| Malignant biliary obstruction (MBO) may be caused by pancreatic cancer, ampullarycancer, cholangio-carcinoma, gallbladder cancer, and malignant lymphadenopathy or metastatic lesions. Surgery offers the only hope for cure in patients with MBO, but patients usually present late in their course, have either locally extensive or metastatic disease, and have an extremely grim prognosis.All that is left is therefore palliative treatment,aimed at both relieving jaundice and improving quality of life.There are three methods for palliation of MBO:surgical bypass, percutaneous insertion of stents, and endoscopic insertion of stents.ERCP and biliary stent placement is technically successful in 90-95% of patients with extrahepatic MBO. Plastic stents are commonly used because of their efficacy and low cost. These stents are exchanged easily as long as duodenal narrowing does not prohibit passage of the endoscope.The major drawback of plastic stents is clogging within 3-6 months.More recently, SEMS have been used with the goal of prolonging stent patency and improving overall cost-effectiveness because of the need for fewer repeated interventions. SEMS is commonly used when the survival time is over 4 months in the patients with MBO.EST is routinely used before bilary metal stent placement during ERCP.It is seldom that metal stent is inserted without EST or with EPBD used before metal stent placement. Endoscopic sphincterotomy (ES) may facilitate insertion of selfexpandable metal stent (SEMS) and also help avert the development of pancreatitis from stent-related occlusion of the pancreatic duct.However, ES is not risk free, being associated with a complication rate of approximately 10% (bleeding,pancreatitis, and perforation).It is feasible that metal stent is inserted without EST and the complication rate is lower than with EST in a randomized trial .EPBD before metal stent inserted has never been evaluated.Early complication rates of endoscopic Sphincterotomy versus of endoscopic balloon dilation before deployment of metal stent in distal maglinant biliary obstruction:a multicenter randomized controlled trialObjective:To compare the early complication rate of three precedures:EST before metal stent placement,EPBD before metal stent placement and metal stent insertion alone.Methods:One hundred and twenty patients with unresectable distal bile duct obstruction were prospectively randomized to biliary stenting following ES (group A),biliary stenting following EPBD (group B) and without ES or EPBD (group C). Main outcome measures included early complication rates including cholangitis ,bleeding, perforation, and pancreatitis.Results:The stents were successfully deployed in all patients in each group. Patients in each groups had similar declines in liver function tests and resolution of jaundice within a week and a month after the procedure. Bilirubin levels before and after the procedure in a week were 134.66±96.08umol/l,109.58±93.07 umol/1 and 120.09±81.54 umol/1, respectively; Bilirubin levels before and after the procedure in a month were 200.35±137.31 umol/l,146.12±115.29 umol/1 and 170.42±109.03 umol/1 .There is no difference in total procedure times and stent insertion times in three groups.Total procedure times of Group A,Group B and Group C were 34.50±13.63 min,31.53±12.31min and 34.65±10.22min; stent insertion times were 19.75±13.94min,17.73±11.36min and 16.78±11.95min, respectively. Early complications (mild hemorrhage, pancreatitis, cholangitis) occurred among 5 patients in group A,3 patients in group B and 5 patients in group C.There were 2 pancreatitis in group B and mild hemorrhage in group A. There were 3 cholangitis in Group A,1 cholangitis Group B and 5 cholangitis Group C.Conclusions:Deployment of metal stent without prior ES or EPBD in patients with distal common bile duct obstruction is feasible.EPBD may increase the risk factor of PEP in metal stent placement in in patients with distal common bile duct obstruction.
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