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Introduction: Endosonography-guided biliary drainage (EUS-BD) serves as a rescue treatment modality for patients with malignant biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Objectives: This study explores the effects of EUS-BD on liver function and quality of life (QoL). Patients and Methods: Patients with malignant biliary obstruction and failed ERCP were enrolled to undergo EUS-BD. QoL, including pruritus severity, was evaluated using EQ-5D-5L and PSS-10 questionnaires before and after EUS-BD. Serum bilirubin and liver function tests were measured on the procedure day, two days, and at least 14 days post-procedure. Results: During a 20-month study period, 1755 ERCPs were performed, with 595 for malignant cases. Of these, 49 underwent EUS-BD following failed ERCP, and 37 (54% women, age range 34–87 years) completed the 14-day follow-up. Pancreatic cancer was the most common (49%) condition, and the median hospital stay was 4 days. Serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase significantly decreased 2 and 14 days after EUS-BD (all p < 0.001). Pruritus significantly improved, with an average reduction of 5.19 points on the PSS-10 scale two weeks post-procedure (p < 0.001). EUS-BD led to improvements in anxiety and depression according to the EQ-5D-5L (p = 0.013). Conversely, deteriorations were observed in the Mobility, Self-Care, and Usual Activities domains over time (all p < 0.05). Successful EUS-BD enabled the resumption of chemotherapy in 11 (30%) patients. The median post-procedure survival was 112 (range 27–1030) days. Conclusions: EUS-BD improves liver parameters and some aspects of life quality in patients with malignant biliary obstruction, thereby increasing their eligibility for optimal palliative care. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in managing malignant biliary obstruction. The success of ERCP has limitations, whereas surgical biliary bypass and percutaneous transhepatic approaches, as alternative modalities, come with significant costs, longer durations, and higher levels of mortality and morbidity. Endoscopic ultrasonography (EUS)‐guided biliary drainage with two approaches, hepaticogastrostomy (EUS‐HGS) and choledochoduodenostomy (EUS‐CDS), is a favored and evolving alternative modality. This study aims to compare the efficacy and safety of EUS‐HGS and EUS‐CDS. We conducted a systematic review and meta‐analysis by searching PubMed, ScienceDirect, Cochrane Library, and Scholar databases up to August 2023, based on the 2020 PRISMA guidelines. We identified randomized and nonrandomized studies comparing the efficacy and safety of EUS‐HGS and EUS‐CDS. Outcome measures included technical and clinical success, side effects, and mean procedure time. Nine nonrandomized studies and two randomized controlled trials involving 537 patients (225 EUS‐HGS, 312 EUS‐CDS) were analyzed. No difference was found in technical success (OR, 0.83; 95% CI, 0.41–1.68; I2 = 0%) and clinical success between the two procedures (OR, 0.96; 95% CI, 0.51–1.81; I2 = 9.94%). Side effects were significantly higher in EUS‐HGS (OR, 2.01, 95% CI, 1.14–3.59; I2 = 0%). No significant difference in mean procedure time was observed between the two procedures (0.13; 95% CI, −0.15–0.41; I2 = 34.89%). There are differences in efficacy and safety between EUS‐HGS and EUS‐CDS. EUS‐CDS has a faster procedure time, lower risk of side effects, and ease of puncture during the procedure. [ABSTRACT FROM AUTHOR]

Background and Aim: Several meta‐analyses have analyzed the technical and clinical success of endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) by using lumen‐apposing metal stents (LAMS) in malignant biliary obstruction, but those concerning adverse events (AEs) are scarce. The current systematic review and meta‐analysis was conducted to evaluate the AEs after EUS‐CDS with LAMS. Methods: A comprehensive literature search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Library was conducted for studies reporting the outcomes of EUS‐CDS with LAMS. The main endpoints were the incidence of overall and specific AEs. Moreover, the stent dysfunction, and reintervention rates were evaluated independently. Results: A total of 21 studies (n = 1438) were included in the final meta‐analysis. The pooled rate of technical and clinical success was 93.5% (95% confidence interval [CI]: 91.3–95.1) and 88.0% (95% CI: 83.9–91.1), respectively. After EUS‐CDS with LAMS, the pooled incidence of overall AEs was 20.1% (95% CI: 16.0–24.9). The estimated rate of early AEs was 10.6% (95% CI: 7.9–14.2), and late AEs was 11.2% (95% CI: 8.2–15.2). Infection/cholangitis was the commonest AE, with a pooled incidence of 6.1% (95% CI: 3.7–10.1). The estimated incidence of stent dysfunction and reintervention was 10.5% (95% CI: 7.5–14.4), and 12.1% (95% CI: 9.3–15.7), respectively. Conclusion: Despite with a high technical and clinical success rate, EUS‐CDS with LAMS may be associated with overall AEs and stent dysfunction in one‐fifth and one‐tenth of cases, respectively. Further efforts are required to optimize its safety and long‐term stent patency. [ABSTRACT FROM AUTHOR]

Abstract Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in managing malignant biliary obstruction. The success of ERCP has limitations, whereas surgical biliary bypass and percutaneous transhepatic approaches, as alternative modalities, come with significant costs, longer durations, and higher levels of mortality and morbidity. Endoscopic ultrasonography (EUS)‐guided biliary drainage with two approaches, hepaticogastrostomy (EUS‐HGS) and choledochoduodenostomy (EUS‐CDS), is a favored and evolving alternative modality. This study aims to compare the efficacy and safety of EUS‐HGS and EUS‐CDS. We conducted a systematic review and meta‐analysis by searching PubMed, ScienceDirect, Cochrane Library, and Scholar databases up to August 2023, based on the 2020 PRISMA guidelines. We identified randomized and nonrandomized studies comparing the efficacy and safety of EUS‐HGS and EUS‐CDS. Outcome measures included technical and clinical success, side effects, and mean procedure time. Nine nonrandomized studies and two randomized controlled trials involving 537 patients (225 EUS‐HGS, 312 EUS‐CDS) were analyzed. No difference was found in technical success (OR, 0.83; 95% CI, 0.41–1.68; I2 = 0%) and clinical success between the two procedures (OR, 0.96; 95% CI, 0.51–1.81; I2 = 9.94%). Side effects were significantly higher in EUS‐HGS (OR, 2.01, 95% CI, 1.14–3.59; I2 = 0%). No significant difference in mean procedure time was observed between the two procedures (0.13; 95% CI, −0.15–0.41; I2 = 34.89%). There are differences in efficacy and safety between EUS‐HGS and EUS‐CDS. EUS‐CDS has a faster procedure time, lower risk of side effects, and ease of puncture during the procedure.

Common bile duct stones (CBD) are prevalent, affecting 6 to 12% of patients with gallbladder stones, with incidence rising with age. Often asymptomatic, they can be discovered incidentally. Typical symptoms include fever, epigastric or right upper quadrant pain, and jaundice, present in approximately two-thirds of cases. Choledochal stones can lead to complications such as cholangitis, gallstone pancreatitis, and obstructive jaundice. This study aims to assess the incidence and aetiopathogenesis of Common Bile Duct stones in the southern region of Odisha, India. This prospective study was conducted from august 2022 to January 2024 with a sample size of 21 patients including 7 males and 14 females with diagnosis of choledocholithiasis supported by imaging. In the study we found the highest incidence of CBD stones was in the elderly population, particularly among females. For non-surgical option and small stone <12mm ERCP with stone retrieval with laparoscopic cholecystectomy is ideal but for large stone, multiple stone and surgical opinion where ERCP is not available CBD exploration with choledochoduodenostomy emerged as the primary management modality in our study. [ABSTRACT FROM AUTHOR]

Background: Sump syndrome is one of the rare long-term complications of side-to-side choledochoduodenostomy (CD) leading to attacks of cholangitis due to accumulation of food and debris in the common bile duct distal to the anastomosis is one of the rare long-term complications after CD. Methods: Fifteen patients treated with the Sump syndrome in our institution between 1996 and 2023 were retrospectively evaluated for long-term outcome. Results: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and bile duct clearance was done in 11 patients, while four were subjected to revisional surgery in the form of a Roux-en-Y hepaticojejunostomy. No complications were recorded. There were 5 (38%) recurrences in a median follow-up period of 8 years (10 months–23 years). Of those, 3 patients were treated surgically and two with repeat ERCP. None of the patients developed any cholangiocarcinoma during follow-up. Conclusion: We conclude that although a high recurrence rate was observed, endoscopic treatment may be a valid approach in the treatment of Sump syndrome, with revisional surgery in the form of a Roux-en-Y hepaticojejunostomy as salvage therapy in recurrences. [ABSTRACT FROM AUTHOR]

Purpose: Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning. Methods: A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated. Results: The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien–Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51–79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery. Conclusions: CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD), classified as choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS), is a feasible and effective alternative for distal malignant biliary obstruction (MBO) in failed endoscopic retrograde cholangiopancreatography. However, the preferred technique for better outcomes has not yet been evaluated. Objectives: We compared the long-term outcomes between the techniques. Design: Retrospective comparative study. Methods: We reviewed consecutive patients who underwent EUS-CDS or EUS-HGS with transmural stent placement for distal MBO between 2009 and 2022. The primary outcome was the stent patency. The secondary outcomes were technical and clinical success, adverse events (AEs) of each technique, and independent risk factors for stent dysfunction. Results: In all, 115 patients were divided into EUS-CDS (n = 56) and EUS-HGS (n = 59) groups. Among them, technical success was achieved in 98.2% of EUS-CDS and 96.6% of EUS-HGS groups. Furthermore, clinical success was 96.4% in EUS-CDS and 88.1% in EUS-HGS groups, without significant difference (p = 0.200). The mean duration of stent patency for EUS-CDS was 770.3 days while that for EUS-HGS was 164.9 days (p = 0.010). In addition, the only independent risk factor for stent dysfunction was systematic treatment after EUS-BD [hazard ratio and 95% confidence interval 0.238 (0.066–0.863), p = 0.029]. The incidence of stent dysfunction of EUS-HGS was higher than EUS-CDS (35.1% versus 18.2%, 0.071), despite no significant differences even in late AEs. Conclusion: In distal MBO, EUS-CDS may be better than EUS-HGS with longer stent patency and fewer AEs. Furthermore, systematic treatment after EUS-BD is recommended for the improvement of stent patency. [ABSTRACT FROM AUTHOR]

Simple Summary: Complications of pancreatic cancer include the development of blockage of the bile duct preventing drainage of the liver, blockage of the stomach and duodenum preventing the passage of food and increase in pain levels. Endoscopic ultrasound is a procedure performed through the mouth where a flexible tube with a camera and an ultrasound probe attached allow for visualization of organs around the stomach and small intestine, such as the pancreas, the bile duct, and the liver. It was originally designed to help diagnose pancreatic cancer, but with advances in technology, it can now be used to treat the aforementioned complications without performing surgery. This paper reviews the new advances in technologies and techniques performed through endoscopic ultrasound with an emphasis on clinical trials that have been done to provide an overview of the safety and effectiveness of these procedures. Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease. [ABSTRACT FROM AUTHOR]

Case summary A 5-year-old neutered Somali cat presented with a 2-week history of icterus. Diagnostic imaging revealed extrahepatic biliary obstruction (EHBO) due to a common bile duct (CBD) mass. During exploratory laparotomy, a duodenal perforation was discovered incidentally. Choledochoduodenostomy combined with the Billroth II procedure was performed after resection of the CBD mass and the proximal duodenum to treat the EHBO and duodenal perforation. Based on histological and immunohistochemical findings, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation. The cat recovered almost uneventfully and was discharged 11 days after surgery. The cat survived for nearly 100 days without recurrence of EHBO or duodenal perforation; however, intermittent vomiting and weight loss persisted despite supportive medications. Relevance and novel information To the best of our knowledge, there is no detailed report on the application of choledochoduodenostomy combined with the Billroth II procedure in cats, as we used to treat the EHBO and duodenal perforation in the present case. As serum gastrin concentrations were elevated on the first day of hospitalisation, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation, which seemed to have caused not only EHBO but also duodenal perforation (Zollinger-Ellison syndrome). The cat survived for almost 100 days without any perioperative complications. However, this combined procedure might be considered as only a salvage option and not as a definitive treatment option in cats requiring simultaneous biliary and gastrointestinal reconstruction because postoperative supportive care could not improve the cat's condition or maintain its quality of life. [ABSTRACT FROM AUTHOR]

Abstract Objectives Endoscopic ultrasound (EUS)‐guided biliary drainage encompasses techniques such as EUS‐guided hepaticogastrostomy (EUS‐HGS) and EUS‐guided choledochoduodenostomy (EUS‐CDS). This meta‐analysis compared the efficacy of EUS‐CDS with that of EUS‐HGS for the treatment of biliary obstruction. Methods A systematic meta‐analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS‐CDS and EUS‐HGS. Results This meta‐analysis included 18 eligible studies. There was no significant difference between EUS‐CDS and EUS‐HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62–1.73) and clinical success rate (OR 0.66; 95% CI 0.43–1.04), or with respect to total procedure‐related adverse events (OR 1.39; 95% CI 1.00–1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS‐HGS (OR 2.95; 95% CI 1.54–5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference –11.93 days; 95% CI –47.77–23.91). However, the procedure time was longer for EUS‐HGS (mean difference, 3.21 min; 95% CI 1.24–5.19). Conclusion EUS‐CDS and EUS‐HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS‐CDS is superior with respect to procedure time and preventing RBO.

This article provides information on the management of common bile duct stones in a tertiary care hospital in India. The study found that common bile duct stones were more common in females between the ages of 55 and 64. The study compared the success rates of open surgery and endoscopic procedures, with open surgery being slightly more successful. Complications such as pancreatitis and hemorrhage were observed in some cases. The authors emphasize the importance of individualized treatment and the availability of experienced doctors. The study also provides data on the age distribution and symptoms of patients with common bile duct stones, with pain being the most common symptom. The success rate of endoscopic procedures was 85.3%, while open CBD exploration had a success rate of 85.7%. Complications occurred in a small percentage of cases, with a mortality rate of 1.5% for endoscopic procedures. The study concludes that open surgery is more successful, but further research is needed for validation. [Extracted from the article]

Introduction: Malignant biliary obstruction drainage is essential, since jaundice is associated with morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended procedure for biliary drainage, with percutaneous biliary drainage being the classic alternative in cases of unsuccessful ERCP. Recently, endoscopic ultrasound-guided biliary drainage has been emerged as a new option, with EUS-guided choledochoduodenostomy (EUS-CDS) being considered an effective and safe method in the drainage of distal obstructions of the common bile duct. Aim: The aim of the study was to evaluate the efficacy and safety of EUS-CDS performed in patients with distal malignant biliary obstructions, after failed ERCP. Methods: Single-center retrospective cohort study between July 2017 and June 2022 including all consecutive patients submitted to EUS-CDS in our center. The primary outcomes were “technical success” and “clinical success,” defined as “resolution of jaundice or improvement in total serum bilirubin level above 50% at 7th day and above 75% at 30th day after the procedure.” Secondary outcomes were procedure-related adverse events, endoscopic reintervention, and survival time. Results: EUS-CDS was performed in 20 patients (65.0% male; median age 76 years). The most frequent etiology for the biliary obstruction was pancreatic adenocarcinoma (n = 17; 85.0%), and most patients presented at advanced stages of cancer (12/60% in stages III or IV). ERCP failure was mainly due to the presence of obstruction in the duodenal lumen (n = 11; 55.0%). Fully covered metallic stents were used in all patients, mostly HotAxiosTM (n = 15; 75.0%). The technical success rate was 100%, and the clinical success rate was 89.5% (n = 17/19) at 7th day and 93.3% (n = 14/15) at 30th day. Four patients (20.0%) developed cholangitis within the first 30 days after the procedure; there were no late complications, and no patient died as a complication of the procedure. In 2 patients (10.0%), endoscopic reintervention was necessary due to stent migration, incidentally detected. Median survival was 93 days (minimum 5–maximum 751). Conclusion: EUS-CDS was effective in biliary decompression of malignant obstructions of the common bile duct, with high clinical success and a favorable safety profile.

The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS.

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become comparable to endoscopic retrograde cholangiopancreatography and is now considered a first-line intervention for certain biliary obstructions. Although analysis of experience-related factors may help achieve better outcomes and contribute to its wider adoption, no concrete evidence exists regarding the required operator or institutional experience levels. This study aimed to analyze experience-related factors at beginner multicenters. Patients who underwent EUS-BD using self-expandable metal stents and/or dedicated plastic stents during the study period (up to the first 25 cases since introducing the technique) were retrospectively enrolled from seven beginner institutions and operators. Overall, 90 successful (technical success without early adverse events) and 22 failed (technical failure and/or early adverse events) cases were compared. EUS-BD-related procedures conducted at the time of applicable EUS-BD by each institution/operator were evaluated. The number of institution-conducted EUS-BD procedures (≥7) and operator-conducted EUS screenings (≥436), EUS-guided fine-needle aspirations (FNA) (≥93), and EUS-guided drainages (≥13) significantly influenced improved EUS-BD outcomes (p = 0.022, odds ratio [OR], 3.0; p = 0.022, OR, 3.0; p = 0.022, OR, 3.0; and p = 0.028, OR, 2.9, respectively). Our threshold values, which significantly divided successful and failed cases, were assessed using receiver operating characteristic curve analysis and may provide useful approximate indications for successful EUS-BD. [ABSTRACT FROM AUTHOR]

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device. [ABSTRACT FROM AUTHOR]

Background: Patients with moderate–severe cholangitis require urgent/early biliary drainage and failed endoscopic retrograde cholangiopancreatography (ERCP) warrants use of percutaneous drainage. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved as an effective salvage modality but its safety and efficacy data in moderate–severe cholangitis are limited. Patients and methods: All consecutive moderate–severe cholangitis patients, with failed/technically non-feasible ERCP requiring EUS-BD in two tertiary care centers were included. Baseline laboratory and demographic parameters were documented. Technical and clinical success were primary outcome measures. Additionally, effective biliary drainage, adverse events due to procedure, hospital stay, ICU stay, and mortality were noted. Results: Of the 49 patients (23 male; 46.9%) presenting with moderate/severe cholangitis, 23 (46.9%) had severe cholangitis. The median Charleston comorbidity index was 7.0 (IQR 2.0). Majority had malignant disease (87.8%) and 25 (51.0%) had inaccessible papilla. Technical success was achieved in 48 cases (98.0%), while clinical success with improvement of cholangitis was noted in 44 of 48 cases (91.7%). Effective biliary drainage was noted in 85.4% (41/48) cases. Adverse events in the form of mostly bleeding and bile leak were noted in 5 cases (10.2%) but managed conservatively. Distal obstruction exhibited significantly better clinical success (100% vs. 78.9%; p = 0.02) than hilar obstruction. Severe cholangitis had significantly lower clinical success (81.8% vs. 100%; p = 0.04) than moderate cholangitis. Conclusion: EUS-BD can be a safe and effective alternative option for patients with moderate to severe cholangitis, even with significant pre-morbid conditions, with acceptable adverse events rate. [ABSTRACT FROM AUTHOR]

Abstract Background It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing meal stent (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency. The aim of this study is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (BD) for the management of distal malignant biliary obstruction. Methods/design This is a multicenter open-label, randomized controlled trial with two parallel groups. Eighty-four patients with malignant biliary obstruction will undergo EUS-BD (CDS type) using LAMS in 7 tertiary hospitals in Spain and will be randomized to the LAMS and LAMS plus DPS groups. The primary endpoint is the rate of recurrent biliary obstruction, as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin > 50% within 14 days of stent placement), safety, and others (number of reinterventions, time to biliary obstruction, prognostic factors, survival rate). Discussion The BAMPI trial has been designed to determine whether the addition of a coaxial axis-orienting DPS through LAMS is superior to LAMS alone to prevent stent dysfunction. Trial registration ClinicalTrials.gov NCT04595058 . Registered on October 14, 2020.

BackgroundThis study introduces an alternative palliative surgical procedure called laparoscopic bridge choledochoduodenostomy (LBCDD) for patients with advanced malignant obstructive jaundice (AMOJ).MethodsPatients with AMOJ who had LBCDD between January 2017 and August 2021 were identified from databases of two institutions in China.ResultsA total of 35 patients (male 12; female 23) with an average age of 64 years were enrolled. The average diameter of the tumor is 4.24 cm. All patients undertook LBCDD within an average operation time of 75 min with a mean blood loss of 32 ml. One patient had controlled bile leakage after the operation and two developed surgical site infection involving the epigastric orifices. All of them were solved by conservative treatment. All patients were discharged smoothly after an average hospital stay of 5.5 days, and no conversion to open surgery was required.ConclusionsLBCDD is a safe and efficient palliative surgery, which has a good therapeutic effect on patients with AMOJ.

Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUSguided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancerrelated symptoms. [ABSTRACT FROM AUTHOR]

Background: Choledocholithiasis, or stones in the common bile duct (CBD), has two types: primary stones that form in the CBD and secondary stones that migrate from the gallbladder. Management includes endoscopic, laparoscopic, and open surgical methods. In India, the availability of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery is limited often necessitating open procedures. Commonly, open choledochotomy followed by T tube placement was performed. However, postoperative management/management of retained stones can be challenging, requiring referrals for ERCP or revision surgery. This study aims to compare the outcomes of choledochoduodenostomy versus the T tube approach in a hospital setup where ERCP is either unavailable or cumbersome., Materials and Methods: This was a retrospective comparative study carried out at Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India. The study was approved by the Institutional Ethics Committee of RIMS, Ranchi. A total of 62 patients who underwent operations for choledocholithiasis (CBD dilation ≥ 1.2 cm) from January 2023 to January 2024 in the Department of General Surgery of RIMS, Ranchi, were analyzed., Results: The mean age group was 52 years ± 11.5 years, and two-thirds were females with a male-to-female ratio of 1:1.8. The most common presentation was biliary colic (87 %), followed by jaundice (45%). Around three-fourths of them had multiple calculi (n = 46). A total of 36 patients underwent T tube (58.1%) and 26 underwent choledochodudoenostomy (41.9 %). The mean operating time was higher for the T tube approach but not statistically significant. The hospital stay for the patients was significantly higher for the T tube approach with a p-value of <0.001. The mean T tube in situ duration was 17.60 days ± 1.2 days. On performing a T tube cholangiogram postoperatively, it was observed around one-fourth of them had T tube filling defect (n = 8), signifying the residual stone presence and referral to higher center due to unavailability of ERCP. The incidence of wound infection was significantly high among the patient who underwent T tube with a p-value of 0.017, and postoperative bile leak was significantly high among the patient who underwent T tube with a p-value of 0.047., Conclusion: Based on our retrospective analysis, we suggest choledochoduodenostomy was safer and more efficient in aspects of lesser operating time, minimal hospital stay, less or nil retained stones, lesser postoperative wound infection, bile leakage, and possessing advantages especially to elderly patients both economically and psychologically., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Rajendra Institute of Medical Sciences issued approval 08/2023. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Hassan et al.)

Finding intraoperatively an advanced perihilar bile duct tumor involving both hepatic ducts is a difficult situation for a surgeon to perform biliary drainage. We propose a simplified biliary drainage technique by a combined intraoperative biliary stent with choledochoduodenostomy and report the long-term outcomes of four patients who underwent biliary drainage using this technique. This technique is less technically demanding and provides an acceptable patency rate. Choledochoduodenostomy anastomosis also allows the surgeon to reassess and perform additional interventions of the biliary tract. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones.Methods: Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed.Results: One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient.Conclusion: Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution. [ABSTRACT FROM AUTHOR]

Bilioenteric anastomoses were common interventions before the rise of minimal invasion procedures, specifically, before endoscopic retrograde cholangiopancreatography. During a choledochoduodenostomy (CDS) the distal part of the common bile duct is excluded from the bile drainage and behaves as a “sump,” a poorly drained part that works as a reservoir which is responsible of the development of complications of the bilio-pancreatic tract. The consequent sump syndrome is a rare medical complication that presents a diversity of symptoms, for which there is no well-defined diagnostic algorithm. We present the case of a 72-year-old male patient with multiple comorbidities. He presented to the ER because of recurrent episodes of cholangitis; after having obtained the patient’s medical records, lab and image studies, the latter showed pneumobilia. After considering all the results plus the pneumobilia we suspect the presence of this uncommon complication of CDS. The patient was subjected to an unsuccessful endoscopic treatment followed by surgery, after which he showed signs of improvement and adequate evolution till hospital discharge.

Background: It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing meal stent (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency. The aim of this study is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (BD) for the management of distal malignant biliary obstruction. Methods/design: This is a multicenter open-label, randomized controlled trial with two parallel groups. Eighty-four patients with malignant biliary obstruction will undergo EUS-BD (CDS type) using LAMS in 7 tertiary hospitals in Spain and will be randomized to the LAMS and LAMS plus DPS groups. The primary endpoint is the rate of recurrent biliary obstruction, as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin > 50% within 14 days of stent placement), safety, and others (number of reinterventions, time to biliary obstruction, prognostic factors, survival rate). Discussion: The BAMPI trial has been designed to determine whether the addition of a coaxial axis-orienting DPS through LAMS is superior to LAMS alone to prevent stent dysfunction. Trial registration: ClinicalTrials.govNCT04595058. Registered on October 14, 2020. [ABSTRACT FROM AUTHOR]

Purpose of review: Lumen-apposing metal stents (LAMS) are fully covered self-expandable metal stents specifically designed for the endoscopic drainage of pancreatic fluid collections. Initially utilized for pancreatic fluid collections, LAMS are increasingly being applied for various other indications like endoscopic gastroenterostomy, choledochoduodenostomy, drainage of gall bladder, facilitation of ERCP in surgically altered anatomy, and management of refractory gastrointestinal strictures. The availability of electrocautery-enhanced version has simplified the deployment of LAMS and paved the way for their use in these off-label indications. This review summarizes the current evidence regarding the expanding indications of LAMS in the gastrointestinal tract. Recent findings: Endoscopic ultrasound (EUS)-guided biliary drainage using LAMS is a safe and effective alternative to ERCP with the advantage of lower post-ERCP pancreatitis and less re-interventions due to higher stent patency. EUS-guided gastroenterostomy with LAMS provides effective palliation in cases with malignant gastric outlet obstruction. Preliminary data suggests their superiority over enteral stenting, and the results may improve further with the use of large caliber LAMS (20 mm). EUS-directed transgastric ERCP is feasible and safe in cases with surgically altered anatomy. The risk of LAMS migration during ERCP may be reduced by stent fixation using endosuturing and using a larger caliber LAMS (20 mm). LAMS may be effective in selected cases with refractory gastrointestinal strictures (mainly anastomotic). However, encouraging results in the short term may be offset by a high rate of re-interventions on long-term follow-up. Summary: LAMS are potentially useful for a wide range of indications in gastrointestinal tract. While, the role of LAMS has been established for pancreatic fluid collections, EUS-biliary drainage, and gastroenterostomy, their use for other indications like transgastric ERCP and benign strictures is still evolving. [ABSTRACT FROM AUTHOR]

BackgroundAlthough endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) has emerged as an option for patients of failed endoscopic retrograde cholangiopancreatography (ERCP), there has no agreement on which approach is preferred. Therefore, a meta-analysis was performed to examine the two methods.MethodsWe performed a comprehensive search in databases of PubMed, Embase, and Cochrane library to find relevant studies reporting the efficacy and safety of the two EUS-guided biliary drainage methods.ResultsIn total, 12 studies with 623 patients (EUS-CDS: 303 and EUS-HGS: 320) were included. The cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0% (288/303), 93.1% (268/288), and 96.6% (309/320), 91.3% (282/309), respectively. Compared with EUS-HGS, the pooled odds ratio (OR) was 0.74 (95% CI 0.33–1.65; p = 0.46) for EUS-CDS technical success and 0.94 (95% CI 0.56–1.59; p = 0.83) for clinical success. The pooled difference in means of procedure time of EUS-CDS and EUS-HGS was −2.68 (95% CI −5.12 to −0.24; p = 0.03). The cumulative early adverse events for EUS-CDS and EUS-HGS was 12.2% (37/303) and 17.5% (56/320), respectively. Compared with EUS-HGS, the pooled OR of early adverse events for EUS-CDS was 0.58 (95% CI: 0.36–0.93; p = 0.02).ConclusionThis meta-analysis further suggests EUS-CDS and EUS-HGS have equal high technical and clinical success, but EUS-CDS with a slightly short procedure time and with less early adverse events compared to EUS-HGS.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous and surgical drainage in bile duct obstruction when endoscopic retrograde cholangiopancreatography fails. EUS-BD can be achieved with several techniques, including EUS-guided hepaticogastrostomy (HGS), anterograde transpapillary stent placement, choledochoduodenostomy (CDS), and rendez-vous technique. Lately, with increased experience and development of directed equipment, elevated technical and clinical success as well of lower adverse event rates have been reported. In this article, GRUPUGE presents an updated perspective of the potential role of EUS-guided biliary drainage, addressing the selection criteria and technical issues of different techniques and analyzing recent data on their safety and efficacy.

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Painless jaundice is a common presentation of abdominal malignancy seen in elderly patients. While malignancy may be a common cause of obstructive jaundice in that population group, anchor bias should always be avoided. We present a case of an elderly woman who presented with painless jaundice and weight loss. She had a very remote history of cholecystitis. She was found to have Sump syndrome due to a stricture at the Choledochoduodenostomy (CDD) site. She underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement which shortly led to resolution of her jaundice. Biopsy from the stricture site came back negative for malignancy., Competing Interests: Conflict of interest: Authors declare that they do not have any conflict of interest., (© 2024 Greater Baltimore Medical Center.)

Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a minimally invasive procedure that allows for biliary access when conventional endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. The technique can be divided based on biliary access route: intrahepatic or extrahepatic, as well as on stenting approach: rendezvous approach (EUS-RV), antegrade placement, or transluminal (intra or extra hepatic) placement. There is no clear consensus on which approach is superior. Compared to percutaneous transhepatic biliary drainage, EUS-BD offers lower rates of adverse events without the need for an external drain. Compared to conventional ERCP, EUS-BD shows comparable, and in some cases superior, outcomes related to technical success, clinical success, and adverse events., Competing Interests: Disclosures Dr A. Canakis has no disclosures. Dr A. Tyberg has done consulting work for Boston Scientific, Medtronic, Ambu Inc, and Microtech., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Sump syndrome is a rare complication of a side to side choledochoduodenostomy (CDD). After the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in 1968 Kozarek (Gastroenterol Hepatol (N Y) 13(10):620-622, 2017), choledochoduodenostomy and its complications are seldom seen. The diagnosis of sump syndrome is further befogged by the lack of characteristic clinical or laboratory findings, the inability of the patient to provide medical records of their CDD, and the fact that sump syndrome only presents decades after a CDD. In this article, we will present a case of a 39-year-old female patient who presented as a case of ascending cholangitis with an initially unknown past surgical history. A detailed medical history was thoroughly taken, and her previous medical reports were presented after which an ERCP was done with extraction of debris was preformed. In a time where choledochoduodenostomy is rarely being chosen as a choice of treatment and its complications are infrequently encountered, this case serves as a reminder that even in the ERCP era, complications of choledochoduodenostomy should still be well understood. [ABSTRACT FROM AUTHOR]

Abstract Background Intraductal papillary neoplasm of the bile duct (IPNB) is a bile duct neoplasm characterized as a precursor lesion of cholangiocarcinoma. An invasive component is present in approximately 40 to 80% of reported cases and lymph node metastasis is sometimes detected. We experienced a rare case of IPNB with invasive adenocarcinoma and lymph node metastasis that developed 38 years after choledochoduodenostomy. Case presentation A 72-year-old man presented to our hospital for liver dysfunction. The patient had a past medical history of choledochoduodenostomy for a bile duct stone 38 years previously and short bowel syndrome because of strangulation ileus 32 years previously. Ultrasonography and abdominal enhanced computed tomography (CT) revealed a left intrahepatic bile duct dilation and a papillary mass in the left hepatic duct. Positron emission tomography (PET) CT showed abnormal accumulation in the left hepatic duct and in the hepatic hilar lymph node. Endoscopic retrograde cholangiogram showed a filling defect in the left bile duct, and a cytological examination revealed the presence of atypical cells. We diagnosed cholangiocarcinoma (derived from IPNB) with lymph node metastasis and performed extended left hepatectomy, caudate lobectomy, and lymph node dissection without extrahepatic bile duct resection. Histopathological findings showed papillary adenoma and partially invasive poorly differentiated adenocarcinoma in the bile duct. Additionally, the hepatic hilar lymph node was positive. Conclusions The tumor was diagnosed as IPNB with invasive adenocarcinoma and lymph node metastasis. Biliary tract cancer that develops after choledochoduodenostomy is extremely rare, and only 17 cases (including IPNB) have been reported in the literature.

Bilioenteric anastomoses were common interventions before the rise of minimal invasion procedures, specifically, before endoscopic retrograde cholangiopancreatography. During a choledochoduodenostomy (CDS) the distal part of the common bile duct is excluded from the bile drainage and behaves as a "sump," a poorly drained part that works as a reservoir which is responsible of the development of complications of the bilio-pancreatic tract. The consequent sump syndrome is a rare medical complication that presents a diversity of symptoms, for which there is no well-defined diagnostic algorithm. We present the case of a 72-year-old male patient with multiple comorbidities. He presented to the ER because of recurrent episodes of cholangitis; after having obtained the patient's medical records, lab and image studies, the latter showed pneumobilia. After considering all the results plus the pneumobilia we suspect the presence of this uncommon complication of CDS. The patient was subjected to an unsuccessful endoscopic treatment followed by surgery, after which he showed signs of improvement and adequate evolution till hospital discharge. [ABSTRACT FROM AUTHOR]