Introduction

For symptomatic walled off necrosis(WON) drainage, initial assessment of WON is done by percentage of debris and accordingly LAMS, irrigation and necrosectomy(DEN) are performed. This percentage assessment may go wrong once the fluid is drained off. Percentage of debris may not adequately represent the necrosectomy sessions or time. More necrosectomy procedures, require longer endoscopy time, multiple accessories, intravenous sedation and higher costs.

Aims & Methods

This study is aimed at finding the relation between debris amount and necrosectomy sessions.Consecutive symptomatic WON patients who underwent drainage and necrosectomy are enrolled for this study. Collections without definite wall or irregular shaped collections, trans duodenal drainages are excluded. Percentage of debris in WON is assessed. Solid component of collection is measured directly (length, width, sector, segment). Volume of debris is calculated using mathematical calculations for ellipsoid segment calculations. Every patient underwent CT abdomen 24-48hrs after drainage to assess stent position, any complications and amount of resolution of collection. In difficult to define cases by EUS, CT done after WON drainage is used for calculating the amount of debris.

Results

Five patients of symptomatic WON who underwent drainage and necrosectomy are included in this study. Three male and two female. Average debris percent is 28 % highest being 50 %. Necrosectomy is done in all cases following the step up approach. Mean volume of debris is 182.2 cm ³. Mean number of necrosectomy sessions are 2.5. On an average, 50-80cc of debris is removed per hour. More amount of debris requires more number of hours of necrosectomy or more sessions of necrosectomy as depicted in the table 1

Conclusion

In the presence of fluid, debris in WON may be under or overestimated if assessed by percentage. Absolute volume of debris is a better measure to quantify than percentage for deciding and planning on necrosectomy. More volume of debris requires more duration or number of necrosectomy sessions.

References

1. Kumar N, Conwell DL, Thompson CC. Direct Endoscopic Necrosectomy Versus Step-Up Approach for Walled-Off Pancreatic Necrosis: Comparison of Clinical Outcome and Health Care Utilization. Pancreas. 2014 Aug 11
2. Seicean A, Pojoga C, Mostean O, Bolboaca S, Ilie M, Rimbas M, Gheorghiu M, Lucaciu L, Bartos A, Al Hajjar N, Sandru V, Constantinescu G, Seicean R. What is the Impact of the Proportion of Solid Necrotic Content on the Number of Necrosectomies during EUS-Guided Drainage using Lumen-Apposing Metallic Stents of Pancreatic Walled-off Necrosis ?. JGLD [Internet]. 12Dec.2020
3.Rana S, Bhasin D, Kathiresan J et al. Do the morphological features of walled off pancreatic necrosis on endoscopic ultrasound determine the outcome of endoscopic transmural drainage? Endosc Ultrasound 2014; 3: 118
4. Pal P, Lakhtakia S, Jagtap N et al. Interobserver Agreement on “assessment of debris”during endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis. Tech Innov Gastrointest Endosc 2023; 25: 213–220

Introduction

EUS-guided Gallbladder Drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS) is a standard treatment for management of acute cholecystitis (AC) in unfit-for-surgery patients. Gallbladder Perforation is standardly considered as a contraindication to EUS-GBD.

Aims & Methods

This series aims at exploring outcomes of EUS-GBD in patients with AC and contained perforation (cp-AC).
All consecutive patients undergoing EUS-GBD in a single tertiary institution between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055). Patients with cp-AC were included in this series, when presenting gallbladder wall rupture with adjacent encapsulated fluid collections. Baseline demographics and technical details were registered together with Technical success, Clinical success, Adverse Events (AEs), Recurrence and Survival evaluated every 60 days.

Results

From a prospective cohort of 48 EUS-GBD, 19 patients presented with cp-AC (median age 71 [62-78], male 42.1%, Charlson Comorbidity Index of 8 [7-9.8]). Acute cholecystitis was iatrogenic in 79% of these cases (ERCP with metal stenting in 14 and TACE in 1). Reason to avoid surgery was underlying malignancy in 89.5% and comorbidities in 15.8%. Amongst underlying malignancies, the most frequent one was Pancreatic Adenocarcinoma.
Ascites was present in 26.3% of cases. All procedures were performed transduodenally, with an operative luminal space of 31 [25 – 36] mm and a median tract thickness of 6 [5-8] mm.
A 10 mm Hot Axios LAMS was used in 95% of cases, and the release was free-hand in 89% and over-the-wire after former distention in 11% of cases. Antibiotic prophylaxis and coaxial double-pigtail plastic stents were adopted in 95% of cases.
Technical success was 100%. Clinical success was 94.7%, with a statistically significant 7-days reduction of white blood cells (p=0.0017 ) and C Reactive Protein (p=0.0067) .
AEs were registered in 21% of cases, severe/fatal in 11%.
Of note, 2 AEs (1 fatal) were related to additional attempts of draining liver abscesses adjacent to the GBD.
Five patients (27%) underwent additional endoscopic procedures for peroral cholecystoscopy, GBD clearance and LAMS removal, while 2 (11%) patients experienced uneventful LAMS migration.
Median hospital stay was 8 [6-13] days and median time to chemotherapy was 26 [19-56] days for those who were candidate to oncological treatment (N=10).
After a median follow-up of 254 [56-454] days, no AC recurrence was registered.

Conclusion

In the context of AC, contained perforation with adjacent collections does not seem to represent a contraindication to EUS-GBD with LAMS, despite the additional complexity related to a thicker interluminal distance. Management of large adjacent abscesses should involve multidisciplinary management and might require percutaneous drainage.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None

Introduction

EUS-guided gastroenterostomy (EUS-GE) is increasingly used in the management of Gastric Outlet Obstruction. However, significant variability exists in technical choices which might account for heterogeneous clinical outcomes. The aim of this Delphi methodology was to address open questions and establish a consensus on best practices to gather expert opinions on key aspects of EUS-GE.

Aims & Methods

A panel of 25 international leading experts in EUS-GE was invited to revise literature around the technique. A Delphi process was conducted over three rounds, with each round involving anonymous voting on 29 predefined statements, using a 5-point Likert scale (1: strongly disagree – 5: totally agree). Responses were analysed through Medians [Interquartile Ranges], with pre-defined thresholds for approval, revision or discard of the statement. Statements reaching final consensus were graded based on the strength of agreement, defined as the proportion of responses rated 4 or 5.

Results

Response rate was 88% in Round 1 and 100% in Round 2 and 3. Among 29 statements, eight were approved at Round 1, eighteen at Round 2 and four at Round 3, while two were ultimately rejected.
There was early and excellent agreement (>95%) on the need of fluoroscopy for EUS-GE, the need for electrocautery-enhanced Lumen Apposing Metal Stent (LAMS), and the preference for free-hand release. All panellists agreed that endoscopists performing EUS-GE should be familiar with management of Adverse Events (AEs) such as bleedings or perforations. After discussion, excellent agreement was obtained for the management of AEs (misdeployments and bleedings) and LAMS dysfunctions.
Final Strong agreement (>90%) was reached for preferred patient positioning, the required sedation and the preference for saline solution for jejunal distention.
Extensive discussion with final Moderate agreement (>80%) was reached on the use of dye, the preference for catheter-assisted EUS-GE instead of endoscope- or needle-directed instillation, the typical location for EUS-GE and the operative space required for LAMS release.
Statements on the use of contrast and the choice between WEST and EPASS techniques were removed due to lack of agreement.

Conclusion

Despite technical differences (such as the preference of a jejunal catheter or a double-balloon catheter) most EUS-GE experts agree on key technical principles, providing valuable guidance on the standardization of EUS-GE in clinical practice. Conversely, certain topics showed limited agreement, identifying future research priorities in the field of EUS-GE.

Clinical Case Summary

Introduction: Pancreatic involvement in non-Hodgkin lymphomas is rare and often mimics pancreatic adenocarcinoma. We report a case in which endoscopic ultrasound (EUS) was pivotal in establishing the correct diagnosis.
Case Presentation: A 39-year-old male, a chronic smoker, presented with jaundice, anorexia, and fever. Laboratory findings revealed hepatocellular injury and cholestasis (total bilirubin: 15 mg/dL; GGT: 868 U/L; ALP: 679 U/L). CT imaging (Figure 1) demonstrated a large retroperitoneal mass infiltrating both the pancreas and adjacent vascular structures, associated with ascites and omental thickening. EUS (Figure 2) revealed a hypoechoic, poorly defined mass in the head and body of the pancreas (65×55 mm), with evidence of vascular invasion. A fine-needle biopsy (22G) was performed. Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed malignant duodenal stenosis. Histopathology was consistent with diffuse large B-cell lymphoma (DLBCL). The patient was initiated on R-CHOP chemotherapy (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone) after baseline staging. Eight months later, follow-up EUS (Figure 3) showed no residual pancreatic mass.
Discussion: In atypical pancreatic masses—especially in younger patients with systemic symptoms—EUS is essential for tissue acquisition and accurate differential diagnosis. Unlike adenocarcinoma, pancreatic lymphomas respond well to chemotherapy.
Conclusion: Early use of EUS in atypical pancreatic masses can prevent misdiagnosis, reduce time to treatment, and avoid unnecessary surgical interventions.

References

Figure 1 - retroperitoneal mass infiltrating pancreas and vascular structures
Figure 2 - hypoechoic, poorly defined mass in the head and body of the pancreas
Figure 3 - no residual pancreatic mass

Clinical Case Summary

Endoscopic ultrasound (EUS) is an essential tool in the diagnosis, staging, and treatment of various pathologies, playing an increasingly significant role in clinical practice.

We present the case of a 35-year-old patient with a history of hypertriglyceridemia and post-measles pneumopathy at 6 months of age. He was referred to the endocrinology clinic for hypoglycemia detected on routine blood tests. Upon exploration, the patient reported sudden episodes of hunger, sweating, and malaise, relieved by food intake for two years. A prolonged fasting test revealed glucose of 26mg/dL, insulin of 14.8 uUI/mL, and C-peptide of 2.4ng/mL. Initially, an abdominopelvic computed tomography (CT) scan showed an homogeneous pancreas without lesions. Due to persistent suspicion of insulinoma, magnetic resonance cholangiopancreatography was requested but without abnormalities. A chest CT scan also revealed no findings. Finally, the patient underwent EUS, revealing a hypoechoic nodule in the cephalopancreatic region of 10x8mm. Fine-needle aspiration biopsy confirmed a neuroendocrine tumor. After three years since the onset of symptoms, the patient underwent a cephalic duodenopancreatectomy, with histology confirmation of a well-differentiated G1 pT1 pN0 neuroendocrine tumor. One month later, the patient experienced intractable vomiting, fever, and elevated inflammatory markers. Imaging revealed a peri-pancreatic collection, leading to therapeutic EUS. An 85x60mm heterogeneous collection was observed and drained using a pigtail stent, allowing purulent content to flow into the gastric lumen. The patient showed substantial improvement after drainage and antibiotic. One month of follow-up showed no further complications.

Clinical suspicion of insulinoma can be confirmed by standard endocrinological tests, yet its identification remains challenging. This case illustrates how EUS not only enhanced diagnostic sensitivity but also played a key role in managing subsequent complications.

Clinical Case Summary

Drug-induced liver injury is an adverse effect of many pharmaceutical agents. Alverine citrate, an antispasmodic agent found in the fixed-dose combination Meteospasmyl (alverine citrate and simethicone), is widely used in functional gastrointestinal disorders. To date, only three cases are published in the literature. We report a case, with strong evidence, including a rechallenge confirming the causality.
Patient Observation: A 43-year-old woman presented with biliary-type abdominal pain. Her medical history was limited to hypertension treated with bisoprolol with no alcohol use or recent medication. Abdominal ultrasound revealed uncomplicated cholelithiasis; liver tests were normal. Alverine citrate was prescribed for symptomatic relief. Within two weeks, she developed jaundice and fatigue with a normal clinical examination. Blood tests showed severe hepatocellular injury: ALT and AST were 22× and 39× ULN, bilirubin was 274 µmol/L, and GGT/ALP were mildly elevated. Viral and autoimmune panels were negative. Imaging excluded biliary obstruction. Liver biopsy revealed portal inflammation with eosinophilic infiltrates, suggestive of immunoallergic hepatitis. The discontinuation of the drug led to normalization of liver enzymes. 3 years later, the patient was inadvertently re-exposed to alverine citrate, triggering a reproducible episode of acute hepatitis, thereby confirming causality. Diagnostic probability was assessed with the RUCAM score (12, "highly probable") and Naranjo scale (8, "probable"). Only three prior cases of alverine citrate-induced hepatitis, none of which reported a confirmed rechallenge. Although liver biopsy is not routinely required in DILI, it was essential here for diagnostic clarification.
Alverine citrate should be recognized as a rare cause of acute hepatitis. This case confirms its hepatotoxic potential and underscores the importance of early recognition and drug withdrawal to prevent recurrence.

References

1. RUCAM Scale: https://clincasequest.hospital/rucam-scale/
2. Naranjo Scale: https://proeurodilinet.eu/wp-content/uploads/2019/03/Causality-assessment-training-course-15-MARCH-.pdf
3. Couzigou P et al. Hepatitis and Alverine Citrate. J Hepatol. 1997. https://www.sciencedirect.com/science/article/abs/pii/S0168827897801870
4. Turkish case report. Turk J Gastroenterol. 2004. https://pubmed.ncbi.nlm.nih.gov/15259090/
5. Korean case report. Korean J Hepatol. 2010. https://pubmed.ncbi.nlm.nih.gov/20375645/
6. Simethicone safety review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033443/
7. Zhang X et al. Histopathologic Manifestations of Drug-induced Hepatotoxicity. Clin Liver Dis. 2013.