Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study

Endoscopy ◽  
2019 ◽  
Vol 51 (11) ◽  
pp. 1066-1073 ◽  
Author(s):  
Phonthep Angsuwatcharakon ◽  
Santi Kulpatcharapong ◽  
Wiriyaporn Ridtitid ◽  
Chaloemphon Boonmee ◽  
Panida Piyachaturawat ◽  
...  
Keyword(s):  
Bile Duct ◽  
Radiation Exposure ◽  
Clearance Rate ◽  
Balloon Dilation ◽  
Laser Lithotripsy ◽  
Stone Clearance ◽  
Mechanical Lithotripsy ◽  
Cbd Stones ◽  
Large Balloon ◽  
Large Balloon Dilation

Abstract Background Endoscopic papillary large-balloon dilation (EPLBD) allows for the complete removal of large common bile duct (CBD) stones without fragmentation; however, a significant proportion of very large stones and stones floating above a tapering CBD require lithotripsy. Mechanical lithotripsy and cholangioscopy-guided laser lithotripsy are both effective for stone fragmentation. This study aimed to directly compare, for the first time, the efficacy of these two techniques in terms of stone clearance rate, procedure duration, patient radiation exposure, and safety. Methods 32 patients with very large CBD stones or with stones floating above a tapering CBD, and in whom extraction after standard sphincterotomy and/or EPLBD had failed, were randomly assigned to mechanical lithotripsy or cholangioscopy-guided laser lithotripsy at two tertiary referral centers. Crossover was allowed as a rescue treatment if the assigned technique failed. Results Patients’ demographic data were not different between the two groups. Mechanical lithotripsy had a significantly lower stone clearance rate in the first session compared with laser lithotripsy (63% vs. 100%; P < 0.01). Laser lithotripsy rescued 60% of patients with failed mechanical lithotripsy by achieving complete stone clearance within the same session. Radiation exposure of patients was significantly higher in the mechanical lithotripsy group than in the laser lithotripsy group (40 745 vs. 20 989 mGycm2; P  = 0.04). Adverse events (13% vs. 6%; P  = 0.76) and length of hospital stay (1 vs. 1 day; P  = 0.27) were not different. Conclusions Although mechanical lithotripsy is the standard of care for a very large CBD stone after failed EPLBD, where available, cholangioscopy-guided laser lithotripsy is considered the better option for the treatment of this entity as it provides a higher success rate and lower radiation exposure.

scholarly journals Endoscopic Papillary Large Balloon Dilation Reduces the Need for Mechanical Lithotripsy in Patients with Large Bile Duct Stones: A Systematic Review and Meta-Analysis

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Mohammad F. Madhoun ◽  
Sachin Wani ◽  
Sam Hong ◽  
William M. Tierney ◽  
John T. Maple
Keyword(s):  
Bile Duct ◽  
Adverse Events ◽  
Fixed Effects ◽  
Balloon Dilation ◽  
Bile Duct Stones ◽  
Stone Clearance ◽  
Mechanical Lithotripsy ◽  
Large Balloon ◽  
Large Balloon Dilation ◽  
Large Bile Duct

Background. Removal of large stones can be challenging and frequently requires the use of mechanical lithotripsy (ML). Endoscopic papillary large balloon dilation (EPLBD) following endoscopic sphincterotomy (ES) is a technique that appears to be safe and effective. However, data comparing ES + EPLBD with ES alone have not conclusively shown superiority of either technique. Objective. To assess comparative efficacies and rate of adverse events of these methods. Method. Studies were identified by searching nine medical databases for reports published between 1994 and 2013, using a reproducible search strategy. Only studies comparing ES and ES + EPLBD with regard to large bile duct stone extraction were included. Pooling was conducted by both fixed-effects and random-effects models. Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated. Results. Seven studies (involving 902 patients) met the inclusion criteria; 3 of 7 studies were prospective trials. Of the 902 patients, 463 were in the ES + EPLBD group, whereas 439 underwent ES alone. There were no differences noted between the groups with regard to overall stone clearance (98% versus 95%, RR  =  1.01 [0.97, 1.05]; P =0.60) and stone clearance at the 1st session (87% versus 79%, RR = 1.11 [0.98, 1.25]; P =0.11). ES + EPLBD was associated with a reduced need for ML compared to ES alone (15% versus 32%; RR  =  0.49 [0.32, 0.74]; P = 0.0008) and was also associated with a reduction in the overall rate of adverse events (11% versus 18%; RR = 0.58 [0.41, 0.81]; P =0.001). Conclusions. ES + EPLBD has similar efficacy to ES alone while significantly reducing the need for ML. Further, ES + EPLBD appears to be safe, with a lower rate of adverse events than traditional ES. ES + EPLBD should be considered as a first-line technique in the management of large bile duct stones.

Blind Laser Lithotripsy Using a Balloon Catheter Combined with Endoscopic Papillary Large Balloon Dilation for Difficult Bile Duct Stones

2009 ◽  
Vol 69 (5) ◽  
pp. AB148
Author(s):  
Hyun Jong Choi ◽  
Jong Ho Moon ◽  
Bong Min Ko ◽  
Hyun Cheol Koo ◽  
Hyung Ki Kim ◽  
...  
Keyword(s):  
Bile Duct ◽  
Balloon Catheter ◽  
Balloon Dilation ◽  
Laser Lithotripsy ◽  
Bile Duct Stones ◽  
Large Balloon ◽  
Large Balloon Dilation

Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: MARVELOUS trial

Endoscopy ◽  
2020 ◽  
Vol 52 (09) ◽  
pp. 736-744 ◽  
Author(s):  
Hirofumi Kogure ◽  
Shuhei Kawahata ◽  
Tsuyoshi Mukai ◽  
Shinpei Doi ◽  
Takuji Iwashita ◽  
...  
Keyword(s):  
Bile Duct ◽  
Adverse Events ◽  
Randomized Trial ◽  
Endoscopic Sphincterotomy ◽  
Balloon Dilation ◽  
Single Session ◽  
Stone Removal ◽  
Cbd Stones ◽  
Large Balloon ◽  
Large Balloon Dilation

Abstract Background Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. Methods This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. Results 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). Conclusion EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.

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