Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope:A multicenter retrospective international study

Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages:A systematic review focusing on issues and rescue management

BACKGROUND The introduction of lumen-apposing metal stents(LAMS)for endoscopic ultrasound(EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings.Nevertheless,the procedure may conceal unexpected pitfalls.LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences.Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure.To date,no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.AIM To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy(EUS-CDS),gallbladder drainage(EUS-GBD)and pancreatic fluid collections drainage(EUS-PFC)and to describe the endoscopic rescue strategies adopted under the circumstance.METHODS We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022.The search was carried out using the exploded medical subject heading terms“lumen apposing metal stent”,“LAMS”,“endoscopic ultrasound”and“choledochoduodenostomy”or“gallbladder”or“pancreatic fluid collections”.We included in the review on-label EUS-guided procedures namely EUS-CDS,EUS-GBD and EUS-PFC.Only those publications reporting EUS-guided LAMS positioning were considered.The studies reporting a technical success rate of 100%and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment,while studies not reporting the causes of technical failure were excluded.Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques.The following data were collected from each study:Author,year of publication,study design,study population,clinical indication,technical success,reported number of misdeployment,stent type and size,flange misdeployed and type of rescue strategy.RESULTS The overall technical success rate of EUS-CDS,EUS-GBD and EUS-PFC was 93.7%,96.1%,and 98.1%respectively.Significant rates of LAMS misdeployment have been reported for EUS-CDS,EUS-GBD and EUS-PFC drainage,respectively 5.8%,3.4%,and 2.0%.Endoscopic rescue treatment was feasible in 86.8%,80%,and 96.8%of cases.Non endoscopic rescue strategies were required only in 10.3%,16%and 3.2%for EUS-CDS,EUS-GBD,and EUS-PFC.The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%,8%and 64.5%and stent-in-stent in 23.5%,60%,and 12.9%,respectively for EUSCDS,EUS-GBD,and EUS-PFC.Further therapeutic option were endoscopic rendezvous in 11.8%of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1%of EUS-PFC.CONCLUSION LAMS misdeployment is a relatively common adverse event in EUS-guided drainages.There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario,anatomical characteristics,and local expertise.In this review,we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used,with the aim of providing useful data for endoscopists and to improve patient outcomes.

Endoscopic management of benign biliary strictures:Looking for the best stent to place

Benign biliary strictures(BBS)might occur due to different pancreaticobiliary conditions.The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations.The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS,considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable.The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis(ABP) is still being debated. Despite numerous randomized trials have been published,there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography(ERCP) in ABP in metaanalyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography(EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis,but it has been shown to be accurate,safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Malignant gastric outlet obstruction:Which is the best therapeutic option?

Malignant gastric outlet obstruction(MGOO)is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration,with consequent reduction or impossibility of an adequate oral intake.MGOO is mainly secondary to advanced pancreatic or gastric cancers,and significantly impacts on patients’survival and quality of life.Patients suffering from this condition often present with intractable vomiting and severe malnutrition,which further compromise therapeutic chances.Currently,palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents.Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions,at the cost of higher procedure-related risks and longer hospital stay.On the other hand,enteral stenting provides rapid clinical improvement,but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent reinterventions.Recently,a third way has come from interventional endoscopic ultrasound,through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent.This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy,and brought encouraging results so far,even if prospective comparative trial are still lacking.In this Review,we described technical aspects and clinical outcomes of the above-cited therapeutic approaches,and discussed the open questions about the current management of MGOO.

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography(EUS) in the management of acute biliary pancreatitis(ABP).METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low,moderate,or high probability of common bile duct(CBD) stones,according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated:(1) clinical: age,sex,fever;(2) radiological: dilated CBD; and(3) biochemical: bilirubin,AST,ALT,g GT,ALP,amylase,lipasis,PCR. Association between presence of CBD stone at EUS and the individual predictors wereassessed by univariate logistic regression. Predictors significantly associated with CBD stones(P < 0.05) were entered in a multivariate logistic regression model.RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients(38 females,53.5%,mean age 58 ± 20.12 years,range 27-89 years; 33 males,46.5%,mean age 65 ± 11.86 years,range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases(29%),moderate in 26(37%),and high in the remaining 24(34%). The 71 patients included in the study underwent EUS,which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min(range 9-34 min),without any notable complications.The overall CBD stone frequency was 44%(31 of 71),with a significant increase from the group at low pretest probability to that at moderate(OR = 5.79,P = 0.01) and high(OR = 4.25,P = 0.03) pretest probability.CONCLUSION: Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Endoscopic management of difficult common bile duct stones:Where are we now?A comprehensive review

Endoscopic management for difficult common bile duct(CBD)stones still presents a challenge for several reasons,including anatomic anomalies,patients’individual conditions and stone features.In recent years,variable methods have emerged that have attributed to higher stone removal success rates,reduced cost and lower adverse events.In this review,we outline a stepwise approach in CBD stone management.As first line therapy,endoscopic sphincterotomy and large balloon dilation are recommended,due to a 30%-50%reduction of the use of mechanical lithotripsy.On the other hand,cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence.As discussed,findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions.Furthermore,we evaluate the management of CBD stones in various surgical altered anatomy(Billroth II,Roux-en-Y and Roux-en-Y gastric bypass).Moreover,we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use,rather than following a failed management option.In addition,we discuss the importance of dissecting other techniques,such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed.In conclusion,we recognize that endoscopic sphincterotomy and large balloon dilation,mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones,but emerging techniques are in rapid evolution with encouraging results.

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUSguided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and ECLAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Microbiota-gut-brain axis and its affect inflammatory bowel disease:Pathophysiological concepts and insights for clinicians

Despite the bi-directional interaction between gut microbiota and the brain not being fully understood,there is increasing evidence arising from animal and human studies that show how this intricate relationship may facilitate inflammatory bowel disease(IBD)pathogenesis,with consequent important implications on the possibility to improve the clinical outcomes of the diseases themselves,by acting on the different components of this system,mainly by modifying the microbiota.With the emergence of precision medicine,strategies in which patients with IBD might be categorized other than for standard gut symptom complexes could offer the opportunity to tailor therapies to individual patients.The aim of this narrative review is to elaborate on the concept of the gutbrain-microbiota axis and its clinical significance regarding IBD on the basis of recent scientific literature,and finally to focus on pharmacological therapies that could allow us to favorably modify the function of this complex system.

Enhanced endoscopic ultrasound imaging for pancreatic lesions: The road to artificial intelligence

Early detection of pancreatic cancer has long eluded clinicians because of its insidious nature and onset.Often metastatic or locally invasive when symptomatic,most patients are deemed inoperable.In those who are symptomatic,multi-modal imaging modalities evaluate and confirm pancreatic ductal adenocarcinoma.In asymptomatic patients,detected pancreatic lesions can be either solid or cystic.The clinical implications of identifying small asymptomatic solid pancreatic lesions(SPLs)of<2 cm are tantamount to a better outcome.The accurate detection of SPLs undoubtedly promotes higher life expectancy when resected early,driving the development of existing imaging tools while promoting more comprehensive screening programs.An imaging tool that has matured in its reiterations and received many image-enhancing adjuncts is endoscopic ultrasound(EUS).It carries significant importance when risk stratifying cystic lesions and has substantial diagnostic value when combined with fine needle aspiration/biopsy(FNA/FNB).Adjuncts to EUS imaging include contrast-enhanced harmonic EUS and EUS-elastography,both having improved the specificity of FNA and FNB.This review intends to compile all existing enhancement modalities and explore ongoing research around the most promising of all adjuncts in the field of EUS imaging,artificial intelligence.

Use of artificial intelligence in improving adenoma detection rate during colonoscopy:Might both endoscopists and pathologists be further helped

Colonoscopy remains the standard strategy for screening for colorectal cancer around the world due to its efficacy in both detecting adenomatous or precancerous lesions and the capacity to remove them intra-procedurally.Computeraided detection and diagnosis(CAD),thanks to the brand new developed innovations of artificial intelligence,and especially deep-learning techniques,leads to a promising solution to human biases in performance by guarantying decision support during colonoscopy.The application of CAD on real-time colonoscopy helps increasing the adenoma detection rate,and therefore contributes to reduce the incidence of interval cancers improving the effectiveness of colonoscopy screening on critical outcome such as colorectal cancer related mortality.Furthermore,a significant reduction in costs is also expected.In addition,the assistance of the machine will lead to a reduction of the examination time and therefore an optimization of the endoscopic schedule.The aim of this opinion review is to analyze the clinical applications of CAD and artificial intelligence in colonoscopy,as it is reported in literature,addressing evidence,limitations,and future prospects.

Relief of jaundice in malignant biliary obstruction:When should we consider endoscopic ultrasonography-guided hepaticogastrostomy as an option?

Background:Since it was first described in 2001,endoscopic ultrasonography-guided biliary drainage(EUS-BD)has emerged as an alternative procedure for achieving an endoscopic internal drainage in case of endoscopic retrograde cholangiopancreatography(ERCP)failure.Biliary drainage can be achieved by either a transduodenal extrahepatic approach through EUS-guided choledochoduodenostomy(EUS-CDS),or a transgastric intrahepatic approach,namely EUS-guided hepaticogastrostomy(EUS-HGS)which already holds a remarkable place in the treatment of patients with malignant biliary obstruction.Data sources:For this review we did a comprehensive search of PubMed/MEDLINE from inception to May 31,2021 for papers with a significant sample size(at least 20 patients enrolled)dealing with EUS-HGS.Data on technical success,clinical success and rate of adverse events were collected.Results:A total of 22 studies with different design,com prising 874 patients,were included.Technical success was achieved in about 96% of cases(ranging from 65% to 100%).Clinical success was obtained in almost 91% of cases(ranging from 76% to 100%).Overall rate of adverse events was 19%(ranging from 0% to 35%).Abdominal pain,self-limiting pneumoperitoneum,bile leak,cholangitis,bleeding,perforation and intraperitoneal migration of the stent were the most common.Conclusions:Despite both safety and efficacy profile,at the moment HGS still remains a challenging procedure at every single step and must therefore be conducted by a very experienced endoscopist in interventional EUS and ERCP procedures,who is able to deal with the possible severe adverse events of this procedure.A rapid introduction in clinical practice of dedicated devices is desiderable.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years,self-expandable metal stents(SEMSs)have been employed to treat benign gastrointestinal strictures secondary to several conditions:Acute diverticulitis,radiation colitis,inflammatory bowel disease(IBD),and postanastomotic leakages and stenosis.Other applications include endometriosis and fistulas of the lower gastrointestinal tract.Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract,the outcome has been reported to be poor.In fact,in some settings(such as complicated diverticulitis and postsurgical anastomotic strictures),stenting seems to have a limited evidence-based benefit as a bridge to surgery,while in other settings(such as endometriosis,IBD,radiation colitis,etc.),even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement.The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract,both in adult and pediatric settings.

Artificial intelligence technologies for the detection of colorectal lesions: The future is now

Several studies have shown a significant adenoma miss rate up to 35%during screening colonoscopy,especially in patients with diminutive adenomas.The use of artificial intelligence(AI)in colonoscopy has been gaining popularity by helping endoscopists in polyp detection,with the aim to increase their adenoma detection rate(ADR)and polyp detection rate(PDR)in order to reduce the incidence of interval cancers.The efficacy of deep convolutional neural network(DCNN)-based AI system for polyp detection has been trained and tested in ex vivo settings such as colonoscopy still images or videos.Recent trials have evaluated the real-time efficacy of DCNN-based systems showing promising results in term of improved ADR and PDR.In this review we reported data from the preliminary ex vivo experiences and summarized the results of the initial randomized controlled trials.

Advanced imaging and artificial intelligence for Barrett's esophagus:What we should and soon will do

Barrett’s esophagus(BE)is a well-established risk factor for esophageal adenocarcinoma.It is recommended that patients have regular endoscopic surveillance,with the ultimate goal of detecting early-stage neoplastic lesions before they can progress to invasive carcinoma.Detection of both dysplasia or early adenocarcinoma permits curative endoscopic treatments,and with this aim,thorough endoscopic assessment is crucial and improves outcomes.The burden of missed neoplasia in BE is still far from being negligible,likely due to inappropriate endoscopic surveillance.Over the last two decades,advanced imaging techniques,moving from traditional dye-spray chromoendoscopy to more practical virtual chromoendoscopy technologies,have been introduced with the aim to enhance neoplasia detection in BE.As witnessed in other fields,artificial intelligence(AI)has revolutionized the field of diagnostic endoscopy and is set to cover a pivotal role in BE as well.The aim of this commentary is to comprehensively summarize present evidence,recent research advances,and future perspectives regarding advanced imaging technology and AI in BE;the combination of computer-aided diagnosis to a widespread adoption of advanced imaging technologies is eagerly awaited.It will also provide a useful step-by-step approach for performing high-quality endoscopy in BE,in order to increase the diagnostic yield of endoscopy in clinical practice.

Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review

Biliary stenosis may represent a diagnostic and therapeutic challenge resulting in a delay in diagnosis and initiation of therapy due to the frequent difficulty in distinguishing a benign from a malignant stricture.In such cases,the diagnostic flowchart includes the sequential execution of imaging techniques,such as magnetic resonance,magnetic resonance cholangiopancreatography,and endoscopic ultrasound,while endoscopic retrograde cholangiopancreatography is performed to collect tissue for histopathological/cytological diagnosis or to treat the stenosis by insertion of stent.The execution of percutaneous transhepatic drainage with subsequent biopsy has been shown to increase the possibility of tissue diagnosis after failure of the above techniques.Although the diagnostic yield of histopathology and imaging has increased with improvements in endoscopic ultrasound and peroral cholangioscopy,differential diagnosis between malignant and benign stenosis may not be easy in some patients,and strictures are classified as indeterminate.In these cases,a multidisciplinary workup including biochemical marker assays and advanced technologies available may speed up a diagnosis of malignancy or avoid unnecessary surgery in the event of a benign stricture.Here,we review recent advancements in the diagnosis and management of biliary strictures and describe tips and tricks to increase diagnostic yields in clinical routine.

Percutaneous endoscopic gastrostomy and jejunostomy:Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight.Therefore,oral feeding is the main approach for such patients.When physiological nutrition is not possible,positioning of a nasogastric,nasojejunal tube,or other percutaneous devices may be feasible alternatives.Creating a percutaneous endoscopic gastrostomy(PEG)is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk.Many diseases require nutritional support by PEG,with neurological,oncological,and catabolic diseases being the most common.PEG can be performed endoscopically by various techniques,radiologically or surgically,with different outcomes and related adverse events(AEs).Moreover,some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent.These conditions highlight many ethical problems that become difficult to manage as treatment progresses.The aim of this manuscript is to review all current endoscopic techniques for percutaneous access,their indications,postprocedural follow-up,and AEs.

Endoscopic ultrasound-guided ablation of solid pancreatic lesions:A systematic review of early outcomes with pooled analysis

BACKGROUND Endoscopic ultrasound-guided radiofrequency ablation(EUS-RFA)is emerging as a complementary therapeutic approach for pancreatic solid masses.However,results of published data are difficult to interpret because of a retrospective design and small sample size.AIM To systematically review data on EUS-RFA for solid lesions and to pool the results of the different experiences in order to provide more consistent evidence in terms of safety and efficacy.METHODS A comprehensive systematic literature search on the main databases was performed to identify articles in which patients with pancreatic solid lesions underwent EUS-RFA.The primary outcomes were procedure-related adverse events(AEs)and mortality.Secondary outcomes were the technical success rate and the effects on primary tumor growth.Statistical analyses were performed using Stata version 14.0.RESULTS In total,14 studies were included,with 120 patients undergoing 153 ablations of 129 solid pancreatic lesions.The STARmed technology was used in seven studies,the Habib system in six studies,and the HybridTherm probe in one study.The pooled technical success rate was 99.0%(I2:25.82%).The pooled overall AE rate was 8.0%(I2:11.46%).Excluding mild AEs,the pooled rates of serious AEs was 1.0%(I2:0%).No mortality related to the procedure was reported.CONCLUSION The present pooled analysis confirms the safety and feasibility of EUS-RFA.