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Introduction: Common bile duct stone (CBDS) is a common disorder of the biliary tract
and often necessitates intervention to prevent biliary complications. Endoscopic
retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon stone
extraction remain to be the standard treatment for CBDS. For large stones (>12mm),
removal may be challenging. After sphincterotomy, use of mechanical lithotripsy (ML)
has been widely used for clearance of large stone in the last 3 decades. Large balloon
dilatation (LBD) is also established as a highly successful method of removing CBDS.
This present study aims to determine which procedure is more effective and safer in
clearing common bile duct stones.
A literature search of randomized controlled trials (RCTs) comparing balloon dilatation
and mechanical lithotripsy up to April 2020 in electronic databases including Cochrane
Library, MEDLINE (PubMed), Google Scholar, and as well
as hand-search of publications was done. Primary outcome was stone clearance rate.
Secondary outcomes include overall complication rate and specific rates for pancreatitis,
cholangitis, perforation and bleeding.
Results: Three RCTs (enrolling 273 patients) met our inclusion criteria. No significant
difference observed in stone clearance rate between the two groups (OR 1.44, 95% CI
0.68 to 3.87, P=0.34, moderate certainty). The overall complication rate was
significantly higher in the ML group (RR 0.45, 95% CI 0.24 to 0.82, P=0.01, high
certainty). Post-ERCP cholangitis did not occur in the LBD group. Six percent of the
patients in the ML group developed cholangitis and was statistically significant (RR 0.11,
95% CI 0.01 to 0.86, P=0.04, high certainty). No difference in post-ERCP pancreatitis,
perforation and bleeding observed. No significant heterogeneity was seen in the studies
Conclusion: Balloon dilatation is a safer and effective alternative to mechanical
lithotripsy in the removal of large common bile duct stones in terms of developing
cholangitis. There was no difference in rate of pancreatitis, perforation and bleeding
observed in both interventions. A higher risk of cholangitis is observed with the use of
mechanical lithotripsy.

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