SNFGE SNFGE
 
Thématique :
- Endoscopie/Imagerie
Originalité :
Réexamen
Solidité :
Très solide
Doit faire évoluer notre pratique :
Immédiatement
 
 
Nom du veilleur :
Professeur Emmanuel CORON
Coup de coeur :
 
 
Endoscopy
  2017/10  
 
  2017 Oct;49(10):968-976.  
  doi: 10.1055/s-0043-114411  
 
  Complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones: randomized multicenter study  
 
  Karsenti D, Coron E, Vanbiervliet G, Privat J, Kull E, Bichard P, Perrot B, Quentin V, Duriez A, Cholet F, Subtil C, Duchmann JC, Lefort C, Hudziak H, Koch S, Granval P, Lecleire S, Charachon A, Barange K, Cesbron EM, De Widerspach A, Le Baleur Y, Barthet M, Poincloux L  
  https://www.ncbi.nlm.nih.gov/pubmed/28753698  
 
 

Abstract

Background and study aims Endoscopic sphincterotomy plus large-balloon dilation (ES-LBD) has been reported as an alternative to endoscopic sphincterotomy for the removal of bile duct stones. This multicenter study compared complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones. This is the first randomized multicenter study to evaluate these procedures in patients with exclusively large common bile duct (CBD) stones.

Methods Between 2010 and 2015, 150 patients with one or more common bile duct stones ≥ 13 mm were randomized to two groups: 73 without balloon dilation (conventional group), 77 with balloon dilation (ES-LBD group). Mechanical lithotripsy was subsequently performed only if the stones were too large for removal through the papilla. Endoscopic sphincterotomy was complete in both groups. Patients could switch to ES-LBD if the conventional procedure failed.

Results There was no between-group difference in number and size of stones. CBD stone clearance was achieved in 74.0 % of patients in the conventional group and 96.1 % of patients in the ES-LBD group (P < 0.001). Mechanical lithotripsy was needed significantly more often in the conventional group (35.6 % vs. 3.9 %; P < 0.001). There was no difference in terms of morbidity (9.3 % in the conventional group vs. 8.1 % in the ES-LBD group; P = 0.82). The cost and procedure time were not significantly different between the groups overall, but became significantly higher for patients in the conventional group who underwent mechanical lithotripsy. The conventional procedure failed in 19 patients, 15 of whom underwent a rescue ES-LBD procedure that successfully cleared all stones.

Conclusions Complete endoscopic sphincterotomy with large-balloon dilation for the removal of large CBD stones has similar safety but superior efficiency to conventional treatment, and should be considered as the first-line step in the treatment of large bile duct stones and in rescue treatment.Trial registered at ClinicalTrials.gov (NCT02592811).

 

 
Question posée
 
Quelle est la place de la macrodilatation ampullaire pour le traitement des grosses (>13mm) lithiases cholédociennes ?
 
Question posée
 
La macrodilatation ampullaire 1) n’est pas plus morbide que l’extraction conventionnelle, 2) est significativement plus efficace et 3) permet de diminuer très nettement le recours à une lithotritie mécanique.
 
Commentaires

1ère étude française multicentrique (et randomisée), qui démontre solidement l’intérêt de la macrodilatation ampullaire et la place comme traitement de 1ère intention des grosses lithiases du cholédoque. 

 
www.snfge.org