ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION AFTER SPHINCTEROTOMY REDUCES SURGICAL REFERRAL RATE

Aims Endoscopic papillary large balloon dilation (EPLBD) is a safe and effective technique for removal of common bile duct stones (CBDS) with a lower rate of mechanical lithotripsy (ML) and similar CBD clearance rate compared to sphincterotomy (EST). It is unclear if EPLBD reduces the number of patients referred for surgical CBD exploration. We aimed to compare CBD clearance, ML use and referral for CBD exploration between patients treated with EST alone vs. EST followed by EPLBD (EST+EPLBD).

Methods We performed a single-centre retrospective observational cohort study. Data was extracted from the electronic endoscopic reporting system for ERCPs performed from September 2013 to January 2019. Patients who failed CBDS extraction with standard EST at index ERCP were included for analysis. Patients who had repeat ERCP for CBDS extraction without the use of EPLBD (EST group) were compared to those who had EPLBD at time of repeat ERCP (EST+EPLBD). Difficult stones were defined as stones ≥15mm, presence of ≥5 stones or presence of a tapering distal CBD.

Results 117 patients were included for analysis, 48 who had EST and 69 who had EST+EPLBD. Both groups had similar age, number of stones, and stone size. 79% of the EST group had difficult stones vs. 54% in the EST+EPLBD group. We observed a significantly higher rate of CBD clearance in the EST+EPLBD group overall (88% vs. 38%, p< 0.001) and in those with difficult stones (78% vs. 32%, p< 0.001). There was no significant difference in ML use (20% vs. 31%, p=0.18). Surgical referral rates were significantly lower in the EST+EPLBD group (1% vs. 17%, p=0.002). There was no difference in complication rates.

Conclusions The use of EPLBD after previous EST is associated with significantly improved CBD clearance rates compared with EST alone, including for difficult stones, and a significantly reduced referral rate for CBD exploration.