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Background and Aims Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDD) with an electrocautery enhanced lumen-apposing metal stent (EC-LAMS) has emerged as a viable method of establishing biliary drainage in patients with MDBO. Our aim was to assess the efficacy, safety, and outcomes in patients with malignant distal biliary obstruction (MDBO), who underwent EUS-CDD with EC-LAMS. Methods A retrospective review of consecutive patients with MDBO who underwent EUS-CDD with EC-LAMS at 8 tertiary institutions across the United Kingdom and Ireland between September 2016 to November 2020 was undertaken. Results One hundred twenty patients (55% male) with a median age of 73 years (IQR 17, range 43 – 94) were included. The median follow-up period in 117 patients was 70 days (IQR 169, range 3 – 869) and 23 patients (19.2%) were alive at the end of the follow-up. Three patients were lost to follow-up. Technical success was achieved in 109 patients (90.8%). Clinical success (reduction of serum bilirubin to ≤50% of original value within 14 days) was achieved in 94.8% (92/97 patients). The adverse event (AE) rate was 17.5% (n=21). Biliary reintervention after initial technical success was required in 9 patients (8.3%). Conclusion EUS-CDD with EC-LAMS at tertiary institutions within a regional HPB network for treatment of MDBO is effective in those where ERCP was not possible or unsuccessful. When technical failures or adverse events occur, the majority can be managed with conservative or endoscopic therapy

Background and Aims A new core biopsy needle with a novel tip, opposing bevel, and sheath design has recently been introduced for EUS-guided fine-needle biopsy (FNB). The diagnostic utility of this needle for differentiating solid pancreatic masses is currently unknown. The aim of this study was to compare the diagnostic performance and yield for tissue acquisition from solid pancreatic lesions of the opposing bevel needle with those of a reverse bevel EUS-FNB needle. Methods Consecutive patients with solid pancreatic masses undergoing EUS-FNB using the opposing bevel (n = 101) and the reverse bevel (n = 100) core biopsy needles were included in the study. Final diagnosis was based on positive histology or at least 12 months of follow-up in cases with a negative biopsy. The primary outcome was the diagnostic performance of the 2 needles for malignant pancreatic masses. A secondary outcome was the diagnostic yield. Results Compared with the reverse bevel needle, using strict criteria the opposing bevel needle provided significantly higher sensitivity (71.1% vs 90.1%; P = .0006) and overall accuracy (74% vs 92%; I = 0.0006) for discriminating malignant from benign solid pancreatic masses. The proportion of samples classified as adequate for histologic analysis was 87% for the reverse bevel needle versus 99% for the opposing bevel needle ( p = 0.002) Multivariate analysis controlling the needle gauge and site did not show any significant difference in accuracy and sensitivity between the 2 groups. There were no adverse events in either group. Conclusions In this first, large, single-center preliminary cohort study, an EUS core biopsy needle with a novel tip, opposing bevel, and sheath design afforded substantially superior tissue yield and diagnostic performance compared with a reverse-bevel needle. If replicated by randomized controlled trials, our findings suggest that similarly designed needles could become the standard of care for EUS-guided tissue acquisition from solid pancreatic masses.

Background Recent data suggest that quantitative EUS elastography, a novel technique that allows real-time quantification of tissue stiffness, can accurately differentiate malignant from benign solid pancreatic masses. Objective To externally validate the diagnostic utility of this technique in an independent cohort. Design and Setting Prospective, single-center study. Patients, Interventions, and Methods A total of 104 patients with evidence of a solid pancreatic mass on cross-sectional imaging and/or endosonography underwent 111 quantitative EUS elastography procedures. Multiple elastographic measurements of the mass lesion and soft-tissue reference areas were undertaken, and the corresponding strain ratios (SRs) were calculated. The final diagnosis was based on pancreatic cytology or histology. Main Outcome Measurements The area under the receiver-operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of quantitative EUS elastography for discriminating malignant from benign pancreatic masses. Results The final diagnoses were primary pancreatic carcinoma (71.2%), neuroendocrine tumor (10.6%), metastatic cancer (1.9%), and pancreatitis (16.3%). Malignant masses had a higher SR ( P = .01) and lower mass elasticity ( P = .003) than inflammatory ones. The areas under the receiver-operating characteristic curve for the detection of pancreatic malignancy of both SR and mass elasticity (0.69 and 0.72, respectively) were less favorable than reported recently. At the cut points providing the highest accuracy in this cohort (4.65 for SR and 0.27% for mass elasticity), quantitative EUS elastography had a sensitivity of 100.0% and 95.7%, specificity of 16.7% and 22.2%, positive predictive value of 86.1% and 86.4%, negative predictive value of 100.0% and 50.0%, and overall accuracy of 86.5% and 83.8%, respectively. Limitations Relatively small number of patients with benign disease. Conclusion In the largest single-center study to date, the diagnostic utility of quantitative EUS elastography for discriminating pancreatic masses was modest, suggesting that it may only supplement rather than supplant the role of pancreatic tissue sampling in the future.

We read with interest the study of post-ERCP mortality in England by Bodger et al.1 Although the nationwide scale and robust fatality ascertainment are incontestable strengths of this study, we believe it has a number of noteworthy limitations. First, it seems ironic that none of the 150 hospitals included in the analysis had a statistically significant divergent performance, not least because the 2004 National Confidential Enquiry into Patient Outcome and Death2 and British Society of Gasroenterology’s (BSG) audit of ERCP3 have both highlighted concerns about the quality of the United Kingdom’s ERCP practice. Furthermore, over the 18-month period of the study, only 13 of 1078 post-ERCP deaths within 30 days could be attributed to the procedure. This compares with 20 ERCP-related fatalities within the same time span that were reported to the BSG’s ERCP audit in 2004, despite capturing only 20% of the total number of procedures performed nationally during a 6-month period.3 The authors’ assertion that the overall proportion of procedure-related deaths (0.06%) was similar to that recently reported in a large single-center study in the United States4 discounts the fact that the enter in question has some of the world’s most expeienced biliary endoscopists undertaking a higher proortion of benign case load than an average British ospital. Other shortcomings of the study include a awed definition of a first ERCP (as first recorded proedure in the financial year), inference of the cause of eath from discharge diagnosis codes, use of a crude isk-adjustment method (with comorbid disease being lassified as either present or absent and center differnces in procedure complexity not being taken into ccount), omission of analysis of mortality beyond 30 ays, and, last but not least, the considerable proportion 93%) of clinicians who expressed concerns about inomplete capture of their local data.1 We believe these hortcomings undermine the authors’ interpretation of he apparent lack of a significant ERCP volume-outcome ssociation in their study as suggesting a “process under ontrol”—an experience, we submit, not universally hared by biliary endoscopists in the United Kingdom. or now, therefore, we believe that the claim that ERCP rovider volume does not influence postprocedure ortality remains unproven. d