title: Feasibility of nonradiation EUS-based ERCP in patients with uncomplicated choledocholithiasis (with video).
abstract: OBJECTIVE
  ERCP inherently involves radiation exposure. Nonradiation ERCP has been described in pregnancy. Theoretically, the same techniques could be applied to the general population. We prospectively assessed the feasibility of nonradiation, EUS-based ERCP in nonpregnant patients with choledocholithiasis.
  
  
  METHODS
  Consecutive patients referred for ERCP for choledocholithiasis were recruited over a 1-year period. Patients providing study consent underwent the following procedural protocol. First, EUS was performed to verify the presence, size, and number of stones. Second, biliary cannulation was attempted without fluoroscopy for a maximum of 10 minutes. Selective cannulation was based on deep insertion with visible bile in the catheter on aspiration. Third, for stone removal, sphincterotomy was performed and stones were removed using a basket or balloon. The number of stones exiting the papilla was matched to the number seen on EUS. Finally, once the duct was deemed clear by the endoscopist, a final occlusion cholangiogram and ductal sweep served as the reference standard for confirmation of stone clearance.
  
  
  RESULTS
  Nonradiation ERCP was attempted in 31 patients. Cannulation without fluoroscopy was successful in 26 patients (84%). Complete stone removal without fluoroscopy was achieved in all 26 of these cases. The 5 patients with failed nonfluoroscopic cannulation required double guidewire (n = 2) or precut papillotomy (n = 3) for deep biliary access and subsequent stone clearance. One patient who required precut papillotomy for access developed moderate post-ERCP pancreatitis (3%).
  
  
  CONCLUSIONS
  Nonradiation, EUS-based ERCP for uncomplicated choledocholithiasis appears to be successful and safe. (Clinical trial registration number: NCT01678391.).
authors.affiliation: Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Janak N
authors.initials: JN
authors.lastname: Shah
authors.affiliation: Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Yasser M
authors.initials: YM
authors.lastname: Bhat
authors.affiliation: Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Chris M
authors.initials: CM
authors.lastname: Hamerski
authors.affiliation: Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Steve D
authors.initials: SD
authors.lastname: Kane
authors.affiliation: Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Kenneth F
authors.initials: KF
authors.lastname: Binmoeller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D042883:Choledocholithiasis / Q000000981:diagnostic imaging* / Q000628:therapy*; D003135:Common Bile Duct; D019160:Endosonography; D005240:Feasibility Studies; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic; D018084:Ultrasonography, Interventional; D055815:Young Adult