Joo YW, et al. Endoscopic pancreatic sphincterotomy 193 Table 4. Biliary complications: EPST alone vs. EPST with EST Without EST (n=20) With EST (n=26) p value Difference of bilirubin, mg/dL 1.9±5.8 1.0±2.9 0.96 Difference of ALP, U/L 65.6±150.3 117.0±296.3 0.43 Difference of WBC, /mm3 565±3,463 3,049±5,051 0.41 CBD dilatation, n 3 8 0.38 Cholangitis, n 0 1 0.21 ENBD, n 0 6 0.02 EPST, endoscopic pancreatic sphincterotomy; EST, endoscopic biliary sphincterotomy; ALP, alkaline phosphatase; CBD, common bile duct; ENBD, endoscopic nasobiliary drainage. was performed versus the group in which EPST alone was performed (3.1 mg/dL vs. 0.8 mg/dL, respectively; p=0.36). Mean alkaline phosphatase was also higher in the group in which EPST with EST was performed versus the group in which EPST alone was performed (337.6 U/L vs. 101.5 U/L, respectively; p=0.35). In other laboratory findings, differences were not statistically significant (Table 4). The incidence of complications was 17.6% (3/17) in cases in which pancreatic drainage was performed and 10.3% (3/29) in other cases. This difference was not statistically significant (p=0.66; data not shown). In cases in which complications occurred, the symptoms were improved only by medical treatments. In no case was the hospitalization prolonged, and no death occurred. Of the 46 subjects, follow-up observations were available for 34 patients. In these patients, the mean follow-up period was 62.6 months (range, 1-132 months). The only late- stage complication associated with EPST was one case of restenosis of the pancreatic duct, which developed after 38 months (2.1%, 1/46). DISCUSSION EST has been used for treatment since the 1970s, and is acknowledged as a relatively safe procedure based on studies reporting that the early complication rate was about 10% and the mortality rate was about 1%. In contrast, EPST was introduced to the clinical setting about 10 years later in the 1980s [10]. In recent years, the clinical indications of EPST have become more widely accepted, but due to the low frequency of the procedure and procedure-related complications, no standard treatment regimen has been established. Elton et al. proposed that EPST be used for the diagnosis and treatment of various pancreatic diseases, such as SOD, chronic pancreatitis, pancreatic pseudocysts, pancreatic divisum, papillary adenoma, pancreatic cancer, and pancreatic fistula [9]. EPST makes it easier to approach the pancreatic duct to insert a pancreatic stent, remove a pancreatolith, and biopsy tissue from a pancreatic stenosis. It is also used in the treatment of pancreatic sphincter dysfunction. As described here, EPST is a useful procedure, together with pancreatic drainage, for the diagnosis and treatment of pancreatic diseases. However, because of operator concern regarding technical difficulties and the occurrence of complications, EPST is not performed as frequently as EST [13]. The incidence of complications following EPST is similar to that following EST. Early-stage complications include pancreatitis, bleeding, duodenal perforation, and cholangitis [10-15]. The incidence of complications following EPST has been reported to be 3.2% to 15.7% (mean, 13.6%). In the current study, we made a comparison of other reports on the incidence of severe complications for which hospitalization was prolonged or treatment was needed, excluding mild complications requiring no treatment [11,13,15]. This analysis showed no difference in the incidence of complications or their severity following EPST. Most of the complications were dealt with by con- servative management only. In no case was the treatment period prolonged or any additional procedure or surgery needed due to the occurrence of a procedurerelated com- plication, such as severe bleeding, pancreatitis, or per- foration. Thus, we conclude that EPST is a relatively safe procedure, and the incidence of complications due to its technical difficulty was actually lower than for EST. EPST is a single procedure, but it is rarely used alone in diagnosis or treatment. In many cases, it is used con- comitantly with other procedures, such as the removal of pancreaticoliths, the insertion of pancreatic stents, and the dilatation of pancreatic stenosis. Therefore, symptoms deemed to be complications of EPST cannot be stated to