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Objectives

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is usually performed for unresectable malignant distal biliary obstruction (MDBO) when endoscopic retrograde cholangiopancreatography-guided biliary stenting with fully covered self-expandable metallic stents (EBS-MSs) fails. We aimed to clarify the clinical outcomes of EUS-HGS with plastic stents (HGS-PSs) compared to EBS-MS.

Methods

We retrospectively reviewed patients who underwent either HGS-PS with or without antegrade stenting using MS (AS-MS) or EBS-MS as initial biliary drainage for unresectable MDBO between January 2017 and July 2024.

Results

A total of 27 patients were included in the HGS-PS group, and 128 patients were included in the EBS-MS group. Median procedure time was significantly shorter for the HGS-PS group (24 vs. 39 min, p < 0.001), and the incidence of adverse events was comparable (22% vs. 32%, p = 0.365). The HGS-PS group had a significantly higher recurrent biliary obstruction (RBO) rate (48% vs. 26%, p = 0.002) and shorter time to RBO (TRBO) (169 vs. 341 days, p = 0.001). After propensity score matching, no significant differences were observed in either the RBO rate or TRBO. Subgroup analyses showed that TRBO was comparable between the HGS-PS with AS-MS and EBS-MS groups (273 vs. 341 days, p = 0.609).

Conclusions

Although TRBO tended to be shorter for HGS-PS compared to EBS-MS, the addition of AS-MS to HGS-PS led to comparable TRBO, suggesting that this combination may be a viable alternative.

Clinical Trial Registration: The authors have confirmed clinical trial registration is not needed for this submission.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of biliary diseases. Successful biliary cannulation is the first step. Advanced cannulation techniques, such as the double-guidewire technique (DGW), precut techniques, and endoscopic ultrasound (EUS)-guided rendezvous (RV), have been developed to improve cannulation success. However, comprehensive evaluations of a structured cannulation algorithm remain limited.

Aims

To evaluate the status of biliary cannulation and associated adverse events (AEs) using a stepwise cannulation algorithm.

Methods

A retrospective evaluation of 1,000 consecutive patients with a naïve papilla who underwent ERCP for biliary disease was performed between 2012 and 2022. Biliary cannulation was attempted using a stepwise algorithm, beginning with wire-loaded cannulation (WLC), followed by DGW, precut techniques, and EUS-RV. The primary endpoint was overall technical success; secondary endpoints included AEs, incidence of post-ERCP pancreatitis (PEP), and risk factor analysis.

Results

Initial WLC achieved selective biliary cannulation in 69.2% of cases. Salvage techniques achieved high success rates: DGW (74.9%), precut techniques (77.6%), and EUS-RV (97.0%). Overall, the final cannulation success rate was 97.8%. The overall AE rate was 7.5%, with PEP being the most common (6.1%). AEs were significantly more frequent in advanced cannulation techniques than WLC (13.3% vs. 5.2%, p < 0.001). Multivariate analysis identified advanced cannulation techniques, pancreatography, and metallic stent placement as independent factors increasing the risk of PEP.

Conclusion

A structured stepwise approach achieves very high biliary cannulation success in patients with a naïve papilla, though advanced cannulation techniques increase AE risk. Appropriate timing and positioning of EUS-RV may further optimize safety and efficacy in biliary cannulation.

Objectives

Anastomotic biliary stricture (ABS) is a common complication following living donor liver transplantation (LDLT). Although plastic stents (PSs) have traditionally been the standard treatment, fully covered self-expandable metal stents (FCSEMSs) have recently gained attention because of their potential advantages. This study aimed to retrospectively analyze cases of ABS after LDLT that were treated with intraductal FCSEMSs (ID-FCSEMS) at our institution.

Methods

This study included 46 adult patients who developed anastomotic bile duct stricture following LDLT. Twenty patients underwent ID-FCSEMS placement, and 22 patients underwent PS placement. The FCSEMSs were scheduled for removal after 16 weeks.

Results

Placement of FCSEMSs was technically successful in all 20 patients. Early complications included cholangitis in five patients, whereas late complications included one case of stent migration and one case of obstructive cholangitis. Clinical success was achieved in 16 patients. Restenosis occurred in two patients. No significant differences were found between the FCSEMS group and the PS group in terms of reimbursement points (as defined by the Japanese medical fee schedule), number of hospitalizations, and total inpatient days.

Conclusions

ID-FCSEMSs demonstrate a high success rate and favorable long-term outcomes for ABS after LDLT. Although no significant difference in cost reduction is observed, ID-FCSEMSs are a safe and effective therapeutic option for ABS.

Objectives

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is an adverse event of ERCP-related procedures. The present study aimed to evaluate the incidence of PEP in patients with an intact papilla who underwent ERCP for common bile duct stones and identify risk factors and preventive measures for PEP.

Methods

Between April 2017 and March 2018, ERCP-related procedures were performed in 16,032 patients with an intact papilla at 36 institutions affiliated with the Bilio-pancreatic Study Group of West Japan. Of these, 3739 were prospectively enrolled to investigate adverse events of ERCP-related procedures targeting the biliary tract; the present study included 2106 patients with common bile duct stones.

Results

PEP occurred in 132 patients (6.3%), and its severity was graded as mild (n = 104), moderate (n = 17), and severe (n = 11). Multivariable analysis identified the followin significant risk factors for PEP: age <50 years, female sex, wire-guided biliary cannulation, pancreatic guidewire-assisted biliary cannulation, biliary cannulation attempt duration ≥10 min, and total procedure time ≥60 min. Only pancreatic stenting was a preventive factor for PEP.

Conclusions

To prevent PEP, it is necessary to avoid guidewire insertion into the pancreatic duct, prolonged biliary cannulation attempts, and long ERCP procedure time, regardless of biliary cannulation with or without guidewire assistance. When a guidewire is inserted into the pancreatic duct in patients at high risk of PEP, pancreatic stenting should be considered.

Objectives

Self-expandable metal stents (SEMS) may become embedded because of tissue hyperplasia or tumor ingrowth, making their removal challenging. The stent-in-stent (SIS) method, which involves placing another SEMS inside to compress the tissue and aid removal, is a known rescue approach for stent removal. However, its efficacy across anatomical routes, optimal timing of removal, and predictors of difficult stent removal remain unclear.

Methods

We retrospectively reviewed 17 patients treated between April 2018 and May 2025. Embedded stents were placed via the transpapillary route, endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS), or choledochojejunal anastomosis. Technical success rates and adverse events were evaluated.

Results

The overall technical success rate was 76.5%, with rates of 80.0%, 100%, and 33.3% for the transpapillary route, EUS-HGS, and choledochojejunal anastomosis, respectively. Three of the four failures occurred when removal was attempted within 4 weeks of the second stent placement. Stent removal was successful in 100% of the hyperplasia cases but in 60% of the ingrowth cases. Cholecystitis occurred in one case after the second stent placement.

Conclusions

The SIS method is feasible for the transpapillary route and EUS-HGS but may show limited efficacy in choledochojejunal anastomosis. Stent removal 4 weeks after the second stent placement improves the success rate. The SIS method may be less effective in cases of malignant ingrowth.

Objectives

Regular exchange of percutaneous endoscopic gastrostomy (PEG) catheters is crucial for preventing infection and maintaining function; however, procedure-related complications and patient discomfort remain major concerns. This study aimed to compare the clinical outcomes of the conventional Ideal Button with those of the newly developed Ideal Button ZERO (Olympus Corporation).

Methods

In this retrospective observational study, we included 82 PEG catheter exchange procedures, performed in 42 patients. Because some patients underwent repeated exchanges, analyses were conducted on a per-procedure basis. Patients were categorized into two groups: Group N (conventional to conventional Ideal Button exchange, n = 33) and Group Z (exchange to Ideal Button ZERO, n = 49). Group Z was further subdivided into subgroups Z1 (conventional to ZERO, n = 29) and Z2 (ZERO to ZERO, n = 20). The outcomes included the procedure time, complication rates (procedure-related and postoperative), and family satisfaction score.

Results

Procedure-related complications occurred only in Group Z (0/33 vs. 6/49; 0% vs. 12.2%) (p = 0.076). Postoperative complication rates were similar between the groups (Group N 6/33 [18.2%] vs. Group Z 9/49 [18.4%], p = 1.00). However, procedure time was shorter in Group Z than in Group N (8.24 ± 5.21 vs. 6.14 ± 4.28 min, p = 0.049). Family satisfaction scores showed no significant differences between the groups (Group N: 3.88 ± 1.52 vs. Group Z: 3.94 ± 1.39, p = 0.854).

Conclusions

The new Ideal Button ZERO showed a reduced procedure time; however, it revealed a trend toward higher procedure-related complications without clear superiority over conventional devices. Improved proficiency with the new device may reduce complication rates, warranting further investigation as its adoption increases.

Trial Registration

2025-047