<i>Aims</i>. To evaluate the success rate and related factors of endoscopic ultrasound guided-biliary drainage (EUS-BD).<i> Material and Methods</i>. We conducted a retrospective study among 24 patients with malignant biliary obstruction who underwent EUS-BD after failed ERCP from January 2015 to December 2016 in a tertiary health center. The bilirubin levels before and after the procedure were used to define the clinical success rate, while the stent deployment was used to define the technical success rate. We placed either transluminal biliary stents or transpapillary biliary stents.<i> Results</i>. Among 24 patients, choledochoduodenostomy technique was conducted in 23 patients (95.8&#x25;) and hepaticogastrostomy technique in 1 patient (4.2&#x25;). Transluminal stent placement was conducted in 23 patients, while transpapillary stent placement was conducted in 1 patient. The clinical success rate was 78.2&#x25; (18) in choledochoduodenostomy route and 100&#x25; (1) in hepaticogastrostomy route. EUS-BD was 2.37 times and 2.11 times more likely to be successful in reducing the bilirubin level in patients with tumor of the head of pancreas and periampullary tumor, respectively, but not in cholangiocarcinoma.<i> Conclusions</i>. EUS-BD is an effective and efficient procedure to achieve biliary drainage among patients with malignant biliary obstruction after ERCP failure.

Dadang Makmun

Achmad Fauzi

Murdani Abdullah

Ari Fahrial Syam

The Role of EUS-BD in the Management of Malignant Biliary Obstruction: The Indonesian Perspective

<i>Background and Aims.</i> EUS-guided liver biopsy is an emerging method of liver tissue acquisition which is safe and had been shown to produce excellent histological yield. There is limited data comparing the diagnostic yield of different FNA needles. We aimed to compare the diagnostic performance of four commercially available 19-gauge FNA needles.<i> Methods</i>. Four FNA needles and one percutaneous needle were used to perform liver biopsies on two human cadaveric livers: Cook Echotip Procore&#x2122;, Olympus EZ Shot 2&#x2122;, Boston Scientific Expect Slimline&#x2122;, Covidien SharkCore&#x2122;, and an 18-gauge percutaneous needle (TruCore&#x2122;, Argon Medical Devices). Each needle obtained biopsies by three, six, and nine complete back-and-forth motions of the needle (&#x201c;throw&#x201d;) with a fanning technique. The combined lengths of specimen fragments and the total number of complete portal tracts (CPT) were measured by a blinded pathologist. One-way analysis of variance (ANOVA) and Bonferroni correction were used for statistical analysis.<i> Results.</i> A total of 52 liver biopsies were performed. The Covidien SharkCore needle had significantly greater number of CPT compared to other FNA needles. The number of &#x201c;throws&#x201d; did not impact the number of CPT significantly. There was no statistically significant difference in mean total specimen length between each FNA needle type.<i> Conclusion</i>. The Covidien SharkCore needle produced superior histological specimen by capturing more CPT, possibly due to its unique needle design.

Woo Jung Lee

Lance T. Uradomo

Yang Zhang

William Twaddell

Peter Darwin

Comparison of the Diagnostic Yield of EUS Needles for Liver Biopsy: Ex Vivo Study

<i>Introduction</i>. Walled-off pancreatic necrosis (WOPN) is a major complication of acute pancreatitis. We hypothesized that an extended (2 cm) cystogastrostomy opening combined with hydrogen peroxide irrigation can increase the success of endoscopic necrosectomy and decrease the number of required endoscopic interventions. The aim of the study is to assess the safety and feasibility of the technique in the management of WOPN.<i> Methods</i>. This is a retrospective chart review of all cases that underwent EUS with extended cystogastrostomy and hydrogen peroxide irrigation prior to necrosectomy in a tertiary referral medical center. Clinical success was defined as complete resolution of the cyst cavity or a cyst cavity less than 2 cm in size on follow-up imaging.<i> Results</i>. 19 patients satisfied the inclusion criteria. The mean size of the walled-off cavity was <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="23.017pt" style="vertical-align:-0.3499298pt" id="M1" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 23.017 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,15.386,0)"><path id="g117-36" d="M535 230V280H323V490H265V280H52V230H265V-3H323V230H535Z"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="15.444pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="25.872183800000002 -8.34882 15.444 8.69875"><g transform="matrix(.013,0,0,-0.013,25.922,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,32.162,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,35.126,0)"><path id="g113-58" d="M244 635C114 635 38 519 38 422C38 317 111 240 217 240C236 240 255 244 277 256L345 292C311 140 203 39 59 15L64 -15C89 -15 150 -5 204 17C339 72 440 202 440 386C440 521 368 635 244 635ZM228 602C326 602 352 479 352 390C352 370 351 347 348 324C327 308 293 296 258 296C174 296 124 369 124 458C124 517 152 602 228 602Z"/></g></svg></span> cm. Technical success of the procedure was 100%. The median number of necrosectomy sessions was 2 (range 1 to 7). Cavity resolution was noted in 18 out of 19 patients resulting in a clinical success of 94.7%. The median follow-up period was 12 months. The adverse events rate in our cohort was 15.7%.<i> Conclusion</i>. Extended cystogastrostomy coupled with hydrogen peroxide irrigation of WOPN cavity is safe and feasible.

Mohamed O. Othman

Sherif Elhanafi

Mohammed Saadi

Christine Yu

Brian R. Davis

Extended Cystogastrostomy with Hydrogen Peroxide Irrigation Facilitates Endoscopic Pancreatic Necrosectomy

<i>Background and Aim.</i> Endoscopic nasobiliary drainage (NBD) effects according to diameter remain unclear. We aimed to assess the drainage effects of the 4-Fr and 6-Fr NBD catheters.<i> Methods.</i> This prospective, multicenter, randomized, controlled study was conducted at Hiroshima University Hospital and related facilities within Hiroshima Prefecture. Endoscopic retrograde cholangiopancreatography (ERCP) in 246 patients revealed acute cholangitis, obstructive jaundice, and/or extrahepatic cholestasis; 4-Fr or 6-Fr NBD catheters were randomly allocated and placed in these patients. The primary endpoint was the efficacy of NBD based on the technical success rate and clinical success (rates of change in blood test and amount of bile output). Secondary endpoints included the spontaneous catheter displacement rate and nasal discomfort.<i> Results.</i> The technical success rate and clinical success did not differ significantly between groups. No spontaneous catheter displacement was noted in either group. Nasal discomfort due to catheter placement was significantly lower in the 4-Fr group versus the 6-Fr group (24 h after ERCP: 2.4 versus 3.5 cm, <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.2064009pt" id="M1" height="8.8423pt" version="1.1" viewBox="-0.0498162 -8.6359 51.1027 8.8423" width="51.1027pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g><g transform="matrix(.013,0,0,-0.013,22.921,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><path id="g113-54" d="M153 550H386L412 615L406 623H120L82 318C104 327 142 338 184 338C294 338 347 275 347 187C347 112 305 39 221 39C160 39 119 71 97 89C88 97 80 96 71 90C59 80 50 67 49 57C48 45 52 36 66 23C80 9 123 -12 169 -12C221 -11 288 15 342 59C403 109 431 165 431 225C431 308 366 395 238 395C212 395 165 379 127 364L153 550Z"/></g></svg>; 48 h after ERCP: 2.2 versus 3.1 cm, <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.2064009pt" id="M2" height="8.8423pt" version="1.1" viewBox="-0.0498162 -8.6359 44.8393 8.8423" width="44.8393pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.013,0,0,-0.013,22.921,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg>).<i> Conclusion.</i> The 4-Fr NBD catheter was not inferior to 6-Fr NBD catheter in terms of clinical success; the 4-Fr NBD catheter was useful to reduce nasal discomfort.

Tomofumi Tsuboi

Masahiro Serikawa

Tamito Sasaki

Yasutaka Ishii

Yoshifumi Fujimoto

Atsushi Yamaguchi

Takashi Ishigaki

Akinori Shimizu

Keisuke Kurihara

Yumiko Tatsukawa

Eisuke Miyaki

Kazuaki Chayama

Use of 4-Fr versus 6-Fr Nasobiliary Catheter for Biliary Drainage: A Prospective, Multicenter, Randomized, Controlled Study

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Diagnostic and Therapeutic Endoscopy