Strategy for the endoscopic treatment of common bile duct stones: Should we cut or Dilate the papilla?

Endoscopic sphincterotomy (EST) is a well-established standard technique for treating common bile duct stones. However, endoscopic papillary balloon dilation (EPBD) has recently been introduced as an alternative to avoid bleeding and perforation. In addition, this procedure can also help preserve the papillary function. However, the occurrence of postprocedure pancreatitis remains an important problem with EPBD. Indeed, EPBD has been abandoned in the United States owing to concerns about the increased risk of pancreatitis. On the other hand, it is still widely performed in Japan, and various measures have been taken to prevent the occurrence of postprocedure pancreatitis. In patients for whom EST is unsuitable, such as those with coagulopathy and those with a prior Billroth II gastrectomy, EPBD is considered to be indicated. Patients with a single stone or only a few small stones may also be considered for this procedure, because neither mechanical lithotripsy nor repeated cannulations will be necessary. Using a relatively small balloon and inflation with a low pressure for short durations is currently the most popular treatment strategy for EPBD in Japan. Nevertheless, in order to expand the number of patients considered for this treatment modality, special medication and treatment, such as an intravenous drip infusion of iso sorbide dinitrate and stent placement in the pancreatic duct, are considered to be necessary.