Endoscopic papillary balloon dilation: Revival of the old technique

Table 1 Comparison of endoscopic balloon dilation methods according to balloon diameter

	Small-balloon EPBD	Large-balloon EPBD
Balloon diameter used	≤ 10 mm (6-10 mm)	≥ 12 mm (12-20 mm)
Target stone	Small to moderate sized stones in no or minimally dilated CBD	Large stones in considerably dilated CBD
Endoscopic biliary sphincterotomy	Not performed	Mostly, in conjunction with a small EST1

¹Preceding small-endoscopic biliary sphincterotomy (EST) use may shift the expansile force more toward the common bile duct (CBD) rather than the pancreatic orifice. EPBD: Endoscopic papillary balloon dilation.

Table 2 Techniques and outcomes of small balloon-endoscopic papillary balloon dilation in randomized controlled trials

Ref.	Patients (n)	Balloon diameter (mm)	Maximum pressure of inflation (atm)	Time of inflation (s)	duration of maximal dilation (s)	Number of ballooning	Overall success rate	Post-EPBD pancreatitis	Bleeding	Perforation	Infection	Death (n)
Arnold et al[7]	30	8	10	60		2	77%	20%	0%	0%	10%	0
Bergman et al[49]	101	8	Waist	60-120	45-60	1	89%	7%	0%	2%	4%	1 for perforation
DiSario et al[8]	117	8 or less		60		1	97.4%	15.4%	10.5%	0%	1%	2 for pancreatitis
Fujita et al[2]	138	4-8	Waist	180	15	1	99%	10.8%	0%	0%	2.9%	0
Lin et al[53]	51	8-12	8-12		120/300	1	94.1%	0%	2%	0%	0%	0
Natsui et al[58]	41	8	3		120	1	93%	5%	0%	0%	2%	0
Ochi et al[11]	51	8	60-80 mmHg	60		3	93%	0%	0%	0%	2%	0
Tanaka et al[59]	16	8	8	120		1	100%	19%	0%	0%	0%	0
Vlavianos et al[60]	103	10	12	30 or more		Repeated until satisfaction	87.4%	4.8%	0%	0%	1.9%	0
Yasuda et al[44]	35	8	6		60	2	100%	5.7%	0%	0%	0%	0

EPBD: Endoscopic papillary balloon dilation

Table 3 Techniques and outcomes of endoscopic papillary large balloon dilation in various studies

Ref.	Patients (n)	Extent of EST	Balloon diameter (mm)	duration of balloon dilation (s)	Overall success rate	Use of ML	Post-EPBD pancreatitis	Bleeding	Perforation	Infection	Death (n)
Ersoz et al[9]	58	Full	12-20	20-45	100%	6.9%	3%	9%	0%	3%	0
Bang et al[21]	22	small	10-15	40	100%	9.1%	4.5%	0%	0%	0%	0
Heo et al[28]	100	small	12-20	60	97%	8%	4%	0%	0%	1%	0
García-Cano et al[35]	30	Variable	10-18	60	94.5%		10%	10%	0%	3.3%	0
Stefanidis et al[30]	44	full	15-20	10-12	97.7%	0%	2.2%	2.2%	0%	0%	0
Attasaranya et al[20]	103	Full	12-18		95%	27.2%	0%	2%	1%	0%	0
Kochhar et al[18]	74	small	10-18	60	91.9%	2.7%	2.7%	8.1%	0%	0%	0
Lee et al[14]	55	small	15-20	30-60	100%	5.5%	0%	3.6%	0%	0%	0
Misra et al[22]	50	Full	15-20	30-45	100%	10%	8%	6%	0%	0%	0
Minami et al[61]	88	small	20		98.9%	1%	1%	1%	0%	1%	0
Maydeo et al[23]	60	Full	12-15	30	100%	5%	0%	8.3%	0%	0%	0
Itoi et al[24]	53	Full	15-20	15-30	100%	5.6%	1.9%	0%	0%	1.9%	0
Park et al[50]	946	Variable	12-20	30-180	96.9%	10.0%	2.5%	5.9%	0.9%	0.6%	4 (1 for bleeding, 3 for perforation)
Jeong et al[16]	38	Without EST	15-18	10-60	97.4%	21.1%	2.6%	0%	0%	0%	0

ML: Mechanical lithotripsy; EPBD: Endoscopic papillary balloon dilation; EST: Endoscopic biliary sphincterotomy.

Table 4 Indications for endoscopic balloon dilation according to balloon diameter

	Small-balloon EPBD	Large-balloon EPBD
Absolute indication	Patients with coagulopathy and need for anticoagulation to avoid sphincterotomy-induced bleeding	No indication
Relative indication	Patients with anatomical abnormalities including gastric bypass surgery (Billroth II gastrectomy) or periampullary diverticulum	Patients with altered anatomy, such as gastric bypass surgery (Billroth II gastrectomy), periampullary diverticulum and prior biliary sphincterotomy
Possible indication	To preserve SO functions	To reduce the use of ML for removal of large CBD stonesTo avoid full EST-induced bleeding

SO: Sphincter of Oddi; EPBD: Endoscopic papillary balloon dilation; CBD: Common bile duct.

Table 5 Tips for avoiding severe complications of endoscopic papillary balloon dilation

EPBD

EPLBD

1. A balloon smaller than the diameter of the CBD is recommended to reduce damage to the SO and pancreatic orifice. 2. Graded balloon inflation may significantly reduce the incidence of post-EPBD pancreatitis. 3. If the balloon’s waist remains after 2–3 s at maximal balloon inflation, balloon dilation must be stopped immediately.

1. Maximal inflated diameter of balloon should not exceed the CBD diameter. 2. A small extent of EST followed by large balloon dilation may be recommended, rather than large balloon dilation without EST. 3. The balloon should be inflated gradually to avoid perforation and bleeding. 4. If the balloon’s waist remains at 80% of the maximum inflation capacity, balloon dilation must be stopped immediately and change to alternative procedures, such as EST and ML. 5. Close monitoring must be necessary after EPLBD to detect the delayed complications, such as perforation and delayed bleeding.

SO: Sphincter of Oddi; EPBD: Endoscopic papillary balloon dilation; CBD: Common bile duct; EST: Endoscopic biliary sphincterotomy; ML: Mechanical lithotripsy; EPLBD: Endoscopic papillary large balloon dilation.