Original Article: Clinical Endoscopy
Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones

https://doi.org/10.1016/j.gie.2007.02.033Get rights and content

Background

Endoscopic sphincterotomy (EST) to remove bile-duct stones is the most frequently used endoscopic technique. Few reports exist regarding application of large-balloon dilation (LBD) after EST for treatment of patients with bile-duct stones.

Objective

To compare the effect of EST plus LBD with that of EST alone.

Design

A prospective randomized controlled trial.

Setting

A large tertiary-referral center.

Patients and Interventions

Two hundred consecutive patients with bile-duct stones were randomized in equal numbers to EST plus LBD (12- to 20-mm balloon diameter) or EST alone.

Main Outcome Measurements

Successful stone removal and complications such as pancreatitis and bleeding.

Results

EST plus LBD compared with EST alone resulted in similar outcomes in terms of overall successful stone removal (97.0% vs 98.0%), large size (>15 mm) stone removal (94.4% vs 96.7%), and the use of mechanical lithotripsy (8.0% vs 9.0%). Complications were similar between the 2 groups (5.0% vs 7.0%, P = .767). Complications were as follows for the EST plus LBD group and the EST group: pancreatitis, 4.0% and 4.0%; cholecystitis, 1.0% and 1.0%; and bleeding (delayed), 0% and 2.0%, respectively.

Conclusions

Based on the similar rates of successful stone removal and complications, EST plus LBD should be an effective alternative to EST. EST plus LBD is a safe and effective treatment for endoscopic removal of common bile duct stones.

Section snippets

Patients

Inclusion criteria were the following: (1) choledocholithiasis, 40 mm or less in maximum shorter diameter (ie, the shorter diameter of the largest stone) and (2) deep cannulation of the bile ducts, with or without needle-knife sphincterotomy. Exclusion criteria included coagulopathy (international normalized ratio [INR] > 1.5), platelet count <50,000/mL, anticoagulation therapy within 72 hours of the procedure, acute pancreatitis, septic shock, prior EST, Billroth II or Roux-en-Y anatomy, stone

Methods

ERCP was done with side-viewing endoscopes (JR-240 or TJF-240; Olympus Optical Co, Ltd, Tokyo, Japan). The Olympus electrosurgical unit (UES-30; Olympus) was used at a setting of blended 1 current with a power setting of 40 W/s for both the cut and coagulation currents (cut:coagulation ratio, 4:1). The 2 endoscopists who participated in this study had considerable experience, based on their performance of more than 300 biliary interventions per year. The patients were sedated with a standard

Results

There was no difference between groups 1 and 2 with regard to prothrombin time/INR (1.12 ± 0.3 vs 1.15 ± 0.2, P = .562), periampullary diverticulum (49.0% vs 45.0%, P = .571), pre-cut sphincterotomy (12.0% vs 18.0%, P = .235), or size (16.0 ± 0.7 mm vs 15.0 ± 0.7 mm, P = .283) and number (2.7 ± 2.7 vs 2.2 ± 1.0, P = .141) of stones.

In the first session, stone clearance did not differ significantly between the 2 groups, with 83.0% for group 1 versus 87.0% for group 2, P = .428. In patients whose

Discussion

EST is the most commonly used technique for the removal of bile-duct stones. However, EST carries substantial procedure-related risks, such as hemorrhage and perforation, and perhaps an increased incidence of ascending cholangitis and de novo formation of bile-duct stones, especially in younger patients.3, 17, 18, 19 EPBD has been advocated as an alternative, because it is thought to preserve sphincter of Oddi function and reduce complications, such as hemorrhage and perforation, compared with

Acknowledgments

We thank Myung Hwan Kim, MD, and Ji Ho Lee, MD (University of Ulsan), for their advice and assistance.

References (32)

See CME section; p. 768.

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