The Effect of Periampullary Diverticulum on the Outcome of Bile Duct Stone Treatment with Endoscopic Papillary Large Balloon Dilation

Ji Won Lee; Jung Ho Kim; Yeon Suk Kim; Hyun Seok Choi; Ju Seung Kim; Seok Hoo Jeong; Min Su Ha; Yang Suh Ku; Yun Soo Kim; J Hyun Kim

doi:10.4166/kjg.2011.58.4.201

Journal List > Korean J Gastroenterol > v.58(4) > 1006863

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Kim, Kim, Choi, Kim, Jeong, Ha, Ku, Kim, and Kim: The Effect of Periampullary Diverticulum on the Outcome of Bile Duct Stone Treatment with Endoscopic Papillary Large Balloon Dilation

Original Article

Korean J Gastroenterol 2011;58(4):201-207.

Published online: 4 October 2011

DOI: https://doi.org/10.4166/kjg.2011.58.4.201

The Effect of Periampullary Diverticulum on the Outcome of Bile Duct Stone Treatment with Endoscopic Papillary Large Balloon Dilation

Ji Won Lee, Jung Ho Kim, Yeon Suk Kim, Hyun Seok Choi, Ju Seung Kim, Seok Hoo Jeong, Min Su Ha, Yang Suh Ku, Yun Soo Kim, J Hyun Kim

Department of Internal Medicine, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea

Correspondence to: Yeon Suk Kim, Department of Internal Medicine, Gachon Gil Hospital, Gachon University of Medicine and Science, 1198, Guwol-dong, Namdong- gu, Incheon 405-760, Korea. Tel: +82-32-460-3778, Fax: +82-32-460-3408, E-mail: drkim@gilhospital.com

Received 7 May 2011 Accepted 20 July 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment.

Methods

We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed.

Results

PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9±11.1 years. Mean diameter of the stones was 14.8±6.0 mm and mean diameter of CBD was 21.6±7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (≥15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups.

Conclusions

PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.

Keywords: Diverticulum, Common bile duct, Choledocholithiasis, Balloon dilation, Endoscopic sphincterotomy

References

1. Lobo DN, Balfour TW, Iftikhar SY, Rowlands BJ. Periampullary diverticula and pancreaticobiliary disease. Br J Surg. 1999; 86:588–597.

2. Vaira D, Dowsett JF, Hatfield AR, et al. Is duodenal diverticulum a risk factor for sphincterotomy? Gut. 1989; 30:939–942.

3. Dalal AA, Rogers SJ, Cello JP. Endoscopic management of hemorrhage from a duodenal diverticulum. Gastrointest Endosc. 1998; 48:418–420.

4. Sim EK, Goh PM, Isaac JR, Kang JY, Gangaraju CR, Ti TK. Endoscopic management of a bleeding duodenal diverticulum. Gastrointest Endosc. 1991; 37:634.

5. Rao PM. Diagnosis please. Case 11: perforated duodenal diverticulitis. Radiology. 1999; 211:711–713.

6. Boix J, Lorenzo-Zúñiga V, Añaños F, Domènech E, Morillas RM, Gassull MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech. 2006; 16:208–211.

7. Park SH, Kim IH, Kim EJ, et al. Two cases of extended endoscopic sphincterotomy in patients with periampullary diverticulum -How do we estimate the upper margin of intramural ampulla in patients with periampullary diverticulum? Korean J Gastrointest Endosc. 2001; 22:239–244.

8. Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc. 2003; 57:156–159.

9. Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J Gastroenterol. 2007; 13:2179–2182.

10. Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy. 2007; 39:958–961.

11. Kim HJ, Choi HS, Park JH, et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc. 2007; 66:1154–1160.

12. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991; 37:383–393.

13. Sandstad O, Osnes T, Skar V, Urdal P, Osnes M. Common bile duct stones are mainly brown and associated with duodenal diverticula. Gut. 1994; 35:1464–1467.

14. Skar V, Skar AG, Osnes M. The duodenal bacterial flora in the region of papilla of Vater in patients with and without duodenal diverticula. Scand J Gastroenterol. 1989; 24:649–656.

15. Løtveit T, Osnes M, Larsen S. Recurrent biliary calculi: duodenal diverticula as a predisposing factor. Ann Surg. 1982; 196:30–32.

16. Miyazaki S, Sakamoto T, Miyata M, Yamasaki Y, Yamasaki H, Kuwata K. Function of the sphincter of Oddi in patients with juxtapapillary duodenal diverticula: evaluation by intraoperative biliary manometry under a duodenal pressure load. World J Surg. 1995; 19:307–312.

17. McHenry L, Lehman G. Difficult bile duct stones. Curr Treat Options Gastroenterol. 2006; 9:123–132.

18. Neuhaus H. Endoscopic and percutaneous treatment of difficult bile duct stones. Endoscopy. 2003; 35:S31–S34.

19. Kirk AP, Summerfield JA. Incidence and significance of juxtapapillary diverticula at endoscopic retrograde cholangiopancreatography. Digestion. 1980; 20:31–35.

20. Tham TC, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy. 2004; 36:1050–1053.

21. Panteris V, Vezakis A, Filippou G, Filippou D, Karamanolis D, Rizos S. Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate. Gastrointest Endosc. 2008; 68:903–910.

22. Kim HW, Kang DH, Choi CW, et al. Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula. World J Gastroenterol. 2010; 16:4335–4340.

23. Cho YD, Jeong SW, Cheon YK, et al. Minor EST with EPLBD is a safe treatment modality for removal of difficult bile duct stones in patients with periampullary diverticuli. Gastrointest Endosc. 2007; 65:AB220.

24. Liu F, Li F, Zhou Y, Xi M, Zou D, Li Z. Minor endoscopic sphincterotomy plus endoscopic balloon dilation is an effective and safer alternative for endoscopic sphincterotomy during ERCP in patients with peiampullary diverticula and bile duct stones. Gastrointest Endosc. 2008; 67:AB230.

25. Siegel JH, Cohen SA, Kasmin FE, Veerappan A. Stent-guided sphincterotomy. Gastrointest Endosc. 1994; 40:567–572.

26. Komatsu Y, Kawabe T, Toda N, et al. Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases. Endoscopy. 1998; 30:12–17.

27. Fogel EL, Sherman S, Lehman GA. Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by precut biliary sphincterotomy. Gastrointest Endosc. 1998; 47:396–400.

28. Boender J, Nix GA, de Ridder MA, et al. Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy. 1994; 26:209–216.

29. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996; 335:909–918.

30. Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc. 2002; 56:652–546.

31. Deenitchin GP, Konomi H, Kimura H, et al. Reappraisal of safety of endoscopic sphincterotomy for common bile duct stones in the elderly. Am J Surg. 1995; 170:51–54.

32. Sugiyama M, Suzuki Y, Abe N, Masaki T, Mori T, Atomi Y. Endoscopic retreatment of recurrent choledocholithiasis after sphincterotomy. Gut. 2004; 53:1856–1859.

Table 1.

Results of Endoscopic Stone Removal Using EPLBD

	Total (n=141)	PAD (＋) group (n=65)	PAD (−) group (n=76)	p-value^a
Age (yr)	70.6±12.7	72.9±11.1	68.6±13.7	0.043
Male	54 (38.3)	23 (35.4)	31 (40.8)	0.51
Billoth II operation	7 (5.0)	4 (6.2)	3 (3.9)	0.703
Previous EST	31 (22.0)	10 (15.4)	21 (27.6)	0.08
CBD stone
Size of the largest stone (mm) ≥15	71 (50.4)	39 (60)	32 (42.1)	0.034
Multiple stones ≥	88 (62.4)	42 (64.6)	46 (60.5)	0.617
Precut before balloon dilation	7 (5.0)	2 (3.1)	5 (6.6)	0.452
Enodoscopic papillary balloon
Balloon diameter (mm)	16.5±2.6	16.4±2.5	16.6±2.7	0.753
Ballon diameter (mm) ≥18	78 (55.3)	36 (55.4)	42 (55.3)	0.988
Characteristics of CBD
Bile duct diameter (mm) ≥15	115 (81.6)	56 (86.2)	59 (77.6)	0.193
CBD arm (mm) ≤36	41.7±13.3	20 (30.8)	34 (44.7)	0.089
CBD angle (degree) ≤135	146.0±16.9	17 (26.2)	19 (25.0)	0.876
Mechanical lithotripsy performed	5 (3.5)	3 (4.6)	2 (2.6)	0.426
Sussess of stone remove in the 1st session	73 (51.8)	32 (49.2)	41 (53.9)	0.576
Overall complete stone removal	132 (93.6)	63 (96.9)	69 (90.8)	0.137

Values are presented as mean±SD or n (%).

EPLBD, endoscopic large balloon dilation; PAD, periampullary diverticulum; EST, endoscopic sphincterotomy; CBD, common bile duct.

^a Comparison of PAD (＋) group and PAD (−) group.

Table 2.

Outcome according to Type of Periampullary Diverticulum

Characteristics	Type 1^a	Type 2^b	Type 3^c	p-value^d
Number of patients	8 (12.3)	37 (56.9)	20 (30.8)
Age (yr)	76.0±9.7	73.4±11.0	70.9±11.9	0.511
Male	2 (25.0)	15 (40.5)	6 (30.0)	0.588
Billoth II operation	0 (0)	1 (2.7)	3 (15.0)	0.135
Previous EST	2 (25.0)	5 (13.5)	3 (15.0)	0.715
CBD stone
Size of largest stone (mm) ≥15	4 (50.0)	24 (64.9)	11 (55.0)	0.636
Multiple stones ≥2	5 (62.5)	23 (62.2)	14 (70.0)	0.832
Precut before balloon dilation	0 (0)	0 (0)	2 (10.0)	0.098
Enodoscopic papillary balloon
Balloon diameter (mm)	15.8±2.7	16.6±2.4	16.4±2.7	0.707
Ballon diameter (mm) ≥18	4 (50.0)	20 (54.1)	12 (60.0)	0.864
Characteristics of CBD
Largest bile duct diameter (mm) ≥15	7 (87.5)	33 (89.2)	16 (80.0)	0.627
CBD arm (mm) ≤36	5 (62.5)	25 (67.6)	15 (75.0)	0.767
CBD angle (degree) ≤135	7 (87.5)	30 (81.1)	11 (55.0)	0.065
Mechanical lithotripsy	0 (0)	1 (2.7)	2 (10)	0.366
Sussess of stone remove in 1st session	6 (75.0)	18 (48.6)	8 (40.0)	0.245
Overall stone removal	8 (100)	35 (94.6)	20 (100)	0.458

Values are presented as mean±SD or n (%).

EST, endoscopic sphincterotomy; CBD, common bile duct; NA, not available.

^a Papilla was located to inside of diverticulum.

^b Papilla was located to lower rim of diverticulum.

^c Papilla was located outside of diverticulum (＜2 cm).

^d Comparison of subgroups of periampullary diverticula.

Table 3.

Complication Incidences after EPLBD

Characteristics	PAD (＋) group	PAD subtypes				PAD (−) group	p-value^e
Characteristics	PAD (＋) group	Type 1^a	Type 2^b	Type 3^c	p-value^d	PAD (−) group	p-value^e
Number of patients	65 (46.1)	8 (12.3)	37 (56.9)	20 (30.8)		76 (53.9)
Hemorrahge	1 (1.5)	0 (0)	1 (2.7)	0 (0)	NA	1 (1.3)	0.902
Pancreatitis	13 (20.0)	0 (0)	7 (18.9)	6 (30.0)	0.194	15 (19.7)	0.969
Perforation	0 (0)	0 (0)	0 (0)	0 (0)	NA	3 (3.9)	NA
Other complications^f	2 (3.1)	0 (0)	2 (5.4)	0 (0)	NA	0 (0)	0.211
All complications	14 (21.5)	0 (0)	8 (21.6)	6 (30)	0.218	19 (25.0)	0.692

Values are presented as n (%).

EPLBD, endoscopic large balloon dilation; PAD, periampullary diverticulum; NA, not available.

^a Papilla was located to inside of diverticulum.

^b Papilla was located to lower rim of diverticulum.

^c Papilla was located outside of diverticulum (＜2 cm).

^d Comparison of subgroups of periampullary diverticula.

^e Comparison of PAD (＋) group and PAD (−) group.

^f One case was biliary sepsis with pancreatitis, the other case was pneumonia with pancreatitis.

TOOLS

Similar articles