Vinay Chandrasekhara

Background and study aims: Pancreatic ductal adenocarcinoma (PDAC) with malignant biliary obstruction is frequently unresectable and carries a median survival of less than one year. Uncovered self-expandable metal stents (UCSEMS) are standard for biliary decompression but are limited by tumor ingrowth. Temperature-controlled endobiliary radiofrequency ablation (TC-RFA) has been proposed to prolong stent patency. We evaluated the efficacy and safety of TC-RFA followed by UCSEMS compared with UCSEMS alone for PDAC-related biliary stricture. Patients and methods: In this single-center study, PDAC patients were prospectively treated with TC-RFA plus UCSEMS and compared with a retrospective cohort treated with UCSEMS alone. The primary outcome was time to recurrent biliary obstruction (TRBO) within six months. Secondary outcomes included technical and clinical success, adverse events (AEs), surgical resection, and mortality. Results: Among 176 patients, 129 received UCSEMS alone and 47 received TC-RFA plus UCSEMS. Technical success was higher with UCSEMS alone (100% vs. 95.7%; p = 0.02), while clinical success was similar between groups (94.4% vs. 95.7%; p = 0.72). Six-month cumulative incidence of recurrent biliary obstruction (RBO) was significantly higher with TC-RFA (56.5% vs. 24.0%; p<0.001), with tissue ingrowth the most common cause. AEs, surgical resection, and mortality did not differ between groups. Conclusions: TC-RFA before UCSEMS placement was safe but associated with shorter TRBO and higher RBO incidence, without improvement in surgical or survival outcomes. These findings do not support routine TC-RFA for PDAC-related biliary strictures. ClinicalTrials.gov: NCT05826639.

Goals: Evaluate the relationship between metabolic syndrome (MetS) and clinical outcomes in individuals with necrotizing pancreatitis (NP) and infected pancreatic necrosis (IPN). Background: MetS affects a significant proportion of the global population and is associated with low-grade systemic inflammation and immune dysregulation. This has implications for several disease processes, but the impact of MetS on patients with NP is not well characterized. Study: A retrospective cohort study of patients admitted with NP at a single tertiary center was performed. MetS was defined as meeting any 3 of the following criteria: BMI ≥30 kg/m ² , triglycerides ≥150 mg/dL, fasting glucose ≥110 mg/dL, blood pressure ≥130/85 mm Hg, and low HDL (P P =0.029). There was a higher risk of sepsis in those with MetS (27.5% vs. 15.6%; P =0.019), as well as respiratory failure (31.2% vs. 18%; P =0.013), renal failure (35.7% vs. 21.3%; P =0.009), and in-hospital mortality (17.5% vs. 8.2%; P =0.024). The incidence of IPN was higher in patients with MetS (39.6% vs. 23.0%; P =0.003). Conclusion: The presence of MetS in individuals with NP was associated with worsened outcomes, including increased incidence of IPN, sepsis, organ failure, ICU admission, and mortality during index hospitalization.

Objectives: Pancreatic duct (PD) brush cytology (BC) and fluorescence in-situ hybridization (FISH) are viable techniques but underutilized due to limited data on their diagnostic accuracy for pancreatic malignancy and associated risks. This study evaluates the safety and diagnostic performance of BC, FISH, and their combination for detecting pancreatic malignancy. Methods: A retrospective analysis was conducted on subjects undergoing endoscopic retrograde cholangiopancreatography (ERCP) PD brushings at a tertiary hospital. Data included demographics, procedural details, adverse events, and outcomes. Malignancy was confirmed by EUS-guided biopsy or surgical histology. Diagnostic metrics for BC, FISH, and their combination were calculated. Results: Of the 205 subjects who underwent ERCP PD brushings from 2004 to 2023, 35 (17.1%) were diagnosed with pancreatic malignancy. BC had a sensitivity of 31.4% and specificity of 95.9% (AUC 0.64). Abnormal FISH showed 45.7% sensitivity and 89.4% specificity (AUC 0.68), while polysomy FISH had 28.6% sensitivity and 97.1% specificity (AUC 0.63). Combined BC and abnormal FISH yielded 54.3% sensitivity and 87.7% specificity (AUC 0.71). AEs included post-ERCP pancreatitis in 16 cases (7.8%), bleeding in 2 (1.0%), and micro-perforation in 1 (0.5%). Conclusions: PD brushing for BC and FISH is generally safe with modest diagnostic accuracy for malignancy. While novel diagnostic tests such as molecular biomarkers in pancreatic fluid for detecting PC are still needed, PD brushings can assist in the detection of PC with low rates of PEP in select subjects.

Background: The optimal self-expandable metallic stent (SEMS) choice for endoscopic drainage of unresectable extrahepatic malignant biliary obstruction (MBO) with endoscopic retrograde cholangiopancreatography (ERCP) remains unclear due to limited randomized controlled trial (RCT) evidence. Prior meta-analyses have relied on observational data, introducing heterogeneity and bias. To overcome these limitations, an RCT-only network meta-analysis (NMA) was performed to evaluate the efficacy and safety of SEMS types. Methods: A literature search was conducted to identify RCTs assessing fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and/or uncovered SEMS (UCSEMS) for ERCP drainage of unresectable extrahepatic MBO. Study outcomes included recurrent biliary obstruction (RBO), specific causes of RBO, overall survival (OS), and adverse events (AEs). A frequentist NMA was performed to estimate hazard ratios (HRs) and incidence rate ratios (IRRs) with their 95% confidence intervals and overall P-scores. Results: Ten RCTs (1,659 patients) were included. There were no significant differences in time to RBO, incidence of any RBO, or OS between stent types. UCSEMS had the lowest rates of stent migration, tumor overgrowth, and sludge occlusion, whereas FCSEMS most effectively prevented tumor ingrowth. AE rates were similar across groups; however, only FCSEMS, but not PCSEMS, had significantly higher rates of acute cholecystitis than UCSEMS in patients with an intact gallbladder. Conclusion: There were no differences in RBO, OS, or AE excluding acute cholecystitis between each SEMS type, although each type has its advantages and disadvantages. FCSEMS was associated with a higher risk of acute cholecystitis, emphasizing careful patient selection, particularly regarding gallbladder status.

Accurate staging is crucial for managing cholangiocarcinoma (CCA). Endoscopic ultrasound with tissue acquisition (EUS-TA) may enhance cross-sectional imaging-based staging; however, the impact of EUS on CCA management decision-making is unclear. 6 electronic databases were searched through to 10 July 2025 for studies on EUS-TA in staging CCA cases eligible for surgical resection or liver transplantation. The primary outcome was the pooled proportion of patients excluded from curative-intent surgery based on the EUS findings, which included newly detected findings and confirmation by EUS-TA of cross-sectional imaging findings. Secondary outcomes included the pooled incremental benefit of EUS (IBEUS) over cross-sectional imaging and EUS-specific adverse events. The IBEUS was defined as the proportion of patients with malignant lymph nodes identified by EUS-TA but not by cross-sectional imaging, relative to all patients who underwent cross-sectional imaging. 9 studies with 831 patients were included. The rate of exclusion from curative-intent surgery based on EUS findings was 10% overall (95%CI 6%–18%; 9 studies), 7% for perihilar CCA (pCCA; 95%CI 2%–19%; 5 studies), 10% for those planned for resection (95%CI 4%–22%; 5 studies), and 8% for those planned for transplantation (95%CI 3%–22%; 3 studies). The pooled IBEUS was 3% (95%CI 1%–10%; 5 studies) overall, 4% (95%CI 1%–17%; 3 studies) for pCCA, 1% (95%CI 0%–3%; 2 studies) in patients intended for operative resection, and 7% (95%CI 1%–26%; 2 studies) in those intended for transplantation. EUS may impact CCA staging and support treatment decisions.

Malignant hilar biliary obstruction (MHBO) is most commonly caused by cholangiocarcinoma or gallbladder cancer and frequently presents with obstructive jaundice, pruritus, and/or cholangitis. These symptoms impair performance status and delay the initiation of chemotherapy, making biliary drainage essential for both palliation and oncologic treatment. Endoscopic transpapillary biliary stenting via endoscopic retrograde cholangiopancreatography is the standard approach for biliary decompression. In patients with unresectable disease, either plastic or self-expandable metal stents may be used. Optimal outcomes are achieved when drainage encompasses more than 50% of functional liver volume, while atrophic segments should be avoided. When transpapillary access is not feasible or unsuccessful, alternative approaches such as percutaneous transhepatic biliary drainage or endoscopic ultrasound-guided biliary drainage may be considered. Adjunctive therapies, including photodynamic therapy and radiofrequency ablation, are being investigated to enhance local tumor control and prolong stent patency. With continued advances in stent technology, imaging modalities, and endoscopic techniques, the management of MHBO is expected to become increasingly individualized and effective.

Endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition is the cornerstone for assessment of suspected malignant biliary strictures. Conventional techniques, including biliary brush cytology and transpapillary forceps biopsy, are highly specific but are limited by modest sensitivity for detection of malignancy, often leaving a substantial proportion of individuals without a definitive diagnosis. To improve diagnostic sensitivity for cancer, several adjunctive approaches have been integrated into ERCP-based sampling. Peroral cholangioscopy (POC)-guided biopsies have become a reliable ERCP-based adjunctive modality, allowing direct visualization and targeted sampling, particularly in individuals with prior nondiagnostic procedures. Fluorescence in situ hybridization (FISH) is a technique used to improve diagnostic yield with biliary brushings by detecting chromosomal abnormalities, but is limited to specialized centers due to the need for specialized processing and training. Next-generation sequencing provides high sensitivity and can enable identification of actionable genomic alterations, while methylated DNA markers represent a promising, scalable molecular approach with strong diagnostic performance. Additional techniques include artificial intelligence–augmented direct visualization by POC and bile-based liquid biopsy. Current guidelines recommend multimodal ERCP-based sampling, combining at least two modalities where feasible, to optimize diagnostic accuracy. This review highlights the clinical performance, strengths, and limitations of established and emerging ERCP-guided techniques, emphasizing their evolving role in improving the diagnosis and management of malignant biliary strictures.

Background and Aims EUS-guided gastroenterostomy (EUS-GE) is an effective option to palliate symptoms of gastric outlet obstruction (GOO). While the jejunum is conventionally targeted (EUS-GJ), targeting the duodenum (EUS-GD) may offer clinical advantages. Outcomes were compared for EUS-GJ and EUS-GD. Methods Adult patients who underwent EUS-GE for GOO between 2020 and 2024 were included and categorized as an EUS-GD if the stent entered the transverse or ascending duodenum or an EUS-GJ if the stent entered more distally. The primary outcome was clinical success (soft diet tolerance at 7 days). Secondary outcomes included adverse events (AEs), stent misdeployment, and unplanned endoscopic reintervention. Baseline demographic variables and outcomes were compared with statistical significance at p < 0.05. Results Of the 139 included patients (median age 67 years (IQR 61–74); 41% female), 105 underwent EUS-GJ and 34 underwent EUS-GD. Clinical success was 98% for EUS-GJ and 94% for EUS-GD (p = 0.25). The misdeployment rate was 7% for EUS-GJ and 0% for EUS-GD (p = 0.19). The AE rate was 22% for EUS-GJ and 12% for EUS-GD (p = 0.23). There were no significant differences for stent obstruction (EUS-GJ 12% vs. EUS-GD 6%), bleeding (2% vs. 6%), perforation (4% vs. 0%), stent migration (1% vs. 0%), infection (3% vs. 0%), and unplanned reintervention (14% vs. 9%). Conclusion Both EUS-GJ and EUS-GD demonstrate high clinical success with no significant differences in adverse event rates. These data can support intraprocedural decision-making for endoscopists performing EUS-GE.