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Competing Interests: Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic, and M.I.Tech.

Background: Post-cholecystectomy transected bile ducts (TBDs) are not amenable to standard endoscopic management. Combined ERCP and endosonography (CERES) including EUS-guided hepaticoenterostomy enhance therapeutic biliary endoscopy. CERES treatment of post-cholecystectomy TBDs is evaluated., Methods: Among 165 consecutive patients who underwent ERCP for post-cholecystectomy bile duct injury (Amsterdam A/B/C/D grades [%] = 47/30/7/16) between January 2009-November 2020 at a tertiary-care center, 10/26 (38%) with TBDs (6 female; 32-92 years old) underwent CERES before attempted endoscopic repair (staged CERES, n = 7) or surgical repair (preoperative CERES, n = 1), or as destination therapy (definitive CERES, n = 2). Short-term clinical success rate, final clinical success rate and comprehensive complication index (CCI) were retrospectively determined. Additionally, number of follow-up procedures, adverse events, recurrences, final patency grades and definitive cure rate were determined in patients with staged CERES., Results: Index CERES (hepaticogastrostomy, 60%; hepaticoduodenostomy, 40%) achieved bile leak and jaundice resolution in 10 patients (100% short-term clinical success rate). Overall, 9/10 patients maintained good/excellent biliary drainage over a median 3.2 years without any unplanned percutaneous/surgical procedures (90% final clinical success rate; median CCI = 8.7). Staged CERES using recanalization (n = 6) or diversion (n = 1) strategies achieved Grade A patency in 5/7 (71%) patients after a median of 2 follow-up procedures over a median 12-month treatment period; 2 failed recanalization patients were salvaged by indefinite hepaticoenterostomy stent or elective surgery, respectively. Among staged CERES, 2 treatment-related cholangitis occurred (29%) and 2 recurring strictures (29%) developed over a median 8.4 year follow-up; recurring strictures were endoscopically remodeled (n = 1) or indefinitely stented (n = 1); final Grade A/B biliary patency was achieved in 5/7 (71%) and definitive cure in 4/7 (57%)., Conclusions: CERES controls acute symptoms in selected post-cholecystectomy TBD patients allowing subsequent staged endoscopic therapy. Definitive cure or long-term biliary drainage is possible in most cases and elective surgery can be facilitated in the remainder., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure., Methods: Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as "index" in patients without prior endoscopic duct access and "combined" when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates., Results: EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205])., Conclusions: EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases., Competing Interests: Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic, and M.I.Tech. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aim: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging option for acute cholecystitis in non-surgical candidates. Combining endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stones with EUS-GBD in a single session might become a non-surgical management strategy to comprehensively treat gallstone disease in selected patients., Methods: Single-center retrospective cohort study comparing outcomes between EUS-GBD alone (group A) and single-session ERCP combined with EUS-GBD (group B). Consecutive patients who underwent EUS-GBD with a lumen-apposing metal stent (LAMS) between June 2011 and August 2018 were analyzed. Exclusion criteria were subjects included in randomized clinical trials, patients who had had ERCP within 5 days of EUS-GBD, patients in whom ERCP or EUS-GBD was carried out for salvage of one or the other procedure, and patients who underwent concurrent EUS-guided biliary drainage., Results: One hundred and nine consecutive patients underwent EUS-GBD with LAMS during the study period. Seventy-one patients satisfied the inclusion criteria and 34 patients were in group A and 37 in group B. Baseline characteristics were similar in both groups. There were no significant differences in technical (97.1% vs 97.3%; P = 0.19) and clinical success rates (88.2% vs 94.6%; P = 0.42) of EUS-GBD in group A versus group B. Rate of adverse events was similar in both groups, five (14.7%) in group A versus five (13.5%) in group B., Conclusions: Single-session EUS-GBD combined with ERCP has comparable rates of technical and clinical success to EUS-GBD alone. A combined EUS-GBD and ERCP procedure does not appear to increase adverse events and makes possible comprehensive treatment of gallstone disease by purely endoscopic means., (© 2019 Japan Gastroenterological Endoscopy Society.)

EUS-guided biliary access procedures can target the gallbladder or the bile duct for drainage in selected cases. EUS-guided gallbladder drainage offers comparable results to percutaneous cholecystostomy in high-surgical risk patients with acute cholecystitis refractory to medical treatment. The procedure is not yet widely available. Novel lumen-apposing stents may improve long-term outcomes, resulting in rapid dissemination. EUS access to the bile duct is coupled with ERCP techniques into a hybrid procedure, endosono-cholangiopancreatography (ESCP). ESCP admits six variant approaches to bile duct drainage based on the combination of two access routes (intrahepatic and extrahepatic) with three drainage routes: transmural, retrograde transpapillary and antegrade transpapillary. A thousand ESCP cases have been reported to date with good outcomes. When the expertise is available, ESCP is increasingly replacing percutaneous transhepatic biliary drainage to provide biliary drainage in patients in whom ERCP is not feasible, predominantly in the setting of palliation, but not limited to it.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to gaining access to the biliary and pancreatic ductal systems. However, in a small subset of cases anatomic constraints imposed by disease states or abnormal anatomy preclude ductal access via conventional ERCP. With the advent of endoscopic ultrasonography (EUS), with its unique capabilities of accurate imaging and ductal access via transmural puncture, there is now an alternative to surgical and percutaneous radiologic approaches in situations inaccessible to ERCP: endosonographic cholangiopancreatography (ESCP). This article reviews the background, technical details, published experience, and role of ESCP in clinical practice., (Copyright © 2012 Elsevier Inc. All rights reserved.)