Introduction

With accumulating evidence on endoscopic ultrasonography-guided hepaticogastrostomy (EUS‑HGS) as a salvage treatment for malignant biliary obstruction (MBO), EUS-HGS has now recognized as one of the primary options even in patients with possible ERCP. However, recurrent biliary obstruction (RBO) occasionally occurs after EUS-HGS and it might impose a heavy burden on patients.

Aims & Methods

This study aimed to investigate the safety and effectiveness of reintervention for RBO after EUS-HGS.
Between August 2011 and February 2023, 177 patients with MBO underwent EUS-HGS using self-expandable metal stent (SEMS), and among them a total of 45 patients who required reintervention for RBO after EUS-HGS were enrolled in this study. Technical success (defined as successful reintervention through the HGS stent), clinical success (defined as successful management of cholangitis and/or a 50% decrease or normalization of the bilirubin level within 14 days after any reintervention), adverse events (AEs), time to RBO (TRBO) and overall survival (OS) were investigated. Potential factors associated with technical success were also explored.

Results

MBO was located at distal in 26 (57.8%) and at proximal in 19 (42.2%), with major underlying disease of biliary tract cancer (n = 21, 46.7%) and pancreatic cancer (n = 18, 40.0%). Five patients with proximal MBO underwent EUS-HGS combined with bridging stenting across the hepatic hilum, while all of the remaining had EUS-HGS alone. Median time to reintervention after EUS-HGS was 80 days (95% CI, 62-131 days) and the major causes of reintervention were hyperplasia at uncover portion of the EUS-HGS stent (n = 24, 53.3%) followed by food impaction or sludge formation (n = 8, 17.8%), stent migration (n = 5, 11.1%) and additional biliary obstruction (n = 4, 8.9%). Technical success was achieved in 39 (88.9%). In 6 cases with technical failure, salvage procedures including ERCP (n = 3), PTBD (n = 2) and additional HGS (n = 1) were performed, which eventually resulted in clinical success in 43 patients (95.5%). Although a mild transit fever was developed in one patient, no severe AEs or procedure-related deaths were observed. Median TRBO and OS after reintervention were 168 days and 161 days, respectively. Notably, patients with distal MBO had a longer TRBO while a shorter OS as compared to those with proximal MBO (median TRBO of 168 days vs. 118 days, p = 0.041 and median OS of 113 days vs. 345 days, p = 0.025). Proximal MBO was associated with technical failure of reintervention in multivariable analysis (odds ratio of 7.26, 95% confidence interval, 0.18-0.98, p = 0.046).

Conclusion

Reintervention for RBO after EUS‑HGS was technically feasible and clinically effective, without any severe AEs, especially in patients with distal MBO.

Introduction

Endoscopic submucosal dissection (ESD) is one of the effective treatments for superficial non-ampullary duodenal epithelial tumors (SNADETs). To avoid postoperative perforation and bleeding, our hospital had introduced D-LECS with ESD for SNADETs. From 2021, D-LECS was divided into D-LECS with FTR, which is a full-thickness resection, and D-LECS with ESD, which is intended for post-ESD reinforcement (1). D-LECS with ESD is considered to be a therapeutic procedure that not only ensures safety but also contributes to the improvement of endoscopic skills.

Aims & Methods

The aim of this study is to evaluate the impact of D-LECS with ESD on the skill development of endoscopists. The subjects were 17 cases in which D-LECS was performed among 79cases diagnosed with SNADA by biopsy at our hospital between January 2000 and October 2023. 5 cases in which D-LECS with ESD was performed. The ESD assessment score was defined using a ladder chart based on muscle layer exposure, perforation, ESD time, and pathological examination results. The scoring for points each item is as follows. (Exposure of muscle layer none: 0, <3mm: 1pt, 3~10mm: 2pt, 10mm<: 3pt, Perforation of the muscle none: 0, <3mm: 1pt, 3~10mm: 5pt, 10mm<: 10pt, ESD time <60min.: 0pt, 60~120min.: 5pt, 120min.<: 10pt, Pathological examination result pR0: 0pt, cR0+pRX: 5pt, pR1:10pt) Images and videos were used in combination to evaluate the muscle layer.

Results

ESD assessment scores of cases undergoing D-LECS with ESD were presented. The state of exposure of the muscle layer had a median of 5 (1-7), a mean of 4.8, and a standard deviation (SD) of 2.3. The state of perforation of the muscle layer had a median of 0 (0-10), a mean of 2.6, and a SD of 4.3. The median ESD time was 170 minutes, the mean was 146 minutes (41-198). The state of pathological examination had a median of 0 (0-10), a mean of 2.0, and a SD of 4.5. The ESD assessment scores are presented as follows: (Exposure of muscle layer, Perforation of muscles layer, ESD, Pathological examination result). The results of each score are as shown on the right, Case1: (7, 0,10, 0), Case2: (5,10, 10, 0), Case3: (5, 0, 10, 0), Case4: (6, 3, 10, 10), Case5: (1, 0, 1, 0). Although the number of cases was small, the time required for ESD was shortened and the degree of perforation tended to improve with experience. 2 examples revealed some important points. Case 1: This case had many blood vessels, and the ST hood was needed because it is difficult to perform ESD. When the endoscope was extended, perforation occurred. Once the perforation was made, it was difficult to move the patient to other bed, so the muscle layer was sutured with OTSC, and a PGA sheet. Case 2: The endoscopic strategy and device were improved, and the lesion could be dissected within 1 hour. ESD was performed with Dual Knife J 1.5. Pulling the lesion with an S-O clip. The RDI function was used during hemostasis to avoid the burn effect on the muscle layer.

Conclusion

D-LECS with ESD will lead to improvements of duodenal ESD techniques. But to ensure safety, laparoscopic closure is preferable until reliable suturing via endoscope becomes possible.

References

(1) Souya Nunobe, Motonari Ri, Naoki Hiki et al: Safety and Feasibility of laparoscopic and endoscopic cooperative surgery for duodenal neoplasm: a retrospective multicenter study. Endoscopy 53: 1065-1068, 2021

Introduction

A biliary stricture is a narrowing of intrahepatic and/or extrahepatic biliary system with upstream dilatation¹; 70-80% of biliary strictures are malignant¹ therefore histological diagnosis is necessary to distinguish benign from malignant causes and guide management. Strictures without confirmed histology are referred to unexplained biliary strictures². ESGE (European Society of Gastrointestinal Endoscopy) guidelines recommend an integrated diagnostic approach that combines multiple techniques to improve diagnostic accuracy. Endoscopic ultrasound(EUS) has demonstrated high sensitivity for evaluating biliary strictures and unexplained common bile duct (CBD) dilatation, due to its ability to provide high-resolution images of CBD walls and surrounding structures, so is the preferred diagnostic modality for both imaging and tissue acquisition(TA), even in absence of abnormal laboratory test.¹ The introduction of ancillary techniques, as DFI (Detective Flow Imaging), which enables the detection of low-velocity blood flow without the use of contrast media, represents a potential useful addition in the diagnostic algorythm³.

Aims & Methods

The aim of this single-centre retrospective study is to validate the role of EUS-DFI in characterizing unexplained biliary strictures and CBD dilatation. We included consecutive patients (pts) with unexplained biliary strictures/CBD dilatation who underwent biliopancreatic EUS between January 2024 and April 2025 at the Digestive Diseases Unit of Sant’Andrea University Hospital, Rome. During EUS, biliary stricture (lesions or thickening of CBD wall) were described as hypoechoic or isoechoic. DFI was performed to evaluate strictures: if microvascularization was observed, vascular pattern was classified as regular or irregular⁴. Results were compared with the final diagnosis, defined by histopathology and/or ≥6 months clinical follow-up as gold standard. TA was performed with EUS-FNB (fine needle biopsy) and/or ERCP(Endoscopic Retrograde Cholangiopancreatography) intraductal biopsies/brushing.

Results

Of 13 patients included, 8(61.5%) were male, median age 72 (range 56-86). All underwent Magnetic Resonance Imaging/Contrast-Enhanced Computed Tomography as first line imaging: 3(23%) had a perihilar stricture, 9(69%) a medio-distal, 1(8%) had “in toto” CBD thickening. Among the 13 strictures, EUS identified 10(76.9%) lesions, with a mean diameter of 17 mm (median 16 mm; range, 5–35 mm), and 3(23.1%) CBD wall thickening. Twelve (92%) strictures were hypoechoic, 1(8%) was isoechoic. EUS-TA was performed in all pts, revealing 7(54%) cases of malignancies, of whome 5 cholangiocarcinoma and 2 pancreatic ductal adenocarcinoma (PDAC), 3(23%) high-grade dysplasia, and 3(23%) fibroinflammatory disease on histopatological evaluation. All pts underwent DFI-EUS. Microvascularization was detected in 12 cases (92%), with an irregular pattern observed in 9 pts. Among these, 5 (55.6%) were diagnosed with cholangiocarcinoma, 1(11.1%) with PDAC infiltrating CBD, and 3(33.3%) with high-grade dysplasia. The 3 benign strictures demonstrated a homogeneous pattern. One case (8%), corresponding to a PDAC, appeared hypovascular on DFI.

Conclusion

In a small cohort of patients with unexplained or indeterminate biliary strictures, the novel DFI-EUS technique proved to be feasible for assessing microvascularization in CBD stenosis and revealed characteristic irregular patterns or hypovascularization in malignant lesions. Further prospective studies with a larger patient population are needed to confirm these preliminary findings.

References

1. Facciorusso, A. et al. Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 57, 166–185 (2025).
2. Zhang, W., Chai, N., Wu, Q. & Linghu, E. The new criteria for differential diagnosis of indeterminate biliary stricture under super minimally invasive peroral cholangioscopy. Chin Med J (Engl) 137, 255–256 (2024).
3. Yamashita, Y. et al. A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study. Diagnostics 11, 2018 (2021).
4. Yamashita, Y. et al. Novel Technique of Endoscopic Ultrasonography for the Differential Diagnosis of Gallbladder Lesions and Intraductal Papillary Mucinous Neoplasms: A Single-Center Prospective Study. Diagnostics 13, 2132 (2023).

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the best choice to treat choledocholithiasis and obstructive jaundice in pancreatic or biliary neoplasms. Endoscopic ultrasound (EUS) has shown the best diagnostic accuracy for detecting common bile duct (CBD) stones, also showing an essential role for correctly staging pancreatic and biliary neoplasms. EUS and ERCP have been considered historically as two separate procedures; however, during the last decade, a same-session execution has gained popularity. Towards this process, bilio-pancreatic endoscopy was born.

Aims & Methods

We aimed to evaluate the efficacy and safety of same-session EUS-ERCP (SSEE) in treating choledocolithiasis and distal malignant biliary strictures compared to two-session procedures (TSEE). We retrospectively studied all consecutive patients enrolled in a 2-year period (January 2021 and December 2023) undergoing EUS and ERCP to treat choledocolithiasis or obstructive jaundice for malignant distal CBD strictures at an Italian tertiary referral Centre. Patients were divided into two groups: “same session EUS and ERCP group” (SSEE) and “two sessions EUS and ERCP group” (TSEE). Procedural ERCP success, the onset of major adverse events (moderate-to-severe-post-ERCP acute pancreatitis [ASGE guidelines], moderate-to-severe early and/or delayed bleeding [ASGE guidelines], duodenal and/or biliary perforation [Stapfer classification]), and all variables conventionally associated with the procedure were compared between the two groups of therapeutic strategy.

Results

At the end of the study, 200 patients were included (M/F 103/97; mean age: 71 years). The main features of the patients are reported in Table 1. Hundred (50%) patients were treated by the SSEE approach, while the remaining 100 (50%) by the TSEE modality. No statistically significant difference between the two groups was recorded in terms of ERCP overall success (95% vs 99%; p=n.s.). When considering major adverse events, no significant difference was seen between the two groups (0% vs 1%; p=n.s.). Regarding procedural features, the total procedure time (EUS + ERCP) did not significantly differ between the two groups (71.40 min vs 75.05 min; p=n.s.). We did not record major complications (acute pancreatitis, acute cholangitis, acute cholecystitis) during the waiting time between EUS and ERCP (average of 4.03 days) in the TSEE group. By contrast, a mean 3-day gain in terms of hospitalization length was observed in the SSEE group.

Conclusion

Our single-centre experience shows that both SSEE and TSEE approaches are safe and effective in patients undergoing EUS plus ERCP. Delaying the execution of ERCP from EUS, with reduced and appropriate inter-procedural waiting times, proves to be safe and effective, especially in cases involving specific patient conditions (altered anatomy, need for anaesthesiologic assistance, major comorbidities etc.) or the pathology to be treated. Finally, the SSEE approach seems to be more cost-effective with a gain of 3-mean-day in terms of hospitalization length.