Published online Jul 16, 2022. doi: 10.4253/wjge.v14.i7.424
Peer-review started: January 21, 2022
First decision: April 19, 2022
Revised: May 10, 2022
Accepted: June 24, 2022
Article in press: June 24, 2022
Published online: July 16, 2022
Endoscopic papillary large balloon dilation is increasingly being used in treating difficult bile duct stones, since it is faster and less laborious than performing multiple mechanical lithotripsies, with comparable results in terms of safety and effectiveness. However, this method is not recommended in patients with nondilated distal bile ducts, due to a theoretically higher complication rate, especially perforation.
Papillary large balloon dilation is an important tool to extract difficult duct stones and very few studies examined this technique in patients with nondilated distal ducts, although in its original report, this method was used in this setting.
To analyze the feasibility of papillary large balloon dilation in patients with difficult bile duct stones and nondilated distal bile ducts, as well as the complication rate and effectiveness of this method in this subset of stone patients. To investigate the demographic characteristics of this patient group. Data on these issues may stimulate future research and assist endoscopists in choosing the best endoscopic modality to treat difficult bile duct stones.
We retrieved data from 1289endoscopic retrograde cholangiopancreatography (ERCP) procedures from 2 prospective randomized controlled trials dealing with post-ERCP pancreatitis (PEP). Of these, 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct) and 191 underwent papillary large balloon dilation up to 15 mm after endoscopic sphincterotomy for stone retrieval. Cholangiographies of these cases were retrospectively reviewed by the authors in order to classify the distal bile duct as dilated or nondilated, as well as stone size and number. Primary outcomes were clearance rate at first ERCP and complications.
Of the 191 patients, 113 (59%) had a nondilated or tapered distal duct (75 F/38 M, mean age: 52 years) and 78 (47 F/31 M mean age: 68 years) a dilated distal duct. Cases with a nondilated distal duct had fewer (mean = 2 vs 4.1, P < 0.05) and smaller (mean 1.1 cm vs 1.7 cm, P < 0.05) stones than those with a dilated distal duct and were significantly younger than patients with dilated distal). Patients with a nondilated distal duct were also significantly younger and more likely to receive mechanical lithotripsy (25% vs 6.4%, P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, P < 0.005). Complications were similar in both groups: 8/113 (7.1%) vs 5/78 (6.4%), however the 2 perforations occurred in patients with nondilated ducts. There was no mortality.
Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct. Although the latter patients had smaller stones, they are more difficult to remove, since ERCP procedures in these patients require mechanical lithotripsy more often and last longer.
Future prospective multicenter studies should evaluate the feasibility of large balloon dilation in patients with nondilated distal bile ducts and difficult stones, since current guidelines do not recommend the procedure in this group of patients.