Fluoroscopy-Free ERCP for Choledocholithiasis Is Safe and Effective in a Pilot Study

Fluoroscopy-Free ERCP for Choledocholithiasis Is Safe and Effective in a Pilot Study

Rajesh N. Keswani, MD, MS, reviewing Ridtitid W, et al. DEN Open 2023 Jun 1.

In select patients – most commonly during pregnancy – using a fluoroscopy-free approach to stone removal is preferred. Given some initial success with this approach to stone removal, there has been further interest in expanding the use of fluoroscopy-free ERCP with cholangioscopy.

The authors of this study have initiated a multicenter, prospective, randomized, controlled study comparing traditional ERCP with fluoroscopy-free removal of stones via direct solitary cholangioscopy (DSC). However, before commencing the randomized trial, the 12 participating endoscopists were required to perform up to 5 DSC cases. 

Briefly, DSC is performed via standard cannulation followed by aspiration of bile to confirm biliary cannulation. At this point, a biliary sphincterotomy is performed followed by cholangioscopy to determine the stone number. DSC attempts were performed for up to 30 minutes; after 15 minutes, techniques such as the double-guidewire technique and transpancreatic septotomy were allowed (without the use of fluoroscopy). The authors noted that “brief” fluoroscopy was allowed during cannulation attempts in select cases.

Pure DSC was successful in 42 of 47 patients (89.4%). An additional 4 patients underwent successful cannulation via brief fluoroscopy, with one patient requiring extended fluoroscopy for successful cannulation. Of the 46 patients with either pure DSC or DSC plus brief fluoroscopy, 45 had stones seen on cholangioscopy; subsequently, all these patients underwent DSC-based stone removal. However, in 3 patients, persistent stone disease was seen on confirmatory fluoroscopy. There was a single episode of pancreatitis and no episodes of cholangitis.



This mainly descriptive, prospective study shows that fluoroscopy-free ERCP to treat biliary stone disease is largely successful and safe. However, I have a few concerns that I suspect the upcoming randomized controlled trial will answer, the most pressing being whether the use of advanced cannulation techniques such as double guidewire and transpancreatic septotomy without fluoroscopy is safe because it is unclear how one would confirm the correct placement of a guidewire with or without a pancreatic stent. Furthermore, the relative benefits of limiting fluoroscopy require more clarity.


Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Ridtitid W, Rerknimitr R, Ramchandani M, et al. Endoscopic clearance of non‐complex biliary stones using fluoroscopy‐free direct solitary cholangioscopy: initial multicenter experience. DEN Open 2023 Jun 1. (https://doi.org/10.1002/deo2.241)

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