The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphinecterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.
Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) over 40 years ago, our ability to tackle large common bile duct stones has continued to improve largely due to the use of various lithotripsy methods. Nevertheless, the search for the ideal common bile duct stone extraction technique continues despite the recent advances in technology. To be able to extract a whole stone or a large fragment of it has always remained limited by the size of the one end outlet of the biliary tree – that is the biliary orifice. ERCP-practicing gastroenterologists have waxed and waned on how to best navigate a large stone through a small orifice. In 2015, most would consider endoscopic sphincterotomy (ES) as the key intervention and the backbone for all biliary therapeutic procedures. Despite the efficacy of ES, balancing this with the risks of post-sphincterotomy adverse events like bleeding and perforation remains a very fine act. This fueled the search for an alternative safe technique for stone extraction – either to supplement a “limited ES” or to replace it altogether.
Endoscopic papillary large bile duct dilation (EPLBD) emerged as an acceptable technique that theoretically could achieve large stone extraction without necessarily having to resort to mechanical or electrohydraulic lithotripsy and limits the number of ERCP procedures needed to achieve this task. However, the lack of enthusiasm towards such a technique and its rather limited adoption stemmed from some of the literature reports on the risk of potentially serious adverse events, such as pancreatitis and bile duct perforation.[1,2,3]
But is it time that we revisit our stand on EPLBD? In the current issue of the Saudi Journal of Gastroenterology, Akiyama et al. report on the utility of endoscopic papillary balloon dilation (EPBD) in biliary stone extraction and the short- and long-term outcomes of 10- and 8-mm EPBD for extraction of CBD stones. The study addressed technical success and adverse events rates over the short and intermediate term. The authors reported that their ability to remove stones in a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%, P < 0.001). In addition, the use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%, P < 0.001). Among the adverse events assessed, post-ERCP pancreatitis rates were no different between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% and 94% at 1 year and 69% and 80% at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not reported, and pneumobilia was found in 5% during the follow-up period.