• Humans
• Bile Duct Neoplasms/complications
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis/etiology
• Cholestasis/surgery
• Drainage/methods
• Endosonography/methods
• Operative Time
• Pancreatic Neoplasms/complications
• Pancreatitis/complications
• Randomized Controlled Trials as Topic
• Stents
• Treatment Outcome
• Ultrasonography, Interventional

• Choledochoduodenostomy
• ERCP
• Hepaticogastrostomy
• Lumen-apposing metal stent
• Transhepatic biliary drainage

• Humans
• Drainage/methods
• Drainage/instrumentation
• Endosonography/methods
• Ultrasonography, Interventional/methods
• Stents
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis/surgery
• Cholestasis/diagnostic imaging

• biliary stricture
• endoscopic ultrasonography
• gastroenterology
• minimally invasive techniques
• therapeutic endoscopy

• Humans
• Male
• Female
• Drainage/methods
• Retrospective Studies
• Middle Aged
• Endosonography/methods
• Aged
• Adult
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Treatment Outcome
• Aged, 80 and over
• Cholestasis/surgery
• Cholestasis/diagnostic imaging
• Stents
• Jaundice, Obstructive/surgery
• Jaundice, Obstructive/diagnostic imaging

• Acute cholecystitis
• Endoscopic ultrasound-guided gallbladder drainage
• Gallbladder drainage
• Interventional endoscopic ultrasound
• Lumen-apposing metal stents
• Malignant obstruction

• Humans
• Gallbladder/diagnostic imaging
• Gallbladder/surgery
• Stents
• Endosonography/methods
• Drainage/adverse effects
• Drainage/methods
• Cholecystitis, Acute/surgery
• Ultrasonography, Interventional
• Treatment Outcome

• Humans
• Male
• Aged
• Female
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholestasis/etiology
• Cholestasis/surgery
• Retrospective Studies
• Endosonography/methods
• Pancreatic Neoplasms
• Drainage/methods
• Stents/adverse effects
• Ultrasonography, Interventional

• Choledochoduodenostomy
• EUS-guided biliary drainage
• Endoscopic ultrasonography
• Lumen-apposing metal stent
• Obstructive jaundice

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.

To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.

We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms “lumen apposing metal stent”, “LAMS”, “endoscopic ultrasound” and “choledochoduodenostomy” or “gallbladder” or “pancreatic fluid collections”. We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.

The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.

LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

• Lams misdeployment
• Endoscopic ultrasound-guided drainage
• Lams maldeployment
• Biliary drainage
• Gallbladder drainage
• Pancreatic fluid collections
• Lumen-apposing metal stents

• Humans
• Treatment Outcome
• Endosonography/adverse effects
• Endosonography/methods
• Stents/adverse effects
• Pancreatic Diseases
• Ultrasonography, Interventional/adverse effects
• Ultrasonography, Interventional/methods
• Drainage/adverse effects
• Drainage/methods

• endosonography
• choledochostomy
• biliary tract neoplasms
• stents
• cholestasis
• endossonografia
• coledocostomia
• neoplasias do sistema biliar
• colestase

• Stents
• Endosonography/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Drainage/methods
• Ultrasonography, Interventional

• acute cholangitis
• biliary drainage
• disseminated intravascular coagulation
• endoscopic retrograde cholangiopancreatography
• recombinant thrombomodulin

• Biliary drainage
• Double guidewire
• Endoscopic ultrasound
• Endoscopic ultrasound-guided hepaticogastrostomy
• Interventions

• Humans
• Endosonography/methods
• Cholestasis/etiology
• Retrospective Studies
• Treatment Outcome
• Drainage/methods
• Stents/adverse effects
• Ultrasonography, Interventional/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods

• Adverse events
• Biliary tract
• Dilation
• Endoscopic ultrasound-guided hepaticogastrostomy

• Humans
• Dilatation
• Propensity Score
• Feasibility Studies
• Gastrostomy/adverse effects
• Gastrostomy/methods
• Endosonography/methods
• Stents/adverse effects
• Ultrasonography, Interventional/adverse effects
• Plastics
• Drainage/methods
• Cholestasis/etiology

• EUS
• EUS-guided biliary drainage
• adverse event
• elderly
• sedation

Obstructive jaundice induced by pancreatic adenocarcinoma is typically treated with biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP)‐guided biliary drainage (ERCP‐BD). Recently, endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) was employed as an alternative method after ERCP‐BD failed. We aimed to determine the efficacy and safety of EUS‐BD for primary biliary drainage.

Between December 2011 and February 2019, at Kawasaki General Medical Center, we retrospectively enrolled 33 patients who had undergone endoscopic biliary drainage with a metal stent, in a first attempt to relieve obstructive jaundice caused by unresectable pancreatic adenocarcinoma. We compared the technical and clinical outcomes between ERCP‐BD and EUS‐BD.

Twenty‐three patients underwent ERCP‐BD and 10 underwent EUS‐BD. Both groups achieved 100% technical success. The clinical success rates were similar between the groups: 91% (21/23 patients) for ERCP‐BD and 100% (10/10 patients) for EUS‐BD (P = 0.48). Biliary obstruction recurred in 6/23 patients (26%) treated with ERCP‐BD and 1/10 patients (10%) treated with EUS‐BD (P = 0.40). Other adverse events occurred in 4/23 patients (17%) in the ERCP‐BD group and 1/10 patients (10%) in the EUS‐BD group (P = 0.99).

We suggest that EUS‐BD could be employed for primary biliary drainage in patients with obstructive jaundice caused by unresectable pancreatic adenocarcinoma.

• Biliary Tract Surgical Procedures/adverse effects
• Biliary Tract Surgical Procedures/methods
• Drainage
• Endosonography
• Humans
• Retrospective Studies
• Stents
• Ultrasonography, Interventional/adverse effects
• United States

• biliary drainage
• cholecystitis
• endoscopic ultrasound
• gallbladder drainage
• jaundice
• lumen-apposing metal stents
• malignant biliary obstruction

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

• Endoscopic ultrasound-guided biliary drainage
• Malignant bile duct obstruction
• Endoscopic ultrasound-guided hepaticogastrostomy
• Endoscopic ultrasound-guided rendezvous technique
• Endoscopic ultrasound-guided choledochoduodenostomy
• Endoscopic ultrasound-guided antegrade stenting
• Endoscopic retrograde cholangiopancreatography

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

• benign biliary stricture
• biliary drainage
• guidelines
• malignant biliary strictures
• percutaneous transhepatic biliary drainage

• Bile Ducts
• Drainage
• Endosonography
• Humans
• Pancreas
• Ultrasonography, Interventional

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP for distal biliary obstruction in expert hands. Various routes for EUS-guided access in distal biliary obstruction include EUS choledochoduodenostomy, EUS-guided rendezvous, and EUS-antegrade (EUS-AG) stent placement. While percutaneous transhepatic biliary drainage and ERCP are established modalities in management of malignant hilar biliary obstruction, the role of EUS-BD is emerging. Various methods of drainage in hilar obstruction include EUS hepaticogastrostomy, EUS hepaticoduodenostomy, EUS-guided bridging stent placement, and combined ERCP and EUS-guided biliary drainage. In this review, we discuss the role of EUS-BD in malignant hilar biliary obstruction with the currently available evidence, along with the limitations and challenges to the use of this modality in management of these patients.

• EUS
• biliary drainage
• hilar biliary obstruction
• neoplasms

• Bile duct cannulation
• Biliary access
• Biliary drainage
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Endoscopic ultrasound (EUS)

• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis/therapy
• Endosonography/methods
• Humans
• Randomized Controlled Trials as Topic
• Ultrasonography, Interventional/methods

• Biliary drainage
• Biliary obstruction
• Choledochoduodenostomy
• Endoscopic ultrasound
• Gallbladder drainage
• Hepaticogastrostomy
• Rendez-vous technique

Although several techniques for endoscopic ultrasound-guided biliary drainage (EUS-BD) are available at present, an optimal treatment algorithm of EUS-BD has not yet been established.

To evaluate the clinical utility of treatment method conversion during single endoscopic sessions for difficult cases in initially planned EUS-BD.

This was a single-center retrospective analysis using a prospectively accumulated database. Patients with biliary obstruction undergoing EUS-BD between May 2008 and April 2016 were included. The primary outcome was to evaluate the improvement in EUS-BD success rates by converting the treatment methods during a single endoscopic session. Secondary outcomes were clarification of the factors leading to the conversion from the initial EUS-BD and the assessment of efficacy and safety of the conversion as judged by technical success, clinical success, and adverse events (AEs).

A total of 208 patients underwent EUS-BD during the study period. For 18.8% (39/208) of the patients, the treatment methods were converted to another EUS-BD technique from the initial plan. Biliary obstruction was caused by pancreatobiliary malignancies, other malignant lesions, biliary stones, and other benign lesions in 22, 11, 4, and 2 patients, respectively. The reasons for the difficulty with the initial EUS-BD were classified into the following 3 procedures: Target puncture (n = 13), guidewire manipulation (n = 18), and puncture tract dilation (n = 8). Technical success was achieved in 97.4% (38/39) of the cases and clinical success was achieved in 89.5% of patients (34/38). AEs occurred in 10.3% of patients, including bile leakage (n = 2), bleeding (n = 1), and cholecystitis (n = 1). The puncture target and drainage technique were altered in subsequent EUS-BD procedures in 25 and 14 patients, respectively. The final technical success rate with 95%CI for all 208 cases was 97.1% (95%CI: 93.8%-98.9%), while that of the initially planned EUS-BD was 78.8% (95%CI: 72.6%-84.2%).

Among multi-step procedures in EUS-BD, guidewire manipulation appeared to be the most technically challenging. When initially planned EUS-BD is technically difficult, treatment method conversion in a single endoscopic session may result in successful EUS-BD without leading to severe AEs.

• Endoscopic ultrasound
• Endoscopic ultrasound-guided biliary drainage
• Interventional endoscopic ultrasound
• Biliary drainage
• Biliary obstruction

• Adult
• Aged
• Aged, 80 and over
• Algorithms
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/diagnostic imaging
• Bile Duct Neoplasms/therapy
• Bile Ducts/pathology
• Cholestasis/complications
• Cholestasis/diagnostic imaging
• Cholestasis/therapy
• Colonic Neoplasms/complications
• Colonic Neoplasms/diagnostic imaging
• Colonic Neoplasms/therapy
• Drainage
• Endoscopy
• Endosonography
• Female
• Gallstones/complications
• Gallstones/diagnostic imaging
• Gallstones/therapy
• Humans
• Male
• Middle Aged
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/diagnostic imaging
• Pancreatic Neoplasms/therapy
• Retrospective Studies
• Stomach Neoplasms/complications
• Stomach Neoplasms/diagnostic imaging
• Stomach Neoplasms/therapy
• Treatment Outcome
• Ultrasonography