الفهرس 
Anatomy of the biliary systemOnly 14 pages are availabe for public view
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Abstract
Since its introduction in 1968, endoscopic retrograde cholangio-pancreatography (ERCP) has become a commonly performed endoscopic procedure. The diagnostic and therapeutic utility of ERCP has been demonstrated for a variety of disorders (Mallery et al., 2003).
Endoscopic retrograde cholangiopancreatography has become one of the most important techniques for diagnosis and treatment of choledocholithiasis. It is usually combined with sphincterotomy for the extraction of bile duct stones by using standard balloon or basket catheter, although papillary balloon dilatation has also been used in this setting (Irfan at al 2008).
Endoscopic sphincterotomy (ES) is widely accepted for the treatment of patients with common bile duct stones (CBDs). Despite improvement in this technique, ES is still associated with complications including significant hemorrhage, retroperitoneal perforation, cholangitis, pancreatitis and late complications such as recurrent CBDS or cholangitis (Lin et al., 2004).
Endoscopic papillary balloon dilation (EBD) was first proposed in 1983 and has recently been re-evaluated as a potential alternative to ES by several endoscopists, after Bergman et al. reported its usefulness in 1994. As EBD enlarges the bile duct opening by balloon inflation rather than cutting, there is little risk of bleeding (Masaaki et al., 2002). So endoscopic balloon dilatation can be safely applied in patients with coagulopathy as an alternative to ES and does not increase the incidence of pancreatitis or bleeding (Takeshi et al., 2005).
The aim of this study was to evaluate prospectively both endoscopic sphincterotomy and endoscopic balloon dilatation in removal of common bile duct stones as regards their effectiveness in complete stone removal and the frequency of complications associated with each technique.
In order to fulfill this aim, a prospective study was conducted on 100 consecutive patients with a common bile duct stones at two different ERCP units in Ain Shams University Hospitals over a period of two years, from January 2007 to February 2009.
The enrolled patients were randomly divided into 2 groups:
• Group1: 50 patients underwent endoscopic sphincterotomy.
• Group2: 50 patients underwent endoscopic balloon dilatation.
Patient’s outcomes were observed and any complications occurring during or within 30 days after the procedure were recorded.
The patients of both groups had been matching as regard age with mean age 54.82±16.05 in the ES group compared to 49.76±14.82 in the EBD group. Forty eight percent of the patients of both groups were males while the remaining 52% were females.
The rate of complete stone removal in one session in the present study was achieved in 82% of the patients with ES which was comparable to 80% of the patients in the EBD group; while the overall success rate was achieved in 88% of cases of the ES group versus the same percentage in the EBD group which was also a comparable results.
The rate of overall complications was similar in each group, where the procedural-related abdominal pain was the most common observed complication in 38% in the patients of the ES group versus 44% in the EBD group.
The second most common complication was acute pancreatitis which was recorded in 14% of patients in ES group and 16% of patients in the EBD group.
Also, our study revealed a highly significant rate of procedural-related bleeding among the patients of ES group which is a very serious and life threatening complication. A 10% of cases in the ES group complicated by post-procedural bleeding, 4% with mild bleeding, 2% with moderate and the remaining 4% with severe bleeding, inspite of normal bleeding profile pre-procedural. None of the patients in EBD group developed procedural-related bleeding.
We showed similar rates of biliary infections, haematemsis, melena, ICU admission and mortalities among the studied groups.
The present study, reported a higher rate of hyperamylasemia among the patients with EBD group than ES group which may indicate more pancreatic irritation when balloon dilatation is planned.
The univariate analysis revealed that the significant factor for complete stone removal in the ES group includes:
• The common bile duct diameter.
• The diameter of largest stone.
While after application of multivariate analysis, only the diameter of the common bile duct was the independent factor for successful stone removal.
On the other hand, we reported that the significant factors for overall success in the EBD group were:
• Balloon size.
• The common bile duct diameter.
• The diameter of largest stone, with only significance of the diameter of the large stone (more with smaller diameter) on multivariate analysis.
By univariate analysis, the largest stone diameter was the independent risk factor for post-ES complication while the balloon size and the diameter of largest stone were the factors which can seriously impact the post-EBD outcome.
On multivariate logistic regression analysis, the largest stone diameter was confirmed to be an important factor for occurrence of post-ES complication, while only the balloon diameter was the independent risk factors for post-ERCP complications after endoscopic balloon dilatation.
Very importantly, we found in our work that the optimal diameter of the largest stone associated with the highest efficacy of stone removal and the least hazardous out come was 10 mm stones, while CBD which was 11 mm in diameter was associated with best outcome and rate of complications is increased significantly as CBD became wider.