Systematic Reviews
Copyright ©The Author(s) 2019.
World J Gastroenterol. Jun 28, 2019; 25(24): 3091-3107
Published online Jun 28, 2019. doi: 10.3748/wjg.v25.i24.3091
Table 1 Characteristics of the 43 studies included in the systematic review
StudyStudy designNo.Indications for ERCPType of endoscopeSphincter therapyA-loop intubation, No. (%)Selective cannulation, No. (%)Adverse events
Forbes and Cotton[1], 1984Retrospective cohort53N/ASEST45/53 (84.9)35/45 (77.8)Bowel perforation (n = 1, 1.9%)
Osnes et al[2], 1986Retrospective cohort147N/ASEST134/147 (91.2)134/134 (100)Bowel perforation (n = 1, 0.7%)
Pancreatitis (n = 1, 0.7%)
Bleeding (n = 1, 0.7%)
Mortality (n = 2, 1.4%)
Hintze et al[31], 1997Retrospective cohort59CBD stoneSEST54/59 (91.5)54/54 (100)Bowel perforation (n = 1, 1.7%)
Papillary stenosisMortality (n = 1, 1.7%)
Tumor stenosis
Juxtapapillary diverticulum
Kim et al[3], 1997Prospective comparative45N/AF (n = 23)EST±NK44/4536/44 (80.0)Bowel perforation (n = 4, 8.9%)
(97.8)
S (n = 22)Pancreatitis (n = 3, 2.2%)
Lin et al[32], 1999Retrospective cohort56CBD stoneFEST43/56 (76.6)35/43 (81.3)Bleeding (n = 3, 5.4%)
CBD dilation
RUQ pain with cholestasis
Faylona et al[33], 1999Retrospective cohort110Cholangitis (n = 58)SEST2132/185 (71.4)2122/132 (92.4)Bowel perforation (n = 11, 5.9%)
CBD stone (n = 41)Pancreatitis (n = 1, 0.5%)
Jaundice (n = 28)
CBD dilation (n = 19)Bleeding (n = 3, 1.6%)
Pancreatitis (n = 9)Mortality (n = 2, 1.1%)
Others (n = 30)
Bergman et al[11], 2001Prospective comparative34CBD stone (n = 34)SEST/EPBDN/A28/34 (82.4)Bowel perforation (n = 1, 2.9%)
Pancreatitis (n = 1, 2.9%)
Bleeding (n = 3, 8.8%)
Respiratory insufficiency (n = 1, 2.9%)
Swarnkar et al[34], 2005Retrospective cohort41CBD stone (n = 16)SEST242/48 (87.5)241/42 (97.6)Bowel perforation (n = 1, 2.1%)
CBD dilation (n = 9)
Pancreatitis (n = 4)
Gastric cancer (n = 3)
Pancreatic cancer (n = 2)
Others (n = 7)
Bleeding (n = 2, 4.2%)
Kikuyama et al[35], 2005Retrospective cohort24CBD stone (n = 14)AOEEST24/24 (100)22/24 (91.7)Bowel perforation (n = 1, 4.2%)
Pancreaticobiliary malignancy (n = 8)Pancreatitis (n = 1, 4.2%)
Bleeding (n = 1, 4.2%)
Others (n = 2)
Ciçek et al[36], 2006Retrospective cohort52CBD stone (n = 27)SEST±NK45/52 (94.2)43/45 (95.6)Bowel perforation (n = 6, 11.5%)
Jaundice (n = 11)Bleeding (n = 3, 1.6%)
Pancreatico-biliary malignancy (n = 10)
(n = 2, 3.8%)
Bile leakage (n = 2)
Others (n = 2)
Park et al[37], 2007Retrospective cohort10CBD stone (n = 9)1FEST10/10 (100)10/10 (100)None
CBD stricture (n = 1)
Dolay and Soylu[38], 2008Retrospective cohort11SEST11/11 (100)11/11 (100)None
Nakahara et al[39], 2009Retrospective comparative43CBD stone (n = 43)AOEEST/EPBD±NK38/43 (88.4)36/38 (94.7)None
Koo et al[10], 2009Retrospective cohort14CBD stone (n = 8)Multiple bending endoscopeEST/EPBD14/14 (100)13/14 (92.9)None
Biliary pancreatitis (n = 2)
Pancreatico-biliary malignancy (n = 3)
Bile leakage after cholecystectomy (n = 1)
Shimatani et al[40], 2009Retrospective cohort17N/ADBEEST/EPBD222/22 (100)222/22 (100)None
Kikuyama et al[41], 2009Retrospective cohort11CBD stone (n = 8)AOE with over tubeEST/EPBD210/15 (66.7)210/10 (100)None
Pancreatico-biliary malignancy (n = 3)
Chronic pancreatitis (n = 1)
Lin et al[42], 2010Retrospective cohort32N/AS (n = 22)EPBD30/32 (68.8)28/30 (93.3)Bowel perforation (n = 2, 6.3%)
DBE (n = 8)
Itoi et al[12], 2010Retrospective cohort11CBD stone (n = 11)F (n = 8)EST+EPLBD11/11 (100)11/11 (100)None
S (n = 1)
AOE (n = 1)
SBE (n = 1)
Lee et al[30], 2012Retrospective cohort13CBD stone (n = 13)1FEPLBD13/13 (100)12/13 (92.3)Bleeding (n = 1, 7.7%)
Byun et al[43], 2012Retrospective cohort46CBD stone (n = 37)FEST+EPBD42/46 (91.3)42/42 (100)Bowel perforation (n = 1, 2.2%)
Pancreatico-biliary malignancy (n = 5)Pancreatitis (n = 1, 2.2%)
Benign biliary stricture (n = 4)
Choi et al[44], 2012Retrospective comparative26CBD stone (n = 26)S (n = 13)EST±EPBD26/26 (100)26/26 (100)None
F (n = 13)
Kianicka et al[45], 2012Retrospective cohort120Cholestasis (n = 100)FEST109/120 (90.8)109/120 (90.8)Bowel perforation (n = 1, 0.8%)
Biliary pancreatitis (n = 12)Pancreatitis (n = 2, 1.7%)
Acute cholangitis (n = 6)Bleeding (n = 2, 1.7%)
Bile leakage (n = 2)
Osoegawa et al[27], 2012Retrospective cohort15N/ADBEEST/EPBD±NK218/19 (94.7)216/18 (88.9)Bowel perforation (n = 1, 0.5%)
Sen-Yo et al[46], 2012Retrospective comparative65CBD stone (n = 38)AOEEST/EPBD±NK60/65 (92.3)60/60 (100)Bowel perforation (n = 1, 1.5%)
Pancreatico-biliary malignancy (n = 17)Pancreatitis (n = 3, 4.6%)
Cholangitis (n = 2, 3.0%)
Other malignancy (n = 2)
Chronic pancreatitis (n = 2)
Bile leakage (n = 2)
Others (n = 4)
Jang et al[47], 2013Retrospective cohort40CBD stones (n = 40)SEPLBD±NK40/40 (100)40/40 (100)Pancreatitis (n = 2, 5.0%)
Yao et al[9], 2013Retrospective cohort46CBD stone (n = 38)Dual-lumen gastroscopeEST/EPBD38/46 (82.6)38/38 (100)None
Biliary stricture (n = 3)
Pancreatico-biliary malignancy (n = 5)
Kawamura et al[48], 2013Retrospective comparative65CBD stone (n = 49)F (n = 56)N/A61/65 (93.8)51/61 (83.6)Bowel perforation (n = 2, 3.1%)
Pancreatico-biliary malignancy (n = 26)S (n = 2)Pancreatitis (n = 4, 6.2%)
SBE (n = 3)
Others (n = 4)Bleeding (n = 1, 1.5%)
Benign biliary stricture (n = 1)
Kim et al[49], 2014Retrospective cohort30CBD stone (n = 30)SEPLBD±EST30/30 (100)30/30 (100)Pancreatitis (n = 2, 6.7%)
Bleeding (n = 2, 6.7%)
Iwai et al[50], 2014Retrospective comparative19N/ASBEN/A18/19 (95)18/18 (100)None
Cheng et al[51], 2015Retrospective cohort77CBD stone (n = 77)DBEEPLBD/ EPBD±NK73/77 (95)67/73 (92)Bowel perforation (n = 3, 3.8%)
Intestinal mucosal tear (n = 2, 2.6%)
Jang et al[52], 2015Retrospective cohort36CBD stone (n = 28)1FEPBD± EST36/36 (100)32/36 (88.9)Bowel perforation (n = 3, 8.3%)
Benign biliary stricture (n = 6)Pancreatitis ((n = 2, 5.6%)
Pancreatico-biliary malignancy (n = 1)
Post-operative bile leakage (n = 1)
Ki et al[53], 2015Retrospective cohort72CBD stone (n = 55)1FEST/EPBD2125/126 (99.2)2125/125 (100)Bowel perforation (n = 1, 0.7%)
Cholangitis (n = 11)
CBD stricture (n = 7)
Pancreatico-biliary malignancy (n = 3)
IHD stone (n = 2)
Pancreatitis (n = 3, 2.2%)
Bleeding (n = 8, 5.9%)
Nakahara et al[54], 2015Retrospective cohort25CBD stone (n = 15)AOEEST/EPBD226/30 (86.7)226/26 (100)Pancreatitis (n = 1, 3.3%)
Pancreatico-biliary malignancy (n = 7)
Chronic pancreatitis (n = 3)
Bove et al[17], 2015Retrospective cohort713CBD stone (n = 365)S (n = 600)EST618/713 (86.7)580/618 (93.8)Bowel perforation (n = 22, 3.1%)
F (n = 18)
Obstructive jaundice (n = 177)Pancreatitis (n = 5, 0.7%)
Acute cholangitis (n = 61)
Chronic pancreatitis (n = 55)Bleeding (n = 11, 1.5%)
Biliary pancreatitis (n = 21)
Mortality (n = 2, 0.3%)
Benign biliary stricture (n = 9)
Others (n = 5)
Wu et al[18], 2016Retrospective cohort135CBD stone/cholangitisSEST+EPBD120/135 (88.8)117/135 (86.3)2Bowel perforation (n = 1, 0.7%)
Benign biliary stricturePancreatitis (n = 9, 4.1%)
Bleeding (n = 2, 0.9%)
Park et al[19], 2016Retrospective cohort165CBD stone (n = 133)1FEPBD±NK151/165144/151Bowel perforation (n = 3, 1.8%)
Benign biliary stricture (n = 21)(91.5)(95.4)Pancreatitis (n = 13, 7.9%)
Pancreatico-biliary malignancy (n = 11)
Hyperamylasemia (n = 22, 13.3%)
Wang et al[28], 2016Retrospective cohort18CBD stone (n = 15)Dual-lumen gastroscopeEST/EPBD15/18 (83.3)15/15 (100)Pancreatitis (n = 2, 11.1%)
Pancreatico-biliary malignancy (n = 3)Bleeding (n = 1, 5.6%)
Wang et al[29], 2016Retrospective cohort52CBD stone (n = 38)C (n = 31)EST/EPBD±NK50/52 (96.2)50/52 (96.2)Pancreatitis (n = 2, 3.8%)
Biliary stricture (n = 9)F (n = 13)Hyperamylasemia (n = 2, 3.8%)
Pancreatico-biliary malignancy (n = 5)S (n = 11)
Shimatani et al[25], 2016Prospective cohort26Cholangitis (n = 13)DBEEST25/26 (96.2)25/25 (100)Bowel perforation (n = 2, 7.7%)
Hepatobiliary disorder (n = 4)Pancreatitis (n = 5, 19.2%)
Obstructive jaundice (n = 4)Cholangitis (n = 1, 3.8%)
CBD stone (n = 2)
Aspiration pneumonia (n = 1, 3.8%)
Others (n = 3)
Shimatani et al[55], 2017Retrospective cohort11CBD stone (n = 7)DBEEST11/11 (100)11/11 (100)None
Obstructive jaundice (n = 2)
Others (n = 2)
Yane et al[26], 2017Retrospective cohort20CBD stoneSBEN/A20/20 (100)19/20 (95)Bowel perforation (n = 2, 1.0%)
Bile duct stricturePancreatitis (n = 3, 1.5%)
Aanstomosis site strictureCholangitis (n = 4, 2.0%)
Cholecystitis (n = 1, 0.5%)
Li et al[56], 2017Retrospective cohort49CBD stone (n = 49)SEPBDN/A42/49 (85.7)Pancreatitis (n = 3, 6.1%)
Han et al[57], 2018Retrospective cohort15CBD stone (n = 15)1FEST/EPBD±NK15/15 (100)15/15 (100)Pancreatitis (n = 1, 6.7%)
1Cap-fitted forward-viewing endoscope;
2The data are per procedure, not per patient. A-loop: Afferent loop; ERCP: Endoscopic retrograde cholangiopancreatography; N/A: Not available; RUQ: Right upper quadrant; EST: Endoscopic sphincterotomy; NK: Needle knife; EPBD: Endoscopic papillary balloon dilation; EPLBD: Endoscopic papillary large balloon dilation; CBD: Common bile duct; IHD: Intrahepatic duct; F: Forward-viewing endoscope; S: Side-viewing endoscope; C: Colonoscope; SBE: Single-balloon enteroscope; DBE: Double-balloon enteroscope; AOE: Anterior oblique-viewing endoscope.
Table 2 Detailed characteristics of the most recently published studies with more than 100 patients
Bove et al[17], 2015
Wu et al[18], 2016
Park et al[19], 2016
(n = 713)(n = 135)(n = 165)
Study designRetrospective cohort in single centerRetrospective cohort in single centerRetrospective cohort in 5 centers
Male gender, n (%)567 (79.5)N/A116 (70.3)
Age (yr), n (%) or mean ± SD> 60 yr, 565 (79.2)N/A71.1 ± 10.0
Type of endoscopeSide-viewing or forward-viewingSide-viewingCap-fitting forward- viewing
Type of sphincter therapyESTESTEPBD±NK
Success of afferent loop intubation, n (%)618/713 (86.7)120/135 (88.8)151/165 (91.5)
Success of selective cannulation, n (%)580/618 (93.8)117/120 (97.5)144/151 (95.4)
Bowel perforation, n (%)22/713 (3.1)1/135 (0.7)3/165 (1.8)
Post-ERCP pancreatitis, n (%)5/713 (0.7)N/A13/165 (7.9)
Bleeding, n (%)11/713 (1.5)N/A-
Mortality, n (%)2/713 (0.3)--
ERCP: Endoscopic retrograde cholangiopancreatography; SD: Standard deviation; EST: Endoscopic sphincterotomy; NK: Needle knife; EPBD: Endoscopic papillary balloon dilation; N/A: Not available.
Table 3 Results of the systematic review
No. (%)
Study design, n (%)
Retrospective cohort36/43 (83.7)
Retrospective comparative4/43 (9.3)
Prospective comparative2/43 (4.7)
Prospective cohort1/43 (2.3)
Total number of identified patients2669
1Type of endoscope, n (%)
Side-viewing endoscope1432/2575 (55.6)
Forward-viewing endoscope664/2575 (25.8)
Balloon-assisted enteroscope197/2575 (7.7)
Anterior oblique-viewing endoscope169/2575 (6.6)
Dual-lumen endoscope64/2575 (2.5)
Colonoscope31/2575 (1.2)
Multiple bending endoscope14/2575 (0.5)
Others4/2575 (0.2)
Overall success of afferent loop intubation, n (%)2437/2669 (91.3)
Overall success of selective cannulation, n (%)2346/2437 (87.9)
Overall adverse events, n (%)195 (7.3)
Bowel perforation74 (2.8)
Post-ERCP pancreatitis65 (2.4)
Bleeding37 (1.4)
Mortality9 (0.3)
2Others10 (0.4)
1Total number can be changed due to unavailable or incomplete specific data;
2Cholangitis (n = 7), respiratory insufficiency (n = 1), aspiration pneumonia (n =1), and cholecystitis (n = 1). ERCP: Endoscopic retrograde cholangiopancreatography.
Table 4 Subgroup analysis according to the type of endoscope
Side-viewing endoscope
Forward-viewing endoscope
Balloon-assisted enteroscope
Oblique-viewing endoscope
Dual-lumen endoscope
(n = 1432)(n = 664)(n = 197)(n = 169)(n = 64)
Afferent loop intubation, n (%)1406 (98.2)647 (97.4)188 (95.4)159 (94.1)53(82.8)
Selective cannulation, n (%)1340 (95.3)616 (95.2)179 (97.5)155 (97.5)53 (100)
Adverse events, n (%)113 (7.9)47 (7.1)14 (7.1)6 (3.6)3 (4.7)
Bowel perforation, n (%)51 (3.6)11 (1.7)8 (4.1)2 (1.2)2 (3.1)
Post-ERCP pancreatitis, n (%)26 (1.8)27 (4.1)6 (3.0)3 (1.8)1 (1.6)
Bleeding, n (%)27(1.9)9 (1.4)-1 (0.6)-
Mortality, n (%)9 (0.6)----
ERCP: Endoscopic retrograde cholangiopancreatography.
Table 5 Subgroup analysis according to the sphincter management methods
ESTEST+EPBDEPBDEPLBD
(n = 1478)(n = 598)(n = 246)(n = 171)
1Clinical success, n (%)1268 (85.8)546 (91.3)214 (87.0)160 (93.6)
Adverse events, n (%)103 (7.0)38 (6.4)21 (8.5)10 (5.8)
Bowel perforation, n (%)51 (3.5)8 (1.3)5 (2.0)3 (1.8)
Post-ERCP pancreatitis, n (%)18 (1.2)22 (3.7)16 (6.5)4 (2.3)
Bleeding, n (%)25 (1.7)8 (1.3)-3 (1.8)
Mortality, n (%)9 (0.6)--
1Clinical success was defined as the achievement of the planned therapeutic goals including bile duct stone clearance, endobiliary biopsy, biliary stent or nasobiliary catheter insertion. The number of patients is much decreased because three studies, unavailable sphincter management information, were excluded from the subgroup analysis. ERCP: Endoscopic retrograde cholangiopancreatography; EST: Endoscopic sphincterotomy; EPBD: Endoscopic papillary balloon dilation; EPLBD: Endoscopic papillary large balloon dilation.