Cholangioscopy-guided lithotripsy versus mechanical lithotripsy for large common bile duct stones during balloon enteroscopy-assisted ERCP after gastrectomy with a native papilla

Background: Balloon enteroscopy-assisted ERCP (BE-ERCP) for large common bile duct stones in patients with surgically altered anatomy (SAA) remains challenging. Mechanical lithotripsy (ML) is commonly used, but stone capture and fragmentation can often be difficult. This study evaluated the usefulness of a peroral cholangioscopy-guided lithotripsy (POCL)-first strategy compared with a conventional ML-first strategy. Methods: This study used a registry of patients with large common bile duct stones and SAA after gastrectomy in whom BE-ERCP was performed at seven institutions in Japan. From this registry, patients treated with an ML-first or POCL-first strategy were included. Outcomes were compared between patients treated with a POCL-first strategy and those treated with an ML-first strategy. The primary outcome was complete stone clearance during the initial session. Results: A total of 104 patients were analyzed: 39 in the POCL-first group and 65 in the ML-first group. Complete stone clearance during the initial session was achieved in 95% of the POCL-first group and 62% of the ML-first group (risk difference, 33.3%; 95% CI, 17.3–46.0%). POCL-first was associated with fewer patients requiring ≥2 sessions among those achieving final clearance (5% vs 32%; risk difference, −27.1%; 95% CI, −40.3 to −11.3). Adverse event rates did not differ significantly. After adjustment, POCL-first was associated with a higher probability of initial-session complete stone clearance (adjusted risk ratio, 1.40; 95% CI, 1.08–1.83). Conclusions: In this retrospective cohort of postgastrectomy patients with an accessible native papilla, a POCL-first strategy during BE-ERCP was associated with higher initial-session complete stone clearance, supporting prospective evaluation.