Introduction

In the case that tract dilation fails using the initially selected dilation device during EUS-guided hepaticogastrostomy (HGS), it should be re-attempted using another device. However, switching the device has the disadvantages of prolonged procedure time and sudden loss of the correct axis, and it is therefore highly desirable that the initial tract dilation is successful. Recently, a novel drill dilator has recently become available in Japan. However, comparison study between this device and other has been not reported as initial dilation technique. Here we describe the technical feasibility of this device for use during EUS-HGS, and compared with balloon catheter.

Aims & Methods

This retrospective study included patients who underwent EUS-HGS using SEMS between October 2021 and October 2022. Patients who developed bleeding associated with EST were enrolled. Excluded from the study were patients who underwent EUS-HGS using a plastic stent or stent deployment without tract dilation.

Results

A total of 49 patients were enrolled, of whom 19 underwent EUS-HGS using the drill dilator and 30 underwent EUS-HGS using a balloon catheter. EUS-HGS using the drill dilator initially was performed mainly by non-expert hands (n=19), whereas non-expert hands performed few procedures in the balloon catheter group (n=2) (P<0.0001). The initial tract dilation was successful in all patients in the drill dilator group (19/19, 100%) and in 29/30 (97%) in the balloon catheter group (P=0.4214). However, to insert stent delivery system, additional tract dilation was needed in 73.7% (14/19) of the drill dilator group. On the other hand, stent delivery system insertion was successful in all patients of the balloon catheter group.

Conclusion

The novel drill dilator shows promise for initial dilation during EUS-BD. However, balloon dilation technique should be attempted first when deploying a dedicated metal stent using an 8.5Fr stent delivery system.

Introduction

To prevent stent migration during EUS-HGS, intra-scope channel release technique is important, but are unfamiliar to non-expert hands. The self-expandable metal stent (SEMS) is an additional factor to prevent stent migration. However, no comparative studies of laser-cut and braided types during EUS-HGS have been reported.

Aims & Methods

The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut- and braided-type SEMS. To evaluate stent anchoring function, we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS, one day after EUS-HGS, and 7 days after EUS-HGS.　Also, propensity score matching was performed to create a propensity score for using Laser cut type group and Braided group with a logistic regression model.

Results

A total 144 patients were enrolled in this study. Among them, 24 patients underwent EUS-HGS using a laser-cut-type SEMS, and 118 patients underwent EUS-HGS using a braided-type SEMS. EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists (n=21). However, EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists (n=98), showing a significant difference. The distance after 1 day was significantly shorter with the laser-cut-type group (2.91 ± 1.88 mm) compared with the braided-type group (8.19 ± 6.07 mm). In addition, this distance remained significantly shorter in the laser-cut type group compared with the braided-type group after 7 days.　Although these results were similar after propensity score matching analysis, the distance between hepatic parenchyma and stomach after 7 days was increased 4mm compared with the distance after 1 day in Braided group. On the other hand, in Laser cut type group, the distance after 1 day and 7 days was almost same.

Conclusion

In conclusion, EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration, even in non-expert hands, compared with a braided-type SEMS, although a randomized trial is warranted.

Disclosure

None

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

EUS-guided hepaticogastrostomy (EUS-HGS) is a novel technique that allows internal drainage of the biliary system via the stomach. This approach may be of value in patients with duodenal obstruction, surgically altered anatomy, or in hilar strictures with inadequate drainage of the left hepatic duct by other techniques (1, 2). However, this procedure has a high technical complexity and until recently no dedicated stents were available exposing the patient to adverse events such as the risk of biliary leakage and stent migration (3). A partially covered self-expanding metallic stent (pcSEMS) with anti-migration flaps may overcome these risks. So far, the available data on the use of this specific stent is limited, and prospective studies are particularly missing.

Aims & Methods

Aim of this study was to assess the safety and feasibility of EUS-HGS in patients with an inoperable malignant biliary obstruction, with the use of this dedicated stent. This prospective single-center study included patients with inoperable malignant biliary obstruction that underwent an EUS-HGS. Patients were ineligible in case of uncontrolled coagulopathy, tumor infiltration in the gastric wall, intervening blood vessels or extensive amount of ascites. Procedure was performed with a 10cmx10mm pcSEMS (Giobor stent, Taewoong Medical). Primary outcome was safety, defined as rate of procedural related adverse events (AEs) and mortality <30 days. Technical and clinical success rate were evaluated as secondary endpoints, defined as successful deployment of the stent in the intended location and at least 50% decrease of bilirubin <14 days.

Results

Between January 2022 and July 2024, 25 patients (14 female [56%], median age 70 years [IQR 64-76]) were included. Reason to perform EUS-HGS included duodenal obstruction (n=12), altered anatomy (n=6) or failed drainage of the left hepatic duct by ERCP (n=7). In 21/25 patients EUS-HGS was technically successful (84%). In one patient the procedure was aborted due to a self-limiting bleeding after puncture of the bile duct, in one patient due to unsuccessful cannulation of the central bile duct and in two patients the cholangiogram showed previously unidentified intrahepatic strictures that precluded adequate drainage by EUS-HGS. No severe periprocedural AEs occurred. Three patients (14%) were re-admitted with presumed cholangitis <30 days after the procedure; two with undrained right-sided bile ducts for which a percutaneous drain was placed, and one patient due to obstruction of the bile duct branches by the covered part of the stent, for which an endoscopic re-intervention was performed replacing the Giobor stent by a fully covered and uncovered SEMS. Five patients died within 30 days due to fulminant disease progression. None of these patients experienced procedural related AEs. Clinical success was achieved in 18/19 (95%) patients with technical success and follow-up of at least two weeks. Six out of the 18 patients with clinical success developed recurrent biliary obstruction after a mean of 105 days (SD 80). Obstruction was caused by hyperplasia at the uncovered portion of the stent (n=3) and due to sludge obstructing the stent (n=3). Successful re-intervention was performed in all patients.

Conclusion

This prospective study shows that EUS-HGS with a dedicated partially covered stent is feasible and safe. Tissue hyperplasia in the uncovered part of the stent and sludge obstruction may compromise long-term stent patency. Larger, comparative studies addressing stent design and timing of EUS-HGS are eagerly awaited.

References

1. Pawa, S., et al., American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendations. Gastrointest Endosc, 2024.
2. van der Merwe, S.W., et al., Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy, 2022. 54(2): p. 185-205.
3. Binda, C., et al., Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis. Endoscopy, 2024. 56(9): p. 694-705

Introduction

Balloon dilation and plastic stent deployment have been performed as hepaticojejunostomy stricture (HJS) treatment techniques by PTBD or under DB-ERCP guidance. Although these techniques have shown favorable clinical results, the treatment period can be long because stent deployment is required. In addition, HJS may recur even after treatment because the scar tissue itself remains. To overcome these challenges, we developed an transluminal antegrade piecemeal dilation technique (TAPD) for treating HJS. The aim of this study was to evaluate the technical feasibility and safety of this technique in terms of the pre- and post-cholangioscopic findings.

Aims & Methods

This retrospective study included consecutive patients who were complicated with symptomatic HJS between November and February 2022. The primary outcome of this study was the technical success rate of TAPD using a drill dilator. Technical success was defined as resolution of the HJS, based on the cholangioscopic findings. The secondary outcome was adverse events associated with TAPD such as bleeding or perforation.

Results

TAPD was attempted at around 11 days after EUS-HGS in 19 patients. Among the 19 patients, passage of the guidewire across the HJS into the intestine was unsuccessful in 4 patients, and the technical success rate of this procedure was 78.9%. TAPD was successful in all 15 patients in whom passage of the guidewire was achieved. After TAPD, cholangioscopy identified no bleeding or perforation in any patient. During the follow-up period, no recurrence of HJS was observed in any patient who underwent TAPD.

Conclusion

In conclusion, TAPD appears to be technically feasible and safe. Although it is necessary to conduct a randomized trial in comparison with other methods, with long-term follow up, TAPD may be a useful option for the treatment of HJS.