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Background and Aims: EUS-guided biliary drainage has emerged as a technique to enable endobiliary drainage in failed ERCP. A newer model, lumen-apposing metal stents (LAMS), with a cautery-enhanced delivery system became available in the USA in late 2015. This cautery-tipped version may facilitate EUS-guided choledochoduodenostomy (EUS-CD), but data using this model are lacking.Methods: We reviewed outcomes of attempted EUS-CD using cautery-enhanced LAMS from 6, US centers. The following data were collected: patient and procedure details, technical success, adverse events, clinical success (resolution of jaundice or improvement in bilirubin > 50%), and biliary re-interventions.Results: EUS-CD was attempted in 67 patients (mean age 68.8) with malignant obstruction after failed ERCP between September 2015 and April 2018. EUS-CD was technically successful in 64 (95.5%). A plastic or metal stent was inserted through the lumen of the deployed LAMS in 50 of 64 (78.1%) patients to maintain a non-perpendicular LAMS axis into the bile duct. Adverse events occurred in 4 (6.3%) and included: abdominal pain (n = 2), peritonitis that responded to antibiotics (n = 1), and bleeding requiring transfusion (n = 1). Among 40 patients with follow-up of > 4 weeks, clinical success was achieved in 100%. Biliary re-interventions for obstruction were needed in 7(17.5%), in 3 of 6 (50.0%) that underwent EUS-CD with LAMS alone versus 4 of 34 (5%) with LAMS plus an axis-orienting stent (p = 0.02).Conclusion: EUS-CD using LAMS with cautery-enhanced delivery systems has high technical and clinical success rates, with a low rate of adverse events. Inserting an axis-orienting stent through the lumen of the LAMS may reduce the need for biliary re-interventions. [ABSTRACT FROM AUTHOR]

Background and study aim: Endoscopic ultrasound- guided fine needle aspiration (EUS-FNA) is frequently performed for suspected biliary tumors for diagnosis and staging but carries a theoretical risk of needle-track seeding. We aimed to evaluate the impact of preoperative EUS-FNA on long-term outcomes for patients with cholangiocarcinoma (CCA). Patients and methods: In a retrospective singlecenter study of consecutive patients with CCA with preoperative EUS-FNA,main outcomemeasures were overall survival and progression-free survival. Results: In 150 patients with confirmed CCA, 61 underwent preoperative FNA. Median overall survival was 18.5 months (95% confidence limits [CL] 15.4, 25.7): 111 patients died and 39 survived. Of the 150 patients, 119 underwent curative- intent surgical resection, with median progression- free survival of 17.8 months (95%CL 14.5, 22.8); 89/119 patients had tumor recurrence or died, and 30/119 remained alive and disease- free. On multivariable analysis, overall survival was associated with: undergoing curativeintent surgery (hazard ratio [HR] 5.79, P=0.001), lack of lymph node involvement (HR 1.89, P= 0.011), younger age (HR 1.51 for every 10 years, P<0.0015), and small tumor size (HR 1.11 for every 1cm, P=0.029). For patients undergoing curative- intent surgery, on multivariable analysis, improved progression-free survival was associated with: lack of lymph node involvement (HR 1.88, P=0.010), smaller tumor size (HR 1.16 for every 1cm smaller, P=0.003), and younger age (HR 1.53 for every 10 years, P<0.001). Number of needle passes showed no statistically significant impact on overall survival. Conclusion: Preoperative EUS-FNA in patients with CCA does not appear to adversely affect overall or progression-free survival. [ABSTRACT FROM AUTHOR]

Background: Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described. Aims: To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level. Methods: Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl. Results: Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers ( P = 0.05), upper endoscopy ( P < 0.0001), with propofol ( P = 0.0008), longer procedures ( P = 0.0001), and hiccups ( P = 0.01). The association between supine positioning during colonoscopy and cough approached significance ( P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation ( P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites ( P = 0.03), males ( P = 0.004), nonsmokers ( P = 0.04), during colonoscopy ( P < 0.0001), and in patients receiving midazolam and fentanyl ( P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy ( P = 0.002). HR increased >20% in 20% of patients and was more common with coughing ( P < 0.0001) and in younger patients ( P = 0.0002). No patient required pharmacologic treatment of BP or HR. Conclusions: We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant. [ABSTRACT FROM AUTHOR]