Published online Dec 28, 2013. doi: 10.3748/wjg.v19.i48.9453
Revised: September 27, 2013
Accepted: December 13, 2013
Published online: December 28, 2013
AIM: To perform a meta-analysis of large-balloon dilation (LBD) plus endoscopic sphincterotomy (EST) vs EST alone for removal of bile duct stones.
METHODS: Databases including PubMed, EMBASE, the Cochrane Library, the Science Citation Index, and important meeting abstracts were searched and evaluated by two reviewers independently. The main outcome measures included: complete stone removal, stone removal in the first session, use of mechanical lithotripsy, procedure time, and procedure-related complications. A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio (OR) when heterogeneity was not significant among the studies. When a Q test or I2 statistic indicated substantial heterogeneity, a random-effects model weighted by the DerSimonian-Laird method was used.
RESULTS: Six randomized controlled trials involving 835 patients were analyzed. There was no significant heterogeneity for most results; we analyzed these using a fixed-effects model. Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone (OR = 0.53, 95%CI: 0.33-0.85, P = 0.008); subcategory analysis indicated a significantly lower risk of perforation in the EST plus LBD group (Peto OR = 0.14, 95%CI: 0.20-0.98, P = 0.05). Use of mechanical lithotripsy in the EST plus LBD group decreased significantly (OR = 0.26, 95%CI: 0.08-0.82, P = 0.02), especially in patients with a stone size larger than 15 mm (OR = 0.15, 95%CI: 0.03-0.68, P = 0.01). There were no significant differences between the two groups regarding complete stone removal, stone removal in the first session, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, infection of biliary tract, and procedure time.
CONCLUSION: EST plus LBD is an effective approach for the removal of large bile duct stones, causing fewer complications than EST alone.
Core tip: This meta-analysis demonstrates that endoscopic sphincterotomy (EST) plus large-balloon dilation (LBD) is an effective approach for the removal of large bile duct stones. Specifically, when compared with the outcomes of EST alone, the combined technique is associated with fewer complications. Furthermore, use of mechanical lithotripsy in the EST plus LBD group decreased significantly, especially in patients with a stone size larger than 15 mm. However, more well-designed trials are required to clarify whether this combined technique is preferable.