Table 1. Comparison of the success, mortality and complication rate of endoscopic sphincterotomy. Country W.Germany Japan Italy England USA Vietnam No. of centers Year No. of patients Success % Complications (%) Mortality (%) 9 1978 955 92.1 7.3 1.7 25 1979 486 96.5 8.5 0.4 8 1979 239 81 6.7 0.5 14 1981 679 87 8.5 1.9 21 1981 1250 89 8.7 1.2 1 1995-96 108/271 68 12.5 0 stones is an effective measure to manage these prob- lems.8,10,11,21,22 Endoscopic Sphincterotomy: Endoscopic sphincterotomy, in cases of retained common bile duct stones is an inexpensive, effective alternative to open exploration of the common bile duct.14,17,19,22 In this series, 108 cases underwent attempted sphincterotomy. Seventy-four cases (68%) of endoscopic sphincterotomy were completed successfully. A comparison of the success, mortality, and complication rate of endoscopic sphincterotomy procedures from repre- sentative countries is shown in the following (Table 1).23-24 From this data it is seen that in Germany 955 patients were treated at nine centers for an average of 106 patients per center. In Japan, 468 patients were treated at 24 centers for an average of 18 patients per center. In the United States, 1,250 patients were treated at 21 centers for an average of 59 patients per center. In our series, 108 patients were treated at Binh Dan Hospital during the study period. No mortality was seen in our series as cases were carefully selected to avoid the more compromised patient. As we tra- verse the learning curve, more difficult cases will be includ- ed in our case load. Special Situations: One female patient was determined to have gallstones by sonography and was prepared for laparoscopic cholecys- tectomy. The operative intervention was delayed because of equipment malfunction and the patient developed icterus. ERCP was performed and common bile duct stones were extracted. One day post-ERCP, the patient experi- enced subcutaneous emphysema of the neck, and chest. Free air was detected in the abdominal cavity. Conservative treatment was initiated and consisted of noth- ing per os, parenteral feeding and antibiotic. After five days, the patient's symptoms resolved and she did not require an operative intervention. Subcutaneous emphysema may be the result of forcefully removing common bile duct stones when the incised papil- la is not patent enough to permit unrestrained removal. Gas in the abdominal cavity is an endoscopic-induced com- plication. In the above case, this complication was man- aged conservatively. However, a lacerated duodenum may require surgical intervention and requires vigilant monitor- ing of the patient's status during conservative treatment. Another case involved a male patient with a common bile duct stone of 3-4 centimeters diameter. ERCP stone extrac- tion was not successful and the patient developed subcuta- neous emphysema. Open laparotomy was performed and a laceration of the posterior duodenum was found. The perforation was repaired and the patient recovered. With our current knowledge, we believe intensive conservative management could have been initiated and laparotomy possibly avoided. Retrospective analysis has suggested that five of our cases which developed post-ERCP amylasemia arid pancreatitis suffered this complication from injection of large amounts of contrast material into the pancreatic duct or due to trau- ma from the insertion of a catheter deep into the pancreat- ic duct. Our experience suggests that the endoscopist should keep the tip of the catheter at the papilla and inject only the amount of contrast necessary to define the biliary tract. Nine of 108 cases (6%) experienced postsphincterotomy bleeding. Two of these cases were successfully controlled with local injection of 1/10000 adrenaline.12,17,22 Postendoscopic biliary sepsis is a feared complication, par- ticularly in those patients with biliary obstruction. Prophylactic antibiotic was used in all cases of ERCP per- formed for diagnostic or therapeutic purposes in this study. In those cases of biliary obstruction, decompression should be attempted either via a nasogastric tube insertion, stent insertion or sphincterotomy.10-12 One 16-year-old female patient with cystic dilatation of the common bile duct was not decompressed during ERCP and subsequently died after open surgical biliary decompression was performed on the third day post-ERCP. JSLS (1997)1:345-348 347