SNFGE SNFGE
 
Thématique :
- Endoscopie/Imagerie
Originalité :
Intermédiaire
Solidité :
Très solide
Doit faire évoluer notre pratique :
Dans certains cas
 
 
Nom du veilleur :
Docteur Vincent VALANTIN
Coup de coeur :
 
 
Endoscopy
  2019/06  
 
  2019 Jun;51(6):548-559.  
  doi: 10.1055/a-0818-3638  
 
  A cumulative meta-analysis of endoscopic papillary balloon dilation versus endoscopic sphincterotomy for removal of common bile duct stones.  
 
  Tringali A, Rota M, Rossi M, Hassan C, Adler DG, Mutignani M  
  https://www.ncbi.nlm.nih.gov/pubmed/30727009  
 
 

Abstract

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 meta-analysis 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 ( ≥ 10 mm) 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 < 10 mm (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 (≥ 10 mm) was as effective as endoscopic sphincterotomy, both in stone clearance and the need for endoscopic mechanical lithotripsy, without carrying an increased risk of pancreatitis.
 

 
Question posée
 
Meta-analyse (25 études randomisées contrôlées) comparant le dilatation au ballon vs la sphincterotomie biliaire en se focalisant sur la taille du calcul, la taille du ballon et le temps de dilatation.
 
Question posée
 
Si la taille du ballon est >10 mm et que le temps de dilatation est d’au moins une minute alors la dilatation permet une clairance choledocienne identique avec une baisse de l’utilisation de la lithotritie mécanique. Il en est de même pour le taux de pancréatite surtout si le ballon est >10 mm. Le taux d’hémorragie et de cholécystite seraient même inférieurs à la technique de sphincterotomie.
 
Commentaires

Technique déjà éprouvée à privilégier dans les calculs de taille moyenne <10 mm avec des ballons d’au moins 10mm pendant un temps de dilatation d’au moins une minute de préférence chez les patients présentant des troubles de la coagulation (relais AAP ou AOD…).

On peut imaginer cette technique chez les jeunes patients pour éviter le reflux chronique qui peuvent être source de cholangiocarcinome.

 
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