Comprehensive review on small common bile duct stones

Table 1 Short- and long-term complications of endoscopic papillary balloon dilatation/endoscopic sphincterotomy

	Short-term complications			Long-term complications
	Bleeding	PEP	Perforation	Cholecystitis	Recurrence of stones in CBD
Incidence
EST	3%	3%	Rare	EST > EPBD	EST > EPBD
EPBD	Less than 0.1%	10%	Very rare
Prophylactic methods	Cessation of anticoagulant and antiplatelet agents referred to each country's guidelines; EST with cutting at approximately 11 o'clock direction	Diclofenac; Pancreatic stenting in selected patients at high risk for PEP; 2-3 min EPBD in patients with EPBD	There is no evidence comparing incision size, the incidence of procedural adverse events, and therapeutic outcomes following EST	We consider EPBD in cases of small bile duct stones, bleeding tendency, young age, and even in surgically altered anatomy in which EST is difficult	We consider EPBD in cases of small bile duct stones, bleeding tendency, young age, and even in surgically altered anatomy in which EST is difficult

CBD: Common bile duct; EST: Endoscopic sphincterotomy; EPBD: Endoscopic papillary balloon dilatation; PEP: Post endoscopic retrograde cholangiopancreatography pancreatitis.

Table 2 Key points of each guideline

	JGES/TG18	ESGE	ASGE
Papillary dilatation	EST is standard	EST is standard	EST is standard
	EPBD is determined by age, scheduled RFA, antithrombotic medications, parapapillary diverticulum, reconstructed bowel, and stone diameter and number	In anticoagulant users and in cases of SAA, EPBD is an option for stones smaller than 8 mm	In anticoagulant users, in cases of SAA, and in cases of intradiverticular papilla, EPBD is an option
Cases of antithrombotic agents use (EST, high bleeding risk procedures)	ASA or CLZ alone may be continued	ASA or CLZ alone may be continued	ASA or CLZ alone may be continued
	Thienopyridines discontinued for 5-7 d or replaced with ASA or CLZ	Thienopyridines discontinued for 5-7 d or replaced with ASA or CLZ	Thienopyridines discontinued for 5-7 d or replaced with ASA or CLZ
	Warfarin may be continued if in therapeutic range; DOAC is withdrawn on the EST day only	Warfarin stopped 5 d ago and LMWH was started 2 d ago (LMWH also stopped 24 h ago). DOAC stopped 48 h ago	Warfarin users can be treated urgently if INR < 2.5. DOACs should be discontinued prior to treatment, with a discontinuation period of twice the half-life. Heparin replacement is recommended in patients at high risk of thrombosis
	Resumed the next day	Warfarin or DOAC resume within 48 h. Warfarin is used with LMWH until the optimal concentration is reached	Resume at the end of the procedure if hemostasis is confirmed. However, evidence for DOACs and APAs are scant
Stone retrieval	No superiority of balloons and baskets is noted	Efficacy of balloons and baskets is almost equal	Recommend using balloons rather than baskets
Complicated cases of cholangitis	Patients who are hemodynamically unstable, coagulopathic, or receiving antithrombotic agents; it was believed that decompression alone should be considered.EBS and ENBD are almost equal	Not stated	Given that hemodynamically unstable patients might not tolerate procedural bleeding or adverse events, it was believed that decompression alone should be considered in this group as well as for patients who are coagulopathic and/or are receiving antithrombotic agents and those who would need to have anticoagulation resumed immediately after sphincterotomy (e.g., patients with mechanical heart valves)

APA: Antiplatelet agent; ASA: Acetylsalicylic acid; ASGE: American Society for Gastrointestinal Endoscopy; CLZ: Cilostazol; DOAC: Direct oral anticoagulant; EBS: Endoscopic biliary stent; ENBD: Endoscopic nasobiliary drainage; EPBD: Endoscopic papillary balloon dilation; ESGE: European Society of Gastrointestinal Endoscopy; EST: Endoscopic sphincterotomy; JGES: Japan Gastroenterological Endoscopy Society; LMWH: Low-molecular-weight heparin; SAA: Surgically altered anatomy; TG18: Tokyo guideline 2018.