Multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video)

Prevention of Adverse Events in Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used when biliary drainage using endoscopic retrograde cholangiopancreatography fails. Recently, it has been adopted as a primary biliary drainage method, and its indications have expanded. Since EUS-BD can cause adverse events (AEs), such as bile leakage and stent migration, which do not occur in endoscopic retrograde cholangiopancreatography, endoscopists need to be well-versed in its management and preventive techniques. EUS-BD includes several procedures, such as EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided antegrade stenting (EUS-AS), and EUS-guided rendezvous (EUS-RV). A recent meta-analysis reported that the overall AE rate of EUS-BD was 13.7% (EUS-CDS, 11.9%; EUS-HGS, 15.5%; EUS-AS, 9.9%; and EUS-RV, 8.8%). Among various EUS-BD techniques, EUS-CDS and EUS-HGS are the most frequently reported. Tubular self-expandable metal stents have been traditionally used in EUS-CDS; however, lumen-apposing metal stents have recently gained popularity. A systematic review showed that the rates of early AEs were similar between self-expandable metal stents and lumen-apposing metal stents; however, stent maldeployment was more problematic with lumen-apposing metal stents. Although tubular self-expandable metal stents are used in EUS-HGS, stent maldeployment remains a serious issue, and available devices and technical tips for preventing this AE should be well understood. Furthermore, AEs, such as sepsis, cholangitis, and bleeding, can occur, and strategies to mitigate these risks are essential. In this narrative review, we discussed AEs related to EUS-BD with a focus on management options and strategies for prevention.

Effective use of the novel rotatable sphincterotome for reintervention of endoscopic ultrasound-guided antegrade stenting

Watch a video of this article.

Late-onset Rupture of the Intrahepatic Pseudoaneurysm Developed by Endoscopic Ultrasonography-guided Hepaticogastrostomy: A Case Report and Literature Review

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative drainage technique for patients with malignant biliary obstruction. However, few reports have discussed the occurrence of late-onset rupture of hepatic artery pseudoaneurysms following EUS-HGS. A recently available drill dilator equipped with a long screw segment was used in the dilation step of EUS-HGS. We highlight the potential concern that this long screw segment may increase the risk of damage to the hepatic artery, leading to late-onset life-threatening rupture of a pseudoaneurysm.

Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Updates on therapeutic endoscopic ultrasound

PURPOSE OF REVIEW

Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms.

RECENT FINDINGS

Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted.

SUMMARY

Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.

Biliary drainage in patients with malignant distal biliary obstruction: results of an Italian consensus conference

BACKGROUND

Malignant Distal Biliary Obstruction (MBDO) is a common event occurring along the natural history of both pancreatic cancer and cholangiocarcinoma. Epidemiological and biological features make MBDO one of the key elements of the clinical management of patients suffering for of pancreatic cancer or cholangiocarcinoma. The development of dedicated biliary lumen-apposing metal stents (LAMS) is changing the clinical work up of patients with MBDO. i-EUS is an Italian network of clinicians and scientists with a special interest in biliopancreatic endoscopy, EUS in particular.

METHODS

The scientific methodology was chosen in line with international guidance and in a fashion similar to those applied by broader scientific associations. PICO questions were elaborated and subsequently voted by a broad panel of experts within a simplified Delphi process.

RESULTS AND CONCLUSIONS

The manuscripts describes the results of a consensus conference organized by i-EUS with the aim of providing an evidence based-guidance for the appropriate use of the techniques in patients with MBDO.

Endoscopic ultrasound-guided hepaticogastrostomy vs. antegrade metal stent placement keeping an access route in patients with malignant biliary obstruction

BACKGROUND

Few studies have compared endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) with EUS-guided antegrade metal stent placement (AGMS). The purpose of this study was to compare times to recurrent biliary obstruction (TRBO) in patients who underwent HGS using metal stents (MS) and those who underwent AGMS keeping access routes with plastic stents (AGMS-AR).

METHODS

This study retrospectively evaluated consecutive patients who underwent HGS or AGMS between September 2016 and December 2022. TRBO, overall survival (OS), and adverse event (AE) rates were compared in the two groups. The risk factors for RBO were determined using a multivariable Cox proportional hazards model.

RESULTS

This study included 32 patients in the HGS group and 30 in the AGMS-AR group. Technical success rate was significantly higher in the HGS than in the AGMS-AR group (100 vs. 80%; P = 0.009). The technical success rate without tract dilation was significantly higher in the AGMS-AR than in the HGS group (83 vs. 38%; P < 0.001). RBO rates were significantly higher in the HGS than in the AGMS-AR group (53 vs. 17%; P = 0.024), whereas AE rates did not differ significantly. TRBO differed significantly in the HGS and AGMS-AR groups (159 days vs. not reached, P = 0.011), whereas OS did not differ significantly. Multivariable analysis revealed that HGS was an independent risk factor for RBO (hazard ratio, 6.48, P = 0.014).

CONCLUSION

TRBO was significantly longer in patients who underwent AGMS with PS than HGS. AGMS with PS may be effective after the failure of ERCP in patients with malignant biliary obstruction.

EUS-guided hepaticogastrostomy versus EUS-guided hepaticogastrostomy with antegrade stent placement in patients with unresectable malignant distal biliary obstruction: a propensity score-matched case-control study

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HGS) is a rescue procedure when ERCP fails. Peritonitis and recurrent biliary obstruction (RBO) are adverse events (AEs) associated with EUS-HGS. Antegrade stent placement across a malignant distal biliary obstruction (DBO) followed by EUS-HGS (EUS-HGAS) creates 2 biliary drainage routes, potentially reducing peritonitis and prolonging time to RBO (TRBO). We compared the outcomes of the 2 techniques.

METHODS

Data of consecutive patients with malignant DBO who underwent attempted EUS-HGS or EUS-HGAS across 5 institutions from January 2014 to December 2020 were retrospectively analyzed. A matched cohort of patients was obtained using 1-to-1 propensity score matching. The primary outcome was TRBO, and secondary outcomes were AEs except for RBO and overall survival.

RESULTS

Among 360 patients, 283 (176 and 107 in the HGS and HGAS groups, respectively) were eligible. The matched cohorts included 81 patients in each group. AEs developed in 10 (12.3%) and 15 (18.5%) patients (P = .38) in the HGS and HGAS groups, respectively. RBO occurred in 18 and 2 patients in the HGS and HGAS groups, respectively (P < .001). TRBO was significantly longer in the HGAS group (median, 194 days vs 716 days; hazard ratio, .050; 95% confidence interval, .0066-.37; P < .01). However, no significant differences occurred in overall survival between the groups (median, 97 days vs 112 days; hazard ratio, .97; 95% confidence interval, .66-1.4; P = .88).

CONCLUSIONS

EUS-HGAS extended TRBO compared with EUS-HGS, whereas AEs, except for RBO and overall survival, did not differ. The longer TRBO of EUS-HGAS could benefit patients with longer life expectancy.

Is Endoscopic Ultrasound-Guided Hepaticogastrostomy Safe and Effective after Failed Endoscopic Retrograde Cholangiopancreatography?-A Systematic Review and Meta-Analysis

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

Factors Associated With Difficult Endoscopic Ultrasonography-guided Biliary Drainage

BACKGROUND AND AIMS

When endoscopic retrograde cholangiopancreatography-guided biliary drainage is challenging, endoscopic ultrasound-guided biliary drainage (EUS-BD) can be used as an alternate treatment; however, this method requires operator expertise. Therefore, this study aimed to clarify the factors that are associated with a difficult EUS-BD.

PATIENTS AND METHODS

Patients who successfully underwent EUS-BD were enrolled in this study. The patients were divided into the easy group and difficult group depending on whether the procedural time was more than 60 minutes, which was the cutoff value elicited from past reports. Patient characteristics and procedural factors were compared between the two groups. The factors associated with difficult procedures were also investigated.

RESULTS

The patient characteristics were not significantly different between the easy group (n=22) and the difficult group (n=19). The diameter of the punctured bile duct was significantly different between the two groups. In the multivariate analysis, the diameter of the punctured bile duct was the only factor associated with a difficult EUS-BD (odds ratio 0.65, 95% confidence interval 0.46-0.91, P value=0.012). The cutoff value for the diameter of the punctured bile duct in predicting a difficult EUS-BD was 7.0 mm (area under the curve: 0.83, sensitivity 84.2%, specificity 86.4%).

CONCLUSIONS

A nondilated bile duct might be a predictive factor for a difficult EUS-BD. For beginners of EUS-BD, the cutoff value for the punctured bile duct diameter found in this study, 7.0 mm, might become a barometer for puncture point selection.

Asymptomatic Pneumoperitoneum With a Large Amount of Gas Appeared During Endoscopic Ultrasound-Guided Biliary Drainage

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

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

Endoscopic Biliary Drainage in Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures.

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.

Covered self-expandable metallic stents versus plastic stents for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction

BACKGROUND/AIMS

Covered self-expandable metallic stents (cSEMS) have become popular for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting (EUS-HGS). We compared the time to recurrent biliary obstruction (TRBO), complications, and reintervention rates between EUS-HGS using plastic stent (PS) and cSEMS in patients with unresectable malignancies at multicenter institutions in Japan.

METHODS

Patients with unresectable malignant biliary obstruction who underwent EUS-HGS between April 2015 and July 2020 at any of the six participating facilities were enrolled. Primary endpoint: TRBO; secondary endpoints: rate of complications other than recurrent biliary obstruction and technical success rate of reintervention were evaluated.

RESULTS

PS and cSEMS were used for EUS-HGS in 109 and 43 patients, respectively. The TRBO was significantly longer in the cSEMS group than in the PS group (646 vs. 202 days). Multivariate analysis identified two independent factors associated with a favorable TRBO: combined EUS-guided antegrade stenting with EUS-HGS and the use of cSEMS. No significant difference was observed in the rate of complications other than recurrent biliary obstruction between the two groups. The technical success rate of reintervention was 85.7% for PS and 100% for cSEMS (p=0.309).

CONCLUSION

cSEMS might be a better option for EUS-HGS in patients with unresectable malignancies, given the longer TRBO.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Drainage of Afferent Limb Obstruction via the Trans-gastric-bile Duct Formed after Endoscopic Ultrasound-guided Hepaticogastrostomy in a Patient with Pancreatic Cancer

A 63-year-old man with advanced pancreatic cancer and pyloric obstruction underwent surgical gastrojejunostomy. Malignant biliary obstruction appeared eight months after surgery and was managed with endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). Subsequently, afferent limb obstruction caused by cancer invasion occurred. Although an intestinal metal stent could not be placed, a biliary metal stent was deployed via the HGS route, which successfully decompressed the afferent limb; the abdominal symptoms subsequently disappeared. In future similar cases, decompression of the dilated intestine through the HGS and biliary stent might be a viable treatment option.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.

Endoscopic Ultrasound-Guided Antegrade Stent Placement in Patients with Failed ERCP as a Modality of Preoperative and Palliative Biliary Drainage

BACKGROUND

No large studies have addressed the role of endoscopic-ultrasound biliary drainage (EUS-BD) as preoperative biliary drainage (PBD) for malignant extrahepatic biliary obstruction (MEBO). We aimed to discuss the outcomes of EUS antegrade stent placement (EUS-AG) in the preoperative and palliative setting.

METHODS

Retrospective review of patients who underwent EUS-AG for MEBO between December 2019 and December 2021 was done. Primary outcome measures were technical success and clinical success. Secondary outcome measures were number of days of hospitalization postprocedure, adverse events related to EUS-AG procedure, morbidity related to surgery, and 3-month mortality after surgery.

RESULTS

54 patients underwent attempt for EUS-AG (mean age 54.8 ± 12.1 years; female 44.4%). Most common primary cancer was pancreatic cancer in 42.1% (23/54) patients. Indication was palliative in 34 (62.9%) patients and PBD in 20 (37%) patients. Level of block was distal in 35 (64.8%) and proximal in 19 (35.1%) patients. Technical success of EUS-AG was 88.7% (47/53). Clinical success was seen in 95.7% (45/47) patients. Median number of days of hospitalization postprocedure was 1 day. No procedure-related severe adverse events were seen. Of 20 patients who underwent EUS-AG as PBD, 19 had technical success (95%) with clinical success in 94.5% (18/19). Surgery was performed in 11 patients, of whom 10 patients underwent successful PPPD (one intraoperative liver metastasis). Two patients had Clavein-Dindo III/IV complication post-PPPD, with one mortality within 30 days of surgery.

CONCLUSION

EUS-AG is safe and effective after failed ERCP in both preoperative and palliative setting.

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.

Can endoscopic retrograde cholangiopancreatography-related procedures for resolving acute cholangitis be effectively and safely performed in patients with surgically altered anatomy? Comparison study to evaluate the timing of short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography

OBJECTIVES

Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)-assisted ERCP in patients with SAA and AC.

METHODS

Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS).

RESULTS

Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4-9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS.

CONCLUSIONS

Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.

Endoscopic ultrasound‑guided biliary drainage in patients with surgically altered anatomy: a systematic review and Meta‑analysis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography is technically challenging to perform in patients with surgically altered anatomy (SAA). For these patients, endoscopic ultrasound-guided biliary drainage (EUS-BD) is one of the good indications. The aim of our systematic review and meta-analysis was to identify and evaluate evidence of the efficacy and safety of EUS-BD in patients with SAA.

METHODS

A systematic review of the PubMed was conducted through to December 2021 to identify studies performing EUS-BD in patients with SAA. The primary outcome was the pooled technical success proportion in patients with SAA. The pooled clinical success and adverse event proportions in patients with SAA were also analyzed.

RESULTS

The search identified 1195 possible records, with 18 studies meeting our criteria for analysis, reporting data for 409 patients with SAA who underwent EUS-BD. The pooled technical success, clinical success and adverse event proportions in patients with SAA were 97.8% (95% confidence interval [CI], 95.8-99.7%), 94.9% (95% CI, 91.8-98.1%), and 12.8% (95% CI, 7.4-18.1%), respectively.

CONCLUSIONS

EUS-BD is effective for patients with SAA. However, adverse events should be considered when performing EUS-BD in these patients.

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.

Endoscopic Ultrasound-Guided Hepaticogastrostomy with Antegrade Stenting Without Dilation Device Application for Malignant Distal Biliary Obstruction in Pancreatic Cancer

BACKGROUND

Endoscopic ultrasound-guided hepaticogastrostomy with antegrade stenting (EUS-HGAS) is a promising therapeutic option for malignant distal biliary obstruction (MDBO) in the event of transpapillary approach failure. Eliminating the fistula dilation step may further decrease the incidence of adverse events (AE) and simplify the procedure.

AIMS

This study focused on MDBO associated with pancreatic cancer and aimed to examine the utility of EUS-HGAS without the use of any dilation devices.

METHODS

This retrospective study investigated consecutive patients in whom the transpapillary approach had failed or was difficult, and who underwent EUS-HGAS without dilation device usage, using a tapered small-diameter catheter, ultrathin delivery system, and tapered dedicated plastic stent. The outcomes of this study included the technical success, clinical success, AE incidence, and recurrent biliary obstruction (RBO) associated with the procedure.

RESULTS

During the study period, EUS-HGAS without dilation device usage was attempted for 57 patients with MDBO due to pancreatic cancer. The technical and clinical success rates were 91.2% (52/57) each. The median procedural time was 25 min. The rates of early and late AE besides RBO were 3.5% (2/57) and 1.9% (1/52), respectively. The incidence rate of RBO was 30.8% (16/52), and the median time to RBO was 245 days. The rate of successful endoscopic reintervention for RBO via the fistula was 100% (16/16).

CONCLUSIONS

EUS-HGAS without the use of dilation devices showed good technical feasibility with a low AE rate. It may be a useful option for MDBO associated with pancreatic cancer when the transpapillary approach is difficult.

Utility of Digital Single-operator Video Cholangioscopy for the Endoscopic Management of Biliary Complications After Liver Transplantation-A Single-center Experience

BACKGROUND

Liver transplant recipients (LTRs) frequently develop biliary complications, and endoscopy is crucial for their subsequent management. Recently, single-operator video cholangioscopy (SOVC) with digital imaging quality was introduced. This study evaluated the utility of digital SOVC for the management of biliary complications in LTRs.

METHODS

This observational study retrospectively analyzed all LTRs undergoing digital SOVC between 2015 and 2019 at a tertiary referral center. Endpoints included the assessment of biliary strictures, performance of selective guidewire passage across biliary strictures, and diagnosis and treatment of biliary stone disease.

RESULTS

In total, 79 digital SOVCs performed in 50 LTRs were identified. Fifty-eight percent of the procedures were performed for biliary stricture assessment, and using visual signs or guided biopsies, SOVC excluded malignancy in all cases (100%). Of all the examinations, 29.1% (23/79) were performed solely because of a previous failure of conventional endoscopic methods to pass a guidewire across a biliary stricture. Using SOVC, guidewire passage was successfully performed in 73.9% of these examinations, enabling subsequent endoscopic therapy. Furthermore, biliary stones were found in 16.5% (13/79) of the examinations. In 38.5% of these cases, standard fluoroscopy failed to detect stones, which were only visualized using digital SOVC. Biliary stone treatment was successful in 92% (12/13) of the examinations. Complications occurred in 11.4% of all SOVCs. No procedure-associated mortalities were observed.

CONCLUSIONS

Digital SOVC is effective and safe for the endoscopic management of biliary complications in LTRs and offers unique diagnostic and therapeutic opportunities that strongly impact the clinical course in selected cases.

Introduction of endoscopic ultrasound-guided hepaticoenterostomy - experience from a general hospital in Japan

Background and study aims Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a widely used alternative to endoscopic retrograde cholangiopancreatography (ERCP) when ERCP is unsuccessful or there are contraindications such as duodenal stenosis or postsurgical intestinal reconstruction. Therefore, we retrospectively investigated the therapeutic outcomes of EUS-BD in a medium-sized hospital.

Patients and methods We included 31 consecutive patients who underwent EUS-BD at the Kitasato University Medical Center between April 2018 and October 2021. Patient characteristics, technical and clinical success rates, stent patency, adverse events (AEs), and procedure time were analyzed.

Results Of the 31 patients included in this study, one underwent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and 30 underwent endoscopic ultrasound-guided hepaticoenterostomy (EUS-HES). The technical success rates were 100 % for EUS-CDS and 96.8 % for EUS-HES because EUS-HES was unsuccessful in one patient who then underwent EUS-CDS as an alternative treatment. The clinical success rates were 100 % for EUS-CDS and 96.7% for EUS-HES. The median follow-up period was 84 days (range: 14–483 days). Zero and 5 (16.6 %) patients who underwent EUS-CDS and EUS, respectively had stent dysfunction. The median stent patency (stent dysfunction and death) for EUS-HES was 124 days. AEs were observed in only two patients (6.7 %) who underwent EUS-HES.

Conclusions EUS-BD is now more widely used than before, and advances in the devices used have enabled the procedure to be performed more safely. Our results suggest that this introduction in medium-sized hospitals can be conducted safely.

Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures

There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.

Investigator initiated clinical trial to validate usefulness of specific system for endoscopic ultrasound guided hepaticogastrostomy (HG01) in malignant biliary obstruction (HG01)

INTRODUCTION

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a novel drainage option for patients with an inaccessible papilla. Although EUS-HGS has clinical benefits in patients for whom endoscopic retrograde cholangiopancreatography (ERCP) has failed, the rates of adverse events (AEs) associated with EUS-HGS, such as bile peritonitis and stent migration, are higher than for other procedures. The development of a dedicated system for EUS-HGS is therefore desirable to reduce the rate of AEs. We developed a dedicated system for EUS-HGS (HG01 system) which is composed of a 19-gauge needle, 0.025-inch guidewire, a thin delivery system for tract dilation, and an antimigration metal stent. This study is designed to evaluate the efficacy and safety of EUS-HGS using the HG01 system in malignant biliary obstruction.

METHODS/DESIGN

This is a single-arm multicenter prospective study involving 40 patients across six tertiary centers in Japan. Patients with an unresectable malignant biliary obstruction in whom biliary drainage with ERCP failed, is not possible, or is very difficult will be registered in the study. The primary endpoint is the clinical success rate. The secondary endpoints are the technical success rate, procedure-related AE rate, procedure time, procedure success rate using only the HG01 system, stent patency rate, re-intervention success rate, re-intervention method, survival rate, and distance of movement of the stent position.

DISCUSSION

We expect use of the HG01 system to reduce the rate of AEs during EUS-HGS, especially bile leakage and stent migration. If the efficacy and safety of EUS-HGS using the HG01 system is confirmed in the present study, it is likely to be considered the first-choice device for use during EUS-HGS.

Comparison of Radiation Exposure between Endoscopic Ultrasound-Guided Hepaticogastrostomy and Hepaticogastrostomy with Antegrade Stenting

Fluoroscopy forms an essential part of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and hepaticogastrostomy with antegrade stenting (EUS-HGAS). To date, no study has assessed and compared radiation exposure between EUS-HGS and EUS-HGAS. This study aimed to compare the radiation exposure parameters between EUS-HGS and EUS-HGAS. This retrospective single-center cohort study included consecutive patients who underwent EUS-HGS or EUS-HGAS from October 2017 to March 2019. The air kerma (AK: mGy), kerma-area product (KAP: Gycm2), fluoroscopy time (FT: min), and procedure time (PT: min) were assessed and compared between the two procedures. Altogether, 45 and 24 patients underwent EUS-HGS and EUS-HGAS, respectively. The median AK, KAP, FT, and PT were higher in the EUS-HGAS group than in the EUS-HGS group. A comparison revealed no difference in the technical success rate, complications rate, adverse event occurrence rate, and re-intervention rate between both procedures. This is the first report in which radiation exposure was used as a comparative parameter between EUS-HGS and EUS-HGAS. This study revealed that radiation exposure is significantly higher in EUS-HGAS than in EUS-HGS. Increased awareness on radiation exposure is warranted among gastroenterologists so that they choose the procedure with lower radiation exposure in cases where both procedures are indicated.

Application of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting in patients with malignant biliary obstruction after failed ERCP

BACKGROUND

This study was aimed at comparing the safety and effectiveness of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and EUS-HGS combined with antegrade stenting (EUS-HGAS) in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients diagnosed with MBO and receiving EUS-HGS or EUS-HGAS from September 2015 to October 2020 were enrolled in this study. Clinical success, complications, reintervention rate, post-operative hospital stay, time to stent dysfunction, and patient death were compared.

RESULTS

A total of 45 patients (21 in the EUS-HGAS group and 24 in the EUS-HGS group) were enrolled in this study. In the EUS-HGAS group, 21 patients all achieved clinical success (100%); in the EUS-HGS group, 24 patients also achieved technical success (100%) (P > 0.05). The differences between pre- and post-operative TB and ALT and AST levels were greater in the single-step EUS-HGAS group (P < 0.05). The incidence of complications was 2 of 21 (9.5%) in the EUS-HGAS group and 5 of 24 (20.8%) in the EUS-HGS group (P > 0.05). The reintervention rate was 0 in the EUS-HGAS group and 1 (4.2%) in the EUS-HGS group (P > 0.05). Time to stent dysfunction or patient death was longer in the EUS-HGAS group (P < 0.05). The post-operative hospital stay was longer and the total cost was higher in the EUS-HGAS group.

CONCLUSION

EUS-HGAS was superior to EUS-HGS in terms of biliary drainage effectiveness and time to stent dysfunction or patient death in patients with MBO after failed ERCP. Furthermore, two-step EUS-HGAS may be safer in some patients.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

Endoscopic ultrasound-guided biliary drainage: Are we there yet?

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.

Utility of dedicated bougie dilator for a 0.018-inch guidewire during EUS-guided biliary drainage: A multi-center retrospective cohort study

BACKGROUND

During endoscopic ultrasound-guided biliary drainage (EUS-BD), a combination of a 19-gauge needle and a 0.025-inch guidewire is generally used. However, a 19-gauge needle has poor maneuverability because of their stiffness and rigidity and might have poor penetrability in non-dilated bile ducts because of their large bore. In contrast, the application of a 22-gauge needle is expected to have improved maneuverability. However, only a 0.018-inch guidewire, which has less supportability, is applicable in the subsequent guidewire selection. This study aimed to evaluate the feasibility and safety of a dedicated bougie dilator for a 0.018-inch guidewire.

METHODS

From September 2019 to May 2020, 26 patients underwent fistula dilation using the dilator after accessing the bile duct using a 22-gauge needle and a 0.018-inch guidewire during EUS-BD. The success and adverse event rates of EUS-BD were evaluated.

RESULTS

Biliary access with a combination of a 22-gauge needle and a 0.018-inch guidewire was successful in all with a median bile duct diameter of 5 mm. Dilation of the fistula using the dedicated dilator was also successful in all cases. Subsequently, the dilator was successfully exchanged to an ERCP catheter that allowed for exchange to a 0.025-inch guidewire, except in one case where the catheter did not cross the fistula and a dilation balloon was inserted for an exchange to a 0.025-inch guidewire. The technical success rate of the EUS-BD was 100%. The adverse event rate was 19%.

CONCLUSION

The application of the dedicated dilator for a 0.018-inch guidewire was considered feasible and safe for EUS-BD.

Endoscopic Ultrasound-Guided Antegrade Radiofrequency Ablation and Metal Stenting With Hepaticoenterostomy for Malignant Biliary Obstruction: A Prospective Preliminary Study

Endobiliary radiofrequency ablation (RFA) for malignant biliary obstruction is a promising option for improving biliary stent patency, but its efficacy and safety with endoscopic ultrasound (EUS)-guided biliary drainage are uncertain. We examined the feasibility of EUS-guided hepaticoenterostomy with antegrade stenting (EUS-HEAS) and RFA in patients with unresectable malignant biliary obstruction.

Technical Review of Developments in Endoscopic Ultrasound-Guided Hepaticogastrostomy

Endoscopic ultrasound-guided biliary drainage has been developed as an alternative method for biliary drainage. EUS-guided hepaticogastrostomy (EUS-HGS) can be attempted via the trans-gastric route. These procedures are technically complex for two reasons. First, puncture of the intrahepatic bile duct via the trans-gastric route can be more difficult than that by other approaches because of the small diameter of the target site, and guidewire insertion or manipulation is challenging during EUS-HGS. Second, critical adverse events, such as stent migration into the abdominal cavity, could occur because of the greater mobility of the stomach compared to the duodenum. Therefore, endoscopists should be cautious when performing EUS-HGS. An advantage of EUS-HGS is that it can be performed in patients with complications such as duodenal bulb obstruction or surgically altered anatomy. Recent advances in technique and improvements in devices and stents for EUS-HGS have shown promise for improving the technical success rate of EUS-HGS and reducing the rate of adverse events. However, endoscopists should remain aware of the possibility of critical adverse events such as stent migration.

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.

Urgent and early EUS-guided biliary drainage in patients with acute cholangitis

Background and Objectives:

EUS-guided biliary drainage (EUS-BD) has been reported as an effective alternative drainage technique. However, clinical data on EUS-BD for patients with acute cholangitis (AC) are limited. The aim of this study was to analyze the clinical outcomes of EUS-BD in patients with AC.

Patients and Methods:

Nineteen patients with AC who underwent urgent or early drainage (within 96 h) by EUS-guided hepaticoenterostomy (EUS-HES) between January 2014 and November 2019 were retrospectively reviewed. Furthermore, the clinical outcomes of EUS-HES using a plastic stent in the AC group (n = 15) were compared to those in the non-AC group (n = 88).

Results:

In the 19 AC cases, the technical and clinical success rate was 100% with 5.3% of moderate adverse events (biliary peritonitis [n = 1]). Regarding the comparison between the AC group and the non-AC group, the clinical success rate was 100% in both groups and the adverse event rate was not statistically significantly different (P = 0.88). Although the recurrent biliary obstruction (RBO) rate was not statistically significantly different (P = 0.43), the early RBO rate was statistically significantly higher in the AC group (26.7% vs. 3.4%, P < 0.001). Kaplan–Meier curves showed that AC was associated with a shorter time to RBO (P = 0.046). The presence of AC was found to be an independent risk factor of early RBO (odds ratio = 10.3; P = 0.005).

Conclusions:

Urgent or early biliary drainage (within 96 h) by EUS-BD can be a feasible and safe alternative procedure for patients with AC, although there is a tendency of early RBO.

Comparison of endoscopic ultrasound-guided hepaticogastrostomy and the antegrade technique in the management of unresectable malignant biliary obstruction: study protocol for a prospective, multicentre, randomised controlled trial

BACKGROUND

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used after failed endoscopic retrograde cholangiopancreatography. Based on existing studies, intrahepatic (IH) approaches are preferred in patients with dilated IH bile ducts. Both ultrasound-guided hepaticogastrostomy (EUS-HGS) and ultrasound-guided antegrade treatment (EUS-AG) are appropriate for patients with unreachable papillae. Nevertheless, there have been no direct comparisons between these two approaches. Therefore, we aim to evaluate and compare the safety and efficiency of EUS-HGS and EUS-AG in patients with an unreachable papilla.

METHODS

This is a prospective, randomised, controlled, multicentre study with two parallel groups without masking. One hundred forty-eight patients from three hospitals who met the inclusion criteria will be randomly assigned (1:1) to undergo either EUS-HGS or EUS-AG for relief of malignant biliary obstruction. The final study follow-up is scheduled at 1 year postoperatively. The primary endpoint is efficiency, described by technical and clinical success rates of EUS-HGS and EUS-AG in patients with unreachable papillae. The secondary endpoints include stent patency, overall survival rates, complication rates, length of hospital stays, and hospitalisation expenses. The chi-square test, Kaplan-Meier methods, log-rank test, and Cox regression analysis will be used to analyse the data.

DISCUSSION

To our knowledge, this is the first study to compare these two EUS-BD approaches directly using a multicentre, randomised, controlled trial design. The clinical economic indexes will also be compared, as they may also affect the patient's choice. The result may contribute to establishing a strategic guideline for choosing IH EUS-BD approaches.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900020737 . Registered on 15 January 2019.

Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction with surgically altered anatomy: a multicenter prospective registration study

BACKGROUND

Endoscopic treatment for malignant biliary obstruction (MBO) in patients bearing surgically altered anatomy (SAA) is not well-established. Although endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a new treatment option for MBO, limited data are available regarding the efficacy and safety of EUS-BD in patients with SAA. We conducted a multicenter prospective registration study to evaluate the efficacy and safety of EUS-BD in this population.

METHODS

This study involved 10 referral centers in Japan. Patients with SAA who were scheduled to receive EUS-BD for unresectable MBO between May 2016 and September 2018 were prospectively registered. The primary endpoint was technical success and the secondary outcomes were clinical success, procedure time, procedure-related adverse events (AEs), stent patency, and overall survival.

RESULTS

In total, 40 patients were prospectively enrolled. The surgical reconstruction methods were gastrectomy with Roux-en-Y reconstruction (47.5%), gastrectomy with Billroth-II reconstruction (15%), pancreaticoduodenectomy (27.5%), and hepaticojejunostomy with Roux-en-Y reconstruction (10%). EUS-BD was performed for primary biliary drainage in 31 patients and for rescue biliary drainage in nine patients. Transmural stenting alone (60%), antegrade stenting alone (5%), and a combination of the two techniques (35%) were selected for patients treated with EUS-BD. Technical and clinical success rates were 100% (95% confidence interval, 91.2-100.0%) and 95% (95% confidence interval, 83.1-99.4%), respectively. Mean procedure time was 36.5 min. Early AEs were noted in six patients (15%): three self-limited bile leak, one bile peritonitis, and two pneumoperitonea. Late AEs occurred in six patients (15%): one jejunal ulcer and five stent occlusions. Stent patency rate after 3 months of survival was 95.7% (22/23). Median overall survival was 96 days.

CONCLUSION

EUS-BD for MBO in patients with SAA appears to be effective and safe not only as a rescue drainage technique after failed endoscopic retrograde cholangiography but also as a primary drainage technique.

CLINICAL TRIAL REGISTRATION

UMIN000022101.