Introduction

Difficult benign biliary and pancreatic strictures are generally managed by Soehendra screw or cystotome. Many studies described the techniques without information even of mid -term follow-up.

Aims & Methods

The main aim of the study is to verify the long-term patency of the dilated strictures after the use of cystotome. Data were retrospectively collected from October 2018 to September 2021 and all consecutive patients affected by difficult biliary or pancreatic strictures treated using cystotome were included. Technical success was considered the ability to overpass the stricture. Clinical success was defined as drainage of biliary or pancreatic strictures and symptoms resolution. Patients were evaluated at median follow-up of 28 months since the index procedure.

Results

Of the 13 patients included in the study (5 males, 8 females; mean age: 53 years old), 8 had biliary and 5 pancreatic strictures. Technical success was obtained in 12 patients. Only minor adverse events were reported in three patients. At follow-up, 7 patients presented stable resolution of the stricture, 4 recurrence of stricture and 2 showed persistence of the stricture.

Conclusion

The use of a cystotome can be considered an alternative method for dilation of difficult pancreatic and biliary strictures, after the failure of conventional modalities. According to follow-up, this alternative approach allows 54% of long-term stricture resolution.

Introduction

Endoscopic stenting is considered the mainstay of biliary treatment for benign biliary strictures [1]; temporary insertion of multiple plastic stents or of a fully covered self-expandable metal stent (FC-SEMS) are the preferred methods due to their favorable results [2]. However, there is a not-negligible rate of stricture recurrence and spontaneous stent migration, the latter being a leading cause of treatment failure [3]. Lumen-apposing metal stents (LAMS), developed for transluminal drainages, have a unique design with short length, large diameter and wide flanges which make them less prone to migration [4]. LAMS have recently been proposed as a novel modality for treating short benign gastrointestinal strictures [5].

Aims & Methods

Aim of our study was to describe the intraluminal use of LAMS to treat short benign biliary strictures. This was a retrospective, single-arm, single Centre study. All consecutive patients who underwent retrograde LAMS placement for benign biliary strictures, from October 2016 to July 2022, were included. Clinical data, including stricture etiology, previous upper-GI or hepatobiliary surgery, previous treatments for biliary stricture and type of LAMS used were collected from medical records. Primary outcomes were technical success and stricture resolution; secondary outcomes were stricture recurrence, number of endoscopic retrograde cholangiopancreatography (ERCP), stent migration.

Results

During the study period, seventy patients (35 male, mean age 67, range 27-90 years) underwent retrograde LAMS placement for benign biliary strictures; distal biliary stricture was the most common etiology (n=36), followed by anastomotic stricture (n=31) and proximal non-anastomotic stricture (n=3). LAMS placement was a second-line therapy, after failure of other methods, in 38 patients (54.2%). A 16-mm LAMS was used in 44 patients and a 12-mm LAMS in 26 (NAGI stent, Taewoong Medical, South Korea). Technical and clinical success were obtained in 100% and 83% of patients, respectively. Stent migration occurred in 9 (12,8%) of cases, 3 of which determined treatment failure. Stricture recurred in 9 patients within a mean of 16 months onset (range 3-30 months). We found a statistically significant higher success if the treatment was performed as a second line therapy than as a first attempt, with success rate of 91.1% and 79.3%, respectively (p=0.04). No statistically significant differences were seen between 16-mm LAMS and 12-mm LAMS placement (87% vs 76%, p=0.23).

Conclusion

LAMS placement could be a safe and effective alternative for short, benign biliary strictures, especially as a second line therapy in patients who experienced a previous endoscopic treatment failure.

References

1. Nakai Y, et al. International consensus statements for endoscopic management of distal biliary stricture. J Gastroenterol Hepatol. 2020 Jun;35(6):967-979. doi: 10.1111/jgh.14955. PMID: 31802537.
2. Dumonceau JM, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy. 2018 Sep;50(9):910-930. doi: 10.1055/a-0659-9864. PMID: 30086596.
3. Park JS, et al. Long-term outcomes of covered self-expandable metal stents for treating benign biliary strictures. Endoscopy. 2016 May;48(5):440-7. doi: 10.1055/s-0042-101406. PMID: 26919262.
4. Sharma P, et al. Alternative uses of lumen apposing metal stents. World J Gastroenterol. 2020 Jun 7;26(21):2715-2728. doi: 10.3748/wjg.v26.i21.2715. PMID: 32550749.
5. Larson B, Adler DG. Lumen-apposing metal stents for gastrointestinal luminal strictures: current use and future directions. Ann Gastroenterol. 2019 Mar-Apr;32(2):141-146. doi: 10.20524/aog.2018.0337. PMID: 30837786;

Introduction

Transection of common bile duct represents a rare but serious complication during hepatobiliary surgery. ERCP could play a pivotal role in treating this kind of complications, allowing the restoration of common bile duct integrity.

Aims & Methods

Aim of the study is to evaluate technical and clinical success of totally retrograde endoscopic access to re-establish the continuity of biliary tract after accidental surgical complete transection of common bile duct. In our retrospective study, since January 2018 to January 2022, 14 consecutive patients (6 M, 8 F, mean age: 58 y.o.) underwent ERCP after surgical complete transection of the common bile duct. Technical success was considered as re-establishment of biliary continuity. Our technique consists in puncturing the proximal biliary disconnected stump using a hydrophilic guidewire backward from the distal biliary stump and subsequent placing of one or two fully-covered self-expandable metal stents (fc SEMS) across the level of transection. Abdominal surgical drainage was always retrieved to allow the correct biliary-duodenal pressure gradient. Clinical success was considered as resolution of associated bile leak and/or removal of percutaneous/surgical drainage and/or no need for further redo surgical treatment during three-months follow-up.

Results

Of our case series, ten patients underwent cholecystectomy and four patients major hepatectomy. Only two patients had previously placed a percutaneous transhepatic biliary drainage and it was used to inject contrast medium to visualize the edge of the proximal biliary stump. The access to the proximal disconnected biliary stump was performed in two possible ways: 1. totally blind (without injection of contrast medium into the proximal biliary stump) in seven cases; 2. EUS-transgastric approach additionally performed to evidence the disconnected proximal biliary tract in seven cases. One 10mm 6 cm fc-SEMS was inserted in six patients, two 8mm 6 cm fc-SEMS were placed in seven patients and three 8mm 6cm fc-SEMS were used in one case. Technical success was obtained in all the patients (considering these two different approaches). During the follow-up, clinical success (as above described) was obtained in all the patients. In 13 patients, fc-SEMSs were successfully removed; one patient died because of complications related to ischemic stroke with the stents in place. No intraprocedural adverse events were reported in our case series (ten cases of extraluminal flow of contrast did not require any further procedure).

Conclusion

This method confirms the important role of ERCP in the treatment of post-surgical biliary adverse events, also in case of complete loss of biliary continuity. Our method required experienced endoscopists skilled in both interventional EUS and ERCP. It permits to solve this challenging surgical adverse event also in patients temporarily unfit for redo surgery.

Introduction

Acute cholecystitis in high-risk surgical candidates remains a clinical challenge. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with lumen-apposing metal stent (LAMS) has emerged as a minimally invasive alternative. Initially reserved for extremely frail patients, EUS-GBD has seen broader application over the past decade. However, the criteria for defining patients as "frail" or "unfit for surgery" remain debated and lack standardization. Furthermore, long-term data remain limited.

Aims & Methods

A retrospective, single-center study was conducted, including all consecutive patients who underwent EUS-GBD between January 2014 and December 2024, with the aim of evaluating changes over time in patient selection, procedural technique, and clinical outcomes. Patients were stratified into two cohorts based on the date of the procedure: Group A (procedures performed up to December 31, 2020) and Group B (procedures performed from January 1, 2021, onward). A comparative analysis was conducted between the groups.

Results

A total of 50 patients were included, of whom 25 (50%) were female, with a mean age of 79.6 (± 12.8) years. The median age-adjusted Charlson Comorbidity Index (a-CCI) was significantly lower in Group B compared to Group A (8.0 vs 9.5, p = 0.047). The prevalence of biliopancreatic malignancies decreased from 45.8% in Group A to 23.1% in Group B (p = ns). The use of electrocautery-tip LAMS (Hot AXIOS™, Boston Scientific) increased significantly over time (62.5% vs 100%, p = 0.001). Thirty-day survival improved from 83.3% in Group A to 100% in Group B (p = 0.046). Although not statistically significant, 12-month survival showed a trend toward improvement (33.3% vs 56.2%), as did 36-month survival (25.0% vs 60.0%), though the latter was limited by shorter follow-up in the more recent cohort. Technical and clinical success rates remained high across both groups. The overall rate of biliary adverse events (including recurrence and other complications) was 24%, with both early and delayed events remaining infrequent.

Conclusion

Our data show that over the past decade, EUS-GBD has evolved from an approach reserved for highly comorbid patients to a more broadly applied therapeutic option, coinciding with reduced baseline comorbidity and oncologic burden among treated patients. This shift was paralleled by increased procedural standardization—most notably, the universal adoption of electrocautery-tip LAMS—and was associated with improved early survival outcomes. Although longer-term survival also trended favorably, further prospective data are needed. The incidence of complications and reinterventions remained infrequent, supporting the safety and durability of the procedure.

References

Rimbaş M, Crinò SF, Rizzatti G, La Greca A, Sganga G, Larghi A. EUS-guided gallbladder drainage: Where will we go next? Gastrointest Endosc. 2021 Aug;94(2):419-422. doi: 10.1016/j.gie.2021.03.933. Epub 2021 Apr 9. PMID: 33845110.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the choice of the optimal technique remains debatable in clinical practice.

Aims & Methods

Aim of the study is to evaluate technical and clinical success of ERCP performed for biliopancreatic adverse events after pancreaticoduodenectomy (PD) using a wide caliber operative working channel (3.8 mm) pediatric colonoscope. It is a retrospective study conducted in a tertiary referral center. Patients who underwent ERCP between 01/02/2012 and 15/11/2022 for biliopancreatic complications after PD were included. Technical success was considered as effective endoscopic treatment of the specific complication including cannulation of pancreatico-jejunal or hepatico-jejunal anastomosis. Clinical success was considered as no need for rescue treatment (surgery or interventional radiology).

Results

During the period study, 129 patients (76 males, mean age 66 y.o., range 23-87 y.o.) underwent a total of 315 ERCP for endoscopic treatment of biliopancreatic complications after PD. The most frequent indications were biliary complications (78 patients, 60.4%, included 44 patients with anastomosis stricture, 27 patients with dehiscence and 7 patients with biliary stones), pancreatic complications (39 patients, 30.2%, included 10 patients with anastomosis strictures and 29 dehiscence) and other complications in the remaining 12 patients (6 patients with recurrence of neoplasia, 6 patients with bowel strictures). Timing between diagnosis of complication and ERCP was significantly shorter in septic patients than in the elective ones (p < 0.0001). In 78 patients (60.4%) ERCP has been performed with pediatric colonoscope; each patients underwent a mean of 2.6 ERCP (median 2 procedures). Concerning this group, anastomosis cannulation has been achieved directly in 69 patients and thanks to EUS-guided entero-enteral bypass approach in 9 patients and the procedure was performed with retrograde approach. Technical success, described as cannulation was obtained in 100% of cases. In 65/78 cases (83.3%) clinical success was obtained retrograde and in 13/78 cases (16.6%) technical success was obtained with anterograde EUS-guided approach: hepaticogastrotomy (6 cases), pancreaticogastrostomy (4 cases) and EUS-guided endoscopic drainage placement (3 cases).
Clinical success was 93,8% (121 patients). 8 patients experienced adverse events: 4 patients had recurrence of acute cholangitis and 4 patients needed rescue treatment (PTBD or surgical).

Conclusion

Endoscopic treatment for adverse events after PD achieved high technical and clinical success rates in tertiary referral centers with specific know-how in ERCP in surgically altered anatomy.

Clinical Case Summary

The syndrome of buried lumen-apposing metal stents (LAMS) occurs in 4.7% of cases and is caused by a foreign body reaction characterised by tissue overgrowth embedded in the stent. This complication often requires surgery or "stent-in-stent" endoscopic procedures (1). Stent in a stent safely and effectively recanalises LAMS placed as esophagogastric anastomosis (2), gallbladder drainage (3), and endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) (4). We report the first EUS-directed transenteric ERCP (EDEE) case using this approach. In 2023 a patient with Roux-en-Y hepaticojejunostomy (HJ) substenosis and recurrent cholangitis was admitted to our institution. The first attempt to perform an EUS-guided gastrojejunostomy (GJ) as part of EDEE failed; EUS -Hepaticogastrostomy (HGS) was conducted. One month later, a Hot-Axios LAMS (15mm x 15mm) EUS-GJ was placed, and prior 15 mm balloon dilatation, the second part of the EDEE operation was conducted, accessing the surgical HJ with a paediatric colonoscope and placing a Nagi stent (16mm x 20mm) towards the substenosis. The LAMS completely buried itself during the 6-month Nagi removal follow-up, making it impossible to determine its gastric mucosal location. We placed a fully covered self-expandable metal stent (10mm x 8cm) on the HGS for antegrade Nagi stent extraction. Recurrent HJ substenosis and bile duct stones induced cholangitis in 2024. EUS-guided identification and cannulation of the buried LAMS involved passing a 19-G fine needle biopsy needle through the LAMS, advancing a Jagwire deep into the jejunum, and bridging it with a second Hot-Axios LAMS (15mm x 15mm) using a non-cautery enhanced (cold LAMS-in-LAMS) technique.A frontal scope was used to remove bile duct stones before the latest 15 mm balloon was expanded, and a third 15 mm x 10 mm LAMS was placed across the substenotic HJ. EUS-guided management of buried LAMS was safe and effective, with normal liver function tests and clinical outcomes.

References

1) Nayar, M., Leeds, J. S., UK & Ireland LAMS Colloborative, & Oppong, K. (2022). Lumen-apposing metal stents for drainage of pancreatic fluid collections: does timing of removal matter?. Gut, 71(5), 850–853. https://doi.org/10.1136/gutjnl-2021-325812
2) Bazaga Pérez de Rozas, S., Chahal, P., Sánchez-Ocaña, R., García-Alonso, F. J., Carbajo, A. Y., de la Serna-Higuera, C., & Manuel, P. M. (2019). Buried lumen-apposing metal stent (LAMS) in esophagogastric anastomosis: the LAMS-in-LAMS rescue treatment. Endoscopy, 51(6), 600–601. https://doi.org/10.1055/a-0861-99074)
3) Ligresti, D., Cipolletta, F., Amata, M., Cimavilla, M., Traina, M., & Tarantino, I. (2018). Buried lumen-apposing metal stent (LAMS) following endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS rescue treatment. Endoscopy, 50(8), 822–823. https://doi.org/10.1055/a-0624-2050
4) Honan, B. M., Mulki, R., & Sánchez-Luna, S. A. (2024). Bridging the Buried GATE: LAMS-in-LAMS Rescue Technique for Endoscopic Ultrasound-Directed Transgastric ERCP. ACG case reports journal, 11(9), e01497. https://doi.org/10.14309/crj.0000000000001497