We aimed to determine risk factors for technical failure of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), evaluate short- and long-term consequences, and identify salvage techniques in patients with biliary obstruction.

 This retrospective multicenter study of EUS-CDS (2018-2024) included technical failure, classified as type 1 (digestive flange mispositioned), type 2 (biliary flange mispositioned), type 3 (stent deployment failure), type 4 (catheter/lumen-apposing metal stent [LAMS] through the bile duct), and type 5 (others). Controls were successful EUS-CDS in the same center and period. The primary end point was risk factors for failure. Secondary end points were endoscopic rescue techniques and immediate- and long-term consequences.

 Technical failure occurred in 7 % (95 %CI 5-9). Across 23 centers, 296 patients were analyzed (mean age 71 [SD 16] years, 53 % male), including 100 technical failures: type 1 (26 %), type 2 (41 %), type 3 (11 %), type 4 (6 %), type 5 (16 %). Risk factors for technical failure in multivariate analysis included CBD diameter ≤ 15 mm, duodenal stenosis, wired technique, and low operator experience (≤ 10 LAMS). Endoscopic salvage was successful in 77 %, with 53 % using a covered metal stent and 22 % using a new LAMS. Early failures were mild in 56 % of cases, but 12 % resulted in death within 30 days. Immediate endoscopic salvage reduced severe clinical adverse events (P < 0.001) and increased success rates (P < 0.001).

 EUS-CDS failures were not rare and were severe in half of cases. Recognizing risk factors, identifying failures during the procedure, and knowing endoscopic salvage methods are crucial.

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.

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.

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.

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.).

Percutaneous transhepatic bile duct stent insertion is a useful alternative to the endoscopic approach for malignant biliary strictures. This study retrospectively reviewed the cases of percutaneous metallic stent insertion at our institution to evaluate its safety and usefulness.

The study included cases of percutaneous bile duct stent insertion performed between April 2016 and August 2024. All patients included those with malignant biliary obstruction and those in whom an endoscopic approach was first attempted but could not reach or cannulate the papilla of Vater. Two procedures were used: a two-stage procedure, in which a drain was inserted to create an external or internal fistula, followed by stent insertion, and a one-stage procedure, in which the stent was inserted at the same time as the approach to the bile duct. The causes of biliary strictures and complications were examined.

The study included 14 cases: seven patients had pancreatic head cancer, including biliary tract cancer (n = 4) and postoperative gastric cancer (n = 3); three patients who underwent a one-stage insertion. The number of inserted stents tended to increase in patients with postoperative cholangiocarcinoma recurrence. No complication occurred in any patient. One patient had severe cholangitis, eight had moderate cholangitis, and four had mild cholangitis; two patients who underwent one-stage procedures had moderate cholangitis and one had mild cholangitis. In cases of two-stage expandable metal stent (EMS) insertion, the average time from initial drainage to EMS insertion was 10.5 days (4-25).

The stent can be safely inserted in a one-stage procedure without compromising the patient's quality of life. Therefore, one-stage insertion of EMS for malignant biliary stricture may be performed aggressively unless the patient has severe cholangitis.

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative to percutaneous transhepatic biliary drainage (PTBD) for cases with obstructive jaundice in which the bile duct obstruction is below the confluence of the cystic ducts. This retrospective study aimed to evaluate the usefulness of PTGBD and PTBD in patients with obstructive jaundice. We recruited patients who had undergone percutaneous biliary drainage for acute cholangitis and obstructive jaundice at two institutions between January 2017 and March 2024. In principle, PTBD was the first choice. PTGBD was selected for cases where the intrahepatic bile duct diameter was ≤ 5 mm or ≥ 6 mm with significant respiratory-related variability of the positioning of the bile ducts. In other cases, PTBD was chosen. Fifty-five patients were included in this analysis. However, patients with intrahepatic or hilar bile duct stenosis, post choledocholithiasis, complex cholecystitis, total bilirubin levels of < 2.0 mg/dL, and uncorrectable bleeding tendency and those who had undergone the procedure and later discontinued without puncture were excluded. The technical success rates, clinical success rates, and complication rates of the procedure were evaluated. The technical success rates were 96.3% (26/27) and 82.1% (23/28) in the PTGBD and PTBD groups, respectively. The clinical success rates were 85.2% (23/27) and 67.9% (19/28) in the PTGBD and PTBD groups, respectively. The complication rates were 18.5% (5/27) and 25.0% (7/28) in the PTGBD and PTBD groups, respectively. No serious complications were observed in either group. Hence, the two groups did not significantly differ in any of the endpoints. The outcomes of PTGBD were comparable to those of PTBD in patients with obstructive jaundice. Hence, PTGBD is a reasonable treatment option for cases of obstructive jaundice in which PTBD is not feasible.

Endoscopic ultrasound (EUS)-guided lumen-apposing metal stent (LAMS) placement is increasingly being used in lieu of surgery for multiple procedures, including transmural fluid drainage. However, few studies have evaluated adverse events (AEs) associated with LAMS placement. Our aim was to characterize the rates of AEs associated with several LAMS placement strategies across different procedures and indications.

A single-center retrospective cross-sectional study was conducted on patients who underwent EUS-guided LAMS placement between 2015 and 2023 at a single institution. Technical and clinical success rates and rates of early and late AEs were analyzed. Comparisons of AE rates were determined for patients who had LAMS dilation versus those without dilation, patients who had plastic stent placement in addition to LAMS placement versus those with no plastic stents, and patients who had combined dilation and plastic stent procedures versus those with LAMS dilation only.

A total of 243 patients underwent EUS-guided LAMS interventions: 110 (45.3%) women and 133 (54.7%) men (mean age 53.7 ± 15.9 years). There were 96 (39.5%) patients who had at least one AE. Abdominal pain was the most common early and late AE. Plastic stent placement alongside LAMS placement was associated with a significantly higher rate of overall AEs (48.3% vs 29.9%; P = 0.009), late AEs (33% vs 17.9%; P = 0.021), and stent occlusion (5.7% vs 0%; P = 0.046). LAMS dilation was associated with higher rates of late AEs (34.2% vs 20.6%; P = 0.022) and stent occlusion (6.2% vs 1.0%; P = 0.049).

LAMS placement showed high technical and clinical success rates across different indications with mostly mild AEs, suggesting that LAMSs may be safe and effective for pancreatic and biliary drainage.

Whether metal stents (MS) or plastic stents (PS) yield better outcomes for malignant biliary obstruction in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is controversial. We aimed to compare outcomes of initial EUS-HGS performed with MS or PS.

In this single-center retrospective study, we included patients (MS/PS groups: n = 151/72) with unresectable malignant biliary obstruction and performed multivariable analysis. The landmark date was defined as day 100 and used to evaluate the time to recurrent biliary obstruction (TRBO).

The clinical success rate was similar in both groups. The mean total bilirubin percentage decrease at week 2 was significantly higher in the MS group than in the PS group (-45.1% vs. -23.7%, P = 0.016). Median TRBO was significantly different between the MS and PS groups (183 and 92 days, respectively; P = 0.017). TRBO within 100 days was comparable in both groups but was significantly shorter only after 100 days in the PS group (adjusted hazard ratio 12.8, P < 0.001). Adverse events were significantly more common in the MS group (23.8% vs. 9.7%, P = 0.012), although they occurred relatively frequently even with PS in the cholangitis subgroup (Pinteraction = 0.034). After endoscopic re-intervention, TRBO tended to be longer with revision PS (hazard ratio 0.40, P = 0.47).

Although MS provided early improvement of jaundice and long stent patency, PS provided a better safety profile and comparable stent patency until 100 days. PS might also be an adequate and optimal palliation method in EUS-HGS.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for the diagnosis and treatment of biliary diseases. However, selective biliary cannulation, the essential first step in ERCP, can sometimes fail due to anatomical variations or technical limitations. In these cases, the endoscopic ultrasound-guided rendezvous technique (EUS-RV) offers a valuable salvage option. Nevertheless, it is crucial to be aware of potential adverse events associated with bile duct puncture. To optimize the success rate and safety of EUS-RV, understanding the basic techniques, technical tips for each procedural step, and troubleshooting strategies for potential difficulties is essential. This review article summarizes the clinical outcomes and technical considerations of EUS-RV, including a comprehensive analysis of the current evidence.

Duodenal invasion (DI) is a risk factor for early recurrent biliary obstruction (RBO) in endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) may reduce early RBO in cases of asymptomatic DI, even when ERCP is possible.

We enrolled 56 patients with pancreatic cancer and asymptomatic DI who underwent EUS-HGS (n=25) or ERCP-BD (n=31). Technical and clinical success, early (<3 months) and overall RBO rates, time to RBO (TRBO), and adverse events were compared between the EUS-HGS and ERCP-BD groups. Risk factors for early RBO were also evaluated.

Baseline characteristics were similar between the groups. Both procedures demonstrated 100% technical and clinical success rates, with a similar incidence of adverse events (48% vs. 39%, p=0.59). While the median TRBO was comparable (5.7 vs. 8.8 months, p=0.60), EUS-HGS was associated with a lower incidence of early RBO compared to ERCP-BD (8% vs. 29%, p=0.09). The major causes of early RBO in ERCP-BD were sludge and food impaction, rarely occurring in EUS-HGS. EUS-HGS was potentially reduced early RBO (odds ratio, 0.32; p=0.07).

EUS-HGS can be a viable option for treating pancreatic cancer with asymptomatic DI.

Pancreatic cancer is a highly aggressive malignancy with a profoundly poor prognosis. Clinically, the condition most frequently manifests with symptoms including painless jaundice, abdominal discomfort, and back pain. Early diagnosis and the implementation of effective therapeutic strategies are critical for improving patient survival outcomes. However, merely 10-20% of patients are diagnosed at an early stage, with the majority presenting at advanced stages, often with metastasis. Consequently, early detection and intervention are crucial for enhancing prognosis. The widespread adoption of endoscopic ultrasonography (EUS) technology in recent years has significantly enhanced the diagnostic accuracy for pancreatic space-occupying lesions. EUS is increasingly recognized for its pivotal role in alleviating malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and refractory pain in advanced pancreatic cancer. This article aims to provide an overall review of the current applications of EUS in the diagnosis and treatment of pancreatic cancer, exploring its advantages and limitations in early screening, diagnosis, and palliative care. Furthermore, this review explores potential future directions in the field, aiming to provide valuable insights to inform and enhance the clinical management of pancreatic cancer.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has dramatically spread and improved in the last two decades and is changing the paradigm of drainage in case of malignant biliary obstruction (MBO). EUS-BD can be achieved from different routes, including the common bile duct (choledochoduodenostomy), intrahepatic bile ducts (hepaticogastrostomy), and gallbladder as a rescue (cholecystogastrostomy/cholecystoduodenostomy). EUS-guided hepaticogastrostomy (EUS-HGS) is a valuable option for biliary drainage in MBO when ERCP fails or is not feasible. EUS-HGS has demonstrated high efficacy with a good rate of technical and clinical success. The safety profile is also overall favorable, although severe adverse events may occur in a significant proportion of patients. From a technical perspective, EUS-HGS is considered one of the most demanding procedures in biliopancreatic endoscopy, requiring multiple steps and high technical skills and experience. In this comprehensive review, technical tips and clinical outcomes of EUS-HGS are reviewed according to the latest evidence in the literature.

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.

Combining antegrade stenting (AGS) and hepaticogastrostomy (HGS) is an increasingly used endoscopic ultrasound-guided intervention when stenting by endoscopic retrograde cholangiopancreatography is impossible.

We comprehensively assessed the benefits and downsides of combined AGS and HGS (HGS procedure with AGS, HGAS).

From 788 HGS and 295 HGAS cases, a random-effects meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Five electronic databases were searched for studies on HGS with or without AGS from inception until May 2024. The odds ratio (OR) and pooled rates were used for single and two-arm comparisons with 95% confidence intervals (CI).

From 26 eligible studies. The pooled technical and clinical success was 94% (CI: 92%-96%) and 88% (CI: 84%-91%) for HGS and 89% (CI: 83%-93%) and 94% (CI: 89%-97%) for HGAS, respectively. Pooled OR of HGAS and HGS showed an OR = 0.38 (CI: 0.07-2.00) for technical success and an OR = 1.02 (CI: 0.50-2.06) for clinical success. The pooled adverse event rates were 20% (CI: 16%-25%) for HGS and 14% (CI: 9%-20%) for HGAS, whereas pooled OR showed an OR = 1.09 (CI: 0.30-3.94). For re-intervention, an OR = 0.37 (CI: 0.27-0.52) was found. Time to stent dysfunction increased, HGAS 333 (CI: 280-Not reached) and HGS 209 (CI: 120-325) with no change in overall survival HGS 117 (CI: 94-147) and 140 (CI: 105-170).

The use of HGAS appears to increase clinical success and reduce the need for re-intervention. Overall adverse event rates were similar but bile leakage prevalence was decreased. Time to stent dysfunction seems to increase with no change in overall survival.

Our protocol was prospectively registered with PROSPERO (CRD42024509412).

EUS-guided gastroenterostomy (EUS-GE) is a novel and effective procedure for the management of malignant gastric outlet obstruction (GOO) with more durable results when compared to enteral stenting (ES). However, data comparing EUS-GE to ES in patients already treated with EUS-guided choledocoduodenostomy (EUS-CDS) for distal malignant biliary obstruction (DMBO) are lacking. We aimed to compare outcomes of EUS-GE and ES for the palliation of GOO in this specific population of patients.

A multicenter, retrospective analysis of patients with DMBO treated by EUS-CDS and subsequent GOO treated by EUS-GE or ES from 2016 to 2021 was conducted. Primary outcomes were overall AEs rate and dysfunction of the EUS-CDS after GOO treatment. Secondary outcomes included clinical success, technical success, procedure duration, length of hospital stay and relapse of GOO symptoms.

A total of 77 consecutive patients were included in the study: 25 patients underwent EUS-GE and 52 underwent ES. AEs rate and patency outcomes of the EUS-CDS after GOO treatment were comparable between the two groups (12.5% vs. 17.3%; p = 0.74). No recurrence of GOO symptoms was registered in the EUS-GE group while 11.5% of ES patients had symptoms recurrence, even if not statistically significant (p = 0.16), after a mean follow-up period of 63.5 days.

EUS-GE and ES are both effective and safe for the palliation of GOO in patients already treated by EUS-CDS for DMBO with no difference in the biliary stent dysfunction rate and overall AEs. EUS-GE is associated with less recurrence of GOO symptoms.

Lumen-apposing metal stents have ushered a new frontier for interventional endoscopic ultrasound. Initial use for the drainage of pancreatic fluid collections has rapidly expanded to the bile duct, gallbladder and small bowel. Intra-luminal applications for short strictures have also emerged. Electrocautery enhancement has made the stent delivery speedy. While the advent of lumen-apposing metal stents (LAMS) has brought a paradigm shift in the practice of interventional endoscopic ultrasound, their use is associated with certain technicalities that any advanced endosonologist should know. Understanding indications for LAMS is critical and their use in appropriate settings. Troubleshooting in tricky situations is always a challenge and the background considerations for their use include knowing the target organ, cautery and puncture technique, managing partially opened LAMS and also managing maldeployment. In this review, we discuss the intricacies and technical tips for the use of lumen-apposing metal stents.

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) includes EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided gallbladder drainage (EUS-GBD), EUS-guided antegrade stenting (EUS-AG) and EUS-guided rendezvous (EUS-RV). While EUS-HGS, EUS-CDS and EUS-GBD are transluminal drainage procedures, EUS-AG is a traspapillary drainage procedure and EUS-RV is a procedure intended to facilitate endoscopic retrograde cholangio pancreatography (ERCP) in instances of failed cannulation. These procedures were initially developed as options for endoscopic salvage of failed ERCP, but have evolved to become first-line interventions also for select indications over time as the technique and expertise improved. Several randomised controlled trials have demonstrated EUS-BD, especially EUS-CDS has similar or even better outcomes as compared to ERCP in malignant biliary obstruction. However, widespread adoption of these modalities is limited by the availability of expertise, steep learning curve, lack of standardization of techniques and cost. In this review, we aim to provide an overview of various EUS-BD procedures including the indications, accessories, technique, outcomes and follow-up of each of these procedures.

Commentary on the article written and published by Peng et al, investigating the role of endoscopic ultrasound (EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography (ERCP). For 40 years endoscopic biliary drainage was synonymous with ERCP, and EUS was used mainly for diagnostic purposes. The advent of therapeutic EUS has revolutionized the field, especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents. Complete biliopancreatic endoscopists with both skills in ERCP and in interventional EUS, would be ideally suited to ensure patients the best drainage technique according to each individual situation.

In this editorial, we comment on the article by Peng et al. Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage. The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound, endoscopic ultrasound (EUS), or both. Endoscopic retrograde cholangiopancreatography (ERCP) has been primarily recommended for the management of biliary obstruction, while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage (PTBD) are alternative choices for cases where ERCP has failed or is impossible. PTBD is limited by shortcomings of a higher rate of adverse events, more reinterventions, and severe complications. EUS-guided biliary drainage has a lower rate of adverse events than PTBD. EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) enables EUS-guided biliary-enteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire. The present meta-analysis showed that ECE-LAMS has a high efficacy and safety in relieving biliary obstruction in general, although the results of LAMS depending on the site of biliary obstruction. This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Increasing evidence supports EUS-guided biliary drainage (EUS-BD) as a potential alternative to ERCP-guided biliary drainage (ERCP-BD) in the primary treatment of malignant biliary obstruction (MBO). This systematic review and meta-analysis aimed to compare the efficacy and safety of both techniques as the initial approach for MBO.

We systematically searched in MEDLINE, Embase, and Cochrane databases for randomized controlled trials comparing both techniques and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model, and I2 statistics were used to evaluate heterogeneity.

We included 6 randomized controlled trials (577 patients). There were no significant differences between both groups in terms of stent patency (mean difference [MD], 8.18 days; 95% confidence interval [CI], -22.55 to 38.91), procedure time (MD, -6.31 minutes; 95% CI, -12.68 to 0.06), and survival (MD, 4.59 days; 95% CI, -34.23 to 43.40). Technical success (risk ratio [RR], 1.04; 95% CI, 0.96-1.13), clinical success (RR, 1.02; 95% CI, 0.96-1.08), overall adverse events (RR, 0.58; 95% CI, 0.24-1.43), and cholangitis (RR, 1.19; 95% CI, 0.39-3.61) were also similar between groups. However, the hospital stay was significantly shorter (MD, -1.03 days; 95% CI, -1.53 to -0.53), and the risk of reintervention (RR, 0.57; 95% CI, 0.37-0.88), postprocedure pancreatitis (RR, 0.15; 95% CI, 0.03-0.66), and tumor ingrowth/overgrowth (RR, 0.28; 95% CI, 0.11-0.70) were significantly lower with EUS-BD.

EUS-BD and ERCP-BD had similar efficacy and safety as the initial approach for MBO. However, EUS-BD had a significantly lower risk of reintervention, postprocedure pancreatitis, tumor ingrowth/overgrowth, and reduced hospital stay.

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative option for biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Limited data exist on the safety and efficacy of EUS-HGS. In this comprehensive meta-analysis, we aim to study the safety and efficacy of EUS-HGS in cases of failed conventional ERCP. Methods: Embase, PubMed, and Web of Science databases were searched to include all studies that evaluated the efficacy and safety of EUS-HGS. Using the random effect model, the pooled weight-adjusted event rate estimate for clinical outcomes in each group were calculated with 95% confidence intervals (CIs). The primary outcomes were technical and clinical success rates. Secondary outcomes included overall adverse events (AEs), rates of recurrent biliary obstruction (RBO), and rates or re-intervention. Results: Our analysis included 70 studies, with a total of 3527 patients. The pooled technical and clinical success rates for EUS-HGS were 98.1% ([95% CI, 97.5-98.7]; I2 = 40%) and 98.1% ([95% CI, 97.5-98.7]; I2 = 40%), respectively. The pooled incidence rate of AEs with EUS-HGS was 14.9% (95% CI, 12.7-17.1), with bile leakage being the most common (2.4% [95% CI, 1.7-3.2]). The pooled incidence of RBO was 15.8% [95% CI, 12.2-19.4], with a high success rate for re-intervention (97.5% [95% CI, 94.7-100]). Conclusions: Our analysis showed high technical and clinical success rates of EUS-HGS, making it a feasible and effective alternative to ERCP. The ongoing development of dedicated devices and techniques is expected to make EUS-HGS more accessible and safer for patients in need of biliary drainage.

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.

With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.

Endoscopic transpapillary biliary stenting via endoscopic retrograde cholangiopancreatography is the preferred therapy for benign and malignant distal biliary obstruction. In cases of failed endoscopic retrograde cholangiopancreatography, endoscopic ultrasound-guided choledochoduodenostomy has been shown to be as effective as percutaneous methods with an improved safety profile. Despite its efficacy, it is complicated by stent occlusion in 9%-26% of cases. To our knowledge, this is the first case in which biliary obstruction was relieved by performing a rendezvous procedure utilizing a pre-existing choledochoduodenostomy.

<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.

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.

During endoscopic ultrasound-guided biliary drainage (EUS-BD), there is a risk for bile leakage until stent deployment, which can result in severe peritonitis, particularly when passing a drainage stent becomes challenging despite tract dilation. There is no established method or dedicated device to optimize EUS-BD. Therefore, we have developed a novel stent deployment technique using the tapered sheath dilator. To address the safety and technical aspects of the EUS-BD technique, we retrospectively analyzed 11 consecutive patients who underwent EUS-BD using the tapered sheath dilator. The procedure involved the insertion of a guidewire, followed by mechanical dilation using the tapered sheath dilator. Subsequently, the inner catheter was removed and drainage stents (up to 6 Fr in diameter) were deployed through the outer sheath. We found a 100% technical success rate for tract dilation and stent deployment; moreover, all patients achieved clinical success. The median time for dilation was 40 s (range, 8-198), whereas the median time from dilation to stent deployment was 10 min (range, 6-19). Notably, no cases of bile leakage or peritonitis were observed. In conclusion, the use of the integrated device for tract dilation and stent delivery system might provide a safe and straightforward technique for drainage stenting during EUS-BD.

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.

We compared the long-term outcomes between the techniques.

Retrospective comparative study.

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.

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.

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.

Background and study aims EUS-guided choledochoduodenostomy (EUS-CDS) is a minimally invasive procedure used to treat malignant biliary obstruction (MBO) by transduodenal placement of a lumen-apposing metal stent (LAMS) into the extrahepatic bile duct. To identify factors that contribute to safe and effective EUS-CDS using LAMS, we performed a systematic review of the literature and meta-analysis. Methods The methodology of our analysis was based on PRISMA recommendations. Electronic databases (Medline, Scopus, EMBASE) were searched up to November 2022. Full articles that included patients with distal malignant biliary obstruction who underwent EUS-CDS using LAMS after failed endoscopic retrograde cholangiopancreatography were eligible. Random-effect meta-analysis was performed reporting pooled rates of technical success, clinical success, and adverse events (AEs) by means of a random model. Multivariate meta-regression and subgroup analysis were performed to assess possible associations between the outcomes and selected variables to assess the correlation between outcomes and different variables. Results were also stratified according to stent size. Results Twelve studies with 845 patients were included in the meta-analysis. Pooled technical and clinical success rates were 96% (95% confidence interval [CI] 94%-98%; I 2 = 52.29%) and 96% (95%CI 95%-98%), respectively, with no significant association with baseline characteristics, such are sex, age, common bile duct diameter, or stent size. The pooled AE rate was 12% (95%CI: 8%-16%; I 2 = 71.62%). The AE rate was significantly lower when using an 8 × 8 mm stent as compared with a 6 × 8 mm LAMS (odds ratio 0.59, 0.35-0.99; P = 0.04), with no evidence of heterogeneity (I 2 = 0%). Conclusions EUS-CDS with LAMS is a safe and effective option for relief of MBO. Selecting an appropriate stent size is crucial for achieving optimal safety outcomes.

To evaluate outcomes of ERCP as first-line management in patients with malignant biliary obstruction (MBO) of all causes and stages, reflecting a real-life setting.

Retrospective observational study of patients with ERCP as the first-line management of MBO at Oslo University Hospital between 2015 and 2021. Primary outcome measure was a ≥ 50% decrease from the pre-procedural bilirubin within 30 days after ERCP. Secondary outcome measures were technical success of ERCP, complications and overall mortality.

A total of 596 patients were included, median age 70 years. ASA score was ≥ III in 67% of patients. The most common cancers causing MBO were pancreatic cancer (52%), metastatic lesions (20%) and cholangiocarcinoma (16%). The primary outcome measure was achieved in 62% of patients. With endoscopic access, overall technical success was 80% with 85% for the distal extrahepatic group, 71% for the perihilar, 40% for the intrahepatic and 53% for multiple level MBOs. Reinterventions were performed in 27% of the patients. Complications occurred in 15% of the patients, including post-ERCP pancreatitis in 9%. Most complications were of minor/moderate severity (81%). Overall mortality was 33% within the first 90 days. Patients deceased by the end of the study period (83%) had median survival of 146 days (range 1-2,582 days).

ERCP has a high rate of clinical effect and technical success in the management of both distal extrahepatic and perihilar MBO. Our data indicate that ERCP is a valid option in the first-line management of MBO.

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) is useful for patients with biliary cannulation failure or inaccessible papillae. However, it can lead to serious complications such as bile peritonitis in patients with ascites; therefore, development of a safe method to perform EUS-HGS is important. Herein, we evaluated the safety of EUS-HGS with continuous ascitic fluid drainage in patients with ascites.

Patients with moderate or severe ascites who underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after the procedure at our institution between April 2015 and December 2022, were included in the study. We evaluated the technical and clinical success rates, EUS-HGS-related complications, and feasibility of re-intervention.

Ten patients underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after completion of the procedure. Median duration of ascites drainage before and after EUS-HGS was 2 and 4 days, respectively. Technical success with EUS-HGS was achieved in all 10 patients (100%). Clinical success with EUS-HGS was achieved in 9 of the 10 patients (90 %). No endoscopic complications such as bile peritonitis were observed.

In patients with ascites, continuous ascites drainage, which is initiated before EUS-HGS and terminated after completion of the procedure, may prevent complications and allow safe performance of EUS-HGS.

Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.

Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO). Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) could represent an easy and valid option. We performed a prospective study with a new EC-LAMS with the primary aim to assess the clinical success rate of EUS-GBD as a first-line approach to the palliation of DMBO.

In all, 37 consecutive patients undergoing EUS-GBD with a new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 h and >50% within 14 days after EC-LAMS placement.

The mean age was 73.5 ± 10.8 years; there were 17 male patients (45.9%). EC-LAMS placement was technically feasible in all patients (100%) and the clinical success rate was 100%. Four patients (10.8%) experienced adverse events, one bleeding, one food impaction, and two cystic duct obstructions because of disease progression. No stent-related deaths were observed. The mean hospitalization was 7.7 ± 3.4 days. Median overall survival was 4 months (95% confidence interval 1-8).

Endoscopic ultrasound-guided gallbladder drainage with the new EC-LAMS is a valid option in palliative endoscopic biliary drainage as a first-step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC-LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potential food impaction, which could result in stent dysfunction.

Obstructive jaundice is a clinical syndrome that is commonly seen in gastroenterology. Endoscopic retrograde cholangiopancreatography (ERCP) has been recognized as a first-choice therapeutic approach, with percutaneous biliary interventions (PBIs) being a viable alternative. Recent data questions the performance and safety profile of PBIs.

We report a case in which a large amount of intraperitoneal free gas developed during endoscopic ultrasound-guided biliary drainage with the rendezvous technique. A 62-year-old woman presented with obstructive jaundice caused by a pancreatic head tumor. Endoscopic retrograde cholangiopancreatography was attempted but failed due to difficulty cannulating the bile duct. Consequently, endoscopic ultrasound-guided hepaticogastrostomy was performed using a fully covered metal stent. Subsequently, the rendezvous technique was employed to access the biliary system and perform an endoscopic sphincterotomy. Finally, a fully covered metal stent was placed transpapillary. Fluoroscopic imaging during the procedure revealed a large amount of gas between the liver and diaphragm. Despite the pneumoperitoneum, the patient experienced no abdominal pain or fever. One week later, a computed tomography scan confirmed the disappearance of free air in the intraperitoneal cavity. The patient's subsequent clinical course remained uneventful, and she was discharged from the hospital. This case highlights the potential for pneumoperitoneum to develop during endoscopic ultrasound-guided biliary drainage, particularly when using the rendezvous technique. It is crucial to differentiate this finding from gastrointestinal perforation based on clinical presentation and imaging features.