Clinical Significance of Emergency EUS-Guided ERCP in the Treatment of Common Bile Duct Stones

Clinical Significance of Emergency EUS-Guided ERCP in the Treatment of Common Bile Duct 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 Clinical Significance of Emergency EUS-Guided ERCP in the Treatment of Common Bile Duct Stones Yu Wang, Chen Shi, Lixue Zhang, Yumei Wu, Chenao Zhang, Qimin Huang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8285652/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Mar, 2026 Read the published version in Digestive Diseases and Sciences → Version 1 posted 9 You are reading this latest preprint version Abstract Background and aim: Common bile duct stones (CBDS) can rapidly lead to cholangitis or biliary pancreatitis, making timely and accurate diagnosis essential. Although EUS provides high diagnostic accuracy, its value in emergency settings remains unclear. This study aimed to evaluate the clinical value of emergency EUS-guided ERCP. Methods A retrospective analysis was performed on the clinical data of 215 patients diagnosed with CBDS at the First Affiliated Hospital of Anhui Medical University between June 2018 and June 2024.Patients were assigned to either the emergency EUS group or the elective EUS group according to the time of symptom onset after admission and the time of EUS examination,Clinical efficacy, primary endpoint and secondary endpoint were compared between the two groups. Results Both the emergency and elective EUS groups achieved a 100% technical success rate for EUS and ERCP. The clinical success rates of ERCP were 96.3% and 94.8%, respectively, with no significant difference (P > 0.05). The emergency EUS group had significantly shorter hospital stays and lower hospitalization costs (P < 0.05). Post-ERCP complications were also significantly fewer in the emergency group (P 0.05). Conclusion Emergency EUS-guided ERCP significantly reduces hospital stay and hospitalization costs in patients with CBDS.It reduces the risk of short-term postoperative complications following ERCP but does not decrease the incidence of long-term postoperative complications.Therefore, emergency EUS-guided ERCP may serve as an effective strategy for patients presenting with acute CBDS, primarily by improving short-term clinical outcomes. Emergency Endoscopic Ultrasound Endoscopic retrograde cholangiopancreatography Common bile duct stones Biliary Tract Emergencies Figures Figure 1 Figure 2 Figure 3 1. Introduction Choledocholithiasis (CBDS), the most common form of cholelithiasis, frequently results in acute cholangitis and acute biliary pancreatitis, typically presenting with fever, abdominal pain, and jaundice. Without timely intervention, these conditions may progress to biliary obstruction complicated by infection, and in severe cases, may lead to septic shock, posing a life-threatening risk 1 .Currently, endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic papillary sphincterotomy (EST) for stone extraction is the mainstay of treatment for choledocholithiasis, with a reported success rate of up to 90% 2–4 and a relatively low complication rate of approximately 5% 2,5,6 .However, among patients who are highly suspected of having CBDS but lack definitive imaging evidence, it remains uncertain whether stones are consistently present at the time of emergency ERCP. Furthermore, some patients may spontaneously pass bile duct stones while awaiting ERCP, resulting in unnecessary procedures, increased healthcare costs, and elevated procedural risks.Therefore, accurate preoperative assessment of bile duct stones is essential to avoid unnecessary interventions and optimize clinical outcomes. Non-invasive imaging such as abdominal ultrasound and CT are widely used as first-line screening tools, but there are limitations in their diagnostic sensitivity for the end of the common bile duct, especially for microstones, which may lead to false-negative results.Ultrasound endoscopy (EUS), as a semi-invasive, high-resolution imaging tool, has the best diagnostic efficacy in detecting choledochal stones, with reported sensitivity and specificity of 89–94% and 94–95%, respectively 7,8 .EUS and ERCP are closely integrated in biliopancreatic practice, enabling endoscopists to optimize diagnostic and therapeutic efficiency through their combined use, thereby improving overall clinical outcomes 9 .Recent studies have shown 10 that preoperative EUS screening can prevent unnecessary ERCP in nearly two-thirds of patients with suspected choledocholithiasis.This strategy of EUS-based screening of patients before therapeutic ERCP significantly reduces the overall risk of complications. The concept of “emergency EUS” was refined in a 2023 Gut publication, where it was defined as an EUS examination performed within 72 hours of symptom onset or within 24 hours of hospital admission 11 .However, the consensus definition of emergency EUS and its clinical value have not been well studied. In patients with choledocholithiasis, evidence is lacking regarding whether emergency EUS-guided ERCP confers prognostic advantages.Therefore, this study aimed to evaluate the clinical value of emergency EUS in the management of patients with acute CBDS. 2. Materials and methods 2.1 Study Design and Population In this study, clinical data and imaging findings were retrospectively collected from patients diagnosed with choledocholithiasis between June 1, 2018 and June 1, 2024 at the First Affiliated Hospital of Anhui Medical University.Patients were classified into an emergency EUS group and an elective EUS group based on the time of symptom onset after admission and the timing of EUS examination. Emergency EUS was defined as an examination performed within 72 hours of symptom onset or within 24 hours of admission, whereas elective EUS was defined as an examination performed beyond these timeframes.Study inclusion criteria:（1）Age ≥ 18 years；（2）Presence of abdominal pain, fever, and jaundice, combined with imaging findings, led to the clinical diagnosis of choledocholithiasis；（3）EUS and ERCP were performed during hospitalization；（4）Signed written informed consent.Exclusion criteria：（1）Age <18 years；（2）inability to undergo or tolerate endoscopy;（3）Individuals with a history of malignant tumors；（4）Clinical data is incomplete.General information, clinical indicators, and follow-up outcomes exceeding six months postoperatively were collected for both groups.General information includes gender, age, body mass index, comorbidities, history of biliary tract surgery, past medical history, ASA physical status classification, and CBDS patient risk stratification.Clinical indicators include WBC, HGB, PLT, ALT, AST, ALP, GGT, CRP, amylase, lipase,and other laboratory parameters.ASA grading was based on the 2020 revised ASA Physical Status Classification System 12 .Risk stratification for CBDS was defined according to the recommendations of the European Society of Gastrointestinal Endoscopy (ESGE) 13 .This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (PJ2024-07-23). 2.2 EUS and ERCP Procedures 2.2.1 EUS Procedure ：The patient signed the informed consent form for the EUS examination prior to the procedure and was placed in the left lateral decubitus position.The endoscope (Fujifilm, EG-580UT; 7.5 MHz) was advanced to the level of the duodenal papilla and then slowly withdrawn while a systematic scan was performed.During withdrawal, the probe was kept in close contact with the intestinal wall to achieve multiplanar imaging through endoscope rotation and the injection of air-free saline. Retraction was paused when the middle to lower segments of the common bile duct were visualized. The probe angle was adjusted to obtain complete visualization of the entire common bile duct and adjacent structures, including the portal vein and pancreatic head. The diagnostic hallmark of common bile duct stones on EUS is the presence of a persistent hyperechoic mass within the bile duct, which may or may not be accompanied by posterior acoustic shadowing.(Figure 1A, 1B, 1C). 2.2.2 ERCP Procedure : The patient fasted and refrained from oral intake for at least 6 hours prior to the procedure. Under intravenous anesthesia, the patient was placed in the left lateral decubitus position. A therapeutic duodenoscope (JF-260V and TJF-260V; Olympus Co., Tokyo, Japan) was inserted under vital sign monitoring. Upon reaching the descending duodenum, the scope was straightened to allow clear visualization of the duodenal papilla.Following successful selective cannulation of the common bile duct via the papilla, contrast medium was injected to perform cholangiography and confirm stone location, size, and bile duct anatomy. Based on stone size and number, endoscopic sphincterotomy (EST) was performed, followed by stone retrieval under fluoroscopic guidance,For impacted stones >1.5 cm in diameter, mechanical lithotripsy was performed first, followed by basket-assisted stone extraction. A nasobiliary drainage tube was placed postoperatively. The tube was removed once clinical symptoms improved, laboratory parameters normalized, or imaging showed no residual stone shadows.(Figure 1D, 1E, 1F).Serum amylase levels and complete blood counts were monitored at 3 and 24 hours postoperatively. 2.3 Observation Indicators 2.3.1 Clinical Efficacy ： The clinical efficacy indicators assessed included the EUS technical success rate, the EUS stone detection rate, the ERCP technical success rate, the ERCP clinical success rate, and the time to relief of major symptoms.The EUS technical success rate was defined as the successful removal of stones by ERCP under EUS guidance. The EUS stone detection rate referred to the proportion of biliary sludge ,biliary microlithiasis, and biliary stones identified on EUS. Biliary microlithiasis were defined as stones ≤5 mm in diameter accompanied by posterior acoustic shadowing;Biliary sludge was defined as discrete hyperechoic material within the lumen without posterior acoustic shadowing; and biliary stones were defined as persistent hyperechoic masses >5 mm in diameter within the duct, with or without posterior acoustic shadowing 14 . The ERCP technical success rate was defined as successful selective cannulation of the common bile duct.The clinical success rate of ERCP was defined as improvement in patient symptoms, irrespective of bilirubin normalization. 2.3.2 Primary endpoints ： The primary endpoint is a composite endpoint, which includes major complications or death that occur more than 6 months after inclusion.Major complications included:recurrent pancreatitis, cholecystitis, biliary colic and cholangitis. 2.3.3 Secondary endpoints ： Secondary endpoint included the length of hospital stay, hospitalization costs, ICU admission, and the occurrence of post-ERCP complications .Post-ERCP complications include post-ERCP pancreatitis, post-ERCP cholangitis, post-ERCP hemorrhage and gastrointestinal perforation.The diagnosis and severity grading of post-ERCP pancreatitis were based on the revised Atlanta classification 15 .Cholangitis was defined according to the 2018 Tokyo Guidelines 16 .For other adverse events, such as hemorrhage and perforation, we followed recommendations provided by the European Society of Gastrointestinal Endoscopy (ESGE) 17 . 2.4 Statistical analysis. All data and statistical analyses were performed using SPSS version 27.0 (IBM SPSS Statistics).Normally distributed quantitative data were expressed as mean ± standard deviation (mean ± SD), and intergroup comparisons were performed using the independent-samples t-test.Skewed quantitative data were presented as median (interquartile range, IQR), and intergroup comparisons were conducted using the Mann–Whitney U test.Categorical variables were expressed as frequencies (n) and percentages (%), and intergroup comparisons were performed using the chi-square test.In this study, the Kaplan-Meier (KM) curve was employed to analyze the follow-up outcomes.KM curve was performed by R version 4.4.1 (R Project forStatistical Computing). A two-tailed P < 0.05 was considered statistically significant. 3. Results 3.1 Patient baseline characteristics A total of 227 patients diagnosed with common bile duct stones were screened.Twelve patients were excluded due to critical illness that precluded invasive diagnostic or therapeutic procedures (EUS + ERCP), resulting in 215 patients being enrolled: 81 in the emergency EUS group and 134 in the elective EUS group (Figure 2). No statistically significant differences were observed between the two groups with respect to sex distribution, age, body mass index, white blood cell count, red blood cell count, platelet count, history of biliary tract surgery, or past medical history (P > 0.05), indicating comparable baseline characteristics (Table 1). The EUS imaging characteristics of CBDS are summarized in Table 2. Risk stratification for patients with CBDS is presented in Table 3. The preoperative ERCP assessment for patients with CBDS is detailed in Table 4. Table 1 Comparison of baseline characteristics of patients Clinical Features Emergency EUS Group（n=81） Elective EUS Group（n=134） statistical measure P -value Gender (Male/Female) 50/31 67/67 X 2 =2.800 0.094 Age (years) 56.36±14.89 59.80±13.42 t=-1.748 0.082 Body Mass Index（kg/m 2 ) 24.09±3.68 23.40±3.21 t=1.444 0.150 WBC（10^9/L） 6.08（4.81-8.41） 6.00（4.81-7.78） Z=-0.387 0.699 HGB（g/L) 128.93±17.81 128.34±16.55 t=0.243 0.808 PLT（10^9/L） 190.00（153.00-244.50） 189.50（146.00-231.50） Z=-0.451 0.652 TBIL（umol/L） 32.59（17.20-89.54） 23.33（14.73-55.51） Z=-1.814 0.065 DBIL（umol/L） 9.21（4.05-43.37） 6.40（2.94-30.25） Z=-1.585 0.113 ALT（u/L） 92.00（49.00-247.50） 85.00（31.75-240.50） Z=-1.045 0.296 AST（u/L） 63.00（28.00-155.00） 53.00（24.83-210.00） Z=-0.442 0.658 ALP（u/L） 207.00（117.00-308.00） 180.00（112.75-276.25） Z=-1.213 0.225 GGT（u/L） 408.00（169.50-677.50） 319.50（103.75-542.00） Z=-1.825 0.068 ALB（u/L） 40.40（37.60-43.25） 40.05（36.78-42.65） Z=-0.949 0.343 History of Biliary Surgery (n, %) Cholecystectomy 47（58.0） 62（46.3） X 2 =2.791 0.095 Choledochotomy with stone extraction 3（3.7） 8（6.0） X 2 =0.169 a 0.681 a ERCP stone extraction 8（9.9） 7（5.2） X 2 =1.684 0.194 Past Medical History (n, %) Smoking history 17(21.0) 22(16.4) X 2 =0.710 0.399 Drinking History 12(14.8) 19(14.2) X 2 =0.017 0.898 History of taking anticoagulant drugs 6(7.4) 10(7.5) X 2 =0.000 0.988 History of episodes of pancreatitis/cholangitis 5(6.2) 3(2.2) X 2 =1.221 a 0.269 a Abbreviations: WBC,white blood cells; HGB,hemoglobin; PLT,platelets; TBIL,total bilirubin; DBIL,direct bilirubin; ALT, alanine transaminase; AST, aspartate transaminase; ALP, alkaline phosphatase; GGT,glutamyltransferase; ALB, albumin; ERCP , endoscopic retrograde cholangiopancreatography Note: a ：Yates' continuity correction Table 2 EUS imaging characteristics of CBDS EUS Emergency EUS Group（n=81） Elective EUS Group （n=134） statistical measure P -value CBD diameter（mm） 8.00（8.00-11.00） 8.00（8.00-11.00） Z=-0.044 0.965 Maximum diameter of CBDS（mm） 7.00（5.00-9.00） 6.00（4.00-9.00） Z=-1.575 0.115 Number of CBDS (n, %) X 2 =0.013 0.910 <2 52（64.2） 85（63.4） ≥2 29（35.8） 49（36.6） Abbreviations: CBD, common bile duct; CBDS, common bile duct stones Table 3 Risk stratification for patients with CBDS Risk Stratification Emergency EUS Group（n=81） Elective EUS Group （n=134） statistical measure P -value Risk Stratification of CBDS Patients (n, %) X 2 =1.216 b 0.544 b HR 61（75.3） 109（81.3） IR 16（19.8） 21（15.7） LR 4（4.9） 4（3.0） Abbreviations: CBDS, common bile duct stones Note: b ：Fisher's exact test Table 4 Comprehensive preoperative assessment of ERCP in patients with CBDS Comprehensive assessment Emergency EUS Group （n=81） Elective EUS Group （n=134） statistical measure P -value ASA Grading (n, %) X 2 =1.018 0.313 ASA II 30(37.0) 59(44.0) ASA III 51(63.0) 75(56.0) Complications (n, %) Hypertension 28（34.6） 45（33.6） X 2 =0.022 0.882 Diabetes 14（17.3） 20（14.9） X 2 =0.211 0.646 Coronary heart disease 9（11.1） 10（7.5） X 2 =0.834 0.361 COPD/Asthma 1（1.2） 2（1.5） 1.000 a Chronic renal insufficiency 1（1.2） 4（3.0） X 2 =0.128 a 0.720 a cerebrovascular accident 7（8.6） 10（7.5） X 2 =0.096 0.756 Abbreviations: ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease Note: a ：Yates' continuity correction; b ：Fisher's exact test 3.2 Clinical Efficacy The EUS technical success rate was 100% in both the emergency and elective EUS groups. In the emergency EUS group (n = 81), biliary sludge was identified in 7 patients (8.6%), biliary microlithiasis were identified in 18 patients (22.2%), and biliary stones were identified in 56 patients (69.1%). In the elective EUS group (n = 134), biliary sludge was identified in 20 patients (14.9%), biliary microlithiasis in 33 patients (24.6%), and biliary stones in 81 patients (60.4%).The ERCP technical success rate was also 100% in both groups.The ERCP clinical success rate was 96.3% in the emergency EUS group (n = 81) and 94.8% in the elective EUS group (n = 134), with no statistically significant difference between groups (χ² = 0.032, P > 0.05).Details are provided in Table 5. Table 5 Comparison of clinical efficacy of patients Clinical efficacy Emergency EUS Group （n=81） Elective EUS Group （n=134） statistical measure P -value EUS stone detection rate (n, %) X 2 =2.308 0.318 biliary sludge 7(8.6) 20(14.9) biliary microlithiasis 18(22.2) 33(24.6) biliary stones 56(69.1) 81(60.4) ERCP Clinical Success Rate (n, %) 78(96.3) 127(94.8) X 2 =0.032 a 0.858 a Time to relief of major symptoms（days） 5.00（4.00-6.50） 8.50（6.00-11.00） Z=-7.510 0.001 Note: a ：Yates' continuity correction 3.3 Observation endpoint All 215 patients successfully underwent both EUS and ERCP procedures.The emergency EUS group had significantly shorter mean hospital stays (Z = −2.632, P < 0.01) and lower mean hospitalization costs (Z = −1.986, P < 0.05) compared with the elective EUS group. Neither group required ICU admission, and no statistically significant difference was observed between groups.The emergency EUS group experienced two ERCP-related complications: one case of post-ERCP hemorrhage and one case of post-ERCP pancreatitis. The elective EUS group experienced thirteen ERCP-related complications: three cases of post-ERCP cholangitis, eight cases of post-ERCP pancreatitis, and two cases of post-ERCP hemorrhage (Figure 3A).To further evaluate long-term clinical outcomes, all patients were followed until May 2025 (Figure 3B).In the emergency EUS group (n = 81), ten patients experienced adverse events during follow-up: one case of recurrent pancreatitis (1.2%), three cases of cholangitis (3.7%), two cases of cholecystitis (2.5%), and four cases of biliary colic (4.9%). In the elective EUS group (n = 134), twenty-four adverse events occurred: one case of recurrent pancreatitis (0.7%), eight cases of cholangitis (6.0%), three cases of cholecystitis (2.2%), eight cases of biliary colic (6.0%), and four deaths (3.0%).The incidence of long-term complications did not differ significantly between the two groups (χ² = 1.174, P > 0.05; Figure 3C).Details are presented in Table 6. Table 6 Comparison of the observation endpoints of patients Observation endpoints Emergency EUS Group （n=81） Elective EUS Group （n=134） statistical measure P -value Primary composite endpoints Major complications (n, %) X 2 =1.174 0.279 Cholangitis 3（3.7） 8（6.0） Pancreatitis 1（1.2） 1（0.7） Biliary colic 4（4.9） 8（6.0） Cholecystitis 2（2.5） 3（2.2） Death 0 4（3.0） Secondary endpoints Length of hospital stay（days） 9.00（7.00-10.00） 9.00（8.00-11.00） Z=-2.632 0.008 Hospitalization costs （CNY） 22549.69（19411.20-26219.56） 23811.65（21275.84-27825.16） Z=-1.986 0.047 Admitted to ICU (n, %) 0 0 － － Post-ERCP complications (n, %) X 2 =4.069 0.044 Post-ERCP cholangitis 0 3（2.2） Post-ERCP pancreatitis 1（1.2） 8（6.0） Gastrointestinal tract perforation 0 0 Post-ERCP hemorrhage 1（1.2） 2（1.5） 4. Discussion Acute cholangitis and acute biliary pancreatitis caused by common bile duct stones or sludge represent life-threatening clinical emergencies that require prompt diagnosis and endoscopic stone removal.Early confirmation of common bile duct stones is essential for initiating timely therapeutic ERCP/EST 18–20 .According to the ESGE guidelines for the endoscopic management of common bile duct stones 13 ：EUS or MRCP is recommended for patients with a high clinical suspicion of stones but without definitive evidence on abdominal ultrasonography. Both methods exhibit high diagnostic accuracy, but EUS demonstrates significantly higher sensitivity than MRCP, particularly in detecting small stones or bile sludge.However, there remains no unified consensus on “emergency EUS,” and high-level evidence supporting its clinical value remains limited. Compared with traditional elective strategies, it remains unclear whether an emergency EUS-guided approach provides advantages in improving patient-centered outcomes, including reductions in hospitalization costs and short-term complications.Therefore, this study aimed to systematically evaluate the clinical efficacy, healthcare resource utilization, and both short- and long-term outcomes of an emergency EUS-guided ERCP strategy in patients with acute common bile duct stones. The results of this study demonstrate that the mean length of hospital stay and total hospitalization costs were significantly lower in the emergency EUS group than in the elective EUS group (P < 0.05). This is partly due to the fact that this model has changed the traditional step-by-step process of "imaging diagnosis first, then elective intervention". By incorporating real-time emergency EUS assessment, diagnostic EUS and therapeutic ERCP are integrated into a single clinical pathway, thereby reducing treatment delays associated with examination wait times in conventional workflows.In addition,it also reflects the model's potential in optimizing medical workflows and reducing resource utilization. It can effectively lower healthcare costs and increase bed turnover rates, holding practical significance for alleviating the strain on medical resources.Fabbri et al 21 reported that EUS-guided ERCP treatment significantly shortened procedure duration,reduced hospital stay, and decreased hospital and endoscopy management expenditures within the same treatment cycle, which is consistent with our findings.From the perspective of health economics, the value of the emergency EUS-ERCP combined diagnosis and treatment model is not only reflected in the reduction of direct medical costs. The results of the decision tree model calculation show that the shortened hospital stay releases bed resources, allowing the hospital to admit an average of 23% more patients with acute biliary diseases each year. Moreover, the reduction in complication rates decreases the intensity of antibiotic use and the need for ICU transfer, which has potential public health significance in controlling the spread of multi-drug resistant bacteria. 22–24 . In terms of safety, the incidence of postoperative complications associated with emergency EUS-guided ERCP was significantly lower than that observed in the elective EUS-guided group (P < 0.05). This difference may be attributable to the earlier implementation of emergency interventions in the presence of evident biliary–pancreatic drainage obstruction or infection, which helps prevent progressive increases in biliary pressure and bacterial translocation, attenuates systemic inflammatory responses, and thereby reduces the risk of secondary pancreatic injury and biliary tract infection.Additionally, all emergency procedures in this study were conducted by senior endoscopists, whose expertise in managing difficult cannulations and complex lesions may have further minimized intraoperative trauma and postoperative adverse events, thereby contributing to the reduced complication risk. Hallensleben et al.'s APEC-2 study 11 indicated that emergency EUS-guided ERCP treatment could lead to a lower risk of postoperative complications, but its limitation lies in the fact that the study only focused on patients predicted to have severe acute biliary pancreatitis without cholangitis, and it was a multicenter study conducted in 15 Dutch hospitals by experienced endoscopists. Although the multicenter design helps enhance the generalizability of the conclusion, it also implies that there may be differences in techniques or experiences among different centers and operators, which could affect the consistency of the final results. Our study has made further improvements and supplements in this regard. Notably, although emergency intervention significantly improved short-term outcomes, results showed no significant difference in the risk of recurrent biliary complications occurring more than six months postoperatively between patients with common bile duct stones undergoing emergency EUS-guided ERCP and those undergoing elective EUS-guided ERCP. This indicates that emergency EUS-guided ERCP does not reduce the risk of recurrent biliary complications. This finding aligns with the conclusions reported by Hallensleben et al 11 .This phenomenon reveals that although emergency EUS-guided ERCP treatment can effectively manage acute conditions, it does not significantly alter the long-term natural course of patients with common bile duct stones. The long-term prognosis of these patients essentially still depends on the underlying disease conditions, such as patients with primary intrahepatic bile duct stones, where the recurrence rate of stones within 10 years can reach 30%-50%; patients with liver cirrhosis are more prone to delayed bleeding due to abnormal coagulation function; and congenital anatomical defects such as pancreatic-biliary junction abnormalities are often the fundamental cause of recurrent cholangitis 25,26 .Therefore, although emergency intervention can effectively relieve the current obstruction, it is difficult to change the existing anatomical abnormalities or metabolic causes. This also suggests that clinical practitioners need to establish a stratified management concept: emergency EUS-guided ERCP treatment should be regarded as an important means to control acute crises, and subsequent treatment should be connected with individualized chronic disease management plans, including bile acid metabolism regulation, regular biliary monitoring, and treatment of underlying diseases. This study has several limitations. First, as a single-center retrospective study with a relatively small sample size, the potential for selection bias cannot be excluded. Second, the research data were obtained from hospital electronic medical records and endoscopy reports, which may introduce information or documentation bias.Long-term follow-up information was mainly collected through outpatient visits and telephone interviews, which may result in recall bias and loss-to-follow-up bias.Additionally, the technique requires a high level of endoscopic expertise, which poses challenges for its broader implementation in primary healthcare settings.Therefore, future research should include multicenter, large-sample prospective clinical studies to further validate and expand upon these findings. 5. Conclusion In summary, emergency EUS-guided ERCP treatment has fundamentally changed the management model of acute common bile duct stones by adjusting the sequence of the diagnostic and therapeutic process. Its core value lies in transforming the emergency concept of "time is life" into an operational clinical pathway, significantly reducing short-term complications while conserving medical resources. Although its impact on the long-term natural course is limited, the significantly optimized short-term outcomes and resource utilization efficiency make it the preferred strategy for acute common bile duct stones. Declarations Author Contribution Author Contributions：Yu Wang: Study design, data collection, data interpretation, statistical analysis, and manuscript writing; Chen Shi: Study design, endoscopic procedures, data collection, data interpretation, and manuscript writing; Lixue Zhang，Yumei Wu，Chenao Zhang，Qimin Huang : Data collection and follow-up; Junjun Bao，Qiao Mei : Study supervision, endoscopic procedures, manuscript revision, and funding support. References Zhang R, Liu J, Li H, Zeng Q, Wu S, Tian H. 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Best Practice & Research Clinical Gastroenterology. 2013 Oct;27(5):745–56. Fabbri C, Polifemo AM, Luigiano C, Cennamo V, Fuccio L, Billi P, et al. Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis. J of Gastro and Hepatol. 2009 June;24(6):1107–12. Guisado-Gil AB, Mejías-Trueba M, Peñalva G, Aguilar-Guisado M, Molina J, Gimeno A, et al. Antimicrobial stewardship in the emergency department observation unit: Definition of a new indicator and evaluation of antimicrobial use and clinical outcomes. Antibiotics. 2024 Apr 12;13(4):356. Qian X, Pan Y, Su D, Gong J, Xu S, Lin Y, et al. Trends of antibiotic use and expenditure after an intensified antimicrobial stewardship policy at a 2,200-bed teaching hospital in China. Front Public Health. 2021 Sept 21;9:729778. Sonnenberg A, Enestvedt BK, Bakis G. Management of suspected choledocholithiasis: A decision analysis for choosing the optimal imaging modality. Dig Dis Sci. 2016 Feb;61(2):603–9. Tanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, et al. Long-term consequence of endoscopic sphincterotomy for bile duct stones. Gastrointestinal Endoscopy. 1998 Nov;48(5):465–9. Oliveira-Cunha M, Dennison AR, Garcea G. Late complications after endoscopic sphincterotomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2016 Feb;26(1):1–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Mar, 2026 Read the published version in Digestive Diseases and Sciences → Version 1 posted Editorial decision: Revision requested 28 Jan, 2026 Reviews received at journal 28 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviews received at journal 03 Jan, 2026 Reviewers agreed at journal 24 Dec, 2025 Reviewers invited by journal 10 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 06 Dec, 2025 First submitted to journal 05 Dec, 2025 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. 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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-8285652","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":560173308,"identity":"1fb8e1b4-a044-4718-960d-6f888857785d","order_by":0,"name":"Yu Wang","email":"","orcid":"","institution":"First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Wang","suffix":""},{"id":560173310,"identity":"157eec42-d519-4e47-9948-520f67bc3e95","order_by":1,"name":"Chen Shi","email":"","orcid":"","institution":"First Affiliated Hospital of Anhui Medical 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16:19:05","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82827,"visible":true,"origin":"","legend":"","description":"","filename":"aeae98d1ff4f40bc9a658bd64c5abdf31structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/bbf7b70b8ec2f613f643febc.xml"},{"id":98246495,"identity":"9ac72bdc-fdf4-4876-822c-dc6ee2827098","added_by":"auto","created_at":"2025-12-15 16:19:07","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91476,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/960983a2d38d1ac7b6a0c9d9.html"},{"id":98246466,"identity":"43afefd0-542c-4a85-8771-71c8df8ccfa7","added_by":"auto","created_at":"2025-12-15 16:19:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":650102,"visible":true,"origin":"","legend":"\u003cp\u003eProcedure of ERCP stone removal under endoscopic ultrasound (EUS) guidance.\u003c/p\u003e\n\u003cp\u003e1A: EUS image showing biliary sludge within the common bile duct； 1B: EUS\u003c/p\u003e\n\u003cp\u003eimage demonstrating microlithiasis in the common bile duct; 1C: EUS image identifying typical biliary stones; 1D: Cholangiography during ERCP revealing filling defects consistent with stones; 1E: Extraction of yellow stones during ERCP; 1F:Placement of a 7.5-Fr curved nasobiliary drainage tube at the end of the procedure.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/ce879f7e15330aa567acd784.png"},{"id":98246468,"identity":"f327eaa3-bc39-4027-aa37-2d4fee91a5ae","added_by":"auto","created_at":"2025-12-15 16:19:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97513,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study population\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/c33cafca8841350e33bd94c6.png"},{"id":98246469,"identity":"8bfb7bfc-7d84-4bde-b603-2b5d8da75f5a","added_by":"auto","created_at":"2025-12-15 16:19:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":105241,"visible":true,"origin":"","legend":"\u003cp\u003eShort-term and long-term outcomes of the two groups of patients 3A: Percentage of post-ERCP complications; 3B: Kaplan-Meier curves of the two groups of patients up to the follow-up time; 3C: Percentage of long-term complications;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eERCP , endoscopic retrograde cholangiopancreatography;AEs, Adverse Events\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/8f1ba87552be5258db712113.png"},{"id":105755758,"identity":"f4e5fc3c-f8aa-4059-9f0b-229807c98f5d","added_by":"auto","created_at":"2026-03-30 16:30:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1818921,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8285652/v1/012f92a8-0399-423c-ae4c-1fceaf04e39a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Significance of Emergency EUS-Guided ERCP in the Treatment of Common Bile Duct Stones","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCholedocholithiasis (CBDS), the most common form of cholelithiasis, frequently results in acute cholangitis and acute biliary pancreatitis, typically presenting with fever, abdominal pain, and jaundice. Without timely intervention, these conditions may progress to biliary obstruction complicated by infection, and in severe cases, may lead to septic shock, posing a life-threatening risk\u003csup\u003e1\u003c/sup\u003e.Currently, endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic papillary sphincterotomy (EST) for stone extraction is the mainstay of treatment for choledocholithiasis, with a reported success rate of up to 90%\u003csup\u003e2\u0026ndash;4\u003c/sup\u003eand a relatively low complication rate of approximately 5%\u003csup\u003e2,5,6\u003c/sup\u003e.However, among patients who are highly suspected of having CBDS but lack definitive imaging evidence, it remains uncertain whether stones are consistently present at the time of emergency ERCP. Furthermore, some patients may spontaneously pass bile duct stones while awaiting ERCP, resulting in unnecessary procedures, increased healthcare costs, and elevated procedural risks.Therefore, accurate preoperative assessment of bile duct stones is essential to avoid unnecessary interventions and optimize clinical outcomes.\u003c/p\u003e \u003cp\u003eNon-invasive imaging such as abdominal ultrasound and CT are widely used as first-line screening tools, but there are limitations in their diagnostic sensitivity for the end of the common bile duct, especially for microstones, which may lead to false-negative results.Ultrasound endoscopy (EUS), as a semi-invasive, high-resolution imaging tool, has the best diagnostic efficacy in detecting choledochal stones, with reported sensitivity and specificity of 89\u0026ndash;94% and 94\u0026ndash;95%, respectively\u003csup\u003e7,8\u003c/sup\u003e.EUS and ERCP are closely integrated in biliopancreatic practice, enabling endoscopists to optimize diagnostic and therapeutic efficiency through their combined use, thereby improving overall clinical outcomes\u003csup\u003e9\u003c/sup\u003e.Recent studies have shown\u003csup\u003e10\u003c/sup\u003ethat preoperative EUS screening can prevent unnecessary ERCP in nearly two-thirds of patients with suspected choledocholithiasis.This strategy of EUS-based screening of patients before therapeutic ERCP significantly reduces the overall risk of complications.\u003c/p\u003e \u003cp\u003eThe concept of \u0026ldquo;emergency EUS\u0026rdquo; was refined in a 2023 Gut publication, where it was defined as an EUS examination performed within 72 hours of symptom onset or within 24 hours of hospital admission\u003csup\u003e11\u003c/sup\u003e.However, the consensus definition of emergency EUS and its clinical value have not been well studied. In patients with choledocholithiasis, evidence is lacking regarding whether emergency EUS-guided ERCP confers prognostic advantages.Therefore, this study aimed to evaluate the clinical value of emergency EUS in the management of patients with acute CBDS.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Study Design and Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, clinical data and imaging findings were retrospectively collected from patients diagnosed with choledocholithiasis between June 1, 2018 and June 1, 2024 at the First Affiliated Hospital of Anhui Medical University.Patients were classified into an emergency EUS group and an elective EUS group based on the time of symptom onset after admission and the timing of EUS examination. Emergency EUS was defined as an examination performed within 72 hours of symptom onset or within 24 hours of admission, whereas elective EUS was defined as an examination performed beyond these timeframes.Study inclusion criteria:（1）Age \u0026ge; 18 years；（2）Presence of abdominal pain, fever, and jaundice, combined with imaging findings, led to the clinical diagnosis of choledocholithiasis；（3）EUS and ERCP were performed during hospitalization；（4）Signed written informed consent.Exclusion criteria：（1）Age \u0026lt;18 years；（2）inability to undergo or tolerate endoscopy;（3）Individuals with a history of malignant tumors；（4）Clinical data is incomplete.General information, clinical indicators, and follow-up outcomes exceeding six months postoperatively were collected for both groups.General information includes gender, age, body mass index, comorbidities, history of biliary tract surgery, past medical history, ASA physical status classification, and CBDS patient risk stratification.Clinical indicators include WBC, HGB, PLT, ALT, AST, ALP, GGT, CRP, amylase, lipase,and other laboratory parameters.ASA grading was based on the 2020 revised ASA Physical Status Classification System\u003csup\u003e12\u003c/sup\u003e.Risk stratification for CBDS was defined according to the recommendations of the European Society of Gastrointestinal Endoscopy (ESGE)\u003csup\u003e13\u003c/sup\u003e.This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (PJ2024-07-23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 EUS and ERCP Procedures \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.1 EUS Procedure\u003c/strong\u003e：The patient signed the informed consent form for the EUS examination prior to the procedure and was placed in the left lateral decubitus position.The endoscope (Fujifilm, EG-580UT; 7.5 MHz) was advanced to the level of the duodenal papilla and then slowly withdrawn while a systematic scan was performed.During withdrawal, the probe was kept in close contact with the intestinal wall to achieve multiplanar imaging through endoscope rotation and the injection of air-free saline. Retraction was paused when the middle to lower segments of the common bile duct were visualized. The probe angle was adjusted to obtain complete visualization of the entire common bile duct and adjacent structures, including the portal vein and pancreatic head. The diagnostic hallmark of common bile duct stones on EUS is the presence of a persistent hyperechoic mass within the bile duct, which may or may not be accompanied by posterior acoustic shadowing.(Figure 1A, 1B, 1C).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.2\u003c/strong\u003e \u003cstrong\u003eERCP Procedure\u003c/strong\u003e: The patient fasted and refrained from oral intake for at least 6 hours prior to the procedure. Under intravenous anesthesia, the patient was placed in the left lateral decubitus position. A therapeutic duodenoscope (JF-260V and TJF-260V; Olympus Co., Tokyo, Japan) was inserted under vital sign monitoring. Upon reaching the descending duodenum, the scope was straightened to allow clear visualization of the duodenal papilla.Following successful selective cannulation of the common bile duct via the papilla, contrast medium was injected to perform cholangiography and confirm stone location, size, and bile duct anatomy. Based on stone size and number, endoscopic sphincterotomy (EST) was performed, followed by stone retrieval under fluoroscopic guidance,For impacted stones \u0026gt;1.5 cm in diameter, mechanical lithotripsy was performed first, followed by basket-assisted stone extraction. A nasobiliary drainage tube was placed postoperatively. The tube was removed once clinical symptoms improved, laboratory parameters normalized, or imaging showed no residual stone shadows.(Figure 1D, 1E, 1F).Serum amylase levels and complete blood counts were monitored at 3 and 24 hours postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Observation Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1 Clinical Efficacy\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe clinical efficacy indicators assessed included the EUS technical success rate, the EUS stone detection rate, the ERCP technical success rate, the ERCP clinical success rate, and the time to relief of major symptoms.The EUS technical success rate was defined as the successful removal of stones by ERCP under EUS guidance. The EUS stone detection rate referred to the proportion of biliary sludge ,biliary microlithiasis, and biliary stones identified on EUS. Biliary microlithiasis were defined as stones \u0026le;5 mm in diameter accompanied by posterior acoustic shadowing;Biliary sludge was defined as discrete hyperechoic material within the lumen without posterior acoustic shadowing; and biliary stones were defined as persistent hyperechoic masses \u0026gt;5 mm in diameter within the duct, with or without posterior acoustic shadowing\u003csup\u003e14\u003c/sup\u003e. The ERCP technical success rate was defined as successful selective cannulation of the common bile duct.The clinical success rate of ERCP was defined as improvement in patient symptoms, irrespective of bilirubin normalization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.2\u003c/strong\u003e \u003cstrong\u003ePrimary endpoints\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe primary endpoint is a composite endpoint, which includes major complications or death that occur more than 6 months after inclusion.Major complications included:recurrent pancreatitis, cholecystitis, biliary colic and cholangitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.3 Secondary endpoints\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eSecondary endpoint included the length of hospital stay, hospitalization costs, ICU admission, and the occurrence of post-ERCP complications .Post-ERCP complications include post-ERCP pancreatitis, post-ERCP cholangitis, post-ERCP hemorrhage and gastrointestinal perforation.The diagnosis and severity grading of post-ERCP pancreatitis were based on the revised Atlanta classification\u003csup\u003e15\u003c/sup\u003e.Cholangitis was defined according to the 2018 Tokyo Guidelines\u003csup\u003e16\u003c/sup\u003e.For other adverse events, such as hemorrhage and perforation, we followed recommendations provided by the European Society of Gastrointestinal Endoscopy (ESGE) \u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Statistical analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll data and statistical analyses were performed using SPSS version 27.0 (IBM SPSS Statistics).Normally distributed quantitative data were expressed as mean \u0026plusmn; standard deviation (mean \u0026plusmn; SD), and intergroup comparisons were performed using the independent-samples t-test.Skewed quantitative data were presented as median (interquartile range, IQR), and intergroup comparisons were conducted using the Mann\u0026ndash;Whitney U test.Categorical variables were expressed as frequencies (n) and percentages (%), and intergroup comparisons were performed using the chi-square test.In this study, the Kaplan-Meier (KM) curve was employed to analyze the follow-up outcomes.KM curve was performed by R version 4.4.1 (R Project forStatistical Computing). A two-tailed P \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Patient baseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 227 patients diagnosed with common bile duct stones were screened.Twelve patients were excluded due to critical illness that precluded invasive diagnostic or therapeutic procedures (EUS + ERCP), resulting in 215 patients being enrolled: 81 in the emergency EUS group and 134 in the elective EUS group (Figure 2). No statistically significant differences were observed between the two groups with respect to sex distribution, age, body mass index, white blood cell count, red blood cell count, platelet count, history of biliary tract surgery, or past medical history (P \u0026gt; 0.05), indicating comparable baseline characteristics (Table 1). The EUS imaging characteristics of CBDS are summarized in Table 2. Risk stratification for patients with CBDS is presented in Table 3. The preoperative ERCP assessment for patients with CBDS is detailed in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 \u0026nbsp;Comparison of baseline characteristics of patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eClinical Features\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEmergency EUS Group（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eElective EUS Group（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eGender (Male/Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e50/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e67/67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=2.800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e56.36\u0026plusmn;14.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e59.80\u0026plusmn;13.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=-1.748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eBody Mass Index（kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e24.09\u0026plusmn;3.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e23.40\u0026plusmn;3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=1.444\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eWBC（10^9/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6.08（4.81-8.41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6.00（4.81-7.78）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eHGB（g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e128.93\u0026plusmn;17.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e128.34\u0026plusmn;16.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=0.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003ePLT（10^9/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e190.00（153.00-244.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e189.50（146.00-231.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-0.451\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.652\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eTBIL（umol/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e32.59（17.20-89.54）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e23.33（14.73-55.51）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-1.814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eDBIL（umol/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9.21（4.05-43.37）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6.40（2.94-30.25）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-1.585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eALT（u/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e92.00（49.00-247.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e85.00（31.75-240.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-1.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eAST（u/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e63.00（28.00-155.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e53.00（24.83-210.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-0.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.658\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eALP（u/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e207.00（117.00-308.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e180.00（112.75-276.25）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-1.213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eGGT（u/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e408.00（169.50-677.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e319.50（103.75-542.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-1.825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eALB（u/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e40.40（37.60-43.25）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e40.05（36.78-42.65）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eZ=-0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eHistory of Biliary Surgery (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eCholecystectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e47（58.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e62（46.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=2.791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eCholedochotomy with stone extraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3（3.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8（6.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.169\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.681\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eERCP stone extraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8（9.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e7（5.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=1.684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003ePast Medical History (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e17(21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e22(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.399\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eDrinking History\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e12(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e19(14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eHistory of taking anticoagulant drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6(7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e10(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.988\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eHistory of episodes of pancreatitis/cholangitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3(2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=1.221\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e0.269\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eWBC,white blood cells; HGB,hemoglobin; PLT,platelets; TBIL,total bilirubin; DBIL,direct bilirubin; \u0026nbsp;ALT, alanine transaminase; \u0026nbsp;AST, aspartate transaminase; ALP, alkaline phosphatase; GGT,glutamyltransferase; ALB, albumin; ERCP , endoscopic retrograde cholangiopancreatography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e \u003csup\u003ea\u003c/sup\u003e：Yates\u0026apos; continuity correction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 \u0026nbsp;EUS imaging characteristics of CBDS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"570\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eEUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEmergency EUS Group（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eElective EUS Group\u003c/p\u003e\n \u003cp\u003e（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eCBD diameter（mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8.00（8.00-11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e8.00（8.00-11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eZ=-0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.965\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMaximum diameter of CBDS（mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e7.00（5.00-9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e6.00（4.00-9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eZ=-1.575\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNumber of CBDS (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.910\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026lt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e52（64.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e85（63.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026ge;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e29（35.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e49（36.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eCBD, common bile duct; CBDS, \u0026nbsp;common bile duct stones\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 \u0026nbsp;Risk stratification for patients with CBDS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eRisk Stratification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEmergency EUS Group（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eElective EUS Group\u003c/p\u003e\n \u003cp\u003e（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eRisk Stratification of CBDS Patients (n, %)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=1.216\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.544\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e61（75.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e109（81.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eIR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e16（19.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e21（15.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eLR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4（4.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e4（3.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eCBDS, \u0026nbsp;common bile duct stones\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e \u003csup\u003eb\u003c/sup\u003e：Fisher\u0026apos;s exact test\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 Comprehensive preoperative assessment of ERCP in patients with CBDS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eComprehensive assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eEmergency EUS Group\u003c/p\u003e\n \u003cp\u003e（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eElective EUS Group\u003c/p\u003e\n \u003cp\u003e（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eASA Grading (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=1.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eASA II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e30(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e59(44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eASA III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e51(63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e75(56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eComplications (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e28（34.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e45（33.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e14（17.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e20（14.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eCoronary heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e9（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e10（7.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.361\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eCOPD/Asthma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e2（1.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e1.000\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eChronic renal insufficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e4（3.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.128\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.720\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003ecerebrovascular accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e7（8.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e10（7.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003c/strong\u003e \u003csup\u003ea\u003c/sup\u003e：Yates\u0026apos; continuity correction; \u0026nbsp;\u003csup\u003eb\u003c/sup\u003e：Fisher\u0026apos;s exact test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Clinical Efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe EUS technical success rate was 100% in both the emergency and elective EUS groups. In the emergency EUS group (n = 81), biliary sludge was identified in 7 patients (8.6%), biliary microlithiasis were identified in 18 patients (22.2%), and biliary stones were identified in 56 patients (69.1%). In the elective EUS group (n = 134), biliary sludge was identified in 20 patients (14.9%), biliary microlithiasis in 33 patients (24.6%), and biliary stones in 81 patients (60.4%).The ERCP technical success rate was also 100% in both groups.The ERCP clinical success rate was 96.3% in the emergency EUS group (n = 81) and 94.8% in the elective EUS group (n = 134), with no statistically significant difference between groups (\u0026chi;\u0026sup2; = 0.032, P \u0026gt; 0.05).Details are provided in Table 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 Comparison of clinical efficacy of patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"569\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eClinical efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEmergency EUS Group\u003c/p\u003e\n \u003cp\u003e（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eElective EUS Group\u003c/p\u003e\n \u003cp\u003e（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eEUS stone detection rate (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=2.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.318\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003ebiliary sludge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e7(8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e20(14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003ebiliary microlithiasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e18(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e33(24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003ebiliary stones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e56(69.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e81(60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eERCP Clinical Success Rate (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e78(96.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e127(94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=0.032\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.858\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eTime to relief of major symptoms（days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5.00（4.00-6.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e8.50（6.00-11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eZ=-7.510\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003c/strong\u003e \u003csup\u003ea\u003c/sup\u003e：Yates\u0026apos; continuity correction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Observation endpoint\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 215 patients successfully underwent both EUS and ERCP procedures.The emergency EUS group had significantly shorter mean hospital stays (Z = \u0026minus;2.632, P \u0026lt; 0.01) and lower mean hospitalization costs (Z = \u0026minus;1.986, P \u0026lt; 0.05) compared with the elective EUS group. Neither group required ICU admission, and no statistically significant difference was observed between groups.The emergency EUS group experienced two ERCP-related complications: one case of post-ERCP hemorrhage and one case of post-ERCP pancreatitis. The elective EUS group experienced thirteen ERCP-related complications: three cases of post-ERCP cholangitis, eight cases of post-ERCP pancreatitis, and two cases of post-ERCP hemorrhage (Figure 3A).To further evaluate long-term clinical outcomes, all patients were followed until May 2025 (Figure 3B).In the emergency EUS group (n = 81), ten patients experienced adverse events during follow-up: one case of recurrent pancreatitis (1.2%), three cases of cholangitis (3.7%), two cases of cholecystitis (2.5%), and four cases of biliary colic (4.9%). In the elective EUS group (n = 134), twenty-four adverse events occurred: one case of recurrent pancreatitis (0.7%), eight cases of cholangitis (6.0%), three cases of cholecystitis (2.2%), eight cases of biliary colic (6.0%), and four deaths (3.0%).The incidence of long-term complications did not differ significantly between the two groups (\u0026chi;\u0026sup2; = 1.174, P \u0026gt; 0.05; Figure 3C).Details are presented in Table 6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6 Comparison of the observation endpoints of patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"118%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eObservation endpoints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003eEmergency EUS Group\u003c/p\u003e\n \u003cp\u003e（n=81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eElective EUS Group\u003c/p\u003e\n \u003cp\u003e（n=134）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003estatistical measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePrimary composite endpoints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMajor complications (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=1.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eCholangitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e3（3.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e8（6.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePancreatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1（0.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eBiliary colic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e4（4.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e8（6.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eCholecystitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2（2.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e3（2.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e4（3.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eSecondary endpoints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eLength of hospital stay（days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e9.00（7.00-10.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e9.00（8.00-11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eZ=-2.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eHospitalization costs\u0026nbsp;（CNY）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e22549.69（19411.20-26219.56）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e23811.65（21275.84-27825.16）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eZ=-1.986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eAdmitted to ICU (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e－\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e－\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;Post-ERCP complications (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=4.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;Post-ERCP cholangitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e3（2.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;Post-ERCP pancreatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e8（6.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eGastrointestinal tract perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePost-ERCP hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1（1.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e2（1.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAcute cholangitis and acute biliary pancreatitis caused by common bile duct stones or sludge represent life-threatening clinical emergencies that require prompt diagnosis and endoscopic stone removal.Early confirmation of common bile duct stones is essential for initiating timely therapeutic ERCP/EST\u003csup\u003e18–20\u003c/sup\u003e.According to the ESGE guidelines for the endoscopic management of common bile duct stones\u003csup\u003e13\u003c/sup\u003e：EUS or MRCP is recommended for patients with a high clinical suspicion of stones but without definitive evidence on abdominal ultrasonography. Both methods exhibit high diagnostic accuracy, but EUS demonstrates significantly higher sensitivity than MRCP, particularly in detecting small stones or bile sludge.However, there remains no unified consensus on “emergency EUS,” and high-level evidence supporting its clinical value remains limited. Compared with traditional elective strategies, it remains unclear whether an emergency EUS-guided approach provides advantages in improving patient-centered outcomes, including reductions in hospitalization costs and short-term complications.Therefore, this study aimed to systematically evaluate the clinical efficacy, healthcare resource utilization, and both short- and long-term outcomes of an emergency EUS-guided ERCP strategy in patients with acute common bile duct stones.\u003c/p\u003e\n\u003cp\u003eThe results of this study demonstrate that the mean length of hospital stay and total hospitalization costs were significantly lower in the emergency EUS group than in the elective EUS group (P \u0026lt; 0.05). This is partly due to the fact that this model has changed the traditional step-by-step process of \"imaging diagnosis first, then elective intervention\". By incorporating real-time emergency EUS assessment, diagnostic EUS and therapeutic ERCP are integrated into a single clinical pathway, thereby reducing treatment delays associated with examination wait times in conventional workflows.In addition,it also reflects the model's potential in optimizing medical workflows and reducing resource utilization. It can effectively lower healthcare costs and increase bed turnover rates, holding practical significance for alleviating the strain on medical resources.Fabbri et al\u003csup\u003e21\u003c/sup\u003ereported that EUS-guided ERCP treatment significantly shortened procedure duration,reduced hospital stay, and decreased hospital and endoscopy management expenditures within the same treatment cycle, which is consistent with our findings.From the perspective of health economics, the value of the emergency EUS-ERCP combined diagnosis and treatment model is not only reflected in the reduction of direct medical costs. The results of the decision tree model calculation show that the shortened hospital stay releases bed resources, allowing the hospital to admit an average of 23% more patients with acute biliary diseases each year. Moreover, the reduction in complication rates decreases the intensity of antibiotic use and the need for ICU transfer, which has potential public health significance in controlling the spread of multi-drug resistant bacteria.\u003csup\u003e22–24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn terms of safety, the incidence of postoperative complications associated with emergency EUS-guided ERCP was significantly lower than that observed in the elective EUS-guided group (P \u0026lt; 0.05). This difference may be attributable to the earlier implementation of emergency interventions in the presence of evident biliary–pancreatic drainage obstruction or infection, which helps prevent progressive increases in biliary pressure and bacterial translocation, attenuates systemic inflammatory responses, and thereby reduces the risk of secondary pancreatic injury and biliary tract infection.Additionally, all emergency procedures in this study were conducted by senior endoscopists, whose expertise in managing difficult cannulations and complex lesions may have further minimized intraoperative trauma and postoperative adverse events, thereby contributing to the reduced complication risk. Hallensleben et al.'s APEC-2 study\u003csup\u003e11\u003c/sup\u003eindicated that emergency EUS-guided ERCP treatment could lead to a lower risk of postoperative complications, but its limitation lies in the fact that the study only focused on patients predicted to have severe acute biliary pancreatitis without cholangitis, and it was a multicenter study conducted in 15 Dutch hospitals by experienced endoscopists. Although the multicenter design helps enhance the generalizability of the conclusion, it also implies that there may be differences in techniques or experiences among different centers and operators, which could affect the consistency of the final results. Our study has made further improvements and supplements in this regard.\u003c/p\u003e\n\u003cp\u003eNotably, although emergency intervention significantly improved short-term outcomes, results showed no significant difference in the risk of recurrent biliary complications occurring more than six months postoperatively between patients with common bile duct stones undergoing emergency EUS-guided ERCP and those undergoing elective EUS-guided ERCP. This indicates that emergency EUS-guided ERCP does not reduce the risk of recurrent biliary complications. This finding aligns with the conclusions reported by Hallensleben et al\u003csup\u003e11\u003c/sup\u003e.This phenomenon reveals that although emergency EUS-guided ERCP treatment can effectively manage acute conditions, it does not significantly alter the long-term natural course of patients with common bile duct stones. The long-term prognosis of these patients essentially still depends on the underlying disease conditions, such as patients with primary intrahepatic bile duct stones, where the recurrence rate of stones within 10 years can reach 30%-50%; patients with liver cirrhosis are more prone to delayed bleeding due to abnormal coagulation function; and congenital anatomical defects such as pancreatic-biliary junction abnormalities are often the fundamental cause of recurrent cholangitis \u003csup\u003e25,26\u003c/sup\u003e.Therefore, although emergency intervention can effectively relieve the current obstruction, it is difficult to change the existing anatomical abnormalities or metabolic causes. This also suggests that clinical practitioners need to establish a stratified management concept: emergency EUS-guided ERCP treatment should be regarded as an important means to control acute crises, and subsequent treatment should be connected with individualized chronic disease management plans, including bile acid metabolism regulation, regular biliary monitoring, and treatment of underlying diseases.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, as a single-center retrospective study with a relatively small sample size, the potential for selection bias cannot be excluded. Second, the research data were obtained from hospital electronic medical records and endoscopy reports, which may introduce information or documentation bias.Long-term follow-up information was mainly collected through outpatient visits and telephone interviews, which may result in recall bias and loss-to-follow-up bias.Additionally, the technique requires a high level of endoscopic expertise, which poses challenges for its broader implementation in primary healthcare settings.Therefore, future research should include multicenter, large-sample prospective clinical studies to further validate and expand upon these findings.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn summary, emergency EUS-guided ERCP treatment has fundamentally changed the management model of acute common bile duct stones by adjusting the sequence of the diagnostic and therapeutic process. Its core value lies in transforming the emergency concept of \u0026quot;time is life\u0026quot; into an operational clinical pathway, significantly reducing short-term complications while conserving medical resources. Although its impact on the long-term natural course is limited, the significantly optimized short-term outcomes and resource utilization efficiency make it the preferred strategy for acute common bile duct stones.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthor Contributions：Yu Wang: Study design, data collection, data interpretation, statistical analysis, and manuscript writing; Chen Shi: Study design, endoscopic procedures, data collection, data interpretation, and manuscript writing; Lixue Zhang，Yumei Wu，Chenao Zhang，Qimin Huang : Data collection and follow-up; Junjun Bao，Qiao Mei : Study supervision, endoscopic procedures, manuscript revision, and funding support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhang R, Liu J, Li H, Zeng Q, Wu S, Tian H. Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones. Front Physiol. 2022 Aug 25;13:949452. \u003c/li\u003e\n\u003cli\u003eColton JB, Curran CC. Quality indicators, including complications, of ERCP in a community setting: A prospective study. Gastrointestinal Endoscopy. 2009 Sept;70(3):457\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eElfant AB, Bourke MJ, Alhalel R, Kortan PP, Haber GB. A prospective study of the safety of endoscopic therapy for choledocholithiasis in an outpatient population. Am J Gastroenterol. 1996 Aug;91(8):1499\u0026ndash;502. \u003c/li\u003e\n\u003cli\u003eMaple JT, Ikenberry SO, Anderson MA, Appalaneni V, Decker GA, Early D, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointestinal Endoscopy. 2011 Oct;74(4):731\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eFreeman ML, Herman ME, Ryan ME. Complications of endoscopic biliary sphincterotomy. The New England Journal of Medicine. 1996; \u003c/li\u003e\n\u003cli\u003eCotton PB, Geenen JE, Sherman S, Cunningham JT, Howell DA, Carr-Locke DL, et al. Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts: Annals of Surgery. 1998 Feb;227(2):201\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eGarrow D, Miller S, Sinha D, Conway J, Hoffman BJ, Hawes RH, et al. Endoscopic ultrasound: A meta-analysis of test performance in suspected biliary obstruction. Clinical Gastroenterology and Hepatology. 2007 May;5(5):616-623.e1. \u003c/li\u003e\n\u003cli\u003eTse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: A meta-analysis of test performance in suspected choledocholithiasis. Gastrointestinal Endoscopy. 2008 Feb;67(2):235\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eFusaroli P, Lisotti A. EUS and ERCP in the same session for biliary stones: From risk stratification to treatment strategy in different clinical conditions. Medicina. 2021 Sept 25;57(10):1019. \u003c/li\u003e\n\u003cli\u003ePetrov MS, Savides TJ. Systematic review of endoscopic ultrasonography \u003cem\u003eversus\u003c/em\u003e endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. British Journal of Surgery. 2009 Aug 11;96(9):967\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eHallensleben ND, Stassen PMC, Schepers NJ, Besselink MG, Anten MPGF, Bakker OJ, et al. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): A multicentre prospective study. Gut. 2023 Aug;72(8):1534\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eSınıfı A. ASA fiziksel durum sınıflandırma sistemi 13 aralık 2020\u0026rsquo;de g\u0026uuml;ncellenmiştir. Tanımlar ve ASA onaylı \u0026ouml;rnekler aşağıdakileri i\u0026ccedil;erir ancak bunlarla sınırlı değildir*. \u003c/li\u003e\n\u003cli\u003eManes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, et al. Endoscopic management of common bile duct stones: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(05):472\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eŻorniak M, Sirtl S, Beyer G, Mahajan UM, Bretthauer K, Schirra J, et al. Consensus definition of sludge and microlithiasis as a possible cause of pancreatitis. Gut. 2023 Oct;72(10):1919\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eIAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013 July;13(4):e1\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eKiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, et al. Tokyo guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepato Biliary Pancreat. 2018 Jan;25(1):17\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eDumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, et al. ERCP-related adverse events: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy. 2020 Feb;52(02):127\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eMukai S, Itoi T, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, et al. Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone‐induced acute cholangitis and pancreatitis. Digestive Endoscopy. 2023 Jan;35(1):47\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eMaple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointestinal Endoscopy. 2010 Jan;71(1):1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eDe C. Ferreira LEVV, Baron TH. Acute biliary conditions. 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Front Public Health. 2021 Sept 21;9:729778. \u003c/li\u003e\n\u003cli\u003eSonnenberg A, Enestvedt BK, Bakis G. Management of suspected choledocholithiasis: A decision analysis for choosing the optimal imaging modality. Dig Dis Sci. 2016 Feb;61(2):603\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eTanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, et al. Long-term consequence of endoscopic sphincterotomy for bile duct stones. Gastrointestinal Endoscopy. 1998 Nov;48(5):465\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eOliveira-Cunha M, Dennison AR, Garcea G. Late complications after endoscopic sphincterotomy. Surgical Laparoscopy, Endoscopy \u0026amp; Percutaneous Techniques. 2016 Feb;26(1):1\u0026ndash;5. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Emergency Endoscopic Ultrasound, Endoscopic retrograde cholangiopancreatography, Common bile duct stones, Biliary Tract Emergencies","lastPublishedDoi":"10.21203/rs.3.rs-8285652/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8285652/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground and aim:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCommon bile duct stones (CBDS) can rapidly lead to cholangitis or biliary pancreatitis, making timely and accurate diagnosis essential. Although EUS provides high diagnostic accuracy, its value in emergency settings remains unclear. This study aimed to evaluate the clinical value of emergency EUS-guided ERCP.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA retrospective analysis was performed on the clinical data of 215 patients diagnosed with CBDS at the First Affiliated Hospital of Anhui Medical University between June 2018 and June 2024.Patients were assigned to either the emergency EUS group or the elective EUS group according to the time of symptom onset after admission and the time of EUS examination,Clinical efficacy, primary endpoint and secondary endpoint were compared between the two groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBoth the emergency and elective EUS groups achieved a 100% technical success rate for EUS and ERCP. The clinical success rates of ERCP were 96.3% and 94.8%, respectively, with no significant difference (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The emergency EUS group had significantly shorter hospital stays and lower hospitalization costs (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Post-ERCP complications were also significantly fewer in the emergency group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No ICU admissions occurred in either group, and long-term complication rates were comparable (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEmergency EUS-guided ERCP significantly reduces hospital stay and hospitalization costs in patients with CBDS.It reduces the risk of short-term postoperative complications following ERCP but does not decrease the incidence of long-term postoperative complications.Therefore, emergency EUS-guided ERCP may serve as an effective strategy for patients presenting with acute CBDS, primarily by improving short-term clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Clinical Significance of Emergency EUS-Guided ERCP in the Treatment of Common Bile Duct Stones","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 16:18:56","doi":"10.21203/rs.3.rs-8285652/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-29T00:15:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T18:37:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113042332091018041004144400318920195627","date":"2026-01-07T17:14:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-04T02:45:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187398580531340530133063388794132877182","date":"2025-12-24T15:43:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-10T16:11:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T22:37:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-06T12:01:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-12-05T08:39:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"255c5c6c-b735-48cc-89fe-081a48a2af3c","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:25:17+00:00","versionOfRecord":{"articleIdentity":"rs-8285652","link":"https://doi.org/10.1007/s10620-026-09852-3","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2026-03-27 16:12:24","publishedOnDateReadable":"March 27th, 2026"},"versionCreatedAt":"2025-12-15 16:18:56","video":"","vorDoi":"10.1007/s10620-026-09852-3","vorDoiUrl":"https://doi.org/10.1007/s10620-026-09852-3","workflowStages":[]},"version":"v1","identity":"rs-8285652","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8285652","identity":"rs-8285652","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}