Introduction

EUS-guided biliary rendezvous (RV) is an EUS-assisted technique described as a rescue method in cases of failed biliary cannulation via endoscopic retrograde cholangiography (ERC). Current literature remains unclear regarding its current role.

Aims & Methods

Aim: to evaluate the efficacy and safety of biliary EUS-RV (benign vs malignant) and compare outcomes with EUS-guided transmural drainage (TMD) in malignant biliary obstruction.
Methods: Retrospective observational study with prospective consecutive inclusion in a specific database from a tertiary-center. All patients that underwent a EUS-assisted ERC between October-2010 and November-2022 for failed ERC were included. A comparison analysis between benign vs. malignant disorders was performed. The outcomes of the EUS-RV malignant group were compared with an EUS-TMD group. Main outcomes were technical/overall success and adverse events (AEs).

Results

A total of 69 patients who underwent EUS-RV procedures, with benign and malignant pathologies (n=40 vs n=29), were included. Technical/overall success and related-AEs were 79.7% (95%CI, 68.3-88.4)/74% (95%CI, 61-83.7) and 24% (95%CI, 15.1-36.5), respectively. Failed cases were mainly related with guidewire manipulation. Seven failed RV were successfully rescued by EUS-TMD. On multivariable analysis, EUS-RV and malignant pathology was associated with a greater failure rate (technical success: OR,0.21; 95%CI,0.05-0.72; p=0.017), and higher AEs rate (OR,3.46; 95%CI,1.13-11.5; p=0.034). Also, the EUS-TMD group had greater technical success (OR,16.96; 95%CI,4.69-81.62; p<0.001) and overall success (OR, 3.09; 95%CI,1.18-8-16; p<0.026) with a lower AEs rate (OR,0.30; 95%CI,0.11-0.78; p=0.014) than EUS-RV in malignant disorders.

Table 1:Comparison of clinical outcomes between groups.

Conclusion

EUS-RV is a demanding technique with better outcomes in benign than in malignant disorders. Comparison of the EUS-TMD group on malignant disorders showed worse outcomes with EUS-RV. Therefore, EUS-RV might be reserved basically for benign cases.

References

1. van der Merwe SW, van Wanrooij RLJ, Bronswijk M et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022; 54: 185-205.
2. Klair JS, Zafar Y, Ashat M et al. Effectiveness and safety of EUS rendezvous after failed biliary cannulation with ERCP: A systematic review and proportion meta-analysis. J Clin Gastroenterol. 2023; 57: 211-217.

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with transmural stenting has increased for biliary decompression in patients with an inaccessible papilla or when endoscopic retrograde cholangiopancreatography fails or is impossible. Substantial technical and procedural progress in performing EUS-HGS has been achieved.

Aims & Methods

The present study wanted to analyze whether growing experience in current practice has changed patient outcomes over time.
We retrospectively analyzed data from patients with malignant biliary obstruction treated by EUS-HGS between 2023 and 2025 at a tertiary center.

Results

A total of 53 patients were included (34 male; mean age 68,2 years). Clinical success was achieved in 91% of patients with available 30-days follow-up (49), and the rate of procedure-related morbidity and mortality after one month was 20% and 7%, respectively. The cumulative sum (CUSUM) learning curve suggests a slight improvement in the rate of early complications during the second learning phase (23% vs 32%; P = 0.14; including death for any cause and intensive care). Procedure time and adverse events were shorter after 24 cases, and stabilized at 30 cases of EUS-HGS, respectively. Recurrent biliary stent occlusion is the main cause for endoscopic reintervention (7/53; 13,2%).

Conclusion

The rate of procedure-related complications after EUS-HGS has improved over time. However, the overall morbidity rate remains high, emphasizing the importance of dedicated expertise, appropriate patient selection and multidisciplinary discussion. In our learning curve analysis, over 30 cases might be required to achieve the plateau phase for successful EUS-HGS.

Introduction

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is becoming an important and effective alternative to percutaneous drainage (PTD) for patients not suitable for surgery. It is also an acceptable option for biliary drainage in oncologic patient, if retrograde drainage failed. Placing of a lumen apposing metal stent (LAMS) for EUS-GBD allows the removal of gallbladder stones too, so becoming a possible alternative to surgery in very selected cases.

Aims & Methods

The study aims to describe our endoscopic experience and management in patients unfit for surgery and in those oncologically advanced. Retrospectively analyzed cases with EUS-GBD, from December 2019 to September 2023, in a single peripheral hospital (Hopital Riviera-Chablais), using 3 types of LAMS (10x10mm, 15x10mm, 16x20mm), delivered with an electrocautery-enhanced catheter.

Results

EUS-GBD was performed in 23 patients (15:8=M:F) with median age of 83 years old (52-89). 13 patients (56.2%) had advanced cancer (6 pancreatic metastatic cancer, 5 cholangiocarcinoma, 1 breast metastatic cancer, 1 metastatic pulmonary NET) and 10 patients were affected by symptomatic lithiasic cholecystitis and they were not considered fit for surgery (whose 2 already received a PTD). EUS-GBD was attempted through the duodenum in all cases but one, previously treated with PTD and that was drained through the stomach. In one case, the stent was mis-deployed through the duodenum (without entering the gallbladder lumen), so requiring the placement of an over-the-scope-clip and a different biliary drainage for biliary obstruction in an oncological patient. A 15x10 mm LAMS was used in 14 cases, 10x10 mm LAMS was used in 6 cases (including the failed one), and 16x20 mm in 2 cases. A double pigtail 5 Fr 7cm was placed through all 22 successfully placed LAMS. 3 patients underwent electrohydraulic-lithotripsy (EHL) through the LAMS after 4-8 weeks. In 5 patients LAMS was then removed. Generally, except one complication, it was not described short term or long-term adverse events. 6/23 (26%) patients died for oncological disease progression and for other causes not procedure related.

Conclusion

EUS-GBD represents a promising therapeutic approach in patients with high risk of mortality. Considering the high rate of clinical and technical success as well as the possibility of managing endoscopically potential complications, this approach could be also proposed in peripheral centers and not only in advanced endoscopic ones.

References

1. Anthony Yuen Bun Teoh et al. EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data,
Gastrointestinal Endoscopy, Volume 93, Issue 3, 2021.
2. van der Merwe SW et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185-205.
3. McDonagh, P et al.Endoscopic Ultrasound-Guided Gallbladder Drainage for Malignant Biliary Obstruction: A Systematic Review. Cancers 2023, 15, 2988.

Introduction

Endoscopic biliary drainage for malignant obstruction can be technically challenging, particularly in patients with high-grade hilar strictures or progressive distal lesions that extend beyond the reach of ERCP alone. While ERCP remains the first-line approach, it may prove inadequate in complex scenarios. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative or complementary technique. However, data on outcomes that combine ERCP and EUS-BD in routine clinical practice remain insufficient and limited.

Aims & Methods

This study aims to evaluate the clinical success, stent patency, and complication rates of combined ERCP and EUS-BD in patients with malignant biliary obstruction while identifying factors associated with complications. We included 40 patients who underwent combined ERCP and EUS-BD for malignant biliary obstruction at a tertiary center from March 2020 to March 2025. The patients were divided into two groups: one-session procedures, in which both techniques were performed during the same session (n=14), and staged procedures, where EUS-BD was followed by at least one prior ERCP (n=26). Clinical success was defined as resolving jaundice and/or cholangitis without additional drainage. The outcomes assessed included clinical success, stent patency, complications, and reintervention. Univariate analysis was employed to identify predictors of complications.

Results

The cohort included 21 (52.5 %) males and 19 (47.5%) females, with a median age of 65.6 years. The distribution of strictures was as follows: 23 (57.5%) high-grade hilar (Bismuth III/IV), 7 (17.5%) Bismuth I/II, and 10 (25%) distal. Underlying malignancies included 12 (30%) hilar cholangiocarcinoma, 8 (20%) pancreatic adenocarcinoma, and 16 (40 %) liver or hilar metastasis from other tumors.
Clinical success was achieved in 90% of patients (36/40), with no significant difference between one-session and staged groups (85.7% vs. 92.3%, p=0.60). The median procedural time was 39.3 minutes. Overall, 12 patients (30%) experienced complications, including stent-related infections in 10 (25%), post-ERCP pancreatitis in 1(2.5%), and bleeding in 1 (2.5%). Complication rates were similar between the one-session and staged groups (28.6% vs. 31.0%, p=1.00). Reintervention was required in 3 patients (7.5%). A significant association was observed between undergoing more than two prior ERCPs and the risk of complications (66.7% vs. 22.6%, p=0.038). Neither the presence of hilar strictures (p=0.56) nor procedural timing (one-session vs. staged; p=1.00) was significantly associated with increased complications.

Conclusion

Combining ERCP and EUS-guided biliary drainage is a safe and effective strategy for managing malignant biliary obstruction, including complex hilar and progressive distal strictures. Performing both procedures in a single session does not increase complication rates and may provide comparable clinical success. The number of prior ERCPs was the only significant predictor of complications, suggesting a potential benefit from earlier use of EUS-BD in selected patients. Further prospective studies are warranted to confirm these findings and guide treatment algorithms for complex biliary obstruction.

Introduction

Biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) implies a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). When standard techniques, (sphincterotome, and guidewire) fail, the endoscopist may proceed with advanced cannulation techniques, such as the double
guidewire technique, needle-knife precut papillotomy or fistulotomy, and transpancreatic sphincterotomy. Despite the higher risk of adverse events, these advanced strategies can still fail in
up to 15% of cases. In recent times, endoscopic ultrasound-guided biliary drainage (EUS-BD) emerged as a viable alternative in case of DBC due to its favorable profile in terms of both technical success, and safety.

Aims & Methods

Multi-center (4 centers), international (Italy, France), retrospective, propensity score-matched study including patients with DMBO, and common bile duct (CBD) diameter >12mm. DBC cases managed with either advanced cannulation techniques (aERCP group), or direct EUS- guided approach (performed straight away after failure of standard cannulation; EUS-BD group) were considered for the analysis. A 2:1 propensity score-matched analysis was performed balancing age, sex, and CBD diameter to reduce confounding, and ensure comparability between groups. The outcomes of interest were the rates BD failure, clinical success, and adverse events (AEs).

Results

Standard cannulation techniques failed in 524 cases during the study period. Advanced cannulation techniques, and EUS-guided approach were attempted in 472, and 52 cases, respectively. After matching, 76 (aERCP group), and 38 patients (EUS-BD group) were included in the analysis (age: 77.4+10.5 and 76.7+12.6, male: 70.6% vs 71.1%, CBD diameter: 16.5+2.9 and 17.2+3.3, respectively). In aERCP group, also advanced cannulation techniques failed in 17 22.4%) cases, however all these patients were successfully treated by EUS-guided approach as a rescue strategy. No cases of BD failure were reported in EUS-BD group (p<0.05). Clinical success was comparable between the two groups (aERCP:91.2%, vs EUS-BD:94.7%, p=0.46). The 20.6% of patients experienced AEs in the aERCP group (7 cholangitis, 6 pancreatitis, 2 bleeding, 2 other), compared to the 7.9% reported in EUS-BD group (2 cholangitis, 1 pancreatitis, 1 bleeding; p=0.14).

Conclusion

EUS-guided biliary drainage shows higher technical success rate compared to advanced cannulation techniques, with comparable clinical success. Regarding safety, the observed trend of reduced adverse events (AEs) with the EUS-guided approach may require a larger, adequately powered study to confirm statistical significance. In patients with dilated CBD (>12mm).
EUS-BD may be considered an efficient option in case of DBC, possibly minimizing the risk of adverse events.