Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review

Evaluating the use of EUS-guided hepaticogastrostomy combined with antegrade stenting for malignant biliary obstruction and comparing to EUS-guided hepaticogastrostomy alone for patients who failed ERCP: a pairwise and single-arm meta-analysis

BACKGROUND AND AIMS

When ERCP is not feasible in the management of malignant biliary obstruction (MBO), endoscopic ultrasound-guided biliary drainage has been proven to be a valuable alternative. EUS-guided hepaticogastrostomy (EUS-HGS) carries a relatively high risk of complications. To mitigate these risks, EUS-guided antegrade stenting combined with EUS-HGS (EUS-HGAS) has been explored. We aimed to conduct a pairwise and a single-arm meta-analysis comparing both techniques and analyzing the efficacy and safety of HGAS for MBO, respectively.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library. We included randomized controlled trials or observational studies enrolling patients who underwent EUS-HGAS placement with or without a control group of EUS-HGS without antegrade stenting. We used R statistical software, version 4.4.1.

RESULTS

Eight studies were included in the pairwise meta-analysis, and 11 studies were included in the single-arm meta-analysis. Analysis of the need for reintervention showed a significant difference between HGAS and HGS groups, favoring HGAS (p = 0.005), but this group also had a significantly higher rate of pancreatitis (p = 0.027). For HGAS, the pooled analyses demonstrated high technical and clinical success rates (94.06% and 98.05%, respectively); a need for reintervention rate of 8.03%, an overall adverse events rate of 11.67%, mean survival time of 118.53 days, and mean time to stent dysfunction or patient death of 134.61 days.

CONCLUSION

The performance of HGAS in patients who failed ECRP for MBO showed lower need for reintervention rates but higher pancreatitis rates compared to HGS alone. Performing HGAS is associated with high technical and clinical success rates and a low overall adverse event occurrence.

Usefulness of a dedicated laser-cut metal stent with an anchoring hook and thin delivery system for EUS-guided hepaticogastrostomy in malignant biliary obstruction: a prospective multicenter trial (with video)

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HGS) carries a risk of serious adverse events (AEs). A newly designed, partially covered laser-cut stent with antimigration anchoring hooks and a thin tapered tip (7.2F), called a Hook stent (Zeon Medical, Tokyo, Japan), has been developed to prevent serious AEs associated with EUS-HGS. The present prospective multicenter clinical trial evaluated the efficacy and safety of the Hook stent for EUS-HGS after failure of ERCP in patients with unresectable malignant biliary obstruction.

METHODS

The primary endpoint was the rate of clinical success, and secondary endpoints were the rates of technical success, AEs, recurrent biliary obstruction (RBO), procedure success without using a tract dilation device, reintervention for RBO, time to RBO, and overall survival (OS).

RESULTS

Thirty-eight patients underwent EUS-HGS using the Hook stent. The technical and clinical success rates in patients undergoing EUS-HGS were 100% and 92.1%, respectively. The procedure success rate without using a tract dilation device was 94.7%. Four patients (10.5%) developed early AEs, but there were no severe AEs such as stent migration. RBO developed in 26.3% of patients. Reintervention for RBO had a 100% success rate. The median time to RBO was not reached, and the median OS was 191 days.

CONCLUSIONS

EUS-HGS using the Hook stent demonstrated a high clinical success rate, low rate of early AEs, and an acceptable stent patency. The Hook stent is safe and feasible for use in patients undergoing EUS-HGS. (Clinical trial registration number: jRCT2052210020.).

Feasibility and safety of EUS-guided biliary drainage in inexperienced centers: a multicenter study in southwest Japan

BACKGROUND AND AIMS

EUS-guided biliary drainage (EUS-BD) has shown promising procedural outcomes in high-volume centers. Although inferior procedural outcomes were reported in inexperienced centers during the early days of EUS-BD, the current outcomes are unknown. This study aimed to clarify the feasibility and safety of EUS-BD in centers that recently introduced EUS-BD.

METHODS

This multicenter retrospective study was conducted at 22 centers that introduced EUS-BD between 2017 and 2022. A maximum of 20 initial EUS-BD cases at each center were evaluated. The clinical outcomes and experience of 84 endoscopists who performed these procedures were examined. Primary outcomes were the rate of technical success and adverse events (AEs), whereas secondary outcomes were risk factors associated with technical failure and procedure-related AEs.

RESULTS

Two hundred fifty-five patients were enrolled. The technical success rate was 91.4% (233/255). Among 22 technical failure cases, guidewire manipulation failure was the most common cause (n = 12) followed by tract dilation failure (n = 5). The AE rate was 10.2% (26/255). Multivariate analysis identified a puncture target diameter of <5 mm (odds ratio, 3.719; 95% CI, 1.415-9.776; P = .008) and moderate ascites extending to the liver surface (odds ratio, 3.25; 95% CI, 1.195-8.653; P = .021) as independent risk factors for technical failure and procedure-related AEs, respectively. Endoscopists' procedural experience was not a risk factor for technical failure or procedure-related AEs.

CONCLUSIONS

The feasibility and safety of EUS-BD were maintained during the induction phase at inexperienced centers. These data will be helpful to better understand the current status of EUS-BD. (Clinical trial registration number: UMIN 000053615.).

Study of factors influencing the insertion failure of single balloon enteroscopy-assisted ERCP treatment after bilioenteric Roux-en-Y anastomosis

BACKGROUND AND STUDY AIMS

Fail to reach the bilioenteric anastomosis is the main cause of treatment failure during single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-assisted ERCP) in patients after bilioenteric Roux-en-Y anastomosis. We aim to evaluate factors influencing the endoscopic insertion failure.

PATIENTS AND METHODS

We retrospectively reviewed the clinical data of 231 cases undergoing SBE-assisted ERCP from January 2016 to December 2021. Treatment details and outcomes were studied to analyze the factors involved in endoscopic insertion failure.

RESULTS

The enteroscopy success rate and procedural success rate were 88.3% and 84.4%. Incidence of postoperative adverse events was 3.9%. No serious adverse events occurred. Risk factors of endoscopic insertion failure include first ERCP attempt, side to side anastomosis at the Rou-Y anastomosis, the use of Endo-GIA anastomosis, three bowel lumens seen at the Rou-Y anastomosis under endoscopy, steep angle of the afferent loop at the Rou-Y anastomosis with a U-shape, length of the afferent loop ≥ 50 cm, and twisted afferent loop. Among which the multifactorial analysis suggested that the presence of three bowel lumens at the Rou-Y anastomosis and twisted afferent loop were independent risk factors for enteroscopy failure. For case with twisted afferent loop, the use of a transparent cap with X-ray-assisted guidance during insertion is an effective strategy to improve the success rate.

CONCLUSIONS

SBE-assisted ERCP is safe and effective in patients after bilioenteric Roux-en-Y anastomosis. The severity of afferent loop twisting and Rou-Y anastomosis shape were risk factors for endoscopic insertion failure. Surgeons should take into account the feasibility of postoperative ERCP treatment at the time of operation.

Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Therapeutic endoscopy: Recent updates and future directions

The landscape of therapeutic endoscopy has undergone a remarkable evolution over the past few decades, carving out a niche that merges innovative technology with advanced clinical practice. As we venture further into the 21st century, the horizon of this field continues to expand, driven by rapid advancements in technology and a deeper understanding of gastrointestinal pathology. This review article aims to shed light on the recent advances and future trajectories of therapeutic endoscopy, focusing on pivotal areas such as third space endoscopy, endoscopic resection techniques, artificial endoscopy, endoscopic ultrasound (EUS), the integration of artificial intelligence (AI), and endoscopic anti-reflux therapies.

Thin Delivery Stents Can Obviate the Need for Additional Fistula Dilatation of Large Diameter in Endoscopic Ultrasound-Guided Hepaticogastrostomy

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) often requires fistula dilation owing to the placement of a large diameter of the delivery stent. The recently developed delivery devices, which are as thin as 5.9/6.0 Fr, may save the need for fistula dilation. Therefore, we investigated whether large fistula dilation would be required or not in the case of this newly developed thin-diameter delivery stents. Methods: We conducted a retrospective study involving 33 patients implemented with a self-expandable metal stent (SEMS) during EUS-HGS. The patients were categorized based on the delivery device diameter into thin (n = 13; delivery device diameter: 5.9/6.0 Fr) and thick (n = 20; delivery device diameter: 8.5 Fr) groups. We compared the initial rate of success, technical success, and clinical success between the thin and thick groups. The initial rate of success was defined as successful stent placement without a balloon or large diameter mechanical dilation. Results: The rate of the initial stenting success was significantly higher in the thin group (100% [13/13]) compared with that in the thick group (65.0% [13/20]) (p = 0.027). In the thick group, seven cases with technical difficulty in terms of stent placement could be successfully completed with additional fistula dilation with a 9 Fr bougie dilator or 4 mm balloon dilator; this resulted in a technical success of 100% in both groups ultimately. The rate of clinical success was 100% and 95.0% in the thin and thick groups, respectively (p = 1.00). Conclusions: Thin delivery stents may facilitate stent placement without the need for a balloon fistula or large-diameter mechanical dilation.

The New Potential for Using Franseen Needles in Interventional EUS

Objective Adverse events such as bile leakage and bleeding are among the issues that need to be resolved in EUS-guided choledochoduodenostomy (EUS-CDS). To overcome this problem, we developed a new EUS-CDS technique using a 19-G Franseen needle without tract dilation. This study aimed to evaluate the safety and efficacy of the new EUS-CDS technique. Methods This single-center retrospective study included 20 consecutive patients who underwent EUS-CDS for primary drainage using a 19-G Franseen needle between March 2020 and May 2023. The primary endpoint was the technical success rate of EUS-CDS without tract dilation. Results The technical success rate of EUS-CDS was 20/20 (100%). None of the patients required any additional tract dilation, such as by using a balloon or electric cautery. The median procedure time was 7.8 [range, 3.2-19.4] min. No early adverse events were observed. Conclusion The 19-G Franseen needle appeared to have a sufficient dilatory effect during puncturing. This EUS-CDS technique appears to be safe and effective and has the advantages of no adverse events and it is also a simplified procedure, which suggests its potential for widespread use in primary drainage.

Endoscopic retrograde cholangiopancreatography using a pediatric colonoscope in patients with Roux‑en‑Y gastrectomy and an intact major duodenal papilla

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastrectomy and an intact major duodenal papilla is challenging and difficult, with unsatisfactory outcomes using various endoscopes. Limited data are available regarding the outcomes of ERCP using a pediatric colonoscope in such patients. To evaluate the efficacy of a pediatric colonoscope in patients with Roux-en-Y gastrectomy and an major duodenal intact papilla, 93 consecutive patients with Roux-en-Y gastrectomy and an intact major duodenal papilla who underwent ERCP using a pediatric colonoscope at the Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, (Nanjing, China) between January 2018 and December 2022 were retrospectively reviewed. Following the failure of bile duct cannulation, a double-guidewire or precut technique was utilized for advanced cannulation. Interventions were performed using standard ERCP therapeutic accessories. The results indicated that distal gastrectomy with Roux-en-Y reconstruction was performed in 38 out of 93 patients, while 55 patients underwent total gastrectomy with Roux-en-Y reconstruction. The success rates associated with endoscope insertion, endoscopic cannulation and therapeutic ERCP were 88.17% (82/93), 85.37% (70/82) and 95.71% (67/70), respectively, while the clinical intervention success and complication rates were 72.04% (67/93) and 7.53% (7/93), respectively. The endoscope insertion time was 40.78±10.04 min, and the ERCP procedure time was 88.55±16.38 min. Student's t-test showed that the endoscope insertion time and the ERCP procedure time in patients undergoing distal gastrectomy were longer than those in patients undergoing total gastrectomy (P<0.05). Binary logistic regression analysis showed that age and number of previous abdominal surgeries were independent risk factors associated with endoscope insertion failure. In conclusion, the present study demonstrated that the use of a pediatric colonoscope is efficacious and safe for patients with Roux-en-Y gastrectomy and an intact major duodenal papilla undergoing ERCP.

Comparative Effectiveness of ERCP and EUS-Guided Techniques for "Primary Biliary Drainage" in Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a viable alternative in cases with failed ERCP transpapillary drainage (ERCP-TPD). This systematic review and meta-analysis aimed to compare the efficacy and safety of EUS-BD and ERCP-TPD for primary biliary drainage in patients with distal malignant biliary obstruction (DMBO).

METHODS

We searched Embase, PubMed, and Medline databases for studies comparing EUS-BD and ERCP-TPD in DMBO, from inception until September 2023. The primary endpoint was clinical success and secondary endpoints included technical success, procedure duration, and adverse events.

RESULTS

Eight studies (815 patients, 56.1% male) were included in this analysis. Indications for biliary drainage were pancreatic carcinoma (75.1%), followed by cholangiocarcinoma (10.1%). Clinical success was comparable between EUS-BD and ERCP-TPD groups (OR 1.34; 95% CI, 0.75-2.40; P=0.32). Technical success was similar between the 2 groups (OR 2.09; 95% CI, 0.83-5.25; P=0.12). There was a trend toward fewer adverse events in the EUS-BD group (OR 0.65; 95% CI, 0.40-1.07; P=0.09), with significantly lower odds of post-procedure pancreatitis (OR 0.17; 95% CI, 0.06-0.50; P=0.001).

CONCLUSION

EUS-BD is comparable to ERCP for primary biliary drainage in DMBO patients with shorter procedural time and a significantly reduced risk of post-procedure pancreatitis.

Puncture angle on an endoscopic ultrasound image is independently associated with unsuccessful guidewire manipulation of endoscopic ultrasound-guided hepaticogastrostomy: a retrospective study in Japan

BACKGROUND/AIMS

Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed globally, the procedure remains challenging. Guidewire manipulation is the most difficult step, and there are few reports on the factors associated with unsuccessful guidewire manipulation. This study aimed to assess the significance of the puncture angle on EUS images and identify the most effective guidewire rescue method for patients with unsuccessful guidewire manipulation.

METHODS

We retrospectively enrolled 115 patients who underwent EUS-HGS between May 2016 and April 2022 at two centers. The puncture angle between the needle and the intrahepatic bile duct was measured through EUS movie records.

RESULTS

Guidewire manipulation was unsuccessful in 28 patients. Receiver operating characteristic (ROC) curves identified an optimal puncture angle cutoff value of 85° (cutoff value, 85°; area under the ROC curve, 0.826; sensitivity, 85.7%; specificity, 81.6%). Multivariate analysis demonstrated that a puncture angle <85° was a significant risk factor for unsuccessful guidewire manipulation (odds ratio, 19.8; 95% confidence interval, 6.42-61.5; p<0.001). Among the 28 unsuccessful cases, 24 patients (85.7%) achieved successful guidewire manipulation using various rescue methods.

CONCLUSIONS

The puncture angle observed on EUS is crucial for guidewire manipulation. A puncture angle of <85° was associated with unsuccessful guidewire manipulation.

Endoscopic ultrasound-guided hepaticogastrostomy vs. antegrade metal stent placement keeping an access route in patients with malignant biliary obstruction

BACKGROUND

Few studies have compared endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) with EUS-guided antegrade metal stent placement (AGMS). The purpose of this study was to compare times to recurrent biliary obstruction (TRBO) in patients who underwent HGS using metal stents (MS) and those who underwent AGMS keeping access routes with plastic stents (AGMS-AR).

METHODS

This study retrospectively evaluated consecutive patients who underwent HGS or AGMS between September 2016 and December 2022. TRBO, overall survival (OS), and adverse event (AE) rates were compared in the two groups. The risk factors for RBO were determined using a multivariable Cox proportional hazards model.

RESULTS

This study included 32 patients in the HGS group and 30 in the AGMS-AR group. Technical success rate was significantly higher in the HGS than in the AGMS-AR group (100 vs. 80%; P = 0.009). The technical success rate without tract dilation was significantly higher in the AGMS-AR than in the HGS group (83 vs. 38%; P < 0.001). RBO rates were significantly higher in the HGS than in the AGMS-AR group (53 vs. 17%; P = 0.024), whereas AE rates did not differ significantly. TRBO differed significantly in the HGS and AGMS-AR groups (159 days vs. not reached, P = 0.011), whereas OS did not differ significantly. Multivariable analysis revealed that HGS was an independent risk factor for RBO (hazard ratio, 6.48, P = 0.014).

CONCLUSION

TRBO was significantly longer in patients who underwent AGMS with PS than HGS. AGMS with PS may be effective after the failure of ERCP in patients with malignant biliary obstruction.

Outcomes of partially covered self-expandable metal stents with different uncovered lengths in endoscopic ultrasound-guided hepaticogastrostomy: a Japanese retrospective study

BACKGROUND/AIMS

The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO).

METHODS

Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared.

RESULTS

Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS.

CONCLUSIONS

No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Transenteric Endoscopic Retrograde Cholangiopancreatography in Non-roux-en-Y Surgically Altered Anatomy

EDEE is a relatively safe and effective procedure when performed by expert endoscopists to establish pancreaticobiliary access in patients who have failed, or are not candidates for, traditional ERCP or alternative drainage modalities. Careful preprocedural planning with attention to the patient's specific postsurgical anatomy can optimize outcomes and minimize AEs.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD)

Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a minimally invasive procedure that allows for biliary access when conventional endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. The technique can be divided based on biliary access route: intrahepatic or extrahepatic, as well as on stenting approach: rendezvous approach (EUS-RV), antegrade placement, or transluminal (intra or extra hepatic) placement. There is no clear consensus on which approach is superior. Compared to percutaneous transhepatic biliary drainage, EUS-BD offers lower rates of adverse events without the need for an external drain. Compared to conventional ERCP, EUS-BD shows comparable, and in some cases superior, outcomes related to technical success, clinical success, and adverse events.

Comparison between Endoscopic Ultrasound-Guided Antegrade and Transluminal Stent Implantation in Distal Malignant Biliary Obstruction after Failed ERCP

Background

Distal malignant biliary obstruction (DMBO) can result in obstructive jaundice. Endoscopic ultrasound- (EUS-) guided biliary drainage (EUS-BD) has been an alternative for DMBO after failed ERCP.

Aim

To compare the efficacy and safety between antegrade and transluminal approaches in patients with unresectable DMBO when ERCP failed.

Methods

Patients with DMBO leading to obstructive jaundice after failed ERCP were enrolled in this study. We retrospectively evaluated the safety and efficacy between EUS-guided transluminal stenting (TLS group) and antegrade stenting (AGS group).

Results

82 patients were enrolled, of which 45 patients were in TLS group and 37 in AGS group. There were no statistical differences in the malignancy type, baseline common bile duct diameter, total bilirubin level, reason for EUS-BD, and history of biliary drainage between TLS and AGS groups. The technical success rate was statistically higher in TLS group than in AGS group (97.8 vs. 81.1%, P = 0.031). There were no statistical differences in clinical success rate, procedure-related adverse events, stent migration rate, stent dysfunction rate, reintervention rate, and overall patient survival time between TLS and AGS groups. The median time to stent dysfunction or patient death in TLS and AGS groups was 53 and 81 days, respectively (P = 0.017).

Conclusions

Although AGS had a lower technical success rate than TLS, it was superior to TLS in stent patency in patients with DMBO.

Safety and effectiveness of consecutive 191 endoscopic ultrasonography-guided biliary drainage procedures: a single-center experience

<b>Introduction:</b> The development of endoscopic ultrasonography (EUS) has enabled extra-anatomical transmural access to the bile ducts, thus making it possible to perform endoscopic biliary anastomoses with the gastrointestinal (GI) tract and obtain extra-anatomical transpapillary access. EUS provides an alternative to the existing methods of biliary drainage (BD) for cases in which endoscopic retrograde cholangiopancreatography (ERCP) is ineffective.<b>Aim:</b> This study aimed to evaluate the efficacy and safety of extraanatomical endoscopic biliary access methods for the treatment of benign and malignant biliary strictures.<b>Material and methods:</b> This retrospective analysis included treatment results of all patients with obstructive jaundice and biliary strictures who were treated endoscopically in our department between 2016 and 2023. The study group comprised patients in whom EUS-guided transmural access was used during ERCP because of biliary strictures and the lack of transpapillary access.<b>Results:</b> Twenty-eight patients (14.66%) underwent endoscopic transpapillary biliary stenting via a transmural approach under EUS guidance. The remaining 163 patients (85.34%) underwent extraanatomical transmural biliodigestive anastomosis. Technical success was achieved in 186 of 191 (97.38%) patients. Clinical success was achieved in 170 of 191 (89.01%) patients. Complications were reported for 32 of 191 (16.75%) patients, including fatal complications for 6 of 191 (3.14%) patients.<b>Conclusions:</b> Advanced endoscopic techniques involving EUS-guided transmural access are effective and safe for biliary strictures. They provide an alternative to other drainage techniques when ERCP is ineffective and improve the quality of life of patients undergoing palliative treatment for biliary strictures with unresectable cancer of the biliopancreatic area.

Controversies in Endoscopic Ultrasound-Guided Biliary Drainage

In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications.

Is ERCP still the elective primary biliary drainage technique in patients with malignant distal biliary obstruction?

Endoscopic retrograde cholangiopancreatography (ERCP) has been established as the first line therapy for the resolution of biliary and pancreatic diseases. The main disadvantage of the procedure is the rate of adverse events, around 10%1. So, despite being a minimally invasive procedure, ERCP has a non-negligible rate of adverse effects (AEs) and secondary mortality.

Safety of skipping the tract dilation step for EUS-guided biliary drainage in patients with unresectable malignant biliary obstruction (with video)

BACKGROUND

Thin delivery system stents can be inserted directly without the need for a tract dilation step and are expected to reduce bile leakage during endoscopic ultrasound-guided biliary drainage (EUS-BD). The present study retrospectively compared the safety and efficacy of EUS-BD using a thin metal stent (< 7.5 Fr) with those of EUS-BD using a conventional stent (≥ 7.5 Fr).

METHODS

The present study enrolled 112 patients who underwent EUS-BD using metal stents for unresectable malignant biliary obstruction between April 2016 and July 2022. The primary endpoint was the rate of adverse events (AEs). The secondary endpoints were clinical success rate, procedure time, procedure success rate in the absence of the tract dilation step, recurrent biliary obstruction rate, time to biliary obstruction, and overall survival. Risk factors associated with early AEs were also evaluated.

RESULTS

The rate of early AEs was significantly lower (12% vs. 35%, P = 0.013) and the procedure success without the tract dilation step was significantly higher (82% vs. 33%, P < 0.001) in the thin than in the conventional delivery system stent group. None of the other secondary endpoints differed significantly between the two groups. Multivariate analysis showed that employing the tract dilation step during EUS-BD was a significant independent risk factor for early AEs (skipping vs. employing; HR, 9.66; 95% CI, 1.13-83.0, P = 0.028).

CONCLUSION

Employing the tract dilation step during EUS-BD was a significant risk factor for early AEs. Metal stents with a delivery diameter < 7.5 Fr can be inserted directly without the tract dilation step, resulting in lower early AE rates.

Advanced technical tips and recent insights in ERCP using balloon-assisted endoscopy

Pancreatobiliary endoscopic interventions using balloon-assisted endoscopes have been widely acknowledged as the first-line therapy for pancreatobiliary diseases in postoperative patients with reconstructed gastrointestinal anatomy (excluding the Billroth I procedure). However, there are many technical difficulties, and the procedural completion rates vary in a wide range among institutions, indicating the procedural technique is yet to be standardized. This article aims to provide technical tips of procedures and insights into the advanced aspects, including the management of extremely difficult cases and troubleshooting of endoscopic retrograde cholangiopancreatography using balloon endoscopy, along with a review of recent advancements in this field.

Usefulness of endoscopic ultrasound-guided transhepatic biliary drainage with a 22-gauge fine-needle aspiration needle and 0.018-inch guidewire in the procedure's induction phase

Endoscopic ultrasound (EUS)-guided transhepatic biliary drainage is usually performed with a 19-gauge fine-needle aspiration (FNA) needle and a 0.025-inch guidewire. The combination of a 22-gauge FNA needle and a 0.018-inch guidewire is reported to be effective as a rescue option when the bile duct diameter is small or technically challenging. Experts in EUS-guided transhepatic biliary drainage have reported that bile duct puncture with a 19-gauge FNA needle is possible in most cases, but is not easy to reproduce by endoscopists with less experience in EUS-guided transhepatic biliary drainage. We investigated the usefulness of EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire during the procedure's induction phase. Consecutive patients who underwent EUS-guided transhepatic biliary drainage at our institution from March 2021 to May 2023 were evaluated, and 37 were included. Biliary drainage was performed for malignant bile duct stricture in 36 patients and choledocholithiasis in one patient. The median target bile duct diameter was 4.5 mm (2.5-9.4). Biliary access, fistula dilation, and stent placement were successful in the 37 patients (100%). The median procedure time was 35 min (16-125). Adverse events occurred in four (10.8%) patients. EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire is a useful and promising option for endoscopists with limited experience in EUS-guided transhepatic biliary drainage in the procedure's induction phase.

Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis

Objectives

Endoscopic ultrasound (EUS)-guided biliary drainage encompasses techniques such as EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). This meta-analysis compared the efficacy of EUS-CDS with that of EUS-HGS for the treatment of biliary obstruction.

Methods

A systematic meta-analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS-CDS and EUS-HGS.

Results

This meta-analysis included 18 eligible studies. There was no significant difference between EUS-CDS and EUS-HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62-1.73) and clinical success rate (OR 0.66; 95% CI 0.43-1.04), or with respect to total procedure-related adverse events (OR 1.39; 95% CI 1.00-1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS-HGS (OR 2.95; 95% CI 1.54-5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference -11.93 days; 95% CI -47.77-23.91). However, the procedure time was longer for EUS-HGS (mean difference, 3.21 min; 95% CI 1.24-5.19).

Conclusion

EUS-CDS and EUS-HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS-CDS is superior with respect to procedure time and preventing RBO.

Comparison of long-term outcomes of endoscopic ultrasound-guided hepaticogastrostomy and choledochoduodenostomy for distal malignant biliary obstruction: a multicenter retrospective study

Background

Endoscopic ultrasound-guided biliary drainage (EUS-BD), classified as choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS), is a feasible and effective alternative for distal malignant biliary obstruction (MBO) in failed endoscopic retrograde cholangiopancreatography. However, the preferred technique for better outcomes has not yet been evaluated.

Objectives

We compared the long-term outcomes between the techniques.

Design

Retrospective comparative study.

Methods

We reviewed consecutive patients who underwent EUS-CDS or EUS-HGS with transmural stent placement for distal MBO between 2009 and 2022. The primary outcome was the stent patency. The secondary outcomes were technical and clinical success, adverse events (AEs) of each technique, and independent risk factors for stent dysfunction.

Results

In all, 115 patients were divided into EUS-CDS (n = 56) and EUS-HGS (n = 59) groups. Among them, technical success was achieved in 98.2% of EUS-CDS and 96.6% of EUS-HGS groups. Furthermore, clinical success was 96.4% in EUS-CDS and 88.1% in EUS-HGS groups, without significant difference (p = 0.200). The mean duration of stent patency for EUS-CDS was 770.3 days while that for EUS-HGS was 164.9 days (p = 0.010). In addition, the only independent risk factor for stent dysfunction was systematic treatment after EUS-BD [hazard ratio and 95% confidence interval 0.238 (0.066-0.863), p = 0.029]. The incidence of stent dysfunction of EUS-HGS was higher than EUS-CDS (35.1% versus 18.2%, 0.071), despite no significant differences even in late AEs.

Conclusion

In distal MBO, EUS-CDS may be better than EUS-HGS with longer stent patency and fewer AEs. Furthermore, systematic treatment after EUS-BD is recommended for the improvement of stent patency.

Preoperative Endoscopic Ultrasound-Guided Hepaticogastrostomy for Definite Biliary Drainage in Hilar Cholangiocarcinoma Laparoscopic Resection: A Hybrid Minimal-Invasive Technique

BACKGROUND AND STUDY AIMS

Laparoscopic approach of perihilar cholangiocarcinoma (PHC) is still challenging. We report the original use of a endoscopic hepaticogastrostomy (EHG) for definite biliary drainage in order to avoid biliary reconstruction.

PATIENTS AND METHODS

A 70-year-old man presenting with jaundice was referred for resection of a Bismuth type IIIa PHC. Repeated endoscopic retrograde cholangiopancreatography failed to drain the future liver remnant, enabling only right anterior liver section drainage. EHG was performed three weeks before surgery. A hepatogastric anastomosis was created, placing a half-coated self-expanding endoprosthesis between biliary duct of segment 2 and the lesser gastric curvature.

RESULTS

A laparoscopic right hepatectomy extended to segment 1, common bile duct, and hepatic pedicle lymphadenectomy was performed. The left hepatic duct was sectioned and ligated downstream to the biliary confluence of segment 2-3 and 4 allowing exclusive biliary flow through the EHG. The patient was disease free at 12 months, postoperative outcomes were uneventful except three readmissions for acute cholangitis due to prosthesis obstruction.

CONCLUSIONS

EHG may be used as definite biliary drainage technique in laparoscopic PHC resection, at the expense of prosthesis obstruction and cholangitis.

The Lambda stenting technique: a new approach to address EUS-guided biliary drainage-associated adverse events

BACKGROUND AND AIMS

EUS-guided biliary drainage (EUS-BD) has been performed increasingly worldwide, especially in patients with malignant tumors in which ERCP is difficult, patients with surgically altered GI tracts, and older patients who are at high risk for surgery. EUS-BD requires high-level skills and has limited options for managing adverse events, particularly when stent migration and cholangitis occur. Adverse events, such as persistent bile leakage from the fistula and continuous reflux from the GI tract, are believed to always have a risk of severe exacerbation that could threaten the patient's life.

METHODS

We encountered 2 cases of stent migrations and 1 case with repeated cholangitis in patients with malignant tumors among the patients who underwent EUS-BD. The migrated stent was visualized under EUS in 2 patients with stent migration, and an EUS-guided FNA needle was used to puncture the mesh of the stent. The cannulation catheter was directly inserted into the mesh of the stent in 1 case with repeated retrograde cholangitis, while the stent was visualized with an endoscope. Subsequently, a guidewire was inserted through the puncture site, and a second metal stent was deployed between the meshes of the first stent, bridging the GI wall again (Lambda stenting technique). All procedures were performed with the patient under general anesthesia, and the patients safely completed the intervention.

RESULTS

Patients' conditions significantly improved after the second stent insertion, allowing for chemotherapy resumption while maintaining their activities of daily living. The second stent remained in place without any migration, and the stent successfully prevented further cholangitis.

CONCLUSIONS

The Lambda stenting technique is considered highly effective for managing stent migration and repeated cholangitis, which is a major EUS-BD adverse event. This procedure helps avoid more invasive surgeries when stent migration and cholangitis occur and contributes to expanding EUS-BD applicability.

Early and late effects of endoscopic interventions in patients with malignant afferent loop syndrome: A single-center experience and literature review

BACKGROUND/PURPOSE

Afferent loop syndrome (ALS) is a rare adverse event after gastrointestinal surgery requiring appropriate early decompression treatment. Several endoscopic interventions have been attempted for treatment, including endoscopic enteral metal stent placement (EMSP), endoscopic ultrasound (EUS)-guided entero-enterostomy (EUS-EE), and EUS-guided hepaticogastrostomy (EUS-HGS). However, there are limited data on outcomes, including duration of stent patency. In this study, we evaluated the usefulness of each endoscopic intervention for malignant ALS.

METHODS

We retrospectively investigated nine patients with malignant ALS who underwent EMSP, EUS-EE, or EUS-HGS. Information on technical success, clinical efficacy, adverse events, stent dysfunction, and overall survival was collected and analyzed.

RESULTS

The most common symptoms were abdominal pain and cholangitis. ALS was treated by EMSP in three patients, EUS-EE in three patients, and EUS-HGS in three patients. Stent placement was successful and clinically effective in all patients with no adverse events. During follow-up, stent dysfunction occurred in two patients treated by EUS-HGS. Eight patients died of primary disease during a median follow-up of 157 days.

CONCLUSIONS

Each of the available endoscopic interventions for malignant ALS can be expected to produce similar outcomes, including duration of stent patency. The choice of endoscopic intervention should be made based on the characteristics of each treatment.

Long-term outcomes after EUS-guided antegrade intervention for benign bilioenteric anastomotic stricture

BACKGROUND AND AIMS

Bilioenteric anastomotic stricture (BES) is a well-known adverse event after bilioenterostomy. Recently, EUS-guided antegrade intervention (EUS-AI) has been developed for cases that are difficult to treat by balloon enteroscopy-assisted ERCP. However, no data are available on the long-term outcomes after EUS-AI. The main goal of the present study was to clarify the long-term outcomes of EUS-AI in such patients.

METHODS

Between November 2013 and November 2021, 34 patients who were followed for more than 1 year after EUS-AI for BES were identified. The primary endpoint was the rate of stricture resolution. Secondary endpoints were factors associated with stricture resolution, rate of BES recurrence, rate of conversion to surgery, and rate of hepatic fibrosis progression during follow-up.

RESULTS

The median follow-up period was 56.7 months. Stricture resolution was achieved in 17 of 34 patients (50%). A multivariate analysis confirmed that the presence of bile duct stones (odds ratio, 9.473; 95% confidence interval, 1.66-53.98; P = .01) was significantly associated with stricture resolution. The stricture recurrence rate was 33%, and the median time from stent removal to recurrence was 31.2 months. Four patients underwent surgery because of recurrent cholangitis. During the median follow-up period of 56.7 months, 25% progressed to hepatic fibrosis based on the Fibrosis-4 index grade. Interestingly, patients without cholangitis during follow-up did not show progression of hepatic fibrosis.

CONCLUSIONS

EUS-AI has achieved acceptable long-term clinical outcomes. EUS-AI can be a viable alternative treatment of choice before surgical treatment in patients who are difficult to treat by conventional approaches.

Current trends of minimally invasive therapy for cholecystocholedocholithiasis

INTRODUCTION

The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures.

MATERIALS AND METHODS

We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs).

RESULTS

We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs.

CONCLUSION

The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.

The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain

Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Utility of interventional endoscopic ultrasound in pancreatic cancer

Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.

Complete migration of a fully covered self-expandable metallic stent after endoscopic ultrasound-guided hepaticogastrostomy: A case report

A male patient underwent gastrojejunal bypass surgery in 2017. In 2020, he was referred to our hospital for suspected obstructive jaundice. Subsequently, he was diagnosed with cholangiocarcinoma, and endoscopic retrograde cholangiopancreatography was attempted via balloon-assisted enteroscopy. However, the endoscope did not reach the duodenal papilla owing to the abdomen-small intestine adhesion. Therefore, endoscopic ultrasound-guided hepaticogastrostomy was performed using a dedicated plastic stent. After stent placement, obstructive jaundice and cholangitis promptly improved. However, we replaced the plastic stent with a fully covered self-expandable metal stent because stent occlusions occurred frequently. Two months after fully covered self-expandable metal stent placement, the patient developed cholangitis again. Notably, during the endoscopic procedure, the stent was found to be completely migrated. Nevertheless, the fistula was still open, and the patient was successfully retreated with the maintained fistula of endoscopic ultrasound-guided hepaticogastrostomy.

EUS-Guided Choledochoduodenostomy after Failed Endoscopic Retrograde Cholangiopancreatography in Distal Malignant Biliary Obstruction

Introduction

Malignant biliary obstruction drainage is essential, since jaundice is associated with morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended procedure for biliary drainage, with percutaneous biliary drainage being the classic alternative in cases of unsuccessful ERCP. Recently, endoscopic ultrasound-guided biliary drainage has been emerged as a new option, with EUS-guided choledochoduodenostomy (EUS-CDS) being considered an effective and safe method in the drainage of distal obstructions of the common bile duct.

Aim

The aim of the study was to evaluate the efficacy and safety of EUS-CDS performed in patients with distal malignant biliary obstructions, after failed ERCP.

Methods

Single-center retrospective cohort study between July 2017 and June 2022 including all consecutive patients submitted to EUS-CDS in our center. The primary outcomes were "technical success" and "clinical success," defined as "resolution of jaundice or improvement in total serum bilirubin level above 50% at 7th day and above 75% at 30th day after the procedure." Secondary outcomes were procedure-related adverse events, endoscopic reintervention, and survival time.

Results

EUS-CDS was performed in 20 patients (65.0% male; median age 76 years). The most frequent etiology for the biliary obstruction was pancreatic adenocarcinoma (n = 17; 85.0%), and most patients presented at advanced stages of cancer (12/60% in stages III or IV). ERCP failure was mainly due to the presence of obstruction in the duodenal lumen (n = 11; 55.0%). Fully covered metallic stents were used in all patients, mostly HotAxiosTM (n = 15; 75.0%). The technical success rate was 100%, and the clinical success rate was 89.5% (n = 17/19) at 7th day and 93.3% (n = 14/15) at 30th day. Four patients (20.0%) developed cholangitis within the first 30 days after the procedure; there were no late complications, and no patient died as a complication of the procedure. In 2 patients (10.0%), endoscopic reintervention was necessary due to stent migration, incidentally detected. Median survival was 93 days (minimum 5-maximum 751).

Conclusion

EUS-CDS was effective in biliary decompression of malignant obstructions of the common bile duct, with high clinical success and a favorable safety profile.

Prospective clinical trial of EUS-guided choledochoduodenostomy without fistula dilation for malignant distal biliary obstruction

Background and Objectives

During EUS-guided choledochoduodenostomy (EUS-CDS), fistula dilation before stent insertion is associated with adverse events (AEs), such as bile leakage and peritonitis. We hypothesized that EUS-CDS without fistula dilation using a novel self-expandable metal stent (SEMS) with a thin delivery system could overcome this problem, and we conducted this study to evaluate its feasibility and safety.

Methods

This was an open-label, single-arm, phase II study at a single institution. We planned EUS-CDS without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system for unresectable malignant distal biliary obstruction. The primary outcome was overall technical success. Secondary outcomes were technical success without fistula dilation, procedure time, functional success, time to recurrent biliary obstruction, and AEs. The planned sample size was 25 patients.

Results

In total, 24 patients were included in this study. In 21 patients, EUS-CDS was performed as primary drainage. The overall technical success rate was 100% (24 of 24 patients). The technical success rate without fistula dilation was 96% (23 of 24). The median procedure time was 16 min (range, 10-66 min). The functional success rate was 96% (23 of 24). The median time to recurrent biliary obstruction was 148 days (95% confidence interval, 29-266 days). There were no procedure-related AEs. Furthermore, computed tomography immediately after the procedure showed no leakage of contrast medium into the abdominal cavity in any patient.

Conclusions

EUS-guided choledochoduodenostomy without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system is feasible with a high probability and can be achieved quickly while effectively preventing bile leakage and peritonitis.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

The Role of Lumen Apposing Metal Stents in the Palliation of Distal Malignant Biliary Distal Obstruction

Malignant biliary obstruction (DMBO) has been traditionally managed by endoscopic retrograde cholangiopancreatography (ERCP). In the case of ERC failure, percutaneous transhepatic biliary drainage (PT-BD) has been widely utilized as a salvage procedure. However, over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing popularity, especially after the advent of electrocautery-enhanced lumen apposing metal stent devices (EC-LAMSs) which enable a one-step procedure, granting prevention of biliary leakage and minimizing occurrence of adverse events (AEs). In parallel, increasing evidence suggests a possible role of EUS-BD in the management of DMBO as a primary palliative drainage modality. In the current paper, we aim to review all the available evidence on the role of EUS-BD performed with EC-LAMSs and discuss salient technical aspects of this type of procedure.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.

Endoscopic ultrasound-guided biliary drainage: a literature review

Neoplasms of the biliopancreatic confluence may present with obstruction of the bile tract, leading to jaundice, pruritus and cholangitis. In these cases drainage of the bile tract is imperative. Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a choledochal prosthesis is an effective treatment in about 90% of cases, even in experienced hands. In cases of ERCP failure, therapeutic options traditionally include surgical bypass by hepaticojejunostomy (HJ) or percutaneous transparietohepatic drainage (DPTH). In recent years, endoscopic ultrasound-guided biliary drainage techniques have gained space because they are less invasive, effective and have an acceptable incidence of complications. Endoscopic echo-guided drainage of the bile duct can be performed through the stomach (hepatogastrostomy), duodenum (choledochoduodenostomy) or by the anterograde drainage technique. Some services consider ultrasound-guided drainage of the bile duct the procedure of choice in the event of ERCP failure. The objective of this review is to present the main types of endoscopic ultrasound-guided biliary drainage and compare them with other techniques.

Experience-Related Factors in the Success of Beginner Endoscopic Ultrasound-Guided Biliary Drainage: A Multicenter Study

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become comparable to endoscopic retrograde cholangiopancreatography and is now considered a first-line intervention for certain biliary obstructions. Although analysis of experience-related factors may help achieve better outcomes and contribute to its wider adoption, no concrete evidence exists regarding the required operator or institutional experience levels. This study aimed to analyze experience-related factors at beginner multicenters. Patients who underwent EUS-BD using self-expandable metal stents and/or dedicated plastic stents during the study period (up to the first 25 cases since introducing the technique) were retrospectively enrolled from seven beginner institutions and operators. Overall, 90 successful (technical success without early adverse events) and 22 failed (technical failure and/or early adverse events) cases were compared. EUS-BD-related procedures conducted at the time of applicable EUS-BD by each institution/operator were evaluated. The number of institution-conducted EUS-BD procedures (≥7) and operator-conducted EUS screenings (≥436), EUS-guided fine-needle aspirations (FNA) (≥93), and EUS-guided drainages (≥13) significantly influenced improved EUS-BD outcomes (p = 0.022, odds ratio [OR], 3.0; p = 0.022, OR, 3.0; p = 0.022, OR, 3.0; and p = 0.028, OR, 2.9, respectively). Our threshold values, which significantly divided successful and failed cases, were assessed using receiver operating characteristic curve analysis and may provide useful approximate indications for successful EUS-BD.

Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis

BACKGROUND

Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed.

OBJECTIVES

We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage.

REVIEW METHODS

English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant.

RESULTS

Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06).

CONCLUSIONS

Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.

Clinical Outcomes of EUS-Guided Choledochoduodenostomy for Biliary Drainage in Unresectable Pancreatic Cancer: A Case Series

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Contemporary advances in the endoscopic management of cholangiocarcinoma: a review of accomplished milestones and prospective opportunities

INTRODUCTION

Cholangiocarcinoma, a primary malignancy of epithelial cells of the bile ducts, has been shown to have increasing incidence rates globally. Many of the current advances aim to improve the accuracy of differentiation between benign biliary strictures and cholangiocarcinoma, which include endoscopic techniques, devices, image processing, and the use of genomic sequencing in acquired specimens.

AREAS COVERED

In this review, the authors explore the historical timeline of changes leading to modern management of cholangiocarcinoma, with special emphasis on endoscopic modalities and novel therapeutic interventions. The authors also expand on the strengths and shortcomings of endoscopic diagnostics and techniques in biliary drainage and finally discuss potential areas to focus for future research and development.

EXPERT OPINION

Despite the advances in diagnosis and management of cholangiocarcinoma, there remain multiple tasks that are still awaiting to be completed. Next-generation sequencing in the diagnosis of cholangiocarcinoma needs to be further tested, validated, and easily obtainable. Other innovative diagnostic modalities, such as the use of artificial intelligence in cholangioscopy, may provide an effective complementary modality to existing techniques. A consensus on biliary drainage needs to be defined and account for longevity and patient convenience.

Effectiveness and Safety of EUS Rendezvous After Failed Biliary Cannulation With ERCP: A Systematic Review and Proportion Meta-analysis

BACKGROUND

Endoscopic ultrasound-guided rendezvous (EUS-RV) endoscopic retrograde cholangiopancreatography (ERCP) is an alternative to interventional radiology-guided rendezvous ERCP in patients who failed biliary cannulation with conventional ERCP. However, there is significant variation in reported rates of success and adverse events associated with EUS-RV-assisted ERCP. We performed a systematic review and a proportion meta-analysis to reliably assess the effectiveness and safety of the EUS-RV-assisted ERCP.

MATERIALS AND METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through August 2020) to identify studies reporting EUS-RV-assisted ERCP in patients who failed biliary cannulation with conventional ERCP techniques. Using the random-effects model described by DerSimonian and Laird, we calculated the pooled rates of technical success, clinical success, and adverse events of EUS-RV-assisted ERCP.

RESULTS

Twelve studies reporting a total of 342 patients were included in the meta-analysis. The pooled rate of technical success (12 studies reporting a total of 342 patients) was 86.1% [95% confidence interval (CI): 78.4-91.3]. The pooled rate of clinical success (4 studies reporting a total of 94 patients) was 80.8% (95% CI: 64.1-90.8). The pooled rate of overall adverse events (12 studies; 42 events in 342 patients) was 14% (95% CI: 10.5-18.4). Low to moderate heterogeneity was noted in the analyses.

CONCLUSIONS

EUS-RV-assisted ERCP appears to be effective and safe in patients who failed biliary cannulation with conventional ERCP. Given the risk of adverse events, it should be performed in centers with expertise in therapeutic endoscopic ultrasound.