Common bile duct stones—cut or stretch?

Endoscopic sphincterotomy (ES) is the standard method for dealing with common bile duct stones but papillary balloon dilatation (EPBD) is an attractive alternative, at least theoretically. Early studies of successful EPBD have been tempered by reports of a high complication rate and its exact role is not clear. Fujita et al carried out a prospective randomised multicentre trial comparing ES and EPBD in 282 patients with CBD stones <15mm (167 men, mean age 67.7 years, range 26–91). The study was adequately powered and the evaluation parameters were duct clearance, number of sessions required and complications occurring up to 30 days. Both techniques achieved duct clearance well (100% for EST and 99.3% for EPBD) with a similar number of sessions and equal procedure times. There was no overall difference in complications (11.8 % for ES and 14.5% for EPBD) and no deaths occurred. While bleeding only occurred in the ES group (2 patients), pancreatitis, mostly mild, was more common in the EPBD group (10.9% v 2.8%, p<0.05). In contrast, biliary infection was more common in the ES group (7.6% v 3.6%, p=NS).

This study shows what can be done to provide a strong evidence base for therapeutic endoscopic practice. It confirms that EPBD is not superior to the established technique of sphincterotomy but only long term follow up will tell whether there is a difference between the procedures in recurrence rate for stones and effects on sphincter of Oddi function. For the time …