Evaluation of a new stent for EUS-guided pancreatic duct drainage: long-term follow-up outcome

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Guidewires are indispensable tools in biliopancreatic endoscopy, playing a critical role in facilitating access and enabling the advancement of various devices during interventions such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS)-guided procedures. These devices are primarily used to achieve and maintain access to lumens, ensuring the success of complex therapeutic maneuvers. Guidewires vary widely in terms of material, structure, length, diameter, and tip shape, offering distinct advantages depending on the clinical context. Therefore, selecting the appropriate guidewire is crucial and must be tailored to the specific requirements of each procedure. This article provides a comprehensive review of the current landscape of guidewire use in biliopancreatic endoscopy, emphasizing their importance, characteristics, and best practices for selection to optimize patient outcomes. By reviewing existing guidelines and the literature, this paper aims to enhance the endoscopist's understanding of guidewire technology and its application in biliopancreatic endoscopy.

A review on pancreatic duct stents: materials and emerging trends

Pancreatic duct strictures, which can arise from trauma, inflammation, or malignancy, often result in complications such as duct obstruction, pancreatic parenchymal hypertension, and ischemia. Endoscopic stenting is an effective therapeutic approach for managing these strictures. However, traditional plastic pancreatic duct stents fail to conform to the physiological curvature of the pancreas, while metal pancreatic duct stents with flared ends reduce migration but are associated with complications such as de novo strictures. Additionally, plastic and metal pancreatic duct stents require surgical removal. Whereas biodegradable pancreatic duct stents present a promising alternative due to their superior biocompatibility and ability to decompose into non-toxic materials, potentially eliminating the need for additional surgeries. Despite these advantages, biodegradable pancreatic duct stents remain in the experiment stage. This review assesses current materials of pancreatic duct stents, and emphasizes recent advancements in biodegradable options and emerging trends in clinical applications.

Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage includes two procedures: EUS-guided drainage/anastomosis (EUS-D/A) and trans-papillary drainage with EUS-assisted pancreatic rendezvous. EUS-guided pancreatogastrostomy is the most common EUS-D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS-D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS-D/A and subsequent trans-endosonographically/EUS-guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS-D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS-D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post-pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans-endosonographically/EUS-guided created route procedures following initial EUS-D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS-D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS-D/A, including its indications, techniques, and success-enhancing strategies.

Endoscopic Ultrasound-guided Pancreatic Duct Drainage: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as a minimally invasive therapeutic option for patients who cannot undergo traditional retrograde access to the pancreatic duct due to difficulties in cannulation or surgically altered anatomy. This meta-analysis aimed to evaluate the overall outcomes and safety of EUS-PD.

METHODS

We conducted a comprehensive search of major databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, up until October 2023. The meta-analysis focused on technical and clinical success rates, as well as the overall adverse event (AE) rate.

RESULTS

A total of 27 trials involving 902 patients were included in the study. The cumulative rate of technical success is 89%, and the clinical success is 88%, whereas the AE rate was 17%. The most common AE observed was post-EUS-PD acute pancreatitis, with a rate of 3%. In addition, the cumulative rates of bleeding, perforation, pancreatic leak, and infection were 2%, 2%, 1%, and 1%, respectively.

CONCLUSION

EUS-PD demonstrates highly favorable technical and clinical success rates, alongside acceptable AE rates, making it a highly effective procedure.

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Safety and efficacy of trans-afferent loop endoscopic ultrasound-guided pancreaticojejunostomy for post pancreaticoduodenectomy anastomotic stricture using the forward-viewing echoendoscope: a retrospective study from Japan

BACKGROUND/AIMS

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is a well-established procedure for managing pancreaticojejunostomy anastomotic strictures (PJAS) post-Whipple surgery. In this study, we examined the effectiveness and safety of EUS-guided pancreaticojejunostomy (EUS-PJS).

METHODS

This retrospective, single-arm study was performed at Aichi Cancer Center Hospital on 10 patients who underwent EUS-guided pancreaticojejunostomy through the afferent jejunal loop using a forward-viewing echoendoscope when endoscopic retrograde pancreatography failed. Our primary endpoint was technical success rate, defined as successful stent insertion. The secondary endpoints were early and late adverse events.

RESULTS

A total of 10 patients underwent EUS-PJS between February 2019 and October 2023. The technical success rate was 100%. The median procedure time was 23.5 minutes. No remarkable early or late adverse events related to the procedure, except for fever, occurred in two patients. The median follow-up duration was 9.5 months, and the median number of stent exchanges was two. A stent-free state was achieved in three patients.

CONCLUSIONS

EUS-PJS for PJAS management after pancreaticoduodenectomy appears to be an effective and safe procedure with the potential advantages of fewer reinterventions and the creation of a permanent drainage fistula.

Long-term outcomes of endoscopic ultrasound-guided pancreatic duct interventions: A single tertiary center experience

BACKGROUND AND AIMS

Endoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is one of the most technically challenging procedures. There remains a knowledge gap due to its rarity. The aim is to report the accumulated EUS-PDI experience in a tertiary center.

METHODS

Single tertiary center, retrospective cohort study of prospectively collected data during the study period, from January 2013 to June 2021.

RESULTS

In total, 14 patients (85% male; mean age, 61 years, range 37-81) and 25 EUS-PDI procedures for unsuccessful endoscopic retrograde pancreatography (ERP) were included. Principal etiology was chronic pancreatitis with pancreatic duct obstruction (78%). EUS-guided assisted (colorant and/or guidewire, rendezvous) ERP was performed in 14/25 (56%); and transmural drainage in 11 procedures, including pancreaticogastrosmy in 9/25 (36%) and pancreaticoduodenostomy in 2/25 (8%). Overall technical and clinical success was 78.5% (11/14). Three (21%) patients required a second procedure with success in all cases. Two failed cases required surgery. Three (21%) adverse events (AEs) were noted (fever, n=1; perforation, n=1; pancreatitis, n=1). Patients underwent a median of 58 months (range 24-108) follow-up procedures for re-stenting. Spontaneous stent migration was detected in 50% of cases.

CONCLUSIONS

EUS-PDI is an effective salvage therapy for unsuccessful ERP, although 21% of patients may still experience AEs. In case of EUS-guided rendezvous failure, it can cross over to a transmural drainage.

Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy

BACKGROUND

Although balloon enteroscopy-assisted ERCP and transgastric EUS-guided pancreatic duct drainage (EUS-PD) are treatment option for pancreaticojejunostomy anastomotic stricture (PJAS), they are often challenging with several limitations. This study aimed to examine the feasibility of transanastomotic forward-viewing EUS-PD (FVEUS-PD) via the afferent loop for PJAS after pancreaticoduodenectomy.

METHODS

Ten consecutive patients with symptomatic PJAS who underwent FVEUS-PD between 2015 and 2021 were retrospectively evaluated. Study outcomes included technical and clinical success, adverse events, and recurrence rates associated with FVEUS-PD. A short dumbbell-shaped, fully covered metal stent was deployed in all cases, and the stent was removed 3 month after placement, after which it became stent-free.

RESULTS

The technical success rate was 80% (8/10), and the scope could not reach the PJAS in two patients. Clinical success was achieved in all technically successful patients. No procedure-related adverse events observed. All patients were followed up for over three years after metal stent removal and becoming stent-free; the median follow-up period was 63 month. One patient developed symptomatic stricture recurrence 36 month after removal, with a stricture recurrence rate of 13% (1/8). The remaining patients did not experience any recurrence or late adverse events during the study period.

CONCLUSIONS

This study is the first to investigate FVEUS-PD, demonstrating promising technical feasibility with low adverse event and recurrence rates, potentially becoming a useful treatment option for PJAS.

Endoscopic Ultrasonography-Guided Drainage of the Pancreatic Duct (EUS-PD)-Indications and Results with a Literature Review

Background/Objectives: Drawing upon over twenty years of clinical experience in endoscopic and endosonographic procedures, along with comprehensive literature research, we present an overview on EUS-guided pancreatography and pancreatic duct drainage (EUS-PD) as an alternative approach, encompassing indications, procedural methods, and outcomes, including complications and the success rate. Methods: Narrative review. Results: (corner points): EUS-PD is indicated for cases, for which conventional methods are ineffective due to altered abdominal anatomy of the upper gastrointestinal (GI) tract, such as congenital or postoperative conditions that prevent access to the papilla or pancreatoenteric anastomosis. It is also considered if there is symptomatic retention of the pancreatic duct due to pathological changes in the papillary region or stenosis of the pancreatic duct or anastomosis, especially if surgery is not feasible or poses higher risks. EUS-PD has a technical success rate ranging from 25 to 92%, albeit with a complication rate spanning from 14 to 40%, primarily comprising bleeding, perforation, pancreatitis, and pain. Long-term clinical success, measured by pain and symptom relief, falls within a range of 65-85%. Conclusions: The method offers advantages such as minimal invasiveness, enhanced quality of life, the potential for endoscopic revision in the case of complications, and compatibility with most conventional endoscopic instruments requiring extensive expertise in interventional endoscopy and endosonography.

Safety and efficacy of endoscopic ultrasound-guided pancreatic duct drainage using a drill dilator: a retrospective study in Japan

BACKGROUND/AIMS

Dilation of the tract before stent deployment is a challenging step in endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD). In this study, we examined the effectiveness and safety of a novel spiral dilator, Tornus ES (Asahi Intec), for EUS-PDD.

METHODS

This was a retrospective, single-arm, observational study at Aichi Cancer Center Hospital. The punctured tract was dilated using a Tornus ES dilator in all EUS-PDD cases. Our primary endpoint was the technical success rate of initial tract dilation. Technical success was defined as successful fistula dilation using a Tornus ES followed by successful stent insertion. Secondary endpoints were procedure times and early adverse events.

RESULTS

A total of 12 patients were included between December 2021 and March 2023. EUS-PDD was performed in 11 patients for post-pancreaticoduodenectomy anastomotic strictures and one patient with pancreatitis with duodenal perforation. The technical success rates of stent insertion and fistula dilation using a Tornus ES dilator was 100%. The median procedure time was 24 minutes. No remarkable adverse events related to the procedure were observed, apart from fever, which occurred in 2 patients.

CONCLUSIONS

Tract dilation in EUS-PDD using a Tornus ES is effective and safe.

Endoscopic ultrasound-guided pancreatic duct drainage: a comprehensive state of the art review

INTRODUCTION

Endoscopic retrograde pancreatography (ERP) has traditionally been the standard modality for pancreatic endotherapy. However, in certain situations, failure of retrograde ductal access may warrant an alternative modality of drainage. This can occur in various settings like difficult and/or surgically altered anatomy or duodenal obstruction. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a relatively newer addition to the armamentarium for endoscopic access to the PD.

AREAS COVERED

This comprehensive state-of-art review aims to give an overview of the indications, technical details, different approaches, and outcomes of EUS-PDD, with the latest evidence available in scientific literature.

EXPERT OPINION

Akin to its biliary drainage counterpart, EUS-PDD enables an EUS-assisted-ERP using rendezvous technique or EUS-guided drainage through transmural stenting. The technique has evolved over the ensuing years with multitude of accessories, approaches, and devices to optimize the outcomes. However, the technical success and adverse events rates need to be further improved. Additionally, it has a steep learning curve with requirements of advanced technical skill and optimum infrastructure back-up. Meticulous patient selection, precise knowledge of ductal anatomy, appropriate approach, and carefully chosen accessories can improve its clinical outcomes.

Feasibility and safety of a novel plastic stent designed specifically for endoscopic ultrasound-guided pancreatic duct drainage

Background and study aims Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) is emerging as an effective alternative treatment for obstructive pancreatitis after unsuccessful endoscopic retrograde pancreatography (ERP). However, the high incidence of adverse events associated with EUS-PD (approximately 20%) remains an issue. Recently, we developed a novel plastic stent for EUS-PD, with a radiopaque marker positioned at approximately one-third of the length from the distal end of the stent and side holes positioned exclusively distal to the marker. This study aimed to evaluate the feasibility and safety of using this stent in EUS-PD. Patients and methods We retrospectively reviewed data from 10 patients who underwent EUS-PD with the novel plastic stent at the National Cancer Center Hospital between March 2021 and October 2023. Technical and clinical success, procedure times, adverse events (AEs), recurrent pancreatic duct obstruction (RPO), and time to RPO were assessed. Results Of the 10 patients, five had postoperative benign pancreaticojejunal anastomotic strictures and five had malignant pancreatic duct obstruction. The technical and clinical success rates were both 100% (10/10). An AE (self-limited abdominal pain) occurred in one patient (10.0%). Two patients (20.0%) died of their primary disease during the follow-up period (median, 44 days; range, 25-272 days). The incidence of RPO was 10.0% (1/10), and the 3-month non-RPO rate was 83.3%. Conclusions The novel plastic stent shows potential as a useful and safe tool in EUS-PD.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract)

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Endoscopic Ultrasound-Guided Pancreatic Duct Interventions

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

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.

Techniques and Outcomes of Endoscopic Ultrasound Guided-Pancreatic Duct Drainage (EUS- PDD)

Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.

Pancreatic duct stents

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

[Endoscopic Ultrasound-guided Drainage in Pancreatobiliary Diseases]

EUS-guided drainage for gallbladder, bile duct, pancreatic duct, and peripancreatic fluid collection has been performed more frequently in the last decade. The development of dedicated stents and delivery systems for EUS-guided interventions have improved the efficacy and safety of these procedures. Furthermore, the introduction of lumen-apposing metal stents has reduced the complication significantly of endoscopic transmural drainage of pancreatic collections and gallbladder. Recent studies show that EUS-guided drainage of pancreaticobiliary ducts and peripancreatic fluid collection produces good results and low complication rates. This review describes the current position and role of interventional EUS for pancreatobiliary disease in clinical practice.

When ERCP Fails: EUS-Guided Access to Biliary and Pancreatic Ducts

Pancreaticobiliary (PB) endotherapy continues to progress in the era of therapeutic endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary method for PB access in native and altered anatomy. In altered anatomy, PB access can be obtained via enteroscopy-assisted ERCP (e-ERCP) or laparoscopy-assisted ERCP; however, both approaches have significant limitations. Endoscopic ultrasound-guided biliary and pancreatic duct drainage (EUS-BPD) are increasingly becoming the preferred alternative when ERCP fails, with advantages over percutaneous drainage. EUS-BPD continues to evolve with better feasibility, safety and efficacy as dedicated procedural equipment continues to improve. In this article, we discuss the role of endoscopic ultrasound (EUS) when ERCP fails and their indications, technique, and outcomes.

Therapeutic endoscopic ultrasound

Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.

Efficacy and Safety of Peroral Pancreatoscopy Through the Fistula Created by Endoscopic Ultrasound-Guided Pancreaticogastrostomy

OBJECTIVES

Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy (EUS-PGS) is a useful alternative when endoscopic retrograde pancreatography is difficult. Recently, many procedures, including peroral pancreatoscopy (POPS), have been performed through the mature fistula (MF) created by EUS-PGS. We evaluate the efficacy and safety of POPS to diagnose and treat pancreatic ductal stricture/pancreato-jejunal anastomotic stricture (PDS/PJAS) through the MF.

METHODS

Twenty patients underwent EUS-PGS; 13 of these underwent POPS through the MF at Juntendo University Hospital. All patients were studied retrospectively in terms of technical and clinical success rates and adverse events (AEs).

RESULTS

The technical and clinical success rates of EUS-PGS were 95% and 100%. The early and late AEs rates were 20% and 15%. The technical success rate of POPS was 100%, with one AE. Biopsy of PDS/PJAS under POPS guidance revealed recurrent/residual intrapapillary mucinous adenoma (3 patients) and benign fibrotic stricture (10 patients). In the latter patients, multiple plastic stents were placed to dilate PDS/PJAS. Four patients with improvement of PDS/PJAS were stent free, but the remaining patients were not yet.

CONCLUSIONS

Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy and various procedures (including POPS) performed through the MF are feasible and effective and can diagnose and treat PDS/PJAS with acceptable AEs rates.

Approach to management of pancreatic strictures: the gastroenterologist's perspective

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.

EUS-guided pancreatic duct drainage with rendezvous technique for post-Whipple pancreatic duct stone

Video 1EUS-guided pancreatic drainage using the rendezvous technique in a patient with pancreaticojejunal anastomosis stenosis and pancreatic duct stone.

EUS guided pancreatic duct decompression in surgically altered anatomy or failed ERCP - A systematic review, meta-analysis and meta-regression

INTRODUCTION

EUS-PD (EUS guided pancreatic duct drainage) is classified into two types: EUS-guided rendezvous techniques and EUS-guided PD stenting. Prior studies showed significant variation in terms of technical success, clinical success and adverse events.

METHODS

Three independent reviewers performed a comprehensive review of all original articles published from inception to June 2020, describing pancreatic duct drainage utilizing EUS. Primary outcomes were technical success, clinical success of EUS-PDD and safety of EUS-PD in terms of adverse events. All meta-analysis and meta-regression tests were 2-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test.

RESULTS

A total of sixteen studies (503 patients) described the use of EUS-PD for pancreatic duct decompression yielded a pooled technical success rate was 81.4% (95% CI 72-88.1, I 2 = 74). Meta-regression revealed that proportion of altered anatomy and method of dilation of tract explain the variance. Overall pooled clinical success rate was 84.6% (95% CI 75.4-90.8, I 2 = 50.18). Meta-regression analysis revealed that the type of pancreatic duct decompression, proportion of altered anatomy and follow up time explained the variance. Overall pooled adverse event rate was 21.3% (95% CI 16.8-26.7, I 2 = 36.6). The most common post procedure adverse event was post procedure pain. Overall pooled adverse event rate of post EUS-PD pancreatitis was 5% (95% CI 3.2-7.8, I 2 = 0).

CONCLUSION

The systematic review, meta-analysis and meta-regression provides answer to the questions of the overall technical success, clinical success and the adverse event rate of EUS-PD by summarizing the available literature.

Radial incision and cutting combined with balloon dilation for refractory pancreaticojejunostomy anastomotic strictures

Background and study aims Endoscopic balloon dilation (BD) and temporary stent placement for pancreaticojejunostomy anastomotic stricture (PJAS) achieves good short-term outcomes; however, stricture recurrences remain frequent. We examined the feasibility of performing radial incision and cutting (RIC) combined with BD for refractory PJAS.

Patients and methods Five consecutive patients with refractory PJAS who underwent RIC with BD between 2015 and 2018 were retrospectively investigated. We evaluated the technical and clinical success, adverse event (AE), and recurrence rates associated with RIC with BD.

Results In all five patients, technical and clinical success were achieved. Pancreatic stone removal was simultaneously performed in one patient. The mean procedure time was 18 minutes (range 12–23 minutes). There were no procedure-related AEs. All patients were followed for over 2 years, with a mean follow-up period of 33 months (range 24–40 months). During the follow-up period, none of the patients developed stricture recurrence and all anastomoses remained patent.

Conclusions This is the first report of RIC with BD for the treatment of refractory PJAS, showing favorable results. This combined procedure might be a useful option for treating refractory PJAS.

Which Are the Most Suitable Stents for Interventional Endoscopic Ultrasound?

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

Efficacy and safety of endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD): A systematic review and meta-analysis of 714 patients

Background and study aims  Endoscopic ultrasound guided pancreatic duct drainage (EUS-PDD) is a minimal-invasive therapeutic option to surgery and in patients with failed endoscopic retrograde pancreatography (ERP). The aim of this review was to quantitatively appraise the clinical outcomes of EUS-PDD by meta-analysis methods. Methods  We searched multiple databases from inception through March 2020 to identify studies that reported on EUS-PDD. Pooled rates of technical success, successful drainage of pancreatic duct, clinical success, and adverse events were calculated. Study heterogeneity was assessed using I ² % and 95 % prediction interval. Results  A total of 22 studies (714 patients) were included. The pooled rate of technical success in EUS-PDD was 84.8 % (95 % CI 79.1-89.2). The pooled rate of successful PD drained by EUS-PDD was 77.5 % (95 % CI 63.1-87.4). The pooled rate of clinical success of EUS-PDD was 89.2 % (95 % CI 82.1-93.7). The pooled rate of all adverse events was 18.1 % (95 % CI 14.2-22.9). On sub-group analysis, the pooled technical success and clinical success of EUS-PDD from Japanese data were considerably superior (91.2 %, 83-95.6 & 92.5 %, 83.9-96.7, respectively). The pooled rate of post EUS-PDD acute pancreatitis was 6.6 % (95 % CI 4.5-9.4), bleeding was 4.1 % (95 % CI 2.7-6.2), perforation and/or pneumoperitoneum was 3.1 % (95 % CI 1.9-5), pancreatic leak and/or pancreatic fluid collection was 2.3 % (95 % CI 1.4-4), and infection was 2.8 % (95 % CI 1.7-4.6). Conclusion  EUS-PDD demonstrates high technical success and clinical success rates with acceptable adverse events. Technical success was especially high for anastomotic strictures.

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: Techniques and Literature Review of Transmural Stenting

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an option in patients with failure of retrograde access to the pancreatic duct (PD) because of difficulty in cannulation or surgically altered anatomy. This article provides a comprehensive review of the techniques and outcomes of EUS-PD, especially EUS-guided pancreatic transmural stenting. The clinical data derived from a total of 401 patients were reviewed in which the overall technical and clinical success rates were 339/401 (85%, range 63%–100%) and 328/372 (88%, range 76%–100%), respectively. Short-term adverse events occurred in 25% (102/401) of the cases, which included abdominal pain (n=45), acute pancreatitis (n=17), bleeding (n=10), and issues associated with pancreatic juice leakage such as perigastric or peripancreatic fluid collection (n=9). In conclusion, although EUS-PD remains a challenging procedure with a high risk of adverse events such as pancreatic juice leakage, perforation, and severe acute pancreatitis, the procedure seems to be a promising alternative for PD drainage in patients with altered anatomy or unsuccessful endoscopic retrograde pancreatography.

Long-term outcome of endoscopic ultrasound-guided pancreatic duct drainage using a fully covered self-expandable metal stent for pancreaticojejunal anastomosis stricture

BACKGROUND AND AIM

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has been proposed for pancreatic duct obstruction after failure of endoscopic retrograde pancreatography. We evaluate the long-term outcomes of EUS-PD using a fully covered self-expandable metal stent (FCSEMS) for pancreaticojejunal anastomosis (PJA) strictures following Whipple procedures.

METHODS

Twenty-three patients with PJA strictures underwent EUS-PD according to the findings of EUS-guided pancreatogram and the passage of the guidewire through PJA stricture (complete vs partial stricture) after failure of endoscopic retrograde pancreatography. Technical and clinical success, adverse events (AEs), and long-term outcomes were assessed.

RESULTS

Technical and clinical success was achieved in all patients. The complete and partial strictures were 11 and 12, respectively. The direct transanastomotic and transmural plastic stenting in partial PJA stricture was successful in only three patients (13%). Therefore, 20 patients underwent EUS-guided transmural FCSEMS placement during the initial attempt. Early AEs, including abdominal pain (n = 3) and peripancreatic fluid collection (n = 1), occurred in four patients (17.4%). During the follow-up periods (median, 27.2 months; interquartile range [IQR], 18.7-40.6), five patients (21.7%) developed late AEs, including asymptomatic stent fracture at the gastric end (n = 3), asymptomatic stent migration (n = 1), and stent occlusion (n = 1). The total duration of stent placement was 27.2 months (IQR, 18.7-40.6), and the median number of stent revision was 2 (IQR, 1-2).

CONCLUSIONS

In terms of safety and efficacy, EUS-PD with an FCSEMS showed favorable success and acceptable AEs rate and durable long-term outcomes.

Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center

BACKGROUND AND AIM

Endoscopic ultrasonography-guided pancreatic ductal intervention (EUS-PDI) serves as a rescue therapy in patients with failure of retrograde access to the pancreatic duct (PD) at the time of endoscopic retrograde pancreatography (ERP). We review our experience of this procedure.

METHODS

This is a retrospective study of patients who underwent EUS-PDI for an unsuccessful ERP and altered anatomy.

RESULTS

A total of 44 (65.9% male) patients underwent EUS-PDI with a mean age of 43.5 years, (range: 23-67). Transgastric rendezvous technique was carried out in 23/44 (52.3%), transgastric pancreaticogastrostomy in 18/44 (40.9%) and transduodenal pancreaticobulbostomy in 3/44 (6.8%). Overall technical and clinical success was seen in 88.6% (39/44) and 81.8% (36/44), respectively. Technical success of transgastric rendezvous was 95.6% and that of transgastric pancreaticogastrostomy was 77.8%. Two of seven patients with failure to access the PD had successfully undergone EUS-PD stenting at subsequent attempt. Ten immediate adverse events (AE) were noted which included abdominal pain (n = 4), pancreatitis (n = 2), fever (n = 2), minor bleeding (n = 1), and stripping of wire (n = 1). Delayed AE included stent blockage in 12/39 (30.8%) and spontaneous stent migration in 5/39 (12.8%) which were managed with stent exchange at follow up. The rendezvous technique was associated with fewer AE than transgastric pancreaticogastrostomy.

CONCLUSIONS

Endoscopic ultrasonography-PDI is an effective treatment modality and salvage therapy in patients with unsuccessful ERP. Technical and clinical success seen with this study is comparable to studies conducted across the world. EUS-PDI needs to show cost-effectiveness in future studies.

Recent innovations in therapeutic endoscopy for pancreatobiliary diseases

The development of endoscopic treatment for pancreatobiliary diseases in recent years is remarkable. In addition to conventional transpapillary treatments under endoscopic retrograde cholangiopancreatography (ERCP), new endoscopic ultrasound-guided therapy is being developed and implemented. On the other hand, due to the development/improvement of various devices such as new metal stents, a new therapeutic strategy under ERCP is also advocated. The present review focuses on recent advances in the endoscopic treatment of pancreatic pseudocysts, walled-off necrosis, malignant biliary strictures, and benign biliary/pancreatic duct strictures.

Endoscopic Ultrasound-Guided Pancreatic Transmural Stenting and Transmural Intervention

Endoscopic ultrasound (EUS)-guided pancreatic access is an emergent method that can be divided into the two main techniques of EUS-guided rendezvous and pancreatic transmural stenting (PTS). While many reports have described EUS-guided procedures, the indications, technical tips, clinical effects, and safety of EUS-guided pancreatic duct drainage (EUS-PD) remain controversial. This review describes the current status of and problems associated with EUS-PD, particularly PTS. We reviewed clinical data derived from a total of 334 patients. Rates of technical and clinical success ranged from 63% to 100% and 76% to 100%, respectively. In contrast, the rate of procedure-related adverse events was high at 26.7% (89/334). The most frequent adverse events comprised abdominal pain (n=38), acute pancreatitis (n=15), bleeding (n=9), and issues associated with pancreatic juice leakage such as perigastric fluid, pancreatic fluid collection, or pancreatic juice leaks (n=8). In conclusion, indications for EUS-PTS are limited, as is the evidence of its viability, due to the scarcity of expert operators. Despite improvements made to various devices, EUS-PTS remains technically challenging. Therefore, a long-term, large-scale, multicenter study is required to establish this technique as a viable alternative drainage method.

Therapeutic EUS: New tools, new devices, new applications

Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.

Endoscopic ultrasound-guided pancreatic duct drainage

Endoscopic transpapillary or transanastomotic pancreatic duct drainage (PD) is the mainstay of drainage in symptomatic pancreatic duct obstruction or leakage. However, transpapillary or transanastomotic PD can be technically difficult due to the tight stricture or surgically altered anatomy (SAA), and endoscopic ultrasound (EUS)-guided PD (EUS-PD) is now increasingly used as an alternative technique. There are two approaches in EUS-PD: EUS-guided rendezvous (EUS-RV) and EUS-guided transmural drainage (EUS-TMD). In cases with normal anatomy, EUS-RV should be the first approach, whereas EUS-TMD can be selected in cases with SAA or duodenal obstruction. In our literature review, technical success and adverse event rates were 78.7% and 21.8%, respectively. The technical success rate of EUS-RV appeared lower than EUS-TMD due to the difficulty in guidewire passage. In future, development of dedicated devices and standardization of EUS-PD procedure are necessary.

Endoscopic treatment of pain in chronic pancreatitis

PURPOSE OF REVIEW

Pain is the most common symptom of chronic pancreatitis, having a profound effect on patients and a broad socioeconomic impact. Endoscopy is guideline recommended as first-line management for chronic pancreatitis pain in certain clinical scenarios. Herein, we provide an evidence-based review of the endoscopic treatment of pain due to chronic pancreatitis while highlighting some important confounders in the measurement of this outcome in clinical practice and research.

RECENT FINDINGS

Multiple recent studies have reported on the efficacy of current endoscopic therapies for chronic pancreatitis pain. Despite the high technical success rates of these procedures, pain outcomes remain disappointing. Complex mechanisms beyond ductal hypertension, such as central sensitization, visceral hypersensitivity and inflammatory neuritis account for some of the discordance observed between the rates of technical and clinical success. In addition, the sham effect is increasingly recognized as a confounder when interpreting the procedural benefit. Nevertheless, there are multiple promising innovations in the field of pancreatic endoscopy that are aimed to improve technical and clinical outcomes, but rigorous investigation is necessary to establish their role in clinical practice.

SUMMARY

Endoscopic therapy for chronic pancreatitis pain appears to be safe and effective in certain contexts and recent innovations in the field will hopefully further improve outcomes. In addition to evaluating the technical success of endotherapy in chronic pancreatitis, methodologically rigorous research focusing on patient-centered outcomes and accounting for the sham effect is necessary to advance this field.