Partially covered self-expandable metallic stents (PCSEMSs) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) provide favorable patency and low migration risk; however, reintervention (RI) remains challenging. We retrospectively evaluated the outcomes of RI after EUS-HGS with PCSEMS placement in 108 patients with malignant biliary obstruction treated between January 2016 and December 2024. Causes of recurrent biliary obstruction (RBO), RI techniques, and post-RI outcomes were analyzed. The median age of patients was 77 years, with pancreatic cancer being the most common (n = 62). RBO occurred in 25 (23

Objectives: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for acute cholecystitis (AC) has a high technical and clinical success rate and is beneficial for patients’ quality of life due to internal fistula drainage, especially for high-risk surgical patients. Two drainage devices (plastic stent [PS] and lumen-apposing metal stent [LAMS]) are available; however, suitable drainage devices remain unclear. Methods: Between 2016 and 2026, 20 PS and 20 LAMS placement high-risk surgical AC were compared. Technical and clinical success rates, the number of dilation cases for the puncture route, procedure time, adverse events (AEs), and hospital stay were evaluated. Results: There was no significant difference in patients’ backgrounds, except for the number of percutaneous gallbladder drainage conversion cases (75% in PS group vs. 10% in LAMS group; P < 0.01). The shortest gallbladder diameter tended to be larger in the LAMS (30-mm) than in the PS group (25-mm; P = 0.052). Dilation of the puncture site was required in all PS cases. The technical and clinical success rates were 100% in both groups. EUS-GBD procedure time was significantly shorter in the LAMS group (7 min. vs. 21 min.; P < 0.01). The AEs occurrence rate was significantly higher in the PS group (40% vs. 5%; P = 0.02), which led to a significantly longer hospital stay in PS group (34-days vs. 10-days; P = 0.047). Conclusions: LAMS placement in EUS-GBD for high-risk surgical patients with AC was associated with a significantly shorter procedure time, shorter hospital stay, and lower occurrence of AEs. LAMS is a safe and useful device for EUS-GBD. Clinical Trial Registration UMIN000060137

Background/Objectives: The optimal timing for biliary drainage in elderly patients remains controversial. This study compared the clinical outcomes of early versus late biliary drainage in elderly patients diagnosed with acute cholangitis associated with common bile duct stones (CBDS). Methods: This single-center, retrospective cohort study compared early (within 24 h of admission) versus late (>24 h after admission) biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP) in 143 elderly patients diagnosed with acute cholangitis, who were divided into early and late groups, respectively. Results: There were no statistical differences in patient characteristics between the early and late drainage groups. Although the time to clinical success was significantly shorter in the early drainage group, there were no significant differences in persistent organ failure, length of hospital stay, in-hospital and 30-day mortality, and ERCP-related adverse events (AEs) between the early and late groups. In the late group, the clinically worsened group tended to exhibit higher white blood cell counts and lower platelet counts on admission. Conclusions: Time to clinical success was significantly shorter in the early drainage group than in the late group. No statistically significant differences in persistent organ failure, length of hospital stay, in-hospital and 30-day mortality, and ERCP-related adverse AEs were detected between early and late biliary drainage in elderly patients with acute cholangitis associated with CBDS.

Background/Objectives: The presence of a mural nodule (MN) is one of the findings indicating malignant transformation of an intraductal papillary mucinous neoplasm (IPMN). It is difficult to distinguish true MNs from mucus clots (MCs) by endoscopic ultrasound (EUS) alone. This study aimed to evaluate the efficacy of contrast-enhanced (CE)-EUS for differentiating true MNs from MCs and carcinoma from adenoma. Methods: A total of 104 patients who were diagnosed as having branch duct-type IPMNs with MN-like structures by EUS and underwent CE-EUS between January 2016 and August 2022 were included. MN-like structures without perfusion on CE-EUS were defined as MCs and those with perfusion were defined as true MNs. This was a retrospective study with limited pathological confirmation, and diagnoses in non-surgical cases were based on imaging and follow-up. Results: CE-EUS showed MN-like structures with perfusion in 35 patients and without perfusion in 69 patients. Surgical resection was eventually performed in a total of 28 patients and the diagnostic sensitivity, specificity and accuracy of MNs among them were 100%, 66.7% and 96.4% in CE-EUS; 48%, 66.7% and 50% in CE-CT; and 61.9%, 33.3% and 58.3% in MRCP, respectively. Possible risk factors indicating malignancy were statistically evaluated and presence of an MN was the only significant factor. Among the 35 true MNs, the height of an MN in carcinoma was significantly higher than that of an adenoma. The ROC analysis for detecting carcinoma in true MNs showed an area under the curve of 0.92 with the optimal cut-off value of 7 mm. When this cut-off value was used for diagnosing carcinoma, the sensitivity, specificity, and accuracy were 94.1%, 83.3% and 88.6%, respectively. Conclusions: CE-EUS may be useful for differentiating true MNs from MCs, although diagnostic performance should be interpreted cautiously because most non-surgical cases lacked pathological confirmation.

Various self-expandable metallic stents (SEMS) have been developed to improve the patency of patients with malignant distal biliary obstruction (MDBO). This retrospective study aimed to evaluate SEMS characteristics associated with longer patency in initial SEMS placement for unresectable MDBO. Patients with unresectable MDBO identified in databases from four medical centers were analyzed. Patient background, SEMS type, and time to recurrent biliary obstruction (TRBO) were analyzed. The extracted variables were subjected to propensity score matching (PSM) to reduce selection bias. Between 2010 and 2025, 780 patients with MDBO were identified, 501 of whom met the inclusion criteria. In the multivariate analysis, 12-mm bore size, laser-cut SEMS, and 8-cm length SEMS were identified as independent significant factors contributing to TRBO. To confirm the utility of three significant factors, PSM analysis was performed on each. A total of 126 patients with 12- and 10-mm bore-size SEMS, 34 patients with laser-cut and braided SEMS, and 169 patients with 8-cm and < 8-cm length SEMS were compared. The hazard ratio of the 12-mm bore size SEMS was 0.65 (95

Bilateral intraductal plastic stent (IS) placement is preferred for unresectable malignant hilar biliary obstruction (MHBO) owing to its stent patency and removability. However, certain clinical and technical conditions permit only unilateral drainage even for unresectable MHBO. A useful stent selection in such cases remains unclear. Among 360 retrospective patients with MHBO, 118 underwent unilateral drainage with an across-papillary plastic stent (PS), IS, or a self-expandable metallic stent (SEMS). Outcomes were compared based on clinical success, adverse events (AEs), recurrent biliary obstruction (RBO), time to RBO (TRBO), and reintervention, using propensity score matching (PSM) analysis. PSM identified 23 patients in each group for comparison. The RBO occurrence rates and median TRBO were 83

BACKGROUND:Intraductal papillary mucinous neoplasm (IPMN) is a well-recognized precursor of pancreatic cancer; however, the optimal surveillance strategy for IPMN remains controversial. This study aimed to evaluate the clinical impact of semiannual surveillance using endoscopic ultrasonography (EUS) and magnetic resonance imaging (MRI) for the detection of malignant transformation, including IPMN-derived and concomitant carcinoma. METHODS:This multicenter prospective observational study included 360 patients with branch-duct or mixed-type IPMN enrolled between April 2018 and December 2025. Patients underwent surveillance every 6 months with blood tests and EUS or MRI. The primary endpoint was the curative resection rate among patients diagnosed with IPMN-derived or concomitant carcinoma. Secondary endpoints included the incidence of newly developed worrisome features (WF) and high-risk stigmata (HRS), as well as the cumulative incidence of malignancy. RESULTS:During a median follow-up period of 69 months, newly developed WF and HRS were observed in 30.3% and 2.5% of patients, respectively. Malignant transformation was confirmed in 12 patients (3.3%), including nine with IPMN-concomitant carcinoma and three with IPMN-derived carcinoma. Curative resection was performed in 9 of these patients, resulting in a surgical transition rate of 75.0%. All malignant pancreatic lesions were detected at a resectable or borderline-resectable stage at diagnosis. CONCLUSIONS:Semiannual surveillance using EUS and MRI facilitated the detection of malignant pancreatic lesions at a surgically treatable stage in patients with IPMN. This surveillance strategy may be clinically valuable for identifying IPMN-derived and concomitant carcinoma at stages amenable to surgical treatment in high-risk populations.

Self-expandable metallic stents (SEMSs) are recommended for preoperative biliary drainage in patients with pancreatic cancer. However, they are associated with a relatively high incidence of non-recurrent biliary obstruction (RBO) adverse events (AEs), such as pancreatitis and cholecystitis. The 11.5-Fr large-bore plastic stent (LBPS) is a newly developed stent with a larger diameter than conventional plastic stents. The aim of the present study was to compare the clinical outcomes of LBPS and SEMS in preoperative biliary drainage for pancreatic cancer. We retrospectively evaluated 80 patients who underwent preoperative biliary drainage for pancreatic cancer between January 2011 and December 2025. Patients were divided into the LBPS and SEMS groups according to the stent placed. RBO occurred in 20.0

BACKGROUND:Transpapillary preoperative biliary drainage (PBD) only for the future remnant liver (FRL) in hilar cholangiocarcinoma (HCCA) can be performed minimally invasively, with the expectation of swelling of the FRL. However, verification of the appropriate transpapillary unilateral PBD method for FRL is limited as the cases of liver resection are insufficient. METHODS:A total of 63 patients with resectable HCCA were evaluated. Of note, 12 unilateral across-the-papilla plastic stent (PS) placement cases (PS group), 14 unilateral intraductal PS (IS) placement cases (IS group), and 11 unilateral endoscopic nasobiliary drainage cases (ENBD group) met the inclusion criteria. Each group was compared in terms of the hospital stay duration for the endoscopic procedure, recurrent biliary obstruction (RBO), time to RBO (TRBO), overall survival (OS), and surgical outcomes. RESULTS:No significant differences were observed in the patient characteristics between the groups. Hospital stay for the endoscopic procedure was significantly longer in the ENBD group (50 days [IQR, 33-163]) than in the PS group (14 days [IQR, 2-36]; P <.01) or IS group (21 days [IQR, 6-118]; P <.01). There were no significant differences in the RBO, TRBO, OS, surgical time, amount of intraoperative blood loss, or postsurgical adverse events (AEs) between the groups. In the multivariate analysis, there were no significantly related factors for RBO, TRBO, OS, and postsurgical AEs. CONCLUSION:The PS, IS, and ENBD groups showed similar clinical outcomes in liver resection cases for HCCA, excluding the hospital stay duration for the endoscopic procedure. Considering the hospital stay duration, unilateral PS and IS placement can be considered acceptable for transpapillary PBD.

Introduction:Bile leakage is one of the complications after hepatobiliary surgery, causing intra-abdominal infections, and is sometimes difficult to treat. The purpose of our study was to investigate the factors related to severity and to evaluate the efficacy of endoscopic treatment. Methods:This was a retrospective multicenter cohort study conducted at three tertiary care medical centers. The severity of bile leakage was classified per the International Study Group of Liver Surgery, and Grades B and C (requiring some intervention or reoperation) were considered as severe. Results:The subjects were 59 patients. The surgical procedures were 31 cholecystectomies, 23 hepatectomies, and five pancreaticoduodenectomies. The severity was Grade A/B/C: 17/40/2. Multivariate logistic regression analysis found that age (unit odds ratio [UOR], 1.09; 95% confidence interval [CI], 1.0-1.19; p = 0.049) and days from surgery to bile leak (UOR, 1.18; 95% CI, 1.04-1.35; p = 0.012) were independent predictors of bile leak severity. Of 40 Grade B biliary leakage patients, 37 patients underwent endoscopic drainage, of which 11 also received intra-abdominal abscess drainage. Eventually, bile leakage was successfully treated in all patients after several endoscopic drainage sessions, and the median drainage period was 18 days (inter-quartile range: 13-35). Conclusion:In the management of bile leakage after hepatobiliary surgery, elderly patients or patients with late onset of bile leak may be at high risk of severity. Endoscopic biliary drainage is considered a safe and effective treatment for severe patients.

ObjectivesThe placement of plastic stents (PS), including intraductal PS (IS), is useful in patients with unresectable malignant hilar biliary obstruction (UMHBO) because of patency and ease of endoscopic reintervention (ERI). However, the optimal stent replacement method for PS remains unclear.MethodsThis retrospective study included 322 patients with UMHBO. Among them, 146 received PS placement as initial drainage (across‐the‐papilla PS [aPS], 54; IS, 92), whereas 75 required ERI. Eight bilateral aPS, 21 bilateral IS, and 17 bilateral self‐expandable metallic stent (SEMS) placements met the inclusion criteria. Rates of technical and clinical success, adverse events, recurrent biliary obstruction (RBO), time to RBO (TRBO), overall survival, and secondary ERI were compared.ResultsThere were no significant intergroup differences in rates of technical or clinical success, adverse events, RBO occurrence, or overall survival. The median TRBO was significantly shorter in the aPS group (47 days) than IS (91 days; P = 0.0196) and SEMS (143 days; P < 0.01) groups. Median TRBO did not differ significantly between the IS and SEMS groups (P = 0.44). On Cox multivariate analysis, the aPS group had the shortest stent patency (hazard ratio 2.67 [95% confidence interval 1.05–6.76], P = 0.038). For secondary ERI, the median endoscopic procedure time was significantly shorter in the IS (22 min) vs. SEMS (40 min) group (P = 0.034).ConclusionsBilateral IS and SEMS placement featured prolonged patency after first ERI. Because bilateral IS placement is faster than SEMS placement and IS can be removed during secondary ERI, it may be a good option for first ERI.