Endoscopic Papillary Large Balloon Dilation: It Is about Time We Did for a Whopper

Endoscopic papillary large balloon dilation (EPLBD) is a procedure which makes major duodenal papilla orifice widen larger than stone using 12to 20-mm diameter of dilation balloon catheter to facilitate stone retrieval in treatment of large common bile duct (CBD) stone 1 cm or more. Theoretically this procedure could remove the large stone effectively without needs of endoscopic mechanical lithotripsy (EML) to shorten the procedure time and lessen the risk of procedure-related complication. It has been introduced in the manner of an EPLBD combined with preceding endoscopic sphincterotomy (EST) for treatment of large choledocholithiasis in 2003. Since then, many relevant clinical studies including several randomized controlled trials have been implemented. However, there is debate yet whether EPLBD will be an alternative method to EST. First, considering safety of EPLBD in large CBD stone, overall adverse event rate of EPLBD with EST was reported to be significantly lower than that of EST (odds ratio [OR], 1.60; p<0.001). Pancreatitis developed in 3.9% (2.6% to 6.4%) of patients who underwent EPLBD with EST. And the rate of pancreatitis after EPLBD with EST was lower than that of EST (OR, 1.80; p=0.006). Meanwhile, the bleeding rate of EPLBD with EST was suggested to be significantly lower than that of EST alone in a meta-analysis (OR, 0.15; p=0.002). The higher rate of bleeding is limited in EPLBD with large EST. The perforation rate of EPLBD with EST was 0.6%, and similar to that of EST. In the current study, Paik et al. reported that overall early complication rate of EPLBD with minor EST was not significantly different from that of EST, and bleeding and post-endoscopic