Evaluation of diagnostic cytology via endoscopic naso-pancreatic drainage for pancreatic tumor

AIM: To evaluate the usefulness of cytology of the pancreatic juice obtained via the endoscopic naso-pancreatic drainage tube(ENPD-C).METHODS: ENPD was performed in cases where a diagnosis could not be made other than by using en-doscopic retrograde cholangiopancreatography and in cases of pancreatic neoplasms or cystic tumors, includ-ing intraductal papillary mucinous neoplasm(IPMN) suspected to have malignant potential. 35 patients(21 males and 14 females) underwent ENPD between January 2007 and June 2013. The pancreatic duct was imaged and the procedure continued in one of ENPD-C or ENPD-C plus brush cytology(ENPD-BC). We checked the cytology result and the final diagnosis.RESULTS: The mean patient age was 69 years(range, 48-86 years). ENPD-C was performed in 24 cases andENPD-C plus brush cytology(ENPD-BC) in 11 cases. The ENPD tube was inserted for an average of 3.5 d. The final diagnosis was confirmed on the basis of the resected specimen in 18 cases and of follow-up findings at least 6 mo after ENPD in the 18 inoperable cases. Malignancy was diagnosed in 21 cases and 14 patients were diagnosed as having a benign condition. The ratios of class Ⅴ/Ⅳ:Ⅲ:Ⅱ/Ⅰ?findings were 7:7:7 in malignant cases and 0:3:11 in benign cases. The sensitivity and specificity for all patients were 33.3% and 100%, re-spectively. The cytology-positive rate was 37.5%(6/16) for pancreatic cancer. For IPMN cases, the sensitivity and specificity were 33% and 100%, respectively.CONCLUSION: Sensitivity may be further increased by adding brush cytology. Although we can diagnosis cancer in cases of a positive result, the accuracy of ENPD-C remains unsatisfactory.

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.

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 pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections(PFCs)result from injury to the pancreas from acute or chronic pancreatitis,surgery,or trauma.Management of these collections has evolved over the last 2 decades.The choice of interventions includes percu-taneous,endoscopic,minimally invasive surgery,or a combined approach.Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract.In this editorial,we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Endoscopic transgastric fenestration versus percutaneous drainage for management of(peri)pancreatic fluid collections adjacent to gastric wall(with video)

BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic stent implantation are common.AIM To introduce a novel endoscopic therapy named endoscopic transgastric fenestration(ETGF),which involves resection of tissue by endoscopic accessory between gastric and PFCs without stent implantation,and to evaluate its efficacy and safety compared with PCD for the management of PFCs adjacent to the gastric wall.METHODS Patients diagnosed with PFCs adjacent to the gastric wall and who subsequently received ETGF or PCD were restrospectively enrolled.Indications for intervention were consistent with related guidelines.We analyzed patients baseline characteristics,technical and clinical success rate,recurrence and reintervention rate,procedure-related complications and adverse events.RESULTS Seventy-two eligible patients were retrospectively identified(ETGF=34,PCD=38)from October 2017 to May 2021.Patients in the ETGF group had a significantly higher clinical success rate than those in the PCD group(97.1 vs 76.3%,P=0.01).There were no statistically significant differences regarding recurrence,reintervention and incidence of complication between the two groups.While long-term catheter drainage was very common in the PCD group.CONCLUSION Compared with PCD,ETGF has a higher clinical success rate in the management of PFCs adjacent to the gastric wall.ETGF is an alternative effective strategy for the treatment of PFCs adjacent to the gastric wall.

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 transluminal drainage and necrosectomy for infected necrotizing pancreatitis:Progress and challenges

Infected necrotizing pancreatitis(INP)represents a severe condition in patients with acute pancreatitis.Invasive interventions are recommended in symptomatic INP.Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures.However,there is still no standardized protocol for endoscopic interventions.Recently,various studies have been published about the endoscopic management of INP.This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey Ⅱ sigmoid colon diverticulitis: A case report

BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound(EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.CASE SUMMARY A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography(CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey Ⅱ diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient’s general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.CONCLUSION We report the first successful management of a pelvic abscess in patient with Hinchey Ⅱ acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography(ERCP)is the preferred modality for drainage of the obstructed biliary tree.In patients with surgically altered anatomy,ERCP using standard techniques may not be feasible.Enteroscope assisted ERCP is usually employed with variable success rate.With advent of endoscopic ultrasound(EUS),biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective.In this narrative review,we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Comparison of trans-gastric vs trans-enteric(trans-duodenal or trans-jejunal)endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents

BACKGROUND Endoscopic ultrasound guided gallbladder drainage(EUS-GBD)is being increasingly used in practice(either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients).Stents are used to create a conduit between the lumen of the gallbladder(GB)and the intestinal lumen through the gastric or enteric routes.Among the various types of stents used,cautery-enhanced lumen apposing metallic stents(LAMS)may be associated with fewer adverse events(AEs).AIM To compare the clinical success,technical success,and rate of AEs between transgastric(TG)and trans-enteric[transduodenal(TD)/transjejunal(TJ)]approach to GB drainage.Further,we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.METHODS Study was registered in PROSPERO(CRD42022319019)and comprehensive literature review was conducted.Manuscripts were reviewed for the data collection:Rate of AEs,clinical success,and technical success.Random effects model was utilized for the analysis.RESULTS No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches(P>0.05)were noted.There was no statistically significant difference in the rate of AEs when comparing two-arm studies only.However,when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach.When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS,a statistically significant difference in the rate of AEs was observed when all the studies were included,with the rate being higher in non-cautery enhanced stents(14.0%vs 37.8%;P<0.01).CONCLUSION As per our study results,TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD.Additionally,use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS.Though the approach chosen depends on several patient and physician factors,the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases:A systematic review and meta-analysis

BACKGROUND In hepatology,the clinical use of endoscopic ultrasound(EUS)has experienced a notable increase in recent times.These applications range from the diagnosis to the treatment of various liver diseases.Therefore,this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases.AIM To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy.METHODS PubMed,Medline,Cochrane Library,Web of Science,and Google Scholar databases were extensively searched until October 2023.The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool.In addition,statistical analyses were performed using the Comprehensive Meta-Analysis software.RESULTS Overall,45 articles on EUS were included(28 on diagnostic role and 17 on therapeutic role).Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4%for focal liver lesions(FLL)and 96.6%for parenchymal liver diseases.EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases(3.1%and 8.7%,respectively).Analysis of data from four studies showed that EUS-guided liver abscess had high clinical(90.7%)and technical success(90.7%)without significant complications.Similarly,EUS-guided interventions for the treatment of gastric varices(GV)have high technical success(98%)and GV obliteration rate(84%)with few complications(15%)and rebleeding events(17%).CONCLUSION EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Propensity score matching analysis for clinical impact of braided-type versus laser-cut-type covered self-expandable metal stents for endoscopic ultrasound-guided hepaticogastrostomy

Background:To prevent stent migration during endoscopic ultrasound-guided hepaticogastrostomy(EUS-HGS),intra-scope channel release technique is important,but is unfamiliar to non-expert hands.The self-expandable metal stent(SEMS)is an additional factor to prevent stent migration.However,no compara-tive studies of laser-cut-type and braided-type during EUS-HGS have been reported.The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut-type and braided-type SEMS.Methods:To evaluate stent anchoring function,we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS,one day after EUS-HGS,and 7 days after EUS-HGS.Also,propensity score matching was performed to create a propensity score for using laser-cut-type group and braided-type group.Results:A total of 142 patients were enrolled in this study.Among them,24 patients underwent EUS-HGS using a laser-cut-type SEMS,and 118 patients underwent EUS-HGS using a braided-type SEMS.EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists(n=21);EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists(n=98).The distance after 1 day was significantly shorter in the laser-cut-type group than that in the braided-type group[2.00(1.70-3.75)vs.6.90(3.72-11.70)mm,P<0.001].In addition,this distance remained significantly shorter in the laser-cut-type group after 7 days.Although these results were similar after propensity score matching analysis,the distance between hepatic parenchyma and stomach after 7 days was increased by 4 mm compared with the distance after 1 day in the braided-type group.On the other hand,in the laser-cut-type group,the distance after 1 day and 7 days was almost the same.Conclusions:EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration,even in non-expert hands.

Is endoscopic ultrasound a promising technique in the diagnosis and treatment of liver diseases?

Percutaneous ultrasound has been a longstanding method in the diagnostics and interventional procedures of liver diseases.In some countries,its use is restricted to radiologists,limiting access for other clinicians,such as gastroenterologists.Endoscopic ultrasound,as a novel technique,plays a crucial role in diagnosis and treatment of digestive diseases.However,its use is sometimes recommended for conditions where no clear advantage over percutaneous ultrasound exists,leaving the impression that clinicians sometimes resort to an endoscopic approach due to the unavailability of percutaneous options.

Contrast-enhanced guided endoscopic ultrasound procedures

Contrast-enhanced endoscopic ultrasound(CH-EUS)can overcome the limi-tations of endoscopic ultrasound-guided acquisition by identifying microvessels inside inhomogeneous tumours and improving the characterization of these tumours.Despite the initial enthusiasm that oriented needle sampling under CH-EUS guidance could provide better diagnostic yield in pancreatic solid lesions,further studies did not confirm the supplementary values in cases of tissue acquisition guided by CH-EUS.This review details the knowledge based on the available data on contrast-guided procedures.The indications for CH-EUS tissue acquisition include isoechoic EUS lesions with poor visible delineation where CH-EUS can differentiate the lesion vascularisation from the surrounding parenchyma and also the mural nodules within biliopancreatic cystic lesions,which occur in select cases.Additionally,the roles of CH-EUS-guided therapy in patients whose pancreatic fluid collections or bile ducts that have an echogenic content have indications for drainage,and patients who have nonvisualized vessels that need to be highlighted via Doppler EUS are presented.Another indication is represented if there is a need for an immediate assessment of the post-radiofrequency ablation of pancreatic neuroendocrine tumours,in which case CH-EUS can be used to reveal the incomplete tumour destruction.

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7^(th) , 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7 th , 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting's agenda and the conclusions generated by the creation of this consortium group.

Retrospective cohort study Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopic nasobiliary drainage(ENBD)or endoscopic biliary stenting]as a temporary drainage in our institution between 2009 and 2014.We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment.The risk factors for biliary reintervention,post-endoscopic retrograde cholangiopancreatography(post-ERCP)pancreatitis,and percutaneous transhepatic biliary drainage(PTBD)were also analyzed using patient-and procedure-related characteristics.The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.RESULTS:In total,137 complications were observed in92(78%)patients.Biliary reintervention was required in 83(70%)patients.ENBD was significantly associated with a low risk of biliary reintervention[odds ratio(OR)=0.26,95%CI:0.08-0.76,P=0.012].Post-ERCP pancreatitis was observed in 19(16%)patients.An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis(OR=3.46,95%CI:1.19-10.87,P=0.023).PTBD was required in 16(14%)patients,and Bismuth type III or IV cholangiocarcinoma was a significant risk factor(OR=7.88,95%CI:1.33-155.0,P=0.010).Of 102 patients with initial unilateral drainage,49(48%)required bilateral drainage.Endoscopic sphincterotomy(OR=3.24,95%CI:1.27-8.78,P=0.004)and Bismuth II,III,or IV cholangiocarcinoma(OR=34.69,95%CI:4.88-736.7,P<0.001)were significant risk factors for bilateral drainage.CONCLUSION:The endoscopic management of hilar cholangiocarcinoma is challenging.ENBD should be selected as a temporary drainage method because of its low risk of complications.

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level < 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.

A novel technique for endoscopic ultrasound-guided biliary drainage

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates. METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients' baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient's overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student's t -test and the χ 2 test were used to assess the significance of inter-group differences. RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure. CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

Biliary drainage for obstructive jaundice caused by unresectable hepatocellular carcinoma: the endoscopic versus percutaneous approach

BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. METHODS: Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. RESULTS: Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).CONCLUSION: Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.

Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage

AIM: To perform a systematic review comparing the outcomes of endoscopic, percutaneous and surgical pancreatic pseudocyst drainage.METHODS: Comparative studies published between January 1980 and May 2014 were identified on Pub Med, Embase and the Cochrane controlled trials register and assessed for suitability of inclusion. The primary outcome was the treatment success rate. Secondary outcomes included were the recurrence rates, re-interventions, length of hospital stay, adverse events and mortalities.RESULTS: Ten comparative studies were identified and 3 were randomized controlled trials. Four studies reported on the outcomes of percutaneous and surgical drainage. Based on a large-scale national study, surgical drainage appeared to reduce mortality and adverse events rate as compared to the percutaneous approach. Three studies reported on the outcomes of endoscopic ultrasound(EUS) and surgical drainage. Clinical success and adverse events rates appeared to be comparable but the EUS approach reduced hospital stay, cost and improved quality of life. Three other studies comparedEUS and esophagogastroduodenoscopy-guided drainage. Both approaches were feasible for pseudocyst drainage but the success rate of the EUS approach was better for non-bulging cyst and the approach conferred additional safety benefits.CONCLUSION: In patients with unfavorable anatomy, surgical cystojejunostomy or percutaneous drainage could be considered. Large randomized studies with current definitions of pseudocysts and longer-term follow-up are needed to assess the efficacy of the various modalities.