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Background While endoscopic management of benign biliary strictures (BBSs) is the standard of care, long-term treatment remains the issue in refractory cases, especially for anastomotic strictures after living-donor liver transplantation (LDLT) and hepaticojejunostomy anastomotic strictures (HJAS). The aim of this prospective study was to evaluate the safety and effectiveness of a fully covered self-expandable metal stent (FCSEMS) for patients with refractory BBSs. Methods Patients with BBSs that were unamenable to endoscopic plastic stent placement with a treatment period of more than 6 months were eligible. An FCSEMS was placed endoscopically and removed after 90 days. In patients with surgically altered anatomy, an FCSEMS was placed using a double-balloon endoscope. The primary outcome was stricture resolution at FCSEMS removal. The secondary outcomes included stricture recurrence and adverse events. Results A total of 30 patients were enrolled: the causes of their BBSs were anastomotic stricture after LDLT in 13, HJAS in 12, post-cholecystectomy in two, chronic pancreatitis in two, and post-hepatectomy in one. The technical success rate of FCSEMS placement was 100 % and all FCSEMSs were successfully removed. The rate of stricture resolution at FCSEMS removal was 96.6 % (91.7 % in the post-LDLT group and 100 % in the HJAS group). Stricture recurrence occurred in three HJAS patients (10.7 %) during a median follow-up period of 15.6 months. Adverse events were observed in 12.1 %: five cholangitis, one pancreatitis, and one perforation. Conclusion Temporary placement of an FCSEMS was a feasible and effective treatment option for refractory BBSs, especially for post-LDLT strictures and HJAS.

Background Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. Methods This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. Results 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). Conclusion EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.

Background and study aim Percutaneous transhepatic biliary drainage (PTBD) is a rescue procedure after a failed endoscopic retrograde cholangiopancreatography. As PTBD causes patient discomfort, conversion of the PTBD to internal biliary stenting (PTBDS) may be required; however, PTBDS is sometimes difficult because of the tight stricture. We evaluated the efficacy and safety of conversion of external PTBD to endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) after failed PTBDS. Patients and methods A total of 16 patients with malignant distal biliary obstruction who underwent conversion of external PTBD to EUS-HGS after failed PTBDS were enrolled from two institutions in Korea and Japan. Data were analyzed retrospectively. Results The technical and clinical success rates were 100 % and 81 %, respectively. Early adverse events developed in two patients: proximal stent migration (n = 1), and cholecystitis (n = 1). Stents were occluded or migrated distally in five patients. The mean duration of stent patency was 402 days. Conclusions Conversion of external PTBD to EUS-HGS may be a good rescue option after failed PTBDS.

Background and study aims: Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is potentially complicated by bile leak and stent migration. The aim of this study was to evaluate the safety and effectiveness of a long (≥ 10 cm), partially covered metal stent (LP-CMS) for EUS-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction. Both the stent length and the uncovered portion at the proximal end of the LP-CMS are designed to prevent stent migration. Patients and methods: A total of 33 patients undergoing EUS-HGS using an LP-CMS in four centers were retrospectively studied. Technical and clinical success, adverse events, and recurrent biliary obstruction were evaluated. Results: Gastric outlet obstruction (76 %) and surgically altered anatomy (15 %) were two major reasons for EUS-HGS. The technical and clinical success rates were 100 %. The median intragastric stent length was 54 mm. The adverse event rate was 9 %. No stent migration was observed. Recurrent biliary obstruction developed in 24 %, with a median cumulative time to recurrence of 8.5 months. Conclusions: EUS-HGS using an LP-CMS for unresectable malignant biliary obstruction was safe and effective.

Background and study aims: Severe bleeding is a potentially lethal complication after endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) for choledocholithiasis. This study aimed to evaluate the impact of antiplatelet agents and anticoagulants on this complication. Patients and methods: Patients who underwent EST and EPBD were identified in a Japanese nationwide administrative database covering 1090 hospitals. Adjusting for other potential risk factors, we evaluated the association between oral administration of antiplatelet agents and/or anticoagulants (continuation, discontinuation, and non-use) and clinically significant bleeding within 3 days of the procedure. Results: In total, 61 002 patients were analyzed (EST, 54 493 patients; EPBD, 6509). The rate of severe bleeding was 0.8 % in both groups, but EPBD was performed more frequently than EST in patients with chronic renal failure, liver cirrhosis, and in those receiving antiplatelet agents or anticoagulants. The impact of continuation/discontinuation of antiplatelet agents on severe bleeding was not statistically significant in the EST or EPBD groups. The use of anticoagulants was associated with a statistically significant increase in severe bleeding compared with non-use for EST (1.6 % 27 of 1688 patients vs. 0.8 % 429 of 52 805 patients; adjusted odds ratio [OR] 1.70; 95 % confidence interval [CI] 1.10 – 2.63) and for EPBD (3.0 % [8 of 263 patients] vs. 0.7 % 46 of 6246 patients; adjusted OR 2.91; 95 %CI 1.36 – 6.24). Conclusions: EST and EPBD can be safely performed in patients receiving antiplatelet agents. Users of anticoagulants are at high risk of bleeding, and the periprocedural management of these should be further investigated.

Background and study aims: There are no guidelines for the timing of conversion from a single-guidewire to a double-guidewire technique to facilitate selective bile duct cannulation and reduce post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), when using wire-guided cannulation. We investigated whether early conversion to the double-guidewire method, at first unintentional insertion of a guidewire into the pancreatic duct, facilitated selective bile duct cannulation and reduced PEP compared with repeated single-guidewire attempts. Patients and methods: A multicenter prospective randomized controlled trial included 274 patients with a naive papilla, undergoing endoscopic retrograde cholangiography (ERC) using wire-guided cannulation in whom there was unintentional insertion of the guidewire into the pancreatic duct. With the guidewire still in the duct, patients were randomly assigned to undergo the double-guidewire technique or repeated single-wire cannulation. Main outcomes were success rates for selective bile duct cannulation and PEP frequency. Results: Success rates for selective bile duct cannulation within 10 attempts and 10 minutes were 75 % and 70 %, respectively, for the early double-guidewire (EDG) and repeated single-guidewire (RSG) cannulation groups (relative rate 1.07, 95 % confidence interval [95 %CI] 0.93 – 1.24, P = 0.42). Corresponding final selective bile duct cannulation rates were 98 % and 97 % (relative rate 1.01, 95 %CI 0.97 – 1.05, P = 1.00). PEP rates were 20 % and 17 %, respectively, for the EDG and RSG cannulation groups (relative risk 1.17, 95 %CI 0.71 – 1.94, P = 0.53). Double-guidewire cannulation was more effective in patients with malignant biliary stricture (relative rate 1.36, 95 %CI 1.05 – 1.77, P = 0.02). Conclusions: During therapeutic ERC using wire-guided cannulation, converting to a double-guidewire technique neither facilitated selective bile duct cannulation nor decreased PEP incidence compared with repeated use of a single-wire technique.

Background and study aim Endoscopic ultrasound-guided rendezvous (EUS-RV) is increasingly reported as a treatment option after failed endoscopic retrograde cholangiopancreatography. We developed a novel “hitch-and-ride” catheter for biliary cannulation to reduce the risk of guidewire loss during EUS-RV. Patients and methods We retrospectively evaluated safety and technical success of EUS-RV between June 2011 and May 2016. Biliary cannulation during EUS-RV using three methods – over-the-wire, along-the-wire, and hitch-and-ride – were compared. Results A total of 30 EUS-RVs were attempted and the technical success rate was 93.3 %, with two failures (one bile duct puncture and one guidewire insertion). After 28 cases of successful guidewire passage, cannulation was attempted by the over-the-wire (n = 13), along-the-wire (n = 4) or hitch-and-ride (n = 11) method. Only the hitch-and-ride method achieved biliary cannulation without guidewire loss or conversion to the other methods. Time to cannulation was shorter with the hitch-and-ride method (4 minutes) than with over-the-wire and along-the-wire methods (9 and 13 minutes, respectively). The adverse event rate of EUS-RV was 23.3 %. Conclusion A novel hitch-and-ride catheter was feasible for biliary cannulation after EUS-RV.

The use of a short double-balloon endoscope facilitates the endoscopic removal of bile duct stones in patients with surgically altered anatomy [1,2]. However, the narrow and long working channel of the double-balloon endoscope occasionally makes the procedure difficult and timeconsuming. Herein, we present the case of a patient with a history of hepaticojejunostomy in whom large bile duct stones were successfully fragmented and removed under direct visualization with a short double-balloon endoscope and electrohydraulic lithotripsy (EHL). An 82-year-old woman with a history of hepaticojejunostomy and Roux-en-Y reconstruction for congenital biliary dilatation was admitted with cholangitis due to intrahepatic bile duct stones. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out with a short double-balloon endoscope (EC-450BI5, 2.8-mm-wide and 152-cm-long working channel; Fujifilm Corp., Tokyo, Japan), and biliary access was readily obtained with a usual ERCP cannula and a 0.025-in guidewire. Cholangiography delineated an 18-mm filling defect in the right hepatic duct (●" Fig.1,●" Fig.2a). After attempts to extract the bile duct stones with a retrieval balloon and basket catheters had failed, EHL was performed with the AUTOLITH System and a 1.9-Fr, 250-cm-long probe (Northgate Technologies, Elgin, Illinois, USA). The distal end of the double-balloon endoscopewas inserted into the bile duct, and water irrigation for EHL was achieved by pushing the balloon against the anastomosis and flushing saline through the channel. Large stones were successfully fragmented with EHL, followed by complete removal with a balloon catheter (●" Fig.2b, ●" Video1). No procedure-related complications were observed. This is the first report of successful stone fragmentation with EHL under direct visualization with a short double-balloon enteroscope. The effectiveness of EHL combined with a single-balloon endoscope has been reported [3], and given the potential superiority of a double-balloon enteroscope over a single-balloon enteroscope in terms of endoscope insertion [4], EHL with a double-balloon enteroscope can further increase the technical success rate of stone removal in patients with surgically altered anatomy.

An 80-year-old man with a history of pancreaticoduodenectomy for intraductal papillary mucinous carcinoma 10 years earlier presented with recurrent pancreatitis caused by stricture at the pancreaticojejunostomy. Magnetic resonance imaging and endoscopic ultrasound (EUS) revealed a dilated main pancreatic duct (MPD) with pancreatolithiasis (●" Fig.1, ●" Fig.2). EUS-guided pancreatic duct drainage [1] was attempted. ThedilatedMPDwaspuncturedunder EUS guidance, and a guidewire was successfully advanced into the jejunum through the anastomotic stricture. Then, the fistula was dilated with coaxial electrocautery and a 4-mm balloon. A 7-Fr double-pigtail stent was then placed through the MPD across the jejunumand stomach. However, after stent deployment in the stomach, the proximal pigtail fell into the peritoneal cavity from the stomach as it curled up (●" Fig.3,●" Video 1). The MPD in the tail of the pancreas was punctured again under EUS guidance, and a 7-Fr straight plastic stent was successfully placed across the MPD and stomach (●" Fig.4, ●" Video 2). However, to leave themisplaced stent end in the peritoneum would lead to leakage of pancreatic juice, and therefore stent repositioning was attempted. The patient already had an indwelling 12-Fr percutaneous transhepatic biliary drainage (PTBD) tube in place for the stricture at the hepaticojejunosotmy. A percutaneous transhepatic cholangioscope (PTCS) was inserted through this PTBD route into the jejunum. The distal end of the misplaced stent was visualized on endoscopic view and was graspedwith a snare. Themisplaced proximal end of the stent was successfully repositioned in the MPD by pulling the PTCS through the PTBD route (●" Fig.5,●" Video 3). The clinical course after the procedure was uneventful without pancreatitis or leakage of pancreatic juice, and 6 weeks later the misplaced stent was completely removed through the PTBD route using the PTCS.The patient had no further episodes of acute pancreatitis.

Background and study aims: Only a few large cohort studies have evaluated the efficacy and safety of endoscopic necrosectomy for infected walled-off pancreatic necrosis (WOPN). Therefore, a multicenter, large cohort study was conducted to evaluate the efficacy and safety of endoscopic necrosectomy and to examine the procedural details and follow-up after successful endoscopic necrosectomy. Patients and methods: A retrospective review was conducted in 16 leading Japanese institutions for patients who underwent endoscopic necrosectomy for infected WOPN between August 2005 and July 2011. The follow-up data were also reviewed to determine the long-term outcomes of the procedures. Results: Of 57 patients, 43 (75 %) experienced successful resolution after a median of 5 sessions of endoscopic necrosectomy and 21 days of treatment. Complications occurred in 19 patients (33 %) during the treatment period. Six patients died (11 %): two due to multiple organ failure and one patient each from air embolism, splenic aneurysm, hemorrhage from a Mallory – Weiss tear, and an unknown cause. Of 43 patients with successful endoscopic necrosectomy, recurrent cavity formation was observed in three patients during a median follow-up period of 27 months. Conclusions: Endoscopic necrosectomy can be an effective technique for infected WOPN and requires a relatively short treatment period. However, serious complications can arise, including death. Therefore, patients should be carefully selected, and knowledgeable, skilled, and experienced operators should perform the procedure. Further research into safer technologies is required in order to reduce the associated morbidity and mortality.

Endoscopic management of malignant biliary obstruction following hepaticojejunostomy can be challenging. With the advent of the short double-balloon endoscope (DBE), therapeutic biliary interventions are possible in surgically altered anatomy [1,2]. Additionally, a novel uncoveredmetal stent (UMS) has been developed with a 200-cm-long, 6-Fr delivery system (Zilver 635; Cook Medical, Winston-Salem, North Carolina, United States) to enable metal stent placement using a short DBE [3]. We present a successful case of multiple metal stenting using a short DBE and UMS for malignant biliary obstruction after hepaticojejunostomy. A 75-year-old man with extrahepatic bile duct cancer underwent pancreaticoduodenectomy with Roux-en-Y reconstruction. He developed cholangitis 11 months postoperatively as a result of liver metastasis in the medial left lobe segment. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to place two plastic stents using a short DBE (EI-530B; Fujifilm Corp., Tokyo, Japan). However, rapid tumor growth resulted in recurrent episodes of cholangitis. Therefore, the decision was made to insert multiple metal stents via another ERCP using the short DBE. The plastic stents were removed, and the hepaticojejunostomy anastomosis was Fig.3 The second uncovered metal stent (UMS) was deployed through the mesh of the initial UMS. Fig.1 The first uncovered metal stent was deployed into the anterior branch of the right hepatic duct.

The effectiveness of pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is widely recognized [1]. However, proximal migration of a pancreatic stent is occasionally encountered, potentially necessitating surgical intervention [2,3]. A gooseneck snare (Amplatz GooseNeck Microsnare Kit; Covidien, Irvine, California, USA), which was originally developed for removing intravascular foreign bodies [4], is a microsnare that forms a 90° angle just after exiting the outer sheath (●" Fig.1). We herein describe a useful technique for endoscopic removal of a proximally migrated pancreatic stent using this snare. A 72-year-old man required endoscopic removal of common bile duct stones. Whilst he was undergoing the procedure, a one-sided pigtail pancreatic stent (Daimon T stent, 5Fr, 5cm; Silux, Saitama, Japan) was incorrectly placed in the main pancreatic duct (MPD). Impaction of its pigtail end into a branch of the pancreatic duct and the non-dilated MPD (●" Fig.2) inhibited the removal of the stent with a small-diameter snare, basket, balloon catheter, and biopsy forceps. The patient was referred to our institution and ERCP was carried out. Access to the MPD was obtained with a conventional cannula (ERCP catheter; MTW-Endoskopie, Wesel, Germany) and 0.035-inch hydrophilic guidewire (Radifocus; Terumo, Tokyo, Japan). The catheter was passed alongside the stent to the tail of the pancreas. A gooseneck snare (4-mm-wide loop, 175-cm long) was then detached from its accessory sheath and inserted through the prepositioned catheter. As the snare was withdrawn, its loop passed over the pancreatic stent until it reached the bend in the pigtail portion of the stent (●" Fig.3a).With the pigtail portion therefore grasped by the loop of the snare, further withdrawal of the snare allowed the stent to be easily pulled back into the duodenum(●" Fig.3b and●" Fig.4;●" Video1). Endoscopic removal of a pancreatic stent located in theMPD is technically demanding [5]. A gooseneck snare can easily expand with a snare loop perpendicular to the MPD, making the stent easier to grasp.