CONCLUSIONS An intelligent DSAS based on deep learning was developed. The DSAS could assist endoscopists by automatically scoring the technical difficulty of CBD stone extraction, and guiding the choice of therapeutic approach and appropriate accessories during ERCP.
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Affiliation(s)
- Li Huang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoyan Lu
- State Key Laboratory of Information Engineering in Surveying, Mapping, and Remote Sensing, Wuhan University, Wuhan, China
| | - Xu Huang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Lianlian Wu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhongyin Zhou
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Deqing Wu
- Department of Gastroenterology, Tenth People Hospital of Tongji University, Shanghai, China
| | - Dehua Tang
- Department of Gastroenterology, Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dingyuan Chen
- State Key Laboratory of Information Engineering in Surveying, Mapping, and Remote Sensing, Wuhan University, Wuhan, China
| | - Xinyue Wan
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhongchao Zhu
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Tao Deng
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lei Shen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jun Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yijie Zhu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Dexin Gong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Di Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yanfei Zhong
- State Key Laboratory of Information Engineering in Surveying, Mapping, and Remote Sensing, Wuhan University, Wuhan, China
| | - Feng Liu
- Department of Gastroenterology, Tenth People Hospital of Tongji University, Shanghai, China
| | - Honggang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.,Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
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20
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Shim DJ, Kim SH, Kim IJ, Chun HJ, Kim D, Park C. Percutaneous stone removal using a compliant balloon after papillary balloon dilatation. MINIM INVASIV THER 2021; 31:603-608. [PMID: 33612051 DOI: 10.1080/13645706.2021.1879156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation. MATERIAL AND METHODS Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attempted via a pushing maneuver using an endoscopic stone extraction balloon. Clinical and technical success rates, complications, and risk factors for failure and complications were evaluated. RESULTS Biliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure. CONCLUSION Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible. Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; PTBD: percutaneous transhepatic biliary drainage.
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Affiliation(s)
- Dong Jae Shim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Su Ho Kim
- Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Il Jung Kim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jong Chun
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Doyoung Kim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chanyeong Park
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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21
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Best Procedure for the Management of Common Bile Duct Stones via the Papilla: Literature Review and Analysis of Procedural Efficacy and Safety. J Clin Med 2020; 9:jcm9123808. [PMID: 33255554 PMCID: PMC7760048 DOI: 10.3390/jcm9123808] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/10/2020] [Accepted: 11/23/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Endoscopic management of common bile duct stones (CBDS) is standard; however, various techniques are performed via the papilla, and the best procedure in terms of both efficacy and safety has not been determined. Methods: Endoscopic procedures were classified into five categories according to endoscopic sphincterotomy (EST) and balloon dilation (BD): (1) EST, (2) endoscopic papillary BD (≤10 mm) (EPBD), (3) EST followed by BD (≤10 mm) (ESBD), (4) endoscopic papillary large BD (≥12 mm) (EPLBD), and (5) EST followed by large BD (≥12 mm) (ESLBD). We performed a literature review of prospective and retrospective studies to compare efficacy and adverse events (AEs). Each procedure was associated with different efficacy and AE profiles. Results: In total, 19 prospective and seven retrospective studies with a total of 3930 patients were included in this study. For EST, the complete stone removal rate at the first session, rate of mechanical lithotripsy (ML), and rate of overall AEs in EST were superior to EPBD, but a higher rate of bleeding was found for EST. Based on one retrospective study, complete stone removal rate at the first session, rate of ML, and rate of overall AEs were superior for ESBD vs. EST, and the rate of bleeding for the former was also lower. Complete stone removal rate at the first session and rate of ML for ESLBD were superior to those for EST, with no significant difference in rate of AEs. For EST vs. EPLBD, complete stone removal rate at the first session and rate of ML were superior for the latter. For EPLBD vs. ESLBD, the efficacy and safety were similar. Conclusions: ESBD is considered the best procedure for the management of small CBDS, but strong evidence is lacking. For large CBDS, both ESLBD and EPLBD are similar.
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22
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Bang JY, Sutton B, Navaneethan U, Hawes R, Varadarajulu S. Efficacy of Single-Operator Cholangioscopy-Guided Lithotripsy Compared With Large Balloon Sphincteroplasty in Management of Difficult Bile Duct Stones in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:2349-2356.e3. [PMID: 32057976 DOI: 10.1016/j.cgh.2020.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/23/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although single-operator cholangioscopy (SOC)-guided lithotripsy and large balloon sphincteroplasty (LBS)-based techniques are effective rescue measures, the ideal approach to management of difficult bile duct stones is unclear. We conducted a randomized trial to compare the effectiveness of SOC-guided lithotripsy and LBS-based approaches for endoscopic management of difficult bile duct stones. METHODS Patients with difficult bile duct stones who failed retrieval using balloon or basket were randomly assigned to groups that received SOC-guided laser lithotripsy (SOC-LL, n = 33) or LBS (n = 33), from June 2016 through August 2018. When assigned treatment was unsuccessful, patients underwent mechanical lithotripsy before crossing over to the other group. The main outcome was treatment success, defined as ability to clear the duct in 1 session. Secondary outcomes were adverse events and treatment costs. RESULTS A higher proportion of patients in the SOC-LL group had treatment success (93.9%) than in the LBS group (72.7%; P = .021). On multiple logistic regression analysis, treatment success was significantly associated with use of SOC-LL (odds ratio [OR], 8.7; 95% CI, 1.3-59.3; P = .026), stone to extrahepatic bile duct ratio of 1 or less (OR, 28.8; 95% CI, 1.2-687.6; P = .038), and lack of a tapered bile duct (OR, 26.9; 95% CI, 1.3-558.2; P = .034). There was no significant difference between groups in adverse events (9.1% in the SOC-LL group vs 3.0% in the LBS group, P = .61) or overall treatment cost ($16,684 in the SOC-LL group vs $10,626 in the LBS group; P = .097). CONCLUSIONS In a randomized trial of patients with difficult bile stones that cannot be cleared by standard maneuvers, SOC-guided lithotripsy leads to duct clearance in a significantly higher proportion of patients than LBS-particularly when stone size exceeds the diameter of the extrahepatic bile duct. Adjunct lithotripsy might be required in patients with tapered distal bile duct, because LBS alone is less likely to be successful. ClinicalTrials.gov no: NCT00852072.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | | | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida.
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23
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Kogure H, Kawahata S, Mukai T, Doi S, Iwashita T, Ban T, Ito Y, Kawakami H, Hayashi T, Sasahira N, Kubota K, Togawa O, Kato H, Okabe Y, Matsubara S, Yagioka H, Saito T, Nakai Y, Isayama H. Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: MARVELOUS trial. Endoscopy 2020; 52:736-744. [PMID: 32299114 DOI: 10.1055/a-1145-3377] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND : Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. METHODS : This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. RESULTS: 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). CONCLUSION : EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinpei Doi
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.,Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tesshin Ban
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Tokyo Takanawa Hospital of Japan Community Health-care Organization, Tokyo, Japan
| | - Kensuke Kubota
- Division of Gastroenterology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University of Medicine, Kurume, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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24
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Lyu Y, Cheng Y, Wang B, Zhao S, Chen L. Comparison of the Efficacy and Safety of Three Endoscopic Methods to Manage Large Common Bile Duct Stones: A Systematic Review and Network Meta-Analysis. J Laparoendosc Adv Surg Tech A 2020; 31:443-454. [PMID: 32762611 DOI: 10.1089/lap.2020.0511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The optimal choice of endoscopic method between endoscopic sphincterotomy (EST), endoscopic papillary large balloon dilation (EPLBD), and EST plus EPLBD (endoscopic sphincterotomy and large balloon dilation [ESLBD]) for patients with large common bile duct stones is unclear. Methods: We systematically searched MEDLINE, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from August 1, 1990 to December 1, 2019. Randomized clinical trials comparing at least two of the following methods EST, ESLBD, or EPLBD were included in this study. The primary outcomes were the overall success rate and initial success rate of common bile duct stone removal. Results: We identified 13 trials comprising 1990 patients. Regarding the overall success rate and initial success rate, EPLBD had the highest probability of being the most successful (surface under the cumulative ranking curve [SUCRA] = 82.8% and 52.9%, respectively) and the lowest probability of bleeding (53.8%). ESLBD had the highest probability (SUCRA) of having the lowest morbidity (88.8%), requiring mechanical lithotripsy (54.9%), perforation (68%), and the lowest mortality (89.3%). EST had the least probability of postendoscopic retrograde cholangiopancreatography pancreatitis and cholangitis (SUCRA: 66.4% and 62.3%, respectively). Conclusions: EPLBD was most successful, and ESLBD was safest for large common bile duct stones. Postendoscopic pancreatitis after EST was less common than that after EPLBD and ESLBD. However, more high-quality trials are required.
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Affiliation(s)
- Yunxiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Yunxiao Cheng
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Sicong Zhao
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
| | - Liang Chen
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Dongyang, China
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25
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Ye LS, Yuan XL, Wu CC, Liu W, Du J, Yao MH, Tan QH, Hu B. Biliary spontaneous dislodgement spiral stent for patients who underwent mechanical lithotripsy. World J Gastroenterol 2020; 26:740-748. [PMID: 32116421 PMCID: PMC7039826 DOI: 10.3748/wjg.v26.i7.740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) in patients who underwent mechanical lithotripsy (ML) for large stone removal is high (up to 13.3%). One of the main causes is remaining small fragments or sludge that can impair normal biliary drainage. Endoscopic placement of a nasobiliary tube or a conventional plastic biliary stent has been commonly used under such conditions, but the patient may suffer from significant discomfort after the placement of a nasobiliary tube, while additional endoscopy is required for stent removal. We developed a biliary spontaneous dislodgement spiral stent (BSDSS) to overcome those shortcomings. AIM To evaluate the feasibility, safety, and effectiveness of inserting a BSDSS for patients who underwent ML for large stone removal. METHODS We conducted a single-center, retrospective, cohort study at West China Hospital, Sichuan University. A total of 91 consecutive patients with large biliary stones (≥ 10 mm) in the common bile duct who underwent ML between November 2017 and July 2018 were included. The 49 eligible patients were divided into the BSDSS group and the nasobiliary tube group. Technical success, post-ERCP adverse events (including PEC, post-ERCP pancreatitis, stone recurrence, BSDSS retention, self-extraction and dislocation of the nasobiliary tube), drainage time, and postoperative stay were measured and compared. RESULTS Twenty-one patients in the BSDSS group and 28 patients in the nasobiliary tube group were included in the analyses. The baseline characteristics and clinical information were similar in the two groups. Insertions of BSDSS and nasobiliary tube were technically successful in all 49 patients. There was no significant difference in the incidence of overall post-ERCP adverse events between the two groups (4.8% in the BSDSS group vs 17.9% in the nasobiliary tube group, P = 0.219). The median duration of drainage time (3 d in the BSDSS group vs 4 d in the nasobiliary tube group) and length of postoperative stay (4 d in the BSDSS group vs 5 d in the nasobiliary tube group) also did not differ (P = 0.934, and P = 0.223, respectively). CONCLUSION Endoscopic placement of a BSDSS appears to be feasible, safe and effective for patients who underwent ML for large stone removal.
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Affiliation(s)
- Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jiang Du
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ming-Hong Yao
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing-Hua Tan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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26
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Johnson KD, Perisetti A, Tharian B, Thandassery R, Jamidar P, Goyal H, Inamdar S. Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review. Dig Dis Sci 2020; 65:361-375. [PMID: 31792671 DOI: 10.1007/s10620-019-05970-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/16/2019] [Indexed: 12/12/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.
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Affiliation(s)
- Kemmian D Johnson
- Department of Internal Medicine, Louisiana State University Health Sciences Center, 1542 Tulane Ave Suite 436, New Orleans, LA, 70112, USA
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Benjamin Tharian
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Ragesh Thandassery
- University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
- VISN-16 MD Lead for Advanced Liver Disease, CAVHS, Little Rock, USA
| | - Priya Jamidar
- Yale University School of Medicine, 333 Cedar Street-1080 LMP, P.O. Box 208019, New Haven, CT, 06520, USA
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, 111 North Washington Avenue, Scranton, PA, 18503, USA.
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
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27
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Kuo CM, Chiu YC, Liang CM, Wu CK, Lu LS, Tai WC, Kuo YH, Wu KL, Chuah SK, Kuo CH. The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones. BMC Gastroenterol 2019; 19:93. [PMID: 31215401 PMCID: PMC6582576 DOI: 10.1186/s12876-019-1017-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 06/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound. METHODS We enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications. RESULTS The limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12-61) min vs. 23.5 (17-68) min vs. 25.0 (14-60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group. CONCLUSIONS Limited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD.
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Affiliation(s)
- Chung-Mou Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Chih-Ming Liang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Cheng-Kun Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Lung-Sheng Lu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Yuan-Hung Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan
| | - Chung-Huang Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Sung Dist, 833, Kaohsiung, Taiwan.
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28
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Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, Cortessis VK, Schilperoort H, Kysh L, Matsuoka L, Yachimski P, Agrawal D, Gurudu SR, Jamil LH, Jue TL, Khashab MA, Law JK, Lee JK, Naveed M, Sawhney MS, Thosani N, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89:1075-1105.e15. [PMID: 30979521 PMCID: PMC8594622 DOI: 10.1016/j.gie.2018.10.001] [Citation(s) in RCA: 305] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022]
Abstract
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, California, USA
| | - Shahnaz Sultan
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology & Nutrition, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Victoria K Cortessis
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hannah Schilperoort
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lynn Kysh
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lea Matsuoka
- Division of Hepatobiliary Surgery & Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Suryakanth R Gurudu
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
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Hakuta R, Kogure H, Nakai Y, Hamada T, Noguchi K, Saito K, Saito T, Takahara N, Mizuno S, Yagioka H, Ito Y, Tada M, Isayama H, Koike K. Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study. Dig Endosc 2019; 31:316-322. [PMID: 30586206 DOI: 10.1111/den.13326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
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.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Radwan MI, Emara MH, Ibrahim IM, Moursy ME. Large Balloon Dilatation Versus Mechanical Lithotripsy After Endoscopic Sphincterotomy in the Management of Large Common Bile Duct Stones in Cirrhotic Patients: A Randomized Study. J Clin Gastroenterol 2019. [PMID: 29521723 DOI: 10.1097/mcg.0000000000001000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIM Removal of large common bile duct (CBD) stones is one of the challenges faced during endoscopic retrograde cholangiopancreatography, and it seems more difficult in cirrhotic patients because of suspected higher rates of adverse events, especially bleeding diathesis. This study aimed at comparing the success rate and complications between mechanical lithotripsy (ML) and large balloon dilation (LBD) after endoscopic sphincterotomy in patients with liver cirrhosis. PATIENTS AND METHODS Ninety-eight cirrhotic patients with calcular obstructive jaundice were included and randomly divided into 2 groups: group A comprising 49 patients treated by LBD and group B comprising 49 patients treated by ML. All patients underwent sphincterotomy initially. All patients were subjected to thorough history taking and complete clinical examination. Pancreatic enzyme concentrations were measured 4 hours before and 24 hours after the procedure, and complete blood cell count and liver function tests were performed before and the morning after the procedure. Before and during endoscopic retrograde cholangiopancreatography, stone size and number were verified. RESULTS The success rate for CBD clearance was 98% and 93.8% for LBD and ML, respectively. The rate of adverse events in this study was 10.2% (10/98), and bleeding was the commonest reported complication (5/10). Group B developed more (16.3%) adverse events than group A (4.1%), and the difference was statistically significant (P=0.04). CONCLUSION Endoscopic sphincterotomy followed by LBD is a safe and effective treatment for large CBD stones in cirrhotic patients in comparison with sphincterotomy followed by ML.
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Affiliation(s)
- Mohamed I Radwan
- Tropical Medicine Department, Faculty of Medicine, Zagazig University
| | - Mohamed H Emara
- Tropical Medicine Department, Faculty of Medicine, Zagazig University
- Hepatology, Gastroenterology and Infectious Diseases Department, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Ibrahim M Ibrahim
- Tropical Medicine Department, Faculty of Medicine, Zagazig University
| | - Mahmoud E Moursy
- Gastroenterology Department, Al-Ahrar Teaching Hospital, Zagazig
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31
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Kedia P, Tarnasky PR. Endoscopic Management of Complex Biliary Stone Disease. Gastrointest Endosc Clin N Am 2019; 29:257-275. [PMID: 30846152 DOI: 10.1016/j.giec.2018.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Choledocholithiasis is a common disorder that is managed universally by endoscopic retrograde cholangiopancreatography (ERCP). For difficult or complex stones, ERCP with conventional techniques may fail to achieve biliary clearance in 10% to 15% of cases. This review summarizes the literature regarding the current available endoscopic techniques for complex stone disease, including mechanical lithotripsy, endoscopic papillary large balloon dilation, cholangioscopy-guided lithotripsy, and endoscopic ultrasound-guided biliary access.
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA.
| | - Paul R Tarnasky
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA
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33
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Hakuta R, Kawahata S, Kogure H, Nakai Y, Saito K, Saito T, Hamada T, Takahara N, Uchino R, Mizuno S, Tsujino T, Tada M, Sakamoto N, Isayama H, Koike K. Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis. Dig Endosc 2019; 31:59-68. [PMID: 29943385 DOI: 10.1111/den.13220] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/22/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Endoscopic papillary large balloon dilation (EPLBD) without endoscopic sphincterotomy (EST) may facilitate extraction of large bile duct stones through achieving adequate dilation of the ampulla. However, contrary to favorable long-term outcomes after endoscopic papillary balloon dilation (EPBD), that of EPLBD without EST has been little investigated. Therefore, we conducted the current study to evaluate short- and long-term outcomes of EPLBD without EST and EPBD after removal of large bile duct stones (LBDS; ≥10 mm). METHODS This retrospective study included patients without a previous history of EST, EPBD or EPLBD who underwent EPLBD without EST or EPBD for removal of LBDS. Each patient in the EPLBD without EST group was matched to a patient in the EPBD group using propensity scores. RESULTS Forty-four patients in each group were matched for the analysis. Baseline characteristics were balanced after propensity matching. Rate of complete stone removal in a single session was higher (80% vs 16%, P < 0.001), number of ERCP sessions (1.3 ± 0.7 vs 2.4 ± 1.5, P < 0.001) and rate of lithotripsy use (30% vs 80%, P < 0.001) were smaller in the matched EPLBD without EST group. Contrary to null between-group differences in early adverse events (P = 0.99), a cumulative rate of late biliary complications was higher in the EPLBD without EST group (P = 0.02). CONCLUSION EPLBD without EST showed higher efficacy for removal of LBDS but was associated with worse long-term outcomes when compared to EPBD.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, USA
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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de Clemente Junior CC, Bernardo WM, Franzini TP, Luz GO, dos Santos MEL, Cohen JM, de Moura DTH, Marinho FRT, Coronel M, Sakai P, de Moura EGH. Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials. World J Gastrointest Endosc 2018; 10:130-144. [PMID: 30147845 PMCID: PMC6107471 DOI: 10.4253/wjge.v10.i8.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/02/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials.
METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis.
RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), I2 = 11%, P = 0.31].
CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.
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Affiliation(s)
- Cesar Capel de Clemente Junior
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Tomazo Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Gustavo Oliveira Luz
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Jonah Maxwell Cohen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Fábio Ramalho Tavares Marinho
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Martin Coronel
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
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35
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Maruta A, Iwashita T, Uemura S, Yoshida K, Iwata K, Mukai T, Doi S, Yasuda I, Imai K, Shimizu M. Comparison of late adverse events after endoscopic sphincterotomy versus endoscopic papillary large balloon dilation for common bile duct stones: A propensity score-based cohort analysis. Dig Endosc 2018; 30:493-500. [PMID: 29399885 DOI: 10.1111/den.13031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Endoscopic sphincterotomy (ES) is a standard procedure for the treatment of common bile duct stones (CBDS). Endoscopic papillary large balloon dilation (EPLBD) is emerging as an effective method to treat difficult CBDS, providing several advantages over ES without increasing early adverse events (AE). However, the late AE of EPLBD have not yet been well studied. The aim of the present study was to compare late AE after EPLBD versus ES for the treatment of CBDS using a propensity score-based cohort analysis. METHODS Propensity score matching was introduced to reduce the possible bias in baseline characteristics between two treatment groups and formed the matched cohort including 240 patients. Primary endpoint was cumulative as well as estimated 1-year and 3-year late AE rates. Secondary outcome was the incidence of early AE. RESULTS Cumulative late AE rates were 12.5% and 16.7% in the ELPBD and ES groups (P = 0.936) with a median follow-up period of 915.5 and 1544.5 days, respectively. Estimated 1-year and 3-year late AE rates were 8.4% and 13.1% in the EPLBD group and 5.0% and 15.0% in the ES group, respectively. In multivariate analysis, ≥two procedures were identified as independent risk factors for late AE. Overall early AE rate did not differ between the groups. CONCLUSION In the present study, late AE rate after EPLBD showed no significant difference compared with that after ES, which had a relatively long follow-up period. Therefore, EPLBD could be used for the treatment of CBDS, if CBDS are considered difficult to treat. Clinical Trial Registry: UMIN000027798.
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Affiliation(s)
- Akinori Maruta
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kensaku Yoshida
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Kenji Imai
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Brown NG, Camilo J, Nordstrom E, Yen RD, Fukami N, Brauer BC, Wani S, Amateau SK, Attwell AR, Shah RJ. Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center's 12-year experience. Scand J Gastroenterol 2018; 53:626-631. [PMID: 29644909 DOI: 10.1080/00365521.2018.1441434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs. METHODS A retrospective query for AETs. PRIMARY OUTCOME Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC). RESULTS From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET's. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1-20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The 'Combination' and 'POC' groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p < .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%). CONCLUSIONS AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs.
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Affiliation(s)
- Nicholas G Brown
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Joel Camilo
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Eric Nordstrom
- b Department of Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Roy D Yen
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Norio Fukami
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Brian C Brauer
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Sachin Wani
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Stuart K Amateau
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Augustin R Attwell
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Raj J Shah
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
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Itoi T, Ryozawa S, Katanuma A, Okabe Y, Kato H, Horaguchi J, Tsuchiya T, Gotoda T, Fujita N, Yasuda K, Igarashi Y, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation. Dig Endosc 2018; 30:293-309. [PMID: 29411902 DOI: 10.1111/den.13029] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironori Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takuji Gotoda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc 2018; 87:1050-1060. [PMID: 28866457 DOI: 10.1016/j.gie.2017.08.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Bile duct stones >1 cm have a decreased incidence of successful endoscopic extraction and often require lithotripsy. Although previous guidelines suggested mechanical lithotripsy for large common bile duct stones, current guidelines suggest cholangioscopy-guided lithotripsy as an adjunct with or without balloon dilation or mechanical lithotripsy. However, no randomized trials have assessed the usefulness of this practice. METHODS Patients with bile duct stones >1 cm in diameter were randomized in a 2:1 ratio to cholangioscopy-guided laser lithotripsy versus conventional therapy only. Conventional therapies such as mechanical lithotripsy or balloon dilation were also allowed in the laser lithotripsy group. Randomization was stratified by history of ERCP in the past 3 months. The primary outcome was endoscopic clearance of the bile duct stones. RESULTS Endoscopic clearance was achieved in 39 (93%) of 42 patients treated with cholangioscopy-guided laser lithotripsy and 12 (67%) of 18 treated with conventional therapy only (P = .009). The 9 patients in whom ERCP was unsuccessful underwent surgical common duct exploration with stone removal. Mean procedure time was 120.7 ± 40.2 minutes for the cholangioscopy-guided laser lithotripsy group compared with 81.2 ± 49.3 minutes for the conventional therapy group (P = .0008). There was no significant difference in fluoroscopy time, number of procedures, or adverse events (cholangitis) (cholangioscopy, 2; conventional, 1) and post-ERCP pancreatitis (cholangioscopy, 2; conventional, 1). CONCLUSION Cholangioscopy-guided laser lithotripsy increases the incidence of endoscopic clearance of large bile duct stones and decreases the need for surgery compared with conventional therapy alone. However, it is associated with longer procedure times. (Clinical trial registration number: NCT0175997.).
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Abstract
PURPOSE OF REVIEW In 10-15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these "difficult bile duct stones." RECENT FINDINGS Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy. Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these "difficult" bile duct stones.
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Affiliation(s)
- Murad Aburajab
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Kulwinder Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, 53226, USA.
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Franzini T, Moura RN, Bonifácio P, Luz GO, de Souza TF, dos Santos MEL, Rodela GL, Ide E, Herman P, Montagnini AL, D’Albuquerque LAC, Sakai P, de Moura EGH. Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial. Endosc Int Open 2018; 6:E131-E138. [PMID: 29399609 PMCID: PMC5794432 DOI: 10.1055/s-0043-122493] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % - 90 %). However, there is no study comparing these 2 techniques. PATIENTS AND METHODS From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. RESULTS The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, - 25.2 min (CI95 % - 12.48 to - 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. CONCLUSION Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
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Affiliation(s)
- Tomazo Franzini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil,Corresponding author Tomazo Franzini, MD, PhD Av. Dr. Enéas de Carvalho Aguiar255 – Prédio dos Ambulatórios Pinheiros05403-000 Sao PauloSP – Brazil
| | - Renata Nobre Moura
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Priscilla Bonifácio
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Gustavo Oliveira Luz
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | | | - Gustavo Luis Rodela
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Edson Ide
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Paulo Herman
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - André Luis Montagnini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | - Paulo Sakai
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
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Vezakis A, Polydorou A, Kontis E, Pantiora E, Papanikolaou IS, Fragulidis G. Safety and efficacy of extending a previous endoscopic sphincterotomy for the treatment of retained or recurrent common bile duct stones. Ann Gastroenterol 2018; 31:109-114. [PMID: 29333075 PMCID: PMC5759604 DOI: 10.20524/aog.2017.0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/26/2017] [Indexed: 11/28/2022] Open
Abstract
Background: The aim of the study was to evaluate the safety and efficacy of extending a previous endoscopic sphincterotomy (ES) in patients with retained or recurrent common bile duct (CBD) stones. Methods: Between 2001 and 2013, extension of a previous ES, for known or suspected CBD stones, was performed in 118 patients (m/f, 53/65) with a median age of 74 (range: 31-91) years (group A). During the same period, ES was performed in 1064 patients with suspected or known choledocholithiasis (group B). The efficacy and complications of the extension (group A) were analyzed and a comparison was made between groups regarding complications. Results: Bile duct cannulation was straightforward in all patients in group A, while it was considered difficult in 49% of patients in group B. Complete clearance was achieved in 76/97 patients (78%) with CBD stones, after a mean of 1.18 attempts per patient. Mechanical lithotripsy was required in 10% of patients. After extension, immediate bleeding occurred in 24 patients (20%), which stopped spontaneously in 9 (37%) and endoscopic hemostasis was required in the remainder. Complications were more frequent in group B (5.3% vs. 0.8%, P=0.031), but there was no significant difference for any individual complication. Immediate bleeding was more common in group B (29% vs. 20%, P=0.035), but there was no difference in clinical bleeding. Conclusion: Extension of a previous ES seems to be a simple, effective and safe technique, allowing stone clearance in nearly 80% of patients; it is thus recommended in patients with CBD stones after ES.
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Affiliation(s)
- Antonios Vezakis
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Andreas Polydorou
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Elissaios Kontis
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK (Elissaios Kontis)
| | - Eirini Pantiora
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Ioannis S Papanikolaou
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
| | - Georgios Fragulidis
- 2 Department of Surgery and Endoscopy Unit, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece (Antonios Vezakis, Andreas Polydorou, Eirini Pantiora, Ioannis S. Papanikolaou, Georgios Fragulidis)
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Huang Q, Shao F, Wang C, Qi W, Qiu LJ, Liu Z. Nasobiliary drainage can reduce the incidence of post-ERCP pancreatitis after papillary large balloon dilation plus endoscopic biliary sphincterotomy: a randomized controlled trial. Scand J Gastroenterol 2018; 53:114-119. [PMID: 29043861 DOI: 10.1080/00365521.2017.1391329] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis can be reduced following endoscopic papillary balloon dilation with the placement of an endoscopic nasobiliary drainage (ENBD) catheter. The aim of this study was to determine whether the placement of an ENBD reduces the risk of post-ERCP pancreatitis following endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy. METHODS A total of 160 patients with bile duct stones were randomly assigned (1:1) to an ENBD group or no-ENBD group. The primary outcome of this study was the incidence of post-ERCP pancreatitis. The secondary outcome was the incidence of post-ERCP hyperamylasemia. RESULTS In total, 160 patients were randomized, and 155 were found to be eligible for the analysis. The two groups were similar regarding clinical and demographic factors as well as patient- and procedure-related risk factors for post-ERCP pancreatitis. Post-ERCP pancreatitis developed in 9 patients, that is, 8/77 (10.4%) of the control group and 1/78 (1.28%) of the ENBD group (p = .018; per protocol analysis). Intention to treat analysis also revealed that ENBD reduced the rate of post-ERCP pancreatitis (8/80 (10%) in the control group vs. 1/80 (1.25%) the ENBD group (p = .034)). Multivariate regression analysis identified not undergoing ENBD as an independent risk factor for post-ERCP pancreatitis (ENBD compared with no-ENBD: OR 0.087, 95% CI 0.011-0.734; p = .025). CONCLUSION This study demonstrated that placement of an ENBD was effective and safe for the prevention of post-ERCP pancreatitis in patients undergoing endoscopic papillary large balloon dilation together with endoscopic biliary sphincterotomy.
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Affiliation(s)
- Qiang Huang
- a Department of General Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
| | - Feng Shao
- b Department of Biliary-Pancreatic Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
| | - Chen Wang
- b Department of Biliary-Pancreatic Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
| | - Wei Qi
- b Department of Biliary-Pancreatic Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
| | - Lu Jun Qiu
- b Department of Biliary-Pancreatic Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
| | - Zheng Liu
- b Department of Biliary-Pancreatic Surgery , Anhui Provincial Hospital Affiliated with Anhui Medical University , Hefei , Anhui , China
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Park CH, Jung JH, Nam E, Kim EH, Kim MG, Kim JH, Park SW. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc 2018; 87:43-57.e10. [PMID: 28756105 DOI: 10.1016/j.gie.2017.07.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although various endoscopic techniques have been introduced for successful removal of common bile duct (CBD) stones, the optimal method is not yet clear. We aimed to compare the efficacy of different endoscopic techniques for CBD stone removal. METHODS We searched for all relevant randomized controlled trials published until June 2017, examining the outcomes of endoscopic techniques for CBD stone removal, including endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and EST with balloon dilatation (ESBD). A Bayesian network meta-analysis was performed. RESULTS Twenty-five studies with 3726 patients were included in the meta-analysis. ESBD had a higher successful rate of stone removal in the first endoscopic session than EPBD (odds ratio [OR] [95% credible interval {CrI}], 2.09 [1.07-4.16]). Mechanical lithotripsy was less common in ESBD than in EPBD (OR [95% CrI], .45 [.25-.83]). EPBD revealed a lower risk of bleeding than both EST and ESBD (OR [95% CrI], vs EST, .06 [.008-.23]; vs ESBD, .12 [.01-.64]). The pooled incidences of bleeding were 3.0% (95% confidence interval [CI], 1.8%-5.2%), 1.1% (95% CI, .6%-2.0%), and 2.0% (95% CI, .9%-4.4%) in the EST, EPBD, and ESBD groups, respectively. Pancreatitis tended to be more common in EPBD than in both EST and ESBD (OR [95% CrI]: vs EST, 1.49 [.84-2.59]; vs ESBD, 1.49 [.61-3.57]). CONCLUSION The efficacy of ESBD in stone removal during the first endoscopic session was superior to that of EPBD. Pancreatitis in ESBD and EST tended to be less common than in EPBD, although this difference was not statistically significant. However, ESBD and EST carried a higher risk of bleeding than EPBD.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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Wan X, Chen S, Zhao Q, Li T, Luo S, Cai X, Ren Y, Yu L, Li B. The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma. Saudi J Gastroenterol 2018; 24:348-354. [PMID: 30027911 PMCID: PMC6253912 DOI: 10.4103/sjg.sjg_94_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma. PATIENTS AND METHODS A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated. RESULTS The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared. CONCLUSIONS The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.
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Affiliation(s)
- Xinjian Wan
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sumin Chen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiuyan Zhao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tian Li
- Department of Gastroenterology, Weihai Municipal Hospital, Weihai, China
| | - Shengzheng Luo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobo Cai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchun Ren
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lanting Yu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baiwen Li
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Address for correspondence: Dr. Baiwen Li, Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, New Songjiang Road No. 650, Shanghai - 200080, China. E-mail:
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Aujla UI, Ladep N, Dwyer L, Hood S, Stern N, Sturgess R. Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy. World J Gastroenterol 2017; 23:8597-8604. [PMID: 29358868 PMCID: PMC5752720 DOI: 10.3748/wjg.v23.i48.8597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/31/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation (EPLBD) in the management of bile duct stones in a Western population.
METHODS Data was collected from the endoscopic retrograde cholangiopancreatography (ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1st August 2009 to 31st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore, we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.
RESULTS EPLBD was performed in 229 patients (46 females) with mean age of 68 ± 14.3 years. 115/229 (50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP (1st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81 (35.4%). Median balloon size was 13.5 mm (10 - 18). In addition to EPLBD, per-oral cholangioscopy (POC) and electrohydraulic lithotripsy (EHL) was performed in 35 (15%) patients at index* ERCP. 63 (27.5%) required repeat ERCP for stone clearance. 28 (44.5%) required POC and EHL and 11 (17.4%) had repeat EPLBD for complete duct clearance. Larger stone size (12.4 mm vs 17.4 mm, P < 0.000001), multiple stones (2, range (1-13) vs 3, range (1-12), P < 0.006) and dilated common bile duct (CBD) (12.4 mm vs 18.3 mm, P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients (20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis (0.87%) each.
CONCLUSION EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.
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Affiliation(s)
- Usman Iqbal Aujla
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Nimzing Ladep
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Laura Dwyer
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Stephen Hood
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Nicholas Stern
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
| | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospital, Liverpool L9 7AL, United Kingdom
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What Is the Value of the Learning Curve in Endoscopic Balloon Dilatation of the Major Papilla? Gastroenterol Res Pract 2017; 2017:6501485. [PMID: 29093736 PMCID: PMC5603744 DOI: 10.1155/2017/6501485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. Objective To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. Methods We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. Results Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. Conclusions Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.
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Kuo YT, Wang HP, Chang CY, Leung JW, Chen JH, Tsai MC, Liao WC. Comparable Long-term Outcomes of 1-Minute vs 5-Minute Endoscopic Papillary Balloon Dilation for Bile Duct Stones. Clin Gastroenterol Hepatol 2017; 15:1768-1775. [PMID: 28603054 DOI: 10.1016/j.cgh.2017.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic papillary balloon dilation (EPBD) is an alternative to endoscopic sphincterotomy for choledocholithiasis. Unlike endoscopic sphincterotomy, EPBD preserves biliary sphincter function, reducing long-term risk of recurrent choledocholithiasis by 50%. Guidelines recommend that duration of EPBD exceeds 2 minutes, to adequately loosen the sphincter and reduce risks of failed stone extraction and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, it is unclear whether this long duration of EPBD impairs sphincter function and negates the long-term benefit of EPBD. We performed a randomized controlled trial to determine whether long-duration (>1 minute) EPBD increases the risk of subsequent choledocholithiasis and hepatobiliary complications compared with short-duration EPBD (<1 minute). METHODS We performed a prospective study of 170 adult patients who underwent ERCP for suspected choledocholithiasis from April 2007 through October 2008 at 2 centers in Taiwan. Patients were randomly assigned to groups that underwent 1-minute (n = 86) or 5-minute (n = 84) EPBD for choledocholithiasis; patients were followed through June 2015. One month after the initial ERCP, patients were examined and liver function tests and abdominal sonographies were performed. Patients were then examined every 3-6 months over a median follow-up period of approximately 7 years. The primary outcome was recurrent choledocholithiasis or acute cholangitis and the secondary outcome was overall hepatobiliary complications. We assessed the effects of EPBD duration by Cox regression. RESULTS Thirteen patients (15.1%) developed recurrent choledocholithiasis or acute cholangitis after 1-minute EPBD, and 10 patients (11.9%) developed recurrent choledocholithiasis or acute cholangitis after 5-minute EPBD (P = .352). There was no significant difference between groups in number of hepatobiliary complications (P = .154). Compared with 1-minute EPBD, 5-minute EPBD did not increase risk of the primary outcome (adjusted hazard ratio, 0.76; 95% confidence interval, 0.32-1.82) or the secondary outcome (adjusted hazard ratio, 0.65; 95% confidence interval, 0.31-1.40). Mechanical lithotripsy, performed for failed stone extraction with EPBD at initial ERCP, was a risk factor for primary and secondary outcomes. CONCLUSIONS In a randomized controlled trial, we found that the risk of recurrent choledocholithiasis and hepatobiliary complications did not increase with long-duration EPBD (>1 minute), but was increased with mechanical lithotripsy.
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Affiliation(s)
- Yu-Ting Kuo
- Department of Internal Medicine, National Taiwan University Hospital Bei-Hu Branch, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, E-DA Hospital and I-Shou University, Kaohsiung, Taiwan
| | - Joseph W Leung
- Division of Gastroenterology, UC Davis Medical Center and Sacramento VA Medical Center, Sacramento, California
| | - Jiann-Hwa Chen
- Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
| | - Ming-Chang Tsai
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Xu XD, Chen B, Dai JJ, Qian JQ, Xu CF. Minor endoscopic sphincterotomy followed by large balloon dilation for large choledocholith treatment. World J Gastroenterol 2017; 23:5739-5745. [PMID: 28883699 PMCID: PMC5569288 DOI: 10.3748/wjg.v23.i31.5739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/29/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate early and late outcomes of endoscopic papillary large balloon dilation (EPLBD) with minor endoscopic sphincterotomy (mEST) for stone removal.
METHODS A total of 149 consecutive patients with difficult common bile duct (CBD) stones (diameter ≥ 10 mm or ≥ 3 stones) underwent conventional endoscopic sphincterotomy (EST) or mEST plus EPLBD from May 2012 to April 2016. Their demographic, laboratory and procedural data were collected, and pancreaticobiliary complications were recorded.
RESULTS Sixty-nine (94.5%) of the patients in the EPLBD + mEST group and 64 (84.2%) in the conventional EST group achieved stone clearance following the first session (P = 0.0421). The procedure time for EPLBD + mEST was shorter than for EST alone (42.1 ± 13.6 min vs 47.3 ± 11.8 min, P = 0.0128). The overall rate of early complications in the EPLBD + mEST group (11%) was lower than in the EST group (21.1%); however, the difference was not significant (P = 0.0938). The cumulative recurrence rate of cholangitis and CBD stones between the two groups was also similar. The procedure time was independently associated with post-endoscopic retrograde cholangiopancreatography pancreatitis (OR = 6.374, 95%CI: 1.193-22.624, P = 0.023), CBD stone diameter ≥ 16 mm (OR = 7.463, 95%CI: 2.705-21.246, P = 0.0452) and use of mechanical lithotripsy (OR = 9.913, 95%CI: 3.446-23.154, P = 0.0133) were independent risk factors for stone recurrence.
CONCLUSION EPLBD with mEST is more effective than EST alone for difficult CBD stone removal, with shorter procedure time and fewer early complications.
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Affiliation(s)
- Xiao-Dan Xu
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Bo Chen
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Jian-Jun Dai
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Jian-Qing Qian
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Chun-Fang Xu
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University, Soozhou 215000, Jiangsu Province, China
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol 2017; 52:276-300. [PMID: 27942871 DOI: 10.1007/s00535-016-1289-7] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 02/08/2023]
Abstract
Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.
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