Introduction

Recently, in endoscopic ultrasound-guided biliary drainage (EUS-BD), combinations of a 22-gauge (G) needle and a 0.018-inch guidewire (GW) has been used for small diameter duct. However, the 0.018-inch GW has low stiffness, which sometimes makes subsequent procedures difficult.

Aims & Methods

The aim of this study was to investigate the efficacy of a new 3F dilator in EUS-BD with a 22-G needle. Between December 2021 and March 2023, the 3F dilator was used in five patients, who underwent EUS-BD with a 22-G needle at our institution. EUS-rendezvous technique was used in four patients, and the puncture site was the extrahepatic bile duct via the second portion of the duodenum in pull position in 1 patient, the extrahepatic bile duct via the first portion of the duodenum in push position in 1 patient, and the left intrahepatic duct via stomach in 2 patients. In one patient, EUS-hepaticogastrostomy was performed. The purpose of the use and its success or failure were examined.

Results

In four patients with EUS-rendezvous technique, a 0.018-inch GW could not pass through the papilla due to low stiffness of the GW, and insertion of a 3F dilator was attempted to reinforce the GW stiffness. The 3F dilator was successfully inserted and it required dilation of puncture route by repeated needle pass under GW placement. Of four patients, insertion of the 3F dilator increased the stiffness of the GW and resulted in successful passage of the papilla in 3 patients; one patient required replacement with a 0.025-inch GW. No biliary peritonitis from puncture route was observed. In one patient with EUS-hepaticogastrostomy, insertion of the 3F dilator to replace a 0.025-inch GW failed to pass through the rigid bile duct wall despite repeated needle pass of bile duct under GW placement. After dilation with a spiral dilater, a 3F dilater could be inserted and successfully replaced with a 0.025-inch GW.

Conclusion

In EUS-BD with a 22-G needle, a 3F dilator is effective for reinforcement of a 0.018-inch GW stiffness and replacement with a 0.025-inch GW.

Introduction

In the endoscopic treatment of bile duct stones (BDS), endoscopic sphincterotomy (ES) as the standard procedure is associated with more late complications such as stone recurrence and cholangitis at long-term follow-up compared to endoscopic balloon dilation (EPBD)¹⁾. In recent years, small incision ES plus EPBD (sES+EPBD) for small BDS has been shown to reduce procedure time and prevent basket-stone impaction without increasing early complications compared to ES alone²⁾; however, its long-term outcomes are not known.

Aims & Methods

This study is a prospective follow-up of the original cohort of a previous randomized controlled trial to compare the early outcomes of ES alone and sES+EPBD for small BDS²⁾. In the previous study, a total of 100 patients with BDS having a maximum short-axis diameter of <12 mm were randomized into the ES and sES + EPBD groups (n = 50 for each). In the ES group, the incision was made beyond the hooding fold but not beyond the papillary roof (upper margin of the oral protrusion). In the sES+EPBD group, the balloon was dilated to at least the stone's maximum short-axis diameter but not beyond the lower bile duct's maximum diameter. Late complications including cholangitis and stone recurrence were evaluated.

Results

The overall median follow-up period was 1915 days (5.2 years), including 1820 days (5.0 years) in the ES group and 2061 days (5.6 years) in the sES+EPBD group. Late complications occurred in 0 (0%) and 7 (25.0%) of the patients who underwent ES and sES+EPBD, respectively (p=0.013). Of the seven patients, six had cholangitis with recurrent stones and one had cholangitis without stones. Kaplan-Meier analysis indicated a significantly higher incidence of late complications in the sES+EPBD group than in the ES group (p=0.009). In multivariate analysis, only sES+EPBD was an independent risk factor for late complications.

Conclusion

In the endoscopic treatment of small BDS, sES+EPBD had significantly more late complications than ES. This suggests that adding ES to the EPBD, even with a small incision, is difficult to preserve sphincter function.

References

1. Yasuda I, Fujita N, Maguchi H, et al. Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones. Gastrointest Endosc 2010;72:1185-1191.
2. Ishida Y, Hisa T, Matsumoto R, et al. Utility and safety of endoscopic papillary balloon dilation with small- incision sphincterotomy for small bile duct stones: A randomized controlled trial. J Hepatobiliary Pancreat Sci 2025;32-160-167.

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 ultrasound guided gallbladder drainage (EUS-GBD) with lumen apposing metal stent (LAMS) has become a favourite drainage option for high surgical-risk patients with acute cholecystitis and as rescue treatment for the relief of jaundice in patients with distal malignant biliary obstruction (DMBO) with high technical and clinical success.
Both trans-gastric and trans-duodenal drainage are described but which is the best way is still controversial.

Aims & Methods

We aim to compare the two different approaches in term of technical success, rate of adverse events, unplanned readmissions and re-interventions.
Single center retrospective analysis of all consecutive cases of EUS-GBD with LAMS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about LAMS features and procedure were collected.

Results

From January 2019 to September 2024 sixty patients were enrolled (50% male; 77±12 years old). The 60% of them underwent EUS-GBD for acute cholecistitis. In 31/60 (52%) patients the trans-gastric access was performed. In 43/60 (71.7%) patients a Hot-Axios LAMS was used and in the majority of procedure (47/60 78.3%) a calibre bigger than 10 mm was used. Overall technical success was obtain in 98.3% of procedures.
In no case the LAMS was dilated. A naso-cistic tube was placed inside the LAMS in 31/60 patients. Double pig-tail plastic stent was placed in two patients. Regarding the adverse events rate, in one patient distal flange misdeployment occurred. LAMS obstruction occurred in 7/60 patients (11.7%) and need of reintervention in 10/60 (16.7%).
There was no difference in term of drainage indication, technical success rate, type and size of LAMS used, naso-cystic tube or pig-tail stent insertion between the two different EUS-GBD access. However, the trans-gastric access was associated with a higher rate of LAMS obstruction (6/7 vs 1/7 p 0.05) and need of re-intervention (8/10 vs 2/10 p 0.03).

Conclusion

EUS-GBD is a safe technique with high technical success rate. Both trans-gastric and trans-duodenal approaches are effective. However, EUS-GBD with trans-gastric access seems to be associated with a higher rate of late adverse events and when possible another way should be preferred.

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.