Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

Background: EUS may be used to reduce the need of diagnostic ERCP Objective: Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. Design: A randomized study Setting: A university medical unit. Patients: Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. Interventions: In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. Main Outcome Measurements: The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. Results: Thirty-three patients were randomized to EUS and 32 to ERCP Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. Conclusions: In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP