Digital Cholangioscopy-Based Radiation-Free Management of Choledocholithiasis: A Retrospective Cohort Study

Endoscopic retrograde cholangiopancreatography (ERCP) is the established therapeutic modality for pancreaticobiliary diseases and has traditionally been performed under fluoroscopic guidance. According to the ALARA principle (radiation exposure as low as reasonably achievable), it is justifiable to perform an ERCP with minimal radiation exposure if it can be done without increased risk, decreased efficacy or compromised efficiency. The study aimed to evaluate management of choledocholithiasis in the general population via a radiation-free (RF) approach based on peroral digital cholangioscopy (DC).

The RF procedure involved non-fluoroscopic biliary cannulation, documentation of stones using direct DC, DC-guided electrohydraulic lithotripsy when necessary, stone extraction, reentry via DC for confirmation of stone clearance, and stent placement. Data from 66 patients who underwent DC-based RF management were retrospectively analyzed and compared with those who were concurrently treated via conventional ERCP.

Following propensity score matching, the overall successful cannulation rate (93.3% vs 100%, p = 0.12), cannulation time (3.3 [IQR 2.5-4.8] vs 3.9 [IQR 1.8-5.7] minutes, p = 0.64), and stone clearance rate at one session (90% vs 96.7%, p = 0.27) were comparable between the RF group and conventional ERCP group. The RF group exhibited remarkably reduced X-ray exposure time (0 [Range 0-442] vs 204 [Range 66-695] seconds, p < 0.001). No severe adverse events were observed. Subgroup analysis of patients with complex stones revealed equivalent procedure time (67 [IQR 51-80] vs 61 [IQR 36-68] minutes, p = 0.06).

DC-based RF management of choledocholithiasis, including selected complex stones, is feasible, safe, and effective. Future research should aim to shorten procedure time and reduce associated costs.