Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: a meta-analysis

Abstract

Aim: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm).

Methods: PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P ≤ 0.1 and I(2) with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias.

Results: Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92).

Conclusion: EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Keywords: Common bile duct stones; Endoscopic papillary large balloon dilation; Endoscopic sphincterotomy; Mechanical lithotripsy; Meta analysis..

Figure 1

Flow diagram of study selection.

Figure 2

Forest plot of risk ratio and 95%CI. A: Efficiency of endoscopic mechanical lithotripsy (EML) for overall common bile duct stones; B: Requirement for EML in large common bile duct stones ( ≥ 15 mm). EST: Endoscopic sphincterotomy; EPLBD: Endoscopic papillary large balloon dilation.