Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Background/Aims: The aim of this study was to evaluate the safety and efficacy of partially covered self-expandable metallic stents (PCSEMS) in patients undergoing neoadjuvant chemo (radio) therapy (NAC) for pancreatic cancer (PC). Methods: This was a prospective multicenter study to evaluate the safety and efficacy of PCSEMS in patients receiving NAC for resectable and borderline resectable PC. The primary endpoint was the rate of recurrent biliary obstruction (RBO). Results: Twenty-six patients with PC (three with resectable PC and 23 with borderline resectable PC) who underwent NAC at seven Japanese centers were included in the analysis. Both the technical and functional success rates of PCSEMS placement were 100%. Early stent-related complications were observed in three patients (11.5%): mild pancreatitis (n=2) and mild liver abscess (n=1). The median time to surgery or palliation was 4.0 months. Surgical resection was eventually performed in 73.1% of patients, and stent removal during surgery was successful in all patients. RBO was observed in nine patients (34.6%): seven with stent occlusion, one with kinking and one with migration. The RBO rates in resected cases and nonresected cases were 36.8% and 28.6%, respectively. Conclusions Biliary drainage by PCSEMS was safe and feasible in patients undergoing NAC for resectable and borderline resectable PC.

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been recognized as an effective treatment for patients at high risk for surgery. An antimigration metal stent with tapered thin delivery system has recently been developed. The aims of this study were to evaluate the feasibility, safety, and longterm outcomes of EUS-GBD using the new metal stent. Methods: Between April 2017 and March 2020, 21 patients with acute cholecystitis unsuitable for cholecystectomy underwent EUS-GBD using the metal stent. The stent was 6 mm in diameter and 6 cm in length, with a large flare at both ends for antimigration, and mounted in a 7.5 Fr delivery catheter, which requires no dilation devices. We retrospectively evaluated clinical and technical success, adverse events, and stent patency. Results: The technical and clinical success rates of EUS-GBD using the metal stent were 95.2% and 100%, respectively. For 75% of the patients, metal stents could be placed without dilatation of the needle tract. These patients had significantly shorter procedure time (23.6 ± 9.8 min) than patients requiring needle tract dilatation (38.4 ± 17.1 min; P = 0.036). The median follow-up periods were 336 days (interquartile range [IQR] 152–919 days) and 1,135 days (IQR 1,009–1,675 days) for all and alive patients, respectively. No adverse events or recurrence of cholecystitis due to stent occlusion that occurred in any patient at follow-up was observed. Conclusion In conclusion, EUS-GBD using the newly designed metal stent showed excellent safety and longterm outcomes, and may be suitable as an alternative treatment in patients who are unsuitable for cholecystectomy.

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been recognized as an effective treatment for patients at high risk for surgery. An antimigration metal stent with tapered thin delivery system has recently been developed. The aims of this study were to evaluate the feasibility, safety, and longterm outcomes of EUS-GBD using the new metal stent. Methods: Between April 2017 and March 2020, 21 patients with acute cholecystitis unsuitable for cholecystectomy underwent EUS-GBD using the metal stent. The stent was 6 mm in diameter and 6 cm in length, with a large flare at both ends for antimigration, and mounted in a 7.5 Fr delivery catheter, which requires no dilation devices. We retrospectively evaluated clinical and technical success, adverse events, and stent patency. Results: The technical and clinical success rates of EUS-GBD using the metal stent were 95.2% and 100%, respectively. For 75% of the patients, metal stents could be placed without dilatation of the needle tract. These patients had significantly shorter procedure time (23.6 ± 9.8 min) than patients requiring needle tract dilatation (38.4 ± 17.1 min; P = 0.036). The median follow-up periods were 336 days (interquartile range [IQR] 152–919 days) and 1,135 days (IQR 1,009–1,675 days) for all and alive patients, respectively. No adverse events or recurrence of cholecystitis due to stent occlusion that occurred in any patient at follow-up was observed. Conclusion In conclusion, EUS-GBD using the newly designed metal stent showed excellent safety and longterm outcomes, and may be suitable as an alternative treatment in patients who are unsuitable for cholecystectomy.

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been recognized as an effective treatment for patients at high risk for surgery. An antimigration metal stent with tapered thin delivery system has recently been developed. The aims of this study were to evaluate the feasibility, safety, and longterm outcomes of EUS-GBD using the new metal stent. Methods: Between April 2017 and March 2020, 21 patients with acute cholecystitis unsuitable for cholecystectomy underwent EUS-GBD using the metal stent. The stent was 6 mm in diameter and 6 cm in length, with a large flare at both ends for antimigration, and mounted in a 7.5 Fr delivery catheter, which requires no dilation devices. We retrospectively evaluated clinical and technical success, adverse events, and stent patency. Results: The technical and clinical success rates of EUS-GBD using the metal stent were 95.2% and 100%, respectively. For 75% of the patients, metal stents could be placed without dilatation of the needle tract. These patients had significantly shorter procedure time (23.6 ± 9.8 min) than patients requiring needle tract dilatation (38.4 ± 17.1 min; P = 0.036). The median follow-up periods were 336 days (interquartile range [IQR] 152–919 days) and 1,135 days (IQR 1,009–1,675 days) for all and alive patients, respectively. No adverse events or recurrence of cholecystitis due to stent occlusion that occurred in any patient at follow-up was observed. Conclusion In conclusion, EUS-GBD using the newly designed metal stent showed excellent safety and longterm outcomes, and may be suitable as an alternative treatment in patients who are unsuitable for cholecystectomy.

BACKGROUND/AIMS: Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy. METHODS: Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wire-grasping method, forceps in the duodenum grasps a guide-wire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination. RESULTS: In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively). CONCLUSIONS: The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall.
Bile Ducts ; Biliary Tract ; Biopsy* ; Constriction, Pathologic* ; Diagnosis ; Duodenum ; Hand Strength ; Humans ; Methods* ; Prospective Studies* ; Sphincterotomy, Endoscopic ; Surgical Instruments*

Background/Aims: Rosemont classification (RC) with en-doscopic ultrasonography (EUS) is important for diagnosing chronic pancreatitis (CP) but is based only on subjective judgement. EUS shear wave measurement (EUS-SWM) is a precise modality based on objective judgment, but its usefulness has not been extensively studied yet. This study evaluated the utility of EUS-SWM for diagnosing CP and esti-mating CP severity by determining the presence of endocrine dysfunction along with diabetes mellitus (DM). Methods: Between June 2018 and December 2018, 52 patients who underwent EUS and EUS-SWM were classified into two groups according to RC: non-CP (indeterminate CP and normal) and CP (consistent and suggestive of CP). The EUSSWM value by shear wave velocity was evaluated with a me-dian value. The EUS-SWM value was compared with RC and the number of EUS features. The diagnostic accuracy and cutoff value of EUS-SWM for CP and DM and its sensitivity and specificity were calculated. Results: The EUS-SWM value significantly positively correlated with the RC and the number of EUS features. The EUS-SWM values that were consistent and suggestive of CP were significantly higher than that of normal. The area under the receiver operating characteristic (AUROC) curve for the diagnostic accuracy of EUS-SWM for CP was 0.97. The cutoff value of 2.19 had 100% sensitivity and 94% specificity. For endocrine dysfunction in CP, the AUROC was 0.75. The cutoff value of 2.78 had 70% sensitiv-ity and 56% specificity. Conclusions EUS-SWM provides an objective assessment and can be an alternative diagnostic tool for diagnosing CP. EUS-SWM may also be useful for pre-dicting the presence of endocrine dysfunction.

Background: No studies have compared balloon-assisted endoscope-guided endoscopic retrograde cholangiopancreatography (BAE-ERCP) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) for emergent treatment of acute cholangitis (AC) in patients with upper gastrointestinal surgically altered anatomy (SAA). Methods: This study retrospectively evaluated consecutive patients who underwent emergent BAE-ERCP or EUS-BD for AC with SAA between January 2020 and March 2024. Technical success, clinical success, procedure time, and adverse events (AEs) were compared between the two groups. Results: This study included 23 patients in the BAE-ERCP group and 14 patients in the EUS-BD group. Technical success and clinical success rates did not significantly differ between the two groups (88% vs. 100%, P = 0.51 and 95% vs. 93%, P = 0.66). Similarly, the rate of AEs was comparable between the two groups (4% vs. 14%, P = 0.54). The median procedure time was significantly shorter in the EUS-BD group than in the BAE-ERCP group (32.5 [interquartile range; IQR, 28.8–52.5] minutes vs. 70.0 [IQR, 60.0–90.0] minutes, P < 0.01). In cases with grade 2 or 3 cholangitis, the rates of technical success, clinical success, and AEs did not significantly differ between the two groups. However, the median procedure time was significantly shorter in the EUS-BD group than in the BAE-ERCP group (32.5 [IQR, 28.8–52.5] minutes vs. 70 [IQR, 56.3–90.0] minutes, P < 0.01). Conclusion While both BAE-ERCP and EUS-BD can be performed safely and effectively in patients with AC and SAA, the procedure time is significantly shorter with EUS-BD than with BAE-ERCP.