title: Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis: a meta-analysis.
abstract: OBJECTIVE
  To perform a meta-analysis of large-balloon dilation (LBD) plus endoscopic sphincterotomy (EST) vs EST alone for removal of bile duct stones.
  
  
  METHODS
  Databases including PubMed, EMBASE, the Cochrane Library, the Science Citation Index, and important meeting abstracts were searched and evaluated by two reviewers independently. The main outcome measures included: complete stone removal, stone removal in the first session, use of mechanical lithotripsy, procedure time, and procedure-related complications. A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio (OR) when heterogeneity was not significant among the studies. When a Q test or I² statistic indicated substantial heterogeneity, a random-effects model weighted by the DerSimonian-Laird method was used.
  
  
  RESULTS
  Six randomized controlled trials involving 835 patients were analyzed. There was no significant heterogeneity for most results; we analyzed these using a fixed-effects model. Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone (OR = 0.53, 95%CI: 0.33-0.85, P = 0.008); subcategory analysis indicated a significantly lower risk of perforation in the EST plus LBD group (Peto OR = 0.14, 95%CI: 0.20-0.98, P = 0.05). Use of mechanical lithotripsy in the EST plus LBD group decreased significantly (OR = 0.26, 95%CI: 0.08-0.82, P = 0.02), especially in patients with a stone size larger than 15 mm (OR = 0.15, 95%CI: 0.03-0.68, P = 0.01). There were no significant differences between the two groups regarding complete stone removal, stone removal in the first session, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, infection of biliary tract, and procedure time.
  
  
  CONCLUSIONS
  EST plus LBD is an effective approach for the removal of large bile duct stones, causing fewer complications than EST alone.
authors.affiliation: Xiao-Ming Yang, Bing Hu, Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China.
authors.forename: Xiao-Ming
authors.initials: XM
authors.lastname: Yang
authors.affiliation: Xiao-Ming Yang, Bing Hu, Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China.
authors.forename: Bing
authors.initials: B
authors.lastname: Hu
mesh_terms: D016009:Chi-Square Distribution; D042883:Choledocholithiasis / Q000628:therapy*; D003131:Combined Modality Therapy; D004106:Dilatation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D016017:Odds Ratio; D012307:Risk Factors; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects; D016896:Treatment Outcome
keywords: Balloon dilation; Cholangiopancreatography; Choledocholithiasis; Endoscopic retrograde; Endoscopic sphincterotomy; Meta-analysis