Background and AimCurrent diagnostic modalities for indeterminate biliary strictures offer low accuracy. Probe‐based confocal laser endomicroscopy (pCLE) permits microscopic assessment of mucosal structures by obtaining real‐time high‐resolution images of the mucosal layers of the gastrointestinal tract. Previously, an interobserver study demonstrated poor to fair agreement even among experienced confocal endomicroscopy operators. Our objective was to assess interobserver agreement and diagnostic accuracy upon completion of a pCLE training session.MethodsForty de‐identified pCLE video clips of indeterminate biliary strictures were sent to five endoscopists at four tertiary care centers for scoring. Observers subsequently attended a teaching session by an expert pCLE user that included 20 training clips and rescored the same pCLE video clips, which were randomized and renumbered.ResultsPre‐training interobserver agreement for all observers was ‘fair’ (Κ: 0.31, P‐value: <0.0001) and diagnostic accuracy was 72% (55–80%). Post‐training interobserver agreement for all observers was ‘substantial’ (Κ: 0.74, P‐value: <0.0001) and diagnostic accuracy was 89% (80–95%). Using a paired t‐test, we observed an increase of 17% (95% CI 7.6–26.4) in post‐training diagnostic accuracy (t = 5.01, df = 4, P‐value 0.007).ConclusionsInterobserver agreement and diagnostic accuracy improved after observers underwent training by an expert pCLE user with a specific sequence set. Users should participate in such training programs to maximize diagnostic accuracy of pCLE evaluation.

Cholecystectomy is contraindicated in patients with comorbidities or unresectable cancer. Percutaneous transhepatic gallbladder drainage ( PTGBD ) is typically offered with response rates ranging from 56% to 100%, but has several risks such as bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter migration. Endoscopic transpapillary gallbladder drainage ( ETGD ) and endoscopic ultrasound‐guided transmural gallbladder drainage ( EUS‐GBD ) are alternative endoscopic modalities that have a technical feasibility, efficacy and safety profile comparable with PTGBD . In this report, we present the first case series of transgastric EUS‐GBD with placement of a fully covered self‐expandable metal stent with anti‐migratory fins. In three pancreatic cancercases with acute cholecystitis when ETGD was unsuccessful, there were no bile leaks or procedurally related complications. There were no acute cholecystitis recurrences. In conclusion, EUS‐GBD is a promising, minimally invasive treatment for acute cholecystitis. Additional comparative studies are needed to validate the benefit of this technique.

Cholecystitis is a complication that can develop in patients with malignant biliary strictures [1,2]. We describe the endoscopic ultrasound (EUS)-guided placement of a novel metal stent to create a cholecystoduodenostomy in a nonoperable candidate with cholecystitis. An 81-year-old woman with metastatic unresectable cholangiocarcinoma developed cholecystitis secondary tomalignant involvement of the cystic duct. Following external percutaneous cholecystostomy drain insertion, the patient continuously drained ascites from around the percutaneous drainage tube. Given her advanced disease, creation of a cholecystoduodenostomy was proposed. A linear array curvilinear EUS scope (Olympus Medical, Tokyo, Japan) was placed in the duodenal bulb (●" Video 1). Under color Doppler imaging, gallbladder access was accomplished with direct puncture using a 19-gauge needle (EchoTip, Cook Medical, Winston-Salem, North Carolina, USA). A 0.035-inch guide wire was placed through the needle into the gallbladder body and the tract was dilated with a 4-mm Hurricane balloon dilator (Boston Scientific, Natick, Massachusetts, USA). The distal end of a 10-mm×15-mm Axios stent (Xlumena Inc., Mountain View, California, USA) was deployed under endosonographic guidance into the gallbladder body, while the proximal end was released in the duodenum (●" Fig.1). Removal of stones was accomplished with aspiration and lavage of the gallbladder using a GIF-H180 diagnostic endoscope (Olympus Medical, Tokyo, Japan) (●" Fig.2). The stent remained in place for palliation with no adverse events. Prior to human studies, the Axios stent was tested in a swine model. Animals were kept alive up to 8 weeks and stents remained in place without migration [3]. Recently, a retrospective human study by Itoi et al. reported the successful use of this novel stent in four patients with cholecystitis [4]. In conclusion, the placement of this novel metal stent allowed resolution of the cholecystitis. Minimally invasive intervention using this novel stent might become the preferred approach for drainage in this patient population. Endoscopy_UCTN_Code_TTT_1AS_2AD