Albert Garcia-Sumalla

Background and objectives: Biliary drainage(BD)in distal malignant biliary obstruction(DMBO)is often hampered by difficult biliary cannulation(DBC)during endoscopic retrograde cholangiopancreatography(ERCP). Advanced cannulation techniques(aERCP)may overcome DBC but still fail in up to 15% of cases, increasing the risk of adverse events(AEs). Early endoscopic ultrasound-guided BD(eEUS-BD)is a potential alternative. The aim of this study is to directly compare safety and efficacy of EUS-BD and aERCP. Methods: This is a retrospective, multicentric study(29 centres in United States, Canada, Europe), including patients with DMBO and common bile duct(CBD)diameter >12 mm, treated up to 2024. DBC cases managed with either eEUS-BD or aERCP were analysed. A 1:2 propensity score-matched cohort was generated to ensure comparability, with regression modeling and inverse probability of treatment weighting(IPTW)performed as sensitivity analyses. AEs rate was the primary outcome; secondary outcomes included BD failure and clinical success. Results: Standard cannulation failed in 2066/10,738(19.2%)ERCPs. aERCP and eEUS-BD were attempted in 1733 and 333 cases, respectively. After matching, 313 patients per EUS-BD group and 626 patients per aERCP group were analyzed. AEs occurred in 18.2% of aERCPs and 9.3% of eEUS-BD(p<0.01), with post-procedural pancreatitis the most frequent AE after aERCP(55 cases, 12.0%). Both regression and IPTW confirmed the robustness of these findings on the entire cohort. Technical success was significantly lower with aERCP(82.0% vs. 95.9%, p<0.01), clinical success was comparable(94.5% vs. 96.4%, p=0.89). Conclusions: In patients with DMBO and dilated CBD, eEUS-BD is associated with fewer AEs and higher technical success than aERCP, supporting its role as a safer, more effective option in DBC.

Unresectable malignant distal biliary obstruction (MDBO) may be treated with endoscopic ultrasound-guided (EUS-BD) or percutaneous transhepatic (PTBD) biliary drainage if endoscopic retrograde cholangiopancreatography fails or is not feasible. This study compared EUS-BD and PTBD using an improved ultrasound-guided method with primary metal stenting. A prospective, longitudinal (follow-up 6 months), nonrandomized, noninferiority (10% margin) trial was conducted. Patients were assigned to centers with high competence in one of the two techniques. The primary end point was technical success, with propensity score matching employed to balance differences. Differences in secondary end points were evaluated with two-sided superiority analyses. 209 patients (mean age 73 years) were enrolled between December 2018 and August 2024 from 14 European centers and were subsequently matched 1:1. Noninferiority of PTBD vs. EUS-BD could not be demonstrated with regard to technical success (91.2% vs. 97.1%; P = 0.17; 95%CI –2.3% to 15.1%). Clinical success (intention-to-treat: 73.5% vs. 55.9%; P = 0.05), procedure time, length of hospital stay, and rate of biliary reintervention within 30 days (0.03 vs. 0.31; P < 0.001) were significantly better in the EUS-BD cohort, driven mainly by EUS-guided choledochoduodenostomy (EUS-CDS). No significant differences were observed in adverse events (grades 1–4) (16.7% vs. 14.5%; P = 0.82), pain score, clinical success (per-protocol), rate of biliary reinterventions within 6 months, or overall survival. EUS-BD, particularly EU-CDS, might be preferred over PTBD in unresectable MDBO owing to better clinical success and a lower biliary reintervention rate.

Background Endoscopic ultrasound (EUS)-guided biliary rendezvous (RV) is an EUS-assisted technique described as a rescue method in cases of failed biliary cannulation via endoscopic retrograde cholangiography (ERC). Current literature remains unclear regarding its current role. The study aim was to evaluate the effectiveness for biliary EUS-RV, and comparison between benign vs malignant biliopancreatic disorders. Methods Retrospective observational study with prospective consecutive inclusion in a specific database from a tertiary-center. All patients with biliopancreatic diseases that underwent a EUS-assisted ERC between October-2010 and November-2022 for failed ERC were included. Main outcomes were technical/overall success. Secondary outcomes were safety, potential factors related to failure/success or safety; and a comparative analysis between EUS-RV and EUS-guided transmural drainage (TMD) in malignant cases. Results A total of 69 patients who underwent EUS-RV procedures, with benign and malignant pathologies (n=40 vs n=29), were included. Technical/overall success and related-adverse events (AEs) were 79.7% (95%CI, 68.3-88.4)/74% (95%CI, 61-83.7) and 24% (95%CI, 15.1-36.5), respectively. Failed cases were mainly related with guidewire manipulation. Seven failed RV were successfully rescued by EUS-TMD. On multivariable analysis, EUS-RV and malignant pathology was associated with a greater failure rate (technical success: OR,0.21; 95%CI,0.05-0.72; p=0.017), and higher AEs rate (OR,3.46; 95%CI,1.13-11.5; p=0.034). Also, the EUS-TMD group had greater technical success (OR,16.96; 95%CI,4.69-81.62; pConclusions EUS-RV is a demanding technique with better outcomes in benign than in malignant biliopancreatic diseases. Comparison of the EUS-TMD group on malignant disorders showed worse outcomes with EUS-RV. Given these findings, maybe EUS-RV is not the best option for malignant biliopancreatic disorders.

Article published online: 28 November 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background Removing lumen-apposing metal stents (LAMSs) may be difficult and even harmful, but these features have seldom been analyzed. We aimed to generate a comprehensive assessment of the feasibility and safety of LAMS retrieval procedures. Methods A prospective multicenter case series including all technically successfully deployed LAMSs between January 2019 and January 2020 that underwent endoscopic stent removal. All retrieval-related data were prospectively recorded using standardized telephone questionnaires as part of centralized follow-up that ended after stent removal had been performed. Multivariable logistic regression models assessed the potential risk factors for complex removal. Results For the 407 LAMSs included, removal was attempted in 158 (38.8 %) after an indwell time of 46.5 days (interquartile range [IQR] 31–70). The median (IQR) removal time was 2 (1–4) minutes. Removal was labelled as complex in 13 procedures (8.2 %), although advanced endoscopic maneuvers were required in only two (1.3 %). Complex removal risk factors were stent embedment (relative risk [RR] 5.84, 95 %CI 2.14–15.89; P = 0.001), over-the-wire deployment (RR 4.66, 95 %CI 1.60–13.56; P = 0.01), and longer indwell times (RR 1.14, 95 %CI 1.03–1.27; P = 0.01). Partial and complete embedment were observed in 14 (8.9 %) and five cases (3.2 %), respectively. The embedment rate during the first 6 weeks was 3.1 % (2/65), reaching 15.9 % (10/63) during the following 6 weeks (P = 0.02). The adverse event rate was 5.1 %, including seven gastrointestinal bleeds (5 mild, 2 moderate). Conclusions LAMS removal is a safe procedure, mostly requiring basic endoscopic techniques attainable in conventional endoscopy rooms. Referral to advanced endoscopy units should be considered for stents with known embedment or long indwell times, which may require more technically demanding procedures.

Recurrent biliary obstruction after endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) performed using lumen-apposing metal stents (LAMSs) has become a major concern (reported in up to 26 %). Its management can be challenging and reported strategies include the insertion of a coaxial plastic double-pigtail stent (DPS) or tubular self-expandable metal stents [1] [2] [3]. Here we present a case in which a specialized hepaticogastrostomy biliary stent was used. Our patient was a 61-year-old man with inoperable pancreatic adenocarcinoma who underwent endoscopic retrograde cholangiopancreatography with plastic stent placement at another center. He was referred to our center 4 months postoperatively for the management of acute cholangitis. The transpapillary approach could not be used due to duodenal stenosis caused by the tumor. An EUS-guided CDS was performed using the 8 × 8-mm Hot Axios system (Xlumena, Mountain View, California, USA) and a coaxial 7-Fr × 5-cm DPS (Advanix, Boston Sc, Marlborough, MA, USA). Despite initial improvement, 2 months later the patient developed cholangitis, which required hospitalization. Endoscopy revealed stent occlusion due to food impaction, which was effectively treated by endoscopic lavage and the coaxial DPS was replaced. However, 2 months later, the patient again presented with cholangitis (i. e., recurrent biliary obstruction) due to LAMS occlusion, which required repeat lavage and insertion of a second 7-Fr coaxial DPS. For a third time, 2 months later, the patient again presented with recurrent biliary obstruction with evident signs of LAMS obstruction, and partly aggravated by the duodenal obstruction ([Fig. 1]). The DPS was removed and a specifically designed hepaticogastrostomy stent (8 × 80-mm, Niti-S Giobor biliary stent; TaeWoong Medical, Seoul, Korea) was inserted through the LAMS ([Fig. 2], [Video 1]). After an initial problem-free course, the patient passed away due to worsening of his terminal disease. Video 1 Placement of a specialized hepaticogastrostomy stent coaxial to a lumen-apposing stent for salvage of dysfunctional endoscopic ultrasound-choledochoduodenostomy. This case provides further evidence that biliary LAMS dysfunction routinely develops after EUS-CDS [4]. Despite the placement of two coaxial DPSs, the patient continued to develop recurrent biliary obstruction. A tubular partially covered self-expanding metal stent was used in the hope of preventing these events. Trials are needed to give a definitive answer to this question [5]. Endoscopy_UCTN_Code_CPL_1AL_2AD Article published online: 11 April 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 91-year-old man with multiple pathologies and a history of subtotal gastrectomy with Roux-en-Y reconstruction for an antral ulcer was admitted with acute cholangitis. A hepatobiliary magnetic resonance imaging (MRI) scan showed multiple choledochal stones causing intra- and extrahepatic bile duct dilatation. Different possible options were discussed, including conservative management, interventional percutaneous radiology, and endoscopic biliary drainage interventions ([Fig. 1]). The latter approaches included enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)-guided options such as: (i) EUS-transenteric ERCP, (ii) transmural (hepaticogastrostomy), (iii) antegrade, and (iv) combined transmural plus antegrade stenting [1] [2] [3] [4]. Finally, based on our previous experience and with motorized spiral enteroscopy not available at our center, it was decided to opt for an EUS-guided technique instead of enteroscopy-assisted-ERCP. An initial EUS examination confirmed that the intrahepatic ducts were sufficiently dilated for an EUS-guided biliary intervention. Firstly, EUS-guided biliary access was achieved by transgastric puncture into a left intrahepatic biliary duct (segment II) and confirmed by serum instillation and bile aspiration. Secondly, a guidewire was advanced antegradely with fluoroscopy guidance until an enteral loop was reached through the papilla. Next, the transgastric hepaticostomy created using a 6-Fr cystotome allowed a cholangiogram and confirmatory enterography to be performed. Lastly, antegrade papilloplasty using a balloon (up to 10 mm) enabled EUS-guided antegrade stenting (biliary fully covered metal stent; 60 × 10 mm) guided by fluoroscopy to be performed without incident ([Fig. 2]; [Video 1]). Video 1 Endoscopic ultrasound-guided antegrade stenting is performed in a patient with benign biliary disease and altered anatomy (Roux-en-Y reconstruction). To limit the procedure time and associated morbidity, it was decided not to perform stone extraction maneuvers or leave an opened hepaticogastrostomy. The academic purpose of this work is to expose the different approaches that may be considered in a surgically altered anatomy (Roux-en-Y reconstruction) and benign biliary pathology scenario. The final choice of EUS-guided antegrade stenting was made as transpapillary biliary drainage was preferred and to choose a less time-consuming procedure over other endoscopy options, such as an enteroscopy-assisted ERCP. Endoscopy_UCTN_Code_TTT_1AR_2AG Article published online: 28 October 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims Analysis of our experience with this type of esophageal stent. Evaluation of its feasibility, safety and efficacy. Methods Retrospective, single-center, and descriptive study. All those patients in whom a NITI-S Cervical Esophageal Stent (Taewoong Medical) was placed between 2012 and 2021 were identified from a specific stent-database. Demographics, technical and clinical data were collected from diagnostic tests and our health service provider. Results Seventeen patients were identified. Demographic and clinical characteristics are summarized in [Table 1]. The most used stent size was: ESP1610FV (58%). Technical success was 82%. Proximal end-flare deployment: 16cm from incisors (range: 12-19cm). Clinical success (oral diet tolerance) was 100%. Adverse events: 2 distal migrations, 1 ingrowth, with endoscopic resolution; 1 proximal migration and 2 intolerances due to pain that required removal. Mean follow-up: 3 months (SD±5.6). Up to 80% of the cases passed away and were related to the malignant disease’s progression. Conclusions This is one of the most extensive case series reporting the use of this dedicated cervical oesophageal stent. The main clinal indication is palliative for severe dysphagia. This stent seems to be effective and a safe option for cervical locations. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 91yo man with history of Roux-en-Y reconstruction was admitted due to acute cholangitis. Cholangio-MRI: choledocholitiasis with intra and extrahepatic bile duct dilatation. A linear echoendoscope was used to perform an endoscopic biliary drainage. Firstly, EUS-guided biliary accesses by transgastric puncture of left intrahepatic biliary radical, confirmed by serum-instillation and bile-aspiration. Secondly, advancement of a guidewire anterogradely until reach enteral loop, through the papilla y by fluoroscopy-guidance. Finally, a transgastric-hepatic ostomy using a 6-Fr cystotome, and antegrade papilloplasty using a CRE balloon allowed a EUS-guided antegrade stenting (Biliary fully-covered metal stent, 60 x 10mm) without incidences. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

To facilitate the safe and simple introduction of an endoscopic ultrasound (EUS)-guided gastroenterostomy technique, we present a step-by-step teaching video of a variant technique for direct EUS-guided gastroenterostomy using a feeding tube ([Video 1]). The stages involved are as follows. Video 1 A teaching video demonstrating the technique of direct endoscopic ultrasound-guided gastroenterostomy using a feeding-tube waterjet system. Endoscopy_UCTN_Code_TTT_1AS_2AG Publication Date: 17 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany