EST+EPBD

Discussion about EPBD or EPLBD after EST in CBD Stones

Recently we focused on several different types of common bile duct stone retrieval operation by duodenal scope with respective advantages and disadvantages under applicable conditions, including EST, EPBD, EPLBD. To choose different clinical operation methods are mainly based on  elements such as stone quantity, diameter, individual diseases, complications of the high-risk factors.

Today we are going to talk about operation method EST+EPBD/EPLBD. It is generally believed that stone retrieval after EST is relatively easy, but permanent damage is caused to the function of the papilla, and it is associated with severe consequences such as bleeding and perforation.

Sphincter function loss and intestinal fluid reflux will lead to the recurrence of stones and even canceration. In addition, for patients of large diverticulum besides papilla, oppression or adhesion of lesions outside the biliary cavity, or patients of BilrothⅡ gastrectomy operations, the cutting of papilla is limited.

Although EPBD can retain the function of papillary sphincter and the incidence of complications such as hemorrhage and perforation is low, the incidence of concurrent pancreatitis is higher than EST, and stone extraction is relatively difficult, especially for large stones.

In 2003, Prof. Ersoz and other doctors proposed that EST + EPBD could safely and effectively remove larger stones. The purpose of this operation is to perform stone retrieval by balloon dilation after the first duodenal papillotomy by duodenoscope.

In 2004, Prof. Fu in China reported the study on this method and the change of pressure in the bile duct. The pressure in the bile duct was measured 3 times after the confirmation of stone retrieval confirmed by angiography, 20 min after stone retrieval, and 3 months after operation.

The results showed that there was no significant difference between the first test and the third test, and the second test was significantly lower than the normal bile duct pressure. It is concluded that this method can achieve the same effect as EST, make up for the deficiency of EPBD, retain part of the function of duodenal papillary sphincter, prevent the occurrence of reflux cholangitis and pancreatitis, and reduce the complications of endoscopic treatment.

From 2007 to 2011, a large number of related studies reported that this method had significant advantages for the treatment of large common duct stones (> 10 mm).

Compared with EST +EPLBD alone, there was no significant difference in the success rate of stone retrieval and the incidence of complications, but the operation time required by EST +EPLBD and the utilization rate of mechanical lithotripsy were significantly reduced.

Compared with EPBD alone, EST + EPLBD can make the bile duct and pancreatic duct open separately from each other after small incision of the nipple. Meanwhile, balloon dilatation after indwelling guidewire of the bile duct can avoid the dilatation of the pancreatic duct, reduce the injury and edema of the pancreatic duct opening, and thus reduce the occurrence of postoperative pancreatitis.

As for the size of balloon dilation after papilla incision, most experts believe that it depends on the size of biliary stone and the diameter of the lower end of bile duct. Retroperitoneal gas has been reported after EST + EPBD stone extraction. In addition, EST + EPBD has also been reported to treat biliary roundworm incarceration, visceral transposition, and elderly patients (70 years old).

In summary, in the selection of specific surgical methods for choledocholithiasis by electronic duodenoscopy, the specific stone volume, stone number, basic diseases and individual differences of patients, as well as high risk factors of complications in the patients' bile duct should be considered. The choice of different types of surgical methods in clinical practice determines the operation time, treatment effect and postoperative complications of patients. Therefore, this series papers aimed to provide reference materials for clinical endoscopic treatment of choledocholithiasis.

Modern Digestion & Intervention 2013, Vol.18, No.5