Three-dimensional ERCP with cone-beam computed tomography: Novel approach to managing complex biliary strictures

Complex perihilar and intrahepatic biliary strictures present significant therapeutic challenges during endoscopic retrograde cholangiopancreatography (ERCP), with traditional two-dimensional fluoroscopy limiting spatial visualization. This prospective cohort study evaluated feasibility and clinical utility of novel three-dimensional (3D) fluoroscopic imaging utilizing cone beam computed tomography (CBCT) in ERCP for managing complex biliary strictures.

Twenty consecutive patients with complex biliary strictures underwent ERCP with CBCT at a single tertiary center between September 2023 and December 2024. All patients had previously failed selective cannulation attempts. Using a specialized fluoroscopic system, 360-degree rotational imaging was performed. Primary outcomes included technical success (selective cannulation rate) and clinical success (successful stenting without percutaneous drainage).

Stricture etiology was malignant in 60% and benign in 40%. CBCT achieved selective cannulation in 100% of cases and clinical success in 90%. Two patients required percutaneous drainage. 3D reconstruction influenced surgical planning in 10% of cases. Standard ERCP resulted in median entrance skin dose (ESD) of 156.0 mGy (range 67.3-273.0) and dose area product (DAP) of 44.4 (range 21.1-94.0] . The 3D reconstruction from CBCT contributed an additional median ESD of 174.0 mGy (range 137.0-240.0) and DAP of 53.1 Gy·cm ² (range 41.8-73.8).

ERCP with CBCT is technically feasible with high selective cannulation rates in complex biliary strictures. Although the technique requires additional radiation exposure, it may provide value in cases with difficult selective cannulation and surgical mapping for malignancies. Further studies are needed to define optimal patient selection and evaluate long-term outcomes.