Background and study aims Difficult biliary cannulation (DBC) remains a significant challenge in endoscopic retrograde cholangiopancreatography (ERCP). When cannulation fails, precut techniques are widely used as rescue techniques. Endoscopic ultrasound-guided rendezvous (EUS-RV) is increasingly used by experts as an alternative to precut for cannulating the bile duct. However, there is limited literature comparing these two techniques. This systematic review and meta-analysis aimed to compare effectiveness and safety of EUS-RV versus precut techniques for biliary access in DBC. Patients and methods A systematic search was conducted across PubMed, Embase, and Cochrane Library databases up to April 2025. Studies comparing EUS-RV and precut techniques in adult patients with DBC were included. Data were pooled using a random-effects model. Primary outcome was technical success rates; secondary outcome was adverse event (AE) rates. P < 0.05 was considered statistically significant. Results Five studies (two randomized controlled trials and three retrospective cohorts) comprising 875 patients were included. Pooled technical success was higher with EUS-RV compared with precut (95.9% vs. 91.4%; relative risk [RR] 1.06; 95% confidence interval [CI] 1.00-1.12; P = 0.036). AE rates were 7.7% for EUS-RV and 11.2% for precut, with no statistically significant difference (RR, 0.78; 95% CI 0.46-1.31; P = 0.349). Conclusions EUS-RV is associated with higher technical success rates compared with precut techniques for rescue biliary cannulation after failed standard ERCP, with a comparable safety profile. These findings suggest that EUS-RV may represent at least a valuable alternative rescue strategy when expertise is available; however, further trials are needed to assess its safety, procedure duration, and learning curve.

Background and Aim: Pediatric ERCP remains significantly less studied compared to its application in adults, particularly in infants, due to the limited procedural volume. This study aims to evaluate the indications, procedural specifics, technical success rates, and adverse events associated with pediatric ERCP at a tertiary care center over an 18-year period, with specific attention to patients weighing less than 10 kg. Methods: A retrospective analysis of all ERCPs performed on patients under 18 years of age at ISMETT between 2005 and 2023. Demographic data, indications, procedural specifics, outcomes, and adverse events were collected and reported. Subgroup analyses focusing on initial ERCP procedures were performed and stratified by weight and indication type. Results: 194 ERCPs were performed on 84 patients. Acute or chronic pancreatitis was the most common indication. Technical success was high across weight groups. Adverse events occurred only in patients ≥ 10 kg (7%), predominantly post-ERCP pancreatitis. No adverse events were reported in the <10 kg group. In the “first-ERCP” subgroup, pancreatic indications were associated with a higher adverse event rate than biliary indications, although the estimate was imprecise owing to the small number of events. Conclusions: In our experience as a specialized center, pediatric ERCPs have proven to be safe and effective, even in infants < 10 kg. Pancreatic indications appeared to carry a higher risk for adverse events than biliary indications, although this estimate was imprecise.

Background/Objectives: Endoscopic Ultrasound with Fine Needle Biopsy (EUS-FNB) of pancreatic lesions often induces patient anxiety. Graphic medicine, an emerging health communication tool, could potentially mitigate this. This pilot study aimed to explore the feasibility of a graphic novel in reducing anxiety in adult patients awaiting EUS-FNB. Methods: This prospective, single-center, randomized pilot study was conducted from June 2024 to March 2025 in patients aged 18-89 years. The intervention group received a comic panel detailing the EUS-FNB routine, while controls had standard care. Anxiety was measured using the Beck Anxiety Inventory (BAI) and modified DASS-21 (mASS-14). Results: Overall, 65 patients (33 "Graphic Novel", 32 "Control") were included. Mean BAI was 4.88 (graphic novel) vs. 7.25 (controls, p = 0.092), and mASS-14 was 4.97 vs. 6.22 (p = 0.261). Anxiety prevalence was low (4.6% BAI, 13.8% mASS-14). Controls were more symptomatic (69.2%) and had a higher rate of pancreatic cancer (n = 20) compared to the graphic novel group (n = 6). Subgroup analyses showed that BAI was slightly lower for patients with children and no prior surgical experience when using graphic novels. Trends for lower anxiety appeared in those on chronic medication, under surveillance, or with solid/suspected metastatic lesions. Conclusions: This pilot study suggests that a graphic novel may help to reduce anxiety and stress scores in patients undergoing diagnostic procedures for pancreatic lesions. However, it needs confirmation in larger, adequately powered trials.

Background and Objectives: Pulmonary and mediastinal masses are diagnostic challenges for digestive endosonographers, and patients with these conditions are usually managed in thoracic or pulmonology units. EUS with tissue acquisition can result in adequate samples for histological examination and molecular analysis. Its spread among digestive endosonographers is limited; thus, we aimed to investigate the current management practices among the EUS Italian centers for those patients with mediastinal or pulmonary lesions to identify the principal areas of disagreement and help guide future research towards useful standardization. Methods: A 44‑question survey was sent during a temporal trend of 3 months to the endosonographers in Italian centers performing EUS. The survey includes questions with either a single answer choice or with multiple options exploring different aspects of the EUS done for the evaluation of thoracic lesions. The questions were grouped into specific sections: expertise of the center, periprocedural management, procedural aspects, and future perspectives. Results: Thirty-nine centers completed the survey, 27 (69.2%) from the north of Italy. Only 2 centers among the responders did not perform any mediastinal EUS (5.13%). The majority of centers (22, 59.5%) performed between 0 and 30 mediastinal EUS yearly, and only 3 centers did more than 100 mediastinal EUS per year. Responders were mainly gastroenterologists (34, 87.2%) versus surgeons (5, 12.8%). Only 5 centers performed mediastinal EUS in a shared room with bronchoscopy and endobronchial ultrasound (13.5%). The procedure was considered simple for 20 (54.1%) responders, complex for 5 (13.5%), and needed to be performed in a tertiary thoracic center for 12 (32.4%). Franseen and Fork tips were the most used tips (67.6% and 27%, respectively), and the most common needle diameter was 22 gauge (86.5%). Fifteen centers (40.5%) preferred deep sedation with an anesthesiologist without endotracheal intubation. The main growing indications appear to be local EUS-guided treatments (tumors or collections). Conclusions: This is the first survey assessing an evaluation on mediastinal/pulmonary EUS, which is well represented in Italy. Nonetheless, centers largely have low volumes of these procedures. Our results show heterogeneity in the management of patients affected with mediastinal/pulmonary lesions needing tissue acquisition. More studies also involving pulmonologists, thoracic surgeons, and oncologists are needed to increase data and understanding regarding this procedure.

Benign gastric outlet obstruction (bGOO) presents a significant therapeutic challenge, with etiologies ranging from peptic strictures to complex postsurgical or inflammatory conditions. While surgery has historically offered durable outcomes, its morbidity in frail populations underscores the need for effective, less invasive alternatives. This review critically examines the current literature up to April 2025 on surgical, endoscopic, and endoscopic ultrasound-guided interventions for bGOO, evaluating technical success, clinical outcomes, recurrence rates, and adverse events. Endoscopic balloon dilation shows excellent efficacy in simple peptic strictures but has limited efficacy in anatomically complex cases. Fully covered self-expandable metal stents can provide temporary relief but are associated with significant migration risk. Among emerging techniques, endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) stands out by combining the anatomical efficacy of surgery with the minimal invasiveness of endoscopy. Recent studies report technical and clinical success rates exceeding 95%, with lower recurrence and complication rates compared to traditional approaches. Comparative data increasingly support EUS-GJ as the preferred option in refractory or high-risk patients. Tailoring treatment strategies based on etiology, anatomical complexity, and patient condition is essential. EUS-GJ is redefining the therapeutic landscape of bGOO, offering a minimally invasive and durable alternative to surgery in carefully selected cases.

Background and Objective:EUS-guided gallbladder drainage (EUS-GBD) has emerged as a viable alternative for patients with acute cholecystitis who are unfit for surgery. However, standardized guidelines for its indications, techniques, and management remain limited. The objective of this study is to develop evidence-based consensus recommendations for EUS-GBD in benign and malignant conditions, aimed at guiding clinical decision-making and improving patient outcomes. Methods:A 3-step modified Delphi process was used by the Interventional Endoscopy and Ultrasound Group, involving multidisciplinary experts in gastroenterology, surgery, and radiology. Four task forces conducted systematic literature reviews and generated PICO (Patients, Interventions, Comparator, and Outcomes)-formatted clinical questions. Evidence was graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, and consensus was defined as ≥80% agreement among panelists. Results:Twenty-two clinical questions were addressed, covering indications, timing, techniques, device selection, procedural aspects, and postprocedural care for EUS-GBD. Recommendations include the preferential use of EUS-GBD over percutaneous and transpapillary approaches in high-risk patients, early intervention in select cases, the use of lumen-apposing metal stents, and tailored postprocedural strategies. All recommendations were conditional, except for one strong recommendation in favor of EUS-GBD over other modalities, supported by moderate-quality evidence. Conclusions:This consensus offers a comprehensive, multidisciplinary guideline for the safe and effective use of EUS-GBD in clinical practice. These recommendations aim to standardize care and support future research in this rapidly evolving field.

The most common adverse event (AE) of orthotopic liver transplantation (OLT) is anastomotic biliary stricture (ABS). Management varies widely between centers, and it is not clear whether a combination of endoscopic dilation of the stenosis followed by multiple plastic stents (MPS) or placement of a fully covered self-expandable metal stent (fcSEMS) is better for the management of post-OLT ABS. This systematic review and meta-analysis aimed to compare the efficacy, safety, and cost of fcSEMS versus MPS in the treatment of post-OLT ABS. We searched PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) comparing fcSEMS with MPS for the treatment of patients with post-OLT ABS and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model, and I2 statistics were used to evaluate heterogeneity. The study included 5 RCTs (245 patients). There was no statistically significant difference between fcSEMS and MPS in stricture resolution (RR 0.99; 95

Endoscopic ultrasound (EUS)-guided drainage using lumen-apposing metal stents (LAMSs) has become the standard for managing pancreatic fluid collections (PFCs), especially walled-off necrosis (WON). However, LAMS-specific adverse events (AEs), including bleeding, stent occlusion, and infection, remain a concern. To mitigate these complications, some experts advocate placing coaxial double-pigtail plastic stents (DPPSs) within LAMSs. This narrative review critically examines the evidence from retrospective and prospective studies, one RCT, and recent meta-analyses on this combined approach. While the routine use of coaxial double-pigtail plastic stents (DPPSs) within LAMSs is not universally supported, emerging data suggest benefits in select high-risk scenarios, such as large WON, debris-rich cavities, or disconnected pancreatic duct syndrome (DPDS), in which coaxial DPPS within LAMSs can reduce occlusion, infection, and recurrence. In addition, the type of LAMS appears to influence safety outcomes: the SPAXUS stent shows lower bleeding and migration rates than the Hot AXIOS. We propose a pragmatic algorithm for the patient-tailored use of coaxial DPPS and discuss technical innovations to improve outcomes. While evidence is still evolving, personalized strategies and future high-quality studies are needed to define the optimal role of coaxial DPPS within LAMSs in the EUS-guided drainage of PFCs.

Endoscopic ultrasound (EUS) with fine-needle biopsy (FNB) is one of the techniques applied for sampling subepithelial lesions (SELs) of the gastrointestinal tract. Elastography and contrast-enhanced evaluation could permit identification of different patterns among areas of the lesions, depending on their consistence and the presence of vital cells or necrosis. Targeting a specific area when performing FNB in the case of large lesions could potentially permit an increase in accuracy and reduce the need for re-sampling. A 61-year-old woman was admitted reporting severe abdominal pain. The patient underwent cholecystectomy many years ago. She had no known family history of gastrointestinal, hepatic, biliary, or pancreatic disease. Laboratory tests were normal. A computed tomography scan showed a large lesion between the stomach and the pancreatic body, suspected to originate from the gastric wall. An endoscopic view showed a large bulging into the gastric lumen and EUS identified a lesion originating from the muscular layer of the gastric wall. Elastography and contrast-enhanced EUS identified two different areas, one softer with lower enhancement (A) and the other harder with higher enhancement after contrast injection (B). FNB was performed targeting both the areas, sending samples for separate histological evaluation. Histology showed a gastrointestinal stromal tumor (GIST), finding differences in amount of necrotic and neoplastic cells between the two areas. EUS-FNB guided by elastography and/or contrast-enhanced EUS could identify differences within large SELs, allowing targeting of areas more likely to collect diagnostic samples.

BACKGROUND:Histopathological interpretation is crucial for diagnosing inflammatory bowel disease (IBD), distinguishing between Crohn's Disease (CD), Ulcerative Colitis (UC), IBD-Unclassified (IBD-U), and Non-IBD colitis (NIBDC). However, interobserver variability and limited expertise can reduce diagnostic accuracy. Large Language Models (LLMs) such as GPT-5 may offer clinical support in interpreting histology reports. METHODS:We analyzed 100 real-life histological reports from ileo-colonoscopies, equally representing CD, UC, IBD-U, and NIBDC, collected across five Italian healthcare centers, including both IBD-specialized and non-specialized hospitals. A reference standard was established by an expert pathologist. Independent classifications were generated by GPT-5, five gastrointestinal pathologists, five IBD-expert gastroenterologists (GIs), and five non-expert GIs. Diagnostic performance (accuracy, recall, precision, F1-score), agreement with the reference standard (Cohen's κ), and inter-rater reliability (Fleiss' κ) were assessed. RESULTS:GPT-5 achieved the highest agreement with the reference standard with the highest accuracy (76.0%), compared to pathologists (68.6%), IBD-experts (69.2%), and non-experts (63.2%). Agreement with the reference standard was substantial for GPT-5 (κ = 0.671) and moderate for human groups (κ = 0.508-0.588). GPT-5 showed perfect recall for CD and UC, high recall for NIBDC (96.0%), but poor performance for IBD-U (recall 8.0%, F1-score 14.3%). Fleiss' κ indicated moderate agreement among pathologists and IBD-experts, and fair agreement among non-experts. CONCLUSION:GPT-5 demonstrated reliable performance in interpreting IBD histological reports, exhibiting high accuracy and strong agreement with the reference standard. While unreliable for IBD-U, GPT-5 may serve as a supportive tool in histopathological interpretation of IBD, particularly in centers with limited access to expert pathologists or IBD-specialists.

BACKGROUND:Gastric outlet obstruction for benign indications (bGOO) is an uncommon condition, typically treated with surgery when medical therapy or endoscopic treatments fail. At present, endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) may prove to be an effective alternative. AIMS:We performed a systematic review with meta-analysis evaluating outcomes of EUS-GJ for bGOO. METHODS:A comprehensive search was conducted up to February 2025. Pooled estimates were obtained using a random-effects model. Study quality was evaluated using the Newcastle-Ottawa quality scale. Heterogeneity was evaluated with I2 statistic. Technical success, clinical success, recurrence rate, and adverse events (AE) rate were the main outcomes. RESULTS:Fifteen (15) studies, including a total of 376 patients, were identified. Pooled technical success was 95.8 % (CI 95 %, 93.8 %-97.8 %, I2 =0 %), while clinical success was 93.4 % (CI 95 %, 90.4 %-96.5 %, I2= 31.83 %). Pooled recurrence rate was 11.6 % (CI 95 %, 5.5 %-17.7 %, I2=32.36 %). The pooled rate of AE was 11.6 % (CI 95 %, 6.8-16.5 %, I2 = 57.18 %). Subgroup analyses found differences in safety when AE classification was used (17 % use vs. 6 % no use, p = 0.02) and based on quality of studies (low 22 % vs. moderate 10 % vs. high 3 %, p = 0.04). CONCLUSION:In conclusion, our findings show that EUS-GJ is effective and safe in those patients with bGOO in whom other endoscopic treatments fail, and surgery is not an option or could be performed as bridge-to-surgery. Our results suggest that safety is influenced by the use of AE classification and the quality of studies.

Background and Aims:Linear EUS has emerged as a key tool for liver assessment and intervention. However, its adoption for liver segmentation remains limited because of the absence of fixed anatomical landmarks and overlapping views. This study proposes a station-wise approach to simplify liver anatomy interpretation during EUS, correlating these findings with computed tomography imaging for greater comprehensibility. Methods:EUS examinations were conducted using a linear echoendoscope with the patient in a left lateral position under deep sedation. A systematic station-wise methodology was applied to identify liver segments, leveraging anatomical landmarks such as portal vein branches, hepatic veins, and the inferior vena cava. Images were evaluated from 6 different stations. Results:The station-wise approach successfully delineated all liver segments. Stations 1 through 3 provided comprehensive visualization of the superior and inferior segments from the gastroesophageal junction and stomach. Stations 4, 5, and 6 enabled additional imaging of challenging segments (eg, caudate lobe and posterior right liver segments). Conclusions:This study provides a practical framework for systematic liver evaluation using linear EUS. Incorporating this station-wise methodology into EUS training programs could expand its role in diagnostic and therapeutic endohepatology.

BACKGROUND AND AIMS:Although contrast-enhanced EUS (CE-EUS) has been suggested to improve the diagnostic yield of EUS-guided fine-needle aspiration (FNA) of solid pancreatic lesions (SPLs), multicenter data to inform its use in fine-needle biopsy (FNB) remain scarce. This multicenter randomized trial aims to compare the diagnostic performance of CE-EUS and conventional EUS-guided FNB with macroscopic on-site evaluation (MOSE) for SPLs. METHODS:Consecutive patients with SPLs ≥1 cm from 3 referral centers (Hong Kong, Italy, and Korea) were randomized to CE-EUS or conventional EUS-guided FNB with MOSE. Outcome measures were false-negative rate, sensitivity, specificity, accuracy, procedural time, and procedure-related adverse events of assigned technique. RESULTS:One hundred twenty-eight patients were randomized between February 2022 and August 2023. B-mode EUS identified avascular areas in 25.0% of SPL in the CE-EUS group and 20.3% of SPL in the conventional EUS group (P = .526). CE-EUS further increased avascular area detection in SPLs from 25.0% to 31.3%. The false-negative rate (6.0% vs 7.9%, P > .999), sensitivity (94.0% vs 92.1%, P > .999), specificity (100% vs 100%, P > .999), diagnostic accuracy (95.3% vs 92.2%, P = .718), number of passes to achieve macroscopic visible core length ≥4 mm (1 vs 1.5, P = .480), and mean macroscopic visible core length (16.8 mm vs 20.6 mm, P = .259) were similar in both groups. CONCLUSIONS:In this multicenter study, CE-EUS and conventional EUS-guided FNB with MOSE had similarly low false-negative rates and high diagnostic accuracies for SPLs. Routine use of CE-EUS did not further improve FNB yield in SPLs when dedicated FNB needles were used.