EUS Guided ERCP in Bile Duct Stone Removal
EUS Guided ERCP in Bile Duct Stone Removal
For endoscopist, ERCP for bile duct stone removal is the most widely performed procedure.
 However, the risk associated radiation exposure to patients and staff are not neglible.
 Earlier studies, ERCP without the use of fluoroscopy has been reported high success for bile
 duct stone removal in pregnant patients to prevent radiation exposure to the fetus. EUS is
 highy accurate technique in detecting common bile duct stone and guiding for therapeutic
 intervention. There has been a few data from literature showed that EUS guided CBD stone (
 CBDS ) removal are equivalent to those following ERCP in term of successful CBDS removal and
 complications. This randomized trial is designed to address the question that EUS guided CBDS
 removal is equivalent to ERCP in term of efficacy and safety.
Common bile duct stones (CBDS) can be complicated with various conditions including biliary
 pain, acute cholangitis, acute pancreatitis and secondary biliary cirrhosis. CBDS should
 therefore be removed even if patients are asymptomatic.

 Endoscopic retrograde cholangiopancreatography (ERCP) is the cornerstone treatment of CBDS.
 ERCP is often performed under fluoroscopic guidance. This comprises biliary cannulation
 whereby the bile duct is achieved with a standard ERCP catheter under fluoroscopy guidance,
 radiocontrast was injected for confirmation and images of biliary system, location and number
 of CBDS, biliary sphincterotomy was then performed followed by stone extraction using a
 standard accessories such as a basket and or balloon. Therefore, the endoscopist, endoscopic
 staff and patient are potentially exposed to ionizing radiation during ERCP. Endoscopists
 should always attempt to minimize radiation exposure to the personnel staffs and patients by
 following the ALARA principle ("As Low As Reasonably Achievable"). ERCP without the use of
 fluoroscopy is the one method to avoid exposure to radiation. A few retrospective case series
 have been shown that ERCP can be performed with high success rate without the need for
 fluoroscopic imaging.

 EUS has been proven to have diagnostic accuracy comparable to ERCP in the diagnosis of CBDS,
 and it's associated with a very low procedure related complications and non-radiation
 exposure procedure. With EUS performed before ERCP, unnecessary ERCP and its related
 complications can be avoided in patients without CBDS. In patients with CBDS, the images of
 pancreaticobiliary tract derived from EUS provide an information regarding the location, size
 and number of CBDS for guiding therapeutic endoscopy, and allowing a therapeutic ERCP in the
 same session of sedation. Vohra et al. reported the retrospective case series of EUS - based
 ERCP in 10 pregnant patients, they have shown that EUS performed prior ERCP can eliminate
 unnecessary ERCP and achieve in CBDS clearance without the use of fluoroscopy. We have
 previously reported the use of EUS guided ERCP in the removal of CBDS without fluoroscopy
 (EGWF) in the pilot study, it showed that EGWF was feasible in selected patients with CBDS.
 The efficacy of EUS guided ERCP in CBDS removal without fluoroscopy compared with standard
 ERCP has not been fully assessed. We therefore prospectively investigated the efficacy and
 safety of EGWF versus ERCP in CBDS removal in a larger patient cohort.
Inclusion Criteria:

 -  Patients who had EUS presence of CBDS ≤ 10 mm, and EUS images absence of CBD stricture
 and CBD narrowing below the stones

 Exclusion Criteria:

 -  pregnancy

 -  concomitant intrahepatic bile duct stones

 -  malignant bile duct stricture

 -  altered gastrointestinal anatomy

 -  instability hemodynamics

 -  concomitant emergency situation

 -  unwilling to participate