ENDOSCOPIC ULTRASOUND-GUIDED HEPATICOJEJUNOSTOMY IN PATIENTS WITH HISTORY OF TOTAL GASTRECTOMY: A MULTICENTER RETROSPECTIVE FEASIBILITY STUDY.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage technique for patients with altered anatomy or duodenal strictures. Endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) can be used to create a fistula between the left hepatic duct and the jejunum in patients with a history of total gastrectomy. No specific data on this technique have been published. The aim of this study was to assess the feasibility and safety of EUS-HJS in patients with a history of total gastrectomy. METHODS: This retrospective multicenter study included all adult patients who underwent EUS-HJS at three tertiary French centers and one tertiary Swiss center between May 2011 and February 2023. The primary outcome was clinical success, which was defined as the disappearance of pruritus, jaundice and/or cholangitis. An improvement in bilirubin greater than 30% within the first week and/or bilirubin normalization within 1 month after the procedure were also considered indicators of clinical success. Secondary outcomes included technical success, the rate of adverse events, the need for endoscopic revision, the possibility of resuming anticancer treatment, median survival, and technical differences compared to EUS-HGS. RESULTS: A total of 21 patients who underwent complete gastrectomy via EUS-HJS were included. Technical success was achieved in 100% of patients (95% CI 85%-100%). Clinical success was achieved in 80% of patients (95% CI 58%-92%). The incidence of recorded adverse events was 33% (95% CI 17%-55%), with cholangitis being the most frequent complication. Seven patients (39%) were able to benefit from anticancer treatment after the procedure. The median survival was 6 months (IQR 1.5-12). CONCLUSION: EUS-HJS is an effective and feasible procedure for patients whose anatomy has been altered by total gastrectomy.

Dedicated Echoendoscope for Interventional Endoscopic Ultrasound: Comparison with a Conventional Echoendoscope.

Background/Objective: Interventional endoscopic ultrasound (I-EUS) is technically difficult and has risks of severe adverse events due to the scarcity of dedicated endoscopes and tools. A new EUS scope was developed for I-EUS and was modified to increase the puncture range, reduce the blind area, and overcome guidewire difficulties. We evaluated the usefulness and safety of a new EUS scope compared to a conventional EUS scope. Methods: All I-EUS procedures were performed at Juntendo University Hospital from April 2020 to April 2022. The primary outcomes included the procedure time and fluoroscopy time. The secondary outcomes included the technical success rate and the rates of procedure-related adverse events. Clinical data were retrospectively reviewed and statistically analyzed between the new and conventional EUS scopes. Results: In total, 143 procedures in 120 patients were analyzed. The procedure time was significantly shorter with the new EUS scope, but the fluoroscopy time was not different. Among the patients only undergoing EUS-guided biliary drainage (EUS-BD), 79 procedures in 74 patients were analyzed. Both the procedure time and fluoroscopy time were significantly shorter with the new EUS scope. Multivariate analysis revealed that a new EUS scope and use of covered metal stents could reduce the fluoroscopy time. The technical success rate and the adverse event rate were not significantly different between the total I-EUS and the EUS-BD only groups. However, the conventional scope showed stent deviation during stent placement, which did not happen with the new scope. Conclusions: The new EUS scope reduced procedure time for total I-EUS and fluoroscopy time for EUS-BD compared to a conventional EUS scope because of the improvement suitable for I-EUS.

Italian Survey on Endoscopic Biliary Drainage Approach in Patients with Surgically Altered Anatomy.

Background and Objectives: Biliary drainage (BD) in patients with surgically altered anatomy (SAA) could be obtained endoscopically with different techniques or with a percutaneous approach. Every endoscopic technique could be challenging and not clearly superior over another. The aim of this survey is to explore which is the standard BD approach in patients with SAA. Materials and Methods: A 34-question online survey was sent to different Italian tertiary and non-tertiary endoscopic centers performing interventional biliopancreatic endoscopy. The core of the survey was focused on the first-line and alternative BD approaches to SAA patients with benign or malignant obstruction. Results: Out of 70 centers, 39 answered the survey (response rate: 56%). Only 48.7% of them declared themselves to be reference centers for endoscopic BD in SAA. The total number of procedures performed per year is usually low, especially in non-tertiary centers; however, they have a low tendency to refer to more experienced centers. In the case of Billroth-II reconstruction, the majority of centers declared that they use a duodenoscope or forward-viewing scope in both benign and malignant diseases as a first approach. However, in the case of failure, the BD approach becomes extremely heterogeneous among centers without any technique prevailing over the others. Interestingly, in the case of Roux-en-Y, a significant proportion of centers declared that they choose the percutaneous approach in both benign (35.1%) and malignant obstruction (32.4%) as a first option. In the case of a previous failed attempt at BD in Roux-en-Y, the subsequent most used approach is the EUS-guided intervention in both benign and malignant indications. Conclusions: This survey shows that the endoscopic BD approach is extremely heterogeneous, especially in patients with Roux-en-Y reconstruction or after ERCP failure in Billroth-II reconstruction. Percutaneous BD is still taken into account by a significant proportion of centers in the case of Roux-en-Y anatomy. The total number of endoscopic BD procedures performed in non-tertiary centers is usually low, but this result does not correspond to an adequate rate of referral to more experienced centers.

Impact of sarcopenia on recurrent biliary obstruction after EUS-guided biliary drainage in patients with malignant biliary obstruction.

BACKGROUND AND AIMS: Sarcopenia is an important prognostic factor for cancer patients. The aim of this study was to assess the ability of sarcopenia to predict recurrent biliary obstruction (RBO) in patients with unresectable cancer after EUS-guided biliary drainage (EUS-BD). METHODS: The study enrolled 113 patients who underwent EUS-BD using the self-expandable metal stent (SEMS) for unresectable malignant biliary obstruction (MBO) between April 2016 and December 2021 at Wakayama Medical University Hospital. The skeletal muscle index at the third lumbar spine level (L3) was calculated from computed tomography images. We analyzed the cumulative incidence of RBO at 180 days after stent insertion. Univariate and multivariate analyses were performed to identify variables significantly associated with RBO. RESULTS: Seventy-six patients were assigned to the sarcopenia group, and 37 were assigned to the non-sarcopenia group. The 180-day cumulative incidence of RBO was 11% in the non-sarcopenia group and 29% in the sarcopenia group (p = 0.034). The time to RBO was significantly shorter for the sarcopenia group (p = 0.028; Gray's test). Multivariate analyses identified sarcopenia as an independent prognostic factor for RBO (present vs absent; HR 4.61; 95% CI 1.76-12.10, p = 0.001). The rates of biliary sludge/food impaction were significantly higher in the sarcopenia group for the causes of RBO (p = 0.048). There were no significant differences between the sarcopenia and the non-sarcopenia groups with respect to related EUS-BD adverse events. CONCLUSION: Sarcopenia is an independent indicator of RBO in patients with MBO who receive EUS-BD with SEMS.

Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice.

INTRODUCTION: Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial. AREA COVERED: This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques. EXPERT OPINION: As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

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

Background and Objectives: During EUS-guided choledochoduodenostomy (EUS-CDS), fistula dilation before stent insertion is associated with adverse events (AEs), such as bile leakage and peritonitis. We hypothesized that EUS-CDS without fistula dilation using a novel self-expandable metal stent (SEMS) with a thin delivery system could overcome this problem, and we conducted this study to evaluate its feasibility and safety. Methods: This was an open-label, single-arm, phase II study at a single institution. We planned EUS-CDS without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system for unresectable malignant distal biliary obstruction. The primary outcome was overall technical success. Secondary outcomes were technical success without fistula dilation, procedure time, functional success, time to recurrent biliary obstruction, and AEs. The planned sample size was 25 patients. Results: In total, 24 patients were included in this study. In 21 patients, EUS-CDS was performed as primary drainage. The overall technical success rate was 100% (24 of 24 patients). The technical success rate without fistula dilation was 96% (23 of 24). The median procedure time was 16 min (range, 10-66 min). The functional success rate was 96% (23 of 24). The median time to recurrent biliary obstruction was 148 days (95% confidence interval, 29-266 days). There were no procedure-related AEs. Furthermore, computed tomography immediately after the procedure showed no leakage of contrast medium into the abdominal cavity in any patient. Conclusions: EUS-guided choledochoduodenostomy without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system is feasible with a high probability and can be achieved quickly while effectively preventing bile leakage and peritonitis.

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

Introduction: Malignant biliary obstruction drainage is essential, since jaundice is associated with morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended procedure for biliary drainage, with percutaneous biliary drainage being the classic alternative in cases of unsuccessful ERCP. Recently, endoscopic ultrasound-guided biliary drainage has been emerged as a new option, with EUS-guided choledochoduodenostomy (EUS-CDS) being considered an effective and safe method in the drainage of distal obstructions of the common bile duct. Aim: The aim of the study was to evaluate the efficacy and safety of EUS-CDS performed in patients with distal malignant biliary obstructions, after failed ERCP. Methods: Single-center retrospective cohort study between July 2017 and June 2022 including all consecutive patients submitted to EUS-CDS in our center. The primary outcomes were "technical success" and "clinical success," defined as "resolution of jaundice or improvement in total serum bilirubin level above 50% at 7th day and above 75% at 30th day after the procedure." Secondary outcomes were procedure-related adverse events, endoscopic reintervention, and survival time. Results: EUS-CDS was performed in 20 patients (65.0% male; median age 76 years). The most frequent etiology for the biliary obstruction was pancreatic adenocarcinoma (n = 17; 85.0%), and most patients presented at advanced stages of cancer (12/60% in stages III or IV). ERCP failure was mainly due to the presence of obstruction in the duodenal lumen (n = 11; 55.0%). Fully covered metallic stents were used in all patients, mostly HotAxiosTM (n = 15; 75.0%). The technical success rate was 100%, and the clinical success rate was 89.5% (n = 17/19) at 7th day and 93.3% (n = 14/15) at 30th day. Four patients (20.0%) developed cholangitis within the first 30 days after the procedure; there were no late complications, and no patient died as a complication of the procedure. In 2 patients (10.0%), endoscopic reintervention was necessary due to stent migration, incidentally detected. Median survival was 93 days (minimum 5-maximum 751). Conclusion: EUS-CDS was effective in biliary decompression of malignant obstructions of the common bile duct, with high clinical success and a favorable safety profile.

Introdução: A drenagem das obstruções biliares malignas é essencial, uma vez que a icterícia está associada a morbimortalidade. A colangiopancreatografia retrógrada endoscópica (CPRE) é o procedimento recomendado para a drenagem biliar, sendo a drenagem biliar percutânea (DBP) a alternativa clássica, se verificado insucesso. Recentemente, a drenagem da via biliar guiada por ecoendoscopia tem-se apresentado como uma nova opção, sendo a coledocoduodenostomia guiada por ecoendoscopia (CGE) considerado um método eficaz e seguro na drenagem de obstruções da via biliar distal. Objetivo: Avaliar o sucesso técnico e clínico e a segurança da CGE em doentes com obstrução da via biliar distal, após falência da CPRE. Métodos: Estudo de coorte retrospetivo, entre Julho/2017 e Junho/2022, de todos os doentes submetidos a CGE no nosso centro. Determinaram-se como outcomes primários o "sucesso técnico" e o "sucesso clínico" ("melhoria ≥50% na bilirrubinemia ao 7.º e ≥ 75% ao 30.º dias após o procedimento"). Os outcomes secundários incluíram a frequência de eventos adversos, necessidade de reintervenção e taxa de sobrevida. Foram utilizadas curvas de Kaplan-Meier para descrever a sobrevida. Resultados: A CGE foi realizada em 20 doentes (65.0% do sexo masculino; idade mediana 76 anos). A etiologia mais frequente para a obstrução foi o adenocarcinoma pancreático (n = 17; 85.0%) e a maioria dos doentes apresentava- se em estadios avançados da neoplasia (12/60% em estadios III ou IV). A falência da CPRE deveu-se à presença de obstrução no lúmen duodenal em 55.0% dos doentes (n = 11). Em todos os doentes foram utilizadas próteses metálicas totalmente cobertas, maioritariamente HotAxiosTM (n = 15; 75.0%). A taxa de sucesso técnico foi de 100% e de sucesso clínico foi de 89.5% ao 7.º dia (n = 17/19) e 93.3% ao 30.º dia (n = 14/15). Quatro doentes (20.0%) desenvolveram colangite nos primeiros 30 dias após o procedimento; não se verificaram complicações tardias e nenhum doente faleceu como complicação do procedimento. Em 2 doentes (10.0%) foi necessária reintervenção por migração da prótese, detetada incidentalmente. A sobrevida mediana foi de 93 dias (mínimo 5 - máximo 751). Conclusões: A CGE foi efetiva na descompressão biliar de obstruções malignas da via biliar distal, com elevado sucesso clínico e um perfil de segurança favorável.

Risk factors for stent dysfunction during long-term follow-up after EUS-guided biliary drainage using lumen-apposing metal stents: A prospective study.

Background: EUS-guided choledoco-duodenostomy using electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) is becoming the gold standard in case of endoscopic retrograde cholangio-pancreatography failure for distal malignant obstruction. Long-term data in larger samples are lacking. Methods: This was a prospective monocentric study including all patients who underwent EUS-guided choledochoduodenostomy (CDS) between September 2016 and December 2021. The primary endpoint was the rate of biliary obstruction during follow-up. Secondary endpoints were technical and clinical success rates, adverse event rates, and identification of risk factors for biliary obstruction. Results: One hundred and twenty-three EUS-guided CDS using ECE-LAMS were performed at Limoges University Hospital were performed during the study period and included in the study. The main cause of obstruction was pancreatic adenocarcinoma in 91 (74.5%) cases. The technical and clinical success rates were 97.5% and 91%, respectively. Twenty patients (16.3%) suffered from biliary obstructions during a mean follow-up of 242 days. The clinical success rate for endoscopic desobstruction was 80% (16/20). In uni- and multivariate analyses, only the presence of a duodenal stent (odds ratio [OR]: 3.6, 95% confidence interval [CI] 95%: 1.2-10.2; P = 0.018) and a bile duct thinner than 15 mm (OR: 3.9, CI 95%: 1.3-11.7; P = 0.015) were the significant risk factors for biliary obstruction during the follow-up. Conclusion: Obstruction of LAMS occurred in 16.3% of cases during follow-up and endoscopic desobstruction is efficacious in 80% of cases. The presence of duodenal stent and a bile duct thinner than 15 mm are the risk factors of obstruction. Except in these situation, EUS-CDS with ECE-LAMS could be proposed in the first intent in case of distal malignant obstruction.

EUS-guided biliary drainage in malignant distal biliary obstruction: An international survey to identify barriers of technology implementation.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) is a promising alternative to ERCP in malignant distal biliary obstruction (MDBO). Despite accumulating data, however, its application in clinical practice has been impeded by undefined barriers. This study aims to evaluate the practice of EUS-BD and its barriers. Methods: An online survey was generated using Google Forms. Six gastroenterology/endoscopy associations were contacted between July 2019 and November 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers. The primary outcome was the uptake of EUS-BD as a first-line modality, without previous ERCP attempts, in patients with MDBO. Results: Overall, 115 respondents completed the survey (2.9% response rate). Respondents were from North America (39.2%), Asia (28.6%), Europe (20%), and other jurisdictions (12.2%). Regarding the uptake of EUS-BD as first-line treatment for MDBO, only 10.5% of respondents would consider EUS-BD as a first-line modality regularly. The main concerns were the lack of high-quality data, fear of adverse events, and limited access to EUS-BD dedicated devices. On multivariable analysis, lack of access to EUS-BD expertise was an independent predictor against the use of EUS-BD, odds ratio 0.16 (95% confidence interval, 0.04-0.65). In salvage situations following failed ERCP, most favored EUS-BD (40.9%) over percutaneous drainage (21.7%) in unresectable cancer. In borderline resectable or locally advanced disease, however, most favored the percutaneous approach due to fear of EUS-BD complicating future surgery. Conclusions: EUS-BD has not reached widespread clinical adoption. Identified barriers include lack of high-quality data, fear of adverse events, and lack of access to EUS-BD dedicated devices. Fear of complicating future surgery was also identified as a barrier in potentially resectable disease.

Comparison of recurrent biliary obstruction with the use of metal and plastic stents in EUS-guided biliary drainage: A propensity score-matched analysis.

Background and Objectives: In transpapillary biliary drainage, metal stents (MSs) exhibit a lower incidence of a biliary obstruction than plastic stents (PSs). However, few studies have compared recurrent biliary obstruction (RBO) when MSs and PSs are used in EUS-guided hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS). We retrospectively evaluated the RBO for both stents in each procedure. Patients and Methods: : Between November 2012 and December 2020, 85 and 53 patients who underwent EUS-HGS and EUS-CDS for unresectable malignant biliary obstruction, respectively, were enrolled. Factors associated with RBO were assessed. Clinical outcomes were compared between the MS and PS groups using propensity score matching. Results: : The clinical success rate and procedure-related adverse events were similar in the MS and PS groups. Multivariate analysis identified the use of PS as a factor associated with RBO (EUS-HGS, P = 0.03; EUS-CDS, P = 0.02). After matching, the median time to RBO in EUS-HGS (MS: 313; PS: 125 days; P = 0.01) in the MS group was longer than that in the PS group. The cumulative incidence of RBO at 1, 3, and 6 months in the MS group was significantly lower than that in the PS group for EUS-HGS (MS: 4.0%, 8.2%, and 8.2%; PS: 12.4%, 24.9%, and 39.5%, respectively, P = 0.01). Conclusions: : MS exhibited a lower rate of RBO than PS for EUS-HGS and EUS-CDS.

Current status of endoscopic ultrasound-guided antegrade intervention for biliary diseases in patients with surgically altered anatomy.

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound-guided antegrade intervention (EUS-AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS-AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS-AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy.

Development of devices for interventional endoscopic ultrasound for the management of pancreatobiliary diseases.

A variety of devices have been developed for interventional endoscopic ultrasound (EUS). EUS-guided drainage of the bile duct and pancreatic duct, as well as fluid collection adjacent to the gastrointestinal tract, is performed by a procedure involving puncture, guidewire manipulation, tract dilation, and stent placement. Devices specialized for interventional EUS are being developed for each step of the procedure. Mechanical dilators such as bougie, balloon, and electrocautery dilators are used for tract dilation. Various types of plastic stents, self-expandable metal stents, and lumen-apposing metal stents specifically designed for interventional EUS are now available, including one-step devices developed to improve the efficacy and safety of interventional EUS. In addition, radiofrequency ablation and the placement of fiducial markers and radioactive seeds under EUS guidance are now becoming established for pancreatic neoplasms. Such development of specialized devices has expanded the indications for interventional EUS, increased the success rate, and lowered the adverse event rate.

Efficacy of a dedicated plastic stent in endoscopic ultrasound-guided hepaticogastrostomy during the learning curve: cumulative multi-center experience.

BACKGROUND AND OBJECTIVES: Currently, there are no reports on the learning curve of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using dedicated plastic stents. Therefore, we evaluated the outcomes of EUS-HGS using dedicated plastic stents at tertiary referral centers during the initial development phase of EUS-HGS. MATERIALS AND METHODS: Endoscopic retrograde cholangiopancreatography (ERCP) was strictly prioritized over EUS-HGS. Twenty-three consecutive patients treated using EUS-HGS with a 7-Fr dedicated plastic stent over 4 years beginning in 2018 were analyzed retrospectively. RESULTS: The most common primary disease was pancreatic cancer, and the most common reason for difficulty in ERCP was duodenal obstruction, followed by surgically altered anatomy. The overall technical success rate of EUS-HGS was 95.7% (22/23). One failed case was converted to EUS-guided choledochoduodenostomy. The clinical success rate was 90.9% (20/22). Adverse events (AEs) related to the procedure were observed in four (17.4%) patients, including mild biliary peritonitis in three (13.0%) and mild cholangitis in one (4.3%) patient; all patients received conservative therapy. No serious AEs, such as stent migration, bleeding, or gastrointestinal perforation, were observed. Recurrent biliary obstruction (RBO) was observed in eight (34.8%) patients. Of these, HGS stent replacement was performed in four patients, and other treatments were performed in the remaining four patients. Another four (17.4%) patients did not develop RBO but underwent periodic HGS stent replacement. CONCLUSIONS: EUS-HGS using a dedicated plastic stent was performed safely even in its initial phase of introduction. The approach using this stent can be useful in case of ERCP failure for biliary decompression because of the high feasibility and low risk of serious adverse events.

Novel drill dilator facilitates endoscopic ultrasound-guided hepaticogastrostomy.

Tract dilation is one of the most difficult stages of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), especially for beginners. To overcome this problem, we applied a special dedicated dilator. Herein, we retrospectively evaluate the safety and usefulness of a novel drill dilator in EUS-HGS. This single-center retrospective study included 20 consecutive patients who underwent EUS-HGS with a novel drill dilator. The tip is 0.77 mm, and it becomes 7F at 3 cm from tip. The track is dilated to 7F by simple clockwise rotation. The technical success rate of both initial tract dilation and stent placement was 20/20 (100%). No cases required additional dilation such as balloon or electric cautery. In 13/20 cases (65.0%), EUS-HGS was performed by beginner endoscopists. Median time required for dilation was 62.5 s (range, 30-144 s). Median procedure time was 13 min (range, 7-25 min). Early adverse events were two cases of mild fever. There was no bile leakage or bleeding. The novel drill dilator appears to be safe and useful for EUS-HGS. As it is not necessary to press the device strongly, there is no pushback during dilation and the scope position is stable. These characteristics facilitate EUS-HGS even for beginners. This device may enable the further development and increased dissemination of EUS intervention.

Endoscopic ultrasound guided biliary interventions.

Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5-10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP. This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.

Endoscopic ultrasound guided access procedures following surgery.

EUS-guided therapeutic procedures have emerged in the recent years as a minimally invasive option for the management of complex hepatobiliary disorders. Gastrointestinal surgeries, e.g., pancreaticoduodenectomy, Roux-en-Y Gastric Bypass, Roux-en-Y hepaticojejunostomy, and partial gastrectomy with different reconstructions are commonly performed for a wide range of indications that include tumour resections and weight loss. Conventional endoscopic procedures are challenging in those patients due to inaccessible or unreachable ampulla. Patients with surgically altered anatomy are good candidates for EUS-guided access procedures that have shown good technical and clinical success rates. This category of procedures includes EUS-guided biliary drainage, EUS-guided pancreatic drainage, EUS-directed transgastric ERCP (EDGE) and EUS-guided Gastroenterostomy. Studies have shown that these procedures have comparable or better results than traditional endoscopic, interventional radiology-guided and surgical procedures. This article discusses the indications, technique and outcome of the different EUS-guided access procedures in patients with surgically altered anatomy.

Feasibility and efficacy of endoscopic reintervention after covered metal stent placement for EUS-guided hepaticogastrostomy: A multicenter experience.

Background and Objectives: Although the use of a long metal stent is favored for EUS-guided hepaticogastrostomy (EUS-HGS) for the relief of malignant biliary obstruction (MBO), endoscopic reintervention (E-RI) at the time of recurrent biliary obstruction (RBO) is challenging due to a long intragastric portion. This study evaluated the feasibility and safety of E-RI after a long partially covered metal stent (L-PCMS) placement during EUS-HGS. Materials and Methods: We performed a multicenter retrospective study between January 2015 and December 2019 examining patients with MBO who underwent E-RI for RBO through the EUS-HGS route after the L-PCMS placement. Technical and clinical success rates, details of E-RI, adverse events (AEs), stent patency, and survival time were evaluated. Results: Thirty-three patients at eight referral centers in Japan who underwent E-RI through the EUS-HGS route were enrolled. The location of MBO was distal in 54.5%. The median intragastric length of the L-PCMS was 5 cm. As the first E-RI attempt, E-RI via the distal end of the existing L-PCMS was successful in 60.6%. The overall technical and clinical success rates of E-RI were 100% and 81.8%, respectively. Liver abscess was noted in one patient. A proximal biliary stricture was associated with the clinical ineffectiveness of E-RI in multivariable analysis (odds ratio, 12.5, P = 0.04). The median survival and stent patency duration after E-RI were 140 and 394 days, respectively. Conclusions: Our study findings suggest that E-RI for RBO after EUS-HGS with a L-PCMS is technically feasible and clinically effective, without any severe AEs, especially for patients with distal MBO.

Utility of Fine-Gauge Balloon Catheter for EUS-Guided Hepaticogastrostomy.

BACKGROUND AND PURPOSE: During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), tract dilation is one of the most important steps, and the placement of conventional metal stents with 8.5 Fr delivery devices is difficult due to the large outer shape of the device. Fine-gauge balloon catheters have become popular because of their stricture penetration ability and ease of dilation. This study aimed to evaluate the utility of fine-gauge balloon catheters. PATIENTS AND METHODS: This retrospective study involved 38 patients who underwent conventional metal stent placement. The patients were classified into two groups: those who underwent dilation with a fine-gauge balloon catheter before initial metal stenting (balloon dilation group) and those who underwent bougie dilation only (non-balloon dilation group). We evaluated the stenting success rate after initial dilation and adverse events. RESULTS: Seventeen and twenty-one patients were included in the balloon dilation and non-balloon dilation groups, respectively. The stenting success rate after initial dilation was 100% (17/17) in the balloon dilation group and 71.4% (15/21) in the non-balloon dilation group (p = 0.024). As adverse events, peritonitis was observed in one case (4.8%) in the balloon dilation group, and in three cases (14.3%) in the non-balloon dilation group (p = 0.613). CONCLUSIONS: Dilation using a fine-gauge balloon catheter before conventional metal stent with 8.5 Fr delivery device placement is considered effective in EUS-HGS.