OBJECTIVE: Several meta-analyses have analyzed the technical and clinical success of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) by using lumen-apposing metal stents (LAMS) in malignant biliary obstruction, but those concerning adverse events (AEs) are scarce. The current systematic review and meta-analysis was conducted to evaluate the AEs after EUS-CDS with LAMS.
METHODS: A comprehensive literature search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Library was conducted for studies reporting the outcomes of EUS-CDS with LAMS. The main endpoints were the incidence of overall and specific AEs. Moreover, the stent dysfunction, and reintervention rates were evaluated independently.
RESULTS: A total of 21 studies (n = 1438) were included in the final meta-analysis. The pooled rate of technical and clinical success was 93.5% (95% confidence interval [CI]: 91.3-95.1) and 88.0% (95% CI: 83.9-91.1), respectively. After EUS-CDS with LAMS, the pooled incidence of overall AEs was 20.1% (95% CI: 16.0-24.9). The estimated rate of early AEs was 10.6% (95% CI: 7.9-14.2), and late AEs was 11.2% (95% CI: 8.2-15.2). Infection/cholangitis was the commonest AE, with a pooled incidence of 6.1% (95% CI: 3.7-10.1). The estimated incidence of stent dysfunction and reintervention was 10.5% (95% CI: 7.5-14.4), and 12.1% (95% CI: 9.3-15.7), respectively.
CONCLUSIONS: Despite with a high technical and clinical success rate, EUS-CDS with LAMS may be associated with overall AEs and stent dysfunction in one-fifth and one-tenth of cases, respectively. Further efforts are required to optimize its safety and long-term stent patency.

In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.

Cystic tumors account for 15% of pancreatic tumors. Of these, serous microcystic adenomas represent 1-2% of pancreatic exocrine neoplasms. While typically benign, a small percentage possess malignant potential. Given imaging improvements, serous cystadenomas are being identified more frequently. A 63-year-old female was admitted with complaints of jaundice and unintentional weight loss. Abdominal computed tomography scan showed a 16 cm obstructive pancreatic mass near the porta hepatis region. Endoscopic ultrasonography and fine needle aspiration biopsy indicated a large pancreatic head cystic mass favoring serous microcystadenoma causing biliary and some pyloric obstruction. Malignant potential could not be ruled out because of size and symptoms. A pylorus-preserving pancreaticoduodenectomy revealed a cystic tumor invading the pancreatic duct and adhering to the duodenum of the pancreatic head. Pathology confirmed a 15 cm benign pancreatic serous cystadenoma. Although most serous cystadenomas are benign, surgical resection was prudent given the size, symptoms, and adjacent organ involvement.

Pancreatic cancer (PC) is ranked as the 14th most common cancer and the 7th leading cause of cancer-related deaths. The most common histological type is adenocarcinoma, other type such as primary pancreatic lymphoma (PPL) still very rare. Due to the lack of specific clinical and imaging characteristics, the diagnostic of PPL remains challenging. We report 4 cases of PPL diagnosed and managed at our gastroenterology department between 2019 and 2023. Case 1: A 16-year-old male presented with abdominal pain, jaundice, and weight loss. Imaging revealed an 8 cm tumor in the pancreas, subsequent biopsies confirming Burkitt\'s lymphoma. Despite chemotherapy, the patient succumbed to the disease. Case 2: A 92-year-old female with no prior medical history presented with abdominal pain, jaundice, pruritus, and weight loss. Imaging revealed a large pancreatic mass, and biopsies identified large B-cell lymphoma. Unfortunately, the patient passed away before treatment initiation. Case 3: A 63-year-old male with a history of tobacco smoking presented with abdominal pain, weight loss, and anorexia. Imaging and biopsies confirmed diffuse large cell B-phenotype lymphoma. The patient achieved complete remission after rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone (R-CHOP) therapy. Case 4: A 67-year-old man with jaundice, abdominal pain, and weight loss was diagnosed with diffuse large cell B lymphoma through imaging and fine needle aspiration (FNA). The patient responded well to R-CHOP therapy. In conclusion, PPL is an uncommon tumor, with no specific clinical or radiological characteristics. A thorough evaluation of clinical, radiological, biological and histological data is necessary to consider it as a differential diagnosis and ensure accurate and timely management.

BACKGROUND: The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment.
METHODS: A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week.
RESULTS: 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18-98.99) and a mean clinical success of 84.96% (CI 95%, 67.99-96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12-48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA.
CONCLUSIONS: EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients.

ERCP is the first line of treatment for malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. EUS-guided gallbladder drainage (EUS-GBD) has been suggested as a rescue treatment for patients who fail EUS-BD and ERCP. In this meta-analysis, we have evaluated the efficacy and safety of EUS-GBD as a rescue treatment of malignant biliary obstruction after failed ERCP and EUS-BD. We reviewed several databases from inception to August 27, 2021, to identify studies that evaluated the efficacy and/or safety of EUS-GBD as a rescue treatment in the management of malignant biliary obstruction after failed ERCP and EUS-BD. Our outcomes of interest were clinical success, adverse events, technical success, stent dysfunction requiring intervention, and difference in mean pre- and postprocedure bilirubin. We calculated pooled rates with 95% confidence intervals (CI) for categorical variables and standardized mean difference (SMD) with 95% CI for continuous variables. We analyzed data using a random-effects model. We included five studies with 104 patients. Pooled rates (95% CI) of clinical success and adverse events were 85% (76%, 91%) and 13% (7%, 21%). Pooled rate (95% CI) for stent dysfunction requiring intervention was 9% (4%, 21%). The postprocedure mean bilirubin was significantly lower compared to preprocedure bilirubin, SMD (95% CI): -1.12 (-1.62--0.61). EUS-GBD is a safe and effective option to achieve biliary drainage after unsuccessful ERCP and EUS-BD in patients with malignant biliary obstruction.

ERCP is the first line of treatment for malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. EUS-guided gallbladder drainage (EUS-GBD) has been suggested as a rescue treatment for patients who fail EUS-BD and ERCP. In this meta-analysis, we have evaluated the efficacy and safety of EUS-GBD as a rescue treatment of malignant biliary obstruction after failed ERCP and EUS-BD. We reviewed several databases from inception to August 27, 2021, to identify studies that evaluated the efficacy and/or safety of EUS-GBD as a rescue treatment in the management of malignant biliary obstruction after failed ERCP and EUS-BD. Our outcomes of interest were clinical success, adverse events, technical success, stent dysfunction requiring intervention, and difference in mean pre- and postprocedure bilirubin. We calculated pooled rates with 95% confidence intervals (CI) for categorical variables and standardized mean difference (SMD) with 95% CI for continuous variables. We analyzed data using a random-effects model. We included five studies with 104 patients. Pooled rates (95% CI) of clinical success and adverse events were 85% (76%, 91%) and 13% (7%, 21%). Pooled rate (95% CI) for stent dysfunction requiring intervention was 9% (4%, 21%). The postprocedure mean bilirubin was significantly lower compared to preprocedure bilirubin, SMD (95% CI): -1.12 (-1.62--0.61). EUS-GBD is a safe and effective option to achieve biliary drainage after unsuccessful ERCP and EUS-BD in patients with malignant biliary obstruction.

OBJECTIVE: Tumors of the ampulla of Vater are a rare set of lesions that arise at the confluence of the common bile duct (CBD) and the pancreatic duct. They can be benign or malignant, often not easy to discriminate before treatment. Malignant tumors have low chances of survival (overall 5-year survival between 0% and 60%) and surgery is still the only curative option. Prognostic factors are being investigated to tailor therapeutic approach and improve outcomes. Due to their location in a complex anatomical region, all treatment options are challenging and associated with relevant morbidity. In this review we discuss different excisional techniques for the treatment of ampullary tumors (AT).
METHODS: A review of medical databases (PubMed and Google Scholar) was conducted selecting most relevant articles in English language without a specific timeframe. After first selection, most relevant citations were identified through snowballing.
UNASSIGNED: Pancreatoduodenectomy (PD) is the gold standard in malignant tumors, achieving the most radical treatment, at the price of worse perioperative morbidity/mortality and quality of life. Trans-duodenal ampullectomy (TDA) was developed before endoscopic resection (ER) and maintains a role only in selected patients. ER is now the first choice for benign lesions and expanding towards early stages malignant AT.
CONCLUSIONS: Pancreatodudenectomy remains the best option for the radical excision of malignant AT, recently being offered also via minimally invasive approach. However, in early-stage malignant tumors, ER is gaining importance with foreseeable further expansion. Transduodenal ampullectomy still has a role in selected patients, such as unfit for PD when ER is not possible mainly due to anatomical abnormalities.

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BACKGROUND: Endoscopic transpapillary stenting is commonly performed in patients with obstructive jaundice caused by a biliary stricture. Although the plastic stent (PS) is widely used for biliary drainage because of the low-cost and easy procedure, patency is short after placement in the bile duct because of the small diameter. Dysfunction of PS is primarily caused by biliary sludge that forms as a result of bacterial adhesion and subsequent biofilm formation on the inner surface of the stent. It is well known that silver ions have excellent antibacterial activity against a wide range of microorganisms.
OBJECTIVE: This review provides an overview and perspective of the significance of silver-coated biliary stents.
METHODS: We collected literature regarding silver-coated biliary stents, reviewed the current research/development status and discussed their possible usefulness.
RESULTS: To date, several in vivo/vitro studies evaluated the patency of silver-blended or silver-coated biliary stents. These studies suggested that the silver coating on a PS was likely to prolong the patency period.
CONCLUSIONS: The development of biliary stents using silver is expected to prolong stent patency and prevent frequent stent replacement.