LAUSR

A 26-year-old woman who was 6 months pregnant presented with a 5-day history of jaundice, right upper abdominal discomfort, and pruritus. Abdominal ultrasound showed gallstones and a dilated common bile duct (CBD) with a suspicious calculous in the lower CBD. Serum bilirubin was 2.9mg/dL and serum alkaline phosphatase was 216 IU. A radiationfree procedure to remove choledocholithiasis was planned under propofol sedation, and informed consent was obtained. A preprocedure endoscopic ultrasound (EUS) confirmed three calculi in the CBD (▶Fig. 1). Using a duodenoscope, the bile duct was cannulated in the 11 o’clock position and golden yellow bile was aspirated (▶Fig. 2). A guidewire was inserted deep into the CBD. After biliary sphincterotomy, three black pigmented stones were removed using an extraction balloon (▶Fig. 3). After presumed ductal clearance, the SpyGlass DS cholangioscope (Boston Scientific, Marlborough, Massachusetts, USA) was inserted up to the biliary confluence and then withdrawn carefully to inspect the CBD down to the ampulla (▶Fig. 4). There were no residual stone fragments or any other additional pathology noted. A 7-Fr doublepigtail plastic stent was inserted into the CBD (▶Video 1). The patient underwent cholecystectomy after completion of pregnancy followed by stent removal. Radiation-free removal of choledocholithiasis is widely reported in the literature [1, 2]. Challenges include: 1) confirming the number of stones in the CBD (overcome by EUS or magnetic resonance cholangiopancreatography); 2) confirmation of guidewire position in the CBD and complete CBD clearance (overcome by aspirating bile, transabdominal ultrasound, or cholangioscopy); 3) ensuring complete ductal clearance and stent position in the CBD (overcome by counting the stones removed from the CBD, postprocedural EUS, or cholangioscopy) [1]. However, the presence of pneumobilia and stent would cause artifacts and interfere with post-procedure EUS imaging of the CBD. Additionally, scope exchange and switching to an echoendoscope E-Videos