Endoscopic papillary balloon dilatation for common bile duct stones: efficacy of combination with extracorporeal shockwave lithotripsy for large stones

Background Endoscopic papillary balloon dilatation (EPBD) is generally cons idered a safe and effective technique for removal of common bile duct (CBD) stones, However, some reports have prompted concern about the risk of panc reatitis following the procedure, and it seems to be more difficult and to require adjunctive procedures more frequently in patients with large stones . Aims To analyse the factors influencing pancreatitis after the procedure, a nd to examine which is the more suitable adjunct for treating large stones, mechanical lithotripsy (ML) or extracorporeal shockwave lithotripsy (ESWL) . Patients and methods EPBD was performed in 92 patients, including 40 with l arge stones (greater than or equal to 12 mm), These 40 patients were random ly assigned to two groups receiving ML or ESWL to fragment stones (20 patie nts each). Results Complete ductal clearance was obtained in all 92 patients. Signific ant elevation of the serum amylase level compared with the prior value (> 3 00 IU/I) was observed in 26 (28%), and eight (8.7%) developed clinical panc reatitis. To assess the influence of various factors on the amylase level, multivariate analysis was used. The number of stones and the time required for treatment had a significant influence on the incidence of increased amy lase level (P < 0.05), and ML also significantly increased it (P < 0.05). O n the other hand, the amylase level remained low in the ESWL group. ML caus ed elevation of amylase level in 11 patients (55%), while three (15%) had e levation after ESWL. Conclusions In patients with multiple stones, elevation of the amylase leve l is more frequent. This seems to be because repeated cannulation and much time is required for treatment. In patients with large stones, the rate was also high if ML was used, but was low when ESWL was used. ESWL may reduce the incidence of pancreatitis. Eur J Gastroenterol Hepatol 10:1045-1050 (C) 1998 Lippincott Williams & Wilkins.