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Background: Few studies have compared endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) with EUS-guided antegrade metal stent placement (AGMS). The purpose of this study was to compare times to recurrent biliary obstruction (TRBO) in patients who underwent HGS using metal stents (MS) and those who underwent AGMS keeping access routes with plastic stents (AGMS-AR). Methods: This study retrospectively evaluated consecutive patients who underwent HGS or AGMS between September 2016 and December 2022. TRBO, overall survival (OS), and adverse event (AE) rates were compared in the two groups. The risk factors for RBO were determined using a multivariable Cox proportional hazards model. Results: This study included 32 patients in the HGS group and 30 in the AGMS-AR group. Technical success rate was significantly higher in the HGS than in the AGMS-AR group (100 vs. 80%; P = 0.009). The technical success rate without tract dilation was significantly higher in the AGMS-AR than in the HGS group (83 vs. 38%; P < 0.001). RBO rates were significantly higher in the HGS than in the AGMS-AR group (53 vs. 17%; P = 0.024), whereas AE rates did not differ significantly. TRBO differed significantly in the HGS and AGMS-AR groups (159 days vs. not reached, P = 0.011), whereas OS did not differ significantly. Multivariable analysis revealed that HGS was an independent risk factor for RBO (hazard ratio, 6.48, P = 0.014). Conclusion: TRBO was significantly longer in patients who underwent AGMS with PS than HGS. AGMS with PS may be effective after the failure of ERCP in patients with malignant biliary obstruction. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) includes EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided gallbladder drainage (EUS-GBD), EUS-guided antegrade stenting (EUS-AG) and EUS-guided rendezvous (EUS-RV). While EUS-HGS, EUS-CDS and EUS-GBD are transluminal drainage procedures, EUS-AG is a traspapillary drainage procedure and EUS-RV is a procedure intended to facilitate endoscopic retrograde cholangio pancreatography (ERCP) in instances of failed cannulation. These procedures were initially developed as options for endoscopic salvage of failed ERCP, but have evolved to become first-line interventions also for select indications over time as the technique and expertise improved. Several randomised controlled trials have demonstrated EUS-BD, especially EUS-CDS has similar or even better outcomes as compared to ERCP in malignant biliary obstruction. However, widespread adoption of these modalities is limited by the availability of expertise, steep learning curve, lack of standardization of techniques and cost. In this review, we aim to provide an overview of various EUS-BD procedures including the indications, accessories, technique, outcomes and follow-up of each of these procedures. [ABSTRACT FROM AUTHOR]

We report a case of an 87 year-old woman who was admitted with jaundice, but had no pain or fever. Contrast-enhanced computed tomography revealed a tumor in the head of the pancreas, which caused distal malignant biliary obstruction. Initial transpupillary drainage by endoscopic retrograde cholangiopancreatography (ERCP) was difficult due to severe biliary stricture caused by the tumor, but cannulation of the pancreatic duct was successful. Pancreatic ductal adenocarcinoma was revealed through cytologic examination of pancreatic juice and the patient underwent percutaneous transhepatic biliary drainage (PTBD). 16 days after the jaundice was resolved, an uncovered Zilver® metallic stent was successfully deployed using a guidewire from the PTBD route, and the patient was discharged with palliative care due to advanced age. However, 54 days after discharge, the patient presented with black vomiting and recurrent jaundice. ERCP revealed an obstructed stent with black debris, and further evaluation revealed a ruptured pseudoaneurysm that branched off the gastroduodenal artery within the metallic biliary stent. Angiography revealed that embolization was successful. The patient recovered and was discharged without further episodes. [ABSTRACT FROM AUTHOR]

Introduction: Palliation of malign biliary obstruction is important which is commonly carried out by percutaneous biliary stenting. Our primary aim with this study was assessment of performance of wall stents, and nitinol stents for the palliation of malign biliary obstruction. Methods: The medical records of 157 patients who underwent biliary stenting in our department between January 1, 1995, and December 31, 2005, were retrospectively analyzed. Technical success, treatment success, mortality in the first 30 days, minor, and major complications were evaluated and compared among the wall stent, and the nitinol stent groups in all patients which constituted the primary study endpoints. Additionally, stent patency, and mean patient survival times after stent implantation were evaluated in patients for whom follow-up information could be obtained. Results: A total of 213 metallic stents were placed in 157 patients. Wall stent was placed in 83 of the patients with mean age, and SD of 60.4 and 13.5. Nitinol stent was placed in 74 of the patients with mean age of 57.8, and SD of 15.5. Gender ratio was equal in both groups. Biliary stent dysfunction was observed in 13 patients in each of nitinol, and wall stent groups throughout the study period. There was no statistical difference among re-occlusion rates (p = 0.91). For the nitinol stent group median primary patency time was 119 days (90–185 days CI 95%), and for the wall stent group median primary patency time was 81 days (60–150 days CI 95%). Conclusion: Nitinol stents, and wall stents are safe options that can be safely used in the percutaneous treatment of malignant biliary obstruction with similar treatment and therapeutic success, low complication rates, and patency times that can extend beyond expected survival times. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary drainage in malignant distal biliary obstruction (MDBO). This meta-analysis of randomized controlled trials (RCTs) aims to compare the outcomes of these 2 approaches. METHODS: Electronic databases from January 2005 through December 2023 were searched for RCTs comparing outcomes of EUS-BD and ERCP for treating MDBO. Pooled proportions, risk ratio (RR), and odds ratio were calculated using random-effects models. RESULTS: Five RCTs comprising 519 patients were included in the final analysis. The pooled RR for overall technical success with EUS-BD compared with ERCP was 1.05 (95% confidence interval [CI] = 0.96-1.16, P = 0.246, I² = 61%) and for clinical success was 0.99 (95% CI = 0.95-1.04, P = 0.850, I² = 0%). The pooled rate of procedure-related pancreatitis was 7.20% (95% CI = 3.60-13.80, I² = 34%) in the ERCP group compared with zero in the EUS-BD group. The pooled RR for stent dysfunction with EUS-BD compared with ERCP was 0.48 (95% CI = 0.28-0.83, P = 0.008, I² = 7%). The weighted mean procedure time was 13.43 (SD = 10.12) minutes for EUS-BD compared with 21.06 (SD = 6.64) minutes for ERCP. The mean stent patency was 194.11 (SD = 52.12) days in the EUS-BD group and 187 (SD = 60.70) days in the ERCP group. DISCUSSION: EUS-BD is an efficient and safe alternative to ERCP in MDBO. An almost nonexistent risk of procedure-related pancreatitis, lower procedure time, and ease of use make this an attractive primary approach to biliary decompression in centers with expertise. [ABSTRACT FROM AUTHOR]

Introduction: Previously we demonstrated that elevated serum CYFRA 21 − 1 is a reliable diagnostic and prognostic biomarker for biliary tract cancers. This study aims to explore the diagnostic performance of bile CYFRA 21 − 1 (bCYFRA 21 − 1) in discriminating malignant biliary obstruction (MBO) caused by cholangiocarcinoma (CCA). Methods: 77 CCA patients ((17 intrahepatic CCA (iCCA), 49 perihilar CCA (pCCA) and 11 distal CCA (dCCA)) and 43 benign patients with biliary obstruction were enrolled. Serum and bile levels of CYFRA 21 − 1, carcinoembryonic antigen (CEA) and carbohydrate antigen 19 − 9 (CA19-9) were quantified. Diagnostic performances of these biomarkers were estimated by receiver operator characteristic curves. Subgroups analysis of these tumor markers among CCA subtypes was performed. Results: High bCYFRA 21 − 1 (cut-off value of 59.25 ng/mL with sensitivity of 0.889 and specificity of 0.750) and high bile to serum ratio of CYFRA 21 − 1 (b/sCYFRA 21 − 1, cut-off value of 31.55 with sensitivity of 0.741 and specificity of 0.778) achieved better diagnostic performance than any other biomarker in discriminating MBO. Subgroup analysis revealed that bCYFRA 21 − 1 was significantly elevated in all CCA subtypes; moreover b/sCYFRA 21 − 1 was upregulated in pCCA and dCCA (the mean b/sCYFRA 21 − 1 of pCCA was highest among CCA subtypes: 57.90, IQR 29.82-112.27). Conclusions: Both high biliary CYFRA 21 − 1 and high bile to serum ratio of CYFRA 21 − 1 were reliable diagnostic biomarkers for MBO caused by CCA. [ABSTRACT FROM AUTHOR]

Introduction: Malignant causes of biliary obstruction are common in low and middle-income countries (LMICs) and patients usually present late with unresectable masses. The options for endoscopic and surgical management are scarce in many LMICs. In settings with access to ultrasound and fluoroscopy, percutaneous biliary drainage (PBD) is a promising and minimally invasive option for relieving obstruction and improving the quality of life of these patients. Method: We present a case series of six patients in northwestern Nigeria with cholestatic jaundice caused by malignant biliary obstruction successfully treated by PBD. Results: In five cases, imaging revealed a locally invasive pancreatic head mass causing obstruction. One of the patients had obstruction from biopsy-proven cholangiocarcinoma. Three patients had internal biliary drainage past the obstruction and three patients had only external biliary drainage due to the severity of the obstructions. One patient with internal drainage went on to cholangioplasty and deployment of the balloon-expandable stent over the stenotic segment. All procedures were uncomplicated and patients had a gradual clearance of jaundice and resolution of pruritus. Two of the elderly patients died within six months of the procedure (one from hepatic encephalopathy and the other from stroke). The remaining four survived but were lost to follow-up by 10 months. Conclusions: PBD is a feasible and beneficial option for decompressing malignant biliary obstruction in LMICs.

Background: Endoscopic ultrasound-guided biliary drainage is widely accepted due to its high success rate, minimal need for re-intervention, and low incidence of pancreatitis. Our objective was to investigate the feasibility, efficacy, and outcomes of primary EUS-guided choledochoduodenostomy (EUS-CDS) compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant distal biliary obstruction (MDBO). Methods: In this prospective multicenter study conducted between May 2021 and April 2023, patients with unresectable MDBO were assigned to either EUS-CDS or ERCP. Technical and clinical success were the primary endpoints. Results: A total of 73 patients at three tertiary centers were enrolled, of whom 37 underwent EUS-CDS and 36 underwent ERCP. Pancreatic cancer was present in 62 patients (84.9%). The technical and clinical success rates were comparable (97.3% and 97.2% for EUS-CDS vs. 94.4% and 100% for ERCP, respectively), with nearly the same procedure duration (P = 0.982) and with no significant difference in adverse events between both groups. Pancreatitis occurred in one patient after ERCP. Short-term re-intervention (within 3 months) was only required in two patients in the EUS-CDS group. Conclusion: Primary EUS-CDS—even in developing countries—is feasible, with comparable safety and non-inferior efficacy to ERCP for palliation in MDBO cases if a highly experienced team is present.

Abstract Background A major challenge of either endoscopic or percutaneous approach to placing palliative biliary stents is the difficulty in traversing tight perihilar malignant obstructions. This can be overcome with a rendezvous approach (combined endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous approach) or may require initial placement of an external drain and reattempting later. Interventional radiology for biliary obstruction is still in infant days in our locality. Herein, we describe two cases of perihilar malignant biliary obstruction (MBO) managed at a private facility in Lagos, Nigeria, in which we had to come up with a creative approach to crossing these tight junctions in the absence of ERCP facilities. This was done by securing percutaneous retrograde access into the common bile duct and combining it with the initially unsuccessful anterograde approach. In both cases, this combined percutaneous anterograde/retrograde approach resulted in successful traversal of the malignant obstruction and placement of internal biliary stents. Case presentation We present the case of two elderly patients with tight malignant biliary obstruction (MBO), one from a suspected cholangiocarcinoma and the other from hepatic metastatic colorectal carcinoma. Both patients had successful traversal of the obstruction via a combined percutaneous anterograde/retrograde approach and biliary stenting. Conclusions Our case reports demonstrate an unusual approach that should assist interventional radiologists in resource-limited setting who seek for a viable option to those presently available for traversing perihilar MBOs in the percutaneous placement of internal stents.

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field. [ABSTRACT FROM AUTHOR]

Biliary stents are used to optimize ductal patency and enable bile flow in the management of obstruction or injury related to biliary tract tumors, strictures, stones, or leaks. Although direct therapeutic applications of biliary stents are less well developed, stents can be used to deliver drugs, radioisotopes, and photodynamic therapy. This report provides an in-depth overview of the clinical indications, and therapeutic utility of biliary stents. Unique considerations for the design of biliary stents are described. The properties and functionalities of materials used for stents such as metal alloys, plastic polymers, or biodegradable materials are described, and opportunities for design of future stents are outlined. Current and potential applications of stents for therapeutic applications for biliary tract diseases are described. Therapeutic biliary stents could be used to minimize inflammation, prevent stricture formation, reduce infections, or provide localized anti-cancer therapy for biliary tract cancers. Stents could be transformed into therapeutic platforms using advanced materials, 3D printing, nanotechnology, and artificial intelligence. Whilst clinical study and validation will be required for adoption, future advances in stent design and materials are expected to expand the use of therapeutic biliary stents for the treatment of biliary tract disorders. [ABSTRACT FROM AUTHOR]

Background: A major challenge of either endoscopic or percutaneous approach to placing palliative biliary stents is the difficulty in traversing tight perihilar malignant obstructions. This can be overcome with a rendezvous approach (combined endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous approach) or may require initial placement of an external drain and reattempting later. Interventional radiology for biliary obstruction is still in infant days in our locality. Herein, we describe two cases of perihilar malignant biliary obstruction (MBO) managed at a private facility in Lagos, Nigeria, in which we had to come up with a creative approach to crossing these tight junctions in the absence of ERCP facilities. This was done by securing percutaneous retrograde access into the common bile duct and combining it with the initially unsuccessful anterograde approach. In both cases, this combined percutaneous anterograde/retrograde approach resulted in successful traversal of the malignant obstruction and placement of internal biliary stents. Case presentation: We present the case of two elderly patients with tight malignant biliary obstruction (MBO), one from a suspected cholangiocarcinoma and the other from hepatic metastatic colorectal carcinoma. Both patients had successful traversal of the obstruction via a combined percutaneous anterograde/retrograde approach and biliary stenting. Conclusions: Our case reports demonstrate an unusual approach that should assist interventional radiologists in resource-limited setting who seek for a viable option to those presently available for traversing perihilar MBOs in the percutaneous placement of internal stents. [ABSTRACT FROM AUTHOR]

Background and aims: Sarcopenia is an important prognostic factor for cancer patients. The aim of this study was to assess the ability of sarcopenia to predict recurrent biliary obstruction (RBO) in patients with unresectable cancer after EUS-guided biliary drainage (EUS-BD). Methods: The study enrolled 113 patients who underwent EUS-BD using the self-expandable metal stent (SEMS) for unresectable malignant biliary obstruction (MBO) between April 2016 and December 2021 at Wakayama Medical University Hospital. The skeletal muscle index at the third lumbar spine level (L3) was calculated from computed tomography images. We analyzed the cumulative incidence of RBO at 180 days after stent insertion. Univariate and multivariate analyses were performed to identify variables significantly associated with RBO. Results: Seventy-six patients were assigned to the sarcopenia group, and 37 were assigned to the non-sarcopenia group. The 180-day cumulative incidence of RBO was 11% in the non-sarcopenia group and 29% in the sarcopenia group (p = 0.034). The time to RBO was significantly shorter for the sarcopenia group (p = 0.028; Gray's test). Multivariate analyses identified sarcopenia as an independent prognostic factor for RBO (present vs absent; HR 4.61; 95% CI 1.76–12.10, p = 0.001). The rates of biliary sludge/food impaction were significantly higher in the sarcopenia group for the causes of RBO (p = 0.048). There were no significant differences between the sarcopenia and the non-sarcopenia groups with respect to related EUS-BD adverse events. Conclusion: Sarcopenia is an independent indicator of RBO in patients with MBO who receive EUS-BD with SEMS. [ABSTRACT FROM AUTHOR]

Purpose The aim of this study was to evaluate the technical feasibility, complication rate, and efficacy of percutaneously delivered plastic biliary stent, compared with that of internal–external biliary drainage catheter.

Background and aims: Self-expandable metal stent (SEMS) insertion is the standard palliative treatment for unresectable malignant extrahepatic biliary obstruction (MBO). Drawbacks of conventional fully covered SEMS (FCSEMS) and uncovered SEMS (USEMS) include stent migration and tumor ingrowth, respectively. This study aimed to compare stent patency in MBO with the newly design multi-hole SEMS (MHSEMS), which has multiple small side holes in the stent membrane, with conventional FCSEMS and UCSEMS. Patients and methods: This retrospective study using a propensity score matching design and stent patency times of 40 patients with MHSEMS was compared to 40 and 34 patients with FCSEMS and UCSEMS during the same period, respectively. Secondary outcomes were procedure-related adverse events, clinical success rate, time to recurrent biliary obstruction (RBO), and etiology of RBO. RBO was compared using Kaplan–Meier analysis. Results: Baseline characteristics after matching were comparable among the 3 groups. RBO rates were 21%, 37%, and 55% for MHSEMS, FCSEMS, and UCSEMS, respectively (p = 0.014), at a mean time of 479, 353, and 306 days, respectively (MHSEMS vs UCSEMS, p = 0.002). Rate of tumor ingrowth was highest in the UCSEMS group (42.4% vs 13.2% in MHSEMS; p = 0.005 and vs 0% in FCSEMS; p < 0.001). Stent migration rate was highest in the FCSEMS group at 15.8% vs 2.6% in MHSEMS (p = 0.047) and 0% in UCSEMS (p = 0.005). Conclusion: MHSEMS provided the longest stent patency time with lowest RBO rate compared to conventional SEMS by showing a lower stent migration rate than FCSEMS and a lower tumor ingrowth rate than UCSEMS. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis is a significant adverse event after self-expandable metal stent (SEMS) placement for malignant biliary obstruction (MBO); however, no appropriate treatment strategy has been established for its management. Aims: This study aimed to examine the feasibility and utility of endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for the management of acute cholecystitis occurring after SEMS placement. Methods: This retrospective study investigated consecutive patients with acute cholecystitis after SEMS placement for unresectable MBO, in whom EUS-NGBD was attempted. The study outcomes included technical success, clinical success, procedure time, adverse event, and cholecystitis recurrence, associated with the procedure. Results: During the study period, EUS-NGBD was performed for SEMS-related acute cholecystitis in 30 patients with MBO. The technical and clinical success rates were 96.7% (29/30) and 96.6% (28/29), respectively. The median procedure time was 15 min, and rate of procedure-related adverse event was 3.3% (1/30). The median duration from the procedure to tube removal was 9 days. No adverse events were observed after removal. The median hospitalization duration after the procedure was 14 days, and the median duration to the (re-)start of chemotherapy from cholecystitis onset was 13 days. The median overall survival after EUS-NGBD was 123 days, and the rate of cholecystitis recurrence until death was 4.2% (1/28). Conclusions: This study demonstrated that EUS-NGBD possesses good technical and clinical feasibility with an acceptable adverse event rates and short hospitalization and chemotherapy withdrawal period. Therefore, EUS-NGBD may be a good option for the treatment of SEMS-related cholecystitis in patients with MBO. [ABSTRACT FROM AUTHOR]

Purpose The aim of this study was to evaluate the technical feasibility, complication rate, and efficacy of percutaneously delivered plastic biliary stent, compared with that of internal–external biliary drainage catheter. Methods Patients with unresectable malignant biliary obstruction were included who underwent percutaneous transhepatic biliary drainage and double pigtail plastic stenting (DPT-PS) or internal–external biliary drainage catheter in 15 months' duration. Results Seventy-seven patients were included in the study who underwent DPT-PS (n = 37) or internal external drainage catheter placement (n = 40). Overall, the technical success rate for percutaneous plastic stenting was 92.5% and technical success rate for primary stenting at the time of initial puncture was 62%. The incidence of fever and hemobilia was similar across the two groups, whereas bile leakage in the perihepatic space and through the skin at puncture site was higher in patients with internal–external drainage catheter. Both the techniques were effective in reducing the bilirubin levels of patients. Re-intervention was done in five patients in DPT-PS and six patients with ring biliary catheter. Conclusion DPT-PS may be used as a viable cost-efficient alternative for unresectable biliary malignancies with low post-procedure life expectancy. [ABSTRACT FROM AUTHOR]

Abstract Introduction Endoscopic self-expandable metal stent (SEMS) placement is the key endoscopic treatment for unresectable malignant biliary obstruction. The benefit of covered SEMS over uncovered SEMS remains unknown as are risk factors for SEMS dysfunction. This study aimed to determine the factors associated with patency of SEMS. Methods Patients with unresectable malignant biliary obstruction who underwent endoscopic SEMS placement at Ramathibodi Hospital, during January 2012 to March 2021 were included. Patient characteristics, clinical outcomes and patency of SEMS were collected. The primary outcome were stent patency and factors associated with patency of SEMS. The factors were analyzed by univariate and multivariate analyses. Median days of stent patency, median time of patient survival, rate of reintervention and complications after SEMS placement were collected. Results One hundred and fourteen patients were included. SEMS dysfunction was found in 37 patients (32.5%). Size of cancer (Hazard ratio (HR), 1.20, (95% CI 1.02, 1.40), p 0.025), presence of stones or sludge during SEMS placement (Hazard ratio (HR), 3.91, (95% CI 1.74, 8.75), p 0.001), length of SEMS, 8 cm (HR 2.96, (95% CI 1.06, 8.3), p 0.039), and total bilirubin level above 2 mg/dL at one month after SEMS placement (HR 1.14, (95% CI 1.06, 1.22), p

Introduction: Endoscopic self-expandable metal stent (SEMS) placement is the key endoscopic treatment for unresectable malignant biliary obstruction. The benefit of covered SEMS over uncovered SEMS remains unknown as are risk factors for SEMS dysfunction. This study aimed to determine the factors associated with patency of SEMS. Methods: Patients with unresectable malignant biliary obstruction who underwent endoscopic SEMS placement at Ramathibodi Hospital, during January 2012 to March 2021 were included. Patient characteristics, clinical outcomes and patency of SEMS were collected. The primary outcome were stent patency and factors associated with patency of SEMS. The factors were analyzed by univariate and multivariate analyses. Median days of stent patency, median time of patient survival, rate of reintervention and complications after SEMS placement were collected. Results: One hundred and fourteen patients were included. SEMS dysfunction was found in 37 patients (32.5%). Size of cancer (Hazard ratio (HR), 1.20, (95% CI 1.02, 1.40), p 0.025), presence of stones or sludge during SEMS placement (Hazard ratio (HR), 3.91, (95% CI 1.74, 8.75), p 0.001), length of SEMS, 8 cm (HR 2.96, (95% CI 1.06, 8.3), p 0.039), and total bilirubin level above 2 mg/dL at one month after SEMS placement (HR 1.14, (95% CI 1.06, 1.22), p < 0.001) were associated with SEMS dysfunction. The median stent patency was 97 days. The median patient survival was 133 days, (95% CI 75–165). The rate of reintervention was 86% in patients with SEMS dysfunction. Conclusion: The size of cancer, presence of stones or sludge during SEMS placement, the length of SEMS, and total bilirubin level above 2 mg/dL at 1 month after SEMS placement were associated with SEMS dysfunction. The median time of stent patency were not statistically different in each type of stent, covered stent, partially covered stent and uncovered stent. Median survival time of patients did not associate with SEMS patency or dysfunction. [ABSTRACT FROM AUTHOR]

Background/aims: Endoscopic biliary stenting is an essential treatment for malignant biliary obstruction (MBO). However, the optimal location for the placement of metal stents (MS) or plastic stents (PS) during the management of MBO, whether above (suprapapillary) or across (transpapillary) the sphincter of Oddi (SO), has not been thoroughly evaluated. This meta-analysis aims to compare the clinical outcomes associated with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stents placed above and across the SO in patients with MBO. Methods: A comprehensive search of electronic databases was carried out to identify studies published from inception to April 2022. The clinical outcomes examined including stent patency, stent occlusion, and overall adverse events (AEs) such as cholangitis, post-ERCP pancreatitis (PEP), cholecystitis, stent migration, and bleeding. The selection of a random-effects model or fixed-effects model was based on the presence of heterogeneity. Results: A total of 12 articles involving 751 patients were analyzed. The findings showed that the suprapapillary approach had longer stent patency compared to the transpapillary approach (mean difference: 38.58; 95% confidence interval 16.02–61.14, P < 0.0001). Additionally, the suprapapillary approach was associated with a lower risk of stent occlusion and overall AEs (P = 0.04, P = 0.002, respectively), particularly in the incidence of PEP (P = 0.009). The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. The subgroup analyses indicated that suprapillary PS had a significant decrease in the incidence of stent occlusion and longer stent patency, while suprapillary MS had a significant decrease in the incidence of overall AEs and PEP than the transpapillary approach. Conclusion: Compared with the transpapillary approach, the suprapapillary stent had superiority in longer stent patency, lower rates of stent occlusion and overall AEs, and notably, a lower incidence of PEP. The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. Further large-scale randomized controlled studies are needed to confirm our findings. Registration No. CRD42022336435. [ABSTRACT FROM AUTHOR]

Background: The purpose of this research was to evaluate the safety and efficacy of a self-expandable metallic stent (SEMS) combined with iodine-125 (125I) seeds in the treatment of Bismuth type I or II malignant biliary obstruction (MBO). Methods: The clinical data of 74 cases of MBO treated with percutaneous SEMS combined with 125I seeds (combination group) and 81 cases of MBO treated with SEMS implantation alone (control group) in our hospital from January 2015 to December 2019 were retrospectively analyzed. The short-term and long-term efficacy of the two groups were compared. Multivariate Cox regression analysis was used to analyze the factors affecting the surgical efficacy and survival rate. Results: The liver blood test results of both groups improved at one week and one month post-stent insertion. No significant difference was established in the short-term efficacy or complications between the two groups (P = NS). Improved stent patency was observed in the combined group, 9.01 ± 4.38 months versus 6.79 ± 3.13 months, respectively (P < 0.001). Improved survival was also noted in the combined group 12.08 ± 5.38 months and 9.10 ± 4.16 months, respectively (P < 0.001). Univariate and multivariate analyses showed that the type of biliary stent and liver metastasis were independent factors affecting survival. Conclusion: The implementation of SEMS combined with 125I seeds resulted in significantly longer stent patency and survival times than that of SEMS implantation alone, which is thus worthy of clinical promotion and application. [ABSTRACT FROM AUTHOR]

Background There are still many controversies about biliary drainage in MBO, and we aimed to summarize and evaluate the evidence associated with biliary drainage. Methods We conducted an umbrella review of SRoMAs based on RCTs. Through July 28, 2022, Embase, PubMed, WOS, and Cochrane Database were searched. Two reviewers independently screened the studies, extracted the data, and appraised the methodological quality of the included studies. GRADE was used to evaluate the quality of the evidence. Results: 36 SRoMAs were identified. After excluding 24 overlapping studies, 12 SRoMAs, including 76 RCTs, and 124 clinical outcomes for biliary drainage in MBO were included. Of the 124 pieces of evidence evaluated, 13 were rated "High" quality, 38 were rated "Moderate", and the rest were rated "Low" or "Very low". For patients with MBO, 125| seeds+stent can reduce the risk of stent occlusion, RFA+stent can improve the prognosis; compared with PC, SEMS can increase the risk of tumor ingrowth and reduce the occurrence of sludge formation, and the incidence of tumor ingrowth in C-SEMS/PC-SEMS was significantly lower than that in U-SEMS. There was no difference in the success rate of drainage between EUS-BD and ERCP-BD, but the use of EUS-BD can reduce the incidence of stent dysfunction. For patients with obstructive jaundice, PBD does not affect postoperative mortality compared to direct surgery. The use of MS in patients with periampullary cancer during PBD can reduce the risk of reintervention and stent occlusion compared to PC. In addition, we included four RCTs that showed that when performing EUS-BD on MBO, hepaticogastrostomy has higher technical success rates than choledochoduodenostomy. Patients who received Bilateral-ENBD had a lower additional drainage rate than those who received Unilateral-ENBD. Conclusions: Our study summarizes a large amount of evidence related to biliary drainage, which helps to reduce the uncertainty in the selection of biliary drainage strategies for MBO patients under different circumstances. [ABSTRACT FROM AUTHOR]

To systematically evaluate the efficacy and safety of the method of placing the distal stent opening above the duodenal papilla (hereinafter referred to Above method) for endoscopic retrograde stent internal drainage in MBO patients. PubMed, Embase, Web of science and Cochrane databases were searched to identify clinical studies comparing the stent distal opening mounted above the papilla and across the papilla (hereinafter referred to Across method), Comparison indicators included stent patency, stent occlusion rate, clinical success rate, overall complication rate, postoperative cholangitis rate, and overall survival. Revman5.4 software was used for meta-analysis, funnel plot and publication bias and Egger's test were completed by Stata14.0 software. A total of 11 clinical studies (8 case-control studies, 3 RCT studies) were included, with a total of 751 patients (318 cases in the Above group and 433 cases Across group). The overall patency of Above method was longer than that of Across method (HR = 0.60, 95%CI [0.46–0.78], p < 0.001). Subgroup analysis showed statistical difference using plastic stent (HR = 0.49, 95%CI [0.33,0.73], p < 0.001). Inversely, there didn't exist significant difference in which metal stent were adopted (HR= 0.74, 95%CI [0.46,1.18], p = 0.21). Similarly, there also without statistical difference between patients with plastic stent placed above the papilla and metal stent mounted Across the papilla (HR = 0.73, 95%CI [0.15,3.65], p = 0.70). Moreover, the overall complication rate of the Above method was lower than that of the Across method (OR = 0.48,95%CI [0.30,0.75], p = 0.002). On the contrary, the differences of stent occlusion rate (OR = 0.86,95%CI [0.51,1.44], p = 0.56), overall survival (HR = 0.90, 95%CI [0.71,1.13]), p = 0.36), the clinical success rate (OR = 1.30, 95%CI [0.52,3.24], p = 0.57) and postoperative cholangitis rats (OR = 0.73, 95%CI [0.34,1.56], p = 0.41) were not statistically significant. The distal opening of the stent can be placed above the duodenal main papilla for eligible MBO patients who receiving endoscopic retrograde stent drainage treatment, which can effectively prolong the patency duration when plastic stent is used, and reduce the overall risk of complications. [ABSTRACT FROM AUTHOR]

Background and Aims: In patients with unresectable malignant biliary obstruction (MBO), endoscopic biliary drainage is the treatment of choice. Self-expanding metallic stents (SEMS) are mainly used for this purpose, and data is limited on the comparative outcomes of laser-cut versus braided SEMS. Herein, we performed the first systematic review and meta-analysis to study the effectiveness and safety of braided and laser-cut SEMS in MBO. Methods: Multiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of braided and laser-cut SEMS in MBO. Outcomes of interest were technical and clinical success, recurrent biliary obstruction, and adverse events. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity. Results: Seven studies were included in the final analysis. (Laser-cut: 271 patients, 46% females, mean age 70 years; and braided: 282 patients, 47% females, mean age 72 years). The pooled rate of technical success and clinical success with laser-cut SEMS was 99% (95% CI [95–99; I2 = 0%]), 86% [60–96; I2 = 74%], and 98% [96–99; I2 = 0%], 89% [74–95; I2 = 78%] with braided. The pooled rate of recurrent biliary obstruction with laser-cut SEMS was 26% [14–43; I2 = 88%] and 12% [5–27; I2 = 56%) with braided. Pooled total adverse events were 11% [5–21; I2 = 77%] in laser-cut and 12% [6–24; I2 = 63%] in braided. Conclusion: Our meta-analysis demonstrates similar clinical outcomes with laser-cut and braided SEMS in MBO. Given the comparable performance, a cost-effectiveness analysis might help in choosing one type versus another in patients with MBO. [ABSTRACT FROM AUTHOR]

This narrative review provides an overview of the application of endoscopic ultrasound-guided biliary drainage (EUS-BD), including EUS-guided gallbladder drainage (EUS-GBD), for the treatment of malignant biliary obstruction. EUS-BD has demonstrated excellent technical and clinical success rates, with lower rates of adverse events when compared with percutaneous trans-hepatic biliary drainage (PTBD). EUS-BD is currently the preferred alternative technique for biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Particularly, this review will focus on EUS-BD performed with the use of lumen apposing metal stent (LAMS). The introduction of these innovative devices, followed by the advent of electrocautery-enhanced LAMS (EC-LAMS), gave the procedure a great technical implementation and a widespread application. [ABSTRACT FROM AUTHOR]

PURPOSETo conduct a meta-analysis comparing the efficacy and safety of two types of iodine-125 (I-125) seed delivery with metal stents (the study group) versus conventional metal stents (the control group) in patients with malignant biliary obstruction (MBO).METHODSOur team systematically searched the PubMed, Embase, and Cochrane Library databases for relevant studies published from January 2012 up to July 2021. Survival time and stent dysfunction were the primary measured outcomes. Subgroup analyses were conducted according to the type of I-125 seed delivery.RESULTSEleven studies, including 1057 patients in total, were pooled for stent dysfunction. The study group showed a lower risk of stent dysfunction than the control group [odds ratio (OR): 0.61, 95% confidence interval (CI) 0.46–0.81, P = 0.001]. The pooled results of six studies reporting overall survival (OS) showed that the study group had a better survival outcome than the control group [hazard ratio (HR): 0.34, 95% CI: 0.28–0.42, P < 0.001]. In the subgroup analyses, the I-125 seed stent group had significantly less stent dysfunction than the control group (OR: 0.49, 95% CI: 0.31–0.76, P = 0.002). Meanwhile, the metal stents + I-125 radioactive seed strand group showed significantly more improvement in OS than the control group (HR: 0.33, 95% CI: 0.26–0.42, P < 0.001). Moreover, our analysis suggests that using I-125 seeds did not result in increasing related adverse events compared with using metal stents alone (all P > 0.05). The study group was significantly superior to the control group, with better survival and decreased stent dysfunction. Meanwhile, the delivery of I-125 seeds did not increase adverse events.CONCLUSIONThe delivery of I-125 with metal stents may be considered a preferable technique for MBO.

Aim: This study aimed to demonstrate the feasibility of the percutaneous endobiliary radiofrequency ablation (ERFA) method, which is used to increase stent patency in malignant biliary strictures. Material and Methods: A total of 25 patients, 9 (36%) female and 16 (64%) male, who developed malignant biliary stenosis secondary to various advanced tumors and underwent ERFA and metallic stenting after percutaneous biliary drainage were retrospectively evaluated. The types of malignancies causing obstruction and the follow-up after the procedure were evaluated to demonstrate the median survival and stent patency values of the patients. Stent patency and survival rates were calculated using the Kaplan-Meier method. Results: The results of the study demonstrated that 17 (68%) out of these 25 patients displayed a significant decrease in their first-week postoperative bilirubin values, with a reduction of greater than 50% compared to the pre-biliary drainage values. The study determined that this treatment approach's overall clinical success rate was 68%. Stent occlusion developed within 180 days in 8 (32%) out of the 25 patients who underwent ERFA and metallic stenting. Additionally, 18 (%72) patients died as a result of malignancy progression. The mortality rates at post-treatment 30 and 180 days were determined to be 24% and 72%, respectively. The median survival and stent patency times were 65 and 70 days, respectively. Conclusion: Percutaneous ERFA and metallic stenting have the potential to improve survival and stent patency, especially in selected patient groups with distal biliary stenosis. Randomized controlled studies are needed to confirm these results.

The most common symptoms of malignant biliary obstruction (MBO) include jaundice, pruritus, weight loss, anorexia, or even cholangitis. In order to improve these symptoms which may have a negative impact on a patient's quality of life (QoL), relief of malignant obstruction is required. Endoscopic--guided stent placement represents the treatment of choice in the cases of unresectable MBO and its utility may be justified by the improvement in QoL of such patients. Aim: Our objective was to provide a comprehensive point of view on palliative endoscopic management of MBO by emphasizing current data on causes of malignant biliary obstruction, types of stents used as well as the effect on QoL. Materials and methods: We performed a search using PubMed, as well as Web of Science, on available studies that involved assessing QoL on MBO by using the terms: "quality of life", "QoL", "endoscopic stenting", "malignant biliary obstruction". The main focus was finding proof that endoscopic stenting followed by successful biliary drainage improved patients' QoL which was evaluated by completing a QoL questionnaire before and after performing the endoscopic stenting. Outcomes: The decompression of biliary obstruction, followed by successful biliary drainage is responsible for the improvement of symptoms such as jaundice, pruritus or weight loss, improvement that impact patients' QoL, as well. Conclusion: The advances in endoscopic techniques, as well as the development of stents available nowadays, place endoscopic stenting in the first position in the management of MBO. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the risk factors and develop a clinical prediction model for early biliary infection (EBI) after percutaneous transhepatic biliary stenting (PTBS) in patients with malignant biliary obstruction (MBO). Methods: The clinical data of 236 patients with MBO treated with PTBS from June 2012 to June 2021 were retrospectively analyzed. Independent risk factors were analyzed by univariate and multivariate logistic regression, and a nomogram model was constructed based on the results. Discrimination, calibration, and clinical usefulness of this model were further assessed. Results: The technical success rate of PTBS was 100%, and EBI after PTBS was 20.3%. Multivariate logistic regression analysis showed that hilar MBO (P = 0.020), diabetes (P = 0.001), previous surgical or endoscopic intervention (P = 0.007), procedure time > 60 min (P = 0.007), and intraprocedural biliary hemorrhage (P = 0.003) were independent risk factors for EBI after PTBS. A nomogram model was developed to predict the probability of EBI. ROC curves showed good discrimination of the model (area under curve = 0.831). The calibration plot indicated that the predicted probability of EBI by this model was in good agreement with the actual probability of EBI. The DCA curves showed that the net benefit of nomogram-assisted decisions was higher than or equal to the net benefit of treatment for all or none at a wide threshold probability (0–0.8). Conclusion: The nomogram model based on the above independent risk factors can predict the probability of EBI and model-assisted treatment decisions contribute to improved clinical outcome. Therefore, MBO patients with probability of EBI > 0.20 based on the model should be recommended for perioperative broad-spectrum antibiotics and close monitoring. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound biliary drainage is an option of choice for treatment of malignant biliary obstruction in cases when retrograde cholangiopancreatography fails or is not possible. In publication demonstrated first ukrainian experience of biliodigestive drainage especially hepaticogastrostomy in patient with malignant biliary obstruction after resection of stomach by Billroth II Balfour`s modificatuion. [ABSTRACT FROM AUTHOR]

Simple Summary: Endoscopic ultrasound-guided gallbladder drainage is emerging as an important technique for patients with malignant biliary obstruction where ERCP has failed. This meta-analysis is conducted to evaluate the efficacy and safety of this procedure. A comprehensive search of key databases was conducted, and all relevant studies were interrogated. A total of 7 studies were included in the final analysis with a total of 136 patients. The pooled clinical success rate of the procedure was 85%. Adverse events occurred in 13% of cases. No severe adverse events were reported. This meta-analysis supports the use of endoscopic ultrasound-guided drainage in malignant biliary obstruction when standard treatment has failed. Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage. Methods: A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events. Results: Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78–90%, I2: 0%). The pooled rate of adverse events (95% CI) was 13% (7–19%, I2: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression. Conclusion: This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis (NC) indications has not been well studied. We compared the clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (n = 8), symptomatic cholelithiasis (n = 1), gallstone pancreatitis (n = 1), choledocholithiasis (n = 1), and Mirizzi's syndrome (n = 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (p > 0.99). The clinical success rate was 94% and 100%, respectively (p > 0.99). There were four adverse events in the AC group and 3 in the NC group (p = 0.33). Procedure duration (median 43 vs. 45 min, p = 0.37), post-procedure length of stay (median 3 vs. 3 days, p = 0.97), and total gallbladder-related procedures (median 2 vs. 2, p = 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC. [ABSTRACT FROM AUTHOR]

Abstract Background According to the European Society of Gastrointestinal Endoscopy guidelines, self-expandable metal stents (SEMSs) are preferable to plastic stents (PSs) in the management of pancreatic cancer, regardless of cancer stage. The aim of this study was to compare the therapeutic efficacy and treatment costs of SEMS and PS in the management of malignant biliary obstruction. Methods One hundred and thirty-five patients who underwent endoscopic stent placement were retrospectively enrolled and divided into PS (41 patients), primary SEMS (39 patients) and secondary SEMS (55 patients) groups. We determined the technical and functional success rate, stent patency, and cumulative treatment cost. Results A total of 111 SEMSs and 153 PSs were placed with similar technical (100% vs. 98.69%) and functional success rate (90.10% vs. 86.27%) but with different stent patency (10.28 vs. 22.16 weeks; p

Introduction. Malignant biliary obstruction represents a poor prognostic sign of metastatic colorectal carcinoma. Percutaneous transhepatic biliary drainage (PTBD) is the procedure of choice for palliative biliary decompression, and this method has both diagnostic and therapeutic values. One of the wellknown complications following this procedure is the development of catheter tract metastases that occur in 0.6–6% of cases post-PTBD. In this case report, we present a patient with implantation metastases of colorectal cancer following PTBD. Case report. In the last six years, 89 patients underwent PTBD procedure at the Oncology Institute of Vojvodina. Among these patients, catheter tract implantation metastasis developed in one patient (1.1%). In this report, we present a patient who underwent right hemicolectomy in January 2015 at the Oncology Institute due to colon cancer located in the transverse colon. In January of 2018, a computed tomography scan of the abdomen showed metastatic disease and chemotherapy was initiated. However, 29 months following the start of chemotherapy, the patient developed jaundice, and as a result, PTBD procedure was performed. A control computed tomography scan of the abdomen in March of 2021 showed a de novo subcutaneous nodule 20 mm in diameter located at the level of ninth right rib. The nodule had been considered a part of the scar that formed at a place of catheter entry, and was still present eight months after PTBD procedure. Biopsy of the subcutaneous mass and pathohistological analysis confirmed well differentiated colon adenocarcinoma. Conclusion. Catheter tract implantation metastasis is not a rare complication following PTBD for malignant biliary obstruction. It generally has a poor prognosis. Nevertheless, literature review shows that radical surgical excision of the catheter tract tissue with hepatectomy can prolong survival in select group of patients.

Abstract Objective This study aimed to develop and validate a nomogram to predict the risk of pancreatitis after percutaneous transhepatic biliary stent insertion (PTBS) in patients with malignant biliary obstruction (MBO). Materials and methods We enrolled 314 patients who underwent PTBS for MBO from March 2016 to July 2021 in this retrospective study. We used univariate analysis to identify potential risk factors, while a multivariate logistic regression model was employed to establish a nomogram for predicting the risk of pancreatitis. The discrimination and calibration of the nomogram were evaluated by estimating the area under the receiver operator characteristic curve (AUC) and by bootstrap resampling and visual inspection of the calibration curve. The clinical utility of the nomogram was assessed using decision curve analysis (DCA). Results After the procedure, 41 (13.1%) patients developed pancreatitis. Based on multivariate logistic regression analysis, young age (OR = 2.57, 95% CI 1.16 to 5.69), stent insertion across the papilla (OR = 6.47, 95% CI 2.66 to 15.70), and visualization of the pancreatic duct (OR = 15.40, 95% CI 6.07 to 39.03) were associated with an elevated risk of pancreatitis. Importantly, the performance of the nomogram was satisfactory, with an identical AUC (0.807, 95% CI 0.730 to 0.883) and high-level agreement between predicted and observed probabilities as suggested in calibration curves. The DCA curve subsequently confirmed the clinical utility. Conclusion A predictive nomogram for pancreatitis after PTBS in patients with MBO was successfully established in the present study.

Background: Endoscopic ultrasound-guided hepaticogastrostomy with antegrade stenting (EUS-HGAS) is a promising therapeutic option for malignant distal biliary obstruction (MDBO) in the event of transpapillary approach failure. Eliminating the fistula dilation step may further decrease the incidence of adverse events (AE) and simplify the procedure. Aims: This study focused on MDBO associated with pancreatic cancer and aimed to examine the utility of EUS-HGAS without the use of any dilation devices. Methods: This retrospective study investigated consecutive patients in whom the transpapillary approach had failed or was difficult, and who underwent EUS-HGAS without dilation device usage, using a tapered small-diameter catheter, ultrathin delivery system, and tapered dedicated plastic stent. The outcomes of this study included the technical success, clinical success, AE incidence, and recurrent biliary obstruction (RBO) associated with the procedure. Results: During the study period, EUS-HGAS without dilation device usage was attempted for 57 patients with MDBO due to pancreatic cancer. The technical and clinical success rates were 91.2% (52/57) each. The median procedural time was 25 min. The rates of early and late AE besides RBO were 3.5% (2/57) and 1.9% (1/52), respectively. The incidence rate of RBO was 30.8% (16/52), and the median time to RBO was 245 days. The rate of successful endoscopic reintervention for RBO via the fistula was 100% (16/16). Conclusions: EUS-HGAS without the use of dilation devices showed good technical feasibility with a low AE rate. It may be a useful option for MDBO associated with pancreatic cancer when the transpapillary approach is difficult. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the necessity of endoscopic sphincterotomy (ES) to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after endoscopic stenting in patients with malignant biliary obstruction. We investigated the incidence of PEP after endoscopic biliary stenting for malignant biliary obstruction with or without ES in a multicenter prospective cohort study. Methods: We enrolled 807 patients who underwent endoscopic biliary stenting for malignant biliary obstruction with a native papilla at 36 hospitals between April 2017 and March 2018. The incidence of PEP in patients with or without ES was compared for subgroups based on stent type, placement method, and patient background. Univariate and multivariate analysis was performed to investigate the incidence of PEP in all stenting patients. Results: Plastic and metal stents (MS) were inserted in 598 and 209 patients, respectively. The incidence of PEP in patients with or without ES was 7.9% and 7.4%, respectively among all stenting patients. The incidences of PEP with or without ES in plastic stent insertion patients, patients with MS insertion, stent insertions across the papilla, stent insertions across the papilla in patients without main pancreatic duct obstruction, and fully covered MS insertions across the papilla were compared. There was no overall significant difference in the incidence of PEP between those with or without ES. Multivariate logistic regression analysis for the incidence of PEP in all stenting patients revealed obstruction of the main pancreatic duct at the pancreatic head and epinephrine spraying on the papilla were significant factors; there was no significant difference in the incidence of PEP between patients with or without ES. Conclusion: Endoscopic sphincterotomy may not contribute to the prevention of PEP after endoscopic biliary stenting for malignant biliary obstruction, even in cases of insertion with a fully covered MS across the papilla. [ABSTRACT FROM AUTHOR]

Background: Although the SpyGlass Direct Visualization System can be clinically useful for diagnosing indeterminate biliary stricture, it employs SpyBite forceps, which typically obtain only a small amount of tissue and have a low sampling rate. An improved forceps biopsy device for SpyGlass DS has recently been released (SpyBite MAX). The aim of this prospective registration study was to assess the diagnostic yield and efficacy of histological biopsy tissue obtained with SpyBite MAX forceps compared with SpyBite forceps in patients with indeterminate biliary stricture. Methods: The primary outcome of the study was the diagnostic accuracy of biopsy specimens obtained by SpyBite MAX forceps. The secondary outcomes were tissue size, number of forceps biopsies, rate of obtaining adequate tissue, and adverse events in the SpyBite MAX forceps group compared with the SpyBite group. Results: Forceps biopsies using SpyBite MAX (n = 47) and SpyBite (n = 50) were performed successfully in all patients. The number of biopsies performed before visible core tissue was obtained was significantly lower in the SpyBite (mean, 1.5 ± 0.7) than in the SpyBite forceps group (mean, 2.3 ± 1.1 mm; P <.001). Tissue sample size was larger in the SpyBite MAX group (mean, 1.8 ± 1.6 mm2) than in the SpyBite group (mean, 1.0 ± 0.9 mm2; P =.004) but there was no significant difference in diagnostic accuracy. Conclusion: Improvements in dedicated forceps for biopsy in SpyGlass DS may contribute to improving the rates of adequate tissue and tissue sample size obtained, and to reducing the number of forceps biopsies required. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: The aim of this study was to determine mortality-related factors in older patients with acute cholangitis and to compare the clinical characteristics of patients aged 65–79 years and ≥ 80 years. Findings: Malignant etiology and hypoalbuminemia were independent risk factors for in-hospital mortality in older patients with acute cholangitis. Being 80 years or older was associated with severe disease in the entire patient population, whereas it was associated with in-hospital mortality in the subgroup of patients with non-malignant etiology. Message: In older patients with acute cholangitis, closer monitoring seems appropriate in those with malignant etiology and hypoalbuminemia, as well as those aged 80 years and over. Purpose: Few studies are available on older patients with acute cholangitis. In this study, we aimed to examine the clinical characteristics of older patients with acute cholangitis. Methods: Patients aged 65 years and over who were diagnosed with acute cholangitis between February 2019 and August 2022 were analyzed retrospectively. Patients eligible for the study were divided into two groups as those aged ≥ 80 years (octogenarian) and those aged 65–79 years (non-octogenarian). These two groups were then compared for many clinical characteristics. In addition, factors associated with in-hospital mortality were identified. Finally, a subgroup analysis was performed in patients with non-malignant etiology. Results: Of a total of 309 enrolled patients, 120 (38.8%) were in the octogenarian group and 189 (61.2%) were in the non-octogenarian group. The mean age was 77.2 ± 8.0 years and 51.8% were women. Severe disease and intensive care unit admission rates were higher in the octogenarian group (p = 0.035 and p = 0.002, respectively), but there was no significant difference in the rate of in-hospital mortality (p = 0.146). Malignant etiology (OR 2.990, 95% CI 1.131–7.904) and hypoalbuminemia (OR 0.824, 95% CI 0.751–0.903) were independent risk factors for in-hospital mortality. In the subgroup analysis of non-malignant etiology, the octogenarian group had a significantly higher in-hospital mortality rate than the non-octogenarian group (8.8% vs. 3.2%, p = 0.048). Conclusions: Among older patients with acute cholangitis, clinicians should closely monitor those aged 80 years and over, as well as those with malignant etiology and hypoalbuminemia, due to their high risk of serious clinical events. [ABSTRACT FROM AUTHOR]

Intraductal self-expandable metal stent (SEMS) placement may prolong stent patency by reducing duodenobiliary reflux. This study aimed to evaluate the efficacy and safety of this biliary drainage method in patients with unresectable distal malignant biliary obstruction (MBO). Consecutive patients with unresectable MBO who underwent initial covered SEMS placement between 2015 and 2022 were retrospectively reviewed. We compared the causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and reintervention rates between two biliary drainage methods (SEMSs placed above and across the papilla). A total of 86 patients were included (above: 38 and across: 48). Overall RBO rates (24% vs. 44%, p = 0.069) and median TRBO (11.6 months vs. 9.8 months, p = 0.189) were not significantly different between the two groups. The frequency of overall AEs was similar between the two groups in the entire cohort, but was significantly lower in patients with non-pancreatic cancer (6% vs. 44%, p = 0.035). Reintervention was successfully performed in the majority of patients in both groups. Intraductal SEMS placement was not associated with a prolonged TRBO in this study. Larger studies are warranted to further evaluate the benefit of intraductal SEMS placement. [ABSTRACT FROM AUTHOR]

Objectives: Although covered self‐expandable metal stents (CSEMSs) are associated with the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis due to pancreatic duct (PD) orifice obstruction, they are often used for biliary drainage treatment in malignant biliary obstruction (MBO). This study aimed to investigate the efficacy of PD stenting in preventing post‐ERCP pancreatitis after CSEMS implantation. Methods: This retrospective cohort study analyzed 554 patients with transpapillary CSEMS for MBO. Patients with noninitial deployment, benign disease, CSEMS deployment above the papilla, surgically altered anatomy, uncovered self‐expandable metal stents, multiple thin self‐expandable metal stents, and unavailable procedure videos were excluded. Logistic regression analysis estimated the association between PD stenting and post‐ERCP pancreatitis incidence. We adjusted for age, sex, pancreatitis history, prophylactic rectal nonsteroidal anti‐inflammatory drug use, naïve papilla, MBO etiology, and prolonged biliary cannulation time. Results: Among 554 patients, 67 (12.1%) experienced post‐ERCP pancreatitis. Post‐ERCP pancreatitis was recorded in 13.7% of patients in the non‐PD stenting and 4.3% in the PD stenting groups. Pancreatic duct stenting was associated with lower risks of post‐ERCP pancreatitis (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.099–0.79; P = 0.028). In multivariable analysis, the association between PD stenting and lower post‐ERCP pancreatitis incidence was consistent (OR 0.19; 95% CI 0.062–0.58; P = 0.0034). Conclusions: Pancreatic duct stenting could reduce the risk of post‐ERCP pancreatitis after CSEMSs. [ABSTRACT FROM AUTHOR]

Background: Malignant obstructive jaundice is associated with a poor prognosis. Patients can undergo percutaneous transhepatic biliary drainage (PTBD), but the impact it has on quality of life is not well understood. Objective: To assess the potential impact of PTBD on quality of life in patients with obstructive jaundice from advanced malignancy using surrogate markers including complications, hospital length of stay, readmission, reintervention, and mortality. Methods: A retrospective analysis of a single-centre cohort of all patients with advanced solid organ malignancy undergoing PTBD between April 2020 and February 2022. Data was collected from electronic medical records. Results: Among the sixteen patients, abdominal pain and cholangitis were observed in 62.5% and 37.5% patients, respectively. Peritonitis, biliary leak, perihepatic abscess, and haemobilia occurred in individual cases. The median hospital length of stay post PTBD was nine days. The 30-day readmission rate for PTBD-related complications was 31.3% with a median of three total readmissions per patient. The 30-day reintervention rate was 62.5%. The 30-day all-cause mortality was 25% (95% CI:8.9-53.3), which included one procedure-related death. Conclusions: Quality of life in patients with obstructive jaundice from advanced solid organ malignancy undergoing PTBD can be adversely impacted due to the high risk of complications, reintervention, hospitalisation, and mortality. Thorough patient assessments are crucial in selecting appropriate candidates for PTBD. [ABSTRACT FROM AUTHOR]

Background: According to the European Society of Gastrointestinal Endoscopy guidelines, self-expandable metal stents (SEMSs) are preferable to plastic stents (PSs) in the management of pancreatic cancer, regardless of cancer stage. The aim of this study was to compare the therapeutic efficacy and treatment costs of SEMS and PS in the management of malignant biliary obstruction. Methods: One hundred and thirty-five patients who underwent endoscopic stent placement were retrospectively enrolled and divided into PS (41 patients), primary SEMS (39 patients) and secondary SEMS (55 patients) groups. We determined the technical and functional success rate, stent patency, and cumulative treatment cost. Results: A total of 111 SEMSs and 153 PSs were placed with similar technical (100% vs. 98.69%) and functional success rate (90.10% vs. 86.27%) but with different stent patency (10.28 vs. 22.16 weeks; p < 0.001). Multiple PS implantations and larger stent diameter increased the length of stent patency compared to 7-Fr PSs (10.88 vs. 10.55 vs. 7.63 weeks, respectively). The cumulative treatment cost of patients with different survival times did not differ significantly between groups, however, among patients surviving 2–4 months it was higher in PS group than primary SEMS and secondary SEMS groups (2888€ vs. 2258€ vs. 2144€, respectively, p = 0.3369) due to increased number of biliary reintervention (2.08 ± 1.04 vs. 1.20 ± 0.42 vs. 1.50 ± 0.53; p < 0.0274) and longer hospital stay (15.77 ± 10.14 vs. 8.70 ± 7.70 vs. 8.50 ± 6.17 days, p = 0.0527). Conclusions: In view of treatment costs, the consequences of illness, and the processes of the health care system, SEMS implantation is recommended regardless of patients' life expectancy. [ABSTRACT FROM AUTHOR]

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound‐guided antegrade intervention (EUS‐AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS‐AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS‐AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to demonstrate the feasibility of the percutaneous endobiliary radiofrequency ablation (ERFA) method, which is used to increase stent patency in malignant biliary strictures. Material and Methods: A total of 25 patients, 9 (36%) female and 16 (64%) male, who developed malignant biliary stenosis secondary to various advanced tumors and underwent ERFA and metallic stenting after percutaneous biliary drainage were retrospectively evaluated. The types of malignancies causing obstruction and the follow-up after the procedure were evaluated to demonstrate the median survival and stent patency values of the patients. Stent patency and survival rates were calculated using the Kaplan-Meier method. Results: The results of the study demonstrated that 17 (68%) out of these 25 patients displayed a significant decrease in their first-week postoperative bilirubin values, with a reduction of greater than 50% compared to the pre-biliary drainage values. The study determined that this treatment approach's overall clinical success rate was 68%. Stent occlusion developed within 180 days in 8 (32%) out of the 25 patients who underwent ERFA and metallic stenting. Additionally, 18 (%72) patients died as a result of malignancy progression. The mortality rates at post-treatment 30 and 180 days were determined to be 24% and 72%, respectively. The median survival and stent patency times were 65 and 70 days, respectively. Conclusion: Percutaneous ERFA and metallic stenting have the potential to improve survival and stent patency, especially in selected patient groups with distal biliary stenosis. Randomized controlled studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]