1. Long-term outcome of EUS-guided choledochoduodenostomy using a lumen-apposing metal stent for malignant distal biliary obstruction: a prospective multicenter study

Gastrointest Endosc Aug 2017


Key points:

– Endoscopic Ultrasound (EUS) guided biliary drainage is an alternative modality after failed ERCP; The procedure is nonstandardized and most devices are being used in an off-label manner.

– Lumen-apposing metal stents (LAMS) originally designed to drain pancreatic fluid collections, can be used in biliary drainage;
– In this study the authors prospectively evaluated outcomes in 19 patients with unresectable cancers who underwent EUS-guided biliary drainage using a fully-covered LAMS with a cautery-enhanced delivery system at five centers in Japan and Hong Kong after failed ERCP;
– All LAMS were successfully deployed without complications;
– During follow-up (median ~5months):
Jaundice improved in 18 patients (95%) by the end of follow-up;
Five patients had recurrence of biliary obstruction;

Five patients developed gastric outlet obstruction in the second part of the duodenum;
The overall complication rate was 37%;



EUS-guided choledochoduodenostomy (EUS-CDS) using conventional tubular stents has been successfully performed. However, EUS-CDS carries a high risk of bile leakage with attendant adverse events. This study aimed to prospectively evaluate the long-term outcome of EUS-CDS using a dedicated lumen-apposing metal stent (LAMS).


Nineteen patients (mean age, 70.6 years; 12 men) with unresectable malignant diseases were treated in 5 tertiary referral centers. EUS-CDS was performed using a fully covered LAMS with a cautery-enhanced delivery system for EUS-CDS.


All stents were successfully deployed without any adverse event. Jaundice improved in 79% of the patients within 7 days and finally in 95%. In 95% of the patients, the stents remained in good anastomotic position without migration or dislocation during the follow-up period (median, 184 days; range, 12-819 days). One patient had a fever the day after the stent placement. During the follow-up period, 5 patients had secondary stent obstruction because of a food residue (n = 2), kinking (n = 1), suspected tumor ingrowth (n = 1), and spontaneous dislodgement (n = 1). Five patients developed obstruction in the second portion of the duodenum. The overall adverse event rate was 36.8% (7/19) mostly with mild severity.

This study revealed that the novel dedicated LAMS used has high technical and clinical success rates for EUS-CDS. The adverse events and patency rates are inferior to the historically reported data of a conventional transpapillary metal stent. Development of a more suitable dedicated LAMS is anticipated.


2. Metal Stents versus Plastic Stents for the Management of Pancreatic Walled-off Necrosis: a Systematic Review and Meta-Analysis
Gastrointest Endosc Aug 2017


Key points:
• Endoscopic transluminal drainage of symptomatic walled-off necrosis (WON) has become popular;
• Stents are used to maintain patency of drainage sites but the choice of the best type of stent remains undefined; Plastic stents are inexpensive but cumbersome when compared with metal stents;
• In this meta-analysis (data from 41 studies, more than 2000 patients), the authors compared the efficacy of plastic and metal stents for draining WON;
• This meta-analysis showed that the use of metal stents results in more WON resolutions, with fewer interventions and less adverse events compared with plastic stents;




Endoscopic transluminal drainage of symptomatic walled-off necrosis (WON) is a good management option, although the optimal choice of drainage site stent is unclear. We performed a systematic review and meta-analysis to compare metal stents (MSs) and plastic stents (PSs) in terms of WON resolution, likelihood of resolution after one procedure, and adverse events.


An expert librarian queried several databases to identify studies that assessed WON management, and selection was according to a priori criteria. Publication bias, heterogeneity, and study quality were evaluated with the appropriate tools. We performed single and two-arm meta-analyses for non-comparative and comparative studies using event rate random-effects model, and odds ratio/different in means, respectively.


We included 41 studies involving 2213 patients. In 2-arm studies meta-analysis, WON resolution was more likely with MSs compared with PSs (OR, 2.8; 95% CI, 1.7-4.6; p<0.001). Resolution with a single endoscopic procedure was similar between stents (47% vs 44%), although, for those cases requiring more than one intervention, the MS group had fewer interventions, favored by a mean difference of -0.9 procedures (95% CI, -1.283 to 0.561). In single-arm studies meta-analysis, when compared with PSs, MS use was associated with lower bleeding (5.6% vs 12.6%; p=0.02), a trend toward lower perforation and stent occlusion (2.8% vs 4.3%; p= 0.2, and 9.5% vs 17.4%; p=0.07), although with higher migration (8.1% vs 5.1%; p=0.1).


Evidence suggests that MSs are superior for WON resolution, with fewer bleeding events, trend toward less occlusion and perforation rate but increased migration rate compared with PS.


3. Comparison of Submucosal Tunneling Biopsy Versus EUS-Guided FNA for Gastric Subepithelial Lesions: A Prospective Study With Crossover Design.
Endosc Int Open Aug 2017


Key points:
– EUS is a key procedure in evaluation of GI subepithelial lesions (SELs) but morphologic features alone have limited specificity; Several tissue sampling methods have been proposed but have a low diagnostic yield;
– Submucosal tunneling biopsy (STB) is a novel sampling method to obtain core biopsy specimens from SELs;
– The authors enrolled 43 patients with gastric SELs and compared the diagnostic yield and safety of STB versus EUS-FNA;
– The diagnostic yield was significantly higher for STB than for FNA, especially for SELs <2cm, without procedure-related complications but the procedure time was more than twice as long as that for FNA and with higher costs;




Endoscopic ultrasound-guided fine needle aspiration (FNA) for gastrointestinal subepithelial lesions (SELs) has limited diagnostic accuracy due to technical problems and small lesion size. We previously reported a novel submucosal tunneling biopsy (STB) technique for sampling SELs. This study aimed to evaluate the diagnostic ability and safety of STB compared to that of FNA for SELs..


The study was a non-randomized, prospective comparative study with crossover design in patients with endoluminal gastric SELs. Forty-three patients, including 29 cases with lesions < 2 cm were enrolled. A crossover design with 2 intervention stages (Group A: FNA followed by STB for 23 SELs, Group B: STB followed by FNA for 20 SELs) was implemented. The primary outcome was the diagnostic yield (DY). Secondary outcomes were technical success rate, procedure time, complication rate, and sample quality.


The DY of STB was significantly higher than that of FNA (100 % vs. 34.8 %; P  < 0.0001) in group A, including 100 % in overall STB. The technical success rate of STB was significantly higher than that of FNA (100 % vs. 56.5 %; P  = 0.0006), whereas the median procedure time of STB was significantly longer than that of FNA (37 minutes vs. 18 minutes; P  < 0.0001). The median specimen area of STB samples was markedly larger than that of FNA samples (5.54 mm 2 vs. 0.69 mm 2 ; P  < 0.001). No complications occurred in either method.

STB had significantly superior diagnostic ability and a more adequate sample quality than FNA for endoluminal gastric SELs, indicating the suitability of STB for small SELs.


4. Long-term outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts
Endoscopy, Sept 2017


Key points:
– This single-center, prospective study of 164 asymptomatic patients with a pancreatic cyst neoplasm demonstrates a durable, long-term effect of EUS-guided cyst ablation with ethanol and paclitaxel (6mg/mL).
– Of the 114 patients (72%) in whom a complete cyst ablation was achieved, only two (1.7%) had cyst recurrence during a median follow-up of 72 months.
– Pancreatic cyst ablation may become an acceptable alternative to surgery or observation for selected pancreatic cystic neoplasms.


Background and study aims:
The aim of this study was to investigate the long-term outcomes after endoscopic ultrasound (EUS)-guided pancreatic cyst ablation.
Patients and methods:
In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts; clinically indeterminate cysts that required EUS fine-needle aspiration; and/or cysts that grew during the observation period. Treatment response was classified as complete resolution, partial resolution, or persistent cyst, with < 5 %, 5 % - 25 %, and 25 % of the original cyst volume, respectively.
The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8 %) had adverse events (1 severe, 4 moderate, and 11 mild). Treatment response was as follows: complete resolution in 114 (72.2 %), partial resolution in 31 (19.6 %), and persistent cysts in 13 (8.2 %). Twelve of the 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50 - 85 months) of the 114 patients with complete resolution, only two patients (1.7 %) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio 7.12, 95 % confidence interval 2.72 - 18.67) and cyst size less than 35 mm (OR 2.39, 95 %CI 1.11 - 5.16) predicted complete resolution.
Among patients with pancreatic cysts in whom complete resolution was achieved after EUS-guided cyst ablation, 98.3 % remained in remission at 6-year follow-up. Unilocular form and small cyst size were predictive of complete resolution. This treatment approach may be an effective and durable alternative to surgery.