• Common bile duct stones
• Complications
• Efficacy
• Endoscopic papillary large balloon dilatation
• Endoscopic papillary sphincterotomy
• Mechanical lithotripsy

• Humans
• Sphincterotomy, Endoscopic/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Gallstones/therapy
• Choledocholithiasis/therapy
• Dilatation/methods
• Treatment Outcome
• Catheterization/methods

To systematically evaluate the application effect of endoscopic papillary balloon dilatation (EPBD) with different balloon dilatation duration for biliary duct calculi, and find the most appropriate dilatation duration for EPBD using a network meta-analysis.

PubMed, Embase and Cochrane Library databases were searched for relevant randomised controlled trials (RCTs) published up to August 2020. Node split, consistency and inconsistency models analysis were all conducted in network meta-analysis.

Eighteen RCTs with 2256 participants were finally analysed. EPBD was divided into four categories based on balloon dilatation duration, including EPBD (P0.5), EPBD (>0.5, ≤1), EPBD (1, ≤2) and EPBD (>2, ≤5). Compared with EPBD (>0.5, ≤1), EPBD (>2, ≤5) had a lower risk of early complications (odds ratio [OR] = 0.23, 95% credible interval [CI] = 0.05–0.96) and post-endoscopic procedure pancreatitis (PEP) (OR = 0.17, 95% CI = 0.03–0.72). Endoscopic sphincterotomy (EST) tended to have less need for mechanical lithotripsy (OR = 0.37, 95% CI = 0.16–0.88) and PEP (OR = 0.26, 95% CI = 0.08–0.71) than EPBD (>0.5, ≤1). EPBD (>2, ≤5) was the safest endoscopic procedure with respect to early complications (surface area under cumulative ranking curves [SUCRA] = 79.0) and PEP (SUCRA = 85.3). In addition, EPBD (>2, ≤5) and EST had the highest probability of being the best (SUCRA = 82.6) and the worst (SUCRA = 10.8), respectively, regarding late complications.

EPBD and EST are two methods used to treat uncomplicated choledocholithiasis (stone diameter <10 mm and stone number <3). The extension of balloon dilatation duration has no significant influence on successful stone removal in the first endoscopic session or preventing the need for mechanical lithotripsy. However, it can reduce the risk of early complications, especially PEP. What's more, EPBD seems to have less late complications compared with EST, and the effect of prolonged balloon dilatation duration on late complications still needs to be further explored. Therefore, 2–5 min is the recommended dilatation duration range for EPBD using balloon with ≤10 mm diameter. Further research based on a specific population and with a longer follow-up time are needed.

• Endoscopic
• endoscopic papillary balloon dilatation
• gallstones
• network meta-analysis
• sphincterotomy

• EPLBD
• ERCP
• endoscopic papillary large balloon dilation
• endoscopic retrograde cholangiopancreatography
• guidelines

• ERCP
• EST
• endoscopic retrograde cholangiopancreatography
• endoscopic sphincterotomy
• guideline

The aim of the study was to evaluate the safety and efficacy of extending a previous endoscopic sphincterotomy (ES) in patients with retained or recurrent common bile duct (CBD) stones.

Between 2001 and 2013, extension of a previous ES, for known or suspected CBD stones, was performed in 118 patients (m/f, 53/65) with a median age of 74 (range: 31-91) years (group A). During the same period, ES was performed in 1064 patients with suspected or known choledocholithiasis (group B). The efficacy and complications of the extension (group A) were analyzed and a comparison was made between groups regarding complications.

Bile duct cannulation was straightforward in all patients in group A, while it was considered difficult in 49% of patients in group B. Complete clearance was achieved in 76/97 patients (78%) with CBD stones, after a mean of 1.18 attempts per patient. Mechanical lithotripsy was required in 10% of patients. After extension, immediate bleeding occurred in 24 patients (20%), which stopped spontaneously in 9 (37%) and endoscopic hemostasis was required in the remainder. Complications were more frequent in group B (5.3% vs. 0.8%, P=0.031), but there was no significant difference for any individual complication. Immediate bleeding was more common in group B (29% vs. 20%, P=0.035), but there was no difference in clinical bleeding.

Extension of a previous ES seems to be a simple, effective and safe technique, allowing stone clearance in nearly 80% of patients; it is thus recommended in patients with CBD stones after ES.

• Endoscopic sphincterotomy
• balloon dilation
• choledocholithiasis
• complications
• extension
• recurrent stones
• retained stones
• sphincteroplasty

To describe the efficacy and safety of endoscopic papillary large balloon dilatation (EPLBD) in the management of bile duct stones in a Western population.

Data was collected from the endoscopic retrograde cholangiopancreatography (ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1^st August 2009 to 31^st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore, we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.

EPLBD was performed in 229 patients (46 females) with mean age of 68 ± 14.3 years. 115/229 (50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP (1^st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81 (35.4%). Median balloon size was 13.5 mm (10 - 18). In addition to EPLBD, per-oral cholangioscopy (POC) and electrohydraulic lithotripsy (EHL) was performed in 35 (15%) patients at index* ERCP. 63 (27.5%) required repeat ERCP for stone clearance. 28 (44.5%) required POC and EHL and 11 (17.4%) had repeat EPLBD for complete duct clearance. Larger stone size (12.4 mm vs 17.4 mm, P < 0.000001), multiple stones (2, range (1-13) vs 3, range (1-12), P < 0.006) and dilated common bile duct (CBD) (12.4 mm vs 18.3 mm, P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients (20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis (0.87%) each.

EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.

• Endoscopic sphincterotomy
• endoscopic papillary large balloon dilatation
• Endoscopic retrograde cholangiopancreatography
• Adverse events
• Common bile duct stones

• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde
• Cholelithiasis/diagnostic imaging
• Cholelithiasis/surgery
• Cross-Sectional Studies
• Dilatation/adverse effects
• Dilatation/methods
• Female
• Humans
• Male
• Middle Aged
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Recurrence
• Sphincterotomy, Endoscopic/adverse effects
• Sphincterotomy, Endoscopic/methods
• Time Factors
• Treatment Outcome

• Biliary tract infection
• Endoscopic retrograde cholangiopancreatography
• Escherichia coli
• Multiple drug resistance
• Virulence

• Ampulla of Vater/surgery
• Catheterization
• Dilatation/methods
• Gallstones/surgery
• Humans
• International Cooperation
• Lithotripsy/methods
• Practice Guidelines as Topic
• Sphincterotomy, Endoscopic

• Adult
• Choledocholithiasis/surgery
• Dilatation/instrumentation
• Dilatation/methods
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Recurrence
• Risk Factors
• Sphincterotomy, Endoscopic
• Time Factors
• Young Adult

AIM: To investigate whether endoscopic papillary large balloon dilation (EPLBD) can be safety and effectively performed in patients aged ≥ 80 years.

METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A (< 80 years) and group B (≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies (ERCP), and incidence of complications were examined in both groups.

RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent (P < 0.05). The success rate of the initial lithotomy was 88.7 (94/106)%. The final lithotomy rate was 100 (106/106)%. Complications due to treatment procedure occurred in 4.72 (5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.

CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.

• Elderly patients
• Endoscopic papillary large balloon dilation
• Endoscopic sphincterotomy
• Large bile duct stones
• Choledocholithiasis

• endoscopic papillary large balloon dilation
• endoscopic sphincterotomy
• large balloon dilation
• large bile duct stone

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• Endoscopic papillary balloon dilation
• Endoscopic papillary large balloon dilation
• Common bile duct stone

• Acute Disease
• Catheters
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholangiopancreatography, Endoscopic Retrograde/mortality
• Choledocholithiasis/diagnosis
• Choledocholithiasis/therapy
• Dilatation/adverse effects
• Equipment Design
• Humans
• Pancreatitis/diagnosis
• Pancreatitis/etiology
• Pancreatitis/mortality
• Risk Factors
• Severity of Illness Index
• Treatment Outcome

• Endoscopic papillary large balloon dilation
• Endoscopic retrograde cholangiopancreatography
• Endoscopic sphincterotomy
• Large bile duct stones
• Multiple bile duct stones

• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholelithiasis/diagnosis
• Cholelithiasis/therapy
• Dilatation
• Female
• Humans
• Japan
• Lithotripsy
• Male
• Middle Aged
• Prospective Studies
• Sphincterotomy, Endoscopic
• Treatment Outcome

Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (≥ 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

• Bile duct stone
• Endoscopic papillary large balloon dilation
• Endoscopic sphincterotomy
• Endoscopic retrograde cholangiopancreatography
• Mechanical lithotripsy

• Common Bile Duct/surgery
• Dilatation/adverse effects
• Dilatation/instrumentation
• Equipment Design
• Gallstones/diagnosis
• Gallstones/surgery
• Humans
• Risk Factors
• Sphincterotomy, Endoscopic/adverse effects
• Treatment Outcome

• endoscopic papillary large balloon dilation
• endoscopic sphincterotomy
• recurrent bile duct stone

• billroth ii gastrectomy
• endoscopic papillary large balloon dilation
• endoscopic sphincterotomy

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

• Balloon dilation
• Endoscopic sphincterotomy
• Common bile duct gallstones
• Lithotripsy
• Complications
• Assessment
• Patient outcomes

• Biliary Tract Surgical Procedures/adverse effects
• Biliary Tract Surgical Procedures/methods
• Cholelithiasis/diagnosis
• Cholelithiasis/surgery
• Dilatation
• Endoscopy/adverse effects
• Endoscopy/methods
• Humans
• Patient Selection
• Postoperative Complications/etiology
• Practice Guidelines as Topic
• Risk Factors
• Sphincterotomy, Endoscopic
• Treatment Outcome

AIM: To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) for bile duct stone extraction in patients with periampullary diverticula.

METHODS: The records of 223 patients with large common bile duct stones (≥ 10 mm) who underwent EPLBD (12-20 mm balloon diameter) with or without limited endoscopic sphincterotomy (ES) from July 2006 to April 2011 were retrospectively reviewed. Of these patients, 93 (41.7%) had periampullary diverticula (PAD), which was categorized into three types. The clinical variables of EPLBD with limited ES (EPLBD + ES) and EPLBD alone were analyzed according to the presence of PAD.

RESULTS: Patients with PAD were significantly older than those without (75.2 ± 8.8 years vs 69.7 ± 10.9 years, P = 0.000). The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and non-PAD groups, however, there was significantly less need for mechanical lithotripsy in the PAD group (3.2% vs 11.5%, P = 0.026). Overall stone removal rates, complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD + ES and EPLBD alone in patients with PAD (96.6% vs 97.1%; 72.9% vs 88.2%; and 5.1% vs 0%, respectively). No significant differences with respect to the rates of pancreatitis, perforation, and bleeding were observed between EPLBD + ES and EPLBD alone in the PAD group (3.4% vs 14.7%, P = 0.095; 0% vs 0%; and 3.4% vs 8.8%, P = 0.351, respectively).

CONCLUSION: EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD, regardless of PAD subtypes.

• Endoscopic papillary large balloon dilation
• Endoscopic sphincterotomy
• Periampullary diverticula

• Adult
• Aged
• Aged, 80 and over
• Analysis of Variance
• Chi-Square Distribution
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Choledocholithiasis/complications
• Choledocholithiasis/diagnosis
• Choledocholithiasis/therapy
• Dilatation
• Diverticulum/complications
• Duodenal Diseases/complications
• Female
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Sphincterotomy, Endoscopic
• Treatment Outcome

• Aged
• Aged, 80 and over
• Ampulla of Vater/surgery
• Anticoagulants/administration & dosage
• Catheterization/adverse effects
• Chi-Square Distribution
• Dilatation/adverse effects
• Female
• Gabexate/administration & dosage
• Gallstones/pathology
• Gallstones/therapy
• Hemorrhage/etiology
• Humans
• Male
• Middle Aged
• Pancreatitis/etiology
• Sphincterotomy, Endoscopic/adverse effects
• Statistics, Nonparametric
• Treatment Outcome

Since endoscopic papillary large balloon dilation (EPLBD) is used to treat benign disease and as a substitute for conventional methods, such as endoscopic sphincterotomy plus endoscopic mechanical lithotripsy, we should aim for zero mortality. This review defines EPLBD and suggests guidelines for its use based on a review of published articles and our large-scale multicenter retrospective review.

• Endoscopic papillary large balloon dilation
• Endoscopic sphincterotomy
• Mechanical lithotripsy

• Catheterization/adverse effects
• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Choledocholithiasis/surgery
• Choledocholithiasis/therapy
• Humans
• Lithotripsy
• Randomized Controlled Trials as Topic
• Research Design
• Sphincterotomy, Endoscopic/adverse effects
• Sphincterotomy, Endoscopic/methods
• Treatment Outcome