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Background: A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used.Methods: 50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet's AC1 coefficient was used to assess interobserver agreement.Results: A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC-MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75).Conclusions: Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted. [ABSTRACT FROM AUTHOR]

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure.Methods: Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as "index" in patients without prior endoscopic duct access and "combined" when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates.Results: EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205]).Conclusions: EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases. [ABSTRACT FROM AUTHOR]

EUS-cholangiography revealed a dilated common bile duct (CBD) and a patent cystic duct above a distal stricture (Fig. In malignant biliary obstruction, EUS-guided gallbladder drainage allows symptomatic decompression when the cystic duct is involved [3] and rescue biliary drainage when it is patent [4]. [Extracted from the article]

Transenteric LAMS allow sequential endoscope passage for combined ERCP and EUS-guided gallbladder drainage as a same-session procedure in high-surgical-risk Roux-en-Y gastrectomy patients. B Video 1 b Endoscopic ultrasound (EUS)-guided transportal cholangiography and jejunoduodenostomy with a lumen-apposing metal stent allowing through-the-stent retrograde passage of the duodenoscope and echoendoscope for single-session endoscopic retrograde cholangiopancreatography and EUS-guided gallbladder drainage in a patient with Roux-en-Y gastrectomy. [Extracted from the article]

Background and study aim There are no data comparing endoscopic ultrasound (EUS)-guided gallbladder drainage (EGBD) with percutaneous cholecystostomy as a treatment for patients with acute cholecystitis. Patients and methods This was a 1 : 1 matched cohort study of all patients who were unfit for cholecystectomy and underwent EGBD or percutaneous cholecystostomy instead for the treatment of acute cholecystitis. The outcomes were matched for age, sex, and American Society of Anesthesiologists grade. Outcome measures included the technical and clinical success rates, adverse events, hospital stay, the number of unplanned admissions, and mortality. Results Between November 2011 and August 2014, a total of 118 patients were included in the study (59 EGBD, 59 percutaneous cholecystostomy). Technical and clinical success rates were similar. In the EGBD group, significantly fewer patients suffered from overall adverse events (19 [32.2 %] vs. 44 [74.6 %]; P < 0.001) and serious adverse events (14 [23.7 %] vs. 44 [74.6 %]; P < 0.001) compared to the percutaneous cholecystostomy group. Patients in the EGBD group required fewer unplanned admissions (4 [6.8 %] vs. 42 [71.2 %]; P < 0.001), which were due to problems related to the cholecystostomy tube in 95.2 %. The 30-day adverse event rates were similar between the groups (17 [28.8 %] vs. 10 [16.9 %]; P = 0.13). For instance, recurrent acute cholecystitis occurred in 0 patients in the EGBD group and in 4 (6.8 %) patients in the percutaneous cholecystostomy group (P = 0.12). The 30-day mortality rates were non-significantly higher in the EGBD group (5 [8.5 %] vs. 1 [1.7 %]; P = 0.21). Conclusions EGBD and percutaneous cholecystostomy were both effective means of achieving gallbladder drainage. EGBD may be a promising alternative to percutaneous cholecystostomy for treatment of acute cholecystitis in patients who are unfit for surgery, provided that experienced endosonographers are available. [ABSTRACT FROM AUTHOR]

Initially, transpapillary gallbladder drainage was attempted, but it was impossible to advance a guidewire through the cystic duct into the gallbladder. 2 Endoscopic ultrasound (EUS)-guided gallbladder drainage. a EUS image showing a distended gallbladder. [Extracted from the article]

: Referring to Kongkam P et al. p. 55-62 Complete drainage of complex MHBO improves patient outcomes; however, complete drainage in high-grade MHBO is not only difficult to achieve but also difficult to maintain, as clogging and ingrowth result in limited stent patency. For two decades now, EUS-guided biliary drainage (EUS-BD) has increasingly been performed in malignant biliary obstruction (MBO) following failed ERCP as an alternative to PTBD, the historical gold standard for difficult biliary drainage. [Extracted from the article]

The article presents a case study of a 59-year-old man who had unresectable ampullary adenocarcinoma which causes biliary obstruction and gastric outlet that was palliated through placement of duodenal self-expandable metal stents (SEMSs).

Competing Interests: Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background and study aim  There are no data comparing endoscopic ultrasound (EUS)-guided gallbladder drainage (EGBD) with percutaneous cholecystostomy as a treatment for patients with acute cholecystitis. Patients and methods  This was a 1 : 1 matched cohort study of all patients who were unfit for cholecystectomy and underwent EGBD or percutaneous cholecystostomy instead for the treatment of acute cholecystitis. The outcomes were matched for age, sex, and American Society of Anesthesiologists grade. Outcome measures included the technical and clinical success rates, adverse events, hospital stay, the number of unplanned admissions, and mortality. Results  Between November 2011 and August 2014, a total of 118 patients were included in the study (59 EGBD, 59 percutaneous cholecystostomy). Technical and clinical success rates were similar. In the EGBD group, significantly fewer patients suffered from overall adverse events (19 [32.2 %] vs. 44 [74.6 %]; P  < 0.001) and serious adverse events (14 [23.7 %] vs. 44 [74.6 %]; P  < 0.001) compared to the percutaneous cholecystostomy group. Patients in the EGBD group required fewer unplanned admissions (4 [6.8 %] vs. 42 [71.2 %]; P  < 0.001), which were due to problems related to the cholecystostomy tube in 95.2 %. The 30-day adverse event rates were similar between the groups (17 [28.8 %] vs. 10 [16.9 %]; P  = 0.13). For instance, recurrent acute cholecystitis occurred in 0 patients in the EGBD group and in 4 (6.8 %) patients in the percutaneous cholecystostomy group ( P  = 0.12). The 30-day mortality rates were non-significantly higher in the EGBD group (5 [8.5 %] vs. 1 [1.7 %]; P  = 0.21). Conclusions  EGBD and percutaneous cholecystostomy were both effective means of achieving gallbladder drainage. EGBD may be a promising alternative to percutaneous cholecystostomy for treatment of acute cholecystitis in patients who are unfit for surgery, provided that experienced endosonographers are available., (© Georg Thieme Verlag KG Stuttgart · New York.)