Large Balloon Dilation versus Mechanical Lithotripsy for Large Bile Duct Stones: A Systematic Review & Meta-Analysis
Philippine Journal of Endo-Laparoscopic Surgery
Introduction: Common bile duct stone (CBDS) is a common disorder of the biliary tract and often necessitates intervention to prevent biliary complications. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon stone extraction remain to be the standard treatment for CBDS. For large stones (>12mm), removal may be challenging. After sphincterotomy, use of mechanical lithotripsy (ML) has been widely used for clearance of large stone in the last 3 decades. Large balloon dilatation (LBD) is also established as a highly successful method of removing CBDS. This present study aims to determine which procedure is more effective and safer in clearing common bile duct stones.
Methodology: A literature search of randomized controlled trials (RCTs) comparing balloon dilatation and mechanical lithotripsy up to April 2020 in electronic databases including Cochrane Library, MEDLINE (PubMed), Google Scholar, Herdin.ph and Clinicaltrials.gov as well as hand-search of publications was done. Primary outcome was stone clearance rate. Secondary outcomes include overall complication rate and specific rates for pancreatitis, cholangitis, perforation and bleeding.
Results: Three RCTs (enrolling 273 patients) met our inclusion criteria. No significant difference observed in stone clearance rate between the two groups (OR 1.44, 95% CI 0.68 to 3.87, P=0.34, moderate certainty). The overall complication rate was significantly higher in the ML group (RR 0.45, 95% CI 0.24 to 0.82, P=0.01, high certainty). Post-ERCP cholangitis did not occur in the LBD group. Six percent of the patients in the ML group developed cholangitis and was statistically significant (RR 0.11, 95% CI 0.01 to 0.86, P=0.04, high certainty). No difference in post-ERCP pancreatitis, perforation and bleeding observed. No significant heterogeneity was seen in the studies included.
Conclusion: Balloon dilatation is a safer and effective alternative to mechanical lithotripsy in the removal of large common bile duct stones in terms of developing cholangitis. There was no difference in rate of pancreatitis, perforation and bleeding observed in both interventions. A higher risk of cholangitis is observed with the use of mechanical lithotripsy.
Pascua, M. N.,
Romero, R. V.,
Large Balloon Dilation versus Mechanical Lithotripsy for Large Bile Duct Stones: A Systematic Review & Meta-Analysis.
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