Comparison of EUS-guided treatment and balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography for large bile duct stone removal in patients with surgically altered anatomy: A multicenter study

Background and Objectives: Large bile duct stone removal in patients with surgically altered anatomy (SAA) is technically challenging. Although balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has been widely adopted, EUS-guided treatment (EUS-T) may achieve higher stone removal rates owing to improved device accessibility after anastomosis. In this multicenter retrospective study, we aimed to compare the outcomes of EUS-T and BE-ERCP for large bile duct stones in patients with SAA. Methods: Patients with SAA who underwent EUS-T or BE-ERCP for large bile duct stones (≥12 mm) between January 2016 and February 2025 were included. The primary outcome was the complete stone removal rate. Secondary outcomes included the number of sessions, procedure time, and adverse events. Propensity score matching was applied to adjust for baseline differences between groups. Results: In total, 22 EUS-T and 87 BE-ERCP procedures were analyzed. After matching, the complete stone removal rate was significantly higher in the EUS-T group than in the BE-ERCP group (90.5% vs. 61.9%, P = 0.030), despite a greater number of sessions (2.1 vs. 1.2, P < 0.001). Mean procedure times and adverse event rates were comparable. Cumulative success significantly improved up to the third session in EUS-T (first session, 27%; third, 86%). Conclusion: EUS-T achieved a higher complete stone removal rate than BE-ERCP without a significant increase in adverse event rates, and may be a first-line treatment option for large bile duct stones in patients with SAA.