The technique of endoscopic balloon dilation of the major duodenal papilla with extraction of bile duct stones was first reported in 19821 but an unacceptably high rate of acute pancreatitis following the procedure impeded its acceptance until further reports in 19942 and 19953 reported its safety. A number of randomised controlled trials have demonstrated its effectiveness in clearing the bile ducts of stones compared with endoscopic sphincterotomy4-8 with variable short term complication rates similar to sphincterotomy. Currently, this technique has not become popular worldwide, but for reasons that are not clear has been adopted much more readily in Japan and Korea than elsewhere.

Those who advocate this technique over sphincterotomy do so on the premise that: (1) it is less traumatic, (2) it is simpler to perform, (3) it is as effective, (4) it avoids the immediate complications, such as bleeding and perforation, (5) it is cheaper or at least equivalent cost, (6) it preserves sphincter of Oddi function, and (7) it avoids the long term complications.

Many of these apparent advantages have been questioned in terms of technical performance and short term outcome and now there is new evidence from the report by Yasuda et al in this issue of Gut 9 that the long term advantages may also be in doubt (see page 686).

The above selection criteria in favour of balloon dilation of the …