Large balloon sphincteroplasty for CBD stone removal during acute cholangitis. Single center propensity-score matched cohort study

Endoscopic biliary drainage is the mainstay of treatment for acute cholangitis. CBD stone removal can be performed in same session with biliary drainage. Our team incorporated the use of endoscopic large balloon sphincteroplasty as an alternative for conventional papillotomy for biliary access. This study aims to identify tips and pitfalls of EPLBD usage during acute cholangitis.

From the period October 2016 to April 2021, Yan Chai Hospital has 209 patients presented with acute cholangitis had ERCP for CBD stone removal performed. Among which, 50 patients had limited papillotomy followed by endoscopic large balloon papillary dilatation for biliary access (EPLBD), while 159 patients had conventional sphincterotomy (EST) done. Propensity score matching analysis was performed in a 1:1 ratio. Primary outcome was complete CBD stone removal as defined by clearance of occlusive cholangiogram. Secondary outcomes are post-ERCP pancreatitis, minor bleeding and major bleeding, flare up of sepsis. Logistic regression analysis was performed to identify risk factors associated with one year recurrence rate. Kaplan Meier analysis was utilized for long-term recurrence rate after ERCP.

In overall cohort, presence of large CBD stone & parapapillary diverticulum was more frequent in EPLBD group (26.0 ≤ 6.2% vs 9.4 ± 2.3%, p = 0.003) & (52.0 ± 7.1% vs 24.5 ± 3.4%, p < 0.001); they were balanced in PSM cohort. The complete CBD stone removal rate were higher in EPLBD group than EST group with statistical significance (80.0 ± 5.7% vs 54.0 ± 7.0%, p = 0.006). Major bleeding requiring reintervention was observed in 2.0 ± 2.0% vs 8.0 ± 3.8%, p = 0.169. Post ERCP pancreatitis were observed in 2.3 ± 2.2% vs 2.4 ± 2.4%, p = 0.960. 1 year recurrence rate was 14.0 ± 4.9% vs 2.0 \(\pm 2.0\%, p=0.027\) $\pm 2.0\%,p=0.027$ .

Deployment of EPLBD during acute cholangitis demonstrated clinical efficacy in CBD stone clearance when compared with conventional sphincterotomy with a non-inferior safety profile. However, long term recurrence rate of acute cholangitis was observed to be higher.