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Background: EUS-guided hepaticogastrostomy (EUS-HGS) is a recognized second-line strategy for biliary drainage when endoscopic retrograde cholangiopancreatography fails or is impossible. Substantial technical and procedural progress in performing EUS-HGS has been achieved. The present study wanted to analyze whether growing experience in current practice has changed patient outcomes over time., Methods: We retrospectively analyzed data from patients with malignant biliary obstruction treated by EUS-HGS between 2002 and 2018 at a tertiary referral center., Results: A total of 205 patients were included (104 male; mean age 68 years). Clinical success was achieved in 93% of patients with available 30-days follow-up (153), and the rate of procedure-related morbidity and mortality after one month was 18% and 5%, respectively. The cumulative sum (CUSUM) learning curve suggests a slight improvement in the rate of early complications during the second learning phase (23% vs 32%; P = 0.14; including death for any cause and intensive care). However, a significant threshold of early complications could not be determined. Recurrent biliary stent occlusion is the main cause for endoscopic reintervention (47/130; 37%)., Conclusion: The rate of procedure-related complications after EUS-HGS has improved over time. However, the overall morbidity rate remains high, emphasizing the importance of dedicated expertise, appropriate patient selection and multidisciplinary discussion., Competing Interests: Declaration of Competing Interest We disclose the following conflicts of interest or financial supports: M Marx: fellowship in advanced endoscopy supported by Boston Scientific JP Ratone: training with Cook, clinical trial with Pentax S Godat: research grant Boston Scientific The other authors have no conflicts of interest to declare., (Copyright © 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma)., Methods: Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70 μm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection)., Results: No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20 μm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20 μm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%., Conclusion: This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.

Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) access to the biliary tract is sometimes impossible and percutaneous access has the disadvantages of increased morbidity and patient discomfort. We present our first results with an alternative technique: endoscopic ultrasonography (EUS)-guided transgastric biliary drainage., Patients and Methods: 11 patients (7 men, mean age 64 years) were referred for failed ERCP and biliary obstruction (malignancy n = 8, benign conditions n = 3). The retrograde approach via the papilla had been impossible due to surgical anatomy, duodenal stenosis, and hilar stricture with occlusion of the left side. EUS-guided drainage was done with endoscopic and fluoroscopic monitoring. After puncture of the left biliary duct a guide wire was inserted into it followed by tract dilation using a cystostome. A plastic or a metallic stent was placed through this gastrobiliary fistula for bile drainage., Results: EUS-guided left hepaticogastrostomy was successfully performed in 10/11 cases, with one failure of guide wire insertion after puncture. Plastic and covered metal stents were inserted in seven and three patients, respectively. Complications in the plastic stent group included one early occlusion requiring stent replacement, and one transient ileus. In the metallic stent group there was one bilioma and one cholangitis, due to stent shortening. Clinically, the stent was efficacious in all 10 cases; during a mean follow-up of 213 days (range 3-610), two patients presented with stent occlusion and one with stent migration, with successful endoscopic treatment in all., Conclusions: EUS-guided hepaticogastrostomy is an efficient technique and could be a future alternative to percutaneous biliary drainage or palliative surgical drainage.

A palliative hepaticogastrostomy was performed under endoscopic ultrasound guidance in a patient with inoperable hepatic hilar obstruction, creating an anastomosis between the dilated left hepatic duct and the stomach, to relieve symptoms of cholangitis and to allow biliary drainage. This therapeutic procedure was used as an alternative method of drainage of the biliary tree because endoscopic retrograde cholangiopancreatography was not possible and because the percutaneous metallic stent which had been inserted earlier had become occluded (probably by tumor overgrowth). It was a two-step procedure. In the first step a hepatic duct was punctured through the gastric wall with placement of a plastic stent, which created a fistula between them. In a second step a covered, metallic, self-expandable stent was substituted for the plastic stent to maintain the anastomosis and to improve patency over the medium term. The patient's fever was relieved and the bilirubin level fell; the patient remained asymptomatic at the five-months-follow-up.

Endoscopic biliary stenting is the most common method of treating obstructive jaundice. We present a new technique of biliary drainage using endoscopic ultrasound (EUS) and EUS-guided puncture of the common bile duct (CBD). A 56-year-old man with obstructive jaundice was referred for EUS and endoscopic retrograde cholangiopancreatography (ERCP) because a computed tomography (CT) scan had shown a pancreatic mass in the head of the pancreas and a dilated CBD. The patient was enrolled in a preoperative chemoradiotherapy protocol and biliary stenting was required. Deep cannulation was not obtained even after a precut and the procedure was stopped. Using a therapeutic EUS scope (FG 38X Pentax), the CBD was punctured with a 5-F needle-knife under EUS guidance and a cholangiogram was obtained. A 0.35-inch guide wire was introduced into the CBD. The EUS scope was removed and a duodenoscope was introduced, allowing the placement through the duodenum of a 10-F plastic stent. The CBD was drained properly. No complication occurred.

Abstract: We report the case of a 60-year-old-woman with a myeloma who was hospitalized with a cholestasis. An endoscopic retrograde cholangiopancreatography was scheduled under general anaesthesia with oral intubation. As the biliary prothesis was placed an air embolism happened. The symptomatic treatment allowed a complete recovery. This complication is rare. The pathophysiology is not well known, we discuss the possible mechanisms. [Copyright &y& Elsevier]