Endoscopic management of choledocholithiasis: To cut, stretch or relax?

Since it was first described in 1974, endoscopic sphincterotomy has been th e procedure of choice for management of choledocholithiasis, especially for retained common bile duct stones. However, it has the dubious distinction of being the most hazardous of all endoscopic retrograde cholangiopancreato graphic procedures and carries an immediate complication rate of 8-10%. Con cern has also been voiced about the long-term complications of sphincteroto my, as the sphincter of Oddi is cut during the procedure. To prevent, or at least lessen, the short- and long-term complications of endoscopic sphinct erotomy, an alternative in the form of balloon dilatation of the papilla, h as been advocated. However, the procedure of balloon dilatation is cumberso me, time consuming and, more importantly, a recent multi-centre study from the US comparing endoscopic sphincterotomy with balloon dilatation observed higher complications with balloon dilatation. The use of nitrites to relax the papilla is another novel method used for removal of common bile duct c alculi. So how should a therapeutic endoscopist decide which method is to b e used? The advantage of endoscopic sphineterotomy is that it has been arou nd for more than two decades and most endoscopists are familiar with the te chnique as well as its complications. It can be accomplished quickly and wi th the advent of wire-guided and balloon-mounted sphincterotomes, the time taken for the procedure to be completed has been reduced further. The compl ications of the procedure are less when it is employed for removal of commo n bile duct stones and when used by experts. It, therefore, still appears t o be the procedure of choice for endoscopic management of choledocholithias is. The other two methods may, however, be useful in patients with coagulop athy.