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Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative to percutaneous transhepatic biliary drainage (PTBD) for cases with obstructive jaundice in which the bile duct obstruction is below the confluence of the cystic ducts. This retrospective study aimed to evaluate the usefulness of PTGBD and PTBD in patients with obstructive jaundice. We recruited patients who had undergone percutaneous biliary drainage for acute cholangitis and obstructive jaundice at two institutions between January 2017 and March 2024. In principle, PTBD was the first choice. PTGBD was selected for cases where the intrahepatic bile duct diameter was ≤ 5 mm or ≥ 6 mm with significant respiratory-related variability of the positioning of the bile ducts. In other cases, PTBD was chosen. Fifty-five patients were included in this analysis. However, patients with intrahepatic or hilar bile duct stenosis, post choledocholithiasis, complex cholecystitis, total bilirubin levels of < 2.0 mg/dL, and uncorrectable bleeding tendency and those who had undergone the procedure and later discontinued without puncture were excluded. The technical success rates, clinical success rates, and complication rates of the procedure were evaluated. The technical success rates were 96.3% (26/27) and 82.1% (23/28) in the PTGBD and PTBD groups, respectively. The clinical success rates were 85.2% (23/27) and 67.9% (19/28) in the PTGBD and PTBD groups, respectively. The complication rates were 18.5% (5/27) and 25.0% (7/28) in the PTGBD and PTBD groups, respectively. No serious complications were observed in either group. Hence, the two groups did not significantly differ in any of the endpoints. The outcomes of PTGBD were comparable to those of PTBD in patients with obstructive jaundice. Hence, PTGBD is a reasonable treatment option for cases of obstructive jaundice in which PTBD is not feasible.

Background Endoscopic transpapillary gallbladder drainage (ETGBD) is used to manage acute cholecystitis (AC) in patients in whom surgery is contraindicated. However, ETGBD is considered challenging, has comparatively lower success rates, and is associated with severe adverse events (AEs). Only a few studies have examined the procedural and anatomical factors that affect the success of technical ETGBD. This study identified predictive factors for ETGBD in AC to improve success rates and minimize AEs. Methods Patients treated with ETGBD for AC were assessed. Factors associated with technical failure were analyzed based on the interval from symptom onset to ETGBD, the presence of cystic duct stones, and cystic duct diameter. Results Among 68 patients, the technical success and AE rates were 64.7% and 19.1%, respectively (cystic duct perforation, 8.8%; pancreatitis, 5.9%). Multivariate analysis revealed that early ETGBD and stone impaction in the cystic duct were significantly associated with technical ETGBD failure. Subgroup analysis demonstrated that early ETGBD was associated with a significantly higher risk of cystic duct perforation and a lower success rate than elective interventions. Thus, elective ETGBD may enhance procedural success and reduce the risk of cystic duct perforations. Conclusion Elective ETGBD may be considered in cases in which ETGBD is anticipated to be challenging.

Background Endoscopic ultrasound-guided transmural drainage (EUS-TD) is widely performed to treat postoperative peripancreatic fluid collection (POPFC). Recent reports on EUS-TD lack a consensus on stent selection. This study aimed to assess the efficacy of EUS-TD for POPFC using an external drainage-based approach. Methods We retrospectively examined the medical records of patients with POPFC treated with EUS-TD using external drainage from October 2016 to July 2024. Technical success was defined as successful placement of the external drainage. Clinical success was defined as the reduction in fluid collection, as evidenced by follow-up computed tomography 1 week post-procedure. Results This study included 14 patients. The median duration from surgery to endoscopic treatment was 13 (range: 11–26) days. The median procedural time was 26 (range: 13–35) min. The technical success rate was 100%, and 6 Fr endoscopic nasocystic drainage was performed in all patients. The clinical success rate was 100%, and no adverse events were observed. One patient experienced self-removal and required repuncture. Conclusions EUS-TD for POPFC with an external drainage-based approach is safe and effective, with a short procedure time. However, this was a retrospective study with a small sample size, suggesting that future prospective studies are warranted.

Objectives The efficacy of uncovered self‐expandable metal stents (UCSEMS) versus fully covered self‐expandable metal stents for distal malignant biliary obstruction remains controversial. Additionally, the heterogeneity of the disease conditions has been indicated in previous studies because pancreatic and non‐pancreatic cancers have different characteristics in clinical course. Therefore, the etiology of biliary obstruction necessitates investigations stratified by primary disease. This study aimed to evaluate the outcomes of UCSEMS, specifically for non‐pancreatic cancer‐induced distal malignant biliary obstruction. Methods We conducted a single‐center retrospective review to evaluate the time to recurrent biliary obstruction and frequency of adverse events (AEs) in patients receiving UCSEMS for unresectable non‐pancreatic cancer‐induced malignant biliary obstruction. Results Overall, 32 patients were enrolled in the study between January 2016 and December 2023. The median time to recurrent biliary obstruction was 140 days. AE rates were low at 3.1% for both pancreatitis and cholecystitis, suggesting a potential benefit of UCSEMS in reducing post‐procedural AEs. Conclusion UCSEMS may reduce the risk of post‐procedural AEs and should be considered in patients at high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis. However, the patency period may be shorter, necessitating future comparative research with fully covered self‐expandable metal stents to determine the optimal stent choice.

Objectives Distal malignant biliary obstruction (DMBO) caused by pancreatic cancer often complicates endoscopic retrograde cholangiopancreatography (ERCP), particularly biliary cannulation. While various factors influencing difficult biliary cannulation (DBC) have been studied, data specific to pancreatic cancer‐related distant malignant biliary obstruction#x000A0;remains limited. This study identifies factors affecting ERCP success in this patient population to improve clinical outcomes. Methods We retrospectively analyzed 119 ERCP procedures for distant malignant biliary obstruction owing to pancreatic cancer with naïve papilla at Showa University Fujigaoka Hospital (January 2020–September 2024). Patient characteristics, duodenal invasion, ampullary bile duct status, papillary morphology, trainee involvement, and adverse events were evaluated. Multivariate analysis identified predictive factors of DBC. Results After excluding 17 ERCP failures, 102 patients were analyzed and categorized into non‐DBC (n = 40) and DBC (n = 62) groups. The DBC incidence rate was 60.8%. The absence of the ampullary bile duct (odds ratio [OR]: 2.58, 95% confidence interval [CI]: 1.02–6.51; p = 0.04) and the macroscopic appearance of type III papillary morphology (enlarged/protruding; OR: 3.32; 95% CI: 1.07–10.30; p = 0.04) were significantly associated with DBC. Adverse events were slightly more frequent in the DBC group; however, this difference was not statistically significant. Alternative cannulation was performed more often in patients without the ampullary bile duct; however, no difference in adverse events was observed. Conclusions The absence of the ampullary bile duct and type III papillary morphology are anatomical risk factors for DBC during ERCP for patients with pancreatic cancer. Early consideration of alternative cannulation techniques or biliary drainage methods may be necessary for such patients.

Objectives Recently, a novel long balloon catheter for tract dilation in endoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) was developed. The balloon measures 6 cm in length, which enables one‐step tract dilation of the gastric wall, liver parenchyma, and bile duct wall, contributing to shorter procedure times and reduced bile leakage. This study investigated the feasibility of EUS‐HGS with this new balloon catheter. Methods This retrospective study included consecutive cases in which EUS‐HGS was performed using a novel long balloon catheter (3 mm in diameter) for malignant distal biliary obstructions between February 2024 and October 2024. The patients' clinical background and procedural details were retrospectively examined using medical records. The primary outcome was technical success, defined as successful stent placement without additional dilation using devices other than the new balloon catheter. The secondary outcomes were clinical success and adverse events. Results This study included 10 patients. The median age was 82.5 years, and there were seven males and three females. The median procedure time was 20 min. Technical success was achieved in 90% and clinical success was achieved in 100%. Regarding adverse events, one patient developed moderate cholecystitis, and percutaneous transhepatic gallbladder drainage was performed. No bile leakage, peritonitis, bleeding, or perforation was observed. Conclusion The new long balloon catheter is an excellent device that can reliably dilate the whole tract with a single inflation. EUS‐HGS using a novel long balloon catheter is a feasible treatment option.

Objective This study aimed to investigate the usefulness of endoscopic ultrasound‐guided tissue acquisition (EUS‐TA) for diagnosing focal liver lesions in patients with a history of multiple primary malignant neoplasms. Methods Among patients who underwent EUS‐TA for focal liver lesions between 2016 and 2022, those with a history of multiple malignant neoplasms were included. A histologically confirmed malignant tumor within the past 5 years before EUS‐TA was defined as a history of malignant neoplasm. The primary outcomes were diagnostic ability and adverse events of EUS‐TA. Results This study included 16 patients (median age, 73 [33–90] years), the median tumor size was 32 (6–51) mm, 14 had a history of double malignant neoplasms, whereas two had triple malignant neoplasms. Malignant neoplasms were detected histologically or cytologically in all cases. Immunohistochemistry was performed in 75% (12/16), and the final diagnosis of EUS‐TA was metastatic liver tumor in 12 patients, and primary malignant liver tumor in four patients. The primary site could be identified in 11 of 12 metastatic tumor cases. The diagnostic yield of EUS‐TA was 100% (16/16) for differentiating benign and malignant tumors and 94% (15/16) for confirming the histological type including the primary site of metastatic lesions. No adverse events were associated with the procedure. Conclusion EUS‐TA is a useful diagnostic modality for focal liver lesions in patients with a history of multiple malignant neoplasms, allowing for the differential diagnosis of primary and metastatic tumors and identification of the primary site of metastatic lesions.

A 62‐year‐old man with right upper quadrant pain and fever was found to have numerous hepatic masses. Endoscopic ultrasound‐guided tissue acquisition (EUS‐TA) using a 22‐gauge fine‐needle biopsy enabled diagnosis of high‐grade T‐cell lymphoma without adverse events. This case underscores the potential of EUS‐TA as a safe and effective alternative to percutaneous biopsy for hepatic malignant lymphoma. Key Clinical Message In recent years, the concept of “Endo‐Hepatology” has increased awareness of the clinical utility of EUS‐TA for liver diseases. Fine needle biopsy needles enable the diagnosis of hepatic malignant lymphoma in combination with immunohistochemistry. EUS‐TA may serve as an alternative to percutaneous biopsy in suspected cases.

A man in his 70s on maintenance dialysis for autosomal dominant polycystic kidney disease was admitted with epigastralgia and a fever lasting for 1 week. Computed tomography showed a thickened liver cyst measuring 121 mm in the caudate lobe, suggesting infection. Percutaneous drainage was impossible because multiple liver cysts and ascites entered the puncture route. Endoscopic ultrasound (EUS) revealed a huge liver cyst with debris‐like echoes. Transgastric EUS‐guided drainage was performed, and internal and external drainage was performed without adverse events. After the procedure, the symptoms quickly improved, and the external drain was removed after 12 days. The internal drainage stent remained in place, and the patient was discharged from the hospital 53 days after the EUS‐guided drainage. EUS‐guided drainage is an effective alternative treatment for infected liver cysts where a percutaneous approach is impossible.

Histological biopsy is essential for diagnosing ampullary tumors; however, it can occasionally result in severe adverse events. A 49‐year‐old male underwent esophagogastroduodenoscopic screening, which revealed an ampulla of Vater with enlargement of the oral protrusion. An endoscopic biopsy was performed; several hours later, the patient developed severe acute pancreatitis requiring hospitalization. The biopsy result was benign, and no gallstones, ductal abnormalities, or other etiologies were identified on endoscopic ultrasonography or magnetic resonance cholangiopancreatography, and the biopsy was considered the most likely trigger. The patient recovered with conservative management and was discharged on day 14. No recurrence has been observed 3 months after discharge. Although acute pancreatitis following biopsy of the ampulla of Vater is extremely rare, it can be fatal. Endoscopists should be aware of this potential risk, carefully assess the necessity of biopsy, and ensure that patients provide informed consent before the procedure.