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Competing Interests: The authors declare that they have no financial conflict of interest with regard to the content of this report.

Competing Interests: Takeshi Ogura is an Editorial Board Member of the journal. This work was subjected to the journal’s standard procedures, with peer review handled independently of the editor and his research group.

Background and Objectives: EUS-guided gallbladder drainage (GBD) has emerged as an alternative GBD technique, particularly for high-risk surgical patients. To prevent stent migration or to facilitate stent deployment, the lumen-apposing metal stent (LAMS) was recently developed for EUS-GBD. However, LAMS remains unavailable in several countries and is expensive compared with conventional fully covered self-expandable metal stent (FCSEMS). Although several studies have shown the clinical benefits of EUS-GBD using novel FCSEMS or LAMS compared with endoscopic transpapillary GBD (ETGBD), the choice between ETGBD and EUS-GBD using conventional FCSEMS and ETGBD remains controversial. The aim of this study was to evaluate EUS-GBD using conventional FCSEMS compared with ETGBD. Materials and Methods: This comparative retrospective study included consecutive symptomatic AC patients who underwent gallbladder drainage by either EUS-GBD or ETGBD between January 2015 and December 2018.The main outcome measures were technical success, clinical success, procedure-related and stent-related adverse events, and recurrence of AC during follow-up., Results: Fifty-four patients (44.4% female, 55.6% male) who underwent EUS-GBD (n = 25) or ETGBD (n = 29) were enrolled. Initial technical success rates were 100% with EUS-GBD and 82.7% (24/29) with ETGBD. The median procedure time was significantly shorter for the EUS-GBD group than for the ETGBD group (11.0 vs. 24.0 min, P < 0.05). Procedure-related adverse events did not differ significantly between groups (P = 0.283). During follow-up (median 522 days, range 43 - 1892 days), recurrent acute cholecystitis (AC) was only observed in 4 patients from the ETGBD group. Overall survival did not differ significantly between the EUS-GBD group (mean 1070 days) and ETGBD group (mean 1470 days) (P = 0.292)., Conclusion: The technical success rate for EUS-GBD using FCSEMS with plastic stent insertion was significantly higher with a shorter procedure time and resulted in a lower rate of recurrent AC., Competing Interests: None

Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field., Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers., Results: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50-200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended., Conclusion: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures., Competing Interests: None

Background and Objective: EUS-guided hepaticogastrostomy (HGS) is performed for patients with advanced cancer because of poor prognosis and compromised status, and bile peritonitis may prove critical for such patients. This adverse event has the possibility of decreasing quality of life by prolonging the time until the start of oral intake, hospital stay, or chemotherapy. Predictors of bile peritonitis in EUS-HGS thus have considerable clinical impact. The aim of this study was to retrospectively determine risk factors of bile peritonitis as adverse events of EUS-HGS., Patients and Methods: As risk factors of bile peritonitis, baseline characteristics of patients, characteristics of procedures such as number of punctures, types of fistula dilation, mean procedure time were analyzed. Furthermore, a receiver operating characteristic (ROC) curve was plotted to assess the influence of this distance and bile peritonitis and determine the optimum cutoff score for predicting the risk of bile peritonitis. Multivariate analysis using logistic regression was performed to examine factors of bile peritonitis., Results: A total of 68 patients were enrolled in this study. A distance of 2.50 cm offered 90.3% sensitivity and 87.5% specificity in predicting bile peritonitis according to the ROC curve. Number of punctures (>1), procedure time (>20 min), distance to the hepatic parenchyma (<2.50 cm), and presence of acute cholangitis were significantly associated with bile peritonitis in univariate analysis. However, according to this multivariate analysis, distance to the hepatic parenchyma (<2.50 cm, odds ratio 96.98, 95% confidence interval 10.12-929.12, P < 0.001) were only significantly associated with bile peritonitis., Conclusions: The short distance of hepatic parenchyma may be a risk factor of bile peritonitis., Competing Interests: None

Background and Objectives: A needle with Franseen geometry for fine needle aspiration is now available. However, no reports have described prospective evaluations of the Franseen needle or comparisons with the standard needle. The aim of this comparative prospective study was to evaluate the histological diagnostic yield of the Franseen needle and the standard needle using tissue obtained by a single pass of each for the same lesion., Patients and Methods: In this study, only tissue obtained by the first pass using the Franseen needle was used. As a comparison group, only tissue obtained from the same lesion by a second pass using the standard needle was used. Evaluation of the histological diagnostic yield of the needles was based on tissue obtained by each single pass with no additional passes., Results: A total of 56 patients were prospectively enrolled. The rate of adequate tissue obtained was significantly higher for the Franseen needle than for the standard needle (89.4% vs. 62.5%, respectively; P < 0.05). The sensitivity and accuracy of the Franseen needle were 80.7%, and 84.6%, respectively, while those for the standard needle were 59.6% and 63.5%, respectively., Conclusions: The Franseen needle offers a better rate of obtaining adequate tissue and higher diagnostic accuracy than the standard needle., Competing Interests: None

Background and Objectives: Biliary drainage (BD) under EUS guidance is usually indicated for malignant biliary obstruction. Recently, EUS-guided transluminal treatment has been applied to benign biliary disease (BBD). This multicenter retrospective study evaluated the clinical impact of EUS-guided transluminal stent deployment for BBD with long-term follow-up., Patients and Methods: This retrospective study investigated patients treated between September 2015 and October 2016 at participating hospitals in the therapeutic endoscopic group. The inclusion criteria comprised complications with BBD obstructive jaundice or cholangitis and failed endoscopic retrograde cholangiopancreatography or inaccessible ampulla of Vater., Results: Twenty-six patients underwent EUS-guided transluminal stent deployment. Indications for EUS-guided transluminal stent deployment comprised anastomotic biliary stricture (n = 17), bile duct stones (n = 5), inflammatory biliary stricture (n = 3), and acute pancreatitis prevention (n = 1). Thirteen of these 26 patients underwent scheduled reintervention, with technical success achieved in all 13 patients. None of the deployed stents became dysfunctional. Among the 13 patients who underwent reintervention on demand, stents had become dysfunctional in six patients (stent patency: 48, 90, 172, 288, 289, and 608 days). Reintervention was successfully performed in all patients. During follow-up (median, 749 days), severe adverse events were not seen in any patients., Conclusion: We concluded that EUS-guided transluminal stent deployment for BBD is feasible and safe. Because metal stent dysfunction was more frequent when deployed on demand, such stents should be exchanged for plastic stents in a scheduled manner if a metal stent is used., Competing Interests: None

Background and Objectives: EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed., Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD., Results: Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended., Conclusion: This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition., Competing Interests: There are no conflicts of interest

Objective: No previous studies have described endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) only for intra-ampullary lesions of the papilla of Vater. We aimed to examine whether EUS-FNA can be used to diagnose such lesions., Methods: This study included a subset of 10 consecutive patients in whom EUS-FNA targeted the ampulla of Vater. All the patients underwent biopsy and/or brushing cytology under endoscopic retrograde cholangiopancreatography (ERCP) prior to EUS-FNA. The final diagnosis was based on pathological examinations of specimens obtained by surgical resection or clinical follow-up more than 1 year in case of evidence of benign lesions., Results: Tissues from the ampulla of Vater could be obtained by EUS-FNA for all 10 patients. The final diagnosis was papillitis (n = 7) and intra-ampullary carcinoma (n = 3). Carcinoma of the ampulla of Vater showed neither exposure on the duodenal mucosal surface nor invasion to the pancreas. The diagnostic accuracy of surface biopsy with duodenoscopy, and intra-ampullary biopsy and/or brush cytology with ERCP and/or intra-ampullary biopsy after endoscopic sphincterotomy (EST) in distinguishing between benign and malignancy was 70%. The diagnostic accuracy of EUS-FNA was 100%. No complications associated with EUS-FNA were encountered in this study., Conclusion: EUS-FNA for ampulla of Vater may be safely and accurately performed, and should be considered as a diagnostic modality before EST.