Journal List > Clin Endosc > v.48(1) > 1152110

Kim: Is the Balloon Dilation Duration in Endoscopic Papillary Balloon Dilation (EPBD) Related to the Occurrence of Post-EPBD Pancreatitis?
See "Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial" by Byoung Wook Bang, Tae Hoon Lee, Tae Jun Song, et al., on page [Related article:] 59-65
Endoscopic papillary balloon dilation (EPBD) was proposed as an alternative to endoscopic sphincterotomy (EST) for opening the bile duct orifice to allow stone extraction with functional preservation of the biliary sphincter. Since its introduction in 1982,1 EPBD has been widely performed because it is associated with lower bleeding and perforation risks compared to EST.2,3,4,5,6 However, EPBD is more likely to cause pancreatitis than EST, resulting in an increased mortality rate.7,8 Therefore, EPBD is reserved for selective patients with a bleeding diathesis or altered anatomy, especially in Western countries.
The reported incidence of post-EPBD pancreatitis varies greatly, ranging from 0% to 15.4%.9,10,11,12,13 This disparity may be explained by differences in the stone size, bile duct size, balloon diameter, and balloon dilation duration (BDD). Although the mechanism is unknown, post-EPBD pancreatitis has been associated with papillary edema or spasm resulting from balloon dilation and papillary trauma during stone extraction through an insufficiently dilated sphincter. Therefore, papillary injury resulting in increased post-EPBD pancreatitis may frequently occur in cases with relatively large stones in small bile ducts and balloon diameters larger than the stone size or bile duct diameter.
BDD was found to correlate with post-EPBD pancreatitis in previous studies, although the results were conflicting. In a prospective randomized trial,14 the risk of pancreatitis was higher with a 1-minute BDD (15.1%, 13/86) than with a 5-minute BDD (4.8%, 4/84; p=0.038). In a systemic review of randomized trials that compared EPBD and EST,15 short EPBD (≤1 minute) had a higher risk for pancreatitis (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.08 to 13.84) compared to EST, but long EPBD (>1 minute) did not pose a higher risk than EST (OR, 1.14; 95% CI, 0.56 to 2.35). A longer BDD may achieve greater loosening of the sphincter of Oddi and cause less papillary damage during stone extraction, resulting in a lower pancreatitis rate. In contrast, however, an initial 2-minute BDD was modified to 15 seconds during the later period of a retrospective study.16 A lesser tendency toward post-EPBD pancreatitis was observed in the modified group (4%, 13/324) relative to the initial group (7.4%, 24/324; p=0.063). A shorter BDD may be less traumatic to the papilla, thus reducing post-EPBD pancreatitis.
Bang et al.17 evaluated the risk of pancreatitis after EPBD with a 20- or 60-second BDD in patients with relatively small bile duct stones (≤12 mm) while using balloon diameters (6 to 10 mm) selected according to the stone size and bile duct diameter. The authors also used a prophylactic pancreatic stent in patients at a high risk of post-ERCP pancreatitis. As a result, all factors that might affect the occurrence of post-EPBD pancreatitis were well controlled except for the BDD. However, they observed no difference in the occurrence of post-ERPD pancreatitis between the 20- and 60-second BDD groups (6.4%, 7/109 vs. 7.5%, 9/119). Bang and colleague17 proposed that EPBD could be adequately performed with a 20-second BDD in carefully selected patients because the BDD had little effect on the incidence of post-EPBD pancreatitis, a difficult finding to accept when compared with previous EPBD studies.
Although this study may not appear to make sense, new approaches and data have made us rethink the best approach for bile duct stone removal. Therefore, we continue to seek the safest and most effective bile duct stone removal method.

Notes

The author has no financial conflicts of interest.

References

1. Staritz M, Ewe K, Meyer zum Büschenfelde KH. Endoscopic papillary dilatation: an alternative to papillotomy? (author's transl). Dtsch Med Wochenschr. 1982; 107:895–897. PMID: 7084054.
2. Mathuna PM, White P, Clarke E, Merriman R, Lennon JR, Crowe J. Endoscopic balloon sphincteroplasty (papillary dilation) for bile duct stones: efficacy, safety, and follow-up in 100 patients. Gastrointest Endosc. 1995; 42:468–474. PMID: 8566640.
crossref
3. Yasuda I, Tomita E, Enya M, Kato T, Moriwaki H. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut. 2001; 49:686–691. PMID: 11600473.
crossref
4. Kozarek RA. Balloon dilation of the sphincter of Oddi. Endoscopy. 1988; 20(Suppl 1):207–210. PMID: 3168949.
crossref
5. Minami A, Nakatsu T, Uchida N, et al. Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function. Dig Dis Sci. 1995; 40:2550–2554. PMID: 8536511.
crossref
6. Sato H, Kodama T, Takaaki J, 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; 41:541–544. PMID: 9391256.
crossref
7. Bergman JJ, Rauws EA, Fockens P, et al. Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones. Lancet. 1997; 349:1124–1129. PMID: 9113010.
crossref
8. Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev. 2006; 4:CD004890. PMID: 17054222.
crossref
9. Baron TH, Harewood GC. 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; 99:1455–1460. PMID: 15307859.
crossref
10. Disario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology. 2004; 127:1291–1299. PMID: 15520997.
11. Vlavianos P, Chopra K, Mandalia S, Anderson M, Thompson J, Westaby D. Endoscopic balloon dilatation versus endoscopic sphincterotomy for the removal of bile duct stones: a prospective randomised trial. Gut. 2003; 52:1165–1169. PMID: 12865276.
crossref
12. Lin CK, Lai KH, Chan HH, et al. Endoscopic balloon dilatation is a safe method in the management of common bile duct stones. Dig Liver Dis. 2004; 36:68–72. PMID: 14971818.
crossref
13. Ochi Y, Mukawa K, Kiyosawa K, Akamatsu T. Comparing the treatment outcomes of endoscopic papillary dilation and endoscopic sphincterotomy for removal of bile duct stones. J Gastroenterol Hepatol. 1999; 14:90–96. PMID: 10029284.
crossref
14. Liao WC, Lee CT, Chang CY, et al. Randomized trial of 1-minute versus 5-minute endoscopic balloon dilation for extraction of bile duct stones. Gastrointest Endosc. 2010; 72:1154–1162. PMID: 20869710.
crossref
15. Liao WC, Tu YK, Wu MS, et al. Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses. Clin Gastroenterol Hepatol. 2012; 10:1101–1109. PMID: 22642953.
crossref
16. Tsujino T, Kawabe T, Isayama H, et al. Efficacy and safety of low-pressured and short-time dilation in endoscopic papillary balloon dilation for bile duct stone removal. J Gastroenterol Hepatol. 2008; 23:867–871. PMID: 18086110.
crossref
17. Bang BW, Lee TH, Song TJ, et al. Twenty-second versus sixty-second dilation duration in endoscopic papillary balloon dilation for the treatment of small common bile duct stones: a prospective randomized controlled multicenter trial. Clin Endosc. 2015; 48:59–65.
crossref
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