Background and Objectives:Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an alternative therapeutic option for unsuccessful endoscopic retrograde cholangiopancreatography in patients with malignant biliary obstruction. Procedure-related adverse events (AEs), such as bile leakage and peritonitis, can lead to prolonged hospitalization and delay the initiation of chemotherapy for underlying malignancies. This study aimed to identify factors associated with the development of peritonitis following EUS-HGS. Methods:Consecutive patients who underwent initial EUS-HGS between July 2016 and November 2022 were retrospectively evaluated. We assessed the preprocedural characteristics (cholangitis and duodenal invasion) and intraprocedural technical factors (small bile duct diameter, short hepatic parenchymal distance at puncture, antegrade stenting, and the use of a plastic stent for HGS). Multivariate logistic regression analysis was conducted to evaluate the factors associated with peritonitis after EUS-HGS. Results:A total of 188 patients were included. The cause of biliary obstruction was malignancy in 96% of the cases, with the majority being pancreatic cancer. The rate of early AEs was 15% and included peritonitis (7%), pancreatitis (3%), cholangitis (3%), cholecystitis (1%), and bleeding (1%). Multivariable logistic regression analysis revealed that the diameter of a punctured bile duct ≤3 mm (odds ratio, 4.0; 95% confidence interval, 1.1-15; p = 0.039) independently increased the risk of peritonitis after EUS-HGS. Conclusions:A punctured bile duct diameter of ≤3 mm was identified as a significant independent risk factor for the development of peritonitis after EUS-HGS. Trial Registration: N/A.

OBJECTIVES:Pancreatic cancer frequently presents with tumor necrosis, which may influence the success of comprehensive genomic profiling in endoscopic ultrasound-guided tissue acquisition specimens. This study aimed to evaluate the relationship between tumor necrosis and comprehensive genomic profiling success. METHODS:This single-center retrospective study enrolled patients diagnosed with pancreatic cancer via endoscopic ultrasound-guided tissue acquisition, whose tissue samples were submitted for FoundationOne® CDx analysis between November 2019 and November 2023. Based on the FoundationOne® CDx report, a 'passed' result indicated successful analysis. Histological type, tumor quantity, and necrosis were evaluated as pathological factors. Univariable and multivariable analyses were conducted to identify factors associated with successful FoundationOne® CDx. RESULTS:Among 109 patients included in this study, the overall success rate of FoundationOne® CDx analysis was 67.9%. Extensive tumor necrosis (>50%) was significantly associated with a lower success rate of FoundationOne CDx analysis (28.6% [>50%] vs. 70.6% [≤50%], P = 0.034). Among the 83 cases that met the quantity criteria for FoundationOne® CDx analysis, the success rate was significantly lower in cases with extensive necrosis (>50%) than in those with limited necrosis (40% [2/5] vs. 83% [65/78]; P = 0.036). Multivariate analysis identified extensive necrosis (odds ratio [OR] 0.09, P = 0.015), samples that met the quantity criteria for FoundationOne® CDx analysis (OR 14.90, P < 0.0001), and pancreatic ductal adenocarcinoma histology (OR 4.21, P = 0.038) as significant factors influencing the success of FoundationOne® CDx analysis. CONCLUSIONS:Extensive tumor necrosis observed on pathological examination is associated with a lower success rate of FoundationOne® CDx analysis in pancreatic cancer.

Background and study aims Mapping biopsy (MB) aids in diagnosing superficial mucosal spread of biliary tract cancer. However, conventional MB is technically challenging, which can reduce the diagnostic yield. This study aimed to assess the usefulness of MB using the newly developed Endosheather (ES) (Piolax, Tokyo, Japan).Patients and methods We retrospectively analyzed data from patients who had biliary tract cancer with hilar biliary obstruction and underwent MB. Outcome measures included the overall technical success rate, quality of specimens, impact of MB results on the treatment strategy, and adverse events (AEs), which were compared between the conventional (Conv) group and the ES group.Results A total of 91 patients were included. The overall technical success rate was significantly higher in the ES group (92%, 43/47) than in the Conv group (59%, 26/44) ( P < 0.05). The rate of samples containing both biliary epithelium and stromal tissue was significantly higher in the ES group than in the Conv group (77% [67/87] vs. 47% [32/68]; P < 0.05). MB results affected the treatment strategy in one patient (2.3%) in the Conv group and five patients (11%) in the ES group ( P = 0.11). There was no significant difference between the two groups in terms of AEs.Conclusions MB using ES significantly improved technical success and specimen quality, providing valuable information for preoperative assessment of patients with biliary tract cancer.

Background and study aims:Matched therapy based on comprehensive genomic profiling is a potential treatment option for patients with inoperable pancreatic cancer; however, the optimal method for obtaining tissue samples suitable for comprehensive genomic profiling using endoscopic ultrasound-guided tissue acquisition remains unclear. This study aimed to determine the optimal endoscopic ultrasound-guided tissue acquisition method to obtain samples for comprehensive genomic profiling. Patients and methods:This retrospective study included 86 consecutive patients with pancreatic cancer who underwent comprehensive genomic profiling using FoundationOne CDx (Foundation Medicine Inc.) and endoscopic ultrasound-guided tissue acquisition between June 2019 and January 2023. Macroscopic visible core length was measured using on-site macroscopic evaluation in all patients. Foundation Medicine Inc. reported analysis results categorized as passed (successful FoundationOne CDx), qualified, or failed. We investigated factors predicting successful FoundationOne CDx treatment. Results:Needles sized 22, 20, and 19 gauge were used in 63, one, and 23 patients, respectively. The stylet slow-pull and suction techniques were performed in 43 and 41 patients, respectively. Median total macroscopic visible core length in the formalin-fixed paraffin-embedded blocks subjected to FoundationOne CDx was 41 mm. The success rate for FoundationOne CDx was 66%. Multiple linear regression analysis revealed that macroscopic visible core length independently affected successful FoundationOne CDx ( P = 0.0019). Conclusions:In tissue specimens obtained using endoscopic ultrasound-guided tissue acquisition, macroscopic visible core length can be associated with an appropriate sample for FoundationOne CDx.

ABSTRACT 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.

BACKGROUND AND AIMS:Patients with autoimmune pancreatitis (AIP) sometimes show characteristic ophthalmologic findings, such as dacryoadenitis and dry eye. However, the ocular findings in AIP patients thus far have not fully been analyzed, especially in patients treated long term with corticosteroids (CS). We aimed to study the current and previous history of ocular diseases in AIP patients and changes of the common ophthalmologic findings during the CS treatment. METHODS:We retrospectively analyzed the history of ophthalmologic diseases in 105 AIP patients and further examined the changes in the ophthalmologic findings and associated factors occurring during CS treatment in 63 patients. RESULTS:Several common ophthalmic diseases, including cataract (33.3%) and glaucoma (6.3%), were recognized in approximately one-third of the AIP patients at their initial diagnosis. Behcet uveitis was seen in the past histories of two AIP patients. During 70 months of CS treatment, exacerbation of cataract was recognized in 31.7%, and new onset of glaucoma in 7.9%. Univariate and multivariate analyses demonstrated the cumulative CS amount as a significant risk of cataract exacerbation (p<0.05) and diffuse pancreatic swelling at the initial diagnosis as a risk of Mikulicz's disease (p<0.01). CONCLUSIONS:An ophthalmologic check at the initial diagnosis and monitoring during CS treatment is required for patients with AIP. Promising steroid-sparing agents are expected to lessen the adverse ophthalmologic events caused by CS.

BACKGROUND AND AIMS:The use of commercially available comprehensive genomic profiling tests, such as the FoundationOne CDx (F1CDx), has increased. However, the success rate of F1CDx using samples obtained by EUS-guided tissue acquisition (EUS-TA) is suboptimal. This study aimed to verify the optimal method for obtaining samples suitable for F1CDx among 3 EUS-TA techniques. METHODS:In a randomized, noncomparative, 3-arm trial, patients with unresectable pancreatic cancer scheduled for EUS-TA using a Franseen needle for pathologic confirmation were randomized into 3 groups: 2 passes with a 19-gauge needle; 4 passes with a 22-gauge needle; and macroscopic on-site evaluation (MOSE) using a 22-gauge needle until the macroscopic visible core length reached ≥40 mm. The primary end point was the acquisition rate of an ideal sample meeting the F1CDx quantity criteria; the secondary end points were procedure time, adverse events, and F1CDx success rate. RESULTS:Seventy-five patients were enrolled. The acquisition rates of ideal samples for F1CDx (96%, 92%, and 96% for the 19-gauge, 22-gauge, and MOSE groups, respectively; all P < .05) were significantly greater than the expected 60%. The 19-gauge and MOSE groups had significantly shorter procedure times than the 22-gauge group (814 seconds vs 896 seconds vs 963 seconds). The 22-gauge group showed moderate abdominal bleeding. F1CDx was successful in 10, 12, and 9 cases in the 19-gauge, 22-gauge, and MOSE groups, respectively, representing a 100% success rate for each group. CONCLUSIONS:Two passes using a 19-gauge needle and MOSE using a 22-gauge needle are recommended to collect ideal samples for F1CDx. (Clinical trial registration: The Japan Registry of Clinical Trials [jRCTs042210083]).

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is performed when biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP) is difficult [1] [2] [3] [4]. Biliary peritonitis is an adverse event that can be fatal; however, it typically develops immediately after the procedure [5]. Metallic stents reduce the risk of peritonitis. However, plastic stents are preferred for patients with benign diseases or who are surgical candidates. Herein, we present a case of peritonitis that developed 6 days after EUS-BD ([Video 1]).

The purpose of preoperative biliary drainage (PBD) is to reduce complications during the perioperative period. The extrahepatic bile duct comprises distal and hilar bile ducts and assessing the need for PBD must be considered separately for each duct, as surgical procedures and morbidities vary. The representative disease-causing distal bile duct obstruction is pancreatic cancer. A randomized controlled trial has revealed that PBD carries the risk of recurrent cholangitis and pancreatitis before surgery, thus eliminating the need for PBD when early surgery is feasible. However, neoadjuvant therapy has seen a rise in recent years, resulting in longer preoperative waiting periods and an increased demand for PBD. In such cases, metal stents are preferable to plastic stents due to their lower stent occlusion rates. When endoscopic transpapillary biliary drainage (EBD) is not viable, endoscopic ultrasound-guided biliary drainage may be a suitable substitute. In the hilar bile duct, the representative disease-causing obstruction is hilar cholangiocarcinoma. PBD's necessity has long been a subject of contention. In spite of earlier criticisms of routine PBD, recent views have emerged recommending PBD, particularly when major hepatectomy is required, to prevent postoperative liver failure. Given the risk of tumor seeding associated with percutaneous transhepatic biliary drainage, EBD is preferable. Nevertheless, as its shortcomings involve recurrent cholangitis until surgery due to stent or tube obstruction, it is necessary to seek out novel approaches to circumvent complications. In this review we summarize the current evidence for PBD in patients with distal and hilar biliary obstruction.

A 73-year-old Japanese man with a history of distal biliary cancer treated by pancreatoduodenectomy developed pancreatic acinar cell carcinoma (PACC) treated by remnant pancreatectomy and adjuvant chemotherapy. Thirteen months after surgery, multiple liver metastases developed and FOLFOX chemotherapy was initiated. Based on the PACC diagnosis and a positive family history for breast and ovarian cancer genetic testing was performed which revealed a pathogenic germline BRCA2 variant (c.8629G > T, p.Glu2877Ter). Olaparib therapy was initiated and the metastases responded well (partial response). PACC is a BRCA2-associated cancer which may respond well to PARP inhibitors.