EST is a well accepted and well documented treatment modality for the removal of bile duct stone, whereas experience with EPBD is relatively limited, and the risk of pancreatitis of EPBD remain unclear. Therefore the choice between EST and EPBD for the removal of bile duct stone is currently not an issue in most patients. The choice between EST and EPBD depends on the following factors; first, the relative success rate of the two procedures in allowing stone removal; secondly, the risk factors present for any post-ERCP complication (both short-term and long-term) and their relative magnitude; thirdly, the relative severity of the different possible complications; and fourthly, the influence of the expertise of the endoscopist on these different factors. The success rate of stone removal after EST and EPBD is dependent on stone characteristics (diameter greater than 10 mm, number over three) and local anatomy (periampullary diverticula, prior Billroth II gastrectomy). In a young patient with a difficult cannulation of the bile duct and no risk factors for bleeding, EST should probably be preferred over EPBD. In elderly patients with coagulopathy and no risk factors for pancreatitis, EPBD may be preferred.
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