Evolution of endoscopic sphincterotomy

Endoscopic sphincterotomy (EST) is a non‐surgical treatment for residual or relapsing common bile duct stones in patients with a history of cholecystectomy and/or choledochotomy. Indications for its use have gradually expanded and now include removal of choledochal stones prior to cholecystectomy and removal of large bile duct stones not originally considered suitable for endoscopic removal. EST is used world wide and it now plays an indispensable role in transpapillary diagnostic and therapeutic procedures such as insertion of thin caliber endoscopes into the biliopancreatic system and inserstion of endoprostheses for malignant biliary obstruction. However, some, doubts have been voiced about the extension of indications for EST. The problem of loss of function of the duodenal papilla, for example, is controversial. We summarize the circumstances surrounding the development of EST, the controversies that have occurred in the process of expanding EST indications, and the history of overcoming the technological problems with transpapillary endoscopic procedures. The importance of conducting well‐controlled clinical trials to determine the usefulness of new techniques is discussed.