Search Results (60)

Endoscopic retrograde cholangiopancreatography (ERCP) remains the reference standard for biliary drainage, yet it fails in up to 15% of cases, most notably when a surgically altered anatomy (SAA) is present. The expanding use of bariatric and oncologic gastrointestinal surgery has increased the number of patients in whom the papilla is displaced, unreachable, or replaced by a biliodigestive anastomosis, making conventional access difficult or impossible. This narrative review appraises the current evidence on endoscopic biliary drainage in SAA, focusing on procedural efficacy, anatomical peculiarities, adverse-event profiles and technical considerations to guide clinical decision-making. Available strategies include luminal techniques, duodenoscope-assisted ERCP, forward-viewing (cap-assisted colonoscope) ERCP, and enteroscope-assisted ERCP, as well as endoscopic ultrasound-guided biliary drainage (EUS-BD), encompassing EUS-guided hepaticogastrostomy, EUS-guided antegrade stenting, EUS-guided rendezvous and EUS-directed transgastric/transenteric ERCP (EDGE/EDEE), and laparoscopic-assisted ERCP (LA-ERCP). No single approach is universally superior and available comparative data is mainly retrospective and affected by major selection bias. Technique selection should be tailored to the reconstruction type, indication (benign vs. malignant), limb length, expected survival, and local expertise, ideally within a multidisciplinary, high-volume setting. Adequately powered randomized trials incorporating quality-of-life and cost-effectiveness endpoints are still needed to define the optimal first-line strategy. This literature review encompasses the multiple strategies to achieve biliary drainage in surgically altered anatomy, highlighting strengths and weaknesses of each technique, as well as the preferred approach for each type of anatomical reconstruction. Full article

Malignant distal biliary obstruction (MDBO) is most commonly managed by endoscopic retrograde cholangiopancreatography (ERCP) with self-expandable metal stent placement. When ERCP fails or is not feasible, endoscopic ultrasound-guided biliary drainage (EUS-BD) has increasingly replaced percutaneous transhepatic biliary drainage in expert centers. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as an indirect route for biliary decompression when the cystic duct is patent. This comprehensive narrative review focuses on the anatomical rationale, patient selection, procedural technique, comparative positioning, clinical outcomes, adverse events, and unresolved issues of EUS-GBD in MDBO. The supporting evidence is predominantly observational. Published meta-analyses report technical success generally exceeding 90%, pooled clinical success of approximately 82–89%, and overall adverse event rates of approximately 10–14%; these estimates vary with study selection, outcome definitions, assessment time points, and predominantly observational study designs. Comparative studies suggest efficacy and safety similar to EUS-guided choledochoduodenostomy after failed ERCP in anatomically selected patients, although nonrandomized allocation and confounding by indication remain major limitations. A prospective study has demonstrated feasibility as primary palliation, but this strategy cannot yet be considered standard of care. Prophylactic EUS-GBD to prevent post-stenting cholecystitis represents a separate indication and should not be conflated with EUS-GBD for biliary decompression. The key determinant of physiological success is unobstructed communication between the gallbladder and the central biliary tree; therefore, cystic duct patency, tumor relationship to the cystic duct take-off, gallbladder distension, and the absence of extensive gallbladder involvement must be assessed before intervention. EUS-GBD is best positioned as a rescue option after failed ERCP when direct EUS-BD is technically impossible, unsafe, or unsuccessful. Prospective randomized trials, standardized outcome definitions, comparative cost-effectiveness analyses, and dedicated long-term stent management protocols are needed before broader adoption. Full article

Background and Objectives: Malignant double obstruction, defined as the coexistence of malignant biliary obstructio (MBO) and malignant gastric outlet obstruction (mGOO), frequently complicates advanced pancreatic and periampullary malignancies. Because biliary and duodenal obstructions are anatomically and functionally interconnected, treatment of one may influence the outcome of the other. This review aims to summarize current evidence on endoscopic management strategies and to propose an anatomy-driven approach integrating conventional and endoscopic ultrasound (EUS)-guided techniques. Materials and Methods: A narrative review of the current literature was performed, focusing on endoscopic approaches for malignant biliary and gastric outlet obstruction. Available evidence regarding endoscopic retrograde cholangiopancreatography (ERCP), EUS-guided biliary drainage (EUS-BD), enteral self-expandable metal stenting, and EUS-guided gastroenterostomy (EUS-GE) was critically analyzed, focusing on technical feasibility, clinical outcomes, adverse events, and therapeutic sequencing. Results: ERCP remains an effective option when papillary access is preserved; however, duodenal obstruction, especially when involving the papilla, represents a major limitation. EUS-BD has emerged as a reliable alternative after failed ERCP and may provide a primary drainage strategy in selected patients. In the setting of concomitant gastric outlet obstruction, EUS-guided hepaticogastrostomy may offer advantages over choledochoduodenostomy by avoiding the obstructed duodenal pathway. For malignant gastric outlet obstruction, enteral stenting provides rapid symptom relief, but is associated with limited long-term durability. EUS-GE has demonstrated high technical and clinical success rates, lower rates of recurrent obstruction compared with enteral stenting, and outcomes comparable to surgical gastrojejunostomy with reduced invasiveness. These findings support an integrated EUS-based approach for selected patients. Conclusions: Malignant double obstruction should be considered a single anatomofunctional entity rather than two independent conditions. An individualized, anatomy-driven strategy combining EUS-guided biliary drainage and EUS-GE may represent the future direction of endoscopic palliation, allowing durable internal bypass and facilitating oncological management. Further prospective studies are required to define optimal treatment sequencing and patient selection. Full article

Background/Objectives: Interventional endoscopic ultrasound (I-EUS) has evolved from a diagnostic imaging modality into a transformative therapeutic platform encompassing biliary drainage, pancreatic interventions, luminal bypass, pain management, and ablative therapies. Despite the rapid proliferation of I-EUS research, a comprehensive bibliometric analysis characterizing the global intellectual architecture of this field is lacking. Methods: A Web of Science Core Collection search identified 4340 records, of which 2237 were included (2001–2024), analyzed with R bibliometrix (version 5.0) and VOSviewer (version 1.6.20). Results: Publication output demonstrated three distinct phases with pronounced acceleration from 2017. The United States led global output (n = 625, 27.9%), followed by Japan (n = 435, 19.4%) and Italy (n = 166, 7.42%). At the continental level, Asia collectively produced the largest share of output (n = 884, 39.5% of the total corpus), exceeding the Americas (n = 687, 30.7%) and Europe (n = 492, 22.0%). Gastrointestinal Endoscopy was the most productive journal (n = 173). Tokyo Medical University was the most productive institution (n = 93, 4.16%). Four thematic clusters were identified: EUS-guided biliary and pancreatic ductal drainage; diagnostic, ablative, and injection EUS for pancreatic tumors; LAMS-enabled luminal bypass and gallbladder drainage; and pancreatic fluid collections and necrotizing pancreatitis. Temporal overlay confirmed EUS-guided gastroenterostomy, EUS-guided gallbladder drainage, and EUS-guided radiofrequency ablation as the leading research frontiers. Annual output showed no discernible contraction during the COVID-19 pandemic period (2020–2021). Conclusions: The United States led global I-EUS research output with higher rates of international collaboration compared with East Asian nations, although Asia as a continent generated the largest aggregate volume of publications. EUS-guided biliary drainage and pancreatic fluid collection management constitute the established, high-volume core of the field, while EUS-guided gastroenterostomy and novel ablative technologies represent the most dynamic investigative frontiers. Full article

Background/Objectives: Acute cholecystitis in patients with malignant biliary obstruction (MBO) is challenging to manage. Evidence for endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using double-pigtail plastic stents (DPPS) in this setting remains limited. We evaluated the efficacy and safety of EUS-GBD using DPPS for acute cholecystitis in patients with MBO. Methods: We retrospectively reviewed 41 consecutive patients who underwent EUS-GBD using DPPS at two centers. The primary endpoint was technical success; secondary endpoints included clinical success, adverse events, recurrence, and subsequent oncologic treatment. Results: Technical success was achieved in 95.1% (39/41), with clinical success in all technically successful cases. Adverse events included biliary peritonitis (14.6%) and procedure-related DPPS migration (2.4%). Recurrence occurred in 2.6% of patients. Systemic therapy was resumed in 10 of 18 patients (55.6%) at a median of 15 days after EUS-GBD. Conclusions: EUS-GBD using DPPS achieved high technical and clinical success rates with a low recurrence rate in selected patients with acute cholecystitis and MBO. Systemic therapy could be resumed in a subset of patients following successful drainage. These findings suggest that DPPS-based EUS-GBD may be a feasible internal drainage option in this setting, although prospective comparative studies are needed to further establish its safety and effectiveness. Full article

Acute cholecystitis (AC) is one of the most prevalent gastrointestinal emergencies, with laparoscopic cholecystectomy representing the definitive treatment per current guidelines. However, a substantial proportion of patients—particularly elderly individuals with major comorbidities, multiorgan dysfunction, or advanced malignancy—are considered poor surgical candidates in whom operative intervention carries prohibitive risk. Although percutaneous transhepatic gallbladder drainage (PT-GBD) has traditionally served as the first-line non-surgical alternative, its significant morbidity and technical limitations in patients with coagulopathy, massive ascites, or an unsafe percutaneous window have driven the development of endoscopic drainage modalities. This review critically appraises the comparative evidence for two endoscopic gallbladder drainage strategies: endoscopic transpapillary gallbladder drainage (ET-GBD), performed via endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), most commonly using lumen-apposing metal stents (LAMS). In appropriately selected high-risk surgical candidates, EUS-GBD with LAMS has emerged as a preferred endoscopic option, supported by high technical success rates, low recurrent AC rates, AGA expert guidance, and FDA regulatory reclassification of the AXIOS stent for gallbladder drainage. Nevertheless, ET-GBD retains distinct clinical indications, including concurrent biliary intervention, large-volume ascites, high bleeding risk, anticipated surgical candidacy, and resource-limited settings. Optimal management requires a systematic, algorithm-driven multidisciplinary approach integrating comorbidity profile, biliary anatomy, cystic duct patency, and institutional expertise. Full article

Background/Objectives: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with Lumen-Apposing Metal Stent (LAMS) is an established option for high-surgical-risk patients, with high technical and clinical success. Indications include acute cholecystitis and palliation of jaundice in malignant distal biliary obstruction (MDBO). Both trans-gastric and trans-duodenal approaches are used, but the optimal route remains debated. The aim of the study was to compare trans-gastric and trans-duodenal access in terms of technical success, adverse events, readmissions, and reinterventions. Methods: We implemented a single-centre retrospective study of consecutive EUS-GBD procedures with LAMS at a tertiary endoscopy unit (January 2020–January 2026). Demographic, clinical, and procedural data were analyzed using appropriate statistical tests. Results: Seventy patients were included (51.4% male; mean age 77 ± 12 years). Indications were acute cholecystitis (64.3%) and MDBO (35.7%). Trans-gastric access was used in 48.5% of cases. A Hot-Axios LAMS was deployed in 77.2% of cases, mostly >10 mm. Technical success was achieved in 98.5% of cases. Naso-cystic drainage (NCD) was used through the LAMS in 47.1% of patients, while a double pig-tail plastic stent was used in 7.2% of patients. Adverse events were rare (1.4% misdeployment). LAMS obstruction occurred in 10% of patients, with reintervention required in 12.8% of patients. No differences were found between access routes in indication, technical success, LAMS type/size, or adjunctive drainage. However, trans-gastric access was associated with a higher reintervention rate (p = 0.01). Conclusions: EUS-GBD is a safe and effective procedure. While both approaches are comparable in most outcomes, the trans-gastric route may carry a higher risk of reintervention and should be avoided when alternative access is feasible. Full article

In this review, we explore the evolving role of endoscopic ultrasound (EUS) in diagnosing and managing pancretobiliary malignancies. For solid pancreatic lesions, techniques like fine-needle biopsy (FNB), contrast-enhanced EUS (CE-EUS), and macroscopic on-site evaluation (MOSE) improve sample quality and diagnostic accuracy. In cystic pancreatic lesions, fine-needle aspiration (FNA), molecular testing, and confocal laser endomicroscopy (nCLE) aid in distinguishing benign from malignant cysts. For cholangiocarcinoma, EUS guided sampling is more accurate than CT in assessing distal lesions and lymph node metastases, while combining EUS with magnetic resonance cholangiography (MRC) enhances diagnostic sensitivity. In gallbladder cancer, EUS surpasses CT and MRI in detecting lymphadenopathy and staging tumors. EUS-FNB (Fine needle biopsy) improves biopsy accuracy, especially for unresectable cases. These advancements highlight EUS as a critical tool for early cancer detection, staging, and tissue acquisition. Beyond diagnosis, EUS plays a pivotal therapeutic role in managing complications such as malignant biliary obstruction and gastric outlet obstruction, offering minimally invasive alternatives like EUS-guided biliary drainage and gastroenterostomy with high clinical success and improved patient outcomes. Full article

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging intervention that provides a minimally invasive approach to drainage of the gallbladder, showing promising results in treating acute cholecystitis (AC) and malignant biliary obstruction (MBO). This review summarizes the current applications of EUS-GBD and compares its clinical effectiveness with traditional methods such as percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic transpapillary gallbladder drainage (ET-GBD). Available evidence suggests that EUS-GBD may offer potential advantages in terms of success rates and complication profiles, particularly in patients who are not candidates for surgery or those at high surgical risk. The method is effective in reducing inflammation, alleviating symptoms from obstruction, and improving patient quality of life. This article also discusses the technical evolution of EUS-GBD, its indications, complications, and its comparative advantages over other drainage techniques. These observations suggest that EUS-GBD may represent a valuable addition to the therapeutic armamentarium for selected high-risk patients. Full article

Therapeutic endoscopic ultrasound (t-EUS) has transformed the management of biliopancreatic diseases by enabling minimally invasive access and intervention through the gastrointestinal wall. This narrative review summarizes current indications and evolving roles of t-EUS in benign and malignant biliary disease, with a focus on the different modalities of transmural drainage, EUS-guided gastroenterostomy (EUS-GE), and EUS-guided radiofrequency ablation (EUS-RFA). In benign settings, EUS-gallbladder drainage (EUS-GBD) has emerged as a minimally invasive alternative to percutaneous cholecystostomy for high-risk patients with acute cholecystitis, offering internal drainage with fewer tube-related adverse events. In malignant biliary obstruction, transmural drainages are consolidated alternatives of endoscopic retrograde cholangiopancreatography (ERCP) as first-line or rescue strategies, providing durable internal biliary drainage, avoiding post-ERCP pancreatitis without deteriorating quality of life. In surgically altered anatomy, t-EUS overcomes the limitations of enteroscopy-assisted ERCP by creating direct access routes to the biliary tree or pancreatic duct. EUS-guided pancreatic duct drainage offers a rescue or primary approach in benign strictures, anastomotic stenosis, and disconnected duct syndrome. EUS-GE has rapidly become a preferred modality for palliation of gastric outlet obstruction in pancreatic cancer, while EUS-RFA provides a platform for locoregional therapy in selected cases of pancreatic neuroendocrine tumors, adenocarcinoma, and pancreatic cystic neoplasms. Collectively, these applications position t-EUS as a central tool in the multidisciplinary management of complex biliopancreatic disease, with ongoing innovations expected to further expand its indications and safety and to refine patient selection and training pathways. Full article

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/Objectives: Biliary complications are common after liver transplantation (LT), with bile leaks representing a major cause of morbidity. Conventional imaging modalities such as ultrasound, CT, MRCP, and endoscopic techniques may fail to localize peripheral or complex leaks. This study aimed to evaluate the feasibility of [⁶⁸Ga]Ga-TEoS-DAZA-PET/CT for non-invasive localization of bile leaks after LT. Methods: Five male patients (mean age 53.2 years) with suspected bile leakage and inconclusive prior imaging underwent [⁶⁸Ga]Ga-TEoS-DAZA-PET/CT. The tracer was synthesized under GMP conditions and administered at a mean activity of 204 ± 42 MBq. Dynamic PET/CT imaging was performed for 60 min, and findings were classified according to the Nagano classification. Results: Bile leaks were detected and anatomically localized in all five patients. Sites included the liver resection surface, central bile ducts, bilioenteric anastomosis, and biliary drainage exit. PET/CT findings guided revision surgery in one case and endoscopic treatment in three, while one patient improved without intervention. No adverse effects occurred. Conclusions: [⁶⁸Ga]Ga-TEoS-DAZA-PET/CT is a feasible and safe imaging technique for the anatomical localization of bile leaks following LT. Its antegrade visualization of biliary flow, high spatial and temporal resolution, and lack of contraindications make it a promising complementary modality when conventional imaging is inconclusive or not feasible. Larger studies are warranted to validate its diagnostic value and clinical utility in postoperative and post-traumatic biliary injuries. Full article