To cut or stretch?

Endoscopic papillary balloon dilation (EPBD) offers an alternative to endoscopic sphincterotomy (EST), which preserves the barrier function of the biliary sphincter. However, reports of increased complications, especially pancreatitis, have stalled the widespread adoption of this technique. A metaanalysis of randomized trials of EPBD versus EST found similar overall complication rates (10.5% vs 10.3%). However, while postprocedure bleeding was reduced with EPBD compared to EST (0% vs 2.0%), the rate of postprocedure pancreatitis was higher (7.4% vs 4.3%). In addition, 20% of EPBD cases required "rescue" EST. EPBD should probably be reserved for special indications, such as uncorrected or anticipated coagulopathy, and unfavorable endoscopic anatomy for EST.