A cumulative meta-analysis of endoscopic papillary balloon dilation versus endoscopic sphincterotomy for removal of common bile duct stones

Background Endoscopic papillary balloon dilation (EPBD)
was introduced to overcome the risk of adverse events
associated with endoscopic sphincterotomy in the removal
of common bile duct (CBD) stones. We performed a metaanalysis
of randomized controlled trials (RCTs) comparing
efficacy and safety of EPBD vs. endoscopic sphincterotomy,
focusing on stone size, balloon diameter, and balloon dilation
time.
Methods A multiple database search was performed, including
MEDLINE, EMBASE and Cochrane Library, from their
inception date until October 2017. RCTs comparing the efficacy
and safety of EPBD vs. endoscopic sphincterotomy in
the removal of CBD stones were included. Cumulative
meta-analyses over time, and subgroup analyses according
to stone size, and balloon diameter and dilation time were
carried out.
Results 25 RCTs met the inclusion criteria. Despite the cumulative
meta-analysis showing a trend over time in favor
of endoscopic sphincterotomy in studies published up to
2004, the conventional meta-analysis revealed that EPBD
was equally efficacious compared with endoscopic sphincterotomy
in stone removal at first attempt (odds ratio [OR]
0.95, 95% confidence interval [CI] 0.65 – 1.38). Endoscopic
sphincterotomy was superior to EPBD in terms of overall
stone clearance (OR 0.65, 95 %CI 0.43 – 0.99) in studies
published since 2002, but no differences emerged in studies
using large ( ≥ 10mm) balloons (OR 1.37, 95 %CI 0.72 –
2.62). No statistically significant difference in pancreatitis
occurrence emerged between EPBD and endoscopic
sphincterotomy (OR 1.35, 95 %CI 0.90 – 2.03). Pancreatitis
was more common with EPBD than with endoscopic sphincterotomy
in studies using balloons < 10mm (OR 1.78, 95%
CI 1.07 – 2.97), whereas no difference emerged in studies
using large balloons (OR 0.84, 95 %CI 0.46 – 1.53). EPBD
had lower rates of bleeding and cholecystitis.
Conclusions Our latest data confirm that EPBD is currently
inferior to endoscopic sphincterotomy in terms of overall
stone clearance. However, EPBD using large balloons
(≥ 10mm) was as effective as endoscopic sphincterotomy,
both in stone clearance and the need for endoscopic mechanical
lithotripsy, without carrying an increased risk of
pancreatitis.