Endoscopic Papillary Large Balloon Dilation Reduces the Need for Mechanical Lithotripsy in Patients with Large Bile Duct Stones: A Systematic Review and Meta-Analysis
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]; ) and stone clearance at the 1st session (87% versus 79%, RR = 1.11 [0.98, 1.25]; ). ES + EPLBD was associated with a reduced need for ML compared to ES alone (15% versus 32%; RR？ =？ 0.49 [0.32, 0.74]; ) and was also associated with a reduction in the overall rate of adverse events (11% versus 18%; RR = 0.58 [0.41, 0.81]; ). 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. 1. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) represents the standard of care for management of bile duct stones [1]. However, removal of stones > 10？mm in diameter can be challenging and often requires the use of mechanical lithotripsy (ML) [2, 3]. Dilation of the biliary orifice and distal common bile duct (CBD) after ES using 12- to 20？mm esophageal or pyloric-type balloons was first described in 2003 as an alternative technique to manage large bile duct stones [4]. The safety and efficacy of this technique, termed endoscopic papillary large balloon dilation (EPLBD), have been confirmed in a number of subsequent reports [5–7]. However, studies comparing ES + EPLBD versus ES alone have not
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