The role of endoscopic retrograde cholangiopancreatography: sphincterotomy versus common bile duct exploration as a primary technique in the management of choledocholithiasis.

253 patients underwent diagnostic or therapeutic intervention for a presumed diagnosis of choledocholithiasis. In 104 (mean age, 60 years) the diagnosis was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) or common bile duct exploration (CBDE). Of this group, 70 patients first underwent a total of 102 attempts at endoscopic sphincterotomy (ERCP-S). Success (clearing the common duct of stones) was achieved in 43 patients (61%), though an average of 1.5 ERCP-S/patient was required (maximum of four per patient). Of the 27 in whom ERCP-S failed, 20 went on to CBDE, which was successful in 18. Significant morbidity occurred in 12 (17%) ERCP-S patients, including hemorrhage. There were no deaths. Of the 34 patients who first underwent CBDE, 30 were cleared of common duct stones (88%). ERCP-S was subsequently employed to retrieve retained stones in three patients. Significant morbidity was documented in three (9%). No patients required perioperative blood transfusion. There were no deaths. While there is, as expected, a lower initial success rate with ERCP-S than with CBDE, the fact that ERCP-S is a less invasive procedure than is CBDE justifies its preferential utilization. However, patients must be informed that successful ERCP-S may require multiple visits to the endoscopy suite. Furthermore, the morbid consequences of ERCP-S, particularly hemorrhage, cannot be understated.