Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the best choice to treat choledocholithiasis and obstructive jaundice in pancreatic or biliary neoplasms. Endoscopic ultrasound (EUS) has shown the best diagnostic accuracy for detecting common bile duct (CBD) stones, also showing an essential role for correctly staging pancreatic and biliary neoplasms. EUS and ERCP have been considered historically as two separate procedures; however, during the last decade, a same-session execution has gained popularity. Towards this process, bilio-pancreatic endoscopy was born.

Aims & Methods

We aimed to evaluate the efficacy and safety of same-session EUS-ERCP (SSEE) in treating choledocolithiasis and distal malignant biliary strictures compared to two-session procedures (TSEE). We retrospectively studied all consecutive patients enrolled in a 2-year period (January 2021 and December 2023) undergoing EUS and ERCP to treat choledocolithiasis or obstructive jaundice for malignant distal CBD strictures at an Italian tertiary referral Centre. Patients were divided into two groups: “same session EUS and ERCP group” (SSEE) and “two sessions EUS and ERCP group” (TSEE). Procedural ERCP success, the onset of major adverse events (moderate-to-severe-post-ERCP acute pancreatitis [ASGE guidelines], moderate-to-severe early and/or delayed bleeding [ASGE guidelines], duodenal and/or biliary perforation [Stapfer classification]), and all variables conventionally associated with the procedure were compared between the two groups of therapeutic strategy.

Results

At the end of the study, 200 patients were included (M/F 103/97; mean age: 71 years). The main features of the patients are reported in Table 1. Hundred (50%) patients were treated by the SSEE approach, while the remaining 100 (50%) by the TSEE modality. No statistically significant difference between the two groups was recorded in terms of ERCP overall success (95% vs 99%; p=n.s.). When considering major adverse events, no significant difference was seen between the two groups (0% vs 1%; p=n.s.). Regarding procedural features, the total procedure time (EUS + ERCP) did not significantly differ between the two groups (71.40 min vs 75.05 min; p=n.s.). We did not record major complications (acute pancreatitis, acute cholangitis, acute cholecystitis) during the waiting time between EUS and ERCP (average of 4.03 days) in the TSEE group. By contrast, a mean 3-day gain in terms of hospitalization length was observed in the SSEE group.

Conclusion

Our single-centre experience shows that both SSEE and TSEE approaches are safe and effective in patients undergoing EUS plus ERCP. Delaying the execution of ERCP from EUS, with reduced and appropriate inter-procedural waiting times, proves to be safe and effective, especially in cases involving specific patient conditions (altered anatomy, need for anaesthesiologic assistance, major comorbidities etc.) or the pathology to be treated. Finally, the SSEE approach seems to be more cost-effective with a gain of 3-mean-day in terms of hospitalization length.

Introduction

A biliary stricture is a narrowing of intrahepatic and/or extrahepatic biliary system with upstream dilatation¹; 70-80% of biliary strictures are malignant¹ therefore histological diagnosis is necessary to distinguish benign from malignant causes and guide management. Strictures without confirmed histology are referred to unexplained biliary strictures². ESGE (European Society of Gastrointestinal Endoscopy) guidelines recommend an integrated diagnostic approach that combines multiple techniques to improve diagnostic accuracy. Endoscopic ultrasound(EUS) has demonstrated high sensitivity for evaluating biliary strictures and unexplained common bile duct (CBD) dilatation, due to its ability to provide high-resolution images of CBD walls and surrounding structures, so is the preferred diagnostic modality for both imaging and tissue acquisition(TA), even in absence of abnormal laboratory test.¹ The introduction of ancillary techniques, as DFI (Detective Flow Imaging), which enables the detection of low-velocity blood flow without the use of contrast media, represents a potential useful addition in the diagnostic algorythm³.

Aims & Methods

The aim of this single-centre retrospective study is to validate the role of EUS-DFI in characterizing unexplained biliary strictures and CBD dilatation. We included consecutive patients (pts) with unexplained biliary strictures/CBD dilatation who underwent biliopancreatic EUS between January 2024 and April 2025 at the Digestive Diseases Unit of Sant’Andrea University Hospital, Rome. During EUS, biliary stricture (lesions or thickening of CBD wall) were described as hypoechoic or isoechoic. DFI was performed to evaluate strictures: if microvascularization was observed, vascular pattern was classified as regular or irregular⁴. Results were compared with the final diagnosis, defined by histopathology and/or ≥6 months clinical follow-up as gold standard. TA was performed with EUS-FNB (fine needle biopsy) and/or ERCP(Endoscopic Retrograde Cholangiopancreatography) intraductal biopsies/brushing.

Results

Of 13 patients included, 8(61.5%) were male, median age 72 (range 56-86). All underwent Magnetic Resonance Imaging/Contrast-Enhanced Computed Tomography as first line imaging: 3(23%) had a perihilar stricture, 9(69%) a medio-distal, 1(8%) had “in toto” CBD thickening. Among the 13 strictures, EUS identified 10(76.9%) lesions, with a mean diameter of 17 mm (median 16 mm; range, 5–35 mm), and 3(23.1%) CBD wall thickening. Twelve (92%) strictures were hypoechoic, 1(8%) was isoechoic. EUS-TA was performed in all pts, revealing 7(54%) cases of malignancies, of whome 5 cholangiocarcinoma and 2 pancreatic ductal adenocarcinoma (PDAC), 3(23%) high-grade dysplasia, and 3(23%) fibroinflammatory disease on histopatological evaluation. All pts underwent DFI-EUS. Microvascularization was detected in 12 cases (92%), with an irregular pattern observed in 9 pts. Among these, 5 (55.6%) were diagnosed with cholangiocarcinoma, 1(11.1%) with PDAC infiltrating CBD, and 3(33.3%) with high-grade dysplasia. The 3 benign strictures demonstrated a homogeneous pattern. One case (8%), corresponding to a PDAC, appeared hypovascular on DFI.

Conclusion

In a small cohort of patients with unexplained or indeterminate biliary strictures, the novel DFI-EUS technique proved to be feasible for assessing microvascularization in CBD stenosis and revealed characteristic irregular patterns or hypovascularization in malignant lesions. Further prospective studies with a larger patient population are needed to confirm these preliminary findings.

References

1. Facciorusso, A. et al. Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 57, 166–185 (2025).
2. Zhang, W., Chai, N., Wu, Q. & Linghu, E. The new criteria for differential diagnosis of indeterminate biliary stricture under super minimally invasive peroral cholangioscopy. Chin Med J (Engl) 137, 255–256 (2024).
3. Yamashita, Y. et al. A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study. Diagnostics 11, 2018 (2021).
4. Yamashita, Y. et al. Novel Technique of Endoscopic Ultrasonography for the Differential Diagnosis of Gallbladder Lesions and Intraductal Papillary Mucinous Neoplasms: A Single-Center Prospective Study. Diagnostics 13, 2132 (2023).

Introduction

EUS-guided choledochoduodenostomy using a lumen-apposing metal stent (EUS-CDSL) has been shown in randomized controlled trials (RCT) to be effective compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with advanced malignant distal biliary obstruction (MDBO). We aimed to further ascertain the safety of EUS-CDSL, which has been limited by inadequate trial sample sizes.

Aims & Methods

We undertook aggregate and individual patient data (IPD) meta-analyses following the PRISMA-IPD statement. A literature search was performed from January 2013 to November 2024 using OVID MEDLINE, EMBASE, Cochrane Library, and ISI Web of Science. Additional searches were performed for abstracts and the grey literature. RCTs comparing EUS-CDSL to ERCP were included. The primary outcome was the rate of procedure-related 14-day severe or fatal adverse events (AE). Secondary outcomes included technical success, 30-day AE, clinical success, stent dysfunction, and procedure time.

Results

A total of 2679 citations were screened with three RCTs included (519 patients). There was no difference in severe or fatal AEs between EUS-CDSL and ERCP (OR 0.64, 95% CI 0.22- 1.83 for IPD data and RR 0.76, 95% CI 0.22, 1.77 for aggregate data). Technical success was greater for EUS-CDSL (OR 4.22, 95% CI 2.35,7.61 and RR 1.14, 95% CI 1.04, 1.25) with shorter procedural time (mean difference -10.50 minutes (95% CI -15.28, -5.73). No significant differences were noted in 30-day AEs, clinical success, and stent dysfunction.

Conclusion

Our aggregate and IPD meta-analyses demonstrate the safety of EUS-CDSL as a first-line alternative to ERCP in advanced MDBO. In addition, EUS-CDSL is technically superior in terms of success rate and procedure time.

Introduction

The Atmo Capsule is a wireless motility capsule that senses and telemetrically transmits measurements of hydrogen (H₂) and carbon dioxide (CO₂) along the gut. In the colon, luminal concentrations of H₂ and CO₂ represent the metabolic activity of the microbial community. We hypothesized that delayed colonic transit would lead to altered gas profiles due to earlier depletion of fermentable substrates relative to transit time and/or facilitation of contact between methanogens and hydrogen (Levitt et al. CGH 2006).

Aims & Methods

The Atmo Capsule was administered to subjects with suspected upper and/or lower gut dysmotility. Colonic transit times (CTT) ≥ 59 h were considered delayed. Luminal H₂ and CO₂ concentrations (as time-normalized, area-under-the-curve [TN-AUC], [%.h]/h) were evaluated across the entire colon. Regional colonic profiles were evaluated per quartile of relative colonic transit, with quartiles 1 and 4 indicative of the proximal and distal colon, respectively. Gas measures were included if ≥ 50% of data were available for the corresponding segment. Fermentation profiles were estimated by the ratio of quartile 1:4 values, and time to peak concentrations were evaluated relative to CTT. Data were analyzed via Mann-Whitney test.

Results

The Atmo Capsule was administered to 209 subjects (median age 41; 188 female) with 170 yielding valid data on both colonic transit and colonic gas concentrations. Delayed colonic transit was identified in 60/170 (35%) subjects. In subjects with delayed CTT, H₂ concentrations tended to be higher in the proximal colon and lower in the distal colon with no overall difference across the region compared with those with normal transit (Table 1). CO₂ concentrations were higher throughout the colon except in the distal colon in subjects with delayed CTT. Peak concentrations of colonic H₂ and CO₂ were higher (H2, 8.7 h vs 5.9 %.h/h, p<0.01; CO2, 37.4 vs 29.9 %.h/h, p<0.01) and tended to occur earlier (H₂, 35.9 vs 47.0 % of colonic transit p=0.14; CO₂, 49.1 vs 86.8 % colonic transit, p<0.01) in patients with delayed compared with normal CTT.

Table 1. Gas profiles in patients with delayed colonic transit and correlation with symptom profiles. Data shown as median (interquartile range) and analyzed via Mann-Whitney test.

Conclusion

Colonic gas profiles, as measured via the Atmo Capsule, differed in patients with delayed compared with normal CTT, with patterns suggesting progressive depletion of fermentable substrates and/or conversion of H2 to methane during transit in those with delayed transit.

References

Levitt MD, Furne JK, Kuskowski M, Ruddy J. Stability of human methanogenic flora over 35 years and a review of insights obtained from breath methane measurements. Clin Gastroenterol Hepatol. 2006 Feb;4(2):123-9. doi: 10.1016/j.cgh.2005.11.006. PMID: 16469670.

Disclosure

These authors disclose the following: Braden Kuo, Anthony J. Lembo, Eammon M.M. Quigley, Satish S.C. Rao, and William D. Chey serve on the Medical Advisory Board of Atmo Biosciences. Michael Cline and Baharak Moshiree served on the Medical Advisory Board of Atmo Biosciences. Braden Kuo has received funding from NIH, Vanda, Atmo Biosciences, and Takeda and has consulted for Evoke, Takeda, Ironwood, Novo Nordisk, Cindome, and Neurogastrx. Thomas Abell has received funding from Gastric Dysrhythmias, Neurogastrx, NIH GpCRC, and Vanda and has consulted for Enterra Medical, Novo Nordisk, Nuvaira, and Vanda. Anthony J. Lembo has received funding from Ardelyx, Biomerica, GSK, Ironwood, Takeda, and Vibrant and holds stock with Allurion, Bristol Myer Squibb, and J&J. Abigail Stocker has received funding from Cindome, Enterra Medical, and Vanda. William D. Chey has received funding from Atmo Biosciences, Commonwealth Diagnostics Intl, QOL Medical, and Salix; has consulted for AbbVie, Ardelyx, Biomerica, Comvita, Gemelli, Ironwood, Nestle, QOL Medical, Phathom, Redhill, Salix, Vibrant, and Takeda; has filed patents with My Nutrition Health, Digital Manometry, and Rectal Expulsion Device; and holds stock options with Coprata, Evinature, Food Marble, Kiwi Bioscience, and Modify Health. The remaining authors disclose no conflicts.

Introduction

Low mucosal impedance has been associated with reduced mucosal integrity and is measured during ambulatory pH/impedance monitoring, defined as mean nocturnal baseline impedance (MNBI)¹. More recently, techniques to measure impedance during endoscopy are emerging². In a prospective cohort of patients with EoE (SWALLeOeW Study, ISRCTN17786884, recruitment ongoing) we assessed the technicality of comparing mucosal impedance using MNBI with impedance measured during high-resolution impedance manometry (HRIM).

Aims & Methods

Here we aim to assess the practicability of obtaining mucosal impedance measurements during HRIM and to compare this with impedance measured using MNBI in a group of patients with EoE.
Prospective participants with EoE were assessed with HRIM and MNBI and this was repeated following a treatment period (Oro-dispersible Budesonide). The pooling of repeat measures from an individual participant was deemed to be appropriate in this evaluation as the purpose was to technically validate the process of comparing MNBI with HRIM, rather than to compare individual data points.
MNBI was calculated during a quiescent nocturnal period (Laborie, Ohmega) using the average of distal impedance channels 3 and 5 cm above the proximal border of the LOS¹. Impedance data was obtained during the supine resting period during HRIM and manually exported from the software (Medtronic). Extracted frames were at least 3 respiratory cycles and up to 30 seconds, and impedance was calculated based on the sensors 2.5 and 4.5, or 3.5 and 5.5 cm above the proximal border of the LOS, depending on catheter position.

Results

22 paired HRIM and MNBI measurements were obtained to date, from 15 participants. Reasons for unsuccessful MNBI measurements were not attempting test (n=2), non-tolerance (n=10), Nickel allergy (n=1), drop-out (n=2), or unable to intubate (n=1). Reasons for unsuccessful impedance measurement during HRIM were reflux during resting pressure measurement (n=1), catheter failure (n=3), drop-out (n=2), non-tolerance (n=8) or measurement not attempted (n=2).
The mean impedance values as measured by the two methods were not significantly different: mean MNBI (95% CI): 1570 (1210-1930) ohms, HRIM (95% CI) = 1330 (920-1740) ohms, p = 0.18. The mean difference between MNBI and HRIM was 245 ohms (1380-1870) (5-95^th percentiles).
Using a normality threshold of <1500 ohms³ being suggestive of impaired mucosal integrity, the majority (19/22) of the readings showed agreement between the two methods. Of the three that did not agree, MNBI suggested impaired mucosal integrity in one, and HRIM in the other two.

Conclusion

Measuring impedance during HRIM appears to be comparably practicable to MNBI measurement in patients with EoE, with the same numbers of successful measurements achieved by the two methods. Comparison of this preliminary data also indicates good agreement between methods. Impedance measurement during HRIM could provide a faster method of assessing mucosal integrity in EoE, whilst simultaneously assessing oesophageal motility. Further work in the SWALLeOeW study will correlate mucosal impedance findings with the Eosinophilic Oesophagitis Histology Scoring System⁴ and assess impedance change in response to treatment.

References

1. Hoshikawa, Y. et al. Measurement of Esophageal Nocturnal Baseline Impedance: A Simplified Method. J Neurogastroenterol Motil 26, 241–247 (2020).
2. Lei, W.-Y., Vaezi, M. F., Naik, R. D. & Chen, C.-L. Mucosal impedance testing: A new diagnostic testing in gastroesophageal reflux disease. Journal of the Formosan Medical Association 119, 1575–1580 (2020).
3. Sifrim, D. et al. Normal values and regional differences in oesophageal impedance-pH metrics: a consensus analysis of impedance-pH studies from around the world. Gut gutjnl-2020-322627 (2020).
4. Collins, M. H. et al. Newly developed and validated eosinophilic esophagitis histology scoring system and evidence that it outperforms peak eosinophil count for disease diagnosis and monitoring. Diseases of the Esophagus 30, (2016).