Introduction

Endoscopic ultrasound-guided biliary drainage (EUS – BD) has become widely accepted over the past several years for complicated biliary drainage when conventional endoscopic retrograde cholagiopancreatography is not successful or feasible due to variety of constrains. The success rate of the procedure is between 90% an 97% and the complication rate is less than 10%.

Aims & Methods

The aim of the study is to evaluate the safety and efficacy of EUS-BD performed in our unit while assessing the risk factors associated with the procedure.
We performed retrospective analysis of a prospective data base from March 2020 to October 2023. The patients underwent EUS – BD using linear scope (Fujifilm EG – 580UT). Several procedures are possible. The procedure was tailored to individual patient’s anatomy.

Results

We identified 140 patients who underwent EUS-BD during the study period ( men- 75, women- 65) – 130 (92.8%) with malignant and 10 (7.1%) with benign disease. Gender distribution shows higher rate of postprocedural complications in men ( 29,7% vs 21,5%), nevertheless there is no statistically significant correlation between gender and complication rate. The medium age of the patients was 66.3 years (38 years – 92 years). No statistically significant correlation was found between age, presence of arterial hypertension, diabetes mellitus and adverse events.
We analyzed the different therapeutic modalities including EUS - CDS (n = 20), EUS - HGS (n = 88), antegrade stenting (n = 12) and rendezvous (n = 13), hepaticojejunostomy (n = 5), cholecystogastrostomy and -duodenostomy (n = 2). We found no statistically significant correlation between the type of technical modality and the incidence of peri- and post-procedural complications.
The technical success was 96.6% (n = 137). Mean duration of the procedure was 42.15 min. (10 min. – 170min.). Mean hospital stay was 5 days (2 days – 10 days ). Adverse events were detected in 38 patients (27.1%). The various complications that have been reported were classified into periprocedural and postprocedural:

• Periprocedural adverse events were detected in 7 (5%) patients: 2 (1.4%) with bleeding, 2 (1.4%) with stent migration, 3 (2,1%) with loss of access.
• Postprocedural complications are deteced in 29 (20,7%) and we divided into:

1. Early (up to 7 days after procedure) – n = 21 (15%) of them 13 (9,3%) with cholangitis, 3 (2,1%) with abdominal pain, 1 (0,7%) with bleeding, 2 (1,4%) with pancreatitis, 1 (0,7%) with pneumoperitoneum and 1 (0,7%) patient with biloma.
2. Late (a week after the procedure) – n = 8 (5,7%) with cholangitis.

• There were 2 deaths related to the procedure (1.4%) in patients with advanced oncologic disease.

Conclusion

EUS-BD is effective tool for biliary drainage both in naïve patients and those with altered biliary anatomy. Along with the possibility of emergency PTBD, it has favourable technical and clinical success rate and safety profile and therefore the potential to shift the current paradigms that define management of complicated biliary obstruction.

References

1. Hatamaru K, Kitano M. EUS-guided biliary drainage for difficult cannulation. Endosc Ultrasound 2019;8(Suppl 1):S67–S71
2. Baars JE, Kaffes AJ, Saxena P. EUS-guided biliary drainage: a comprehensive review of the literature. Endosc Ultrasound 2018;7(01):4–9
3. Kakked G, Salameh H, Cheesman AR, Kumta NA, Nagula S, DiMaio CJ. Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: a systematic review and meta-analysis. Endosc Ultrasound 2020;9(05): 298–307
4. Khan MA, Akbar A, Baron TH, et al. Endoscopic ultrasound-guided biliary drainage: a systematic review and meta-analysis. Dig Dis Sci 2016;61(03):684–703
5. Giri S, Mohan BP, Jearth V, Kale A, Angadi S, Afzalpurkar S, Harindranath S, Sundaram S. Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis. Gastrointest Endosc. 2023 Oct;98(4):515-523
6. 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
7. Ogura T, Higuchi K. Endoscopic ultrasound-guided hepaticogastrostomy: technical review and tips to prevent adverse events. Gut Liver 2021;15(02):196–205
8. Ogura T, Higuchi K. Technical review of developments in endoscopic ultrasound-guided hepaticogastrostomy. Clin Endosc 2021;54(05):651–659

Disclosure

Also presented on ESGE DAYS 2024

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a minimally invasive and promising alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in managing malignant biliary obstruction. Different techniques are available such as choledocoduodenostomy (CDS), gallbladder drainage (GBD) and hepaticogastrostomy HGS). All have been shown to be safe and effective techniques, but which is the most suitable and effective approach is still unknown.

Aims & Methods

We aim to compare the three techniques available in terms of technical success and clinical success, and to assess the adverse events related to the different procedures. Single center retrospective analysis of all consecutive cases of CDS, GBD and HGS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about patients and procedures were collected. Technical success was defined as successful biliary drainage with stent placement. Clinical success was defined as a decrease in total bilirubin level by ⩾30% within 7 days of EUS-BD.

Results

From April 2016 to December 2024 101 patients were included (47.5% male, mean age 74.6 years old), all with malignant biliary obstruction. 52,5% of the subjects (53/101) underwent EUS-CDS, 22,7 % (23/101) underwent EUS-GBD and 24,75% (25/101) underwent EUS-HGS. In 35/101 (34,65%) duodenal stenosis was observed. A total of 7 patients had altered anatomy. The mean procedure time was 26 ± 15,7 minutes. Overall technical success was 93%, 48/53 (90,5%) in the CDS group, 23/23 (100%) in the GBD group and 23/25 (92%) in the HGS group. Overall clinical success was achieved in 57/79 (72%), 29/38 (76,3%) in the CDS group, 12/20 (60%) in the GBD group and 16/21 (76,1%) in the HGS group. When considering a reduction in bilirubin level ⩾50%, the overall clinical success was lower (55%). Adverse events occurred in 6/101 (5,9%) of the patients, 3/53 (5,6%) in the CDS group, 0/23 in the GBD group and 3/25 (12%) in the HGS group. There was no difference in terms of sex, age, altered anatomy, presence of duodenal stenosis and the EUS technique performed. The mean time of the procedure was higher in the HGS group, with a difference statistically significant (CDS=22,87±14,78 min, GBD=26±15,73 min, HGS=41±16,09 min, p=0,005). No difference was observed in terms of technical and clinical success, and adverse events between the three procedures. However, if the reduction in bilirubin level ⩾50% cut-off was used, the HGS was the procedure with the highest rate of clinical success (CDS 59,5% vs GBD 25% vs HGS 76%, p=0,003).

Conclusion

EUS-BD is a safe procedure with high technical and clinical success rate and it s a valid alternative for managing malignant biliary obstruction in high volumes centers. No differences are described between the three approaches. However HGS seems to reduce bilirubin levels more quickly, with longer procedure time.

Introduction

Endoscopic retrograde cholangiopancreatography /ERCP/ is the standard technique in the treatment of unresectable malignant biliary obstruction/MBO/, unfortunately, a failure rate of 3% up to 12 % and a rate of complications up to 6,85% have been reported in the literature. Endoscopic ultrasound-guided biliary drainage/EUS – BD/ is a feasible alternative for biliary drainage, applicable especially with surgically altered anatomy. With several techniques available, hepaticogastrostomy /EUS - HGS/ and choledochoduodenostomy/EUS - CDS/ are most commonly performed amongst them.

Aims & Methods

To compare the most commonly used techniques for endoscopic ultrasound-guided biliary drainage in terms of efficacy and safety.
Methods:Retrospective analysis of a prospective database of patients undergoing EUS -BD in a single tertiary referral center. EUS–BD was performed after the failure of ERCP or as a first choice of drainage procedure in patients with altered anatomy. 102 patients were included in the EUS-HGS group 94,12%(n=96) with malignant biliary obstruction and 5.12%(n=6) with benign underlying disease. Of 24 patients included in the EUS–CDS group 95,83% (n=23) had underlying malignancy against one patient with benign disease.

Results

Considering the application of EUS – BD as a first choice of drainage procedure for patients with surgically altered anatomy we had 46 patients in the HGS group (45.1%) against 16.67%(n=4) for the CDS group. In 56/44,44%/ cases EUS BD was performed during the same session after unsuccessful cannulation. Evaluating results in terms of technical success rate, defined as successful stent placement – we found a 98,04 % success rate for the EUS-HGS group and 95,83% in the EUS–CDS group. We defined clinical success as a drop in the bilirubin levels by one-half in the first week following the procedure. The results between the two groups were not significantly different - 80.46% for the HGS against 80,95% for the CBS group. Concerning adverse events during the procedure, we found a ratio of 7.84% for the patients undergone HGS and 4,76% for EUS – CDS with no significant difference. The most common AE found was proximal stent misdeployment/n=3/. All of the events were managed either conservatively or during the same session with the placement of fully covered SEMS. Concerning early AE /during the first 7 days / we experienced 14,71% early adverse events in the HGS group/n=15/ and 16,67% /n=4/ in the CDS group with most common event postprocedure infection with no significant difference.

Conclusion

The two most common transluminal techniques for EUS biliary drainage - HGS and CDS are a promising tool with comparable technical and clinical success rates, adverse events, and overall survival. Both procedures are valid alternatives after failed ERCP or as a first step especially in patients with surgically altered anatomy.

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

Liver biopsy is a crucial diagnostic procedure for assessing hepatic pathologies, providing valuable insights into the etiology, severity, and prognosis of liver diseases. In recent years, Endoscopic Ultrasound-Guided Liver Biopsy (EUS-LB) using 22G- fine needle biopsy ( FNB) needle has emerged as a promising alternative, leveraging the superior imaging capabilities of endoscopic ultrasound (EUS) to guide biopsy with increased precision and safety. The 22G- FNB needle features a crown tip with three symmetrical cutting edges that enable swift core tissue procurement for histological analysis. The 22G- FNB needle provide greater than 95% tissue adequacy and an excellent diagnostic accuracy.

Aims & Methods

The aim of our study is to evaluate the diagnostic utility and safety of a 22G-FNB needle using the slow -pull technique for EUS-LB of parenchymal and focal liver lesions.
We performed a retrospective analysis of prospective data basefrom January 2021 to March 2024. Each patient underwent anendoscopic ultrasound by using linear scope (Fujifilm EG-580UT) and fine needle biopsy using 22G - tip needle with the slow-pull aspiration technique:

• For 33 patients we used a 22G Trident™ - tip FNB needle (Micro-Tech Endoscopy);
• For 26 patients we used a 22G Acquire- tip FNB needle (Boston Scientific Corp.);
  
• For 4 patients we used a 22G SonoTip Top Gain - tip FNB needle ( MediGlobe);

Results

We identified 63 patients who underwent EUS-LB of the liver during the study period(28 men and 35 women): 47 (74.6%)of them were with malignant and 16 (25.4%)–with benign disease. The medium age of the patients was 56.9 years. The specimen was considered adequate in all 63 patients.
We classified the EUS-FNB of liver diseases into EUS-FNB of parenchymal and focal liver lesions.

• EUS-FNB of parenchymal liver disease were performed to 13 (20.6%) of the patients: cirrhosis was found in 2 (3.17%), nonalcoholic fatty liver disease – in 5 (7.9%) and cholestasis in 6 (9.5%).
• We performed EUS-FNB of focal liver lesions in 50 ( 79.36%) of the patients.
  
  • Metastasis were found in 39 (61,9%): pancreatic ductal adenocarcinoma was detected in 27 (42.8%), pancreatic acinar cell carcinoma – in 1 (1.58%), pancreatic neuroendocrine carcinoma – in 5 (7.9%), lung adenocarcinoma – in 3 (4.7%), ductal adenocarcinoma of breast – in 2 (3.17%) , colorectal adenocarcinoma – in 1 (1.58%) and Ewing sarcoma – in 1 (1.58%).
  • Primary liver cancer - hepatocellular cancer was diagnosed in 4 (6.34%) patients.
    
  • Cholangiocarcinoma was found in 3 (4.7%) patients.
  • There were 3 (4.7%) patients with negative histology for tumor cells in the specimen: in 2 (3.17%) cases liver abscess was proved and 1 (1.58%) hepatic cyst.
    

Conclusion

Our study illustrates that ЕUS-guided liver biopsy using a 22 G- FNB needle provides adequate specimen for histologic analysis, lesser postprocedural recovery time and it is a safe, highly effective alternative to other methods of liver biopsy. The use of real time imaging guidance with doppler also helps to reduce the adverse events.

Introduction

Pathological diagnosis of biliary lesions is usually performed via a transpapillary approach; however, its diagnostic yield is insufficient. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) presents a technically challenging alternative, with concerns about bile leak and tumor cell seeding, resulting in scarce data.

Aims & Methods

In this study, we evaluated the feasibility and safety of EUS-TA for biliary lesions, including the bile duct, gallbladder, and ampullary region.
A retrospective analysis was conducted on 68 patients with 71 biliary lesions who underwent EUS-TA at our institution between April 2017 and December 2024. Final diagnoses were established based on surgical specimens or clinical follow-up in non-surgical cases.

Results

Patient Background: The median age was 75 years (range: 50–90), and 46 patients (65%) were male. The lesions included 27 bile duct lesions (final diagnoses: 15 cholangiocarcinoma, 5 benign biliary stricture, 2 sclerosing cholangitis, 2 IgG4-related sclerosing cholangitis, 2 gallbladder cancer, 1 pancreatic cancer), 30 gallbladder lesions (19 gallbladder cancer, 3 xanthogranulomatous cholecystitis, 3 chronic cholecystitis, 2 post-acute cholecystitis change, 1 hilar cholangiocarcinoma, 1 gallbladder neuroendocrine carcinoma, 1 adenomyomatosis), and 14 ampullary lesions (9 ampullary carcinoma, 4 papillitis, 1 neuroendocrine tumor). Bile duct and ampullary lesions were cases where transpapillary diagnosis was inconclusive. Gallbladder lesions had distinct masses or wall thickening.
Outcomes: The median maximum lesion diameter was 17 mm (range: 3–67 mm). The median number of needle passes was 3 (range: 1–6). Needle sizes were 22G in 70 cases and 25G in 1 case. A fine-needle biopsy needle (FNB needle) was used in 61 cases (86%). The overall diagnostic yield (sensitivity/specificity/accuracy) for differentiating between benign and malignant lesions was 92.3%/100%/94.4%, respectively. In bile duct lesions, sensitivity sensitivity/specificity/accuracy were 80%/100%/85.2%, respectively. In gallbladder and ampullary lesions, diagnostic yield was 100%. Complications were observed in 3 cases (4.2%): one case each of obstructive jaundice, pancreatitis, and hyperamylasemia. One patient required transpapillary biliary drainage, while the others improved with conservative management. Surgery was performed in 21 patients (29.6%), with no cases of peritoneal dissemination observed.

Conclusion

EUS-TA demonstrates high diagnostic yield and safety for biliary lesions, offering a viable alternative when transpapillary approaches fail to differentiate benign from malignant pathology.

Introduction

Indeterminate biliary strictures pose a significant diagnostic challenge, as they can result from a wide spectrum of both benign and malignant conditions. Differentiating between these is crucial due to different management strategies. Conventional methods like endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology have limited sensitivity, often leading to repeated procedures and delays in treatment. Peroral cholangioscopy (POC) offers direct bile duct visualization and targeted biopsies, improving diagnostic accuracy. Modern systems, like the SpyGlass™ DS, enhance procedure feasibility and image quality.

Aims & Methods

Aims: The aim of our study is to assess the effectiveness of single-operator peroral cholangioscopy system (POCS) with its digital version SpyGlass^TM Direct Visualization System with SpyBite biopsies as a promising modality for accurate diagnosis of biliary strictures.
Method: We performed a two-center retrospective analysis of prospective database from March 2019 to March 2025. Each patient underwent peroral cholangioscopy using SpyGlass^TM Direct Visualization System with SpyBite biopsies for the diagnosis of indeterminate biliary strictures.

Results

We identified 162 patients who underwent peroral cholangioscopy during the study period (96 males and 66 females). The medium age of the patients was 63.04 years. There was 100 % technical success of the procedure. All patients underwent POCS due to indeterminate biliary strictures. Before the procedure CT scan was performed and positive for biliary stenosis in 115 (70.9%) of the cases. The biliary stenoses were located as follows: 20 (12.3%) in the distal common bile duct, 29 (17.9%) in the proximal common bile duct, 102 (62.9%) at the hepatic hilum and 11 (6.7%) in the intrahepatic bile ducts.
Benign disease was diagnosed in 39 (24.07 %) of the patients. Visual impression for malignant desease (at least one of the following- tortuous dilated vessels, friability and easily bleeding, infiltrative stricture, polipoid mass, nodular eleveted lesion, vegetative mass, fish-egg lesion, finger - like villiform lesion and irregular papillary or granular lesion) was found in 123 (75.9%) of the patients. The most reliable correlation with malignancy was found to be the presence of infiltrative strictures - 113 (69.7%) patients. A final diagnosis of cholagiocarinoma was established in 84
(51.8%) of them. In 39 (24.07%) patients, no tumor cells were found in the specimen. Visual impression accuracy with SpyGlass was 100% (with 100% sensitivity and 100% specificity). SpyBite biopsies accuracy was 69.05 % (with 68. 3% sensitivity and 100% specificity).

Conclusion

POC has proven valuable in evaluating indeterminate biliary strictures, offering advantages over ERCP by allowing real-time visualization and targeted biopsies. Our study supports POC's superior accuracy, especially in identifying malignant lesions, with visual impression achieving up to 100% sensitivity and specificity. However, POC adoption is limited by operator expertise, the need for standardized interpretation, and availability. While adverse events are rare (<10%), careful patient selection is essential. In conclusion, POC holds substantial promise as a key diagnostic tool for indeterminate biliary strictures, with ongoing improvements enhancing its clinical role.

Disclosure

No conflict of interest