Case Series of Endoscopic Papillary Balloon Dilation for Children with Common Bile Duct Stones and a Review of the Literature

Abstract

Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs) and has been reported to have a high success rate for stone removal. However, EST is associated with a risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years, including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted; pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean 96%). The incidence of pancreatitis was 0-9.6% (mean 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3-5.4% (mean 2.7%). With regards to the grade of bleeding, seven cases were mild (64%) and four were moderate (36%). Compared with adults who underwent EST, the frequencies of pancreatitis and bleeding were almost equal in children; however, in children, once bleeding occurs, it has a higher risk of leading to blood transfusion. Stone removal via EPBD in children has a 100% success rate. Pancreatitis was responsible for all complications were related; its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2-3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal via EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation via EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered to be an effective method for CBDS removal in children.

Keywords: children; choledocholithiasis; common bile duct stone; endoscopic papillary balloon dilation; endoscopic retrograde cholangiopancreatography; endoscopic sphincterotomy.

Figure 1

A 5-month-old girl presented with vomiting and revealed gallbladder and common bile duct stones on ultrasonography. (a) Enhanced computed tomography (CT) showing multiple small gallstones and gallbladder swelling. (b) The patient developed septic shock due to cholangitis. Emergency gallbladder drainage was performed, and a bile stone impacting the distal common bile duct (white arrowhead) was noted. A 4-Fr ENBD tube was inserted.

Figure 2

A 5-month-old girl who presented with vomiting and revealed gallbladder and common bile duct stones on ultrasonography. (a) EPBD is performed following recovery from cholecystitis and sepsis, and the stone is removed by one balloon pulling. (b) Following EPBD, a 5-Fr prophylactic ENBD tube is inserted, and no residual stone is revealed by cholangiography.

Figure 3

An 8-year-old boy complained of gallbladder and common bile duct stones. (a) Enhanced computed tomography (CT) revealing multiple small gallstones and gallbladder swelling. (b) The patient has developed septic shock due to cholangitis. Emergency gallbladder drainage is performed, and a bile stone impacting the distal common bile duct (white arrowhead) is observed. A 4-Fr ENBD tube is inserted.