Fluoroscopy-Free Cholangioscopy for Bile-Duct Stones: GIE | August 2026
Introduction:
Conventional ERCP relies on fluoroscopy for biliary imaging and stone extraction, exposing patients and endoscopy teams to ionising radiation. Fluoroscopy-free direct solitary cholangioscopy (DSC) offers direct intraductal visualisation and potentially eliminates radiation altogether. This randomised trial compared DSC with conventional ERCP for noncomplex bile-duct stones.
Why was this study needed?
ERCP exposes both patients and staff to cumulative radiation.
Direct cholangioscopy enables real-time visualisation of stones and bile ducts.
Whether a completely fluoroscopy-free approach can achieve comparable stone clearance required randomised evidence.
Such an approach could be particularly useful when radiation exposure should be minimized.
Results:
Among 250 randomized patients, stone clearance was 87.1% with DSC vs 88.9% with conventional ERCP, meeting the prespecified criterion for noninferiority.
DSC completely eliminated fluoroscopic radiation exposure: 0 vs 2106 Gy·cm² median dose-area product.
Serious adverse events were comparable (5.6% vs 4.0%).
The trade-off was procedure duration: DSC required approximately 10 minutes longer than conventional ERCP.
Clinical Impact:
This trial demonstrates that fluoroscopy is not necessarily indispensable for selected noncomplex bile-duct stone extraction. Fluoroscopy-free DSC could be particularly attractive when radiation avoidance is important or fluoroscopy access is limited.
However, the longer procedure time, equipment requirements, operator expertise, and applicability primarily to noncomplex stones currently favor selective rather than universal adoption.
Bottom Line:
Fluoroscopy-free direct cholangioscopy achieved bile-duct stone clearance comparable with conventional ERCP while completely eliminating radiation exposure, without increasing serious adverse events. The price is a longer procedure—but for selected patients, “ERCP without radiation” may now be a realistic option.
