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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2016; 22(26): 5909-5916
Published online Jul 14, 2016. doi: 10.3748/wjg.v22.i26.5909
Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?
Toshio Fujisawa, Koichi Kagawa, Kantaro Hisatomi, Kensuke Kubota, Atsushi Nakajima, Nobuyuki Matsuhashi
Toshio Fujisawa, Koichi Kagawa, Kantaro Hisatomi, Nobuyuki Matsuhashi, Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
Kensuke Kubota, Atsushi Nakajima, Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0027, Japan
Author contributions: Fujisawa T, Kubota K, Nakajima A and Matsuhashi N planned and designed the study; Fujisawa T, Kubota K, Hisatomi K and Kubota K performed the EPBD/EPLBD comparisons; Fujisawa T, Hisatomi K and Matsuhashi N wrote the manuscript; All authors approved the authorship.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Toshio Fujisawa, MD, PhD, Department of Gastroenterology, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa, Tokyo 141-8625, Japan.
Telephone: +81-3-34486111 Fax: +81-3-34486541
Received: February 13, 2016
Peer-review started: February 13, 2016
First decision: March 21, 2016
Revised: March 23, 2016
Accepted: April 7, 2016
Article in press: April 7, 2016
Published online: July 14, 2016

Endoscopic papillary balloon dilatation (EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography (ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis (PEP). However, as the efficacy of endoscopic papillary large-balloon dilatation (EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy (EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Keywords: Endoscopic papillary balloon dilatation, Post-endoscopic retrograde cholangio-pancreatography pancreatitis, Endoscopic papillary large-balloon dilatation, Endoscopic sphincterotomy, Randomized controlled trial

Core tip: Some recent studies suggest that Endoscopic papillary balloon dilatation (EPBD) itself does not increase post-endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis (PEP) incidence. Theoretically, endoscopic papillary large-balloon dilatation (EPLBD) can damage the papilla more than EPBD does, but even direct EPLBD without preceding sphincterotomy does not increase PEP rate. An explanation for this paradox is that procedures following EPBD, but not EPBD itself, induce PEP. Since the EPBD stress is limited around the papilla, a prophylactic pancreatic stent could protect against the damage related to EPBD. EPBD has many advantages that endoscopic sphincterotomy does not. Therefore, it is time to re-evaluate the risks and efficacy of EPBD, and to utilize it suitably instead of shelving it.