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As previously stated, the absence of any risk criteria discard with certainty the presence of CDL 4; however, as we believed, those with intermediate and even those classified as high risk for CDL (5-score system= 4 or 5 points, and those with a high probability by ASGE criteria) presented a near 40% chance of negative ERCP.

Therefore, based on previous evidence and on ERCP center expertise, a cost-effective approach could be to perform an imaging study (magnetic resonance cholangiopancreatography or endoscopic ultrasonography) in those with a very high probability of CDL. In patients with an intermediate probability, cholecystectomy with intraoperative cholangiography could be directly performed so that ERCP is performed postoperatively when CDL is detected in intraoperative cholangiography as suggested by Tarnasky et al. 5 Even more, our data show a lower prevalence of a retained common bile …