Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery,a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography.This manusc-ript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage(EUS-BD)technologies,weighing their merits and drawbacks against traditional percutaneous methods.Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage(PTCD).These studies revealed that the technical success rate,clinical success rate,and adverse events were similar between EUS-BD and PTCD.Nevertheless,given that most of these studies preda-te 2015,the safety and effectiveness of novel EUS-BD techniques,including ECE-LAMS,compared with those of percutaneous biliary drainage remain elusive.Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous thera-peutic approaches.

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.

Acute cholangitis with Achromobacter xylosoxidans bacteremia after endoscopic retrograde cholangiopancreatography in hilar cholangiocarcinoma:A case report

BACKGROUND Achromobacter xylosoxidans is a Gram-negative opportunistic aerobe,usually causing nosocomial infections in immunocompromised patients with manifestations including bacteremia,pneumonia,and catheter-related infections.However,A.xylosoxidans have not yet been reported to cause biliary system infections.CASE SUMMARY A 72-year-old woman presented to the outpatient department of our hospital with a chief complaint of jaundice.Computed tomography of her abdomen revealed the presence of a mass of approximately 2.4 cm in the hilar portion of the common hepatic duct,consistent with hilar cholangiocarcinoma.We performed endoscopic retrograde cholangiopancreatography(ERCP)to decompress the obstructed left and right intrahepatic ducts(IHDs)and placed 10 cm and 11 cm biliary stents in the left and right IHDs,respectively.However,the day after the procedure,the patient developed post-ERCP cholangitis as the length of the right IHD stent was insufficient for proper bile drainage.The blood culture of the patient tested positive for A.xylosoxidans.Management measures included the replacement of the right IHD stent(11 cm)with a longer one(12 cm)and administering culturedirected antibiotic therapy,solving the cholangitis-related complications.After the cholangitis had resolved,the patient underwent surgery for hilar cholangiocarcinoma and survived for 912 d without recurrence.CONCLUSION A.xylosoxidans-induced biliary system infections are extremely rare.Clinical awareness of physicians and endoscopists is required as this rare pathogen might cause infection after endoscopic procedures.

Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children

AIM:To assess the indications,findings,therapeutic procedures,safety,and complications of endoscopic retrograde cholangiopancreatography(ERCP) performed in Korean children.METHODS:The demographic characteristics,indications for ERCP,findings,therapeutic procedures,and complications of 122 pediatric patients who underwent 245 ERCPs in the Asan Medical Center between June 1994 and March 2008 were investigated.RESULTS:The mean age of the 122 patients was 8.0 ± 4.2 years.Indications were biliary pathology in 78(64.0%),pancreatic pathology in 43(35.2%),and chronic abdominal pain in one.Biliary indications included choledochal cysts in 40,choledocholithiasis in 24,suspected sclerosing cholangitis in 8,trauma in 2,and other conditions in 4.Pancreatic indications includedacute pancreatitis in 7,acute recurrent pancreatitis in 11,chronic pancreatitis in 20,trauma in 3,and pancreatic mass in 2.Of the 245 ERCPs,success rate was 98.4% and 190(77.6%) were for therapeutic purposes,including endoscopic nasal drainage(51.8%),biliary sphincterotomy(38.0%),pancreatic sphincterotomy(23.3%),stent insertion(15.1%),stone extraction(18.8%),and balloon dilatation(11.0%).Complications were postERCP pancreatitis in 16(6.5%),ileus in 23(9.4%),hemorrhage in 2(0.8%),perforation in 2(0.8%),sepsis in 1(0.4%),and impacted basket in 1(0.4%).There were no procedure-related deaths,and most complications improved under supportive care.CONCLUSION:This study showed that there is a high incidence of choledochal cyst and diagnostic and therapeutic ERCP for the management of various biliary and pancreatic diseases was safe and effective in Korean children.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Role of endoscopic retrograde cholangiopancreatography inthe management of benign biliary strictures:What's new?

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.

Biliary and pancreatic stenting:Devices and insertiontechniques in therapeutic endoscopic retrogradecholangiopancreatography and endoscopic ultrasonography

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.

Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction——stent-in-stent or side-by-side?A systematic review and meta-analysis

BACKGROUND Biliary drainage,either by the stent-in-stent(SIS)or side-by-side(SBS)technique,is often required when treating a malignant hilar biliary obstruction(MHBO).Both methods differ from each other and have distinct advantages.AIM To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO.METHODS A comprehensive search of multiple electronic databases(MEDLINE,Embase,LILACS,BIREME,Cochrane)was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language,since there was at least an abstract in English.The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography.Outcomes analyzed included technical and clinical success,early and late adverse events(AEs),stent patency,reintervention,and procedure-related mortality.RESULTS Four cohort studies and one randomized controlled trial evaluating a total of 250 patients(127 in the SIS group and 123 in the SBS group)were included in this study.There were no statistically significant differences between the two groups concerning the evaluated outcomes,except for stent patency,which was higher in the SIS compared with the SBS technique[mean difference(d)=33.31;95%confidence interval:9.73 to 56.90,I2=45%,P=0.006].CONCLUSION The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO.Both techniques are equivalent in terms of technical success,clinical success,rates of both early and late AEs,reintervention,and procedure-related mortality.

Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer

BACKGROUND Biliary ductal cancer(BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography(ERCP) sessions, etc.] are unknown.AIM To clarify what constitutes an adequate method for biliary biopsy.METHODS In total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group(P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group(N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups.RESULTS The numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions(one/two), P group 72/4 vs N group15/4, P value = 0.048; number of biliary biopsies, P group 2(1-6) vs N group 2(1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies.CONCLUSION This study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods(Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography （EUS）-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography （ERCP）. In the present study, we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCR We performed the procedure in 2 papilla of Vater, including one resectable case, and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 （75%） of 4 cases, an indwelling plastic stent was placed, and in one case in which the stent could not be advanced into the bile duct, a naso-biliary drainage tube was placed instead. In all cases, the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case, pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory, EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.

Role of ciprofloxacin in patients with cholestasis after endoscopic retrograde cholangiopancreatography

AIM： To determine the role of ciprofloxacin in reducing cholangitis in cholestatic patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatogra phy （ERCP）. METHODS： A randomized, controlled trial was performed in 48 cholestatic patients at Rajavithi Hospital （Tertiary Referral Center for ERCP： 600 cases per year）. All the 48 patients received 200 mg ciprofloxacin intravenous injection for 30 min before starting any procedures, and then were randomly divided in two groups. Twenty-two patients in study group continually received dprofloxacin until 48 h after ERCP. Causes of biliary obstruction, bacteriology of bile and blood （in cholangitis） and dinical cholangitis were recorded. RESULTS： Forty-eight patients were enrolled and divided into continuous ciprofloxacin treatment group （/7 = 22） and discontinuous ciprofloxacin treatment group （n = 26）. During ERCP, stones were found in 22 patients, malignant diseases in 24 patients and other pathologic lesions in 5 patients. One （4.5%） of the 22 patients who received ciprofloxacin and 2 （6.3%） of the 26 patients who discontinued ciprofloxacin after ERCP developed cholangitis （relative risk = 0.71; 95% CI = 0.14-3.65; P = 0.88）. Bacterobilia was found in 27 （56.3%） out of 48 patients. E. coli and Streptococcus viridans were the most common organisms. CONCLUSION： Continual use of ciprofloxacin in patients with cholestasis after adequate biliary drainage procedures plays no role in reducing cholangitis.

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

BACKGROUND At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography(ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.AIM To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.METHODS Demographic/clinical variables and records of ERCP patients at the beginning(2008), middle(2013) and end(2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard"(short position) or "non-standard"(e.g., long, semi-long).RESULTS Patients undergoing ERCP were older in 2018 compared to 2008(69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018(P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2%(2008) to 5.6%(2013) and 16.1%(2018)(P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7%(2008) to 0.9%(2013) to 6.6%(2018)(P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/d L predicted use of advanced cannulation techniques(P < 0.03 for each).CONCLUSION Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

Older age, longer procedures and tandem endoscopic-ultrasound as risk factors for post-endoscopic retrograde cholangiopancreatography bacteremia

BACKGROUND Clinically significant post-endoscopic retrograde cholangiopancreatography(ERCP) bacteremia(PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage. However, the current recommendations may not cover all potential risk factors for PEB.AIM To identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis.METHODS A retrospective study of 1082 ERCP procedures performed between January 2012-December 2013 in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures. Exclusion criteria were:(1) Age < 18 years;(2) Positive bacterial blood culture before ERCP;(3) Scheduled antibiotic treatment prior to ERCP;(4) Hospitalization longer than 14 d before ERCP;and(5) missing critical data. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.RESULTS A total of 626 ERCPs performed in 434 patients were included. Mean age 66.49 ± 15.4 years and 46.5% were males. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 139/626(22.2%) cases but was indicated according to the guidelines only in 44/626(7%) cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression [receiver operating characteristic(ROC), 0.766], identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years(OR, 3.780, 95%CI: 1.519-9.408, P = 0.004);Tandem EUS/ERCP with fine needle aspiration(FNA)(OR, 14.528, 95%CI: 3.571-59.095, P < 0.001);ERCP duration longer than 60 min(OR, 5.396, 95%CI: 1.86-15.656, P = 0.002). In a decision tree model(ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration.CONCLUSION The prevalence of PEB in our study is similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. These factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.

Double-balloon endoscopic retrograde cholangiopancreatography for patients who underwent liver operation: A retrospective study

BACKGROUND Double-balloon endoscopic retrograde cholangiography (DB-ERC) is widely performed for biliary diseases after reconstruction in gastrointestinal surgery,but there are few reports on DB-ERC after hepatectomy or living donor liver transplantation (LDLT).AIM To examine the success rates and safety of DB-ERC after hepatectomy or LDLT METHODS The study was performed retrospectively in 26 patients (45 procedures) who underwent hepatectomy or LDLT (liver operation:LO group) and 40 control patients (59 procedures) who underwent pancreatoduodenectomy (control group).The technical success (endoscope reaching the choledochojejunostomy site),diagnostic success (performance of cholangiography),therapeutic success(completed interventions) and overall success rates,insertion and procedure(completion of DB-ERC) time,and adverse events were compared between these groups.RESULTS There were no significant differences between LO and control groups in the technical [93.3%(42/45) vs 96.6%(57/59),P=0.439],diagnostic [83.3%(35/42) vs83.6%(46/55),P=0.968],therapeutic [97.0%(32/33) vs 97.7%(43/44),P=0.836],and overall [75.6%(34/45) vs 79.7%(47/59),P=0.617] success rates.The median insertion time (22 vs 14 min,P <0.001) and procedure time (43.5 vs 30 min,P=0.033) were significantly longer in the LO group.The incidence of adverse events showed no significant difference [11.1%(5/45) vs 6.8%(4/59),P=0.670].CONCLUSION DB-ERC after liver operation is safe and useful but longer time is required,so should be performed with particular care.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,pruritis,and malaise,a triad that develops secondary to obstruction,which often occurs late in the course of the disease process.The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis,staging,and management of patients with pancreatic cancer.Endoscopic retrograde cholangiopancreatography(ERCP)-guided diagnosis(with brush cytology,serial pancreatic juice aspiration cytologic examination technique,or biliary biopsy)and therapeutic interventions such as pancreatobiliary decompression,intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management.In this review,we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation

BACKGROUND Abnormal liver function tests(LFTs)in post-liver transplant(LT)patients pose a challenge in the timing and selection of diagnostic modalities.There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography(ERCP)and liver biopsy(LB)in diagnosing post-transplant complications.AIM To evaluate the diagnostic performance of ERCP and LB in patients with nonvascular post-LT complications.METHODS This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017.Diagnostic operating characteristics including accuracy,sensitivity and specificity for various diagnoses were calculated for ERCP and LB.The R factor(ratio of alkaline phosphatase to alanine aminotransferase)was also calculated for each patient.RESULTS Of the 1284 patients who underwent LT,91 patients(74.7%males,mean age of 51)were analyzed.Anastomotic strictures(AS,24.2%),acute cellular rejection(ACR,11%)and concurrent AS/ACR(14.3%)were the most common diagnoses.ERCP carried an accuracy of 79.1%(95%CI:69.3-86.9),LB had an accuracy of 93.4%(95%CI:86.2-97.5),and the combination of the two had an accuracy of 100%(95%CI:96-100).There was no difference between patients with AS and ACR in mean R factor(AS:1.9 vs ACR:1.1,P=0.24).Adverse events did not differ between the two tests(ERCP:3.1%vs LB:1.1%,P=0.31).CONCLUSION In patients with abnormal LFTs after LT without vascular complications,the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis:Importance of the endoscopist’s expertise level

BACKGROUND Needle-knife fistulotomy(NKF)is used as a rescue technique for difficult cannulation.However,the data are limited regarding the use of NKF for primary biliary cannulation,especially when performed by beginners.AIM To assess the effectiveness and safety of primary NKF for biliary cannulation,and the role of the endoscopist’s expertise level(beginner vs expert).METHODS We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis,who underwent bile duct cannulation at a tertiary referral center.The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation.We assessed the rates of successful cannulation and adverse events.RESULTS The baseline characteristics did not differ between the experienced and lessexperienced endoscopists.The incidence rate of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy(8.9%vs 3.4%for beginner vs expert,P=0.039),but not in those who received NKF.In the multivariable analysis,a lower expertise level of the biliary endoscopist(P=0.037)and longer total procedure time(P=0.026)were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time(P=0.004)was significant risk factor of PEP in those who received NKF.CONCLUSION Primary NKF was effective and safe in patients with prominent and bulging ampulla,even when performed by less-experienced endoscopist.We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.

Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction:Updated meta-analysis

BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography(ERCP)failure.However,most of the studies that have assessed its efficacy and safety were small and hetero-geneous.Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.AIM To update the efficacy and safety of ECE-LAMS for treatment of biliary ob-struction after ERCP failure.METHODS We searched PubMed,EMBASE,and Scopus databases from the inception of the ECE technique to May 13,2022.Primary outcome measure was pooled technical success rate,and secondary outcomes were pooled rates of clinical success,re-intervention,and adverse events.Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R soft-ware(version 4.1.3).RESULTS Fourteen eligible studies involving 620 participants were ultimately included.The pooled rate of technical success was 96.7%,and clinical success was 91.0%.Adverse events were reported in 17.5%of patients.Overall reinter-vention rate was 7.3%.Subgroup analyses showed results were generally consistent.CONCLUSION ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible.The consistency of results across most subgroups suggested that this is a generalizable approach.

Endoscopic ultrasound-guided biliary drainage using electrocauteryenhanced lumen-apposing metal stent for malignant biliary obstruction:A promising procedure

In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Revolutionizing palliative care:Electrocautery-enhanced lumenapposing metal stents in endoscopic-ultrasound-guided biliary drainage for malignant obstructions

Patients with malignant biliary obstruction,following endoscopic retrograde cholangiopancreatography(ERCP)failure could be referred for endoscopicultrasound-guided biliary drainage through electrocautery-enhanced(ECE)lumen-apposing metal stent(LAMS)placement.However,the efficacy and safety of ECE-LAMS in this scenario have remained debatable due to minimal scientific evidence.The current confirmed 91.0%clinical success,96.7%technical success,7.3%reintervention rate,and 17.5%adverse events,following the treatment of malignant biliary obstruction with ECE-LAMS delivery.Finally,ECE-LAMS proved to be a generalizable strategy for managing biliary obstruction for patients who were excluded from ERCP.