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Objectives Methods Results Conclusion Endoscopic ultrasound‐directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is proposed as a less invasive alternative to laparoscopy‐assisted ERCP. However, postponing ERCP for 1–2 weeks to reduce the risk of lumen‐apposing metal stent (LAMS) migration may not be practical in urgent cases such as cholangitis, leading to increased procedural burden. This study aimed to assess the feasibility and safety of a single‐session EDGE utilizing a dedicated over‐the‐scope fixation device.A retrospective analysis of prospectively collected data from three referral centers was performed, including consecutive single‐session EDGE procedures with the Stentfix device, utilizing only 20 × 10 mm LAMS. The primary outcome was LAMS migration, and key secondary outcomes included adverse events and technical success.Twenty patients (mean age 59 [standard deviation (SD) ± 11.3] years, 65.0% female) with a predominantly classic Roux‐en‐Y gastric bypass history (90.0%, mini‐bypass 10.0%) underwent ERCP for indications such as common bile duct stones (60.0%), cholangitis (25.0%), or biliary pancreatitis (15.0%). No LAMS migration occurred, and technical success was achieved in 95.0%. Over a median follow‐up of 102 days (interquartile range [IQR] 24.8–182), two adverse events were reported (10.0%), comprising postprocedural pain (grade I) and post‐ERCP pancreatitis (grade II).While acknowledging potential contributions from LAMS orientation and stent caliber, our data suggest that utilizing a dedicated over‐the‐scope stent fixation device may effectively prevent LAMS migration during single‐session EDGE without the need for endoscopic suturing. [ABSTRACT FROM AUTHOR]

Despite a growing body of evidence, there are limited data regarding the impact of hands-on training on patient safety, with most studies of trainee performance reporting adverse events (AEs) as either a secondary outcome [8][9] or not at all [10][11]. Study groups As there is significant variation in training programs and credentialing across European centers, trainees were defined as endoscopists who had performed fewer than 200 ERCP procedures independently and were working under the direct supervision of an experienced endoscopist (> 1000 ERCP procedures). Graph Introduction Endoscopic retrograde cholangiopancreatography (ERCP) remains one of the most challenging endoscopic procedures to master, as it is both technically demanding and incurs significant risk [1]. [Extracted from the article]

Objectives: Both clinical experience and supporting data have improved drastically in the context of endoscopic ultrasound‐guided gastrointestinal anastomosis (EUS‐GIA). Where outcomes used to be questioned, focus has now moved towards performing comparative studies, optimizing technical approaches, improving patient selection, and developing well‐defined treatment algorithms. Methods: The purpose of this review is to provide an overview of technical developments within EUS‐GIA and to discuss the current status of EUS‐GIA and future directions. Results: EUS‐GIA techniques such as EUS‐guided gastroenterostomy (EUS‐GE), EUS‐directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and EUS‐guided treatment afferent loop syndrome have undergone further development, refining technical approaches, improving patient selection and subsequent outcomes. Retrospective evaluations of EUS‐GE have shown similar safety when compared to enteral stenting, whilst attaining surgical range efficacy. Whereas, in patients with gastric bypass anatomy, EDGE seems less cumbersome and time consuming than enteroscopy‐assisted ERCP, while preventing surgical morbidity associated with laparoscopy‐assisted ERCP. Although less evidence is available on EUS‐guided treatment of afferent loop syndrome, this technique has been associated with higher clinical success and fewer reinterventions and adverse events when compared to enteral stenting and percutaneous drainage, respectively. Several randomized studies are currently underway evaluating EUS‐GE in malignant gastric outlet obstruction (GOO), whereas more prospective data are still required on EDGE and long‐term fistula management. Conclusion: EUS‐GIA has become a crucial alternative to established techniques, overcoming technical limitations and subsequently improving patient outcomes. Although we should focus on prospective confirmation of these results in the context of GOO and EDGE, the current evidence already allows for a prominent role for EUS‐GIA in our everyday practice. Watch a video of this article. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic ultrasound‐guided digestive anastomosis (EUS‐A) is a new alternative under evaluation in patients presenting with afferent limb syndrome (ALS) after Whipple surgery. The aim of the present study is to analyze the safety and effectiveness of EUS‐A in ALS. Methods: This is an observational multicenter study. All patients ≥18 years old with previous Whipple surgery presenting with ALS who underwent an EUS‐A using a lumen‐apposing metal stent (LAMS) between 2015 and 2021 were included. The primary outcome was clinical success, defined as resolution of the ALS or ALS‐related cholangitis. Furthermore, technical success, adverse event rate, and mortality were evaluated. Results: Forty‐five patients (mean age: 65.5 ± 10.2 years; 44.4% male) were included. The most common underlying disease was pancreatic cancer (68.9%). EUS‐A was performed at a median of 6 weeks after local tumor recurrence. The most common approach used was the direct/freehand technique (66.7%). Technical success was achieved in 95.6%, with no differences between large (≥15 mm) and small LAMS (97.4% vs. 100%, P = 0.664). Clinical success was retained in 91.1% of patients. A complementary treatment by dilation of the stent followed by endoscopic retrograde cholangiopancreatography through the LAMS was performed in three cases (6.7%). There were six recurrent episodes of cholangitis (14.6%) and two procedure‐related adverse events (4.4%) after a median follow‐up of 4 months. Twenty‐six patients (57.8%) died during the follow‐up due to disease progression. Conclusion: EUS‐A is a safe and effective technique in the treatment of malignant ALS, achieving high clinical success with an acceptable recurrence rate. [ABSTRACT FROM AUTHOR]

Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUSguided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancerrelated symptoms. [ABSTRACT FROM AUTHOR]

1:  ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence. 2:  ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence. 3:  ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence. 4:  ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence. 5:  ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence. 6:  ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence. 7:  ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence. 8:  ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence. [ABSTRACT FROM AUTHOR]

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence. [ABSTRACT FROM AUTHOR]

Background: The unprecedented situation caused by the coronavirus disease 2019 (COVID-19) pandemic has profoundly affected endoscopic practice in regard to access, volume, and workflow. We aimed to assess the potential changes in the technical outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures carried out in patients with confirmed SARS-CoV-2 infection. Methods: We conducted an international, multicenter, retrospective, matched case-control study of ERCP procedures carried out in patients with confirmed COVID-19. The main outcome was technical success of the procedure as assessed by the endoscopist, and the secondary outcome was the development of procedure-related adverse events. Each case was matched in a 1:4 ratio with controls extracted from each center's database in order to identify relevant changes in outcome measures compared with the pre-pandemic era. Results: Eighteen procedures performed in 16 COVID-19 patients [14 men, 65 years (9–82)] and 67 controls were included in the final analysis. Technical success was achieved in 14/18 COVID-19 cases, which was significantly lower as compared with the control group (14/18 versus 64/67, p = 0.034), with an endoscopic reintervention required in 9/18 cases. However, the rate of procedure-related adverse events was low in both groups (1/18 versus 10/67, p = 0.44). On multivariable analysis, COVID-19 status remained the only risk factor for technical failure of the procedure [odds ratio of 19.9 (95% confidence interval 1.4–269.0)]. Conclusions: The COVID-19 pandemic has affected the volume and practice of ERCP, resulting in lower technical success rates without significantly impacting patient safety. Prioritizing cases and following recommendations on safety measures can ensure good outcome with minimal risk in dedicated centers. [ABSTRACT FROM AUTHOR]

3 Fluoroscopic image revealing distal migration of the self-expandable metal stent (SEMS) into the small bowel lumen, while another fully covered SEMS is being placed into the left bile duct, creating an EUS-guided hepaticogastrostomy. Both the migrated SEMS and double-pigtail stent were scheduled for double-balloon enteroscopy-assisted retrieval after completion of endoscopic biliary leak treatment. With the left-sided bile duct dilation and surgically altered anatomy in mind, EUS-guided antegrade stenting was attempted. [Extracted from the article]

Right: side-viewing duodenoscopic image, showing the sessile pseudopolyp after luxating it out of the bile duct by means of an extraction balloon. gl GLO:FR0/01jul21:den13991-fig-0002.jpg PHOTO (COLOR): 2 Left: digital cholangioscopic image, revealing the polyp in the distal common bile duct after large balloon dilation (15 mm) and retracting it outside of the bile duct using the dedicated cholangioscopy snare. Abdominal computed tomography (CT) revealed predominantly extrahepatic bile duct dilation, after which endoscopic ultrasound (EUS) was performed, identifying a sessile obstructive intraductal lesion (Fig. Digital single-operator cholangioscopy (DSOC) has revolutionized the endoscopic diagnosis and treatment of various hepato-pancreaticobiliary diseases, such as indeterminate biliary strictures and large balloon dilation-refractory common bile duct (CBD) stones, using either a retrograde or antegrade approach.1,2 Direct visualization provided by DSOC has furthermore paved the road towards minimally invasive treatment of intraductal neoplasms, although little evidence is available in this specific context. [Extracted from the article]