Opinion Review
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Feb 16, 2021; 13(2): 33-44
Published online Feb 16, 2021. doi: 10.4253/wjge.v13.i2.33
Dilation assisted stone extraction for complex biliary lithiasis: Technical aspects and practical principles
Giuseppe Grande, Silvia Cocca, Helga Bertani, Angelo Caruso, Flavia Pigo', Santi Mangiafico, Salvatore Russo, Marinella Lupo, Graziella Masciangelo, Paolo Cantu', Raffaele Manta, Rita Conigliaro
Giuseppe Grande, Silvia Cocca, Helga Bertani, Angelo Caruso, Flavia Pigo', Santi Mangiafico, Salvatore Russo, Marinella Lupo, Graziella Masciangelo, Rita Conigliaro, Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
Paolo Cantu', Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milano 20122, Italy
Raffaele Manta, Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia, Perugia 06129, Italy
Author contributions: Grande G and Conigliaro R conceived and designed the study; Grande G, Caruso A, Bertani H, Manta R, and Mangiafico S equally contributed to each topic of the project; Pigo F, Marocchi M, Cantù P, Russo S, Lupo M, and Masciangelo G contributed to the analytic tools and bibliography research; Grande G and Cocca S analyzed the data and wrote the manuscript; Caruso A and Mangiafico S revised the figures; All authors have read and approved the final manuscript.
Conflict-of-interest statement: All authors declare no conflict of interests.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Giuseppe Grande, MD, Staff Physician, Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Via Pietro Giardini 1355, Modena 41126, Italy. grande.giuseppe@aou.mo.it
Received: September 21, 2020
Peer-review started: September 21, 2020
First decision: December 11, 2020
Revised: December 27, 2020
Accepted: January 22, 2021
Article in press: January 22, 2021
Published online: February 16, 2021
Processing time: 135 Days and 5.7 Hours
Abstract

Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography. Endoscopic sphincterotomy (EST) has been used for the removal of bile duct stones for the past 40 years, providing a wide opening to allow extraction. Up to 15% of patients present with complicated choledocholithiasis. In this context, additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy, intraductal or extracorporeal lithotripsy, or endoscopic papillary large balloon dilation (EPLBD). EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter. EPLBD without EST was introduced as a simplified technique in 2009. Dilation-assisted stone extraction (DASE) is the combination of two techniques: EPLBD and sub-maximal EST. Several studies have reported this technique as safe and effective in patients with large bile duct stones, without any increased risk of adverse events such as pancreatitis, bleeding, or perforation. Nevertheless, it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies. The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE, based on current literature and daily clinical experience in biliary referral centers.

Keywords: Dilation-assisted stone extraction; Endoscopic papillary large balloon dilation; Macrolithiasis; Difficult choledochiolithiasis; Stone treatment; Common bile duct stones; Endoscopic retrograde cholangiopancreatography

Core Tip: This narrative and practical review has been written to clarify some issues and key points regarding the treatment of difficult common bile duct stone using dilation assisted stone extraction technique.