A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction

Mechanical evaluation of the dilation force of dilation devices during interventional endoscopic ultrasound

Background and study aims To insert the metal stent delivery system (8.5F) during interventional endoscopic ultrasound (I-EUS), several dilation steps are needed, which may be related to increased bile leakage from a fistula. There have been no definitive studies of dilation force. The aim of the present study was to evaluate dilation force during I-EUS using several dilation devices. Methods In the present study, seven dilation devices were evaluated including bougie dilators such as a straight-shaped dilator (the ES dilator, Soehendra dilator, a standard ERCP catheter) a screw-shaped dilator (Tornus ES, Soehendra stent retriever), and a 4-mm balloon catheter (REN biliary balloon catheter, Hurricane RX). The diameter of each dilator and dilation force were measured. Results Of the bougie dilators, the dilation force of the ES dilator was the highest (0.908±0.035 kg). Of the balloon catheters, the dilation force of the Hurricane RX (3.261±0.024 kg) was slightly higher than that of the REN (3.159±0.072 kg). Of the bougie dilators, although the diameter of the ES dilator was not larger than that of the Tornus ES, the dilation force was stronger. Similarly, the diameter of the Soehendra stent retriever was greater than that of the ERCP catheter or Soehendra dilator and the dilation force was lower. Conclusions Compared with bougie dilators, balloon catheters have stronger dilation force according to our experimental study. The present results should be evaluated in clinical trials.

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.

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.

Covered self-expandable metallic stents versus plastic stents for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction

BACKGROUND/AIMS

Covered self-expandable metallic stents (cSEMS) have become popular for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting (EUS-HGS). We compared the time to recurrent biliary obstruction (TRBO), complications, and reintervention rates between EUS-HGS using plastic stent (PS) and cSEMS in patients with unresectable malignancies at multicenter institutions in Japan.

METHODS

Patients with unresectable malignant biliary obstruction who underwent EUS-HGS between April 2015 and July 2020 at any of the six participating facilities were enrolled. Primary endpoint: TRBO; secondary endpoints: rate of complications other than recurrent biliary obstruction and technical success rate of reintervention were evaluated.

RESULTS

PS and cSEMS were used for EUS-HGS in 109 and 43 patients, respectively. The TRBO was significantly longer in the cSEMS group than in the PS group (646 vs. 202 days). Multivariate analysis identified two independent factors associated with a favorable TRBO: combined EUS-guided antegrade stenting with EUS-HGS and the use of cSEMS. No significant difference was observed in the rate of complications other than recurrent biliary obstruction between the two groups. The technical success rate of reintervention was 85.7% for PS and 100% for cSEMS (p=0.309).

CONCLUSION

cSEMS might be a better option for EUS-HGS in patients with unresectable malignancies, given the longer TRBO.

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.

Drenagem biliar endoscópica ecoguiada: revisão da literatura

RESUMO Neoplasias da confluência biliopancreática podem cursar com obstrução da via biliar, levando a icterícia, prurido e colangite. Nesses casos a drenagem da via biliar é imperativa. A colangiopancreatografia endoscópica retrógrada (CPER) com colocação de prótese coledociana constitui tratamento eficaz em cerca de 90% dos casos mesmo em mãos experientes. Nos casos de insucesso da CPER, tradicionalmente as opções terapêuticas incluem a derivação cirúrgica por hepaticojejunostomia (HJ) ou drenagem percutânea transparietohepática (DPTH). Nos últimos anos as técnicas endoscópicas ecoguiadas de drenagem biliar ganharam espaço por serem menos invasivas, eficazes e apresentarem incidência aceitável de complicações. A drenagem endoscópica ecoguiada da via biliar pode ser realizada pelo estômago (hepatogastrostomia), duodeno (coledocoduodenostomia) ou pela técnica de drenagem anterógrada. Alguns serviços consideram a drenagem ecoguiada da via biliar o procedimento de escolha no caso de insucesso da CPER. O objetivo desta revisão é apresentar os principais tipos de drenagem biliar endoscópica ecoguiada e confrontá-los com outras técnicas.

How to perform EUS-guided biliary drainage

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

EUS-guided biliary drainage with a novel electrocautery-enhanced lumen apposing metal stent as first approach for distal malignant biliary obstruction: a prospective study

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in malignant biliary obstruction (MBO) patients. Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. We aimed to assess the technical and clinical success of a new EC-LAMS as the first approach to the palliation of malignant jaundice due to MBO in patients unfit for surgery. Patients and methods  Twenty-five consecutive patients undergoing endoscopic-guided biliary drainage with the new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease > 15 % 24 hours after EC-LAMS placement. Results  Mean age was 76.6 ± 11.56 years, and male patients were 10 (40 %). EC-LAMS placement was technically feasible in 24 patients (96 %) and clinical success rate was 100 %. Only one patient (4 %) experienced a misplacement rescued by an immediate second EC-LAMS placement. The mean duration of hospital stay was 4.66 ± 4.22 days. The median overall survival was 7 months (95 % CI 1-7). Conclusions  In this preliminary study, the new EC-LAMS seems to allow a single-step palliative endoscopic therapy in patients affected by jaundice due to MBO, with high technical and clinical success and low adverse events. Further large prospective studies are warranted to validate these results.

Propensity score matching analysis for adverse events of EUS-guided biliary drainage in advanced elderly patients (PEACE study)

BACKGROUND

Several studies have suggested that elderly patients, as well as younger patients, can be safely treated using endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic ultrasound-guided biliary drainage (EUS-BD) has not been clinically evaluated for very elderly patients. The present multicenter, retrospective study aimed to determine the safety of EUS-BD for advanced elderly patients.

METHOD

Patients who underwent EUS-BD during this period were retrospectively enrolled, and they were divided into two groups based on age: group A (age  < 75 years) and group B (age ⩾ 75). In this study, capnographic monitoring was used only for elderly patients (age ⩾ 75 years).

RESULTS

A total of 271 patients who underwent EUS-BD were enrolled in this study (group A = 177, group B = 94). The types of adverse events that were associated with EUS-BD was observed in 38 patients, and they did not differ significantly between two groups (p = 0.855). This result was confirmed after propensity score matching (p = 0.510). Adverse events were associated with sedation after propensity score matching; hypoxemia (p = 0.012) and severe hypoxemia (p = 0.003) were significantly higher in group A compared with group B. According to logistic regression analysis, monitoring (non-capnography) was also only risk factor (odds ratio: 0.317, 95% confidence interval: 0.143-0.705; p = 0.005) for sedation-related adverse events.

CONCLUSION

In conclusion, EUS-BD could be safety performed in advanced elderly patients, the same as in younger patients. Also, capnographic monitoring might be helpful in case of sedation by a gastroenterologist in a non-intubated patient. Further prospective, randomized studies are needed to confirm these conclusions.

Usefulness of the laser-cut fully covered self-expandable metallic stent for endoscopic ultrasound-guided hepaticogastrostomy

BACKGROUND/PURPOSE

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has many associated adverse events. We evaluated the clinical efficacy and safety of the laser-cut fully covered self-expandable metallic stent (FCSEMS) for this procedure.

METHODS

This single-center, retrospective study included cases where EUS-HGS with a laser-cut FCSEMS was performed for malignant biliary obstruction. Technical and clinical success, time to recurrent biliary obstruction (TRBO), procedure time, adverse events, and re-interventions were evaluated.

RESULTS

There were 95 eligible cases. Technical and clinical success rates were 100.0% and 95.8%, respectively. Median TRBO was 398 days. RBO causes were hyperplasia (7.4%), debris (3.2%), and migration (4.2%). Adverse events occurred in nine cases (9.5%). Non-occlusion and focal cholangitis occurred in four cases (4.2%) each. Nineteen patients (20%) underwent combined EUS-HGS (CH) procedures: antegrade stenting, bridging methods, plastic stent anchoring in SEMS, and EUS-hepaticoduodenostomy. The solely EUS-HGS (SH) group had significantly longer median TRBO than the CH group (398 vs. 246 days; P=0.04). There were no significant differences in adverse events between the two groups. Re-intervention was performed in 29 cases (technical success rate: 100.0%).

CONCLUSIONS

Laser-cut FCSEMS can be safely placed in the bile duct and easily applied during re-intervention, making it useful in EUS-HGS.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Comparison of Choledochoduodenostomy and Hepaticogastrostomy for EUS-Guided Biliary Drainage: A Meta-Analysis

Background

Although endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) has emerged as an option for patients of failed endoscopic retrograde cholangiopancreatography (ERCP), there has no agreement on which approach is preferred. Therefore, a meta-analysis was performed to examine the two methods.

Methods

We performed a comprehensive search in databases of PubMed, Embase, and Cochrane library to find relevant studies reporting the efficacy and safety of the two EUS-guided biliary drainage methods.

Results

In total, 12 studies with 623 patients (EUS-CDS: 303 and EUS-HGS: 320) were included. The cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0% (288/303), 93.1% (268/288), and 96.6% (309/320), 91.3% (282/309), respectively. Compared with EUS-HGS, the pooled odds ratio (OR) was 0.74 (95% CI 0.33–1.65; p = 0.46) for EUS-CDS technical success and 0.94 (95% CI 0.56–1.59; p = 0.83) for clinical success. The pooled difference in means of procedure time of EUS-CDS and EUS-HGS was −2.68 (95% CI −5.12 to −0.24; p = 0.03). The cumulative early adverse events for EUS-CDS and EUS-HGS was 12.2% (37/303) and 17.5% (56/320), respectively. Compared with EUS-HGS, the pooled OR of early adverse events for EUS-CDS was 0.58 (95% CI: 0.36–0.93; p = 0.02).

Conclusion

This meta-analysis further suggests EUS-CDS and EUS-HGS have equal high technical and clinical success, but EUS-CDS with a slightly short procedure time and with less early adverse events compared to EUS-HGS.

Application of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting in patients with malignant biliary obstruction after failed ERCP

BACKGROUND

This study was aimed at comparing the safety and effectiveness of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and EUS-HGS combined with antegrade stenting (EUS-HGAS) in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients diagnosed with MBO and receiving EUS-HGS or EUS-HGAS from September 2015 to October 2020 were enrolled in this study. Clinical success, complications, reintervention rate, post-operative hospital stay, time to stent dysfunction, and patient death were compared.

RESULTS

A total of 45 patients (21 in the EUS-HGAS group and 24 in the EUS-HGS group) were enrolled in this study. In the EUS-HGAS group, 21 patients all achieved clinical success (100%); in the EUS-HGS group, 24 patients also achieved technical success (100%) (P > 0.05). The differences between pre- and post-operative TB and ALT and AST levels were greater in the single-step EUS-HGAS group (P < 0.05). The incidence of complications was 2 of 21 (9.5%) in the EUS-HGAS group and 5 of 24 (20.8%) in the EUS-HGS group (P > 0.05). The reintervention rate was 0 in the EUS-HGAS group and 1 (4.2%) in the EUS-HGS group (P > 0.05). Time to stent dysfunction or patient death was longer in the EUS-HGAS group (P < 0.05). The post-operative hospital stay was longer and the total cost was higher in the EUS-HGAS group.

CONCLUSION

EUS-HGAS was superior to EUS-HGS in terms of biliary drainage effectiveness and time to stent dysfunction or patient death in patients with MBO after failed ERCP. Furthermore, two-step EUS-HGAS may be safer in some patients.

Endoscopic versus percutaneous biliary drainage for resectable pancreatic head cancer with hyperbilirubinemia and impact on pancreaticoduodenectomy: A randomized controlled study

BACKGROUND

We hypothesized that percutaneous biliary drainage provides more short-term advantages over endoscopic stenting before pancreaticoduodenectomy.

METHODS

Between January 2019 and December 2010, a prospective cohort study was conducted. Sixty patients with potentially resectable pancreatic head cancers and high bilirubin levels were stratified into two equal groups according to the method of biliary drainage: endoscopic stenting or percutaneous drainage. The primary outcome measures were operative difficulties and early postoperative morbidity, the secondary outcome was post-drainage complications.

RESULTS

Both groups were comparable in age; gender; presenting symptoms, type of malignancy, post-drainage complications, and time intervals between drainage and surgery. Key preoperative significant differences were technically higher but clinical success rates was better in the PTD cohort. ERCP patients had significantly more difficult dissections, more blood loss, longer resection time, more postoperative bile leak, and longer hospital stay.

CONCLUSION

From the operative perspective, patients who underwent PTD in the preoperative setting had fewer morbidities and shorter hospital stay. Large scale studies are required to support the validity of these findings in surgical practice.

Snare-assisted precutting and dual-knife fistulotomy performed during difficult biliary cannulation in a patient with an ectopic papilla of Vater

Endoscopic retrograde cholangiopancreatography is widely used in the diagnosis and treatment of pancreatobiliary diseases; however, successful biliary cannulation is a prerequisite for this operation. We herein present a new method in a patient in whom cannulation was difficult. A 56-year-old man was admitted to the hospital with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed, and duodenoscopy revealed that the patient’s duodenal papilla was located at the initial part of the horizontal segment of the duodenum. Because of the ectopic location of the duodenal papilla, the guidewire could not be inserted into the biliary and pancreatic duct. Therefore, we performed a new method to resolve the problem of difficult cannulation. A polypectomy snare was used to excise the mucosa covering the surface of the intramural segment of the common bile duct, and a dual knife was used to form a fistula. A guidewire was then inserted through the stoma into the bile duct. After the procedure, the bile duct was successfully cannulated and the stones were removed. No complications occurred. This new method may be an alternative treatment to precutting for difficult biliary cannulation in patients with a protruded papilla of Vater.

Safety issues in endoscopy ultrasound-guided interventions using lumen apposing metal stents: a review of the literature

Lumen-apposing metal stents (LAMS) are recently introduced devices that allow to create anastomoses. The indications for LAMS placement are increasing and currently these stents can be used in multiple clinical situations such as endoscopic drainage of pancreatic fluid collections (PFCs), endoscopic ultrasound-guided choledocho-duodenostomy (EUS-CDS), endoscopic ultrasound gallbladder drainage (EUS-GBD), endoscopic ultrasound gastrojejunostomy (EUS-GJ). Since their introduction, they have revealed to allow a higher rate of technical and clinical success, and potentially lower risk of adverse events (AEs) compared with previously available devices. Despite ongoing innovation, any advanced intervention carries risks of AEs. These AEs may occur during the deployment or can be delayed because of the consequent effects of the procedure and/or stent itself. This review represents an overview of current indications, technical and clinical results, with an extensive focus on safety issues related to placement and on long-term indwelling related ones.

Endoscopic ultrasonography (EUS) -guided visceral anastomoses: indications and techniques

BACKGROUND

Technologic advancements in the field of therapeutic endoscopy have led to the development of minimally invasive techniques to create gastrointestinal anastomosis instead of surgical interventions. Examples of the potential clinical applications include bypassing malignant and benign gastric outlet obstruction, providing access to the pancreato-biliary tree in those who have undergone Roux-en-Y gastric bypass, and relieving pancreato-biliary symptoms in afferent loop syndrome.

METHODS

starting from the available literature, aim of this narrative review is to summarize indications and techniques of endoscopic ultrasonography-guided visceral anastomoses.

RESULTS

A critical review of literature on the new EUS-guided anastomoses.

CONCLUSIONS

Increasing evidences are accumulating demonstrating advantages of EUS guided visceral anastomoses. These new procedures represent a novel, minimally invasive alternative for managing different type of intestinal obstruction.

Effect of echoendoscope angle on success of guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy

BACKGROUND

With endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), guidewire manipulation might be a critically limiting step for nonexperts. However, the causes of difficult guidewire manipulation remain unclear. The aim of this study was to evaluate factors associated with successful guidewire manipulation.

METHODS

This retrospective cohort study included consecutive patients who underwent EUS-HGS between October 2018 and October 2019. We measured scope angle between the long and needle axes of the echoendoscope using still fluoroscopic imaging immediately after puncturing the intrahepatic bile duct. Factors associated with successful guidewire insertion were assessed by multivariable analysis using logistic regression.

RESULT

The influence of the angle between the fine-needle aspiration (FNA) needle and echoendoscope on failed guidewire insertion was assessed using receiver operating characteristic (ROC) curves. Area under the ROC curve was 0.86 (95 % confidence interval [CI] 0.00 - 0.76), and an angle of 135° offered 88.0 % sensitivity and 82.9 % specificity for predicting successful guidewire insertion. According to multivariable analysis, only angle between the FNA needle and echoendoscope > 135° was independently associated with successful guidewire insertion (odd ratio 0.03, 95 %CI 0.01 - 0.14; P < 0.05), whereas sex, puncture site, and diameter of puncture site were not significant factors. After multivariable analysis, all variables were adjusted using age ≥ 70 or < 70 years, yielding the same results.

CONCLUSION

The angle between the FNA needle and echoendoscope might be associated with successful guidewire manipulation during EUS-HGS. Adjusting this angle to 135° before puncturing the intrahepatic bile duct might be helpful in achieving successful guidewire manipulation during EUS-HGS.

Training in advanced bilio-pancreatic endoscopy

As the clinical applications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) take more and more root in everyday practice and these endoscopic procedures become increasingly more complex and interventional with a higher chance for complications, the demand for expert bilio-pancreatic endoscopists continues to increase. In response to this growing need, specific postgraduate fellowships have been developed, however the standardization of training programs and the assessment of the achieved competence still remains an open debate. ERCP and EUS competency often requires training beyond the scope of a standard GI fellowship program, which lasts at least 1-2 years, and there are some differences in the way to face the issues of advanced bilio-pancreatic endoscopy training between Europe, America and the Asian regions. Today there is no role for the self-teaching of ERCP and EUS through trial and error without supervision and, in the near future, it is necessary to critically revise current training guidelines, to establish a standardized curriculum for advanced bilio-pancreatic endoscopists and to implement universally validated skill assessment tools, able to ensure constant and targeted feedback to trainees.

Role of CH-EUS as guidance for EUS-biliary drainage malignant obstruction

Endoscopic ultrasound (EUS)-guided biliary drainage is the usual method of choice for patients with biliary obstructions difficult to treat by endoscopic retrograde cholangiopancreatography. In some patients, however, the bile duct is difficult to detect during EUS-guided biliary drainage. Contrast-enhanced harmonic endoscopic ultrasound has reportedly been useful for interventional EUS procedures. This study describes five patients who underwent EUS-guided biliary drainage with contrast-enhanced harmonic imaging between April 2017 and March 2020 for malignant biliary obstruction due to bile duct cancer. The procedure was performed through an intrahepatic bile duct approach in three patients and through an extrahepatic bile duct approach in the other two. Although fundamental B-mode EUS was unable to detect the target intrahepatic bile duct because the duct was filled with debris, contrast-enhanced harmonic imaging was able to detect the bile duct by clarifying its border with the hepatic parenchyma. Similarly, in patients who underwent extrahepatic bile duct approach, fundamental B-mode EUS could not distinguish between debris and tumor, whereas contrast-enhanced harmonic EUS was able to differentiate between them. The procedure was technically and clinically successful in all five patients. One patient experienced bleeding as an adverse event. Conclusions: EUS-guided biliary drainage with contrast-enhanced harmonic imaging is useful in detecting the fluid space in bile ducts filled with debris or filled with debris and tumor invasion.

Treatment of acute cholecystitis in high-risk surgical patients. Systematic review of the literature according to the levels of evidence

Acute cholecystitis (AC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for AC, gallbladder drainage is indicated in elderly or high-risk surgical patients. We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. Literature search retrieved 175 manuscripts; most of them were expert opinions (LE V, no. 53) or caseseries (LE IV, no. 29). There was no meta-analysis of RCT (LE Ia), while two randomized controlled trials (LE Ib) demonstrated that EUS-GBD was superior to percutaneous trans-hepatic-GBD (PT-GBD) regarding longterm outcomes (adverse events, recurrent cholecystitis, and reintervention). Several meta-analyses of cohort studies (LE IIa, no. 11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (LE III). The outcomes of conversion from PT-GBD to EUS-GBD were covered by few retrospective studies (LE III). Several manuscripts (no. 69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. The levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.

Palliative endoscopic retrograde biliary drainage for malignant biliary obstruction in Korea: A nationwide assessment

BACKGROUND

Malignant biliary obstruction (MBO) is usually caused by biliary tract cancer or pancreatic cancer. This study was performed to summarize the current situation regarding palliative endoscopic retrograde biliary drainage (ERBD) for MBO in Korea and to determine its clinical significance by analyzing representative nationwide data.

METHODS

Patients that underwent palliative ERBD for MBO between 2012 and 2015 were identified using the Health Insurance Review and Assessment database, which covers the entire Korean population. We assessed clinical characteristics and complications and compared the clinical impacts of initial metal and plastic stenting in these patients.

RESULTS

A total of 9,728 subjects (mean age, 65 ± 11.4 years; male, 61.4%) were identified and analyzed. The most common diagnosis was malignant neoplasm of liver and intrahepatic bile ducts (32.1%) and this was followed by extrahepatic or Ampulla of Vater cancer and pancreatic cancer. Initial plastic stent(s) placement was performed in 52.9% of the study subjects, and metal stent(s) placement was performed in 23.3%. The number of sessions of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) was significantly higher in patients that underwent initial plastic stenting than in patients that underwent metal stenting (2.2 ± 1.7 vs 1.8 ± 1.4, P < 0.0001), but rates of post-ERCP pancreatitis, hospital days, and time to second ERCP or PTBD were not significantly different.

CONCLUSION

This nationwide assessment study suggests that initial metal stenting is associated with fewer sessions of total ERCP or PTBD following the initial procedure, despite the preference for initial plastic stenting in Korea.

Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study

BACKGROUND AND AIMS

Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy.

METHODS

We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP.

RESULTS

36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32.

CONCLUSIONS

EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

BACKGROUND

In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure.

SUMMARY

Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.

Unresectable malignant obstructive jaundice: a 2-year experience of EUS-guided biliary drainage

OBJECTIVES

Endoscopic biliary drainage is a first-line treatment in patients with unresectable malignant biliary obstruction. In most cases the drainage is conducted using endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage or endosonography-guided biliary drainage (EUS-BD) represents therapeutic options after unsuccessful ERCP. Here we report on 2 years experience in the management of patients diagnosed with malignant biliary obstruction using EUS-BD.

METHODS

Retrospective data were collected on patients who underwent EUS-BD due to malignant biliary obstruction at our centre between April 2016 and April 2018. Only patients who had two unsuccessful attempts of ERCP prior to EUS-BD were included. We analysed the technical success (ie, creation of anastomosis and successful placement of a stent) and complication rate of EUS-BD, and monitored changes in serum bilirubin and liver function tests after 2 days, and at least 2 weeks, following the procedure.

RESULTS

Screening of 1781 ERCP procedures performed in our department during the inclusion period led to the identification of 31 patients (18 women, age range 51-92 years, 58% with pancreatic cancer) who fulfilled the inclusion criteria. Hepaticogastrostomy and choledochoduodenostomy were performed in 12 and 19 patients, respectively. The technical success rate was 97% and the complication rate was 12.9%. EUS-BD resulted in a significant decrease in serum bilirubin (p<0.01).

CONCLUSIONS

EUS-BD represents a reasonable therapeutic option after unsuccessful ERCP in patients with malignant biliary obstruction. Possible complications have to be kept in mind and this procedure should be performed at centres experienced in ERCP and EUS.

Lumen-apposing metal stent through the meshes of duodenal metal stents for palliation of malignant jaundice

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard procedure for malignant jaundice palliation; however, it can be challenging when a duodenal self-expandable metal stent (SEMS) is already in place. Patients and methods  The primary aim of our study was to evaluate the technical feasibility of the placement of a lumen apposing metal stent (LAMS) through the mesh (TTM) of duodenal stents. The secondary aims were to evaluate clinical outcomes and adverse events (AEs) related to the procedures. Results  Data from 23 patients (11 F and 12 M; mean age: 69.5 ± 11 years old) were collected. In 17 patients (73.9 %) TTM LAMS placement was performed as first intention, while in six patients (26.1 %) it was performed after a failed ERCP. Thirteen patients (56.5 %) underwent the procedure due to advanced pancreatic head neoplasia. One technical failure was experienced (4.3 %). The TTM LAMS placement led to a significant decrease in the serum levels of bilirubin, ALP, GGT, WBC and CRP. No cases of duodenal SEMS occlusion occurred and no other AEs were observed during the follow-up. Conclusions  Concomitant malignant duodenal and biliary obstruction is a challenging condition. Palliation of jaundice using TTM LAMS in patients already treated with duodenal stent is associated to promising technical and clinical outcomes.

Interventional Endoscopic Ultrasound: Current Status and Future Directions

The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.

Current ERCP practice in Belgium: the BSGIE survey

Background and study aims

Data on procedural outcome and quality of endoscopic retrograde cholangiopancreatography (ERCP) in Belgian practice are scarce. The aim of this study is to assess current status of ERCP-performance in Belgium.

Methods

National multi-institutional survey (online questionnaire) among members of the Belgian Society of Gastrointestinal Endoscopy (BSGIE), conducted in the period June-August 2018. The RIZIV/INAMI provided real-life data on the total number of ERCPs performed in Belgium.

Results

Forty-five responders completed the survey (for 43 centers performing ERCP), providing information for 8368 ERCPs performed in 45% (43/95) of institutions performing ERCP in Belgium. Fifty-eight percent of centers performed > 100 ERCPs/year and 7% of centers (n=3) performed < 50 ERCPs/year. According to the RIZIV/INAMI data, low case-volume centers are underrepresented in this survey. The most common ERCPindication was stone extraction (52%). 74% of endoscopists had more than 10 years of experience in performing ERCP. The majority of centers had their own written protocol (84%) for microbiological duodenoscope surveillance. Monitoring of cannulation rate and post-ERCP pancreatitis (PEP) was only performed in a minority of centers (30%). The majority of centers (76%) provided verbal informed consent relating to the ERCP-procedure ; a minority also requested a written informed consent (23%). 65% of centers systematically use NSAIDs for PEP prophylaxis.

Conclusion

This is the first survey of ERCP performance in Belgium. There were wide variations in practice. Adherence to key performance measures and measurement and evaluation of ERCP performance in daily practice at center and endoscopist level are not uniformly widespread.

Comparison of endoscopic ultrasound-guided hepaticogastrostomy and the antegrade technique in the management of unresectable malignant biliary obstruction: study protocol for a prospective, multicentre, randomised controlled trial

Background

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used after failed endoscopic retrograde cholangiopancreatography. Based on existing studies, intrahepatic (IH) approaches are preferred in patients with dilated IH bile ducts. Both ultrasound-guided hepaticogastrostomy (EUS-HGS) and ultrasound-guided antegrade treatment (EUS-AG) are appropriate for patients with unreachable papillae. Nevertheless, there have been no direct comparisons between these two approaches. Therefore, we aim to evaluate and compare the safety and efficiency of EUS-HGS and EUS-AG in patients with an unreachable papilla.

Methods

This is a prospective, randomised, controlled, multicentre study with two parallel groups without masking. One hundred forty-eight patients from three hospitals who met the inclusion criteria will be randomly assigned (1:1) to undergo either EUS-HGS or EUS-AG for relief of malignant biliary obstruction. The final study follow-up is scheduled at 1 year postoperatively. The primary endpoint is efficiency, described by technical and clinical success rates of EUS-HGS and EUS-AG in patients with unreachable papillae. The secondary endpoints include stent patency, overall survival rates, complication rates, length of hospital stays, and hospitalisation expenses. The chi-square test, Kaplan–Meier methods, log-rank test, and Cox regression analysis will be used to analyse the data.

Discussion

To our knowledge, this is the first study to compare these two EUS-BD approaches directly using a multicentre, randomised, controlled trial design. The clinical economic indexes will also be compared, as they may also affect the patient’s choice. The result may contribute to establishing a strategic guideline for choosing IH EUS-BD approaches.

Trial registration

Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900020737. Registered on 15 January 2019

Antiplatelet and/or anticoagulant treatment does not increase hemorrhagic adverse events during EUS-guided biliary drainage

BACKGROUND AND AIMS

No data appear to have been reported regarding bleeding risk among patients receiving antiplatelet and/or anticoagulant treatment (AP/AC) during EUS-guided biliary drainage (BD) procedures. The aim of this study was to assess whether hemorrhagic adverse events associated with EUS-BD are increased in patients on AP/AC.

METHODS

Patients receiving AP/AC who underwent EUS-BD were retrospectively enrolled between May 2015 and August 2019. Patients who did not receive AP/AC and underwent EUS-BD in the same period were also enrolled as a control group.

RESULTS

One hundred ninety-five patients who underwent EUS-BD were enrolled in this study. Among these, 154 patients were allocated to the control group and 41 patients to the AP/AC group. Overall frequency of adverse events did not differ significantly between the control group (16.2%, 25/154) and AC/AP group (17.1%, 6/41; P = .80). The overall bleeding event rate was 3.6% (7/195), with no significant difference between the 2 groups. No thromboembolic events were observed with or without interruption of AP/AC. According to logistic regression analysis, the use of AP/AC was not a risk factor significantly associated with bleeding events (odds ratio, 2.96; 95% confidence interval, .56-14.0; P = .18). On the other hand, a long procedure time (>20 minutes) was an independent risk factor associated with bleeding events.

CONCLUSIONS

Bleeding events appear to be infrequent among patients who undergo EUS-BD while continuing AP/AC.

Comparison Study between Double Bare Covered and Fully Covered Metal Stent during Endoscopic Ultrasound-Guided Choledochoduodenostomy (with Video)

BACKGROUND

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is a common technique for biliary drainage. However, EUS-CDS is associated with adverse events such as cystic duct obstruction, stent dislocation, and stent kinking caused by powerful axial force. A novel double-bare, covered self-expandable metal stent (DBSEMS) has recently become available in Japan. This pilot study evaluated the clinical outcomes of EUS-CDS using DBSEMS.

METHOD

We retrospectively enrolled patients with malignant lower bile duct obstruction who underwent EUS-CDS due to failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-CDS procedures performed between April 2017 and March 2018 used a conventional fully covered self-expandable metal stent (FCSEMS), and those performed between April 2018 and April 2019 used DBSEMS. In all stents, the diameter was 10 mm and length was 6 cm.

RESULTS

A total of 22 patients underwent EUS-CDS, performed using conventional FCSEMS (n = 12) and DBSEMS (n = 10). Four complications occurred with FCSEMS: cholangitis due to kinking (n = 3) and stent dislocation (n = 1). With DBSEMS, there were no instances of kinking, and reflux cholangitis that developed in 1 patient due to duodenal obstruction was resolved by duodenal stenting. Elapsed time to recurrent biliary obstruction was longer with DBSEMS than FCSEMS (200 vs. 99 days), although the difference was not significant (p = 0.06).

CONCLUSION

BSEMS can help prevent cholangitis due to stent kinking after EUS-CDS, thus increasing stent patency.

Technical feasibility and safety of transluminal antegrade dilation for hepaticojejunostomy stricture using a novel fine-gauge electrocautery dilator (with video)

Background and study aims  A novel fine-gauge electrocautery dilator (ED) has recently become available in Japan. The current study evaluated the safety and feasibility of transluminal antegrade dilation for hepaticojejunal stricture (HJS) using this novel ED. Patients and methods  Patients who with complicated HJS were retrospectively enrolled. The primary and secondary endpoints of this study were rates of technical success defined as functional antegrade HJS dilation using the novel ED and types of adverse events, respectively. A total of 22 patients were enrolled. Among them, six were treated using an enteroscopic approach due to the absence of bile duct dilation or patient refusal to undergo EUS-HGS. Therefore, 16 patients underwent EUS-HGS. Results  The procedure was successful in 15 of 16 patients (93.8 %). The contrast medium flowed from the intrahepatic bile duct to the intestine of 14 of 15 patients (93.3 %). The resolution rate of HJS was 13 of 14 (92.9 %) at 6 months. Conclusion  Our technique might offer a new option with which to treat HJS, although a prospective study with long-term follow-up is needed.

Advances in the endoscopic management of malignant biliary obstruction

Biliary obstruction is common in pancreatobiliary malignancies and has a negative impact on the patient’s quality of life, postoperative complications, and survival rates. Particularly in the last decade, there has been enormous progress regarding the diagnostic and therapeutic options in patients with malignant biliary obstruction. Endoscopy has given a new insight in this direction and novel techniques have been developed for the better characterization and treatment of malignant strictures. We herein summarize the available data on the different endoscopic techniques, and clarify their role in the diagnosis and treatment of malignant biliary obstructive disease. Finally, we propose an algorithm that can facilitate management decisions in these patients.

Risk factors for adverse events associated with bile leak during EUS-guided hepaticogastrostomy

Background and Objective:

EUS-guided hepaticogastrostomy (HGS) is performed for patients with advanced cancer because of poor prognosis and compromised status, and bile peritonitis may prove critical for such patients. This adverse event has the possibility of decreasing quality of life by prolonging the time until the start of oral intake, hospital stay, or chemotherapy. Predictors of bile peritonitis in EUS-HGS thus have considerable clinical impact. The aim of this study was to retrospectively determine risk factors of bile peritonitis as adverse events of EUS-HGS.

Patients and Methods:

As risk factors of bile peritonitis, baseline characteristics of patients, characteristics of procedures such as number of punctures, types of fistula dilation, mean procedure time were analyzed. Furthermore, a receiver operating characteristic (ROC) curve was plotted to assess the influence of this distance and bile peritonitis and determine the optimum cutoff score for predicting the risk of bile peritonitis. Multivariate analysis using logistic regression was performed to examine factors of bile peritonitis.

Results:

A total of 68 patients were enrolled in this study. A distance of 2.50 cm offered 90.3% sensitivity and 87.5% specificity in predicting bile peritonitis according to the ROC curve. Number of punctures (>1), procedure time (>20 min), distance to the hepatic parenchyma (<2.50 cm), and presence of acute cholangitis were significantly associated with bile peritonitis in univariate analysis. However, according to this multivariate analysis, distance to the hepatic parenchyma (<2.50 cm, odds ratio 96.98, 95% confidence interval 10.12–929.12, P < 0.001) were only significantly associated with bile peritonitis.

Conclusions:

The short distance of hepatic parenchyma may be a risk factor of bile peritonitis.

Initial clinical experience of a steerable access device for EUS-guided biliary drainage

BACKGROUND AND AIMS

EUS-guided biliary drainage (EUS-BD) has been used as a rescue procedure after failed endoscopic retrograde cholangiography (ERC), and there is growing interest in EUS-BD as a primary therapy for distal malignant biliary obstruction. After EUS-guided needle puncture of an obstructed bile duct, directional control of wire advancement remains an area of need, potentially addressed by a new steerable EUS access system. The aim of this study was to evaluate the safety and efficacy of this novel steerable access system in patients undergoing EUS-BD after failed ERC.

METHODS

We performed a retrospective study of prospectively acquired data at 3 tertiary academic hospitals. Consecutive patients who had failed ERC followed by EUS-BD using the access device were included. Primary outcomes were safety and technical feasibility (successful completion of EUS-BD). Secondary outcomes were clinical success (75% improvement in liver function tests at 30 days) and device performance.

RESULTS

Twenty-two consecutive patients underwent EUS-BD between October 10, 2018 and March 3, 2019. Needle puncture and selective wire advancement in the intended direction were both successful in 100% of cases (22/22). Technical success was 95% (21/22). Fifty-nine percent (13) underwent rendezvous, 32% (7) underwent choledochoduodenostomy, and 4.5% (1) underwent hepaticogastrostomy. One patient (4.5%) underwent percutaneous transhepatic cholangiography. There were no cases of wire shearing. The adverse event rate was 4.5% (mild pancreatitis in 1 patient). There was no bile leak, bleeding, or death at 30 days' follow-up.

CONCLUSIONS

This first clinical experience with a steerable access system for EUS-BD suggests it is safe and effective, particularly with regard to controlling direction of wire advancement.

Choledochoduodenostomy: Outcomes and limitations

The EUS-guided biliary drainage (EUS-BD) has gained broad acceptance as the preferred approach after failed ERCP for malignant biliary obstruction. Despite the drainage route, namely, transhepatic or transduodenal, the technical and clinical success rates are high. Because of such good outcomes with tolerable adverse events (AEs) rate, the EUS-BD might soon even replace the ERCP for primary biliary decompression in patients at high risk of failed biliary cannulation. Among the EUS-BD techniques, the choledochoduodenostomy seems to carry the lower risk of AEs and should be considered the first-line EUS approach for biliary decompression.

Endoscopic Ultrasound-guided Gastroenterostomy: A Promising Alternative to Surgery

Recently, with the advancement of techniques, endoscopic ultrasound-guided therapies have shown distinct advantages, especially in relieving benign and malignant gastric outlet obstruction (GOO), as well as in postoperative pancreaticobiliary diseases. Herein, we present five currently used approaches in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumenapposing biflanged metal stents (LAMS), along with several examples of LAMS-based EUS treatment of pancreaticobiliary diseases. Compared with traditional treatment methods, EUS-guided procedures have – to some degree – shown higher success rates, both technical and clinical. Moreover, EUS-guided therapies reduce the risk of multiple surgical adverse events, including delayed gastric emptying, prolonged hospital stay, increased costs, and delay in cancer treatment. Particularly in terms of postoperative pancreaticobiliary diseases, EUS-guided therapy has assumed an essential role as a treatment option in cases where traditional methods are difficult to perform. Nevertheless, EUS-guided gastrointestinal procedures are still relatively new, with some clinical failures, and additional prospective clinical trials are warranted.

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.

Comprehensive review on EUS-guided biliary drainage

Feasibility of endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage is not always applicable due to anatomical alterations or to inability to access the papilla. Percutaneous transhepatic biliary drainage has always been considered the only alternative for this indication. However, endoscopic ultrasonography-guided biliary drainage represents a valid option to replace percutaneous transhepatic biliary drainage when ERCP fails. According to the access site to the biliary tree, two kinds of approaches may be described: the intrahepatic and the extrahepatic. Endoscopic ultrasonography-guided rendez-vous transpapillary drainage is performed where the second portion of the duodenum is easily reached but conventional ERCP fails. The recent introduction of self-expandable metal stents and lumen-apposing metal stents has improved this field. However, the role of the latter is still controversial. Echoendoscopic transmural biliary drainage can be challenging with potential severe adverse events. Therefore, trained endoscopists, in both ERCP and endoscopic ultrasonography are needed with surgical and radiological backup.