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Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for drainage in malignant biliary obstruction. However, ERCP is not always successful, due to difficulties with selective biliary cannulation or gastroduodenal obstruction preventing access to the ampulla of Vater. Although percutaneous transhepatic biliary drainage has traditionally been the preferred approach in these circumstances, endoscopic ultrasound-guided biliary drainage (EUS-BD), using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system, has shown a technical success rate of 95% in overseas studies. This multicenter study aimed to evaluate the efficacy and safety of EUS-BD using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for biliary drainage across 11 tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each hospital. The primary outcome measure was technical success, defined as successful EUS-BD. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 41 patients (median age, 72 years [range, 45-94]; 22 [54%] male) had attempted EUS-BD across the 11 hospitals. Etiology of biliary obstruction included pancreatic adenocarcinoma (n = 30), ampullary carcinoma (n = 3), cholangiocarcinoma (n = 1), duodenal cancer (n = 1), and metastatic disease (n = 6). Initial ERCP drainage failed due to inability to access the papilla as a result of malignant duodenal obstruction (n = 8), inability to locate the papilla due to tumor infiltration (n = 11), and failed cannulation (n = 22). The median common bile duct (CBD) diameter was 18 mm (IQR, 16-19.5), with access obtained through the duodenum in all but two procedures (95%), in which the stent was inserted through the gastric antrum. Fluoroscopic guidance was used in two-thi

Introduction: Despite recent progress, the outlook for most patients with pancreatic cancer remains poor. There is variation in how patients are managed globally due to differing interpretations of the evidence, partly because studies in this disease are challenging to undertake. This article collates the evidence upon which current best practice is based and offers an expert opinion from an international faculty on how latest developments should influence current treatment paradigms. Areas covered: Optimal chemotherapy for first and subsequent lines of therapy; optimal management of locally advanced, non-metastatic cancer including the role of neoadjuvant chemo(radio)therapy, current evidence for adjuvant chemotherapy, major advances in pancreatic cancer genomics and challenges in supportive care particularly relevant to patients with pancreatic cancer. For each section, literature was reviewed by comprehensive search techniques, including clinical trial websites and abstracts from international cancer meetings. Expert commentary: For each section, a commentary is provided. Overall the challenges identified were: difficulties in diagnosing pancreatic cancer early, challenges for performing randomised clinical trials in all stages of the disease, some progress in systemic therapy with new agents and in identifying molecular subtypes that may be clinically relevant and move towards personalized therapy, but still, pancreatic cancer remains a very poor prognosis cancer with significant palliative care needs.Copyright © 2017 Informa UK Limited, trading as Taylor & Francis Group.

Background Self expanding metal stents (SEMS) are widely used to alleviate symptoms of malignant gastrointestinal obstructions. Curative surgical resection of malignant gastroduodenal obstructions may not always be possible and there is significant morbidity associated with surgical bypass procedures. SEMS placement represents a minimally invasive method to achieve successful palliation of malignant luminal obstruction. Aims To evaluate the clinical outcomes after SEMS placement for malignant gastroduodenal obstruction, including assessment of survivability. Methods A 10 year multicenter clinical audit of patients undergoing endoscopic stent placement for palliation of gastric outlet or duodenal obstruction was undertaken at both Southern Health and Geelong Hospital. SEMS placement was performed using endoscopic and fluoroscopic guidance. Main outcome measures were technical success (defined as adequate endoscopic and fluoroscopic position of the stent), time to resumption of oral intake, and patient survival. Complications and the need for re-stenting were also analysed. Results From 2001 to 2012 we treated 83 patients with malignant gastric gastroduodenal outlet obstruction. The primary site of malignancy was pancreatic (44), gastric (33), duodenum (8), breast (2), gall bladder (2), other (4; colon, cervix, melanoma, sarcoma). The most proximal site of obstruction was at the pylorus and gastric antrum (34), duodenum (42), and jejunum (9). A total of 82 SEMS were deployed (Boston wallstent 43, Boston wallflex 37, 2 other). Technical success rate was 100%. 6 patients underwent subsequent therapy (5 stent blockages secondary to tumour in-growth and 1 tumour-related bleeding). Complications included perforation in 2 cases and (1?) death within 24 hours possibly secondary to sepsis. 95% of patients were able to resume oral intake within 24 hours and the average patient survival after SEMS placement was 4.5 months (0-48). Conclusion Endoscopic SEMS is an effective metho

Introduction: Self expanding metal stents (SEMS) are widely used to alleviate patient suffering from malignant gastrointestinal obstructions. We report a large, multicentre experience with endoscopic SEMS placement for malignant gastroduodenal outlet obstruction. Method(s): An 8 year multicentre clinical audit of all patients undergoing endoscopic stent placement for palliation of gastric outlet or duodenal obstruction was conducted. SEMS placement was performed using endoscopic and fluoroscopic guidance. Main outcome measures were technical success (defined as adequate endoscopic and fluoroscopic position of the stent), time to resumption of oral intake, and patient survival. Result(s): From 2001 to 2009, we treated 65 patients with malignant gastric outlet obstruction. The primary site of malignancy was pancreatic (30), gastric (22), breast (3), duodenum (4), gall bladder (2) and other (4; colon, cervix, melanoma, sarcoma). The most proximal site of obstruction was pylorus and gastric antrum (28), duodenum (33), and jejunum (4). A total of 71 SEMS were deployed (36 Wallstent, 33 Wallflex, 2 other). Technical success rate was 97%. 5 patients underwent subsequent therapy (4 stent blockage secondary to tumour ingrowth, 1 tumour related bleeding). Perforation rate after SEMS was 3%. 95% of patients were able to resume oral intake within 24 hours. Average patient survival after SEMS placement was 4.5 months (0.03-48 months). Conclusion(s): Endoscopic SEMS is an effective method to palliate gastroduodenal outlet obstruction. Our results highlight a favourable technical success rate and excellent palliation of symptoms of outlet obstruction with minimal adverse outcomes.

Background: Stent placement in the distal duodenum or proximal jejunum with a therapeutic gastroscope can be difficult, because of the reach of the endoscope, loop formation in the stomach, and flexibility of the gastroscope. The use of a colonoscope may overcome these problems. Objective: To report our experience with distal duodenal stent placement in 16 patients using a colonoscope. Methods: Multicenter, retrospective series of patients with a malignant obstruction at the level of the distal duodenum and proximal jejunum and treated by stent placement using a colonoscope. Main outcome measurements are technical success, ability to eat, complications, and survival. Results: Stent placement was technically feasible in 93% (15/16) of patients. Food intake improved from a median gastric outlet obstruction scoring system (GOOSS) score of 1 (no oral intake) to 3 (soft solids) (p = 0.001). Severe complications were not observed. One patient had persistent obstructive symptoms presumably due to motility problems. Recurrent obstructive symptoms were caused by tissue/tumor ingrowth through the stent mesh [n = 6 (38%)] and stent occlusion by debris [n = 1 (6%)]. Reinterventions included additional stent placement [n = 5 (31%)], gastrojejunostomy [n = 2 (12%)], and endoscopic stent cleansing [n = 1 (6%)]. Median survival was 153 days. Conclusion: Duodenal stent placement can effectively and safely be performed using a colonoscope in patients with an obstruction at the level of the distal duodenum or proximal jejunum. A colonoscope has the advantage that it is long enough and offers good endoscopic stiffness, which avoids looping in the stomach.