Background Endoscopic ultrasound (EUS)- guided transhepatic antegrade stone removal (TASR) for choledocholithiasis has been developed in recent years. The aim of this study was to compare the techniques, feasibility, and safety of traditional endoscopic retrograde cholangiopancreatography (ERCP) and single-session EUS-TASR for choledocholithiasis in patients with surgically altered anatomy (SAA).

Methods A retrospective database review of patients with SAA and choledocholithiasis undergoing ERCP or single-session TASR was performed. The success rates and adverse events were evaluated and compared.

Results A total of 38 patients (22 males, median age, 69 years) with SAA underwent primary ERCP with 25 successful ERCP, and 13 patients underwent single-session EUS-TASR as a rescue procedure. Technical success was achieved in 100% in TASR compared with 65.8% in primary ERCP (p<0.05). Multivariate analysis showed Roux-en-Y anatomy reduced the technical success rate of primary ERCP (OR 0.032, 95% CI 0.004~0.265, p <0.05). Clinical success rates of TASR and primary ERCP were 92.3% and 63.2%, respectively (p=0.076). The rates of adverse events of TASR and successful ERCP were 15.4% and 4%, respectively (p= 0.265). Otherwise, operation time was significantly shorter in the TASR group (60 min vs. 79 min, p<0.05).

Conclusions Single-session EUS-TASR as a rescue procedure after ERCP failure, appeared to be effective and safe in the management of choledocholithiasis in patients with SAA, especially in Roux-en-Y anastomosis. However, further evaluation of this technique is still needed, preferably through prospective multicenter trials.