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Objectives: Endoscopic ultrasound‐guided fine‐needle aspiration and fine‐needle biopsy (EUS‐FNA/FNB) is not fully established as a pathological sampling tool for gallbladder lesions due to limited evidence. We therefore aimed to clarify the effectiveness and safety of this procedure in a large‐population cohort. Methods: This study retrospectively evaluated the diagnostic yield of EUS‐FNA/FNB for accurately differentiating between benign and malignant gallbladder lesions. Puncture targets included the gallbladder mass, lymph node, and liver mass. Adverse events and factors associated with diagnostic accuracy were analyzed as well. Results: In 187 patients with gallbladder lesions undergoing EUS‐FNA/FNB, 18 benign lesions and 169 malignant lesions were identified. Overall sampling adequacy was 98% (184/187). The diagnostic accuracy of EUS‐FNA/FNB was 97% (182/187), sensitivity was 97% (164/169), and specificity was 100% (18/18). A single postprocedural complication (minor bleeding) was recorded in one patient. In the 169 cases of malignancy, 203 sites were punctured for pathological sampling of the primary mass (n = 94), lymph node (n = 79), and metastatic liver mass (n = 30). No significant difference was found for diagnostic accuracy among the puncture sites (P = 0.70). In cases having specimens obtained from the primary mass, the accuracy of those targeting liver invasion sites was significantly higher than that of other sites (98% vs. 83%, P < 0.01). Conclusion: EUS‐FNA/FNB demonstrated clinical usefulness and safety for the pathological diagnosis of gallbladder lesions, with high diagnostic yield and a low incidence of adverse events. Targeting the site of liver infiltration may improve the diagnostic rate of EUS‐FNA/FNB in the primary mass. [ABSTRACT FROM AUTHOR]

Tract dilation is one of the most difficult stages of endoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS), especially for beginners. To overcome this problem, we applied a special dedicated dilator. Herein, we retrospectively evaluate the safety and usefulness of a novel drill dilator in EUS‐HGS. This single‐center retrospective study included 20 consecutive patients who underwent EUS‐HGS with a novel drill dilator. The tip is 0.77 mm, and it becomes 7F at 3 cm from tip. The track is dilated to 7F by simple clockwise rotation. The technical success rate of both initial tract dilation and stent placement was 20/20 (100%). No cases required additional dilation such as balloon or electric cautery. In 13/20 cases (65.0%), EUS‐HGS was performed by beginner endoscopists. Median time required for dilation was 62.5 s (range, 30–144 s). Median procedure time was 13 min (range, 7–25 min). Early adverse events were two cases of mild fever. There was no bile leakage or bleeding. The novel drill dilator appears to be safe and useful for EUS‐HGS. As it is not necessary to press the device strongly, there is no pushback during dilation and the scope position is stable. These characteristics facilitate EUS‐HGS even for beginners. This device may enable the further development and increased dissemination of EUS intervention. [ABSTRACT FROM AUTHOR]

Background There are several types of pancreatic mass, so it is important to distinguish between them before treatment. Artificial intelligence (AI) is a mathematical technique that automates learning and recognition of data patterns. This study aimed to investigate the efficacy of our AI model using endoscopic ultrasonography (EUS) images of multiple types of pancreatic mass (pancreatic ductal adenocarcinoma [PDAC], pancreatic adenosquamous carcinoma [PASC], acinar cell carcinoma [ACC], metastatic pancreatic tumor [MPT], neuroendocrine carcinoma [NEC], neuroendocrine tumor [NET], solid pseudopapillary neoplasm [SPN], chronic pancreatitis, and autoimmune pancreatitis [AIP]). Methods Patients who underwent EUS were included in this retrospective study. The included patients were divided into training, validation, and test cohorts. Using these cohorts, an AI model that can distinguish pancreatic carcinomas from noncarcinomatous pancreatic lesions was developed using a deep-learning architecture and the diagnostic performance of the AI model was evaluated. Results 22 000 images were generated from 933 patients. The area under the curve, sensitivity, specificity, and accuracy (95 %CI) of the AI model for the diagnosis of pancreatic carcinomas in the test cohort were 0.90 (0.84–0.97), 0.94 (0.88–0.98), 0.82 (0.68–0.92), and 0.91 (0.85–0.95), respectively. The per-category sensitivities (95 %CI) of each disease were PDAC 0.96 (0.90–0.99), PASC 1.00 (0.05–1.00), ACC 1.00 (0.22–1.00), MPT 0.33 (0.01–0.91), NEC 1.00 (0.22–1.00), NET 0.93 (0.66–1.00), SPN 1.00 (0.22–1.00), chronic pancreatitis 0.78 (0.52–0.94), and AIP 0.73 (0.39–0.94). Conclusions Our developed AI model can distinguish pancreatic carcinomas from noncarcinomatous pancreatic lesions, but external validation is needed. [ABSTRACT FROM AUTHOR]

Background: After multiple uncovered self-expandable metal stent (UCSEMS) deployments, endoscopic revision becomes complex and potentially challenging. A novel stent delivery system with a dilation function has recently been developed in Japan. This study evaluated the technical feasibility of this device for patients with unresectable malignant hilar biliary obstruction (MHO) after multiple UCSEMS deployments. Method: Participants comprised consecutive patients with unresectable MHO who had undergone multiple UCSEMS deployments and required endoscopic revision for the right or left hepatic bile ducts, as decided by cholangiography under endoscopic retrograde cholangiopancreatography (ERCP) guidance. Results: A total of 14 patients requiring endoscopic revision of right and left hepatic bile ducts were enrolled in this study. Among these 14 patients, guidewire insertion through the mesh of previously placed stents failed in 2 patients. As a result, these two patients underwent only unilateral UCSEMS deployment. Because clinical success was not obtained, transmural placement of the UCSEMS under Endoscopic Ultrasound (EUS) guidance to the segment of the liver not being drained was performed in those patients. The molting technique was attempted in 12 patients, proving successful in all patients. The technical success rate was therefore 92.8% (12/14). Mean procedure time was 23.2 min. Conclusion: This novel stent delivery system with a dilation function may be useful in endoscopic revision techniques for bilateral UCSEMS deployment. [ABSTRACT FROM AUTHOR]

A prerequisite for endoscopic ultrasound (EUS)‐guided hepaticogastrostomy (HGS) is adequate dilation of the intrahepatic bile duct. Compared with a 19G needle, the 22G needle offers more flexible manipulation and superior ability to achieve bile duct puncture. However, evidence regarding EUS‐HGS using a 22G needle remains limited. The present study evaluated the feasibility and safety of EUS‐HGS using a novel 0.018‐inch guidewire and 22G needle for patients with insufficient intrahepatic bile duct dilation. If the bile duct diameter was <1.5 mm, a 22G needle was used, and the diameter was ≥1.5 mm; puncture with a 19G needle was first attempted, with the 22G needle being inserted if initial bile duct puncture failed. EUS‐HGS using the 22G needle was attempted in a total of 10 patients, including one patient with failed insertion of a 19G needle. Median diameter of the puncture site was 1.2 mm (range 0.5–2.5 mm). Bile duct puncture using the 22G needle was successful in all patients. Insertion of the novel 0.018‐inch guidewire was also successful in all patients. However, since tract dilation using an ultra‐tapered mechanical dilator failed in two patients, tract dilation was performed using a balloon dilator. Finally, stent deployment was successfully performed in all patients. EUS‐HGS using a 22G needle with a novel 0.018‐inch guidewire appears safe and feasible. [ABSTRACT FROM AUTHOR]

Background: With endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), guidewire manipulation might be a critically limiting step for nonexperts. However, the causes of difficult guidewire manipulation remain unclear. The aim of this study was to evaluate factors associated with successful guidewire manipulation.Methods: This retrospective cohort study included consecutive patients who underwent EUS-HGS between October 2018 and October 2019. We measured scope angle between the long and needle axes of the echoendoscope using still fluoroscopic imaging immediately after puncturing the intrahepatic bile duct. Factors associated with successful guidewire insertion were assessed by multivariable analysis using logistic regression.Result: The influence of the angle between the fine-needle aspiration (FNA) needle and echoendoscope on failed guidewire insertion was assessed using receiver operating characteristic (ROC) curves. Area under the ROC curve was 0.86 (95 % confidence interval [CI] 0.00 - 0.76), and an angle of 135° offered 88.0 % sensitivity and 82.9 % specificity for predicting successful guidewire insertion. According to multivariable analysis, only angle between the FNA needle and echoendoscope > 135° was independently associated with successful guidewire insertion (odd ratio 0.03, 95 %CI 0.01 - 0.14; P < 0.05), whereas sex, puncture site, and diameter of puncture site were not significant factors. After multivariable analysis, all variables were adjusted using age ≥ 70 or < 70 years, yielding the same results.Conclusion: The angle between the FNA needle and echoendoscope might be associated with successful guidewire manipulation during EUS-HGS. Adjusting this angle to 135° before puncturing the intrahepatic bile duct might be helpful in achieving successful guidewire manipulation during EUS-HGS. [ABSTRACT FROM AUTHOR]

Background: Recently, lumen-apposing metal stents (LAMS) have been developed as novel devices for not only endoscopic ultrasound (EUS)-guided pancreatic fluid drainage but also for EUS-guided gallbladder drainage (GBD). Although LAMS might be clinically impactful, these stents have not yet become available as EUS-GBD stents in all countries, including Japan. Instead, improved metal stents (NEO stents) have become available. The aim of this pilot study was to evaluate the feasibility and safety of EUS-GBD using the improved metal stent with an anti-stent migration system for acute cholecystitis (AC). Method: The gallbladder was punctured using a 19-G needle, and a 0.025-inch guidewire was inserted into the gallbladder. After fistula dilation, stent deployment was performed from the gallbladder to the duodenum. Finally, a plastic 7-Fr pigtail stent was placed to prevent stent migration. Result: EUS-GBD using NEO stents with the anti-stent migration system was attempted in 12 consecutive patients with AC as a complication of other conditions. EUS-GBD was successfully performed in all patients without any adverse events, and clinical success was achieved in all patients. Median procedure time was 19.0 min (range, 19–24 min). In 4 patients, stent removal was successfully performed after 3 months. Stent migration during follow-up (median, 189 days) was not seen in any of the patients. Conclusion: Although this study has several limitations such as small number of patients and short follow-up period, the results show that NEO stents might be suitable as EUS-GBD stents in selected patients. Our results should be validated by a larger prospective, randomized study. [ABSTRACT FROM AUTHOR]

However, if a transpapillary bile duct stent has previously been deployed, duodenal stents can become distorted by the bile duct stent. We herein describe technical tips for recanalization of a distorted duodenal metal stent using a novel fine-gauge electrocautery dilator (Medico's Hirata Inc., Osaka Japan) [5]. [Extracted from the article]

Recently, we used a novel drill dilator (Tornus ES, Asahi Intecc) for EUS-HGS in a difficult case of this kind (Fig. The present case demonstrates that Tornus is useful for fistula dilation in difficult cases of EUS-HGS. [Extracted from the article]

Background: Recently, endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) combined with antegrade stenting (AS) has been reported to be associated with longer stent patency and reduced procedure-related adverse events. In EUS-AS, an uncovered metal stent is usually selected to prevent stent misplacement or dislocation. However, because patient survival has improved with advances in chemotherapy, longer stent patency may be required.Aim: The technical feasibility and safety of EUS-guided transhepatic biliary drainage combined with EUS-AS using a novel covered metal stent were evaluated.Methods: Patients with malignant biliary obstruction leading to obstructive jaundice, in whom standard ERCP had failed or was contraindicated, were enrolled in this study between July 2015 and October 2017. As the control group, patients undergoing EUS-AS using an uncovered metal stent were enrolled between October 2014 and June 2015.Results: A total of 39 patients were enrolled in this study. Among them, EUS-AS using a covered metal stent was performed in 17 patients and using an uncovered metal stent in the remaining 22 patients. Median stent patency including stent dysfunction and patient death was longer in the covered metal stent group (153 days) compared with that of the uncovered metal stent group (108 days) although there were no significant differences (P = 0.06). In only cases with stent dysfunction was median stent patency of the covered metal stent group significantly longer than that of the uncovered metal stent group (not available vs 150 days, P = 0.02).Conclusions: In conclusion, EUS-guided transluminal biliary drainage combined with EUS-AS using a covered metal stent may be feasible and safe, although the indications for this procedure should be carefully considered. [ABSTRACT FROM AUTHOR]

2 Reintervention through the occluded stent. a An endoscopic retrograde cholangiopancreatography catheter was inserted into the biliary tract through the mesh of the endoscopic ultrasound-guided hepaticogastrostomy stent. b Obstruction of the stent was apparent (arrow). c The novel uncovered self-expandable metal stent delivery system was inserted across the stricture site into the biliary tract. d Stent deployment was successfully performed. B Video 1 b The novel uncovered self-expandable metal stent delivery system was inserted into the biliary tract through the mesh of an endoscopic ultrasound-guided hepaticogastrostomy stent. As the diameter of the stent delivery system is only 5.4 Fr and the tip is extremely tapered, stent delivery is performed by insertion along a guidewire. [Extracted from the article]

A cholangioscope inserted before intraductal RFA to prevent bile duct perforation revealed a tumor in the bile duct (Fig. 3 Cholangiography views. a The dilated bile duct after radiofrequency ablation. b Deployment of multiple uncovered self-expandable metal stents was easily achieved using the stent-in-stent technique. 2018, 15, 722 - 727 4 Chahal P., Baron T. H. Expandable metal stents for endoscopic bilateral stent-within-stent placement for malignant hilar biliary obstruction. [Extracted from the article]

The article presents a case study of a 48-year-old man with huge pancreatic duct stone and obstructive jaundice, the patient was performed with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided rendezvous method along with antegrade electrohydraulic lithotripsy.

The article focuses on the procedure of endoscopic retrograde cholangiopancreatography (ERCP) used under the pancreatic duct drainage guided with endoscopic ultrasound and fine-gauge balloon catherer for the treatment of chronic pancreatitis.

The article presents a case study of a 82-year-old woman with hepatic hilar carcinoma who had been treated using several metal stents 6 months previously was admitted with obstructive jaundice. It discusses that computed tomography imaging indicated stent obstruction and the endoscopic retrograde cholangiopancreatography showed obstruction in the hepatic bile ducts and subsequent treatment provided to the patient.