Ryota Sagami

Takehiko Koga, Yusuke Ishida, Akihisa Ohno, Ryota Sagami, Yoshitaka Nakamura, Makoto Hinokuchi, Kosuke Takahashi, Hidefumi Nishikori, Nao Fujimori, Yasuhisa Hiroshima, Hiroki Taguchi, Shinichi Hashimoto, Eisuke Ozawa, Hiroaki Tsuji, Naoaki Tsuchiya, Takanori Kitaguchi, Keisuke Matsumoto, Makoto Fukuyama, Tatsuro Nii, Fumihito Hirai. Gut and Liver -0001;0:. https://doi.org/10.5009/gnl260042

Background and Objectives: Large bile duct stone removal in patients with surgically altered anatomy (SAA) is technically challenging. Although balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has been widely adopted, EUS-guided treatment (EUS-T) may achieve higher stone removal rates owing to improved device accessibility after anastomosis. In this multicenter retrospective study, we aimed to compare the outcomes of EUS-T and BE-ERCP for large bile duct stones in patients with SAA. Methods: Patients with SAA who underwent EUS-T or BE-ERCP for large bile duct stones (≥12 mm) between January 2016 and February 2025 were included. The primary outcome was the complete stone removal rate. Secondary outcomes included the number of sessions, procedure time, and adverse events. Propensity score matching was applied to adjust for baseline differences between groups. Results: In total, 22 EUS-T and 87 BE-ERCP procedures were analyzed. After matching, the complete stone removal rate was significantly higher in the EUS-T group than in the BE-ERCP group (90.5% vs. 61.9%, P = 0.030), despite a greater number of sessions (2.1 vs. 1.2, P < 0.001). Mean procedure times and adverse event rates were comparable. Cumulative success significantly improved up to the third session in EUS-T (first session, 27%; third, 86%). Conclusion: EUS-T achieved a higher complete stone removal rate than BE-ERCP without a significant increase in adverse event rates, and may be a first-line treatment option for large bile duct stones in patients with SAA.

A 76-year-old woman was admitted for jaundice caused by recurrent pancreatic cancer after pancreaticoduodenectomy. Computed tomography (CT) revealed dilated intrahepatic bile ducts ([Fig. 1]). Because of her poor respiratory condition, balloon enteroscopy-assisted endoscopy was avoided. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed using a partially covered self-expandable metal stent (SEMS) with a 5.9-Fr thin-delivery system (Hanaro-Benefit 8 mm/12 cm, Boston Scientific, Tokyo, Japan) without tract dilation, aiming for a shorter procedure time and to reduce the risk of bile leakage associated with dilation. The B3 bile duct was punctured ([Fig. 2] a, [Video 1]). Contrast was injected ([Fig. 2] b), and the guidewire was advanced into the hilar bile duct with some unnatural movement. The SEMS delivery system was then smoothly inserted, and the stent was deployed ([Fig. 2] c); however, bile outflow was not observed ([Fig. 2] d, e). Upon EUS, the SEMS appeared to be located within a small peripheral bile duct or liver parenchyma beyond the target duct ([Fig. 2] e). Therefore, another B3 bile duct was re-punctured ([Fig. 3] a), and a guidewire was inserted ([Fig. 3] b) into B2/3 confluence. A rescue SEMS was then placed without dilation, and bile outflow was confirmed ([Fig. 3] c, d). CT revealed the misplacement of the initial SEMS ([Fig. 4]). The patient recovered uneventfully and was discharged after improvement of jaundice. Tract dilation may increase the risk of adverse events during EUS-HGS [1]. SEMS placement without dilation is a useful option to shorten and simplify the procedure [2]. In this case, misalignment between the scope and the guidewire view might have led to inadvertent migration of the guidewire into the hepatic parenchyma or Glisson’s sheath beyond the peripheral ducts after the initial puncture. This misdeployment might have been prevented by catheter insertion and cholangiography. When any unnatural movement of the guidewire is encountered, cholangiography using a catheter should be performed. Endoscopy_UCTN_Code_CPL_1AL_2AD Article published online: 20 April 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Objective: Percutaneous transhepatic liver abscess drainage (PTAD) and endoscopic ultrasound‐guided liver abscess drainage (EUS‐LAD) have several limitations. Recently, because of technical improvements in echoendoscope maneuvers, EUS‐guided access for the right hepatic lobe has been reported. The aim of this multicenter, retrospective study was to compare clinical outcomes of PTAD and EUS‐LAD including the right hepatic lobe in West Japan. Method: This retrospective, multicenter study included consecutive patients with liver abscesses between January 2019 and November 2024. The primary outcome in this study was the clinical success rate compared between EUS‐LAD and PTAD. Results: During the study period, 1012 consecutive patients developed liver abscesses. Of them, 734 patients were excluded, 43 underwent EUS‐LAD and 235 patients underwent PTAD. After propensity score‐matched analysis, the clinical success rate was significantly higher in the EUS‐LAD group (97.7%, 42/43) than in the PTAD group (79.1%, 34/43) ( p = 0.007). After a propensity score‐matched analysis, 25 patients were included in each group. The clinical success rate was significantly higher in the EUS‐LAD group (100%, 25/25) than in the PTAD group (84%, 21/25) ( p = 0.037). Adverse events were also significantly higher in the PTAD group (16%, 5/25) than in the EUS‐LAD group ( p = 0.025). In addition, the median length of hospital stay was significantly shorter in the EUS‐LAD group (15 days) than in the PTAD group (22 days) ( p = 0.005). Conclusions: EUS‐LAD using a metal stent might be one of the options, but further randomized, controlled trials are needed.

Objectives: This multicenter retrospective study aimed to compare surgery‐related adverse events (AEs) of percutaneous transhepatic biliary drainage (PTBD) with those of endoscopic ultrasound‐guided biliary drainage (EUS‐BD) for preoperative management of malignant distal bile duct obstruction (MDBO). Methods: We reviewed data from 15 centers in Japan between 2012 and 2021. Patients with MDBO who underwent PTBD or EUS‐BD after failed endoscopic retrograde cholangiopancreatography (ERCP) and later underwent pancreaticoduodenectomy (PD) were included. The primary outcome was surgery‐related AEs. Secondary outcomes included drainage‐related outcomes, surgery‐related outcomes, disease‐free survival (DFS), and overall survival (OS). Risk factors associated with surgery‐related AEs were also evaluated. Results: In total, 2350 patients received biliary drainage before PD. Of the 73 patients in whom ERCP failed, 65 underwent PTBD and 11 underwent EUS‐BD. EUS‐BD showed a significantly higher internalization rate (100% vs. 28%, p < 0.001), fewer sessions (median 1 vs. 2, p = 0.006), and shorter hospital stay (10 vs. 22 days, p = 0.002). Surgery‐related AEs were similar between groups. In the multivariate analysis, age ≥ 71 years and ASA‐PS ≥ 2 were identified as significant risk factors for surgery‐related AEs, whereas the drainage method was not a significant factor. No significant differences were observed in DFS or OS between the groups. Conclusions: Surgical‐related outcomes, DFS, and OS after EUS‐BD were comparable to those after PTBD; however, EUS‐BD allowed a higher internalization rate, fewer sessions, and a shorter hospital stay, making it the preferred option for preoperative biliary drainage after failed ERCP.

Background and Aims: The present prospective multicenter clinical trial compared the efficacy and safety of balloon enteroscopy‐assisted endoscopic retrograde cholangiopancreatography (BEA‐ERCP) and endoscopic ultrasound‐guided biliary drainage (EUS‐BD) as primary drainage methods for patients with surgically altered anatomy (SAA) and unresectable malignant biliary obstruction (MBO). Methods: Technical and clinical success rates, procedure time, adverse events (AEs), and time to recurrent biliary obstruction (TRBO) were compared. Risk factors associated with technical failure were evaluated, and subgroup analysis investigating whether Roux‐en‐Y reconstruction affected the technical success rate was also performed. Results: Patient characteristics were comparable between the BEA‐ERCP ( n = 54) and EUS‐BD ( n = 44) groups. Compared with the BEA‐ERCP group, the EUS‐BD group had a significantly higher technical success rate, a significantly shorter procedure time, comparable rates of clinical success and AEs, and comparable TRBO. Multivariate analysis showed that BEA‐ERCP was an independent predictor of technical failure. Subgroup analysis revealed that the technical success rate was significantly higher with EUS‐BD than with BEA‐ERCP in patients with Roux‐en‐Y reconstruction, with no significant difference in those without Roux‐en‐Y reconstruction. Conclusions: EUS‐BD may be a more suitable primary drainage method than BEA‐ERCP for patients with SAA and unresectable MBO, especially those with Roux‐en‐Y reconstruction (University Hospital Medical Information Network 000049224). Trial Registration: UMIN000049224