The Utility of Endoscopic Ultrasound in Detecting Missed CBD stones

The Utility of Endoscopic Ultrasound in Detecting Missed CBD stones | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Utility of Endoscopic Ultrasound in Detecting Missed CBD stones Mahmoud Farouk, Mona Kaddah, Adnan Ahmed Mohamed, Katarzyna M. Pawlak, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5152065/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Precise techniques for identifying common bile duct (CBD) and pancreatic disorders are crucial to strategize appropriate interventions. This study aimed to assess the utility of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) in detecting CBD stones compared to endoscopic retrograde cholangiopancreatography (ERCP). Methods: This prospective multicenter research included 200 patients over 18 years old with dilated CBD measuring 6-10 mm, unexplained elevated liver enzymes, and unexplained acute pancreatitis. The patients were evaluated using abdominal ultrasonography, MRCP, and EUS. MRCP is performed just before the EUS and the ERCP being performed at a subsequent stage whenever indicated. Results: Stones were detected in 39.5% of the patients using ERCP compared to 47% using MRCP and 43.5% using EUS. There was a strong agreement between ERCP findings and EUS findings (Kappa=0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, positive predictive value (PPV) of 86.2%, Negative predictive value (NPV) of 96.5%, and accuracy of 92%. There was a moderate agreement between ERCP findings and MRCP findings (Kappa=0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. The accuracy of EUS was significantly higher than accuracy of MRCP. Conclusions: EUS is a more accurate diagnostic tool for detecting stones compared to MRCP, and it has a strong agreement with ERCP findings, which is considered the gold standard?? Common bile duct Endoscopic retrograde cholangiopancreatography Endoscopic ultrasound Magnetic resonance cholangiopancreatography Stones Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The American Society for Gastrointestinal Endoscopy (ASGE) consensus recommendations classify individuals into low, moderate, and high likelihood of common bile duct (CBD) stones based on clinical characteristics, imaging appearance, and biochemical data [ 1 ] . Enhancements in technology and a reduction in the cost of imaging studies have led to the increase in the incidental detection of various conditions, especially bile duct dilation, which may or may not be accompanied by pancreatic duct dilation in symptomatic or asymptomatic pancreaticobiliary disease [ 2 , 3 ] . Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard test, primarily because it offers the possibility of immediate intervention in cases where a CBD stone is identified. Nonetheless, the invasiveness of ERCP carries potential risks of inducing pancreatitis, causing perforations, and bleeding [ 4 ] . Due to their limited reliability, a definitive diagnosis cannot be solely based on clinical assessment and biochemical investigations. Therefore, magnetic resonance cholangiopancreatography (MRCP) is commonly employed as a follow-up diagnostic procedure to substantiate findings from initial ultrasound examinations [ 5 ] . Endoscopic ultrasound (EUS) is a minimally invasive approach that uses a specialized endoscope with an ultrasound probe at its tip to supply detailed images of the internal organs, including the bile ducts. EUS can provide high-resolution images of the bile ducts and detect small stones that may not be visible on MRCP [ 6 ] . In cases where CBD stones are suspected but not detected by MRCP, other imaging modalities, such as EUS and ERCP, may be used to confirm the presence of stones and to guide further management [ 7 ] . Thus, this work assessed the EUS and MRCP utility in detecting CBD stones compared with ERCP. Patients and Methods This prospective multicenter research was conducted on 200 patients over 18 years old with dilated CBD measuring 6–10 mm, unexplained elevated liver enzymes, and unexplained acute pancreatitis. The research was conducted from --to– after approval from the Ethical Committee of Kasr Al Ainy Hospitals in Egypt (approval code: ----). The patient provided informed written consent. Obstructive jaundice patients with any imaging modality showing CBD stones and patients with cholangitis were referred directly to ERCP, and those proved to have malignant masses were excluded. All patients underwent complete history taking, clinical examination, laboratory investigations [complete blood count (CBC), liver function tests, and serum amylase and serum lipase], abdominal ultrasound (US), MRCP, EUS, and ERCP. The sequence of the procedures involved the MRCP being carried out just before the EUS and the ERCP being performed at a subsequent stage. The EUS operator was blind to the MRCP findings. The EUS was performed using a linear Echoendoscope model EG3870UTK from Pentax (HOYA Corporation, Tokyo, Japan), connected to a Hitachi AVIUS system (Hitachi Medical Systems, Tokyo, Japan). During the EUS-Fine Needle Aspiration (EUS-FNA), needles of sizes 19G and 22G from the Cook Echotip range (Wilson-Cook, Winston Salem, NC) were utilized. ERCP was performed using a Pentax ED-3490TK side-view endoscope (HOYA Corporation, Tokyo, Japan). Each procedure of EUS and ERCP was conducted under deep sedation, utilizing intravenous propofol, and was preceded by the prophylactic administration of ceftriaxone (1 gm). The ERCP was conducted as a validation procedure for the findings of the MRCP and EUS results To assess EUS and MRCP sensitivity and specificity in identifying choledocholithiasis, their results were benchmarked against those from ERCP. Additionally, the ability of MRCP and EUS to accurately determine stone size and count in the CBD was analyzed. A follow-up period of three months post-procedure was implemented for the patients, during which clinical and biochemical monitoring was conducted. The sample size calculation: The sample size calculation was performed using EpI-Info 2002 software statistical package designed by World Health Organization (WHO) and by Centers for Disease Control and Prevention (CDC). The sample size was calculated based on the following considerations: 95% confidence level and the Sensitivity of EUS was 95% according to a previous study [ 8 ] ± 5% confidence limit. 17 cases were added to overcome dropout. Therefore, we recruited 200 cases Statistical analysis The SPSS v26 (IBM Inc., Chicago, IL, USA) was used for statistical analysis. Quantitative variables were shown as mean and standard deviation (SD). Qualitative variables were presented as frequency and percentage (%). Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy are used for detecting EUS and MRCP compared to ERCP. Kappa was used to detect the agreement between ERCP findings and (EUS and MRCP findings). A two-tailed P value < 0.05 was considered statistically significant. Results The mean age value (± SD) was 51.2 (± 14.32) years. There were 91 (45.5%) males and 109 (54.5%) females. The mean weight value (± SD) was 79.2 (± 12.84) kg. The mean height value (± SD) was 1.68 (± 0.07) m. The mean BMI value (± SD) was 28.4 (± 5.14) kg/m 2 . Table 1 Regarding ERCP findings, stones were present in 79 (39.5%) patients. Regarding ERCP, Stone location in the biliary tree was proximal CBD in 1 (0.5%) patient, middle CBD in 6 (3%) patients, distal CBD in 39 (19.5%) patients, and ampulla in 33 (16.5%) patients. Table 2 Regarding MRCP findings, stones were present in 94 (47%) patients. 43 (21.5%) patients had single stones and 51 (25.5%) had multiple stones. The stone number's median value (IQR) was 0 (0–2). Stone size's median value (IQR) was 6 (4–9) mm. Stone size was gravel in 4 (2%) patients, microlithiasis in 28 (14%) patients, stone in 45 (22.5%) patients and large stone in 17 (8.5%) patients. Table 2 Regarding EUS findings, stones were present in 87 (43.5%) patients. 40 (20%) patients had single stones and 47 (23.5%) had multiple stones. The stone number's median value (IQR) was 0(0–1). Stone size's mean value (IQR) was 5 (4–7) mm. Stone size was gravel in 1 (0.5%) patient, microlithiasis in 32 (16%) patients, stone in 38 (19%) patients and large stone in 16 (8%) patients. Table 3 There was a strong agreement between ERCP findings and EUS findings (Kappa = 0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, PPV of 86.2%, NPV of 96.5%, and accuracy of 92%. Table 4 There was a moderate agreement between ERCP findings and MRCP findings (Kappa = 0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. Table 4 The accuracy of EUS was significantly higher than accuracy of MRCP (P < 0.001 Discussion Choledocholithiasis affects 15–20% of individuals with symptomatic cholelithiasis. Bile duct stones become more common with higher age, with up to 25% of older individuals having calculi in the bile duct while undergoing cholecystectomy [ 9 ] . In our study, stones were diagnosed in 39.5% of the patients using ERCP compared to 47|% using MRCP and 43.5% using EUS. There was a strong agreement between ERCP findings and EUS findings (Kappa = 0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, PPV of 86.2%, NPV of 96.5%, and accuracy of 92%. There was a moderate agreement between ERCP findings and MRCP findings (Kappa = 0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. The accuracy of EUS was significantly higher than accuracy of MRCP. While the literature indicates that MRCP and EUS have comparable diagnostic efficacy for detecting CBD pathologies (77–100% sensitivity and 70–99% specificity) [ 10 ] , the performance of MRCP decreases for microlithiasis (< 5mm), dilated CBD, and minor ampullary lesions [ 11 ] . Supporting our findings Eissa et al. [ 7 ] reported that the overall prevalence of choledocholithiasis was 83.3% by EUS, and 41.1% by MRCP. EUS detected the number of stones more accurately than MRCP (95% vs 41%, respectively) with higher accuracy of EUS in detecting stones less than 5 mm was than MRCP. In line with our results, Answer et al. [ 12 ] noted that the diagnostic accuracy of EUS for missed CBD stones revealed a sensitivity of 89.5%, specificity of 96.5%, PPV of 91.9%, and NPV of 95.3%. Also, Jeon et al. [ 13 ] studied the accuracy of EUS for identification of the presence of choledocholithiasis in 82.5% of the patients. The sensitivity of EUS was 97.5%, specificity was 79.5%, PPV was 95.2%, NPV was 88.6%, and accuracy was 94.0%. A meta-analysis encompassing five studies was conducted by Meeralam et al. [ 14 ] to evaluate the comparative diagnostic accuracy of EUS and MRCP for choledocholithiasis detection. Their results denoted that the combined sensitivity of EUS was at 97% with 90% specificity and MRCP sensitivity was 87% with 92% specificity. Consistently, Eissa et al. [ 7 ] reported that EUS outperformed MRCP in detecting stones, with a specificity of 98.51% compared to 55.5%. However, MRCP had a higher specificity (100% vs 60.87%). Moreover, Patel et al. [ 15 ] found that EUS was highly effective in detecting choledocholithiasis, with a sensitivity of 93.9%, specificity of 97.3%, PPV of 96.9%, and NPV of 94.7%. Also, the study conducted by Scheiman et al [ 16 ] reported that EUS exhibited significantly superior results in the diagnosis of choledocholithiasis (sensitivity, 95%; specificity, 80%) compared to MRCP (sensitivity, 40%; specificity, 96%). In agreement with our findings, Jeon et al. [ 13 ] noticed that EUS diagnosed a stone in 83% of the patients. EUS had an accuracy of 94%, sensitivity of 97.5%, specificity of 79.5%, PPV of 95.2%, and NPV of 88.6%. Also, Giljaca et al. [ 11 ] compared EUS and MRCP accuracy for CBD stone diagnosis. They concluded that EUS and MRCP exhibit substantial diagnostic precision in identifying CBD stones, implying individuals with negative results from either EUS or MRCB. ERCP has several limitations, such as being an invasive approach with the potential for significant complications, such as pancreatitis, infections, bleeding, and perforation of the bile duct or intestine [ 17 ] . ERCP uses fluoroscopy, which exposes patients to radiation [ 18 ] . The success of ERCP is largely based on the endoscopist's skill and experience [ 19 ] . ERCP requires successful bile duct cannulation, which may not be possible in all cases due to anatomical variations or previous surgeries [ 20 ] . Moreover, ERCP involves injecting contrast into the bile ducts, which can cause allergic reactions or nephrotoxicity in susceptible individuals [ 21 ] . Thus, EUS is recommended for clinical use over MRCP, as EUS is a minimally invasive method that diminishes the risk of adverse events like pancreatitis, perforation, and bleeding [ 12 ] . EUS is more sensitive to detecting small bile duct stones and sludge that MRCP might miss [ 22 ] . A small sample size limits this study. Also, we did not assess complications and the cost-effectiveness of EUS compared to other diagnostic modalities. Conclusion EUS is a more accurate diagnostic tool for detecting stones compared to MRCP, and it has a strong agreement with ERCP findings, which is considered the gold standard. Declarations Financial support and sponsorship: Nil Conflict of Interest: Nil Funding : No fundus Author Contribution M.F , M.k and A.A.M they did the main final paper writing K.M.P , G.M ,P.K and M.Z they did the statisticsM.T , E.G and R.M.M.A they collect the clinical data of the cases E.G , M.A , R.E and k.R they prepare the figures and tablesH.H.O he did the final revision References Lem S-G, Wang S-J, Tsai C-Y, Sun M-S (2022) The efficacy and accuracy of endoscopic ultrasound for detecting common bile duct stones in intermediate to high-risk patients with non-diagnostic CT or MRCP. Adv Dig Med 9:31–37 Rogowska JO, Durko Ł, Malecka-Wojciesko E (2023) The latest advancements in diagnostic role of endosonography of pancreatic lesions. 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Gastrointest Endosc 86:986–993 Patel R, Ingle M, Choksi D, Poddar P, Pandey V, Sawant P (2017) Endoscopic ultrasonography can prevent unnecessary diagnostic endoscopic retrograde cholangiopancreatography even in patients with high likelihood of choledocholithiasis and inconclusive ultrasonography: Results of a prospective study. Clin Endosc 50:592–597 Scheiman JM, Carlos RC, Barnett JL, Elta GH, Nostrant TT, Chey WD et al (2001) Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol 96:2900–2904 Koc B, Bircan HY, Adas G, Kemik O, Akcakaya A, Yavuz A et al (2014) Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations. PLoS ONE 9:e113073 Boix J, Lorenzo-Zúñiga V (2011) Radiation dose to patients during endoscopic retrograde cholangiopancreatography. World J Gastrointest Endosc 3:140–144 Sharma ZD, Puri R (2023) Quality indicators in endoscopic retrograde cholangiopancreatography: a brief review of established guidelines. Clin Endosc 56:290–297 op den Winkel M, Schirra J, Schulz C, De Toni EN, Steib CJ, Anz D et al (2021) Biliary cannulation in endoscopic retrograde cholangiography: How to tackle the difficult papilla. Dig Dis 40:85–96 Shinoura S, Tokushige A, Chinen K, Mori H, Kato S, Ueda S (2020) Association between contrast-induced nephrotoxicity and contrast enhanced computed tomography followed by endoscopic retrograde cholangiopancreatography. Eur J Radiol 129:109074 Hashim AM, Ahmed AN, Esmail YM, Awad A, Elfatah YA (2024) Role of endoscopic ultrasound in gallbladder and biliary system diseases in patients with normal transabdominal ultrasonography. Egypt J Intern Med 36:8 Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table1.png Table2.png Table3.png Table4.png Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5152065","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":359691573,"identity":"644fcbba-65f9-44c4-b0a2-50b2b67cc888","order_by":0,"name":"Mahmoud Farouk","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Farouk","suffix":""},{"id":359691576,"identity":"0724c38d-ce92-4f53-b6b3-4642a224a826","order_by":1,"name":"Mona Kaddah","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"","lastName":"Kaddah","suffix":""},{"id":359691577,"identity":"6805bafc-cb70-4285-ace3-8847f25f9cf2","order_by":2,"name":"Adnan Ahmed Mohamed","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Adnan","middleName":"Ahmed","lastName":"Mohamed","suffix":""},{"id":359691578,"identity":"45bbbdf1-e909-4a84-8682-71f30fa08b20","order_by":3,"name":"Katarzyna M. 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07:04:54","extension":"png","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":13514,"visible":true,"origin":"","legend":"","description":"","filename":"table1.png","url":"https://assets-eu.researchsquare.com/files/rs-5152065/v1/7584d4908126e9634cce3ade.png"},{"id":70908912,"identity":"17ba3e75-d057-404d-b80b-501c1e35b53e","added_by":"auto","created_at":"2024-12-09 07:04:54","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16636,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.png","url":"https://assets-eu.researchsquare.com/files/rs-5152065/v1/eff641d6d4260c37562b3d68.png"},{"id":70908914,"identity":"004fb7d3-d723-4306-b785-edda5216cb05","added_by":"auto","created_at":"2024-12-09 07:04:54","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":45700,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.png","url":"https://assets-eu.researchsquare.com/files/rs-5152065/v1/35b3179939a896bc162ee6ac.png"},{"id":70910408,"identity":"9ed61511-9cd7-41eb-8f42-05cb08a89497","added_by":"auto","created_at":"2024-12-09 07:12:54","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":26842,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.png","url":"https://assets-eu.researchsquare.com/files/rs-5152065/v1/2e6d9c70ad6a6b55baf6a2b1.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Utility of Endoscopic Ultrasound in Detecting Missed CBD stones","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe American Society for Gastrointestinal Endoscopy (ASGE) consensus recommendations classify individuals into low, moderate, and high likelihood of common bile duct (CBD) stones based on clinical characteristics, imaging appearance, and biochemical data \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEnhancements in technology and a reduction in the cost of imaging studies have led to the increase in the incidental detection of various conditions, especially bile duct dilation, which may or may not be accompanied by pancreatic duct dilation in symptomatic or asymptomatic pancreaticobiliary disease \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) is the gold standard test, primarily because it offers the possibility of immediate intervention in cases where a CBD stone is identified. Nonetheless, the invasiveness of ERCP carries potential risks of inducing pancreatitis, causing perforations, and bleeding \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDue to their limited reliability, a definitive diagnosis cannot be solely based on clinical assessment and biochemical investigations. Therefore, magnetic resonance cholangiopancreatography (MRCP) is commonly employed as a follow-up diagnostic procedure to substantiate findings from initial ultrasound examinations \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEndoscopic ultrasound (EUS) is a minimally invasive approach that uses a specialized endoscope with an ultrasound probe at its tip to supply detailed images of the internal organs, including the bile ducts. EUS can provide high-resolution images of the bile ducts and detect small stones that may not be visible on MRCP \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn cases where CBD stones are suspected but not detected by MRCP, other imaging modalities, such as EUS and ERCP, may be used to confirm the presence of stones and to guide further management \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Thus, this work assessed the EUS and MRCP utility in detecting CBD stones compared with ERCP.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis prospective multicenter research was conducted on 200 patients over 18 years old with dilated CBD measuring 6\u0026ndash;10 mm, unexplained elevated liver enzymes, and unexplained acute pancreatitis.\u003c/p\u003e \u003cp\u003e The research was conducted from --to\u0026ndash; after approval from the Ethical Committee of Kasr Al Ainy Hospitals in Egypt (approval code: ----). The patient provided informed written consent.\u003c/p\u003e \u003cp\u003eObstructive jaundice patients with any imaging modality showing CBD stones and patients with cholangitis were referred directly to ERCP, and those proved to have malignant masses were excluded.\u003c/p\u003e \u003cp\u003eAll patients underwent complete history taking, clinical examination, laboratory investigations [complete blood count (CBC), liver function tests, and serum amylase and serum lipase], abdominal ultrasound (US), MRCP, EUS, and ERCP.\u003c/p\u003e \u003cp\u003eThe sequence of the procedures involved the MRCP being carried out just before the EUS and the ERCP being performed at a subsequent stage. The EUS operator was blind to the MRCP findings.\u003c/p\u003e \u003cp\u003eThe EUS was performed using a linear Echoendoscope model EG3870UTK from Pentax (HOYA Corporation, Tokyo, Japan), connected to a Hitachi AVIUS system (Hitachi Medical Systems, Tokyo, Japan). During the EUS-Fine Needle Aspiration (EUS-FNA), needles of sizes 19G and 22G from the Cook Echotip range (Wilson-Cook, Winston Salem, NC) were utilized.\u003c/p\u003e \u003cp\u003eERCP was performed using a Pentax ED-3490TK side-view endoscope (HOYA Corporation, Tokyo, Japan).\u003c/p\u003e \u003cp\u003eEach procedure of EUS and ERCP was conducted under deep sedation, utilizing intravenous propofol, and was preceded by the prophylactic administration of ceftriaxone (1 gm).\u003c/p\u003e \u003cp\u003eThe ERCP was conducted as a validation procedure for the findings of the MRCP and EUS results\u003c/p\u003e \u003cp\u003eTo assess EUS and MRCP sensitivity and specificity in identifying choledocholithiasis, their results were benchmarked against those from ERCP. Additionally, the ability of MRCP and EUS to accurately determine stone size and count in the CBD was analyzed.\u003c/p\u003e \u003cp\u003eA follow-up period of three months post-procedure was implemented for the patients, during which clinical and biochemical monitoring was conducted.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe sample size calculation:\u003c/h2\u003e \u003cp\u003eThe sample size calculation was performed using EpI-Info 2002 software statistical package designed by World Health Organization (WHO) and by Centers for Disease Control and Prevention (CDC). The sample size was calculated based on the following considerations: 95% confidence level and the Sensitivity of EUS was 95% according to a previous study \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;5% confidence limit. 17 cases were added to overcome dropout. Therefore, we recruited 200 cases\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe SPSS v26 (IBM Inc., Chicago, IL, USA) was used for statistical analysis. Quantitative variables were shown as mean and standard deviation (SD). Qualitative variables were presented as frequency and percentage (%). Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy are used for detecting EUS and MRCP compared to ERCP. Kappa was used to detect the agreement between ERCP findings and (EUS and MRCP findings). A two-tailed P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age value (\u0026plusmn;\u0026thinsp;SD) was 51.2 (\u0026plusmn;\u0026thinsp;14.32) years. There were 91 (45.5%) males and 109 (54.5%) females. The mean weight value (\u0026plusmn;\u0026thinsp;SD) was 79.2 (\u0026plusmn;\u0026thinsp;12.84) kg. The mean height value (\u0026plusmn;\u0026thinsp;SD) was 1.68 (\u0026plusmn;\u0026thinsp;0.07) m. The mean BMI value (\u0026plusmn;\u0026thinsp;SD) was 28.4 (\u0026plusmn;\u0026thinsp;5.14) kg/m\u003csup\u003e2\u003c/sup\u003e. Table\u0026nbsp;1\u003c/p\u003e \u003cp\u003eRegarding ERCP findings, stones were present in 79 (39.5%) patients. Regarding ERCP, Stone location in the biliary tree was proximal CBD in 1 (0.5%) patient, middle CBD in 6 (3%) patients, distal CBD in 39 (19.5%) patients, and ampulla in 33 (16.5%) patients. Table\u0026nbsp;2\u003c/p\u003e \u003cp\u003eRegarding MRCP findings, stones were present in 94 (47%) patients. 43 (21.5%) patients had single stones and 51 (25.5%) had multiple stones. The stone number's median value (IQR) was 0 (0\u0026ndash;2). Stone size's median value (IQR) was 6 (4\u0026ndash;9) mm. Stone size was gravel in 4 (2%) patients, microlithiasis in 28 (14%) patients, stone in 45 (22.5%) patients and large stone in 17 (8.5%) patients. Table\u0026nbsp;2\u003c/p\u003e \u003cp\u003eRegarding EUS findings, stones were present in 87 (43.5%) patients. 40 (20%) patients had single stones and 47 (23.5%) had multiple stones. The stone number's median value (IQR) was 0(0\u0026ndash;1). Stone size's mean value (IQR) was 5 (4\u0026ndash;7) mm. Stone size was gravel in 1 (0.5%) patient, microlithiasis in 32 (16%) patients, stone in 38 (19%) patients and large stone in 16 (8%) patients. Table\u0026nbsp;3\u003c/p\u003e \u003cp\u003eThere was a strong agreement between ERCP findings and EUS findings (Kappa\u0026thinsp;=\u0026thinsp;0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, PPV of 86.2%, NPV of 96.5%, and accuracy of 92%. Table\u0026nbsp;4\u003c/p\u003e \u003cp\u003eThere was a moderate agreement between ERCP findings and MRCP findings (Kappa\u0026thinsp;=\u0026thinsp;0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. Table\u0026nbsp;4\u003c/p\u003e \u003cp\u003eThe accuracy of EUS was significantly higher than accuracy of MRCP (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCholedocholithiasis affects 15\u0026ndash;20% of individuals with symptomatic cholelithiasis. Bile duct stones become more common with higher age, with up to 25% of older individuals having calculi in the bile duct while undergoing cholecystectomy \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, stones were diagnosed in 39.5% of the patients using ERCP compared to 47|% using MRCP and 43.5% using EUS. There was a strong agreement between ERCP findings and EUS findings (Kappa\u0026thinsp;=\u0026thinsp;0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, PPV of 86.2%, NPV of 96.5%, and accuracy of 92%. There was a moderate agreement between ERCP findings and MRCP findings (Kappa\u0026thinsp;=\u0026thinsp;0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. The accuracy of EUS was significantly higher than accuracy of MRCP.\u003c/p\u003e \u003cp\u003eWhile the literature indicates that MRCP and EUS have comparable diagnostic efficacy for detecting CBD pathologies (77\u0026ndash;100% sensitivity and 70\u0026ndash;99% specificity) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, the performance of MRCP decreases for microlithiasis (\u0026lt;\u0026thinsp;5mm), dilated CBD, and minor ampullary lesions \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSupporting our findings Eissa et al. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e reported that the overall prevalence of choledocholithiasis was 83.3% by EUS, and 41.1% by MRCP. EUS detected the number of stones more accurately than MRCP (95% vs 41%, respectively) with higher accuracy of EUS in detecting stones less than 5 mm was than MRCP.\u003c/p\u003e \u003cp\u003eIn line with our results, Answer et al. \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e noted that the diagnostic accuracy of EUS for missed CBD stones revealed a sensitivity of 89.5%, specificity of 96.5%, PPV of 91.9%, and NPV of 95.3%.\u003c/p\u003e \u003cp\u003eAlso, Jeon et al. \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e studied the accuracy of EUS for identification of the presence of choledocholithiasis in 82.5% of the patients. The sensitivity of EUS was 97.5%, specificity was 79.5%, PPV was 95.2%, NPV was 88.6%, and accuracy was 94.0%.\u003c/p\u003e \u003cp\u003eA meta-analysis encompassing five studies was conducted by Meeralam et al. \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e to evaluate the comparative diagnostic accuracy of EUS and MRCP for choledocholithiasis detection. Their results denoted that the combined sensitivity of EUS was at 97% with 90% specificity and MRCP sensitivity was 87% with 92% specificity.\u003c/p\u003e \u003cp\u003eConsistently, Eissa et al. \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e reported that EUS outperformed MRCP in detecting stones, with a specificity of 98.51% compared to 55.5%. However, MRCP had a higher specificity (100% vs 60.87%).\u003c/p\u003e \u003cp\u003eMoreover, Patel et al. \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e found that EUS was highly effective in detecting choledocholithiasis, with a sensitivity of 93.9%, specificity of 97.3%, PPV of 96.9%, and NPV of 94.7%. Also, the study conducted by Scheiman et al \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e reported that EUS exhibited significantly superior results in the diagnosis of choledocholithiasis (sensitivity, 95%; specificity, 80%) compared to MRCP (sensitivity, 40%; specificity, 96%).\u003c/p\u003e \u003cp\u003eIn agreement with our findings, Jeon et al. \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e noticed that EUS diagnosed a stone in 83% of the patients. EUS had an accuracy of 94%, sensitivity of 97.5%, specificity of 79.5%, PPV of 95.2%, and NPV of 88.6%.\u003c/p\u003e \u003cp\u003eAlso, Giljaca et al. \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e compared EUS and MRCP accuracy for CBD stone diagnosis. They concluded that EUS and MRCP exhibit substantial diagnostic precision in identifying CBD stones, implying individuals with negative results from either EUS or MRCB.\u003c/p\u003e \u003cp\u003eERCP has several limitations, such as being an invasive approach with the potential for significant complications, such as pancreatitis, infections, bleeding, and perforation of the bile duct or intestine \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. ERCP uses fluoroscopy, which exposes patients to radiation \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The success of ERCP is largely based on the endoscopist's skill and experience \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. ERCP requires successful bile duct cannulation, which may not be possible in all cases due to anatomical variations or previous surgeries \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Moreover, ERCP involves injecting contrast into the bile ducts, which can cause allergic reactions or nephrotoxicity in susceptible individuals \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThus, EUS is recommended for clinical use over MRCP, as EUS is a minimally invasive method that diminishes the risk of adverse events like pancreatitis, perforation, and bleeding \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. EUS is more sensitive to detecting small bile duct stones and sludge that MRCP might miss \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA small sample size limits this study. Also, we did not assess complications and the cost-effectiveness of EUS compared to other diagnostic modalities.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eEUS is a more accurate diagnostic tool for detecting stones compared to MRCP, and it has a strong agreement with ERCP findings, which is considered the gold standard.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship: \u003c/strong\u003eNil\u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest:\u003c/h2\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding :\u003c/h2\u003e \u003cp\u003eNo fundus\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.F , M.k and A.A.M they did the main final paper writing K.M.P , G.M ,P.K and M.Z they did the statisticsM.T , E.G and R.M.M.A they collect the clinical data of the cases E.G , M.A , R.E and k.R they prepare the figures and tablesH.H.O he did the final revision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLem S-G, Wang S-J, Tsai C-Y, Sun M-S (2022) The efficacy and accuracy of endoscopic ultrasound for detecting common bile duct stones in intermediate to high-risk patients with non-diagnostic CT or MRCP. 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Cochrane Database Syst Rev 2015:Cd011549\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnwer M, Asghar MS, Rahman S, Kadir S, Yasmin F, Mohsin D et al (2020) Diagnostic accuracy of endoscopic ultrasonography versus the gold standard endoscopic retrograde cholangiopancreatography in detecting common bile duct stones. Cureus 12:e12162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon TJ, Cho JH, Kim YS, Song SY, Park JY (2017) Diagnostic value of endoscopic ultrasonography in symptomatic patients with high and intermediate probabilities of common bile duct stones and a negative computed tomography scan. Gut Liver 11:290\u0026ndash;297\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeeralam Y, Al-Shammari K, Yaghoobi M (2017) Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis: a meta-analysis of diagnostic test accuracy in head-to-head studies. Gastrointest Endosc 86:986\u0026ndash;993\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel R, Ingle M, Choksi D, Poddar P, Pandey V, Sawant P (2017) Endoscopic ultrasonography can prevent unnecessary diagnostic endoscopic retrograde cholangiopancreatography even in patients with high likelihood of choledocholithiasis and inconclusive ultrasonography: Results of a prospective study. Clin Endosc 50:592\u0026ndash;597\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheiman JM, Carlos RC, Barnett JL, Elta GH, Nostrant TT, Chey WD et al (2001) Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol 96:2900\u0026ndash;2904\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoc B, Bircan HY, Adas G, Kemik O, Akcakaya A, Yavuz A et al (2014) Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations. PLoS ONE 9:e113073\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoix J, Lorenzo-Z\u0026uacute;\u0026ntilde;iga V (2011) Radiation dose to patients during endoscopic retrograde cholangiopancreatography. World J Gastrointest Endosc 3:140\u0026ndash;144\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma ZD, Puri R (2023) Quality indicators in endoscopic retrograde cholangiopancreatography: a brief review of established guidelines. Clin Endosc 56:290\u0026ndash;297\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eop den Winkel M, Schirra J, Schulz C, De Toni EN, Steib CJ, Anz D et al (2021) Biliary cannulation in endoscopic retrograde cholangiography: How to tackle the difficult papilla. Dig Dis 40:85\u0026ndash;96\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShinoura S, Tokushige A, Chinen K, Mori H, Kato S, Ueda S (2020) Association between contrast-induced nephrotoxicity and contrast enhanced computed tomography followed by endoscopic retrograde cholangiopancreatography. Eur J Radiol 129:109074\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashim AM, Ahmed AN, Esmail YM, Awad A, Elfatah YA (2024) Role of endoscopic ultrasound in gallbladder and biliary system diseases in patients with normal transabdominal ultrasonography. Egypt J Intern Med 36:8\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Common bile duct, Endoscopic retrograde cholangiopancreatography, Endoscopic ultrasound, Magnetic resonance cholangiopancreatography, Stones","lastPublishedDoi":"10.21203/rs.3.rs-5152065/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5152065/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Precise techniques for identifying common bile duct (CBD) and pancreatic disorders are crucial to strategize appropriate interventions. This study aimed to assess the utility of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) in detecting CBD stones compared to endoscopic retrograde cholangiopancreatography (ERCP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This prospective \u0026nbsp;multicenter research included 200 patients over 18 years old with dilated CBD measuring 6-10 mm, unexplained elevated liver enzymes, and unexplained acute pancreatitis. The patients were evaluated using abdominal ultrasonography, MRCP, and EUS.\u003c/p\u003e\n\u003cp\u003eMRCP is performed just before the EUS and the ERCP being performed at a subsequent stage whenever indicated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Stones were detected in 39.5% of the patients using ERCP compared to 47% using MRCP and 43.5% using EUS.\u003cstrong\u003e \u003c/strong\u003eThere was a strong agreement between ERCP findings and EUS findings (Kappa=0.837). EUS can significantly detect stones with a sensitivity of 94.9%, specificity of 90.1%, positive predictive value (PPV) of 86.2%, Negative predictive value (NPV) of 96.5%, and accuracy of 92%. There was a moderate agreement between ERCP findings and MRCP findings (Kappa=0.402). MRCP can significantly detect stones with a sensitivity of 72.2%, specificity of 69.4%, PPV of 60.6%, NPV of 79.2%, and accuracy of 70.5%. The accuracy of EUS was significantly higher than accuracy of MRCP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eEUS is a more accurate diagnostic tool for detecting stones compared to MRCP, and it has a strong agreement with ERCP findings, which is considered the gold standard??\u003c/p\u003e","manuscriptTitle":"The Utility of Endoscopic Ultrasound in Detecting Missed CBD stones","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 07:04:49","doi":"10.21203/rs.3.rs-5152065/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06c70fa4-c134-417a-8edb-78414f6a8765","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-26T18:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-09 07:04:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5152065","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5152065","identity":"rs-5152065","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}