1. Endoscopic Large balloon sphincteroplasty lower the recurrence rate in patients with recurrent bile duct stones Department of Gastroenterology, Kyung Hee University College of Medicine, Seoul, Korea Chang hyun Cho, M.D., Seok Ho Dong, M.D

2. Purpose Rate of recurrent CBD stones after CBD stone removal with EST : 5.8%~18% – main cause : post-EST ampullar stenosis. Studied the protective role of EPLBD for second recurrent CBD stone among Pts who were previously treated for CBD stones with EST

3. Method Between 2001 and 2009 577 CBD stone Pts underwent EST for primary bile duct stones at Kyung Hee University College of Medicine CBD stones recurred at least once in 56 Pts (28 male Pts, median age 65.5±12.9 years) during follow up (median 23.1±15.65 months)

4. 577 EST for CBD stone removal 56 / 577, 9.7% 1 st recurrence 34 / 56 EPLBD 22 / 56 EST Compare 2 nd recurrence

5. Clinical characteristic – age, sex, CBD diameter, stone color, periampullar diverticulum, endoscopic sessions and previous cholestectomy history Exclusion criteria – intrahepatic bile duct stone, surgical treatment and malignancy.

6. Result

7. Table 1. Clinical characteristics in patients with recurrent CBD stone after ERCP & EST Clinical FactorN=56 Age65.5 ± 12.9 Sex ( Male ) (%)28 (50) Follow up period (month)23.1 ± 15.65 CBD diameter(%) < 11mm11 (19.6) > 11mm44 (78.6) Periampullary diverticulum (%) No26 (46.4) Juxtapapilla diverticula16 (28.6) Extradiverticular papilla9 (16.1) Recurrent stones(%) Brown41 (73.2) Black6 (10.7) Previous cholecystectomy (%) 40 (71.4) Therapy for old EST revision EST / EPBD (%)22 (39.3)/ 34 (60.7)

8. Table 2. Clinical characteristics in patients with EST & EPLBD for 1 st recurrent stone removal. ESTEPLBDP-value Number of patients2234 Age60.73 ± 13.2665.8 ± 13.50.023 Male/Female12/1016/18 Follow up (month)25.45 ± 18.3521.58 ± 13.710.372 Bile duct diameter < 11mm740.082 > 11mm1430 Multisession ERCP 170.096 Periampullary diverticulum No9170.169 Juxtapapilla diverticula313 Extradiverticular papilla54 Recurrent stone0.434 Brown color1526 Black color24 Previous cholecystectomy0.436 Yes1723 No511 Second CBD stones recurrence0.017 Yes83 No1431

9. No second recurrence Second recurrence P-value Number of patients4511 Age65.5 ± 12.965.8 ± 13.50.944 Men/Female24/214/70.503 Follow up (month)22.7 ± 16.524.7 ± 12.00.706 Bile duct diameter0.184 < 11mm110 > 11mm3410 Multisession ERCP620.680 Periampullary diverticulum0.639 No215 Juxtapapilla diverticula133 Extradiverticular papilla63 Recurrent stone color0.750 Brown color347 Black color51 Therapy for old EST revision0.017 EST148 EPBD313 Previous cholecystectomy0.483 Yes319 No142 Table 3. Univariate analysis of risk factors for 2 nd recurrent stones after 1 st recurrent stone removal.

10. EST vs EPLBD Univariate analysis (p-value=0.017) – EPLBD group : 3 / 34 (8.8%) – EST group : 8/ 22 (36.3%) Multivariate analysis (Logistic regression analysis, p-value=0.008)

11. Figure 1. Kaplan–Meier’s curve comparing EST & EPBD group for old EST revision in relation to second recurrence of bile duct stone (p-value=0.028) Follow up(month) Second CBD stone recurrence EPBD EST

12. Conclusion EPLBD reduces second recurrent CBD stones for patients who were previously treated for CBD stones with EST This study was retrospective, small scale, and single center. Further multicenter, large scale, prospective studies will be needed.