Role of Limited Endoscopic Sphincterotomy (ES) and Endoscopic Papillary Large-Balloon Dilation (EPLBD) in the Management of Difficult Common Bile Duct Stones: A Single-Center Experience
DOI:
https://doi.org/10.35790/msj.v7i2.59702Abstract
Abstract: Difficult common bile duct (CBD) stones provide challenges in their therapeutic management, especially per endoscopic treatment. In this study, the author would like to show the effectiveness of limited ES and EPLBD in the management of patients with difficult CBD stones in their center. This is a retrospective study from June 2020 to April 2024, in which patients with difficult CBD stones received endoscopic management with limited endoscopic sphincterotomy and EPLBD. Length of procedure, success rate, morbidity, and mortality rate were recorded and evaluated. The results showed that a total of 98 patients were included in the study, ages ranging from 23 to 83 y.o. The length of the procedure was 44 + 11 minutes, with the success rate of CBD stone retrieval and duct clearance at 70.4%. Etiologies of difficult CBD stones consist of stone size > 1.5 cm (47.96%), combined cause (27.55%), multiple CBD stones less than 1.5 cm (13.26%), and tapering of distal CBD (11.22%). Morbidities such as melena (5.1%), post-ERCP pancreatitis (PEP) (3.06%), cholangitis (1.02%), and duodenal perforation (1.02%) occurred. One mortality incidence occurred due to severe cholangitis and sepsis. The mean period of EPLBD performed was 2.7 + 1.57 minutes. The pressure strength of the CRE balloon dilator commonly used was 4.5 atm. In conclusion, limited ES and EPLBD offer quite satisfactory results in the management of difficult CBD stones, with the success rate as high as 70.4% and an acceptable morbidity rate.
Keywords: endoscopic papillary large-balloon dilation (EPLBD); difficult CBD stones
References
Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterol. 1999;117(3):632–9. Doi: 10.1016/s0016-5085(99)70456-7
Shaffer EA. Epidemiology of gallbladder stone disease. Best Practice & Research Clinical Gastroenterology. 2006;20(6):981–96. Doi: 10.1016/j.bpg.2006.05.004
Tazuma S. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Practice & Research Clinical Gastroenterology. 2006;20(6):1075–83. Doi: 10.1016/j.bpg.2006.05.009
Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G. Prediction of common bile duct stones by noninvasive tests. Ann Surg. 1999;229(3):362–8. Doi: 10.1097/00000658-199903000-00009
Halldestam I, Enell EL, Kullman E, Borch K. Development of symptoms and complications in individuals with asymptomatic gallstones. Br J Surg. 2004;91(6):734–8. Doi: 10.1002/bjs.4547
Fein M, Bueter M, Sailer M, Fuchs KH. Effect of cholecystectomy on gastric and esophageal bile reflux in patients with upper gastrointestinal symptoms. Digestive Diseases and Sciences. 2008;53(5):1186–91. Doi: 10.1007/s10620-007-9989-8
Gracie WA, Ransohoff DF. The natural history of silent gallstones. NEJM. 1982;307(13):798–800. Doi: 10.1056/NEJM198209233071305
McSherry CK, Ferstenberg H, Calhoun WF, Lahman E, Virshup M. The natural history of diagnosed gallstone in symptomatic and asymptomatic disease patients. Ann Surg. 1985;202(1):69. Doi: 10.1097/00000658-198507000-00009
Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019;51(05):472–91. Doi: 10.1055/a-0862-0346
Wilcox CM, Kim H, Trevino J, Ramesh J, Monkemuller K, Varadarajulu S. Prevalence of normal liver tests in patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography. Digestion. 2014;89(3):232–8. Doi: 10.1159/000358384
Qiu Y, Yang Z, Li Z, Zhang W, Xue D. Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound. BMC Gastroenterol. 2015;15(1):158. Doi: 10.1186/s12876-015-0392-1
Trikudanathan G. Endoscopic management of difficult common bile duct stones. World J Gastroenterol. 2013;19(2):165. Doi: 10.3748/wjg.v19.i2.165.
Kim HJ, Choi HS, Park JH, Park DI, Cho YK, Sohn CI, et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc. 2007;66(6):1154–60. Doi: 10.1016/j.gie.2007.04.033
Stefanidis G, Viazis N, Pleskow D, Manolakopoulos S, Theocharis L, Christodoulou C, et al. Large balloon dilation vs. mechanical lithotripsy for the management of large bile duct stones: a prospective randomized study. Am J Gastroenterol. 2011;106(2):278–85. Doi: 10.1038/ajg.2010.421.
Heo JH, Kang DH, Jung HJ, Kwon DS, An JK, Kim BS, et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointestinal Endoscopy. 2007;66(4):720–6. Doi: 10.1016/j.gie.2007.02.033
Teoh AYB, Cheung FKY, Hu B, Pan YM, Lai LH, Chiu PWY, et al. Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones. Gastroenterology. 2013;144(2):341-345.e1. Doi: 10.1053/j.gastro.2012.10.027
Park SJ, Kim JH, Hwang JC, Kim HG, Lee DH, Jeong S, et al. Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series. Digestive Diseases and Sciences. 2013;58(4):1100–9. Doi: 10.1007/s10620-012-2494-8
Paspatis GA, Konstantinidis K, Tribonias G, Voudoukis E, Tavernaraki A, Theodoropoulou A, et al. Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: a randomized controlled trial. Digestive and Liver Disease. 2013;45(4):301–4. Doi: 10.1016/j.dld.2012.10.015
Testoni P, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(07):657–83. Doi: 10.1055/s-0042-108641
Dumonceau JM, Andriulli A, Elmunzer B, Mariani A, Meister T, Deviere J, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated June 2014. Endoscopy. 2014;46(09):799–815. Doi: 10.1055/s-0034-1377875
Carr-Locke DL. Difficult bile-duct stones: cut, dilate, or both? Gastrointestinal Endoscopy. 2008;67(7):1053–5. Doi: 10.1016/j.gie.2008.02.003
Oh CH, Dong SH. Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy. Korean Journal of Internal Medicine. 2021;36(2):235–46. Doi: 10.3904/kjim.2020.425
Kuo CM, Chiu YC, Liang CM, Wu CK, Lu LS, Tai WC, et al. The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones. BMC Gastroenterol. 2019;19(1):93. Doi: 10.1186/s12876-019-1017-x
Kogure H, Kawahata S, Mukai T, Doi S, Iwashita T, Ban T, et al. 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(09):736–44. Doi: 10.1055/a-1145-3377
Soliman GM, Bakr IS, Alwasif A. Comparative study between endoscopic papillary balloon dilation and endoscopic sphincterotomy for enlargement of papillary opening during endoscopic removal of common bile duct stones. International Journal of Multidisciplinary Research and Development. 2018; 5(4):55–60. Available from: https://www.allsubjectjournal.com/assets/archives/2018/vol5issue4/5-3-27-103.pdf
Sugiyama M. Does endoscopic sphincterotomy cause prolonged pancreatobiliary reflux? The American Journal of Gastroenterology. 1999;94(3):795–8. Doi: 10.1111/j.1572-0241.1999.00953.x
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;13(1):1. Doi: https://doi.org/10.1186/s43066-023-00235-1
Liao W, Tu Y, Wu M, Wang H, Lin J, Leung JW, et al. Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses. Clinical Gastroenterology and Hepatology. 2012;10(10):1101–9. Doi: 10.1016/j.cgh.2012.05.017
Guo SB, Meng H, Duan ZJ, Li CY. Small sphincterotomy combined with endoscopic papillary large balloon dilation vs sphincterotomy alone for removal of common bile duct stones. World J Gastroenterol. 2014;20(47):17962–9. Doi: 10.3748/wjg.v20.i47.17962
Ishii S, Fujisawa T, Ushio M, Takahashi S, Yamagata W, Takasaki Y, et al. Evaluation of the safety and efficacy of minimal endoscopic sphincterotomy followed by papillary balloon dilation for the removal of common bile duct stones. Saudi J Gastroenterol. 2020;26(6):344–50. Doi: 10.4103/sjg.SJG_162_20
Sadeghi A, Dooghaie Moghadam A, Jamshidizade S, Norouzinia M, Jamshidfar N, Hosseini P. Comparison of endoscopic balloon dilatation potency using balloons size more or less than 15 mm in the treatment of large bile duct stones: a clinical trial study. Gastroenterology and Hepatology from Bed to Bench. 2021;14(Suppl1):S112–7. Doi: https://doi.org/10.22037/ghfbb.vi.2288
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Michael Tendean, Toar D. B. Mambu, Ferdinand Tjandra, Billy E. C. R. Salem, Jimmy Panelewen, Steven Paparang
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
COPYRIGHT
Authors who publish with this journal agree to the following terms:
Authors hold their copyright and grant this journal the privilege of first publication, with the work simultaneously licensed under a Creative Commons Attribution License that permits others to impart the work with an acknowledgment of the work's origin and initial publication by this journal.
Authors can enter into separate or additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (for example, post it to an institutional repository or publish it in a book), with an acknowledgment of its underlying publication in this journal.
Authors are permitted and encouraged to post their work online (for example, in institutional repositories or on their website) as it can lead to productive exchanges, as well as earlier and greater citation of the published work (See The Effect of Open Access).
