Search Results (278)

Background: After a failed endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO), second-line drainage is performed with endoscopic ultrasound-guided biliary drainage (EUS-BD) or percutaneous transhepatic biliary drainage (PTBD). We compared their effectiveness, safety, and short-term survival. Methods: We conducted a single-center retrospective cohort of 101 adults with MBO after they had experienced a failed ERCP (EUS-BD n = 37; PTBD n = 64). Allocation was non-randomized and driven by operational availability. Baseline laboratory tests (complete blood count, platelets, and C-reactive protein) and derived indices (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], lymphocyte-to-monocyte ratio [LMR], systemic immune-inflammation index [SII], systemic inflammation response index [SIRI], neutrophil-to-platelet score [NPS], and lymphocyte-to-CRP ratio [LCR]) were compared. Outcomes that were a technical success include: an early biochemical response (bilirubin reduction), complications (Clavien–Dindo), length of stay (LOS), and overall survival (OS). Between-group comparisons used the two-sided Mann–Whitney U test (continuous) and Fisher’s exact (binary) test. Survival was assessed by the Kaplan–Meier estimator using log-rank testing. To address later adoption of EUS-BD, we also estimated a restricted mean survival time of 180 days (RMST_0–180) with 95% confidence intervals (CIs). Results: Baseline inflammatory markers and composite indices were similar; baseline total bilirubin was higher in PTBD. The technical success was 100% in both groups. Early biochemical response was 86.5% after EUS-BD vs. 78.1% after PTBD (p = 0.43). Any complication occurred in 29.7% vs. 12.5% (p = 0.04); major complications (Clavien–Dindo ≥ III) occurred in 10.8% vs. 0% (p = 0.02), respectively; and the LOS did not differ (p = 0.21). OS favored EUS-BD (median 143 vs. 54 days and log-rank p = 0.012). RMST_0–180 was 111.1 days for EUS-BD vs. 71.4 days for PTBD (difference + 39.6 days; 95% CI 11.3–65.9). Conclusions: After a failed ERCP for MBO, EUS-BD and PTBD achieved universal technical success and similar early biochemical responses, but EUS-BD was associated with higher complication rates and a significantly longer six-month survival. These findings support the individualized selection balancing procedural risk with the anticipated survival benefit and highlight the need for prospective comparative studies. Full article

Malignant biliary obstruction (MBO) represents a critical clinical challenge characterized by bile duct compromise leading to severe complications, including intractable jaundice, recurrent cholangitis, biliary cirrhosis, and hepatic failure. Classification into distal MBO (DMBO) and hilar MBO (HMBO) guides therapeutic decision-making, with the former predominantly caused by pancreatic head adenocarcinoma and extrahepatic cholangiocarcinoma, while perihilar cholangiocarcinoma represents the principal etiology of the latter. The high morbidity and mortality associated with MBO necessitate prompt, expert intervention. While endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary biliary drainage (TBD) has traditionally served as the cornerstone of management for unresectable tumors, endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a compelling alternative, particularly when conventional ERCP proves technically unsuccessful or anatomically unfeasible. This review comprehensively examines current endoscopic strategies for MBO, emphasizing the complementary roles of ERCP and EUS-based techniques. Optimal outcomes require intervention by experienced endoscopists at high-volume tertiary centers, with individualized treatment selection based on anatomical considerations, tumor characteristics, patient factors, and local expertise. Full article

Interventional endoscopic ultrasound (EUS) has become a cornerstone in the management of malignant pancreatobiliary diseases, offering minimally invasive alternatives to traditional surgical approaches. More recently, accumulating evidence supports its expanding role in the treatment of benign pancreatobiliary conditions, including acute cholecystitis and pancreatitis, benign gastric outlet obstruction, and scenarios involving altered gastrointestinal anatomy. This narrative review provides an overview of key EUS-guided drainage techniques utilizing lumen-apposing metal stents (LAMSs) in benign settings. It focuses on procedures such as EUS-guided gallbladder drainage, drainage of abdominal collections, EUS-directed transgastric ERCP (EDGE), and EUS-gastroenterostomy. These interventions have demonstrated high technical and clinical success rates, favorable safety profiles, and expanding indications, particularly among patients who are poor surgical candidates. This review highlights evolving techniques, clinical outcomes, and the impact of device innovations on procedural efficacy and safety. Full article

Pancreatic cancer frequently presents with obstructive jaundice resulting from distal malignant biliary obstruction. Neoadjuvant chemotherapy (NAC) is increasingly applied in resectable and borderline resectable disease. In this context, uncontrolled cholestasis or cholangitis may hinder timely chemotherapy initiation and cause unplanned hospitalizations and treatment delays; therefore, preoperative biliary drainage is essential to ensure safe and uninterrupted NAC. This review summarizes current biliary drainage strategies during NAC, focusing on key clinical goals, maintaining durable patency throughout the planned NAC course, minimizing infectious and procedure-related morbidity, reducing the need for reintervention, and avoiding adverse effects on subsequent pancreatoduodenectomy, as well as on practical decision-making in clinical practice. We compare transpapillary drainage via endoscopic retrograde cholangiopancreatography (ERCP) using plastic stents and self-expandable metal stents (SEMSs) and discuss the emerging “slim” fully covered SEMSs designed to reduce the risks of pancreatitis and cholecystitis while maintaining sufficient patency. Endoscopic ultrasound-guided biliary drainage is also reviewed as an important salvage option after failed ERCP and as a potential primary approach in selected patients, and we also discuss conventional percutaneous approaches. Overall, current evidence supports an individualized, algorithm-based strategy that prioritizes durable internal drainage to maintain NAC schedules, reserves percutaneous transhepatic biliary drainage for specific indications, and underscores the need for further prospective studies evaluating long-term surgical and oncologic outcomes in resectable disease. Full article

Background: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) remains technically challenging. Device-assisted ERCP (DAE-ERCP) is widely used for uncomplicated pancreaticobiliary disease but is associated with prolonged procedure times and high failure rates. Endoscopic ultrasound-directed transgastric ERCP (EDGE) offers high technical success but introduces additional cost and the risk of a persistent fistula. We aimed to prospectively identify intra-procedural predictors of DAE-ERCP failure and define an actionable, real-time threshold for early cross-over to EDGE. Methods: We prospectively evaluated consecutive RYGB patients undergoing DAE-ERCP at a tertiary referral center. Patients with established pre-procedural features associated with complex or low-yield DAE-ERCP were triaged directly to EDGE and excluded. Intra-procedural variables were recorded in real time. Univariate and multivariable logistic regression identified predictors of DAE-ERCP failure. Received operating characteristic (ROC) analysis determined optimal cutoffs for cross-over. Results: A total of 94 patients with RYGB underwent ERCP. Amongst these, 42 patients (11 males, 31 females) were included in the analysis and underwent DAE-ERCP with a success rate of 73.8% (n = 31). Significant risk factors of DAE-ERCP failure included excessive resistance to scope advancement (p < 0.0001), failure to reach the ampulla (p < 0.0001), patient position (p = 0.009), BMI (p = 0.004), and time to reach the jejuno-jejunal (J-J) anastomosis (p < 0.0001). Additionally, time needed to reach the J-J anastomosis of ≥23 min [OR 1.360 (95% CI: 1.079–1.713), p = 0.009], excess resistance to scope advancement [OR 2.223 (95% CI: 2.001–4.167)], and failure to reach the ampulla [OR 9.929 (95% CI: 2.004–4.033)] were statistically significant predictors of DAE-ERCP failure. When ≥2 predictors of BA-ERCP failure were present, the likelihood of DAE-ERCP failure was 2.370 with 95.50% sensitivity and 90% specificity with AUC= 0.929 (p = 0.0001). Conclusions: DAE-ERCP remains an effective first-line strategy in appropriately selecting RYGB patients without pre-procedural high-risk features. Real-time intra-procedural predictors can reliably identify impending failure. A structured algorithm incorporating both pre-procedural triage and intra-procedural checkpoints supports timely transition to EDGE, optimizing efficiency, safety, and resource utilization. Full article

Early and accurate date palm disease detection is the key to successful smart farming ecosystem sustainability. In this paper, we introduce DoST-DPD, a new Dual-Stream Transformer architecture for multimodal disease diagnosis utilizing RGB, thermal and NIR imaging. In contrast with standard deep learning approaches, our model receives ontology-based semantic supervision (via per-dataset OWL ontologies), enabling knowledge injection via SPARQL-driven reasoning during training. This structured knowledge layer not only improves multimodal feature correspondence but also restricts label consistency for improving generalization performance, particularly in early disease diagnosis. We tested our proposed method on a comprehensive set of five benchmarks (PlantVillage, PlantDoc, Figshare, Mendeley, and Kaggle Date Palm) together with domain-specific ontologies. An ablation study validates the effectiveness of incorporating ontology supervision, consistently improving the performance across Accuracy, Precision, Recall, F1-Score and AUC. We achieve state-of-the-art performance over five widely recognized baselines (PlantXViT, Multi-ViT, ERCP-Net, andResNet), with our model DoST-DPD achieving the highest Accuracy of 99.3% and AUC of 98.2% on the PlantVillage dataset. In addition, ontology-driven attention maps and semantic consistency contributed to high interpretability and robustness in multiple crop and imaging modalities. Results: This work presents a scalable roadmap for ontology-integrated AI systems in agriculture and illustrates how structured semantic reasoning can directly benefit multimodal plant disease detection systems. The proposed model demonstrates competitive performance across multiple datasets and highlights the unique advantage of integrating ontology-guided supervision in multimodal crop disease detection. Full article

Acute pancreatitis (AP) is an inflammatory condition with varying severity, ranging from mild self-limiting episodes to life-threatening complications. The incidence, clinical presentation, and outcomes of AP differ significantly across age groups, with elderly patients demonstrating distinct challenges. Biliary pancreatitis is more prevalent in older adults, whereas alcohol-induced AP dominates in younger populations. Elderly patients frequently present with atypical or less pronounced abdominal symptoms, which may delay diagnosis. Comorbidities such as kidney failure, cardiovascular disease, diabetes mellitus and arterial hypertension are significantly more common in the elderly and are associated with increased risk of organ dysfunction, systemic complications such as organ failure, multiple organ dysfunction syndrome (MODS), and prolonged hospitalization. The higher incidence of intensive care unit admissions and mortality is noted in the elderly, particularly in those over 80 years, in particular. Evidence on age-related differences in local pancreatic complications is inconsistent, with a possible trend toward lower rates in older adults. Early identification and individualized treatment planning are essential. Abundant fluid administration should be limited in older patients due to frequent cardiac insufficiency but should be carefully monitored due to the present or threatening renal insufficiency. Pain control with opioids may cause severe CNS complications for elderly patients. In contrast, ERCP, when indicated, is usually well tolerated in older patients. Personalized management in elderly patients is strongly recommended. Full article

Background: Post-ERCP pancreatitis (PEP) remains the most common and clinically relevant adverse event following endoscopic retrograde cholangiopancreatography (ERCP). The impact of periampullary duodenal diverticulum and advanced cannulation techniques—particularly needle–knife precut sphincterotomy and transpancreatic septotomy (TPS)—on PEP risk remains debated. This study aimed to evaluate the association of these factors with PEP development in a large tertiary-center cohort. Methods: This retrospective study included 1226 patients who underwent ERCP between January 2018 and October 2022. Demographic, clinical, and procedural variables were recorded. Outcomes included PEP, hyperamylasemia, bleeding, and perforation. Univariable analyses were followed by multivariable logistic regression to identify independent predictors of PEP. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated. Results: PEP occurred in 17.3% of the cohort. Needle–knife precut sphincterotomy and transpancreatic septotomy were frequently used advanced cannulation techniques and were both associated with an increased prevalence of PEP, with PEP occurring in 30.3% of patients undergoing needle–knife precut sphincterotomy and 56.9% of those undergoing transpancreatic septotomy. In the multivariable model, needle–knife precut independently increased PEP risk by 2.45-fold (aOR 2.45; 95% CI 1.78–3.36; p < 0.001), whereas TPS demonstrated the strongest association, increasing the risk nearly fivefold (aOR 4.92; 95% CI 2.98–8.11; p < 0.001). Female sex showed a nonsignificant trend toward increased PEP risk (aOR 1.28; 95% CI 0.96–1.69; p = 0.08). Periampullary duodenal diverticulum, pancreatic duct stenting, comorbidities, and age were not independently associated with PEP development (p > 0.05 for all). Conclusions: Needle–knife precut sphincterotomy and transpancreatic septotomy were independent predictors of PEP, with the highest risk observed for transpancreatic septotomy, whereas periampullary diverticulum and pancreatic duct stenting were not associated with increased risk. Full article

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment option for choledocholithiasis. However, this procedure carries an inherent non-negligible risk of complications, requiring precise indications and careful patient selection. Endoscopic ultrasonography (EUS) can verify the presence of bile duct stones prior to ERCP. The current ESGE recommendations permit ERCP in high-risk patients without confirmation; however, several individuals undergo ERCP without evident advantage, indicating a necessity for enhanced stratification. Objectives: We aim to evaluate the rate of EUS-validated choledocholithiasis in patients with suspected common bile duct (CBD) stones and to determine the predictors of residual stones. A secondary objective was to create and internally validate a streamlined scoring system to enhance risk assessment in ESGE high-risk patients. Methods: We conducted a retrospective analysis of patients who had endoscopic ultrasound for suspected choledocholithiasis from January 2023 to December 2024 at a tertiary center. Multivariate logistic regression determined independent predictors of retained calculi. A simplified score was derived from model coefficients and internally validated. Results: Among 438 examined patients, 186 were included and 87 had choledocholithiasis confirmed via EUS. ERCP was conducted in 81 patients and postponed for 6 patients due to contraindications. According to the ESGE criteria, 10 patients (5.4%) were classified as low risk, 92 (49.5%) as intermediate risk, and 84 (45.2%) as high risk for choledocholithiasis. For high-risk individuals, EUS identified stones in 45 (53.5%), while 39 (46.4%) experienced spontaneous clearance. Acute pancreatitis (aOR 0.075), cholangitis (aOR 6.939), and EUS CBD diameter (aOR 1.220 per mm) were independent predictors of stones. The resultant three-component score (−2 to +4 points) demonstrated effective discrimination (AUROC 0.788). A criterion of ≥2 resulted in 85.7% sensitivity and 59.0% specificity. Conclusions: Almost fifty percent of ESGE high-risk patients were not found to have CBD stones during EUS. Integrating EUS data with a straightforward predictive score may enhance risk classification and avert superfluous ERCP procedures. Full article

Endoscopic nasobiliary drainage (ENBD) is a well-established technique for biliary decompression in both benign and malignant conditions. Over the past decades, its role has been extensively evaluated in comparison with endoscopic biliary stenting and percutaneous transhepatic biliary drainage. ENBD provides distinct clinical advantages, including real-time monitoring of bile output, the possibility to perform irrigation, and the ability to collect bile samples for cytological analysis. However, it also presents specific challenges such as patient discomfort, tube dislodgement, and the need for careful maintenance. This narrative review synthesizes current evidence from randomized controlled trials, retrospective cohorts, systematic reviews, and meta-analyses, highlighting the main indications, technical innovations, comparative outcomes with alternative drainage techniques, and strategies to prevent complications. Furthermore, it discusses emerging approaches aimed at improving patient tolerance, procedural efficiency, and environmental sustainability, offering an updated framework for optimizing patient management in both benign and malignant biliary obstruction. Full article

Background: Open access endoscopy (OAE) allows outpatient endoscopic procedures without prior consultation with the endoscopist, a practice common in adult gastroenterology but not part of pediatric gastroenterology practice. Here we evaluate the feasibility and safety of a newly implemented pediatric OAE program. Methods: We identified patients aged 18 and under who underwent OAE in the first year of our program using a prospectively maintained endoscopy database. The program involved three experienced endoscopists and included demographics, indications, interventions, and adverse events. Patients/parents received follow-up calls on day 1 and day 7 to detect adverse events and assess perceptions of the OAE process. Results: A total of 54 outpatient OAE procedures were performed, with a median patient age of 10 years (range 18 months–18 years). This included 33 esophagogastroduodenoscopies (EGDs) and 16 colonoscopies, all with biopsies. ERCPs were performed for stone management (4) and stricture evaluation/stent exchange (1). All procedures were successful with no adverse events reported, and patient/parent feedback indicated that the OAE approach was beneficial in terms of lifestyle, socioeconomic, and psychological aspects. Some challenges were identified through follow-up discussions. Conclusions: Our early experience suggests that pediatric OAE is feasible and appeared safe within this small pilot cohort, with no adverse events observed. Advantages of pediatric OAE include minimizing missed school days and reducing medical anxiety. Feedback has led to refinements in practice at our institution, and further study on OAE is warranted at the endoscopy society level. Larger studies are needed to determine safety, effectiveness, and generalizability. Full article

Background and Objectives: Fluid leakage through the biopsy port during endoscopic retrograde cholangiopancreatography (ERCP) is a common procedural challenge that can compromise efficiency and increase the risk of contamination. In this study, we aimed to evaluate factors associated with fluid leakage and describe the performance of a novel leakage-collection device. Materials and Methods: A total of 183 patients who underwent ERCP between June and September 2024 at a single center were included. Fluid leakage was measured using a prototype collection device. Patients were categorized into low- (n = 126) and high-leakage (n = 57) groups based on the mean leakage volume. Logistic regression models were used to identify the clinical and procedural factors associated with high leakage. Results: Higher procedural complexity (Schutz grade) was strongly associated with high leakage (OR per grade increase, 3.66; 95% CI, 2.33–6.07; p < 0.001). In multivariable analysis, prolonged procedure duration (aOR, 1.11; 95% CI, 1.06–1.17) and more frequent duodenal flushing (aOR, 5.38; 95% CI, 1.80–18.75) were independently associated with high fluid leakage. Biliary plastic stenting (aOR, 4.53; 95% CI, 1.54–14.69) and malignancy (aOR, 3.02; 95% CI, 1.13–8.39) also showed significant associations. The device collected a mean fluid volume of 11 mL per procedure. Conclusions: Prolonged procedure duration and frequent duodenal flushing were key predictors of increased fluid leakage during ERCP. The leakage-collection device enabled measurement and containment of biopsy-port fluid but requires further validation to determine its broader clinical utility. Full article

Background/Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement is a mainstay of current management for biliary obstruction, with stent occlusion being the most common and severe complication. The mechanism of stent occlusion is well known; however, factors affecting individual stent patency are still controversial. The objective of this study was to determine the duration and factors affecting plastic biliary stent patency. Methods: We conducted a retrospective analysis of the consecutive procedures of endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement in a single tertiary center during the period of 2010–2019. The primary outcome of the study was the time of stent patency. Secondary outcomes were the development of cholangitis upon re-stenting and whether subsequent re-stenting was emergent. Re-stenting was considered emergent if it happened before the planned elective re-stenting date, irrespective of indication (development of cholangitis, rising jaundice, suspected dislodgement, etc.). Results: Between 2010 and 2019, a total of 5462 ERCP procedures were performed, with 2659 resulting in plastic biliary stent placement. On average, the plastic biliary stent was patent for 63 (25, 96) days with significant differences between the indications for ERCP groups. The strongest risk factors for the development of cholangitis upon re-stenting was cholangitis during index ERCP (HR = 1.83; 95% CI: 1.48–2.27; p < 0.001), intrabiliary malignancy being the indication for stenting (HR = 1.34; 95% CI: 1.12–1.60; p < 0.001) and increasing number of stents being placed (HR = 1.73; 95% CI: 1.27–2.36; p < 0.001). Conclusions: Patients with an underlying malignancy, history of cholangitis, and multiple biliary stents are at an increased risk for stent occlusion and cholangitis, warranting a tailored stent exchange interval to prevent complications. Full article

Background and Objectives: Aspiration pneumonia is a well-described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post-endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP). Materials and Methods: All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between 1 April 2022 and 31 August 2024 were retrospectively evaluated. Demographic, clinical and endoscopic data were collected. Results: One thousand one hundred forty consecutive ERCPs were included. The main indication was malignant biliary stricture, and the patient’s mean age was 68 ± 13.9 years. Overall incidence of pEP was 2.7%. The American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated with a higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-day mortality and for prolonged hospital stay. Conclusions: pEP is a relatively frequent adverse event after ERCP. In patients with a high ASA-score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data. Full article

Iatrogenic bile duct injury (IBDI) constitutes a major complication of cholecystectomy. The optimal timing, method, and setting for definitive repair remain subjects of debate. This study aimed to systematically evaluate management strategies, timing of repair, and prognostic factors influencing postoperative outcomes following IBDI. A systematic review and meta-analysis were conducted in accordance with PRISMA and MOOSE guidelines (PROSPERO CRD420251003227). PubMed and the Cochrane Library were searched through March 2025. Eligible randomized trials and cohort studies reporting management outcomes were included. Data extraction and quality assessment were performed independently. Pooled analyses were conducted using random-effects models. Twenty-eight studies (2 randomized trials, 24 cohort studies, 2 systematic reviews) involving >18,000 patients were analyzed. Surgical repair achieved higher success than endoscopic therapy (92.6% vs. 76.1%; RR 1.22, 95% CI 1.10–1.35) and reduced stricture risk (RR 0.24, 95% CI 0.15–0.38). Roux-en-Y hepaticojejunostomy provided durable outcomes (success 83.5%; stricture 8.9%). Early (<2 weeks) or delayed (>6 weeks) repair after sepsis control was associated with lower morbidity (9–11%) compared with intermediate repair (2–6 weeks). Referral to hepatopancreatobiliary (HPB) centers reduced complications (RR 0.32, 95% CI 0.23–0.46). Overall morbidity and mortality were 22.7% and 2.9%. Outcomes following IBDI are determined primarily by surgical expertise and patient stability rather than timing alone. In optimized patients, both early and delayed reconstruction are safe and effective, whereas intermediate repair and non-specialist interventions increase risk. Timely referral to HPB centers should be considered standard practice. Full article