Endoscopic papillary balloon dilation (EPBD) for multiple or large common bile duct stones. - ESWL may reduce the risk of pancreatitis

EPBD has been evaluated as a technique for removal of common bile duct (CBD) stones. It causes less trauma to the papilla, and can preserve the sphincter function better than EST. However, since it does not enlarge the bile duct opening to the same extent as EST, repeating the cannulation into CBD to remove stones is sometimes difficult and results in swelling of papilla easily. Aims: To extend the indication of EPBD, we evaluated the effectiveness of adjunctive ESWL in patients with multiple or large stones. Methods: EPBD was performed in 80 patients, including 35 patients with multiple stones and 30 patients with large stone (≥ 12 mm). In large stone cases, mechanical lithotripter (ML) was used in 14 cases and ESWL was performed in advance after insertion of nasobiliary tube in 16 patients. Results: Complete ductal clearance was obtained in all patients. The elevation of serum amylase level (> 450 mg/dl) was observed in 22 (27.5%), and 7 (8.8%) developed clinical pancreatitis. To assess the influence of various variables on this elevation, multivariate analysis was done. Variables were selected as follows; age (< 60/≥ 60), sex, with or without cholangitis, periampullary diverticulum, number of stones (solitary/multiple), diameter of stone, diameter of CBD, using ML or ESWL in large stone, and the time required (< 40 min/≥ 40 min). The number of stones and the time required had a significant influence on the incidence (p < 0.05), and the use of ML also tended to raise it (p < 0.1). In large stone cases, ML caused an elevation in 7 (50.0%), but 2 (12.5%) had an elevation after pretreatment with ESWL. Conclusion: In cases with multiple stones, complications occurred more frequently. This was attributed to repeating cannulation and much time required to remove stones. In large stone cases, on using ML, the rate was also high, because it produced many fragments. However, pretreatment with ESWL reduced the incidence of pancreatitis because the small fragments were cleared spontaneously in advance and cannulation times could be reduced.