The role of endoscopy in the management of choledocholithiasis

Abstract

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).1Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE Working GroupGRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”TABLE 1GRADE system for rating the quality of evidence for guidelinesAdapted from Guyatt et al.1Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE Working GroupGRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google ScholarQuality of evidenceDefinitionSymbolHigh qualityFurther research is very unlikely to change our confidence in the estimate of effect.⊕⊕⊕⊕Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.⊕⊕⊕○Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.⊕⊕○○Very low qualityAny estimate of effect is very uncertain.⊕○○○ Open table in a new tab This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. Gallstone disease affects more than 20 million American adults2Everhart J.E. Khare M. Hill M. et al.Prevalence and ethnic differences in gallbladder disease in the United States.Gastroenterology. 1999; 117: 632-639Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar at an annual cost of $6.2 billion.3Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States I: overall and upper gastrointestinal diseases.Gastroenterology. 2009; 136: 376-386Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar The incidence of choledocholithiasis ranges from 5% to 10% in those patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis4Hunter J.G. Laparoscopic transcystic bile duct exploration.Am J Surg. 1992; 163: 53-56Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 5Robinson B.L. Donohue J.H. Gunes S. et al.Selective operative cholangiography: appropriate management for laparoscopic cholecystectomy.Arch Surg. 1995; 130: 625-630Crossref PubMed Google Scholar, 6Petelin J.B. Laparoscopic common bile duct exploration.Surg Endosc. 2003; 17: 1705-1715Crossref PubMed Scopus (76) Google Scholar, 7O'Neill C.J. Gillies D.M. Gani J.S. Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically.ANZ J Surg. 2008; 78: 487-491Crossref PubMed Scopus (10) Google Scholar to 18% to 33% of patients with acute biliary pancreatitis.8Chang L. Lo S.K. Stabile B.E. et al.Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.Am J Gastroenterol. 1998; 93: 527-531Crossref PubMed Scopus (61) Google Scholar, 9Chak A. Hawes R.H. Cooper G.S. et al.Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.Gastrointest Endosc. 1999; 49: 599-604Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 10Liu C.L. Lo C.M. Chan J.K.F. et al.Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients.Gastrointest Endosc. 2001; 54: 325-330Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 11Cohen M.E. Slezak L. Wells C.K. et al.Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends.Am J Gastroenterol. 2001; 96: 3305-3311Crossref PubMed Google Scholar The diagnostic approach to patients with suspected choledocholithiasis is addressed in a separate ASGE practice guideline.12Maple J.T. Ben-Menachem T. Anderson M.A. et al.ASGE Standards of Practice CommitteeThe role of endoscopy in the evaluation of suspected choledocholithiasis.Gastrointest Endosc. 2010; 71: 1-9Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar This guideline addresses the role of endoscopy in the management of patients with known choledocholithiasis. Although data regarding the natural history of choledocholithiasis are limited, available studies indicate that 21% to 34% of common bile duct (CBD) stones will spontaneously migrate,13Oria A. Alvarez J. Chiappetta L. et al.Risk factors for acute pancreatitis in patients with migrating gallstones.Arch Surg. 1989; 124: 1295-1296Crossref PubMed Google Scholar, 14Frossard J.L. Hadengue A. Amouyal G. et al.Choledocholithiasis: a prospective study of spontaneous bile duct stone migration.Gastrointest Endosc. 2000; 51: 175-179Abstract Full Text Full Text PDF PubMed Google Scholar and migrating stones pose a moderate risk of pancreatitis (25%-36%)13Oria A. Alvarez J. Chiappetta L. et al.Risk factors for acute pancreatitis in patients with migrating gallstones.Arch Surg. 1989; 124: 1295-1296Crossref PubMed Google Scholar, 14Frossard J.L. Hadengue A. Amouyal G. et al.Choledocholithiasis: a prospective study of spontaneous bile duct stone migration.Gastrointest Endosc. 2000; 51: 175-179Abstract Full Text Full Text PDF PubMed Google Scholar or cholangitis if they obstruct the distal duct.15Lee S.H. Hwang J.H. Yang K.Y. et al.Does endoscopic sphincterotomy reduce the recurrence rate of cholangitis in patients with cholangitis and suspected of a common bile duct stone not detected at ERCP?.Gastrointest Endosc. 2008; 67: 51-57Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The natural history of CBD stones incidentally discovered during routine intraoperative cholangiography (IOC) at elective cholecystectomy may be less morbid than symptomatic CBD stones discovered pre-cholecystectomy.16Collins C. Maguire D. Ireland A. et al.A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited.Ann Surg. 2004; 239: 28-33Crossref PubMed Scopus (114) Google Scholar However, because biliary pancreatitis and cholangitis may be life-threatening conditions, removal of discovered CBD stones is generally recommended.17Williams E.J. Green J. Beckingham I. et al.British Society of GastroenterologyGuidelines on the management of common bile duct stones (CBDS).Gut. 2008; 57: 1004-1021Crossref PubMed Scopus (96) Google Scholar, 18Paul A. Millat B. Holthausen U. et al.Diagnosis and treatment of common bile duct stones: results of a consensus development conference.Surg Endosc. 1998; 12: 856-864Crossref PubMed Google Scholar Endoscopic retrograde cholangriography (ERC) with endoscopic sphincterotomy (ES) and stone extraction was first described in 197419Demling L. Koch H. Classen M. Endoscopic papillotomy and removal of gallstones: animal experiments and first clinical results [in German].Dtsch Med Wochenschr. 1974; 99: 2255-2257Crossref PubMed Google Scholar and has been a first-line management strategy for choledocholithiasis for the past 2 decades. In diverse settings, including community practice, reported success rates for removing CBD stones at ERC have commonly ranged from 87% to 100%,20Cotton P.B. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy.Br J Surg. 1980; 67: 1-5Crossref PubMed Google Scholar, 21Colton J.B. Curran C.C. Quality indicators, including complications, of ERCP in a community setting: a prospective study.Gastrointest Endosc. 2009; 70: 468-470Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 22Mo L.R. Chang K.K. Wang C.H. et al.Preoperative endoscopic sphincterotomy in the treatment of patients with cholecystocholedocholithiasis.J Hepatobiliary Pancreat Surg. 2002; 9: 191-195Crossref PubMed Scopus (10) Google Scholar, 23Bergman J.J. Rauws E.A.J. Fockens P. et al.Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bile duct stones.Lancet. 1997; 349: 1114-1115Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 24Granke K. Jordan F.T. Mazzeo R.J. et al.Endoscopic papillotomy: impact on community hospital treatment of common duct stones.Am Surg. 1988; 54: 347-351PubMed Google Scholar, 25Ponchon T. Bory R. Chavaillon A. et al.Biliary lithiasis: combined endoscopic and surgical treatment.Endoscopy. 1989; 21: 15-18Crossref PubMed Google Scholar, 26Elfant A.B. Bourke M.J. Alhalel R. et al.A prospective study of the safety of endoscopic therapy for choledocholithiasis in an outpatient population.Am J Gastroenterol. 1996; 91: 1499-1502PubMed Google Scholar with acceptably low rates of morbidity (∼5%).21Colton J.B. Curran C.C. Quality indicators, including complications, of ERCP in a community setting: a prospective study.Gastrointest Endosc. 2009; 70: 468-470Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 27Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (1301) Google Scholar, 28Cotton P.B. Geenen J.E. Sherman S. et al.Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.Ann Surg. 1998; 227: 201-204Crossref PubMed Scopus (51) Google Scholar The optimal timing for therapeutic ERC in the management of choledocholithiasis is variable and depends on the specific clinical scenario. Although acute cholangitis should generally lead to an expeditious ERC, the degree of procedure urgency depends on the clinical severity; consensus criteria for defining the severity of acute cholangitis have been proposed.29Mayumi T. Takada T. Kawarada Y. et al.Results of the Tokyo Consensus Meeting Tokyo Guidelines.J Hepatobiliary Pancreat Surg. 2007; 14: 114-121Crossref PubMed Scopus (30) Google Scholar Truly urgent ERC is indicated when obstructing biliary stones are associated with severe acute cholangitis that is not responding to intravenous antibiotics and fluid resuscitation.29Mayumi T. Takada T. Kawarada Y. et al.Results of the Tokyo Consensus Meeting Tokyo Guidelines.J Hepatobiliary Pancreat Surg. 2007; 14: 114-121Crossref PubMed Scopus (30) Google Scholar, 30Bornman P.C. van Beljon J.I. Krige J.E.J. Management of cholangitis.J Hepatobiliary Pancreat Surg. 2003; 10: 406-414Crossref PubMed Scopus (31) Google Scholar, 31Boender J. Nix G.A. de Ridder M.A. et al.Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones.Am J Gastroenterol. 1995; 90: 233-238PubMed Google Scholar In these instances, biliary drainage is the primary focus of management rather than stone extraction. Early ERC (variably defined, but generally <72 hours) is advocated for patients with moderately severe acute cholangitis who are clinically responding to medical therapy.29Mayumi T. Takada T. Kawarada Y. et al.Results of the Tokyo Consensus Meeting Tokyo Guidelines.J Hepatobiliary Pancreat Surg. 2007; 14: 114-121Crossref PubMed Scopus (30) Google Scholar, 31Boender J. Nix G.A. de Ridder M.A. et al.Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones.Am J Gastroenterol. 1995; 90: 233-238PubMed Google Scholar Early ERC has also been advocated for patients with acute biliary pancreatitis and clinical evidence of biliary obstruction (yet not cholangitis)32Acosta J.M. Katkhouda N. Debian K.A. et al.Early ductal decompression versus conservative management for gallstone pancreatitis with ampullary obstruction: a prospective randomized clinical trial.Ann Surg. 2006; 243: 33-40Crossref PubMed Scopus (54) Google Scholar and for patients with predicted severe acute biliary pancreatitis,33Neoptolemos J.P. Carr-Locke D.L. London N.J. et al.Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.Lancet. 1988; 2: 979-983Abstract PubMed Google Scholar, 34Fan S.T. Lai E.C.S. Mok F.P.T. et al.Early treatment of acute biliary pancreatitis by endoscopic papillotomy.N Engl J Med. 1993; 328: 228-232Crossref PubMed Scopus (508) Google Scholar, 35Nowak A. Nowakowska–Dulawa E. Marek T. et al.Final results of the prospective, randomized, controlled study on endoscopic sphincterotomy versus conventional management in acute biliary pancreatitis [abstract].Gastroenterology. 1995; 108: A380Google Scholar as some randomized trials have shown reduced morbidity in these patient groups. However, other trials have not shown a benefit of early ERC in these patient groups,36Oria A. Cimmino D. Ocampo C. et al.Early endoscopic intervention versus early conservative management in patients with acute gallstone pancreatitis and biliopancreatic obstruction: a randomized clinical trial.Ann Surg. 2007; 245: 10-17Crossref PubMed Scopus (67) Google Scholar, 37Folsch U.R. Nitsche R. Ludtke R. et al.Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis; the German Study Group on acute biliary pancreatitis.N Engl J Med. 1997; 336: 237-242Crossref PubMed Scopus (407) Google Scholar and thus uncertainty remains. These data are discussed in more detail in the aforementioned ASGE guideline on the role of endoscopy in the evaluation of suspected choledocholithiasis.”12Maple J.T. Ben-Menachem T. Anderson M.A. et al.ASGE Standards of Practice CommitteeThe role of endoscopy in the evaluation of suspected choledocholithiasis.Gastrointest Endosc. 2010; 71: 1-9Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar When ERC is selected as a management strategy for CBD stones in the setting of a planned laparoscopic cholecystectomy, several options exist with regard to the sequencing of these procedures. Preoperative ERC for patients with a high likelihood of choledocholithiasis38Katz D. Nikfarjam M. Sfakiotaki A. et al.Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis.Endoscopy. 2004; : 361045-361049Google Scholar, 39Byrne M.F. McLoughlin M.T. Mitchell R.M. et al.For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures.Surg Endosc. 2009; 23: 1933-1937Crossref PubMed Scopus (13) Google Scholar or intraoperative40Wright B.E. Freeman M.L. Cumming J.K. et al.Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure?.Surgery. 2002; 132: 729-737Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 41Tricarico A. Cione G. Sozio M. et al.Endolaparoscopic rendezvous treatment: a satisfying therapeutic choice for cholecystocholedocholithiasis.Surg Endosc. 2002; 16: 585-588Crossref PubMed Scopus (17) Google Scholar or postoperative ERC42Nathanson L.K. O'Rourke N.A. Martin I.J. et al.Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi.Ann Surg. 2005; 242: 188-192Crossref PubMed Scopus (74) Google Scholar, 43Ammori B.J. Birbas K. Davides D. et al.Routine vs “on demand” postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography Clinical evaluation and cost analysis.Surg Endosc. 2000; 14: 1123-1126Crossref PubMed Scopus (25) Google Scholar for patients with a positive IOC have all been described, without conclusively superior outcomes with any one strategy.40Wright B.E. Freeman M.L. Cumming J.K. et al.Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure?.Surgery. 2002; 132: 729-737Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar A single randomized trial of patients at intermediate risk of choledocholithiasis prospectively compared routine preoperative ERC and selective postoperative ERC; there was no difference in the rates of ductal clearance.44Chang L. Lo S. Stabile B.E. et al.Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial.Ann Surg. 2000; 231: 82-87Crossref PubMed Scopus (78) Google Scholar However, each ERC-associated strategy is associated with some caveats. With preoperative ERC, there remains a risk of interval migration of additional gallbladder stones before cholecystectomy,45Pierce R.A. Jonnalagadda S. Spitler J.A. et al.Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP.Surg Endosc. 2008; 22: 2365-2372Crossref PubMed Scopus (12) Google Scholar and indiscriminant/routine use of preoperative ERC unnecessarily exposes patients to the risks of ERC. Intraoperative ERC is, by definition, on demand and logistically impractical for most gastroenterologists to offer to their surgical colleagues. Centers that have used this approach typically have surgeons capable of performing ERC. Last, the downside to postoperative ERC for stone clearance is the risk of technical failure, potentially requiring reoperation for duct exploration and clearance1Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE Working GroupGRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar; as such, this strategy may be optimally used in centers with significant expertise in ERC. If preoperative ERC is undertaken for choledocholithiasis, laparoscopic cholecystectomy ideally should be performed within 2 weeks because longer delays have been associated with cholecystitis, biliary colic, recurrent choledocholithiasis, gallstone pancreatitis, and a trend toward higher rates of conversion to open cholecystectomy in multiple retrospective analyses.47De Vries A. Donkervoort S.C. van Geloven A.A. et al.Conversion rate of laparoscopic cholecystectomy after endoscopic retrograde cholangiography in the treatment of choledocholithiasis: does the time interval matter?.Surg Endosc. 2005; 19: 996-1001Crossref PubMed Scopus (18) Google Scholar, 48Schiphorst A.H. Besselink M.G. Boerma D. et al.Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones.Surg Endosc. 2008; 22: 2046-2050Crossref PubMed Scopus (14) Google Scholar, 49Ito K. Ito H. Whang E.E. Timing of cholecystectomy for biliary pancreatitis: do the data support current guidelines?.J Gastrointest Surg. 2008; 12: 2164-2170Crossref PubMed Scopus (18) Google Scholar, 50Chiang D.T. Thompson G. Management of acute gallstone pancreatitis: so the story continues.ANZ J Surg. 2008; 78: 52-54Crossref PubMed Scopus (13) Google Scholar Further, in a recent randomized trial of early (<72 hours) versus delayed (6-8 weeks) laparoscopic cholecystectomy in 96 patients status post endoscopic CBD stone clearance, a 36% incidence of recurrent biliary events (mostly biliary colic and acute cholecystitis) was reported in the delayed surgery arm.51Reinders J.S. Goud A. Timmer R. et al.Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis.Gastroenterology. 2010; 138: 2315-2320Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar This was significantly higher morbidity compared with the early surgery group and necessitated emergency surgery in 24% (4/17) of those patients who experienced a recurrent biliary event. Early reports indicated that recurrent biliary complications after ES and stone clearance developed in a minority (12%) of patients with choledocholithiasis.52Escourrou J. Cordova J.A. Lazorthes F. et al.Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder ‘in situ’.Gut. 1984; 25: 598-602Crossref PubMed Google Scholar However, multiple subsequent randomized, controlled trials have addressed the issue of prophylactic cholecystectomy after ERC versus a watch-and-wait approach to the gallbladder. A systematic review of these trials reported higher rates of mortality, jaundice, or cholangitis; recurrent biliary pain; and the need for further cholangiography in those patients assigned to watch-and-wait, of whom 35% eventually required cholecystectomy.53McAlister V.C. Davenport E. Renouf E. Cholecystectomy deferral in patients with endoscopic sphincterotomy.Cochrane Database Syst Rev. 2007; 4 (CD006233)PubMed Google Scholar As such, cholecystectomy is recommended for most patients with cholelithiasis after ductal clearance by ERC, particularly given the relatively low morbidity of laparoscopic cholecystectomy. In preparation for ERC, antibiotic prophylaxis is unnecessary in the majority of patients with suspected choledocholithiasis, unless cholangitis or immunosuppression is present or biliary drainage is predicted to be incomplete; a relevant ASGE guideline covers this topic in detail.54Banerjee S. Shen B. Baron T.H. et al.ASGE Standards of Practice CommitteeAntibiotic prophylaxis for GI endoscopy.Gastrointest Endosc. 2008; 67: 791-798Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar Proper technique for cholangiographic imaging is essential for successful identification of stones at ERC.55Gardner T.B. Baron T.H. Optimizing cholangiography when performing endoscopic retrograde cholangiopancreatography.Clin Gastroenterol Hepatol. 2008; 6: 734-740Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Despite careful attention to technique, the sensitivity of cholangiography for choledocholithiasis is imperfect (89%-93%)56Prat F. Amouyal G. Amouyal P. et al.Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.Lancet. 1996; 347: 75-79Abstract PubMed Scopus (223) Google Scholar, 57Tseng L.J. Jao Y.T. Mo L.R. et al.Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis.Gastrointest Endosc. 2001; 54: 720-723Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar; false-negative ERCs usually occur when small stones are present in a dilated duct. When a stone is anticipated, yet not seen on cholangiography, the endoscopist often must decide whether to perform an empirical ES to facilitate duct sweeping. Although empirical ES and sweeping may increase the detection rate of small (<5 mm) stones, it is of uncertain clinical benefit,58Siddique I. Mohan K. Khajah A. et al.Sphincterotomy in patients with gallstones, elevated LFTs, and a normal CBD on ERCP.Hepatogastroenterology. 2003; 50: 1242-1245PubMed Google Scholar although perhaps beneficial in the setting of cholangitis.59Lee S.H. Hwang J.H. Yang K.Y. et al.Does endoscopic sphincterotomy reduce the recurrence rate of cholangitis in patients with cholangitis and suspected of a common bile duct stone not detected by ERCP?.Gastrointest Endosc. 2008; 67: 51-57Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The risks of a missed stone must be weighed against the potential complications of an unnecessary sphincterotomy. This decision will also be influenced by the pretest probability for choledocholithiasis, the quality of fluoroscopy used, and the availability of potentially helpful ancillary techniques such as intraductal US or standard EUS. Various methods for sonographically guided biliary endotherapy using a single echoendoscope have yielded promising early results, but these approaches remain investigational at this time.60Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 61Artifon E.L.A. Kumar A. Eloubeidi M.A. et al.Prospective randomized trial of EUS versus ERCP-guided common bile duct stone removal: an interim report (with video).Gastrointest Endosc. 2009; 69: 238-243Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar When 1 or more stones are identified at cholangiography, successful extraction typically requires either ES or EPBD, unless the stones are very small.62May G.R. Cotton P.B. Edmunds S.E. et al.Removal of stones from the bile duct at ERCP without sphincterotomy.Gastrointest Endosc. 1993; 39: 749-754Abstract Full Text PDF PubMed Google Scholar Endoscopic papillary balloon dilation (EPBD) does not permanently ablate the sphincter choledochus and thus was initially proposed as an alternative to ES with potentially less long-term morbidity.23Bergman J.J. Rauws E.A.J. Fockens P. et al.Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bile duct stones.Lancet. 1997; 349: 1114-1115Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar However, multicenter randomized controlled trials,63DiSario J.A. Freeman M.L. Bjorkman D.J. et al.Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones.Gastroenterology. 2004; 127: 1291-1299Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar systematic reviews64Baron T.H. Harewood G.C. Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized controlled trials.Am J Gastroenterol. 2004; 99: 1455-1460Crossref PubMed Scopus (128) Google Scholar, 65Weinberg B.M. Shindy W. Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones.Cochrane Database Syst Rev. 2006; 18 (CD004890)Google Scholar and a large prospective ERC series66Freeman M.L. DiSario J.A. Nelson D.B. et al.Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.Gastrointest Endosc. 2001; 54: 425-434Abstract Full Text Full Text PDF PubMed Scopus (518) Google Scholar demonstrated a significantly higher risk of pancreatitis with EPBD in addition to poorer technical success for stone clearance and more frequent need for mechanical lithotripsy. As such, primary EPBD is not advocated for routine use, although it may be a reasonable option in select circumstances, eg, coagulopathy, periampullary diverticulum, or surgically altered anatomy that increases the difficulty of ES.67Kawabe T. Komatsu Y. Tada M. et al.Endoscopic papillary balloon dilation in cirrhotic patients: removal of common bile duct stones without sphincterotomy.Endoscopy. 1996; 28: 694-698Crossref PubMed Google Scholar, 68Bergman J.J. van Berkel A.M. Bruno M.J. et al.A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy.Gastrointest Endosc. 2001; 53: 19-26Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 69Liao W.C. Huang S.P. Wu M.S. et al.Comparison of endoscopic papillary balloon dilatation and sphincterotomy for lithotripsy in difficult sphincterotomy.J Clin Gastroenterol. 2008; 42: 295-299PubMed Google Scholar EPBD after ES is discussed in the following. ES may be performed using either pure cutting current or blended cutting/coagulation current. Although some trials suggested a reduced frequency of post-ERCP pancreatitis with pure cutting current,70Elta G.H. Barnett J.L. Wille R.T. et al.Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current.Gastrointest Endosc. 1998; 47: 149-153Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 71Stefanidis G. Karamanolis G. Viazis N. et al.A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis.Gastrointest Endosc. 2003; 57: 192-197Abstract Full Text PDF PubMed Scopus (28) Google Scholar a recent meta-analysis found no di