Lesions of ampulla of Vater are uncommon and often discovered incidentally. Most adenomatous lesions can be treated by endoscopic papillectomy which can obviate the need for surgery. Data regarding effectiveness for endoscopic papillectomy especially for larger lesions is lacking. We aimed to assess the impact of polyp size on recurrence on subsequent ERCP procedures following initial papillectomy. After approval of the study from local IRB, patients with diagnosis of ampullary lesion who were treated with endoscopic papillectomy at our quaternary care referral center were included in the study from January 2017 to December 2024. Charts were obtained using the relevant billing and ICD10 codes from electronic medical records and were then individually reviewed by a group of researchers to extract relevant information. Patients were divided into two groups based on polyp size; ≤ 20 mm and > 20 mm for comparison. A total of 71 patients underwent endoscopic papillectomy at our institute during this time period. 37 had polyps less than 20 mm (smaller polyp group), and 34 had polyps ≥ 20 mm (larger polyp group). Patients with larger polyps were older with a mean age of 67.5 ± 10.2 compared to 57.8 ± 16.0 in the smaller polyp group (p = 0.019). There was no significant difference between race and sex of the two groups. Hot snare was the most employed tool in both groups, with occasional use of cold snare in conjunction (44.1

The incidence of cholecystitis and cholelithiasis is higher in patients with cirrhosis. Decompensated liver disease places them at higher risk for morbidity and mortality from cholecystectomy, and many providers prefer non-surgical approaches. We compared cystic duct stenting (CDS) to other modalities mainly percutaneous cholecystostomy (PC), cholecystectomy, and medical management. We performed a retrospective cohort study. After obtaining IRB approval, we gathered records of all patients at our health care system who had acute cholecystitis on presentation and an underlying diagnosis of cirrhosis with MELD-Na ≥ 15 from 2015 to 2022. Outcomes included 30-day mortality, 60-day mortality, 1-year mortality, 30-day readmission, and worsening liver disease as characterized by increasing MELD-Na by ≥ 3 or new onset ascites or encephalopathy following management. 67 patients met our inclusion criteria. 19 patients had CDS and were compared to 48 patients managed by other modalities, i.e., cholecystectomy (n = 12), PC (n = 17) and medical management (n = 19). There was no difference in demographics, etiology of cirrhosis, or mean MELD-Na between the two groups. We noticed a significant difference in the protective effect of CDS on one-month readmission rate and liver function with RR of 0.56 (0.4–0.9, P = 0.038) and RR 0.49 (CI 0.3–0.8, P = 0.01), respectively. The only complication in the cystic duct stent group was one case of pancreatitis (5.2

Background: Endoscopic ultrasound (EUS)-guided lumen-apposing metal stent (LAMS) placement is increasingly being used in lieu of surgery for multiple procedures, including transmural fluid drainage. However, few studies have evaluated adverse events (AEs) associated with LAMS placement. Our aim was to characterize the rates of AEs associated with several LAMS placement strategies across different procedures and indications. Methods: A single-center retrospective cross-sectional study was conducted on patients who underwent EUS-guided LAMS placement between 2015 and 2023 at a single institution. Technical and clinical success rates and rates of early and late AEs were analyzed. Comparisons of AE rates were determined for patients who had LAMS dilation versus those without dilation, patients who had plastic stent placement in addition to LAMS placement versus those with no plastic stents, and patients who had combined dilation and plastic stent procedures versus those with LAMS dilation only. Results: A total of 243 patients underwent EUS-guided LAMS interventions: 110 (45.3%) women and 133 (54.7%) men (mean age 53.7 +/- 15.9 years). There were 96 (39.5%) patients who had at least one AE. Abdominal pain was the most common early and late AE. Plasticstent placement alongside LAMS placement was associated with a significantly higher rate of overall AEs (48.3% vs 29.9%; P = 0.009), late AEs (33% vs 17.9%; P = 0.021), and stent occlusion (5.7% vs 0%; P = 0.046). LAMS dilation was associated with higher rates of late AEs (34.2% vs 20.6%; P = 0.022) and stent occlusion (6.2% vs 1.0%; P = 0.049). Conclusions: LAMS placement showed high technical and clinical success rates across different indications with mostly mild AEs, suggesting that LAMSs may be safe and effective for pancreatic and biliary drainage.

Thymomas are rare, malignant, epithelial tumors of the thymus gland. Extrathoracic metastasis of thymoma is exceedingly rare, particularly when isolated to the liver. We report an 89-year-old man who presented with urinary retention. Exploratory computed tomography imaging revealed a heterogeneous mass in the aortopulmonary window and a 1.9 cm lesion in the left hepatic lobe. Results from magnetic resonance imaging, positron emission tomography-computed tomography, and histopathological analysis of biopsy samples collectively supported a diagnosis of metastatic type B2 thymoma. To the best of our knowledge, this is the oldest patient to be diagnosed with metastatic type B2 thymoma. Metastatic thymoma is difficult to identify, and patients with mediastinal mass identified after any presentation should be evaluated for malignant spread.

Abstract Background and Aims: Treating obstructive bile duct pathologies in individuals with altered bowel anatomy is challenging, since the physiological context may render endoscopic retrograde cholangiopancreatography (ERCP) difficult or unfeasible. Percutaneous transhepatic cholangiography (PTC) with drain placement can provide adequate drainage in this patient group, but it has limited therapeutic options. Methods: In this case series, we present 14 patients with altered bowel anatomy who underwent PTC drain placement followed by percutaneous cholangioscopy (PC) between January 2015 and May 2022 at a single institution. Results: Of the 14 patients, most common indication for PTC was choledocholithiasis in 13 (92.9%) patients and 8 (57.1%) of these patients exhibited cholangitis on initial presentation. The mean age was 66.4 years, and most were female (64.3%). All patients had altered anatomy, with Roux-en-Y gastric bypass being the most common (71.4%). There were 3 patients who had previous unsuccessful attempts at ERCP. Pre-procedural laboratory tests indicated elevated mean liver enzyme levels, and all cases of choledocholithiasis were successfully treated (92.9%). No complications were reported in any patients after a mean follow-up period of more than 2 years. Conclusions Cholangioscopy and lithotripsy via the PTC route may be a viable therapeutic option, with a high success rate and low risks, when ERCP is challenging or impossible due to patient’s altered gut anatomy.

Introduction: Hemorrhagic pancreatic pseudocysts are rare but potentially fatal complication of pancreatitis, often from the development of pseudoaneurysms. We report a case of a large necrotic pancreatic pseudocyst complicated by a pseudoaneurysm bleed, which highlights the importance of thorough evaluation by endoscopic ultrasound (EUS) before therapeutic intervention. Case Description/Methods: Our patient is a 48-year-old woman with a past medical history of recurrent pancreatitis who presents with severe epigastric pain, emesis and 35 pounds of unintentional weight loss. Laboratory studies demonstrated white blood cell count of 13.1 K/uL, AST 33 U/L, ALT 27 U/L, total bilirubin 0.8 mg/dL, alkaline phosphatase 151 IU/L, lipase 395 IU/L. Computed tomography (CT) abdomen showed a large 10x10 cm pancreatic head pseudocyst compressing the superior mesenteric vein, common bile duct (measured 18 mm), and stomach (Figure 1), and a 10x8x6 cm pseudocyst in the pancreatic tail. EUS demonstrated the pancreatic tail pseudocyst that collapsed with fluid aspiration, and a walled-off pancreatic necrosis (WOPN) in the pancreatic head with evidence of extensive intervening vasculature which made lumen-apposing metal stent (LAMS) stent placement impossible. Interventional radiology (IR) was consulted for drainage of the larger cyst, however repeat CT demonstrated interval enlargement with internal hemorrhage. On CT angiography, active intracystic bleeding was noted from a pseudoaneurysm arising from a branch of the inferior pancreaticoduodenal artery, which was successfully embolized by IR. The patient was discharged after remaining hemodynamically stable with no worsening anemia. She was readmitted 2 weeks later with recurrent abdominal pain and emesis. Repeat EUS showed stable 8x8 cm hemorrhagic pancreatic head pseudocyst with a clear window for successful cystgastrostomy AXIOS LAMS placement. Discussion: Pancreatitis can result in pancreatic pseudocysts in ∼1 per 100,000 and are frequently managed endoscopically by either fine needle aspiration or placement of a LAMS in the case of necrotic pseudocyst. In less than 10% of cases, this inflammation can also result in the development of pancreatic pseudoaneurysms, and if bleeding occurs, mortality can reach up to 40%. Thus, this case demonstrates the importance of thorough imaging and endoscopic evaluation of the pancreas and fluid cavity prior to endoscopic therapeutic management to prevent further bleeding complications.Figure 1.: CT abdomen with contrast demonstrating a large 10x10 cm pancreatic head pseudocyst causing compression of surrounding structures.