Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections (PFCs) result from injury to the pancreas from acute or chronic pancreatitis, surgery, or trauma. Management of these collections has evolved over the last 2 decades. The choice of interventions includes percutaneous, endoscopic, minimally invasive surgery, or a combined approach. Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract. In this editorial, we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Endoscopic management of malignant biliary obstructions.

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Current trends of minimally invasive therapy for cholecystocholedocholithiasis.

Introduction: The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures. Materials and methods: We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs). Results: We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs. Conclusion: The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.

Endoscopic Ultrasound in Pancreatology: Focus on Inflammatory Diseases and Interventions.

Background: Endoscopic ultrasound (EUS) is a main tool in pancreatology for both diagnosis and therapy. It allows minimally invasive differentiation of various diseases, with a minimal degree of inflammation or anatomic variations. EUS also enables interventional direct access to the pancreatic parenchyma and the retroperitoneal space, the pancreatic duct, the pancreatic masses, cysts, vascular structures for diagnostic and therapeutic purposes. Summary: This review aimed to summarize the new developments of EUS in the field of pancreatology, with special interest on inflammation and interventions. EUS enables way to perform pseudocyst drainage, necrosectomy, transenteral drainage and transenteric access of the main pancreatic duct, or the direct visualization or therapy of vascular structures adjacent to the pancreas. Key Messages: EUS has a deep impact on pancreatology, and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas has increased in the last years exponentially, allowing minimal invasive diagnostics and therapy and avoiding surgery and percutaneous therapy.

A case of bladder and pelvic dead space inflammation successfully treated with endoscopic ultrasound drainage.

Key Clinical Message: Interventional endoscopic ultrasound (EUS) is effective not only for biopsy, but also for abscess drainage. We report the first use of EUS to drain inflammation of the bladder and pelvic dead space through the ileal conduit. EUS-guided drainage is effective in treating postoperative abscesses and should be employed more routinely. Abstract: The patient was a 77-year-old man with a vesicoureteral fistula. An ileal conduit was placed after abdominoperineal resection and partial bladder resection for local, postoperative recurrence of rectal cancer. During postoperative chemotherapy, the patient developed a high-grade fever and after a thorough examination, he was diagnosed with bladder and pelvic dead-space inflammation. All urine flowed through the ileal conduit, and it was assumed that secretions from the residual bladder and prostate gland had accumulated in the bladder and pelvic cavity, resulting in infection. A transcutaneous drain was inserted through the perineum and the infection was controlled, but it flared up again after the drain was removed. We concluded that long-term drainage was necessary and successfully controlled the infection by placing a plastic stent through the ileal conduit into the bladder and pelvic dead space under ultrasound endoscopy. This is the first report of ultrasound endoscopic drainage of an abscess through the ileal conduit.

Efficacy and safety of endoscopic ultrasound guided drainage of pseudocysts and walled-off necrosis after failure of percutaneous drainage.

BACKGROUND: Endoscopic Ultrasound (EUS) represents the gold standard for initial drainage of pancreatic fluid collections (PFC) due to various etiologies. However, data concerning salvage EUS drainage after initial percutaneous drainage are limited. The purpose of our study was to evaluate the clinical outcomes and safety of EUS-guided drainage of pancreatic collections after failure of percutaneous drainage. METHODS: This retrospective study was conducted in a single, tertiary university center from August 2013 to January 2020. Indication was pancreatic collection after acute pancreatitis with PFC requiring EUS-guided drainage after failure of percutaneous drainage. RESULTS: Twenty-two patients with PFC after acute pancreatitis were included (mean age 64.1 ± 11.3 years) of which 4/22 (18.2%) had pancreatic pseudocyst and 18/22 (81.8%) presented with a walled-off necrosis. Seventy-six interventions were performed among the 22 patients. Lumen-Apposing Metal Stent (LAMS) were used in 5/22 (22.7%) and double pigtail plastic stents in 17/22 (77.3%) of interventions with a median number intervention of 3 per patient (range 1 to 7). Technical success rate was 98.7% (75/76) with an overall clinical success of 81.8% (18/22). Procedure related adverse events rate was 9.1% (2/22) including one bleeding and one pancreatic fistula. Two non-procedure related deaths were observed. CONCLUSION: EUS-guided pancreatic collection drainage is clinically effective and safe after clinical/technical failure of radiological percutaneous management.

Management of severe acute pancreatitis in 2019.

Pancreatic fluid collections (PFCs) are frequent complications in severe acute pancreatitis that are the result of damage to the pancreas to include but not limited to trauma, surgery, autoimmune diseases, alcohol abuse, infections, medications, gallstones, metabolic disorders, and premalignant or malignant conditions. The majority of these collections resolve spontaneously; however, if the collection is infected or causes symptoms to include abdominal pain, nausea, vomiting, diarrhea, fevers, and tachycardia, drainage is indicated. Drainage of PFCs can be accomplished surgically, percutaneously, or endoscopically and should be approached in a multidisciplinary fashion for best overall patient care and outcomes. Before the introduction of endoscopic procedures, surgical and percutaneous drainage was the preferred modality. Today a minimally-invasive "step-up" approach is generally accepted depending upon the specific characteristics of the PFC and clinical presentation. Endoscopic ultrasound-guided PFC drainage is favored due to high success rates, shorter hospital stays, and lower cost. Direct debridement of walled-off pancreatitis can now be performed endoscopically with higher success rates with larger caliber fully covered metal stents. At large, the field of endoscopic techniques has evolved, and more specifically, the management of PFCs continues to evolve with increasing experience and with the advent of new stents and accessories, leading to increased efficacy with less adverse events.

Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided drainage (EUSD) and percutaneous drainage (PD) have reportedly been used for postoperative pancreatic fluid collection (PFC). However, there is limited evidence regarding safety and efficacy in a comparison of EUSD and PD for postoperative PFC. We conducted a search of the databases PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov, to August 2020. Studies comparing EUSD and PD for postoperative PFC were included. The outcomes included technical success, clinical success, adverse events, and recurrence of PFC.We included a total of 6 studies involving 247 patients in the current study. There was no significant difference between EUSD and PD in terms of technical success (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.29-3.12; p = 0.94) and clinical success (OR = 1.36; 95% CI: 0.68-2.72; p = 0.39). PFC recurrence and adverse events were similar between the two groups (OR = 1.82; 95% CI: 0.75-4.37; p = 0.18 and OR = 0.78; 95% CI: 0.31-1.92; p = 0.58, respectively).This meta-analysis confirmed that EUSD has comparable safety and efficacy to PD for postoperative PFC. Additional high-quality studies are required in the future.

A Rare Case of Delayed Perigastric Abscess after Curative Resection of Early Gastric Cancer by Uncomplicated Endoscopic Submucosal Dissection: Successful Treatment with Endoscopic Ultrasound-guided Drainage.

A 72-year-old man had undergone uncomplicated endoscopic submucosal dissection (ESD) with en bloc resection of a localized 20-mm IIc lesion in the anterior wall of the gastric angle. Twenty-eight days later, he was re-admitted with epigastric pain of one-week duration. Contrast-enhanced computed tomography (CT) revealed a 60-mm mass bordered by viscera; repeat endoscopy confirmed a smooth elevated submucosal tumor at the greater curvature on the oral side of the post-ESD ulcer. We diagnosed him with a perigastric abscess as a complication of ESD and performed endoscopic ultrasound-guided drainage. Subsequently, the symptoms and blood inflammatory parameters improved, and follow-up CT showed the disappearance of the abscess.

Endoscopic ultrasonography-guided drainage for spontaneous rupture of a pancreatic pseudocyst into the peritoneal cavity in a patient with autoimmune pancreatitis.

A 75-year-old man was referred to our hospital due to a huge pancreatic cyst. Computed tomography revealed a monocular cyst 15 cm in size without a solid mass lesion nearby. He was diagnosed with pancreatic pseudocyst. Endoscopic ultrasound (EUS)-guided drainage was planned for the next day due to abdominal distension; however, the pseudocyst ruptured into the peritoneal cavity before treatment could be applied. To prevent the progression of peritonitis, EUS-guided drainage of the pseudocyst was performed. A nasocystic tube and plastic stent were placed into the ruptured cyst via the gastric wall through the same puncture tract. After the treatment, the cyst rapidly decreased in size, and the peritonitis improved without surgery. The patient's serum IgG4 level was found to be elevated to 820 mg/dL. Endoscopic retrograde cholangiopancreatography revealed main pancreatic duct stricture without obstruction. No communication between the main pancreatic duct and the pseudocyst was found. An EUS-guided fine-needle aspiration biopsy of the hypoechoic site was performed, revealing IgG4-positive plasma cell infiltration. He was finally diagnosed with AIP associated with the rupture of a pseudocyst. Oral corticosteroid (30 mg/day) treatment was started and gradually tapered. There has been no recurrence in the 28 months since the initiation of treatment.

Effectiveness of endoscopic ultrasound-guided drainage for noncapsulated postoperative pancreatic collection.

BACKGROUND: Postoperative pancreatic collection (POPC) is a frequent complication after pancreatectomy. Although percutaneous drainage (PD) has been the treatment of choice for POPC with encapsulation, endoscopic ultrasound-guided transmural drainage (EUS-TD) was recently reported effective for this condition. The main aim of this retrospective study was to compare EUS-TD and PD in terms of effectiveness and safety as the first procedure in patients with noncapsulated POPC. METHODS: Consecutive patients who underwent pancreatectomy and developed noncapsulated POPC requiring EUS-TD or PD between April 2003 and May 2018 were enrolled. Noncapsulated POPC was defined as pancreatic collection appearing within 28 days postoperatively and lacking a thick encapsulating inflammatory wall on contrast-enhanced computed tomography. The effectiveness of drainage was compared between the two groups before and after propensity-score matching of patient characteristics. Outcomes of interest included re-intervention rate, number of re-interventions, immediate complication, remote complication, and time to clinical resolution after the procedure. RESULTS: A sum of 81 patients were included: 14 underwent EUS-TD, and 67 underwent PD. There were significant differences between groups in POPC size and type of surgery. Propensity-score matching selected 13 patients who underwent EUS-TD and 28 who underwent PD. Re-intervention rate (p = 0.045), and number of re-interventions (p = 0.026) were significantly lower in the matched EUS-TD group than in the matched PD group. There were no significant between-group differences in immediate complication and remote complication. The time to clinical resolution after the procedure was significantly shorter in the matched EUS-TD than in the matched PD group (14 versus 26 days; p < 0.0001). CONCLUSION: EUS-TD is more effective than PD for drainage of noncapsulated POPC. EUS-TD should be considered as the first treatment of choice for noncapsulated POPC visible on EUS.

Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation.

BACKGROUND AND AIM: Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON. METHODS: Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups. RESULTS: Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group. CONCLUSIONS: Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.

Present status and perspectives of endosonography 2017 in gastroenterology.

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

Novel and supplementary management of pancreatic fluid collections: Endoscopic ultrasound-guided drainage.

AIM: To compare efficacy and safety of endoscopic ultrasound (EUS)-guided and surgical drainage in pancreatic fluid collection management. METHODS: Data were obtained retrospectively from January 2012 to December 2016. Patients with pancreatic fluid collection were performed EUS-guided or surgical procedure. Main outcome measures including clinical efficiency, complication, duration of procedures, hospital stay and cost were analyzed. RESULTS: Thirty-six patients were enrolled into the study, including 14 in endoscopic group while 22 in the surgical group. Twelve (86%) patients were treated successfully by endoscopic approach while 21 (95%) patients benefited through surgical procedure. Endoscopic treatment had higher recurrence and complication rates than surgery, resulting in more re-interventions. Meanwhile, duration of procedure, hospital stay and cost were significantly lower in endoscopic group. CONCLUSION: Both approaches were effective and safe. EUS-guided approach should be the first-line treatment in mild and simple cases, while surgical approach should be considered as priority in severe and complex cases.

Endoscopic Ultrasound-Guided Drainage of Intra-Abdominal Abscess after Gastric Perforation in a Patient Receiving Ramucirumab and Paclitaxel for Advanced Gastric Cancer.

Gastrointestinal perforation is a serious adverse event that occurs in approximately 1% of patients receiving ramucirumab and paclitaxel. A 67-year-old man with unresectable advanced gastric cancer was admitted to our hospital and treated with ramucirumab and paclitaxel. Gastric perforation occurred during the second cycle of chemotherapy. Although the patient's condition improved without surgery, an abscess developed in the intra-abdominal fluid collection resulting from the perforation. We performed endoscopic ultrasound-guided abscess drainage. The patient improved and was discharged in satisfactory condition. Endoscopic ultrasound-guided drainage is a treatment option for patients with intra-abdominal abscess following gastric perforation due to ramucirumab.

Clinical Outcome of Endoscopic Ultrasound-Guided Liver Abscess Drainage Using Self-Expandable Covered Metallic Stent (with Video).

BACKGROUND: Percutaneous drainage (PCD) is now the first-line drainage method for liver abscess because of its minimal invasiveness and high technical success rate. However, this procedure has several disadvantages, such as extra-drainage and self-tube removal. Recently, EUS-guided liver abscess drainage (EUS-AD) has been developed. However, only a few reports of EUS-AD have been reported. In addition, the clinical benefits of PCD and EUS-AD have not been reported. AIMS: In the present study, the safety and feasibility of EUS-AD using fully covered SEMS (FCSEMS) and the clinical outcomes of EUS-AD and PCD were examined retrospectively. METHODS: Twenty-seven consecutive patients who underwent PCD or EUS-AD between April 2012 and April 2015 were included in this study. EUS-AD was performed using FCSEMS. In addition, to prevent stent migration, 7-Fr pig tail plastic stent was placed within FCSEMS. RESULTS: Technical success was achieved in all patients of both groups. Clinical success was 100 % in the EUS-AD group although it was 89 % in PCD group (P = 034). Three adverse events were seen in the PCD group (self-tube removal n = 1, tube migration n = 2), but no adverse events were seen in the EUS-AD group. The median hospital stay was significantly shorter in the EUS-AD group than in the PCD group (21 vs 41 days, P = 0.03). CONCLUSION: Because of the short hospital stay, the high clinical success rate, and the low adverse event rate compared to PCD, EUS-AD has potential as a first-line treatment for liver abscess.

Endoscopic ultrasonography in the diagnosis and treatment of a gastric wall abscess.

A gastric wall abscess is rare and it can reportedly appear similar to a submucosal tumor on endoscopy. Few reports have described endoscopic ultrasonographic findings for a gastric wall abscess. An 84-year-old man was admitted to our hospital for tarry stools. Esophagogastroduodenoscopy showed an elevated lesion similar to a submucosal tumor at the posterior wall of the stomach. Erosion and a white coat were observed on top of the lesion. Endoscopic ultrasonography showed an anechoic lesion connected to the proper muscular layer with a hyperechoic area in the center of the lesion. The lesion was diagnosed as a gastric wall abscess using endoscopic ultrasound-guided fine-needle aspiration and was treated with endoscopic ultrasound-guided drainage. The final diagnosis was a gastric wall abscess presenting as gastrointestinal hemorrhage. The patient was discharged with internal drainage stents. Computed tomography performed 3 months after discharge did not show recurrence of the abscess.

Postoperative abdominal collections drainage: Percutaneous versus guided by endoscopic ultrasound.

BACKGROUND AND AIM: Postoperative fluid collections (POFC) have high mortality. Percutaneous drainage (PD) is the preferred treatment modality. Drainage guided by endoscopic ultrasound (EUS-GD) represents a good alternative. The aim of the present study was to compare clinical success and complication rates of EUS-GD versus PD. METHODS: Data collected prospectively were analyzed in a retrospective manner. Patients with POFC from October 2008 to November 2013 were included. All collections were drained percutaneously or by EUS-GD. RESULTS: Sixty-three procedures in 43 patients with POFC were analyzed; 13 patients were drained using EUS-GD and 32 patients with PD. Two patients assigned initially to the PD group were reassigned to EUS-GD. Surgery procedures most often related to the collections were intestinal reconnection, distal pancreatectomy, biliary-digestive bypass, and exploratory laparotomy. Technical success (100% vs 91%; P = 0.25), clinical success (100% vs 84%; P = 0.13), recurrence (31% vs 25%; P = 0.69), hospital stay days (median 22 vs 27; P = 0.35), total costs (8328 ± 1600 USD vs 11 047 ± 1206 USD; P = 0.21), complications (0% vs 6%; P = 0.3), and mortality (8% vs 6%; P = 0.9) were each evaluated in the EUS-GD and PD groups, respectively. In the PD group one death was related to the procedure. CONCLUSIONS: EUS-GD is as effective and safe as PD in patients with POFC. The advantage of not requiring external drainage and a trend to higher clinical success and lower total costs must be considered.

Endoscopic ultrasound-guided drainage of postoperative intra-abdominal abscesses.

Although endoscopic ultrasound (EUS)-guided drainage has become the standard procedure for pancreatic pseudocysts in recent years and is generally regarded as a safe and effective method, there have been few reports of EUS-guided drainage of postoperative intra-abdominal abscesses. Here we report our experience with 4 cases of postoperative intra-abdominal abscesses for which EUS-guided drainage was performed between May 2011 and May 2014. Distal pancreatectomy had been performed in 3 cases, whereas low anterior resection for rectal cancer was performed in the remaining case. All patients underwent transgastric naso-cystic drainage, which resulted in clinical improvement without complications, even when performed within 4 wk after surgery. On average, the naso-cystic drain was removed 10 d after placement, with no abscess recurrence. Based on these findings, we believe that EUS-guided drainage of postoperative intra-abdominal abscesses is a safe and effective method, although further large-scale investigations are required to confirm our findings.

Endoscopic ultrasound-guided gallbladder drainage for the management of acute cholecystitis (with video).

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been introduced as an alternative to percutaneous transhepatic gallbladder drainage for the treatment of acute cholecystitis in non-surgical candidates. A systematic review of the English language literature through PubMed search until June 2014 was conducted. One hundred and fifty-five patients with acute cholecystitis treated with EUS-GBD in eight studies and 12 case reports, and two patients with EUS-GBD for other causes were identified. Overall, technical success was obtained in 153 patients (97.45%) and clinical success in 150 (99.34%) patients with acute cholecystitis. Adverse events developed in less than 8% of patients, all of them managed conservatively. EUS-GBD has been performed with plastic stents, nasobiliary drainage tubes, standard or modified tubular self-expandable metal stents (SEMS) and lumen-apposing metal stents (LAMS) by different authors with apparently similar outcomes. No comparison studies between stent types for EUS-GBD have been reported. EUS-GBD is a promising novel alternative intervention for the treatment of acute cholecystitis in high surgical risk patients. Feasibility, safety and efficacy in published studies from expert centers are very high compared to currently available alternatives. Further studies are needed to establish the safety and long-term outcomes of this procedure in other practice settings before EUS-GBD can be widely disseminated.