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Background Patients with failed endoscopic retrograde cholangiopancreatography (ERCP) are conventionally offered percutaneous transhepatic biliary drainage (PTBD). While PTBD is effective, it is associated with catheter-related complications, pain, and poor quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a minimally invasive endoscopic option increasingly offered as an alternative to PTBD. We compare outcomes of EUS-BD and PTBD in patients with biliary obstruction at a single tertiary care center. Methods A retrospective review was performed in patients with biliary obstruction who underwent EUS-BD or PTBD after failed ERCP from June 2010 through December 2014 at a single tertiary care center. Patient demographics, procedural data, and clinical outcomes were documented for each group. The aim was to compare efficacy and safety of EUS-BD and PTBD and evaluate predictors of success. Results A total of 60 patients were included (mean age 67.5 years, 65 % male). Forty-seven underwent EUS-BD, and thirteen underwent PTBD. Technical success rates of PTBD and EUS-BD were similar (91.6 vs. 93.3 %, p  = 1.0). PTBD patients underwent significantly more re-interventions than EUS-BD patients (mean 4.9 versus 1.3, p  < 0.0001), had more late (>24-h) adverse events (53.8 % vs. 6.6 %, p  = 0.001) and experienced more pain (4.1 vs. 1.9, p  = 0.016) post-procedure. In univariate analysis, clinical success was lower in the PTBD group (25 vs. 62.2 %, p  = 0.03). In multivariable logistic regression analysis, EUS-BD was the sole predictor of clinical success and long-term resolution (OR 21.8, p  = 0.009). Conclusion Despite similar technical success rates compared to PTBD, EUS-BD results in a lower need for re-intervention, decreased rate of late adverse events, and lower pain scores, and is the sole predictor for clinical success and long-term resolution. EUS-BD should be the treatment of choice after a failed ERCP.

Background: Primary sclerosing cholangitis (PSC) is an idiopathic cholestatic liver disease that may lead to biliary strictures and destruction. It is associated with p-ANCA positivity and inflammatory bowel disease, typically ulcerative colitis. The aim of this study is to investigate the trends of inpatient healthcare utilization and mortality from 2008 to 2017 in the United States. Methods: The Nationwide Inpatient Sample (NIS) was examined to identify adult patients diagnosed with PSC between 2008 and 2017. Data on patient demographics, resource utilization, mortality, and PSC-related complications were collected. STATA version 16.0 was employed to perform forward stepwise multivariate regression analysis, generating adjusted odds ratios for both primary and secondary outcomes. Primary outcomes included the inpatient mortality rate and healthcare resource utilization (length of stay, total charges, and trends over the study period). Secondary outcomes focused on trends in associated comorbidities and malignancies in patients with PSC. Results: The average total charge increased by 32.2% ± 2.12 from USD 61,873 ± 2567 in 2008 to USD 91,262 ± 2961 in 2017. Concurrently, the average length of stay declined from 8.07 ± 0.18 days in 2008 to 7.27 ± 0.13 days in 2017. The APR-DRG severity of illness and risk of death significantly increased (major or extreme) during the study period (2008 to 2017), with severity rising from 73.6% to 82.7% (coefficient: 0.21, 95% CI: 0.13–0.28) and risk of death from 45.3% to 60.9% (coefficient: 0.15, 95% CI: 0.08–0.23). The proportion of patients with HCC increased from 1.3% to 7.9% (coefficient: 2.13, 95% CI: 1.9–2.8). Conversely, the percentage of patients with cholangiocarcinoma (CCA) decreased from 5.1% to 2.8% (coefficient: −0.36, 95% CI: −0.25 to −0.46). Conclusions: There was rising mortality and healthcare resource utilization among patients with PSC from the years 2008 to 2017. These trends were paralleled by increasing rates of decompensated cirrhosis, HCC, and liver transplants. However, the incidence of CCA decreased during this time period. African American patients with PSC had worse inpatient mortality outcomes and healthcare utilization as compared to white patients. Further studies are warranted to investigate a possible causal link amongst these trends.

Pancreaticobiliary (PB) endotherapy continues to progress in the era of therapeutic endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary method for PB access in native and altered anatomy. In altered anatomy, PB access can be obtained via enteroscopy-assisted ERCP (e-ERCP) or laparoscopy-assisted ERCP; however, both approaches have significant limitations. Endoscopic ultrasound-guided biliary and pancreatic duct drainage (EUS-BPD) are increasingly becoming the preferred alternative when ERCP fails, with advantages over percutaneous drainage. EUS-BPD continues to evolve with better feasibility, safety and efficacy as dedicated procedural equipment continues to improve. In this article, we discuss the role of endoscopic ultrasound (EUS) when ERCP fails and their indications, technique, and outcomes.

Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD. A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared. One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324). Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

Background Radiofrequency ablation of malignant biliary strictures has been offered for the last 3 years, but only limited data have been published. Aim To assess the safety, efficacy, and survival outcomes of patients receiving endoscopic radiofrequency ablation. Methods Between April 2010 and December 2013, 69 patients with unresectable neoplastic lesions and malignant biliary obstruction underwent 98 radiofrequency ablation sessions with stenting. Results A total of 69 patients (22 male, aged 66.1 ± 13.3) were included in the registry. The etiology of malignant biliary stricture included unresectable cholangiocarcinoma ( n  = 45), pancreatic cancer ( n  = 19), gallbladder cancer ( n  = 2), gastric cancer ( n  = 1), and liver metastasis from colon cancer ( n  = 3). Seventy-eight percentage of patients had prior chemotherapy. All strictures were stented post-radiofrequency ablation with either plastic stents or metal stents. The mean stricture length treated was 14.3 mm. There was a statistically significant improvement in stricture diameter post-ablation ( p  < 0.0001). The likelihood of stricture improvement was significantly greater in pancreatic cancer-associated strictures [RR 1.8 (95 % 1.03–5.38)]. Seven patients (10 %) had adverse events, not linked directly to radiofrequency ablation. Median survival was 11.46 months (6.2–25 months). Conclusion Radiofrequency ablation is effective and safe in malignant biliary obstruction and seems to be associated with improved survival.

Objectives. Radiofrequency ablation (RFA) has replaced photodynamic therapy for premalignant and malignant lesions of the esophagus. However, there is limited experience in the bile duct. The objective of this pilot study was to assess the safety and efficacy of RFA in malignant biliary strictures. Methods: Twenty patients with unresectable malignant biliary strictures underwent RFA with stenting between June 2010 and July 2012. Diameters of the stricture before and after RFA, immediate and 30 day complications and stent patency were recorded prospectively. Results. A total of 25 strictures were treated. Mean stricture length treated was 15.2 mm (SD = 8.7 mm, Range = 3.5–33 mm). Mean stricture diameter before RFA was 1.7 mm (SD = 0.9 mm, Range = 0.5–3.4 mm) while the mean diameter after RFA was 5.2 mm (SD = 2 mm, Range = 2.6–9 mm). There was a significant increase of 3.5 mm (t = 10.8, DF = 24, P value = <.0001) in the bile duct diameter post RFA. Five patients presented with pain after the procedure, but only one developed mild post-ERCP pancreatitis and cholecystitis. Conclusions: Radiofrequency ablation can be a safe palliation option for unresectable malignant biliary strictures. A multicenter randomized controlled trial is required to confirm the long term benefits of RFA and stenting compared to stenting alone.

The rise of endoscopic techniques allowing weight loss offers an attractive alternative to surgical interventions in Western countries where the obesity epidemic has risen dramatically. Endoscopists are well positioned to manage obesity given their broad-based medical knowledge, understanding of gastrointestinal physiology, and training in endoscopic technique. The field of bariatric and metabolic endoscopy has permitted the development of several efficacious and safe technologies. This review focuses on techniques and devices used for endoscopic management of obesity, as well as the fundamental justifications to offer those therapies to obese patients.

INTRODUCTION:Adenocarcinoma is more common in the US than squamous cell cancer of the esophagus. The purpose of this study is to investigate the impact of gender, and race/ethnicity on the incidence of esophageal adenocarcinoma cancer from 2000-2016 using the Surveillance, Epidemiology, and End Results (SEER) database.METHODS:Patients diagnosed with esophageal adenocarcinoma from 2000-2016 were identified from the SEER Registry. We retrospectively evaluated gender-specific, and race/ethnicity variations in age-adjusted annual percent changes in incidence rates during 2000-2016 for people above the age above 20. A secondary analysis was also done in regards to stage distribution for disease from 2007-2016.RESULTS:Based on the SEER 21 areas data sets, the annual percent change of incidence for esophageal adenocarcinoma was 2.3% from 2000-2007 and -0.8% from 2007-2016 for both males and females. The annual percent change for females was 2.0% from 2000-2008, -5.7% from 2008-2011, and 3.5% from 2011-2016. For males, the annual percent change was 2.3 from 2000-2007 and -1.1 from 2007-2016. There was an increase in the annual percent change incidence for females from 2011-2016. Annual percentage of incidence rates by race/ethnicity can be seen in Table 1. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution was evaluated by gender. Males had the highest percent of incidence cases for distant spread at 39.4, and regional spread at 32.5. Females had the highest percent of incidence cases for localized spread at 23.8. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution for race/ethnicity can be seen in Table 2. For distant spread, the highest percent of cases was seen with American Indian/Alaska Natives at 46.5.CONCLUSION:Esophageal adenocarcinoma can be prevented. Our study shows that there has been an increase in the annual percent change of incidence for females in the last decade. In addition, males had the highest incidence cases for distant spread and regional spread. This study shows that American Indian/Alaskan Native and Non-Hispanic White and White (including Hispanics) had the highest percentage of cases for distant and regional spread, respectively. This may support interventions to inform certain gender and race/ethnic populations about the importance of screening for esophageal adenocarcinoma.

INTRODUCTION:In the United States, pancreatic cancer is the fourth leading cause of cancer death for both men and women. The purpose of this study is to investigate the impact of gender, and race/ethnicity on the annual percent change of incidence and mortality rates of pancreatic cancer from 2000–2016 using the Surveillance, Epidemiology, and End Results (SEER) database.METHODS:Patients diagnosed with pancreatic cancer from 2000–2016 were identified from the SEER Registry. We retrospectively evaluated gender-specific, and race/ethnicity variations in age-adjusted annual percent changes in incidence rates and mortality rates for people above the age above 20. We used ethnic groups consisting of White, Non-Hispanic White, Black, Asian/Pacific Islander, American Indian/Alaska Native, and Hispanic.RESULTS:Based on the SEER 21 areas data sets, the age-adjusted incidence rates of pancreatic cancer increased from 2000–2014 but remained stable from 2014–2016. The annual percent of change in incidence for both males and females from 2000–2014 was 0.9 and was −1.4 from 2014–2016. Females had an annual percent change of incidence of 0.7 from 2000 to 2016. For males, the annual percent change was 1.2 from 2000–2009 but the annual percent change from 2009–2016 was 0.2. Females had an upward trend of annual percent change of incidence rates during this period. The annual percent change of incidence by race/ethnicity can be seen in Table 1. The annual percent change in mortality rates was analyzed during 2000–2016. Females had an annual percent change of 0.2 and males had an annual percent change of 0.3. The trend of mortality rates was upward for males and females. The annual percent change of mortality rate by race/ethnicity can be seen in Table 2.CONCLUSION:The poor outcome and silent nature of pancreatic cancer necessitates the need to understand the trends associated with disease. Females had an upward trend in the annual percent change of incidence rates of pancreatic cancer from 2000–2016. There is also upward trend for annual percent change of incidence rates for Asians, Hispanics, and Non Hispanic Whites. The trend of annual percent change of mortality rates was increasing for both males and females during 2000–2016. The trend was increasing for both Non-Hispanic White and White Americans. This may support interventions to inform certain race/ethnic populations about the importance of screening for pancreatic cancer in high-risk populations.