Introduction

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has become an indispensable examination in the clinical fields. Recently therapeutic EUS such as pseudocyst drainage, EUS-biliary drainage, and EUS-pancreatic duct drainage, etc. have become popular. In order to become a good endosonographer, it has been believed that the learning of EUS-FNA takes long time and certain number of case experiences are essential. And it is also difficult to learn EUS/EUS-FNA without instructors. Furthermore, clinical cases are not enough for training young endosonographer. Then hands-on training with models are able to reduce the number of performing clinical Therapeutic EUS on training program.

Aims & Methods

Therefore, we have developed newly designed model for training therapeutic EUS procedure such as EUS-HGS and PFC drainage, conducted the trial of these models with trainees, and investigated its usefulness and limitations.
We have collaborated with Olympus Co. and made model for EUS-HGS by special plastic material (Century medical Co., Tokyo) and pseudocyst model by non-rupture-balloon (SB Kawasumi Co., Tokyo) which is 8cm in diameter. This balloon is filled by lubricant, and these models are put into water tank. We have tried this model at Kitasato Train-The-Trainer (TTT) and Changhai TTT with 26 trainees (11 for HGS and 15 for PFC). We have investigated whether all trainees can complete HGS and PFC drainage procedure (each 5 steps; identify target, needle puncture), GW insertion, dilation, and stenting) and measured these procedure step times. At first each trainee tried these models after simple explanation and they tried it as 2^ndtime after teaching tips and tricks. We have employed UCT-260 (Olympus Co., Tokyo) ,19G EUS-FNA needles and 7Fr plastic stent as a drainage tube.

Results

Concerning about PFC drainage, trainees completed the procedure 11/15(73%) at first try and 11/15(73%) at second time. At first try, 3 trainees completed up to 3rd step, not to 4th, 5thsteps, and at second try, 1 trainee still completed up to 3rd step, but 3 up to 4th step. Averaged time of 1^st try and 2^nd try is 780s vs 594s (p<0.001), respectively. Concerning about HGS model, trainees completed the procedure 11/11(100%) at first try and 11/11(100%) at second time. Averaged time of 1^st try and 2^nd try is 712s vs 490s (p<0.001), respectively. According to their impression, resistance of puncture and putting in a stent is less, compared with clinical cases, even though this model has resistance to pass through the gastric wall,PFC wall, and hepatic parenchyma. Trainees with less experience improved apparently, compared with trainees with more experience. However, it is very useful to understand the procedure of EUS-HGS and EUS-guided PFC drainage for the biggner of therapeutic EUS.

Conclusion

We concluded that newly designed EUS-HGS and pseudocyst model is useful to train the beginner, in order to understand the procedure. Furthermore, using these models, we can brush up their skill by repeating hands-on training.

Introduction

EUS-hepatico-gastrostomy(HGS) has become indispensable procedure in case of inaccessible cases due to malignant invasion to the duodenum etc. , failed ERCP cases, and failed cases after single balloon assisted ERCP(SBE-ERCP) in surgical altered anatomy.

Aims & Methods

From January, 2016 to April, 2024, we have performed EUS-HGS in 131(Male:79, Female 52, averaged age: 72) cases. The indication of EUS-BD was inaccessible to the duodenal papilla due to malignant invasion or failed cases of ERCP in cases of normal anatomy. In cases without duodenal invasion and intrahepatic bile duct dilatation, we perform EUS-CDS and we perform EUS-BD rendezvous in cases of accessible normal anatomy. And we performed EUS-HGS in remained cases. In surgical anatomy cases, we firstly perform SBE-ERCP, EUS-HGS were performed after failed SBE-ERCP. We have investigated the safety and usefulness of HGS.

Results

The subjects were consisted of malignant diseases (pancreatic cancer: 61(46.6%), biliary cancer: 20(15.3%), and others 35(26.7%) and benign disease (stenosis of bilio-jejunum anastomosis 7(5.3%), bile duct stone7(5.3%), primary sclerosing cholangitis 1(0.8%)). The reason for EUS-HGS were consisted of duodenal invasion 84 (64.1%) cases, inaccessible 21(16%), failed deep canulation 20(15.3%), others 6(4.6%). And normal anatomy cases were 90 (68.7%) and surgical anatomy 41(31.3%). Technical and clinical success was 128(97.7%) and 116(88.5%). The median procedure duration was 36 minutes (range 11-109). The used needle was 19 guage: 113(86.3%) and 22 guage: 18(13.7%). The puncturing branch was B3: 95(72.5%), B2: 35(26.7%), and B1: 1(0.8%). The averaged size of punctured branch was 5.0mm (range2.0-13.0). The dilation method was bougie: 97(74%), balloon: 21(16%), electrocautery: 6(4.6%), drill dilator: 5(3.8%), and not dilate: 2(1.5%). The used stent was plastic stent (PS): 105(80.2%) and covered metallic stent (CMS): 24(18.3%). The stent patency was PS: 120 days and CMS: 226 days (p=0.13). The early complication was peritonitis: 10(7.6%), bacteremia: 5(3.8%), cholangitis: 4(3.1%), bleeding: 2(1.5%), and migration: 3(2.3%). The multivariate analysis revealed only longer procedure duration (more than 36 min.) corelated to early complication(p=0.01).

Conclusion

EUS-HGS is safe and effective and essential for inaccessible cases, failed cases after ERCP and SBE-ERCP. And longer procedure duration corelated with early complication.

Introduction

Hepaticojejunostomy anastomotic stricture (HJAS) is one of the common adverse events after bile duct reconstruction surgery, which is reported to occur in 3–13%. Endoscopic approach using BE-ERCP has become the first choice due to less invasiveness, and long-term resolution rate is reported 50-90%.

Aims & Methods

In order to treat symptomatic hepatico-jejunostomy anastomosis stenosis (HJAS), we firstly perform balloon dilation or plastic stent or fully covered self-expandable metallic stent (FCSEMS) by single balloon ERCP (SBE-ERCP) and secondary insert FCSEMS by EUS-BD, in cases of severe stenosis or non-canulation. Then we have investigated the efficacy of FCSEMS for HJAS. From January 2015 to December 2022, we have performed 698 procedures of SBE-ERCP in 348 cases and inserted FCSEMS in 37 cases with symptomatic HJAS (only benign cases, excluded malignancy). We have planned to deploy FCSEMS for 6 months and removed it after that. Then we investigated resolution rate of HJAS at removing FCSEMS, complication, and long-term resolution rate of HJAS after FCSEMS.

Results

Subjects were Male 26: Female 11 and Median age was 70 y/o. Surgical operation were 33 cases in B-Ⅱ+PPPD/ 4 cases in R-Y. Reason of deploying FCSEMS by SBE-ERCP were unresolved stenosis by balloon dilation or plastic stent (PS) in 29 cases. And FCSEMS for severe stenosis in 6 cases were inserted by direct EUS-Choledocho-jejunostomy (EUS-CJS) and undetectable HJA in 2 cases by Rendezvous EUS-HGS. Additionally, side by side PS were inserted in 32 cases. Finally total subjects were 36, except for 1 case not reached to 6 months. Although 1 FCSEMS migrated into intrahepatic bile duct, 21 FCSEMS were removed endoscopically and remaining 15 FCSEMS were spontaneously dislocated after resolving HJAS. Resolution rate of HJAS at removing FCSEMS were 92% (33/36). Remained 3 cases were treated by additional deploying FCSEMS for 141 days in average. In median 19.0 (0.4-69.1) months followed up period, complications were non-obstructive cholangitis in 8 cases which were treated conservatively and intrahepatic stone in 2 cases which were treated by SBE. Resolution rate of HJAS at 1, 2, 3 years was 100%, 100%, and 100%. Recurrent HJAS occurred in 1 case at 46 months and treated by re-FCSEMS for 189 days.

Conclusion

Treatment of HJAS by FCSEMS were effective in long term period. SBE, EUS-CJS, and EUS-HGS were complimentary each other.

Introduction

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is becoming an important and effective alternative to percutaneous drainage (PTD) for patients not suitable for surgery. It is also an acceptable option for biliary drainage in oncologic patient, if retrograde drainage failed. Placing of a lumen apposing metal stent (LAMS) for EUS-GBD allows the removal of gallbladder stones too, so becoming a possible alternative to surgery in very selected cases.

Aims & Methods

The study aims to describe our endoscopic experience and management in patients unfit for surgery and in those oncologically advanced. Retrospectively analyzed cases with EUS-GBD, from December 2019 to September 2023, in a single peripheral hospital (Hopital Riviera-Chablais), using 3 types of LAMS (10x10mm, 15x10mm, 16x20mm), delivered with an electrocautery-enhanced catheter.

Results

EUS-GBD was performed in 23 patients (15:8=M:F) with median age of 83 years old (52-89). 13 patients (56.2%) had advanced cancer (6 pancreatic metastatic cancer, 5 cholangiocarcinoma, 1 breast metastatic cancer, 1 metastatic pulmonary NET) and 10 patients were affected by symptomatic lithiasic cholecystitis and they were not considered fit for surgery (whose 2 already received a PTD). EUS-GBD was attempted through the duodenum in all cases but one, previously treated with PTD and that was drained through the stomach. In one case, the stent was mis-deployed through the duodenum (without entering the gallbladder lumen), so requiring the placement of an over-the-scope-clip and a different biliary drainage for biliary obstruction in an oncological patient. A 15x10 mm LAMS was used in 14 cases, 10x10 mm LAMS was used in 6 cases (including the failed one), and 16x20 mm in 2 cases. A double pigtail 5 Fr 7cm was placed through all 22 successfully placed LAMS. 3 patients underwent electrohydraulic-lithotripsy (EHL) through the LAMS after 4-8 weeks. In 5 patients LAMS was then removed. Generally, except one complication, it was not described short term or long-term adverse events. 6/23 (26%) patients died for oncological disease progression and for other causes not procedure related.

Conclusion

EUS-GBD represents a promising therapeutic approach in patients with high risk of mortality. Considering the high rate of clinical and technical success as well as the possibility of managing endoscopically potential complications, this approach could be also proposed in peripheral centers and not only in advanced endoscopic ones.

References

1. Anthony Yuen Bun Teoh et al. EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data,
Gastrointestinal Endoscopy, Volume 93, Issue 3, 2021.
2. van der Merwe SW et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185-205.
3. McDonagh, P et al.Endoscopic Ultrasound-Guided Gallbladder Drainage for Malignant Biliary Obstruction: A Systematic Review. Cancers 2023, 15, 2988.

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 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.