Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis.

Abstract Background and Aims Several endoscopic methods have been proposed for treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis. Methods 19 randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were success rate of stone removal and incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence. Results All treatments except ML significantly outperformed sphincterotomy in terms of stone removal rate [risk ratios (RRs) ranging from 1.03 to 1.29]. SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR 1.24, 1.07-1.45], vs S+EPLBD [RR 1.23, 1.06-1.42] and vs mechanical lithotripsy [RR 1.34, 1.14-1.58]). Cholangioscopy ranked highest in increasing the success rate of stone removal (SUCRA-score 0.99) followed by S+EPLBD (SUCRA-score 0.68). SOC and L S+EPLBD outperformed the other modalities when only studies reporting on stones > 15 mm were taken into consideration (SUCRA-score 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate as compared to EST or to other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events. Conclusions Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (> 15 mm) stones, whereas S+ EPLBD could represent a less expensive and more widely available alternative.