Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses.
OBJECTIVE
Endoscopic sphincterotomy (EST) is the standard treatment for choledocholithiasis. Endoscopic papillary balloon dilation (EPBD) has a lower risk for bleeding than EST, but EPBD is reserved for patients with bleeding diathesis because some studies reported that it increases the risk for pancreatitis. A short dilation time (≤1 minute) is therefore recommended to reduce pancreatitis. However, there is evidence for an inverse relationship between EPBD duration and pancreatitis, prompting reevaluation of the optimal duration and relative safety of EPBD vs EST.


METHODS
We systematically reviewed randomized controlled trials to compare long EPBD (>1 minute), short EPBD (≤1 minute), and EST regarding pancreatitis and overall complications. In addition to pairwise meta-analyses, Bayesian network meta-analysis was undertaken to compare the 3 procedures together. Relation between duration and outcome was also analyzed by meta-regression.


RESULTS
Compared with EST, short EPBD had a higher risk for pancreatitis (odds ratio [OR] by traditional analysis, 3.87; 95% confidence interval, 1.08-13.84 and OR by network meta-analysis, 4.14; 95% credible interval, 1.58-12.56), but long EPBD did not pose a higher risk than EST (1.14, 0.56-2.35 and 1.07, 0.38-2.76). Long EPBD had a lower overall rate of complications than EST (0.61, 0.36-1.04 and 0.54, 0.20-1.36). In network meta-analysis, probabilities of being the safest treatment for long EPBD/short EPBD/EST regarding pancreatitis and overall complications were 43.9%/0.2%/55.9% and 90.3%/1.3%/8.4%, respectively.


CONCLUSIONS
Duration of EPBD is inversely associated with pancreatitis risk. Currently recommended ≤1-minute dilation actually increases pancreatitis. EPBD with adequate duration may be preferred over EST because of comparable pancreatitis but lower overall complication rates.
Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
Wei-Chih
WC
Liao
Yu-Kang
YK
Tu
Ming-Shiang
MS
Wu
Hsiu-Po
HP
Wang
Jaw-Town
JT
Lin
Joseph W
JW
Leung
Kuo-Liong
KL
Chien
D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects* / Q000379:methods*; D042882:Gallstones / Q000628:therapy*; D006801:Humans; D010195:Pancreatitis / Q000453:epidemiology*; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D013997:Time Factors