Original article
Systematic reviews and meta-analyses
Balloon Dilation With Adequate Duration Is Safer Than Sphincterotomy for Extracting Bile Duct Stones: A Systematic Review and Meta-analyses

https://doi.org/10.1016/j.cgh.2012.05.017Get rights and content

Background & Aims

Endoscopic sphincterotomy (EST) is the standard treatment for choledocholithiasis. Endoscopic papillary balloon dilation (EPBD) has a lower risk for bleeding than EST, but EPBD is reserved for patients with bleeding diathesis because some studies reported that it increases the risk for pancreatitis. A short dilation time (≤1 minute) is therefore recommended to reduce pancreatitis. However, there is evidence for an inverse relationship between EPBD duration and pancreatitis, prompting reevaluation of the optimal duration and relative safety of EPBD vs EST.

Methods

We systematically reviewed randomized controlled trials to compare long EPBD (>1 minute), short EPBD (≤1 minute), and EST regarding pancreatitis and overall complications. In addition to pairwise meta-analyses, Bayesian network meta-analysis was undertaken to compare the 3 procedures together. Relation between duration and outcome was also analyzed by meta-regression.

Results

Compared with EST, short EPBD had a higher risk for pancreatitis (odds ratio [OR] by traditional analysis, 3.87; 95% confidence interval, 1.08–13.84 and OR by network meta-analysis, 4.14; 95% credible interval, 1.58–12.56), but long EPBD did not pose a higher risk than EST (1.14, 0.56–2.35 and 1.07, 0.38–2.76). Long EPBD had a lower overall rate of complications than EST (0.61, 0.36–1.04 and 0.54, 0.20–1.36). In network meta-analysis, probabilities of being the safest treatment for long EPBD/short EPBD/EST regarding pancreatitis and overall complications were 43.9%/0.2%/55.9% and 90.3%/1.3%/8.4%, respectively.

Conclusions

Duration of EPBD is inversely associated with pancreatitis risk. Currently recommended ≤1-minute dilation actually increases pancreatitis. EPBD with adequate duration may be preferred over EST because of comparable pancreatitis but lower overall complication rates.

Section snippets

Data Sources and Searches

This systematic review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline.15 The MEDLINE was searched for RCTs of EPBD for bile duct stone until end of August 2011 without language or date restriction by using the following keywords: endoscopic papillary balloon dilation/dilatation, endoscopic sphincteroplasty, endoscopic balloon sphincter dilation/dilatation, and endoscopic balloon dilation/dilatation. Cochrane Collaboration Central Register of

Results

All included RCTs have been published in full manuscript form. Outcomes and detailed characteristics are summarized in Table 1 and Supplementary Table 1. Eleven studies compared EPBD vs EST without significant small study bias (Supplementary Figure 2); four compared short EPBD (total n = 459) vs EST (total n = 464), and seven compared long EPBD (total n = 277) vs EST (total n = 279). Only one study compared long EPBD vs short EPBD.

Discussion

Although EPBD has a lower risk of post-ERCP bleeding1, 11 and long-term complications than EST11, 29 and is easier to perform in altered/difficult anatomy,30, 31 EPBD is reserved for patients with bleeding diathesis by current consensus because some studies reported a higher risk of pancreatitis,2, 7 and short dilation (≤1 minute) is recommended for presumably lower pancreatitis risk.1, 2, 12 However, our meta-analyses indicate that short EPBD duration increases rather than decreases the risk

Conclusions

Our meta-analyses suggest that compared with EST, treating bile duct stones with EPBD >1 minute may reduce bleeding/overall complications without increasing the risk of pancreatitis. Currently recommended EPBD with ≤1-minute duration has a higher pancreatitis risk than EPBD >1 minute and EST. EPBD with an adequate duration (around 5 minutes) has lower complication rates than the current standard of EST and may be used as the first-line treatment for bile duct stones.

References (48)

  • G. Ersoz et al.

    Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract

    Gastrointest Endosc

    (2003)
  • S. Jeong et al.

    Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study

    Gastrointest Endosc

    (2009)
  • M.A. Anderson et al.

    Management of antithrombotic agents for endoscopic procedures

    Gastrointest Endosc

    (2009)
  • M.L. Freeman

    Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

    Clin Gastroenterol Hepatol

    (2007)
  • T. Aizawa et al.

    Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones

    Gastrointest Endosc

    (2001)
  • M.L. Freeman et al.

    Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success

    Gastrointest Endosc

    (2004)
  • A. Smithline et al.

    Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients

    Gastrointest Endosc

    (1993)
  • S. Tanaka et al.

    Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial

    Gastrointest Endosc

    (2004)
  • T.H. Baron et al.

    Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials

    Am J Gastroenterol

    (2004)
  • P. Vlavianos et al.

    Endoscopic balloon dilatation versus endoscopic sphincterotomy for the removal of bile duct stones: a prospective randomised trial

    Gut

    (2003)
  • A. Minami et al.

    Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones: a randomized trial with manometric function

    Dig Dis Sci

    (1995)
  • Y. Komatsu et al.

    Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases

    Endoscopy

    (1998)
  • H. Sato et al.

    Endoscopic papillary balloon dilatation may preserve sphincter of Oddi function after common bile duct stone management: evaluation from the viewpoint of endoscopic manometry

    Gut

    (1997)
  • B.M. Weinberg et al.

    Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones

    Cochrane Database Syst Rev

    (2006)
  • Cited by (0)

    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by an International Joint Grant from the Royal Society, London, UK, and National Science Council, Taiwan, and by National Taiwan University Hospital.

    View full text