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Background and Aim: Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO., Methods: This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS)., Results: From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002)., Conclusions: Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs., Competing Interests: Declarations. Conflict of interest: F. M. F. is a consultant for Olympus, Boston Scientific, Cook Medical, and Medtronic. The remaining authors have no conflicts of interest to disclose., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aims: Endoscopic drainage of malignant biliary obstruction using metal stents is widely used to treat obstructive jaundice. However, the occurrence of stent occlusion or migration raises the hypothesis using stents with larger diameters may be associated with better outcomes., Methods: PubMed, Embase, and Cochrane databases were systematically searched for studies comparing 10-mm vs. 12-mm covered metallic stents for recurrent unresectable biliary obstruction. The primary outcomes were recurrent biliary obstruction (RBO) and time to RBO (TRBO). Statistical analyses were performed using R software version 4.3.1. The risk ratio (RR) was used for binary outcomes, with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I2 statistics., Results: We included five studies-one randomized clinical trial and four cohort studies-totaling 520 patients. Among these, 280 received 10-mm stents, while 240 were treated with 12-mm stents. The 12-mm stent is associated with a greater TRBO (HR 1.72; 95% CI 1.36 to 2.18), lower incidence of RBO (RR 0.59; 95% CI 0.44 to 0.78; I2=34%), and stent obstruction (RR 0.52; 95% CI 0.34 to 0.81; I2=33%). No significant differences were found for stent migration and adverse events rate between groups., Conclusion: The 12-mm metallic stents significantly increase stent patency and reduce the incidence of RBO and stent obstruction in managing recurrent unresectable biliary obstruction, with no differences regarding stent migration and adverse events compared to 10-mm stents., Competing Interests: Declarations. Conflict of interest: All authors report no relationships that could be construed as a conflict of interest. Ethical approval: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. This study provides all generated and analyzed data., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Percutaneous liver biopsy (PC-LB) has long been the usual method for acquisition of liver tissue. Recently, endoscopic ultrasound-guided liver biopsy (EUS-LB) has gained popularity as an alternative modality. We aimed to compare the efficacy and safety of EUS-LB versus PC-LB., Methods: We systematically searched PubMed, Embase, and the Cochrane Library databases for randomized controlled trials (RCTs) comparing EUS-LB with PC-LB published until October 20, 2023. The primary outcome was diagnostic adequacy. Secondary outcomes were: the number of complete portal tracts (CPTs), longest sample length (LSL), total sample length (TSL), post-procedure pain scores, and adverse events (AEs), including overall AEs and AEs excluding minor post-procedure symptoms. We compared binary outcomes using risk ratios (RRs) and continuous outcomes using the mean difference (MD) or standardized mean difference (SMD), with 95%CIs., Results: Four RCTs (258 patients) were included. The EUS-LB group presented lower post-procedure pain scores (SMD -0.58, 95%CI -0.95 to -0.22) than the PC-LB group. Both groups performed similarly in terms of diagnostic adequacy (RR 1.0, 95%CI 0.96 to 1.04), number of CPTs (MD 2.57, 95%CI -4.09 to 9.22), LSL (MD -2.91 mm, 95%CI -5.86 to 0.03), TSL (MD 4.16 mm, 95%CI -10.12 to 18.45), overall AEs (RR 0.54, 95%CI 0.20 to 1.46), and AEs excluding minor post-procedure symptoms (RR 1.65, 95%CI 0.21 to 13.02)., Conclusions: This meta-analysis suggests that EUS-LB is as safe and effective as PC-LB and is associated with lower post-procedure pain scores.Registration on PROSPERO: CRD42023469469., Competing Interests: F. Maluf-Filho has served on the advisory boards of Boston Scientific, Olympus, Medtronic, and Cook in the past 3 years. P.A. do Espirito Santo, G.C. Meine, A.L. Nau, E.C. Barbosa, S. Baraldo, and L. Lenz declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aim: Malignant hilar obstruction usually presents in advanced-stage disease with a poor prognosis. Effective biliary drainage is essential for the beginning of palliative chemotherapy. There is a debate on the amount of liver parenchyma that should be drained to achieve clinical success. This study aimed to correlate the volume of liver drained with clinical success rate., Methods: The authors conducted a retrospective study including patients with malignant hilar biliary obstruction who underwent retrograde endoscopic cholangiography for biliary drainage from January 2014 to December 2018. The main outcome was a correlation of clinical success rate with hepatic volume drained. Secondary outcomes were correlation of clinical success rate with the quantity of liver sectors drained and unilateral versus bilateral drainage., Results: 82 patients met inclusion criteria (58.5 % female), with a mean age of 60±13 years. The main cause of hilar obstruction was cholangiocarcinoma (32.9 %) followed by lymph node metastasis (23.2 %). Technical success was achieved in 75 patients (91.5 %), and clinical success in 45 patients (60 %). The authors found a significant correlation between clinical success rate when at least 50 % of viable parenchyma was drained (p = 0.016; OR = 4.15, 95 % CI 1.4-12.5). Considering liver sectors, higher clinical success rates were found when at least 2 sectors were drained (p < 0.001; OR = 8.50, 95 % CI 2.7-26.7). The correlation between unilateral versus bilateral drainage and clinical success was not statistically significant., Conclusion: Drainage of at least 50 % of volume hepatic parenchyma was associated with better outcomes as well as drainage of at least 2 hepatic sectors, regardless of if unilateral or bilateral., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: R. Nobre, Y. Okubo: nothing to declare. N. Uedo: Olympus, FUJIFILM, Boston Scientific Japan, Daiichi-Sankyo, Takeda Pharmaceutical, EA Pharma, Otsuka Pharmaceutical, AstraZeneca, Miyarisan Pharmaceutical, AI medical service. R. Ishihara: Olympus, FUJIFILM, Daiichi-Sankyo, Miyarisan Pharmaceutical, AI medical service, AstraZeneca, MSD, Ono Pharmaceutical. J. Li: Olympus, Fujifilm, and Boston Scientific. F. Maluf-Filho: Boston Scientific, Olympus, Meditronic.

This case report highlights the diagnostic challenges in distinguishing between metastatic peritoneal mesothelioma with duodenal involvement and synovial sarcoma of the duodenum, two rare and complex entities. A 59-year-old woman presented with nonspecific abdominal symptoms, and imaging revealed a heterogeneous lesion between the right hepatic lobe and duodenum. Endoscopic ultrasound-guided biopsy and subsequent histopathological analysis initially suggested synovial sarcoma, but further examination, including a FISH assay, confirmed the diagnosis of malignant peritoneal mesothelioma. This case underscores the importance of integrating detailed medical history, imaging, and advanced diagnostic techniques to achieve an accurate diagnosis in rare conditions. Early and precise identification of such diseases is crucial for appropriate therapeutic management and has significant implications for patient prognosis., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Haueisen Figueiredo Zwetkoff et al.)

Background: In the past decades, endoscopic ultrasound has developed from a diagnostic tool to a platform for many therapeutic interventions. Various technological advancements have emerged since the last Brazilian Consensus, demanding a review and update of the recommendations based on the best scientific evidence., Methods: A group of 32 renowned echoendoscopists selected eight relevant topics to be discussed to generate clinical questions. After that, a literature review was conducted to answer these questions based on the most updated evidence., Results: Thirty-three statements were formulated and voted on by the experts to reach a consensus. The Oxford System was used to grade the level of evidence., Conclusion: There is mo-derate evidence to support that the needle shape, gauge, or aspiration technique does not influence the yield of endoscopic ultrasound (EUS)-guided tissue sampling of pancreatic solid lesions. There is moderate evidence to support using EUS-TTNB of the cyst wall to differentiate between mucinous and non-mucinous cystic neoplasms. There is little evidence to support the EUS-guided treatment of gastric varices. There is a high level of evidence to support that EUS-guided biliary drainage and ERCP present similar outcomes in patients with distal malignant biliary obstruction. There is a high level of evidence for using EUS to diagnose neoplastic pancreatic cysts and detect necrosis before indicating drainage. There is moderate evidence to support EUS-GE over duodenal stent for malignant gastric outlet obstruction in patients with a life expectancy higher than 2 months. There is a high level of evidence to support the use of RFA in treating both functioning and non-functioning types of NET.

Background: The unresectable pancreatic head tumors develop obstructive jaundice and cholestasis during follow-up. Cholestasis is associated with complications and treatment options are endoscopic stenting (ES) and biliary bypass surgery (BBS)., Aims: The aim of the current study was to compare the safety and efficacy of biliary bypass surgery (BBS) and endoscopic stenting (ES) for cholestasis in advanced pancreas cancer., Methods: This is a retrospective cohort of patients with cholestasis and unresectable or metastatic pancreas cancer, treated with BBS or ES. Short and long-term outcomes were evaluated. We considered the need for hospital readmission due to biliary complications as treatment failure., Results: A total of 93 patients (BBS=43; ES=50) were included in the study. BBS was associated with a higher demand for postoperative intensive care (37 vs.10%; p=0.002, p<0.050), longer intensive care unit stay (1.44 standard deviation±2.47 vs. 0.66±2.24 days; p=0.004, p<0.050), and longer length of hospital stay (7.95±2.99 vs. 4.29±5.50 days; p<0.001, p<0.050). BBS had a higher risk for procedure-related complications (23 vs. 8%; p=0.049, p<0.050). There was no difference in overall survival between BBS and ES (p=0.089, p>0.050). ES was independently associated with a higher risk for treatment failure than BBS on multivariate analysis (hazard ratio 3.97; p=0.009, p<0.050)., Conclusions: BBS is associated with longer efficacy than ES for treating cholestasis in advanced pancreatic cancer. However, the BBS is associated with prolonged intensive care unit and hospital stays and higher demand for intensive care.

Competing Interests: Bruno Martins is a consultant for Boston Scientific, Olympus, Medtronic, and MI Tech. Manuel Pérez-Miranda is a consultant for Boston Scientific. Fauze Maluf Filho is a consultant for Olympus, Boston Scientific, and Cook. The other authors declare no conflicts of interest.

Background and Aims: Endoscopic sphincterotomy (ES) is not mandatory before biliary stenting. The impact of ES before biliary stent placement remains uncertain. Previous studies have reported that ES can increase adverse event rates by up to 4.5 times compared with no ES. We aimed to assess the occurrence of post-ERCP adverse events following biliary stent placement with and without ES., Methods: PubMed, Embase, and Cochrane databases were systematically searched for randomized controlled trials. The primary outcome was post-ERCP pancreatitis (PEP). Subgroup analyses were performed with patients undergoing biliary drainage due to obstruction, using metal stents, and using plastic stents. Secondary outcomes were postprocedural bleeding, perforation, stent/catheter occlusion, stent/catheter migration, and cholangitis. Heterogeneity was examined with I 2 statistics, and a random-effects model was used. Review Manager 5.4 was used for statistical analyses., Results: Seven RCTs with 1022 patients were included. There was no significant difference between the ES and non-ES groups (odds ratio [OR], .46; 95% CI, .19-1.09; P = .08; I 2  = 59%) regarding PEP; however, a significant difference in bleeding rates was found between groups, favoring non-ES (OR, 7.01; 95% CI, 2.24-21.99; P = .0008; I 2  = 0%). The analysis of the occurrence of cholangitis (OR, 1.25; 95% CI, .58-2.69; P = .56; I 2  = 67%), perforation (OR, 1.95; 95% CI, .07-55.73; P = .70; I 2  = 58%), stent/catheter migration (OR, 2.15; 95% CI, .61-7.57; P = 0.23; I 2 = 6%), and stent/catheter occlusion (OR, .91; 95% CI, .37-2.25; P = .84; I 2 = 0%) did not favor either group., Conclusions: Performing ES before biliary drainage does not affect the PEP rate but is associated with an increased postprocedural bleeding rate., Competing Interests: Disclosure The following author disclosed financial relationships: F. Maluf-Filho: consultant for Boston Scientific, Cook Inc, and Olympus Corporation. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Positive vertical margins (VMs) are common after endoscopic submucosal dissection (ESD) of T1b esophageal cancer (EC) and are associated with an increased risk of recurrence. Traction during ESD provides better exposure of the submucosa and may allow deeper dissection, potentially reducing the risk of positive VMs. We conducted a retrospective multicenter study to compare the proportion of resections with positive VMs in ESD performed with versus without traction in pathologically staged T1b EC., Methods: Patients who underwent ESD revealing T1b EC (squamous or adenocarcinoma) at 10 academic tertiary referral centers in the United States (n = 9) and Brazil (n = 1) were included. Demographic and clinical data were abstracted. ESD using either traction techniques (tunneling, pocket) or traction devices (clip line, traction wire) were classified as ESD with traction (Tr-ESD) and those without were classified as conventional ESD without traction. The primary outcome was a negative VM. Multivariable logistic regression was used to assess associations with negative VMs., Results: A total of 166 patients with pathologically staged T1b EC underwent Tr-ESD (n = 63; 38%) or conventional ESD without traction (n = 103; 62%). Baseline factors were comparable between both groups. On multivariable analysis, Tr-ESD was found to be independently associated with negative VMs (odds ratio, 2.25; 95% confidence interval, 1.06-4.91; P = .037) and R0 resection (odds ratio, 2.83; 95% confidence interval, 1.33-6.23; P = .008)., Conclusion: Tr-ESD seems to be associated with higher odds of negative VMs than ESD without traction for pathologically staged T1b EC, and future well-conducted prospective studies are warranted to establish the findings of the current study., Competing Interests: Disclosure The following authors disclosed financial relationships: F. Maluf-Filho: Consultant for Boston Scientific, Cook, and Olympus America. P. V. Draganov: Consultant for Boston Scientific, Cook, Medtronic, Olympus, Fujifilm, MicroTech, and Merit. M. Al-Haddad: Research support from Amplified Sciences LLC, Cook Endoscopy, and Creatics LLC; consulting and teaching for Interpace Diagnostics. N. Fukami: Consultant for Boston Scientific and Olympus America. H. Aihara: Consultant for Boston Scientific, Fujifilm Medical Systems, Medtronics, ConMed, Creo Medical and 3-D Matrix. N. R. Sharma: Consultant for Covidien, Boston Scientific, Mauna Kea Technologies, US Endoscopy, and Merck Sharp & Dohme Corporation. A. Chak: Consultant for US Endoscopy and investment interest in Lucid Diagnostics. D. Yang: Consultant for Lumendi, Boston Scientific, and Steris. R. Singh: Consultant for Exelixis and Tempus. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)