BACKGROUND : Endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) is emerging as an alternative to choledochoduodenostomy (EUS-CDS) for malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Comparative data on long-term patency are limited. METHODS : This retrospective international study analyzed two historical cohorts of patients who underwent EUS-GBD or EUS-CDS for MDBO after failed ERCP between March 2017 and May 2024. Eligible patients were aged ≥ 18 years with at least 6 months' follow-up or confirmed death. The primary outcome, after 1 : 1 propensity score matching, was 12-month biliary patency. Secondary outcomes included technical and clinical success, adverse events (AEs), reintervention rates, and overall survival. RESULTS : Before matching, 294 patients were included (142 EUS-GBD; 152 EUS-CDS). After matching, 200 patients were analyzed (100 per group). Technical success was 100 % for EUS-GBD and 97 % for EUS-CDS (P = 0.25). Clinical success was 80.5 % for EUS-GBD and 90.6 % for EUS-CDS (P = 0.08). At 12 months, the probability of biliary patency was significantly higher with EUS-GBD than EUS-CDS (86.2 % [95 %CI 74.2 %-92.9 %] vs. 63.8 % [95 %CI 49.5-75.0]; P = 0.01). Biliary reintervention-free survival was significantly longer with EUS-GBD (log-rank, P < 0.001). Periprocedural AEs occurred in 7.0 % vs. 10.0 % (P = 0.61), delayed AEs in 27.0 % vs. 30.0 % (P = 0.75), and reintervention rates were comparable (23.0 % vs. 26.0 %; P = 0.74). Overall survival did not differ significantly (log-rank, P = 0.59). CONCLUSION : In patients with MDBO after failed ERCP, EUS-GBD achieved higher 12-month biliary patency than EUS-CDS, with comparable rates of technical and clinical success, morbidity, reintervention, and overall survival.

Background The diagnosis of cholangiocarcinoma in patients with a biliary stricture without mass syndrome can be obtained by biliary brushing with a sensitivity of ~50 %. We performed a multicenter randomized crossover trial comparing the aggressive Infinity brush with the standard RX Cytology Brush. The aims were to compare sensitivity for cholangiocarcinoma diagnosis and cellularity obtained. Methods Biliary brushing was performed consecutively with each brush, in a randomized order. Cytological material was studied with blinding to the brush type used and order. The primary end point was sensitivity for cholangiocarcinoma diagnosis; the secondary end point was the abundance of cellularity obtained with each brush, with cellularity quantified in order to determine if one brush strongly outperformed the other. Results 51 patients were included. Final diagnoses were cholangiocarcinoma (n = 43; 84 %), benign (n = 7; 14 %), and indeterminate (n = 1; 2 %). Sensitivity for cholangiocarcinoma was 79 % (34 /43) for the Infinity brush versus 67 % (29/43) for the RX Cytology Brush (P = 0.10). Cellularity was rich in 31/51 cases (61 %) with the Infinity brush and in 10/51 cases (20 %) with the RX Cytology Brush (P < 0.001). In terms of quantification of cellularity, the Infinity brush strongly outperformed the RX Cytology Brush in 28/51 cases (55 %), while the RX Cytology Brush strongly outperformed the Infinity brush in 4/51 cases (8 %; P < 0.001). Conclusions This randomized crossover trial showed that the Infinity brush is not significantly more effective than the RX Cytology Brush for biliary stenosis without mass syndrome in terms of sensitivity for cholangiocarcinoma diagnosis, but does offer a significantly higher abundance of cellularity.

Background and Aims: EUS-guided radiofrequency ablation (EUS-RFA) has been described as a potentially curative option for solid and cystic pancreatic neoplasms. We aimed to assess the safety and efficacy of pancreatic EUS-RFA in a large study population. Methods: A retrospective study retrieving all consecutive patients who underwent pancreatic EUS-RFA during 2019 and 2020 in France was conducted. Indication, procedural characteristics, early and late adverse events (AEs), and clinical outcomes were recorded. Risk factors for AEs and factors related to complete tumor ablation were assessed on univariate and multivariate analyses. Results: One hundred patients (54% men, 64.8 +/- 17.6 years old) affected by 104 neoplasms were included. Sixty-four neoplasms were neuroendocrine neoplasms (NENs), 23 were metastases, and 10 were intraductal papillary mucinous neoplasms with mural nodules. No procedure-related mortality was observed, and 22 AEs were reported. Proximity of pancreatic neoplasms (<= 1 mm) to the main pancreatic duct was the only independent risk factor for AEs (odds ratio [OR), 4.10; 95% confidence interval [CI), 1.02-15.22; P = .04). Fifty-nine patients (60.2%) achieved a complete tumor response, 31 (31.6%) a partial response, and 9 (9.2%) achieved no response. On multivariate analysis, NENs (OR, 7.95; 95% CI, 1.66-51.79; P < .001) and neoplasm size <20 mm (OR, 5.26; 95% CI, 2.17-14.29; P < .001) were independently related to complete tumor ablation. Conclusions: The results of this large study confirm an overall acceptable safety profile for pancreatic EUS-RFA. Close proximity (<= 1 mm) to the main pancreatic duct represents an independent risk factor for AEs. Good clinical outcomes in terms of tumor ablation were observed, especially for small NENs.

INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3 % and 77.6 % for ESD and FTRD, respectively (P = 0.25). Lesions treated by ESD were however larger than those treated by FTRD (P < 0.001). The R0 rates for lesions of 20-30 mm were 83.9 % and 57.1 % in the ESD and FTRD groups, respectively, and for lesions of 30-40 mm were 93.6 % and 33.3 %, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size (P = 0.02 and P < 0.001, respectively). The adverse event rate was higher in the ESD group (16.3 % vs. 5.1 %), mostly owing to intraoperative perforations. CONCLUSION:  ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20 mm, the FTRD is an effective alternative.

Background During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct. Methods Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP). Results 142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84%) in the EDG group and in 37/74 patients (50%) in the RSG group within 10 minutes (relative risk 1.34; 95% confidence interval 1.08-6.18; P <0.001). The overall final selective bile duct cannulation rate was 99.3%. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P =0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group. Conclusion The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.

OBJECTIVES:Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases. MATERIALS AND METHODS:Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications. RESULTS:From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64-82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The 'POCP visual impression' of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. 'POCP-guided samples histological analysis' showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1-9.6) and 9.0 (8.8-10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7-9.6) and 9.0 (7.9-9.7). Only three 30-day minor complications occurred without any major complications. CONCLUSIONS:POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

Background and Aims: EUS-guided biliary drainage is indicated in cases of impossibility or failure of classic biliary drainage by ERCP. Recently we reported good efficiency of EUS-guided choledochoduodenostomy (EUS-CDS) using the electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) in a retrospective multicenter study. Use of the recommended technique (direct puncture with the ECE-LAMS with use of a pure cut current and a 6-mm stent) was the only predictive factor of clinical success. We re-evaluated this procedure after 1 year in the same centers. Methods: This was a French retrospective multicenter study of a prospective database including all cases of EUS-guided CDS with ECE-LAMS in the 7 centers that participated in the first study. Results: Seventy consecutive patients were included in this study between September 1, 2017, and September 22, 2018. Failure of primary ERCP was due to duodenal stenosis in 44% of cases and to tumoral infiltration of the papilla in 22% of cases. The mean duration of the procedure was 5 +/- 3 minutes. The recommended technique was used in 98.5% of cases. The technical and clinical success rates were both 97.1% (69/70). Short-term adverse events (periprocedural and intrahospital) occurred in 1.6%. Conclusions: EUS-CDS with the ECE-LAMS is efficacious and safe in distal malignant obstruction of the common bile duct in cases of ERCP failure with impressive results once expertise is acquired and the recommended technique (direct fistulotomy, pure cut current, and 6-mm stent) is followed.

OBJECTIVES:The results of only a few endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid pseudopapillary neoplasm (SPN) have been published, and the safety of the procedure has never been investigated. Our study compared the recurrence rate in patients with and without preoperative EUS-FNA.METHODS:This European multicenter registry-based study was conducted in 22 digestive units, and retrospectively included all patients who underwent complete resection of a pancreatic SPN from 2000 to 2018. Patients with and without initial EUS-FNA were compared, and postsurgery recurrence and the associated risk factors were evaluated.RESULTS:A complete resection of a pancreatic SPN was performed in 149 patients (133 women, 89%), with a mean age of 34 (standard deviation, 14) years. There were no significant differences between the with (78 patients) and without (71 patients) EUS-FNA groups, except for age and tumor size and location.Preoperative EUS-FNA allowed pancreatic SPN diagnosis in 63/78 cases (81%). After a mean follow-up of 43 (standard deviation, 36) months, recurrence was noted in 4 patients (2.7%). Preoperative EUS-FNA was not correlated with recurrence, but an older age (P = 0.005) was significant.CONCLUSIONS:Preoperative EUS-FNA does not affect pancreatic SPN recurrence. In this series, old age was significantly correlated with recurrence.

Background and Aims: In Crohn's disease, strictures are frequent and may require surgical resection or endoscopic balloon dilation. An anti-migration, removable and shaped self-expandable metal stent is available. We evaluated its effectiveness and safety in a real-life setting. Methods: All centres were asked to collect retrospectively or prospectively all data on patients who had a stent for a stricture. The anti-migration stent [Hanarostent HRC-20-080-230-MITech, Seoul, South Korea] was maintained 7 days before its extraction during a second colonoscopy. Short- and long-term efficacy and safety outcomes were evaluated. Results: A total of 46 patients were enrolled. Strictures were anastomotic in 73.9% of cases. The median length of the stricture evaluated by cross-sectional imaging and during colonoscopy was 3.1 1.7 and 2.7 +/- 1.4 cm, respectively. Immediate success [no obstructive symptom at Day 30] was reported in 93.5% of cases (95% confidence interval [CI] = [86.3; 99.9]). Sixteen patients needed a new balloon dilation [n = 8] or surgery [n = 8]. The overall success rate [obstruction-free without any intervention] was 58.7% [n = 27] after a median follow-up of 26 months [8-41 months]. No perforation occurred and three migrations were observed [6.5%]. Perianal disease (hazard ratio [HR] = 0.1 [0.02; 0.58]) and discontinuation of an immunosuppressant (0.12 [0.02; 0.86]), were associated with a lower probability of success, whereas performing imaging (HR = 5.3 [1.2; 23.5]) before stent placement was associated with success. Conclusions: The anti-migration stent is safe and effective in about half of patients, with no perforation reported in this study, and has an extremely low migration rate.

EUS-guided drainage of the gallbladder is becoming the the gold standard treatment for acute cholecystitis in high-risk patient. Several studies showed a higher technical and clinical success of EUS approach compared to percutaneous or trans-cystic one.

Biliary stent placement has become widely accepted as a standard procedure for palliation of jaundice in patients with unresectable malignant biliary strictures. The rate of cholecystitis after ERCP with or without self-expandable metal stent (SEMS) deployment ranges from 5% to 11%.1Suk K.T. Kim H.S. Kim J.W. et al.Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction.Gastrointest Endosc. 2006; 64: 522-529Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 2Coté G.A. Kumar N. Ansstas M. et al.Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents.Gastrointest Endosc. 2010; 72: 748-754Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The use of fully covered SEMSs (FCSEMSs) theoretically may increase the risk of cholecystitis because of obstruction of the cystic orifice; however, contrasting data were reported.3Kullman E. Frozanpor F. Soderlund C. et al.Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study.Gastrointest Endosc. 2010; 72: 915-923Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar Meanwhile, tumoral involvement of the cystic orifice is considered to be an important risk factor for cholecystitis after SEMS placement.4Shimizu S. Naitoh I. Nakazawa T. et al.Predictive factors for pancreatitis and cholecystitis in endoscopic covered metal stenting for distal malignant biliary obstruction.J Gastroenterol Hepatol. 2013; 28: 68-72Crossref PubMed Scopus (51) Google Scholar Acute cholecystitis or symptomatic gallbladder hydrops related to cystic duct malignant obstruction requires urgent gallbladder drainage because affected patients are often unfit for surgery. We report the case of an 80-year-old woman undergoing ERCP for palliation of obstructive jaundice due to unresectable pancreatic cancer. After common bile duct cannulation and cholangiography, a 10- × 60-mm FCSEMS (Wallflex; Boston Scientific, Natick, Mass, USA) was inserted to overcome a severe neoplastic stricture on the middle part of the common bile duct. The stricture involved the cystic duct orifice (Fig. 1). Pneumobilia after FCSEMS deployment, confirming stricture resolution, was seen on the cholangiogram (Fig. 2). The postoperative course was uneventful, and the patient was discharged in good clinical condition on postprocedural day 1. After 1 week, she was seen again because of severe abdominal pain in the right hypochondrium and a palpable right upper-quadrant mass. A laboratory chemistry test highlighted leukocytosis (22,000 × 109/L) and increased level of C-reactive protein up to 390 U/L. A CT scan showed a marked distension of the gallbladder without wall thickness and ascites (Fig. 3). Percutaneous cholecystostomy was not performed in the primary hospital because of ascites. Therefore, she was transferred to our tertiary center, and emergency EUS-guided gastrocholecystostomy was performed with the patient under general anesthesia and a Hot Axios (15-mm × 10-mm) (Boston Scientific) was deployed (Fig. 4). Hot Axios deployment induced immediate symptom resolution (Video 1, available online at www.VideoGIE.org).Figure 4EUS view showing deployment of the distal flange of the lumen-apposing metal stent inside the gallbladder.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Oral diet was restarted after 3 hours, and the patient was discharged on the day of the procedure. Early discharge was feasible because these criteria had been fulfilled: the patient's excellent clinical condition, home distance from hospital within 100 km, and presence of an in-home, trained caregiver. No adverse events occurred after a follow-up time of 2 months. The patient, although experiencing wasting syndrome, eats normally and no longer needs pain medication. EUS-guided drainage of the gallbladder is becoming the criterion standard treatment for acute cholecystitis in high-risk patients.5Law R. Perez-Miranda M. Is it time to stop using percutaneous transhepatic biliary drainage?.Endoscopy. 2017; 49: 521-523Google Scholar Several studies showed a higher technical and clinical success rate of the EUS approach compared with the percutaneous or transcystic approach.6Siddiqui A. Kunda R. Tyberg A. et al.Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an international, multicenter study.Surg Endosc. Epub. 2018 Sep 24; Google Scholar, 7Oh D. Song T.J. Cho D.H. et al.EUS-guided cholecystostomy versus endoscopic transpapillary cholecystostomy for acute cholecystitis in high-risk surgical patients.Gastrointest Endosc. 2018; 98: 289-298Google Scholar Moreover, EUS drainage seems to have significantly fewer long-term adverse events and a lower rate of reintervention compared with the percutaneous approach.8Choi J.H. Kim H.W. Lee J. et al.Percutaneous transhepatic versus EUS-guided gallbladder drainage for malignant cystic duct obstruction.Gastrointest Endosc. 2017; 85: 357-364Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Here we have reported a case of EUS-guided gallbladder drainage with a lumen-apposing metal stent for acute symptomatic gallbladder distension in an outpatient setting. This procedure could be considered feasible, safe, and effective for the management of symptomatic gallbladder pathologic conditions, even in an outpatient setting, as long as no signs of general sepsis are present and an intact gallbladder wall is confirmed at preprocedural imaging. In a similar scenario, when palliative treatments are needed in end-stage patients, the ability to guarantee a 1-day procedure may significantly improve the patient's quality of life. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzMTNmNmEyMzRlMmMzZTg1Nzc3MzEzNjA3ZDI1ZGY2ZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODU1NTMxfQ.P5CHaJaQS5vBRk44--cZDxRzvjNiEY01vPmJQ-kr94x9vbscoWx7xXpnw1_N-b3D19cWZBw-nHUEm7djC_oT-pq0FklRRi8tZTeZlfAHpxIi8uX9-ynSD1u9CyiRbvFNFxram96UbdXeAVpbialXP-gM7H_Iu47nFE2qXkwkOzspzCTqz8y2q8tVEt94v9w22CM3vbtdDVrwCCIzi-FgpUABsSWL2pPEUsXvbIWkX0RK00ZNoQgiv6TFWxunCqm-pJzH7F6BjP-jJh2L1X2sxrftHxunPh9weSAXp4JqSi3GDI6jVJq46B-nHR2Ofzi3opbf30kMWD4SUdrGIhmkXw Download .mp4 (26.01 MB) Help with .mp4 files Video 1Emergency EUS-guided cholecystogastrostomy for acute symptomatic gallbladder distension with deployment of a Hot Axios (15-mm × 10-mm).

Solid-Pseudopapillary neoplasm (SPN) is a rare condition, first described by Frantz in 1959. It occurs mostly in young women, and surgical resection is recommended. Its local recurrence rate is less than 10% and usually occurs within 4 years after surgery. Before such a surgery, especially in young people, EUS-FNA (Endoscopic ultrasonography with fine needle aspiration) is discussed to confirm diagnosis but rarely performed due to suspected needle tract inoculation by neoplastic cells. The aim of our large multicenter study was to assess the short- and long-term safety of preoperative EUS-FNA in SPN.

Abstract Background Endoscopic ultrasound-guided biliary drainage is an alternative to percutaneous biliary drainage in cases of malignant biliary obstruction and failure of classic endoscopic drainage by endoscopic retrograde cholangiopancreatography (ERCP). Recently, a new electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) that allows for endoscopic anastomosis (apposition stent) has become available for use in EUS-choledochoduodenostomy (EUS-CDS) and facilitates the procedure. Methods This was a retrospective study of all EUS-CDS procedures performed in France between April 2016 and August 2017. The primary end point was the technical and clinical success rates of EUS-CDS using an ECE-LAMS. Results 52 consecutive patients were included in the study. The etiology of distal bile duct obstruction was distal pancreatic adenocarcinoma in 43 patients (82.7 %). The technical success rate was 88.5 % (46 /52 patients), and the clinical success rate was 100 % (46/46 patients). The mean duration of the procedure was 10.2 minutes (range 1 – 90). Two patients (3.8 %) presented with short-term complications after EUS-CDS and before discharge from hospital. In univariate analyses, a small diameter of the common bile duct and not following the recommended procedure technique were significant risk factors for technical failure. Over a mean follow-up of 157 days, the median survival time without biliary complications was 135 days. Conclusion EUS-CDS with an ECE-LAMS is efficacious and safe in distal malignant obstruction of the common bile duct and could be proposed as the first option in cases of ERCP failure.

Background and study aims Endoscopic sphincterotomy plus large-balloon dilation (ES-LBD) has been reported as an alternative to endoscopic sphincterotomy for the removal of bile duct stones. This multicenter study compared complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones. This is the first randomized multicenter study to evaluate these procedures in patients with exclusively large common bile duct (CBD) stones.Methods Between 2010 and 2015, 150 patients with one or more common bile duct stones >= 13 mm were randomized to two groups: 73 without balloon dilation (conventional group), 77 with balloon dilation (ES-LBD group). Mechanical lithotripsy was subsequently performed only if the stones were too large for removal through the papilla. Endoscopic sphincterotomy was complete in both groups. Patients could switch to ES-LBD if the conventional procedure failed.Results There was no between-group difference in number and size of stones. CBD stone clearance was achieved in 74.0% of patients in the conventional group and 96.1% of patients in the ES-LBD group (P < 0.001). Mechanical lithotripsy was needed significantly more often in the conventional group (35.6% vs. 3.9 %; P < 0.001). There was no difference in terms of morbidity (9.3% in the conventional group vs. 8.1% in the ES-LBD group; P = 0.82). The cost and procedure time were not significantly different between the groups overall, but became significantly higher for patients in the conventional group who underwent mechanical lithotripsy. The conventional procedure failed in 19 patients, 15 of whom underwent a rescue ES-LBD procedure that successfully cleared all stones.Conclusions Complete endoscopic sphincterotomy with large-balloon dilation for the removal of large CBD stones has similar safety but superior efficiency to conventional treatment, and should be considered as the first-line step in the treatment of large bile duct stones and in rescue treatment.

Because of impossibility of stone extraction in 10% of cases after endoscopic sphincterotomy (ES), mostly because of stone’s size, adjunction of a mechanical lithotripsy (ML) is well established to improve clearance of CBD stones. Because of inconstant success, high cost, and length of ML procedure, an alternative method was proposed: Endoscopic Sphincterotomy plus Large Balloon Dilatation (ESLBD). We conducted this study to determine the superiority of ESLBD on conventional treatment (CONV: ES +/- ML) for the treatment of large bile duct stone after standard ES.

Background and study aims: The hemostatic powder TC-325 (Hemospray; Cook Medical, Winston-Salem, North Carolina, USA) has shown promising results in the treatment of upper gastrointestinal bleeding (UGIB) in expert centers in pilot studies. The aim of this study was to evaluate the feasibility and efficacy of TC-325 in a large prospective registry of use in routine practice. Patients and methods: The data of all patients treated with TC-325 were prospectively collected through a national registry. Outcomes were the immediate feasibility and efficacy of TC-325 application, as well as the rates of rebleeding at Day 8 and Day 30. Multivariate analysis was performed to determine predictive factors of rebleeding. Results: A total of 202 patients were enrolled and 64 endoscopists participated from 20 centers. TC-325 was used as salvage therapy in 108 patients (53.5 %). The etiology of bleeding was an ulcer in 75 patients (37.1 %), tumor in 61 (30.2 %), postendoscopic therapy in 35 (17.3 %), or other in 31 (15.3 %). Application of the hemostatic powder was found to be very easy or easy in 31.7 % and 55.4 %, respectively. The immediate efficacy rate was 96.5 %. Recurrence of UGIB was noted at Day 8 and Day 30 in 26.7 % and 33.5 %, respectively. Predictive factors of recurrence at Day 8 were melena at initial presentation and use of TC-325 as salvage therapy. Conclusion: These multicenter data confirmed the high rate of immediate hemostasis, excellent feasibility, and good safety profile of TC-325, which could become the treatment of choice in bleeding tumors or postendoscopic bleeding but not in bleeding ulcers where randomized studies are needed.TRIAL REGISTRATION:ClinicalTrials.gov (NCT02595853).

Background and study aim: Endoscopic ultrasound (EUS)-guided biliary access is an alternative to percutaneous access after failed endoscopic retrograde cholangiopancreatography (ERCP). This report presents 7 years’ cumulative experience of EUS-guided biliary drainage for obstructive jaundice in patients with failed ERCP. Patients and methods: Between February 2006 and February 2013, 101 patients (malignant = 98, benign = 3) with previous failed ERCP underwent an EUS intra- or extrahepatic approach with transluminal stenting or an EUS-guided rendezvous procedure with transpapillary stent placement. A single endoscopist performed all procedures. Results: A total of 71 patients underwent the intrahepatic approach (66 hepatogastrostomies and 5 EUS-guided rendezvous), and 30 underwent the extrahepatic approach (26 choledochoduodenostomies, 1 choledochojejunostomy, 1 choledochoantrostomy, and 2 EUS-guided cholangiographies). Technical and clinical success rates were 98.0 % and 92.1 %, respectively. There was no difference in efficacy between hepatogastrostomies and choledochoduodenostomies (94 % vs. 90 %; P = 0.69) or in major complications (10.6 % vs. 6.7 %; P = 1). Adverse events occurred in 12 patients (11.9 %): 10 in the hepatogastrostomy group (2 limited pneumoperitoneum, 1 hepatic hematoma, 5 bile leakage, 2 sepsis), and 2 in the choledochoduodenostomy group (1 arteriobiliary fistula and 1 sepsis). There were six procedure-related deaths, five among the first 50 patients and one among the last 51 patients. Hepatogastrostomy vs. choledochoduodenostomy, plastic vs. metal stenting, stent-in-stent vs. 1 stent, nasobiliary drain, or postoperative octreotide infusion were not prognostic of bile leakage. Conclusion: EUS-guided biliary drainage is an efficient technique, but is associated with significant morbidity that seems to decrease with the learning curve. It should be performed in tertiary care centers in selected patients. Prospective randomized studies are needed to compare EUS-guided biliary drainage with percutaneous transhepatic cholangiography drainage.