Role of balloon dilation of the graduated endocsopic papillosphincterotomy area in the treatment of patients with «complex» choledocholithiasis

Budzinsky S.A.; Shapovolyants S.G.; Fedorov E.D.; Zakharova M.A.; Chernyakevich P.L.; Platonova E.N.; Plakhov R.V.

doi:https://doi.org/10.17116/endoskop20202604112

S.A. Budzinsky

Pirogov Russian National Research Medical University;
City Clinical Hospital No. 31

S.G. Shapovolyants

Pirogov Russian National Research Medical University

E.D. Fedorov

Pirogov Russian National Research Medical University of the Russian Ministry of Health

SPIN RSCI: 6785-9959
Scopus AuthorID: 7004381289
ORCID: 0000-0002-6036-7061

M.A. Zakharova

Chaika Clinics

ORCID: 0000-0003-3299-4743

P.L. Chernyakevich

City Clinical Hospital No. 31

E.N. Platonova

City Clinical Hospital No. 31

R.V. Plakhov

Pirogov Russian National Research Medical University;
City Clinical Hospital No. 31

Role of balloon dilation of the graduated endocsopic papillosphincterotomy area in the treatment of patients with «complex» choledocholithiasis

Authors:

S.A. Budzinsky, S.G. Shapovolyants, E.D. Fedorov, M.A. Zakharova, P.L. Chernyakevich, E.N. Platonova, R.V. Plakhov

More about the authors

Journal: Endoscopic Surgery. 2020;26(4): 12‑21

DOI: 10.17116/endoskop20202604112

Read: 2958 times

Download PDF (RU)

Contact the author

Table of contents

To cite this article:

Budzinsky SA, Shapovolyants SG, Fedorov ED, Zakharova MA, Chernyakevich PL, Platonova EN, Plakhov RV. Role of balloon dilation of the graduated endocsopic papillosphincterotomy area in the treatment of patients with «complex» choledocholithiasis. Endoscopic Surgery. 2020;26(4):12‑21. (In Russ.)
https://doi.org/10.17116/endoskop20202604112

Подписка 2026 Эндоскопическая хирургия (Endoscopic Surgery)

Использование инфографики авторами научных работ

Close metadata

JUSTIFICATION

Endoscopic papillosphincterotomy (EPST) followed by lithoextraction (LE) is the gold standard in the treatment of patients with choledocholithiasis (CL). In cases of «complex» CL (the diameter of the calculus is more than 15 mm, the number of calculi is more than 2, non-standard features of the anatomy of the peripapillary area), generally accepted tactics may be unsuccessful. One of the most effective and safe options for the sanation of the biliary tract in patients of this group is an additional balloon dilatation (BD) of the area of previously performed dosed EPST, if necessary combined with intraductal mechanical lithotripsy (MLT).

THE PURPOSE

Demonstration of the results of the DB of dosed area EPST, including in combination with intraductal MLT in patients with «complex» CL.

MATERIAL AND METHODS

A retrospective analysis of 192 cases of DB of the EPST area was performed in 187 patients with «complex» CL who underwent treatment at City Clinical Hospital No. 31 from 01.01.13 to 01.07.19. There were 125 women and 62 men. The average age was 70.7±14.5 years. In 147 (76.6%) cases, the indication for intervention was the clinical picture of obstructive jaundice, and in 45 (23.4%) — dilatation of extrahepatic bile ducts without clinical signs of impaired bile outflow. Single (1 or 2) concrements of the biliary tract were found in 125 (65.1%) cases, and multiple CL (3 calculi or more) — in 67 (34.9%). The diameter of the detected concrements of the biliary tract varied from 8 to 45 mm. The complete sanation of the biliary tract, as well as the regression of obstructive jaundice according to physical examination, laboratory tests and instrumental diagnostics, were the sign of successful in performing the intervention.

RESULTS

In all the observations, a BD of the EPST area was carried out with a subsequent attempt to LE. In 114 (59.4%) cases, success was achieved after the initial intervention, in 10 (5.2%) patients for complete sanation of the biliary tract, staged treatment was required. In 63 (32.8%) cases, when the BD of the EFST area was not enough for performing LE, additional MLT was required, which was effective in 61 (96.8%) patients. Complete sanation of the bile ducts was achieved in 47 (74.6%) cases after the initial intervention, in 14 (22.2%) cases after the second intervention. In 5 (2.6%) cases no additional lithotripsy was attempted. In total, when combining the two methods, it was possible to achieve of clinical success in 185 (96.5%) of 192 cases. It was noted that the use of balloons with a larger diameter (12-20 mm) makes it possible to achieve complete sanation of the gall tree more often than when using balloons with a diameter of less than 12 mm (98.6% versus 90%) after the initial procedure. Complications were observed in 6 (3.2%) cases; 1 (0.53%) death was registered.

CONCLUSION

The method of the BD of the dosed papillosphincterotomy area in combination with mechanical intraductal lithotripsy allows achieving complete bile duct sanation in 96.5% of cases in patients with «complex» CL. At the same time, the use of large-diameter balloons makes it possible to increase the effectiveness of the intervention and to perform a complete sanation in one manipulation with a relatively low frequency of complications and deaths.

Keywords:

ERCP

choledocholithiasis

lithotripsy

lithoextraction

balloon dilatation

Authors:

S.A. Budzinsky

Pirogov Russian National Research Medical University;
City Clinical Hospital No. 31

S.G. Shapovolyants

Pirogov Russian National Research Medical University

E.D. Fedorov

Pirogov Russian National Research Medical University of the Russian Ministry of Health

SPIN RSCI: 6785-9959
Scopus AuthorID: 7004381289
ORCID: 0000-0002-6036-7061

M.A. Zakharova

Chaika Clinics

ORCID: 0000-0003-3299-4743

P.L. Chernyakevich

City Clinical Hospital No. 31

E.N. Platonova

City Clinical Hospital No. 31

R.V. Plakhov

Pirogov Russian National Research Medical University;
City Clinical Hospital No. 31

Received:

27.12.2019

Accepted:

08.04.2020

Close metadata

References:

Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, Barthet M, Domagk D, Dumonceau JM, Gigot JF, Hritz I, Karamanolis G, Laghi A, Mariani A, Paraskeva K, Pohl J, Ponchon T, Swahn F, Ter Steege RWF, Tringali A, Vezakis A, Williams EJ, van Hooft JE. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019;51(5):472-491. https://doi.org/10.1055/a-0862-0346
Klinicheskaya khirurgiya. Natsionalnoe rukovodstvo. V 3 t. VS Saveliev, AI Kirienko, eds. M.: GEOTAR-Media; 2009. (In Russ.)
Van Dijk AH, de Reuver PR, Besselink MG, van Laarhoven KJ, Harrison EM, Wigmore SJ, Hugh TJ, Boermeester MA. Assessment of available evidence in the management of gallbladder and bile duct stones: a systematic review of international guidelines. HPB (Oxford). 2017;19(4):297-309. https://doi.org/10.1016/j.hpb.2016.12.011
Cotton PB. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg. 1980;67:1-5.
Kedia P, Tarnasky PR. Endoscopic Management of Complex Biliary Stone Disease. Gastrointest Endosc Clin N Am. 2019;29(2):257-275. https://doi.org/10.1016/j.giec.2018.11.004
Doshi B, Yasuda I, Ryozawa S, Lee GH. Current endoscopic strategies for managing large bile duct stones. Dig Endosc. 2018;30(1):59-66. https://doi.org/10.1111/den.13019
Zulli C, Grande G, Tontini GE, Labianca O, Geraci G, Sciumè C, Antypas P, Fiocca F, Manes G, Devani M, Manta R, Maurano A. Endoscopic papillary large balloon dilation in patients with large biliary stones and periampullary diverticula: Results of a multicentric series. Dig Liver Dis. 2018;50(8):828-832. https://doi.org/10.1016/j.dld.2018.03.034
Paspatis GA, Paraskeva K, Vardas E. Long-term recurrence of bile duct stones after endoscopic papillary large balloon dilation with sphincterotomy: 4-year extended follow-up of a randomized trial. Surg Endosc. 2017; 31(2):650-655. https://doi.org/10.1007/s00464-016-5012-9
Ichikawa R, Shiraki M, Nagai H. The characteristics of difficult cases of endoscopic papillary large-diameter balloon dilation for choledocholithiasis. J Gastroenterol Hepatol (Australia). 2014;29(3):284.
Kuo CM, Chiu YC, Liang CM, Wu CK, Lu LS, Tai WC, Kuo YH, Wu KL, Chuah SK, Kuo CH. The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones. BMC Gastroenterol. 2019;19(1):93. https://doi.org/10.1186/s12876-019-1017-x
Schneider MU, Matek W, Bauer R, Domschke W. Mechanical lithotripsy of bile duct stones in 209 patients — effect of technical advances. Endoscopy. 1988;20:248-253.
Veld JV, van Huijgevoort NCM, Boermeester MA. A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave. Endoscopy. 2018; 50(9):896-909. https://doi.org/10.1055/a-0637-8806
Bykov AD, Zhambalov VB. Ekstrakorporal’naya udarno-volnovaya litotripsiya v lechenii kholedoholitiaza. Byulleten Vostochno-Sibirskogo nauchnogo tsentra Sibirskogo otdeleniya Rossijskoj akademii meditsinskikh nauk. 2009;3:314. (In Russ.)
Khawaja FI, Ahmad MM. Basketing a basket: A novel emergency rescue technique. World J Gastrointest Endosc. 2012;4(9):429-431. https://doi.org/10.4253/wjge.v4.i9.429
O’Brien JW, Tyler R, Shaukat S, Harris AM. Laparoscopic Common Bile Duct Exploration for Retrieval of Impacted Dormia Basket following Endoscopic Retrograde Cholangiopancreatography with Mechanical Failure: Case Report with Literature Review. Case Rep Surg. 2017;5878614. https://doi.org/10.1155/2017/5878614
Staritz M, Ewe K. Meyerzum Buschebfelde K.H. Endoscopic papillary dilation for the treatment of common bile duct stones and papillary stenosis. Endoscopy. 1983;15:197-198.
Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc. 2003;57:156-159. https://doi.org/10.1067/mge.2003.52
Fujisawa T, Kagawa K, Hisatomi K. Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis? World J Gastroenterol. 2016;22(26):5909-5916. https://doi.org/10.3748/wjg.v22.i26.5909
Aujla UI, Ladep N, Dwyer L, Hood S, Stern N, Sturgess R. Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy. World J Gastroenterol. 2017;23(48):8597-8604. https://doi.org/10.3748/wjg.v23.i48.8597
Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev. 2006;(4). https://doi.org/10.1002/14651858.CD004890.pub2
Dumonceau JM, Andriulli A, Elmunzer BJ, Mariani A, Meister T, Deviere J, Marek T, Baron TH, Hassan C, Testoni PA, Kapral C. European Society of Gastrointestinal Endoscopy. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline — updated June 2014. Endoscopy. 2014;46(9):799-815. https://doi.org/10.1055/s-0034-1377875
Brown NG, Camilo J, Nordstrom E, Yen RD, Fukami N, Brauer BC, Wani S, Amateau SK, Attwell AR, Shah RJ. Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center’s 12-year experience. Scand J Gastroenterol. 2018;53(5):626-631. https://doi.org/10.1080/00365521.2018.1441434
Meng W, Leung JW, Zhang K, Zhou W, Wang Z, Zhang L, Sun H, Xue P, Liu W, Wang Q, Zhang J, Wang X, Wang M, Shao Y, Cai K, Hou S, Li Q, Zhang L, Zhu K, Yue P, Wang H, Zhang M, Sun X, Yang Z, Tao J, Wen Z, Wang Q, Chen B. Shao Q, Zhao M, Zhang R, Jiang T, Liu K, Zhang L, Chen K, Zhu X, Zhang H, Miao L, Wang Z, Li J, Yan X, Wang F, Zhang L, Suzuki A, Tanaka K, Nur U, Weiderpass E, Li X. Optimal dilation time for combined small endoscopic sphincterotomy and balloon dilation for common bile duct stones: a multicentre, single-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol. 2019;4(6):425-434. https://doi.org/10.1016/S2468-1253(19)30075-5
Park CH. The Management of Common Bile Duct Stones. Korean J Gastroenterol. 2018;71(5):260-263. https://doi.org/10.4166/kjg.2018.71.5.260
Itokawa F, Itoi T, Sofuni A, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Umeda J, Tanaka R, Tonozuka R, Honjyo M, Moriyasu F, Kasuya K, Tsuchida A. Mid-term outcome of endoscopic sphincterotomy combined with large balloon dilation. J Gastroenterol Hepatol. 2015;30(1):223-239. https://doi.org/10.1111/jgh.12675. PMID: 24995677.
Alsenbesy M, Shahat K, Nawara A, Sallam M, Fakhry M, Shazly M, Moussa M, Tag-Adeen M, El-Amin H, Sobh M. Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones. Rev Esp Enferm Dig. 2019;111(5):358-363. https://doi.org/10.17235/reed.2019.5865/2018
Madhoun MF, Wani S, Hong S, Tierney WM. Endoscopic papillary large balloon dilation reduces the need for mechanical lithotripsy in patients with large bile duct stones: A systematic review and meta-analysis. Diagn Ther Endoscopy. (2014) 2014 Article Number: 309618. Date of Publication: 2014. https://doi.org/10.1155/2014/309618
Zimmer V. Transpapillary passage of a giant bile duct stone after endoscopic papillary large balloon dilation and short-term stenting. Clin Res Hepatol Gastroenterol. 2017;41(5):503-504. https://doi.org/10.1016/j.clinre.2017.02.007
Kuo CM, Chiu YC, Liang CM, Lu LS, Tai WC, Kuo YH, Wu CK, Chuah SK, Changchien CS, Kuo CH. Limited precut sphincterotomy combined with endoscopic papillary balloon dilation for common bile duct stone removal in patients with difficult biliary cannulation. BMC. Gastroenterol. 2016;16(1):70. https://doi.org/10.1186/s12876-016-0486-4
Draganov PV, Evans W, Fazel A, Forsmark CE. J Large size balloon dilation of the ampulla after biliary sphincterotomy can facilitate endoscopic extraction of difficult bile duct stones. Clin Gastroenterol. 2009;43(8):782-786. https://doi.org/10.1097/MCG.0b013e31818f50a2
Yoon HG, Moon JH, Choi HJ, Kim DC, Kang MS, Lee TH, Cha SW, Cho YD, Park SH, Kim SJ. Endoscopic papillary large balloon dilation for the management of recurrent difficult bile duct stones after previous endoscopic sphincterotomy. Dig Endosc. 2014;26(2):259-263. PMID: 23581623. https://doi.org/10.1111/den.12102
Gallinger YuI, Khrustaleva MV. Bile duct stones: clinic, diagnostics, modern treatment methods. Natsionalnaya shkola gastroenterologov, gepatologov. 2006;5:56. (In Russ.)
Tazuma S, Unno M, Igarashi Y, Inui K, Uchiyama K, Kai M, Tsuyuguchi T, Maguchi H, Mori T, Yamaguchi K, Ryozawa S, Nimura Y, Fujita N, Kubota K, Shoda J, Tabata M, Mine T, Sugano K, Watanabe M, Shimosegawa T. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017;52(3):276-300. https://doi.org/10.1007/s00535-016-1289-7