Aims
Large bile duct stone removal in patients with surgically altered anatomy (SAA) is technically challenging. Although balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has been widely adopted, endoscopic ultrasound-guided treatment (EUS-T) may achieve higher stone removal rates owing to improved device accessibility after anastomosis creation. This multicenter retrospective study aimed to compare the clinical outcomes of EUS-T and BE-ERCP for large bile duct stones in patients with SAA.
Methods
Patients with SAA who underwent EUS-T or BE-ERCP for large bile duct stones (≥12 mm) between January 2016 and February 2025 were included. The primary outcome was the complete stone removal rate. Secondary outcomes included the number of sessions, procedure time, and adverse events. Propensity score matching was applied to adjust for baseline differences between groups.
Results
In total, 22 EUS-T and 87 BE-ERCP procedures were analyzed. After matching, the complete stone removal rate was significantly higher in the EUS-T group than in the BE-ERCP group (90.5% vs. 61.9%, P = .030), despite a greater number of sessions (2.1 vs. 1.2, P < .001). Mean procedure times and adverse event rates were comparable. Cumulative success significantly improved up to the third session in EUS-T (first session, 27%; third, 86) and the second in BE-ERCP (first, 46%; second, 69%). Severe adverse events occurred only in the BE-ERCP group.
|
|
EUS-T (n=21) |
BE-ERCP (n =21) |
P-value |
|
Age, mean (± SD), years |
78.6 ± 9.1 |
79.0 ± 8.1 |
.369 |
|
Female:Male, n (%) |
8:13 |
8:13 |
1.000 |
|
ASA-PS ≥3 |
1 (4.7) |
2 (9.5) |
.604 |
|
Etiology of surgery, n (%) Malignant Benign |
8 (38.1) 13 (61.9) |
9 (42.9) 12 (57.1) |
.753
|
|
Surgical reconstruction, n (%) Billroth type 2 Roux-en-Y Others |
0 (0) 16 (76.2) 5 (23.8) |
4 (19.0) 11 (52.4) 6 (28.6) |
.081
|
|
Hepaticojejunostomy, n (%) |
8 (38.1) |
7 (33.3) |
.747 |
|
Time from surgery to procedures, years, mean (± SD) |
18.8 ± 13.5 |
19.4 ± 18.2 |
.232 |
|
Stone diameter, mean (± SD) |
14.7 ± 3.2 |
14.4 ± 2.8 |
.581 |
|
The number of stone, mean (± SD) |
2.3 ± 2.1 |
2.0 ± 1.1 |
.172 |
|
Stone location, n (%) Common bile duct Lest intrahepatic duct Right intrahepatic duct Left and right intrahepatic duct |
15 (71.4) 5 (23.8) 0 (0) 1 (4.8) |
15 (71.4) 5 (23.8) 1 (4.8) 0 (0) |
.572
|
|
Complete stone removal, n (%) |
19 (90.5) |
13 (61.9) |
.030* |
|
Complete stone removal at the first procedure time, n (%) |
6 (28.6) |
10 (47.6) |
.204 |
|
Total number of sessions, mean (± SD) |
2.1 ± 1.1 |
1.2 ± 0.4 |
<.001* |
|
Total procedure time, mean (± SD) min |
135.1 ± 94.7 |
92.4 ± 39.9 |
<.001* |
|
Mean procedure time, mean (± SD) min |
59.8 ± 27.1 |
78.9 ± 30.2 |
.593 |
|
AE, n (%) |
2 (9.5) |
1 (4.8) |
.549 |
Conclusions
EUS-T achieved a higher complete stone removal rate than BE-ERCP without increased risk, suggesting it may be a viable first-line treatment for large bile duct stones in patients with SAA.