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Main Recommendations1 ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence.2 ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence.3 ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence.4 ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence.5 ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence.6 ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence.7 ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates.Strong recommendation, low quality evidence.8 ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

An 81-year-old woman presented with abdominal distension and right hypochondrial pain. Abdominal contrast computed tomography and magnetic resonance imaging revealed an 11-cm gallbladder tumor. The patient was diagnosed with squamous cell carcinoma of the gallbladder by endoscopic ultrasound-guided fine-needle aspiration from the gastric antrum. Thereafter, the gallbladder tumor enlarged, and cholecysto-duodenal and transverse colon fistulas were formed. A covered metal stent was placed on the transverse colon, and polyglycolic acid sheets were injected into the duodenum to close the fistulas endoscopically. Endoscopic closure is less invasive than surgery and considered effective for patients with poor general health conditions.

Background and Objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD), first reported as an alternative to percutaneous transhepatic BD in failed endoscopic retrograde cholangiography, is sometimes performed as reintervention for transpapillary stent dysfunction such as in patients with new onset gastric outlet obstruction, but direct conversion to EUS-BD can potentially have a risk of leakage of infected bile. The aim of this study is to evaluate the safety and efficacy of conversion to EUS-BD using a temporary endoscopic nasobiliary drainage (ENBD) tube placement as a reintervention for prior BD. Patients and Methods: Sixteen patients with prior BD for malignant biliary obstruction undergoing conversion to EUS-BD using a temporary ENBD tube placement were studied. Technical and clinical success rate and adverse events were evaluated. Results: The major reason for conversion to EUS-BD was recurrent cholangitis due to duodenobiliary reflux (n = 13). In 14 patients with an indwelling covered metal or plastic stent, the stents were removed before temporary ENBD placement. After a median duration of 6 days, subsequent conversion to EUS-BD using a covered metal stent was performed, which was technically and clinically successful in all 16 patients (14 hepaticogastrostomy and 2 choledochoduodenostomy). Adverse events were observed in 3 patients (19%): one bleeding, one cholecystitis, and one cholangitis. No bile leak, peritonitis, or sepsis was observed. Conclusions: Conversion to EUS-BD using temporary ENBD tube placement in patients with prior BD was technically feasible and relatively safe without infectious complications related to bile leakage.

Over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography (ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO). Methods: Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control. Results: A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively). Conclusion: EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.

Pancreatic fluid collections (PFCs) represent a complication of acute pancreatitis. Endoscopic management of PFCs is an alternative to surgery [1]. Classic strategies include access to the collection under endoscopic ultrasound (EUS)-guidance and placement of several double-pigtail stents. PFCs containing organized necrosis are classified as walled-off necrosis (WON). In those cases necrosis is hardly evacuated and will require necrosectomy in most cases. Every necrosectomy session needs prior removal of the stents, dilatation of the tract, debridement and placement of new stents adding up a considerable overall cost to the intervention. A novel double-flanged lumen-apposing fully-covered self-expandable metal stent (FC-SEMS) with a 15 mm diameter accelerates exit of the necrosis and facilitates multiple necrosectomy sessions.We present a 60 year old patient admitted to the intensive care unit for severe acute pancreatitis that developed WON with superinfection. The intensivists and surgeons indicated endoscopic cystgastrostomy to evacuate the collection. Using the echoendoscope we found a large collection adherent to the gastric wall. The collection was accessed under EUS-guidance using the Hot AXIOS™ catheter that features a cautery tip, then a 15 mm AXIOS™ stent was deployed through the cystgastrostomy orifice to keep it patent. The patient required two necrosectomy sessions to clean the cavity. The WON resolved in 6 weeks and the stent was removed unevently. The patient was discharged.A double flange lumen apposing FC-SEMS used as a port for necrosectomy significantly improves management of walled-off pancreatic necrosis. Placement of this stents should be considered when multiple necrosectomy sessions are anticipated. Procedure time can be significantly decreased using a catheter that combines a cautery tip and stent delivery system. Keywords: Pancreatic collection, Pancreatic abscess, Walled-off necrosis, Necrosectomy, Endoscopic ultrasound, Covered metal stent, Video

Background: Temporary stent placement is widely performed for pancreatic duct stenosis due to chronic pancreatitis. A fully covered self-expandable metal stent (FCSEMS) has a larger diameter, and therefore longer stent patency, and the effect of expansion of the main pancreatic duct stricture may be obtained. However, if stent migration upstream occurs, stent removal is extremely difficult. In addition, because of the diameter gap between the FCSEMS and the main pancreatic duct, stent-induced ductal change may occur. To prevent these adverse events, the technical feasibility, safety and efficacy of the placement of a novel 6 mm diameter FCSEMS with a long suture, to facilitate its removal in cases of stent migration upstream, were evaluated in a pilot study. Methods: Between December 2014 and August 2015, symptomatic chronic pancreatitis patients with abdominal pain and a main pancreatic head duct stricture were enrolled. Stent placement for main pancreatic duct stricture was performed under endoscopic retrograde cholangiopancreatography (ERCP) guidance and stent removal was performed within 6 months. Results: A total of 13 patients were retrospectively enrolled in this study. Metal stent insertion was successfully performed in all patients and clinical success was high (12/13, 92%). As adverse events, stent migration upstream was seen in two patients. Another 11 patients successfully underwent stent removal without any adverse events. During follow up (median 258 days), 2 patients still underwent pancreatic duct stenting because of continuing main pancreatic duct stricture. Conclusion: In conclusion, this novel FCSEMS is acceptable for stent placement in cases of chronic pancreatitis with a main pancreatic duct stricture.

REZIMERazličiti patološki entiteti u abdomenu, najčešće maligni, u jednom trenutku svoje patogeneze, kao posledicu daju različiti stepen staze. Bilijarna opstrukcija se proučava i terapijski razmatra od trenutka kada se shvatilo da je značajnija za preživljavanje pacijenta u odnosu na osnovnu bolest koja je izazvala. Poremećaj dinamike oticanja žuči se najdirektnije odražava na čitav niz metaboličkih i hemodinamskih procesa i bez obzira na trenutni stadijum bolesti, diktira vitalnu ugroženost bolesnika. Zato ne treba da čudi što istorija bilijarnih stentova, već sa aspekta sadašnjeg trenutka u medicini obiluje velikim interesovanjem (1) i veoma sistematičnim pristupom usavršavanja materijala i tehnologije izrade stentova (2), kao i tehnike postavljanja. Ekspanzija kliničke primene minimalno invanzivnih tehnika lečenja tokom poslednje decenije nije u većoj meri smanjila incidencu ove bolesti, ali je u velikoj meri povećala stepen preživljavanja (3). U slučaju ireverzibilne holestaze interventna radiologija je ponudila primenu biokompatibilnih metalnih stentova različitih metalnih legura, dizajna, načina postavljanja i dužine nošenja. U grupi bolesnika sa holestazom bilo maligne bilo b eningne etiololgije metalni stentovi su prihvaćeni kao terapijska metoda izbora, obzirom na naša klinička iskustva i iskustva iz literature na terenu prethodnih terapijskih procedura (5). Metalni stentovi ostvarili su svoju predominaciju na terenu procedura koje se primenjuju pre planiranja radikalnih rekonstrukivnih operacija, a po rezultatima iz literature , definitivno su terapijska metoda izbora za neoperabilne forme ovih oboljenja (6). Pre primene u interventnoj radiologiji metalni stentovi su se klinički legitimno pojavili u oblastima endovaskularnih rekanalizacija i lečenju maligne ahalazije jednjaka. U mnogim indikacijama metalni implantanti su stekli značaj terapijske metode izbora (7). Tokom dve decenije stečena su brojna iskustva od značaja za primenu ove metodologije, a brojni radovi na tu temu svedočanstvo su da su pojedini stentovai postali sastavni deo medicinskog rečnika (6). Višedecenijsko iskustavo stečeno u primeni kateterskih stentova rezultiralo je rezmišljanjem o primeni metala kao materijala za izradu stentova u medicini, čija je primena aktuelna i danas. Evolutivnom integracijom endoskopske hirurgije i interventne radiologije nastali su metalni stentovi- kao pokušaj da se na efikasan i trajan način reši problem relativno visokog procenta recidiva postoperativnih striktura na nivou holedohusa. Stent je postao kroz 7 istoriju razvoja medicinske teorije i prakse prepoznatljiv pojam za kliničku primenu predmeta koji se koriste za premošćavanje suženog mesta (stenotične lezije - strikture) u narušenoj morfologiji nekog organa kanalnog izgleda... Different pathological entities in the abdomen, usually malignant, at one point their pathogenesis, as a result give different level paths. Biliary obstruction is studied and therapeutically considered from the moment when it was realized that the more important for the survival of the patient in relation to the underlying disease that caused. Disturbance dynamics of gall is most directly reflected in a range of metabolic and hemodynamic processes, and regardless of the current stage of the disease, dictates a vital threat to patients. So do not wonder that the history of biliary stents, but in terms of the present moment in medicine abounds with great interest (1) and a systematic approach to training materials and the technology of stents (2), as well as techniques of setting. The expansion of the clinical application of minimally invasive treatment techniques over the last decade is largely reduced the incidence of this disease, but it greatly increased the survival rate (3) Interventional radiology methods are applied in the recanalization of biliary strictures about two decades, and the constant technological and methodological improvement of all aspects of importance. Based on the many lessons learned in the recanalization of occlusive lesions of the blood vessels, resulting selective dilatation balloon catheters and metal prosthesis designed for recanalization of strictures nevaskularnih kanalinih body. Today the market for nonvascular each organ (esophagus, urethra, ureter, choledochus) are selective recanalization balloon catheters and catheter or metal prosthesis. The mechanism of therapeutic action dilatacionog balloon in the treatment of biliary tract strictures, a new approach in the treatment of this disease, and the occurrence of high strength balloon distension and strength over 20 atmosphere, have led to significant clinical interventional radiology affirmation of these pathological entities (4). Before the application of interventional radiology metal stents have witnessed their clinical legitimacy in the areas of endovascular recanalization and treatment of malignant esophageal achalasia . In many of the listed indications metal implants have gained important therapeutic method of choice ( 7 ) . Over two decades have gained extensive experience relevant to the implementation of this methodology , a number of papers on the subject testimony was that the names of the stents have become an integral part of medical vocabulary ( 6 ) . The use of metal as a material for making stents in medicine , has come from decades of experience gained in the application of catheter stent whose application is current today. Metal stents were evolutionary integration of endoscopic surgery and interventional radiology 13 - an attempt to efficiently and durable solve the problem of the relatively high percentage of postoperative recurrence of stricture at the level of the common bile duct...