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Background: Endoscopic management of biliary or pancreatic strictures by stent insertion is well established. However, some high-grade strictures are refractory to dilation and stent placement with conventional methods. Objective: To evaluate the safety and efficacy of the wire-guided electrotomy technique in dilating stiff biliary and/or pancreatic stenoses when ordinary methods failed. Design: Retrospective analysis of a prospective database. Setting: Tertiary referral university hospital. Patients: This study involved 279 patients with biliary or pancreatic strictures who underwent ERCP for stenting. Intervention: After conventional dilation failed, wire-guided needle-knife electrocautery was attempted to facilitate insertion of the dilating devices and eventually endoprosthesis. Main Outcome Measurements: The successful treatment and drainage of biliary or pancreatic strictures. Results: With wire-guided needle-knife cauterization, the success rate of stricture dilatation increased from 95.7% (267 of 279 patients) to 98.9% (276 of 279 patients). Dilation of stenoses was successful in 9 of 10 patients (90%) by using electrocautery with the wire-guided needle-knife technique. Postprocedure adverse events included self-limited bleeding, mild acute pancreatitis, hyperamylasemia, cholangitis, and biliary perforation. No procedure-related death occurred. Limitations: Retrospective, single-center study and small sample size. Conclusions: Wire-guided needle-knife electroincision appears to be effective for traversing refractory biliary or pancreatic strictures and can be considered as an alternative approach to conventional methods. However, the safety of such a technique needs to be further evaluated. [Copyright &y& Elsevier]

We sought to compare the efficacy and safety between endoscopic radiofrequency ablation (RFA) and stent placement alone in patients with unresectable extrahepatic biliary cancer (EBC). In this randomized controlled trial, patients with locally advanced or metastatic cholangiocarcinoma (CCA) or ampullary cancer who were unsuitable for surgery were recruited from 3 tertiary centers. Eligible patients were randomly assigned to RFA plus plastic stent placement (RFA group) or plastic stent placement alone (stent placement alone group) in a 1:1 ratio. Both groups underwent 2 scheduled interventions with an interval of approximately 3 months. The primary outcome was overall survival (OS). Altogether, 174 participants completed the 2 index endoscopic interventions. No significant differences in baseline characteristics were noted between the 2 groups. The median OS was significantly higher in the RFA group (14.3 vs 9.2 months; hazard ratio,.488; 95% confidence interval,.351-.678; P <.001). A survival benefit was also shown in patients with CCA (13.3 vs 9.2 months; hazard ratio,.546; 95% confidence interval,.386-.771; P <.001). However, no significant between-group differences were found in jaundice control or stent patency duration. The postprocedural Karnofsky performance scores were significantly higher in the RFA group until 9 months (all P <.001). Adverse events were comparable between the 2 groups (27.6% vs 19.5%, P =.211), except for acute cholecystitis, which was more frequently observed in the RFA group (9 vs 0, P =.003). Compared with stent placement alone, additional RFA may improve OS and quality of life of patients with inoperable primary EBC who do not undergo systemic treatments. (Clinical trial registration number: NCT01844245.) [Display omitted] [ABSTRACT FROM AUTHOR]

The endoscopic management of malignant hilar biliary obstruction (MHBO) remains extremely challenging without universal consensus. For the first time, we compared 4 major modalities aiming to determine the optimal strategy. We reviewed 1239 patients with advanced MHBO who underwent endoscopic stent placement as the primary treatment in 4 tertiary centers. Among them, 633 eligible patients were identified and classified into 4 groups: bilateral metal stent placement (BMS), unilateral metal stent placement (UMS), bilateral plastic stent placement (BPS), and unilateral plastic stent placement (UPS). The outcomes were compared before and after propensity score matching (PSM). After PSM, 87, 97, 91, and 81 patients in the BMS, UMS, BPS, and UPS groups, respectively, were matched. The clinical success rates were 98.9%, 83.5%, 71.4%, and 65.4% in the BMS, UMS, BPS, and UPS groups (P <.001), respectively. The postprocedural cholangitis rates were 8.0%, 17.5%, 26.4%, and 29.6% (P =.002), respectively. The median symptom-free stent patency was 9.6, 6.8, 4.6, and 4.2 months (P <.001), respectively. The mean number of interventions required was 1.2 ± 0.5, 1.7 ± 0.8, 2.0 ± 1.4, and 1.9 ± 1.3 (P <.001), respectively. The median (95% confidence interval) overall survival (OS) was 7.1 (6.0-8.2), 4.4 (3.8-4.9), 4.1 (2.9-5.2), and 2.7 (1.8-3.7) months (P =.001), respectively. Compared with plastic stent placement, metal stent placement achieved higher success in all outcome parameters (P ≤.001). Bilateral stent placement was superior to unilateral stent placement in terms of clinical success (P =.024), stent patency (P =.018), and OS (P =.040). If technically possible, dual metal stent placement is a preferred palliation for inoperable MHBO, and unilateral metal stent placement is the second option. [ABSTRACT FROM AUTHOR]

Background: Esophagectomy is the conventional treatment for Barrett's esophagus with high-grade dysplasia and intramucosal cancer. Endotherapy is an alternative treatment. Objective: To compare the efficacy and safety of these 2 treatments. Design: PubMed, Web of Science, EMBASE, Cochrane Library and momentous meeting abstracts were searched. Studies comparing endotherapy with esophagectomy were included in the meta-analysis. Pooling was conducted in a random-effects model. Setting: Tertiary-care facility. Patients: Seven studies involving 870 patients were included. Intervention: Endotherapy and esophagectomy. Main Outcome Measurements: Neoplasia remission rate, neoplasia recurrence rate, overall survival rate, neoplasia-related death, and major adverse events. Results: Meta-analysis showed that there was no significant difference between endotherapy and esophagectomy in the neoplasia remission rate (relative risk [RR] 0.96; 95% CI, 0.91-1.01); overall survival rate at 1 year (RR 0.99; 95% CI, 0.94-1.03), 3 years (RR 1.03; 95% CI, 0.96-1.10), and 5 years (RR 1.00; 95% CI, 0.93-1.06); and neoplasia-related mortality (risk difference [RD] 0; 95% CI, -0.02 to 0.01). Endotherapy was associated with a higher neoplasia recurrence rate (RR 9.50; 95% CI, 3.26-27.75) and fewer major adverse events (RR 0.38; 95% CI, 0.20-0.73). Limitations: Relatively small number of retrospective studies available, different types of endoscopic treatments were used. Conclusion: Endotherapy and esophagectomy show similar efficacy except in the neoplasia recurrence rate, which is higher after endotherapy. Prospective, randomized, controlled trials are needed to confirm these results. [Copyright &y& Elsevier]