Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis

Background: Endoscopic ultrasonography (EUS) has emerged as an accurate diagnostic alternative to endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review of all randomized controlled trials of EUS‐guided ERCP versus ERCP alone in patients with suspected choledocholithiasis. Methods: The search for eligible studies was carried out using the MEDLINE, Cochrane Central Register of Controlled Trials, and Science Citation Index electronic databases. Meta‐analysis was conducted using a random‐effects model. Results: Four trials containing 213 patients randomized to EUS‐guided ERCP and 210 to ERCP alone were selected. In the EUS‐guided ERCP group, ERCP was avoided in 143 patients (67·1 per cent) when EUS did not detect choledocholithiasis. The use of EUS significantly reduced the risk of overall complications (relative risk 0·35 (95 per cent confidence interval (c.i.) 0·20 to 0·62); P < 0·001) and post‐ERCP acute pancreatitis (relative risk 0·21 (95 per cent c.i. 0·06 to 0·83); P = 0·030). Conclusion: By performing EUS first, ERCP may be safely avoided in two‐thirds of patients with common bile duct stones. Application of EUS in the selection of patients for therapeutic ERCP significantly reduces the complication rate. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.