(D) Occlusion cholangiogram showing no residual filling defect.ĭespite the use of EPLBD, approximately 30% of stone removal cases remain unsuccessful. (C) A large stone removed with an extraction balloon. (B) Endoscopic view of EPLBD after sphincterotomy. (A) Cholangiogram showing a large bile duct stone. Ī large bile duct stone successfully treated with endoscopic papillary large balloon dilation (EPLBD). Notably, the anecdotal concern about the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis after balloon sphincteroplasty has been cleared by a recent meta-analysis showing that EPLBD without prior sphincterotomy did not increase the risk of pancreatitis.
Limited sphincterotomy is recommended before performing EPLBD. In addition, the risk of bleeding can be minimized by choosing an adequate balloon inflation time (approximately 60 sec) and avoiding a large sphincterotomy before performing sphincteroplasty. Because of safety concerns, EPLBD is contraindicated in the presence of biliary strictures or significantly tapered bile ducts, and the selected balloon size should not exceed the bile duct diameter to reduce the risk of perforation. Both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) recommend the use of EPLBD when dealing with difficult biliary stones. 1) can result in up to a 50% reduction in the need for mechanical lithotripsy (ML). Endoscopic papillary large balloon dilation (EPLBD) with a balloon sized ≥12 mm ( Fig. The two main principles to facilitate stone removal in this situation are expanding the stone passage and reducing the stone size. Stone factors (e.g., size, number, or shape), bile duct factors (e.g., associated stricture, narrowing, or angulation), and the relationship between the stone and the bile duct (e.g., impacted stone) influence the success of stone extraction.
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However, there is a 15% failure rate of bile duct stone removal with standard biliary sphincterotomy plus stone extraction with either a balloon, a basket catheter, or their combination. Since the introduction of endoscopic biliary sphincterotomy in 1974, the management of bile duct stones has shifted from surgical bile duct exploration to an endoscopic approach. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy.
It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. EPLBD can reduce the procedural time by shortening the stone removal process. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. A few decades ago, mechanical lithotripsy was usually required to manage these stones. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. However, there are difficult stones that cannot be removed using these standard methods. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography.
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