F. Yadollahzadeh Chari, J. Shokri Shirvani, S. H. Abedi Valukalaei, A. Yadollahzadeh Chari
Background Small common bile duct stones may pass after endoscopic sphincterotomy, but leaving the duct without attempting extraction also leaves clearance uncertain. We compared same-session stone clearance after sphincterotomy alone with clearance after sphincterotomy followed by balloon-based and/or basket extraction. Methods We conducted a single-center observational study of 203 patients with common bile duct stones 5 mm or smaller who underwent therapeutic endoscopic retrograde cholangiopancreatography. The endoscopist chose the treatment during the procedure. Forty-seven patients underwent sphincterotomy alone, and 156 underwent sphincterotomy followed by balloon-based and/or basket extraction. The primary outcome was fluoroscopically confirmed clearance during the same procedure. Intraprocedural bleeding was a secondary outcome. We calculated unadjusted risk ratios and used Fisher's exact test for sparse events. Results The mean age was 58.62 years (standard deviation 20.10), and 90 patients (44.3%) were men. Same-session clearance was documented in 21 of 47 patients (44.7%) after sphincterotomy alone and 130 of 156 (83.3%) after adjunctive extraction (risk ratio 1.87, 95% confidence interval 1.35 to 2.58; P < 0.001). A prominent ampulla was more common in the sphincterotomy-alone group (25.5% vs 10.9%; P = 0.012). Intraprocedural bleeding occurred in 2 patients after sphincterotomy alone and none after adjunctive extraction (4.3% vs 0%; Fisher's exact P = 0.053). Conclusions Adjunctive extraction was associated with a higher rate of documented same-session clearance than sphincterotomy alone. Treatment was not randomized, the groups differed at baseline, and only two bleeding events occurred. These findings therefore do not prove that adjunctive extraction is causally superior or safer. Prospective studies using standardized techniques and follow-up are needed.