Clinical Endoscopy

Review

Endoscopic ultrasound-guided gastroenterostomy, with focus on technique and practical tips: Chi-Ying Yang, Wen-Hsin Huang, Hsing-Hung Cheng; Clin Endosc 2025;58(2):201-217. Published online March 4, 2025; DOI: https://doi.org/10.5946/ce.2024.206

Abstract PDF PubReader ePub: Gastric outlet obstruction (GOO) is a condition characterized by a mechanical obstruction of the stomach or duodenum, caused by either benign or malignant disease. Traditionally, surgical gastrojejunostomy (SGJ) has been the standard treatment for malignant GOO and endoscopic stenting (ES) offers a less invasive option, but it often requires repeat interventions. Recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE), an innovative technique, has been applied as an alternative to SGJ and ES for GOO patients. Direct EUS-GE, device-associated EUS-GE, and EUS-guided double balloon-occluded gastrojejunostomy bypass are the most commonly used techniques with reported technical success rates ranging from 80% to 100%, and clinical success rates between 68% and 100%. Adverse event (AE) rates range from 0% to 28.2% and the stent misdeployment is the most common while other AEs include abdominal pain, bleeding, infection, peritonitis, bowel perforation, gastric leakage, and stent migration. It is clear that EUS-GE may achieve a similar clinical success to SGJ with fewer AEs and a shorter hospital stay. Compared to ES, EUS-GE showed higher clinical success, fewer stent obstructions, and lower reintervention rates.

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Systematic Review and Meta-analysises

Efficacy of endoscopic ultrasound-guided biliary drainage of malignant biliary obstruction: a systematic review and meta-analysis of randomized controlled trials: Yousaf Zafar, Hafsa Azam, Muhammad Abdullah Bin Azhar, Fabeeha Shaheen, Syed Sarmad Javaid, Laila Manzoor, Muaaz Masood, Rajesh Krishnamoorthi; Received July 3, 2024 Accepted September 24, 2024 Published online February 24, 2025; DOI: https://doi.org/10.5946/ce.2024.183 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Malignant biliary obstruction is a major clinical challenge. We assessed the efficacy of endoscopic ultrasound-guided biliary drainage (EUS-BD) compared with that of endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD) or percutaneous transhepatic biliary drainage (PTBD).
Methods
We searched for randomized controlled trials comparing EUS-BD with ERCP or PTBD in treating malignant biliary obstruction. Using random-effects models, we synthesized risk ratios (RRs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs). A subgroup analysis was performed using a comparator (ERCP or PTBD).
Results
EUS-BD significantly reduced the risk of stent dysfunction (RR, 0.46; 95% CI, 0.33–0.64), with consistent results in subgroup analysis for ERCP (RR, 0.54; 95% CI, 0.35–0.84) and PTBD (RR, 0.37; 95% CI, 0.22–0.61). It also lowered the risk of post-procedure pancreatitis (RR, 0.24; 95% CI, 0.07–0.83) and reduced tumor ingrowth or overgrowth risk (RR, 0.27; 95% CI, 0.11–0.65), even when compared to ERCP alone (RR, 0.28; 95% CI, 0.11–0.70). EUS-BD demonstrated a lower risk of adverse events compared to PTBD (RR, 0.37; 95% CI, 0.14–0.97) and reduced length of hospital stay (WMD, –1.03; 95% CI, –1.53 to –0.53) when compared to ERCP.
Conclusions
EUS-BD outperformed ERCP-BD and PTBD in reducing stent dysfunction, postprocedural pancreatitis, and tumor ingrowth or overgrowth.

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Transforming outcomes: the pivotal role of self-expanding metal stents in right- and left-sided malignant colorectal obstructions-bridge to surgery: a comprehensive review and meta-analysis: Sheza Malik, Priyadarshini Loganathan, Hajra Khan, Abul Hasan Shadali, Pradeep Yarra, Saurabh Chandan, Babu P. Mohan, Douglas G. Adler, Shivangi Kothari; Clin Endosc 2025;58(2):240-252. Published online February 3, 2025; DOI: https://doi.org/10.5946/ce.2024.120

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Self-expanding metallic stents (SEMS) are an alternative to emergency surgery (ES) for malignant colorectal obstruction. This study aimed to compare surgical outcomes between SEMS as a bridge to surgery (BTS) and ES in patients with malignant colorectal obstruction.
Methods
A comprehensive database search was conducted until October 2023 to compare outcomes between SEMS as a BTS and ES. A subgroup analysis of results by malignancy site was performed.
Results
We analyzed 57 studies, including 7,223 patients over a mean duration of 35.4 months. SEMS as a BTS showed clinical and technical success rates of 88.0% (95% confidence interval [CI], 86.1%–90.1%; I2=68%) and 91.6% (95% CI, 89.7%–93.7%; I2=66%), respectively. SEMS as a BTS revealed reduced postoperative adverse events (odds ratio [OR], 0.51; 95% CI, 0.41–0.63; I2=70%; p<0.001) and 30-day mortality (OR, 0.52; 95% CI, 0.37–0.72; I2=10%; p<0.001) compared to ES. Subgroup analysis showed postoperative mortality of 5% and 1.5% for left- and right-sided malignancies, respectively. Adverse events were 15% and 33% for the right and left colon, respectively.
Conclusions
SEMS as a BTS demonstrated a higher success rate, fewer postoperative adverse events, and a reduced 30-day mortality rate than ES, supporting its use as the preferred initial intervention for right- and left-sided obstructions and indicating broader clinical adoption.

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Original Article

Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage in hypervascular hepatocellular carcinoma: a retrospective study from Japan: Kenneth Tachi, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Ahmed Mohammed Sadek, Hossam El-Din Shaaban Mahmoud Ibrahim, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto; Received April 2, 2024 Accepted July 29, 2024 Published online November 11, 2024; DOI: https://doi.org/10.5946/ce.2024.079 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Biliary obstruction drainage in patients with hepatocellular carcinoma (HCC) is associated with symptom palliation, improved access to chemotherapy, and improved survival. Stent placement and exchange via endoscopic retrograde cholangiopancreatography biliary drainage risk traversing the HCC, a hypervascular tumor and causing bleeding. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) potentially prevents procedure-related bleeding. Therefore, we evaluated the efficacy and safety of EUS-HGS as an alternative treatment for biliary obstruction in patients with HCC.
Methods
This was a retrospective study of all EUS-HGS procedures performed in patients with HCC at the Aichi Cancer Center Hospital, Japan, from February 2017 to August 2023.
Results
A total of 14 EUS-HGS procedures (42.9% primary) were attempted in 10 HCC patients (mean age 71.5 years, 80.0% male). Clinical and technical success rates were 92.9% and 90.9%, respectively. The observed procedure details in the 13 successful procedures included B3 puncture (53.8%), 22-G needle (53.8%), fully covered self-expandable metal stent (100%), and mean procedure time (32.7 minutes). There was no bleeding. Mild complications occurred in 27.3%. All patients resumed oral intake within 24 hours.
Conclusions
EUS-HGS is a technically feasible and clinically effective initial or salvage drainage option for the treatment of biliary obstruction in patients with HCC.

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Review

Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer: Masahiro Itonaga, Masayuki Kitano; Clin Endosc 2025;58(1):40-52. Published online September 26, 2024; DOI: https://doi.org/10.5946/ce.2023.294

Abstract PDF PubReader ePub: Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

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Original Articles

Development of colonic stent simulator using three-dimensional printing technique: a simulator development study in Korea: Hyundam Gu, Suyoung Lee, Sol Kim, Hye-Lim Jang, Da-Woon Choi, Kyu Seok Kim, Yu Ri Shin, Dae Young Cheung, Bo-In Lee, Jin Il Kim, Han Hee Lee; Clin Endosc 2024;57(6):790-797. Published online September 23, 2024; DOI: https://doi.org/10.5946/ce.2024.110

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Colonic stenting plays a vital role in the management of acute malignant colonic obstruction. The increasing use of self-expandable metal stents (SEMS) and the diverse challenges posed by colonic obstruction at various locations underscore the importance of effective training for colonic stent placement.
Methods
All the components of the simulator were manufactured using silicone molding techniques in conjunction with three-dimensional (3D) printing. 3D images sourced from computed tomography scans and colonoscopy images were converted into a stereolithography format. Acrylonitrile butadiene styrene copolymers have been used in fused deposition modeling to produce moldings.
Results
The simulator replicated the large intestine from the rectum to the cecum, mimicking the texture and shape of the human colon. It enables training for colonoscopy insertion, cecum intubation, loop reduction, and stenting within stenotic areas. Interchangeable stenotic modules for four sites (rectum, sigmoid colon, descending colon, and ascending colon) were easily assembled for training. These modules integrate tumor contours and blood vessel structures with a translucent center, allowing real-time visualization during stenting. Successful and repeatable demonstrations of stent insertion and expansion using the reusable SEMS were consistently achieved.
Conclusions
This innovative simulator offers a secure colonic stenting practice across various locations, potentially enhancing clinical outcomes by improving operator proficiency during actual procedures.

Citations

Citations to this article as recorded by

Novel minimally invasive strategies for achieving source control in intra-abdominal infections
Clayton Wyland, Desmond Zeng, Robert G. Sawyer
Current Opinion in Critical Care.2025; 31(2): 228. CrossRef
Comments on ‘Development of colonic stent simulator using three-dimensional printing technique: a simulator development study in Korea’
Dae Jin Jung, Gwang Ha Kim
Clinical Endoscopy.2025; 58(2): 334. CrossRef

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Endoscopic ultrasound-guided hepaticogastrostomy and endoscopic retrograde cholangiopancreatography-guided biliary drainage for distal malignant biliary obstruction due to pancreatic cancer with asymptomatic duodenal invasion: a retrospective, single-center study in Japan: Naminatsu Takahara, Yousuke Nakai, Kensaku Noguchi, Tatsunori Suzuki, Tatsuya Sato, Ryunosuke Hakuta, Kazunaga Ishigaki, Tomotaka Saito, Tsuyoshi Hamada, Mitsuhiro Fujishiro; Clin Endosc 2025;58(1):134-143. Published online August 23, 2024; DOI: https://doi.org/10.5946/ce.2024.031

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Duodenal invasion (DI) is a risk factor for early recurrent biliary obstruction (RBO) in endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) may reduce early RBO in cases of asymptomatic DI, even when ERCP is possible.
Methods
We enrolled 56 patients with pancreatic cancer and asymptomatic DI who underwent EUS-HGS (n=25) or ERCP-BD (n=31). Technical and clinical success, early (<3 months) and overall RBO rates, time to RBO (TRBO), and adverse events were compared between the EUS-HGS and ERCP-BD groups. Risk factors for early RBO were also evaluated.
Results
Baseline characteristics were similar between the groups. Both procedures demonstrated 100% technical and clinical success rates, with a similar incidence of adverse events (48% vs. 39%, p=0.59). While the median TRBO was comparable (5.7 vs. 8.8 months, p=0.60), EUS-HGS was associated with a lower incidence of early RBO compared to ERCP-BD (8% vs. 29%, p=0.09). The major causes of early RBO in ERCP-BD were sludge and food impaction, rarely occurring in EUS-HGS. EUS-HGS was potentially reduced early RBO (odds ratio, 0.32; p=0.07).
Conclusions
EUS-HGS can be a viable option for treating pancreatic cancer with asymptomatic DI.

Citations

Citations to this article as recorded by

Biliary drainage in pancreatic cancer with duodenal invasion: which route is the best?
Tanyaporn Chantarojanasiri, Thawee Ratanachu-Ek
Clinical Endoscopy.2025; 58(1): 82. CrossRef

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Hepatobiliary scintigraphy of bile excretion after endoscopic ultrasound-guided hepaticogastrostomy for malignant biliary obstruction: a retrospective study in Japan: Masanori Yamada, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Toshitaka Fukui; Clin Endosc 2024;57(6):798-806. Published online August 20, 2024; DOI: https://doi.org/10.5946/ce.2023.291

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Hepatobiliary scintigraphy (HBS) is used to evaluate bile excretion. This study aimed to evaluate biliary excretion during endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using HBS.
Methods
We retrospectively evaluated 78 consecutive patients with malignant extrahepatic biliary obstruction, who underwent HBS after EUS-HGS between April 2015 and July 2022. The peak time and decay rate were scored with 0, 1, or 2 points based on thresholds of 20 and 35 minutes, and 10% and 50%, respectively. A total score of 4 or 3 was considered indicative of good bile excretion, whereas scores of 2, 1, or 0 indicated poor bile excretion.
Results
The good and poor bile excretion groups included 40 and 38 cases, respectively. The group with good bile excretion had a significantly longer time to recurrent biliary obstruction compared to the poor bile excretion group (not reached vs. 124 days, p=0.026). Multivariate analysis identified the site of obstruction as a significant factor influencing good bile excretion (odds ratio, 3.39; 95% confidence interval, 1.01–11.4, p=0.049), with superior bile excretion observed in cases involving upper biliary obstruction compared to middle or lower biliary obstruction.
Conclusions
In patients with malignant biliary obstruction who underwent HGS, the site of obstruction is significantly associated with stent patency.

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Potential of 6-mm-diameter fully covered self-expandable metal stents for unresectable malignant distal biliary obstruction: a propensity score-matched study: Daiki Yamashige, Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Soma Fukuda, Shin Yagi, Kohei Okamoto, Hidenobu Hara, Yuya Hagiwara, Daiki Agarie, Tetsuro Takasaki, Akihiro Ohba, Shunsuke Kondo, Chigusa Morizane, Hideki Ueno, Miyuki Sone, Yutaka Saito, Takuji Okusaka; Clin Endosc 2025;58(1):121-133. Published online July 29, 2024; DOI: https://doi.org/10.5946/ce.2024.044

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS.
Methods
This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed.
Results
Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027).
Conclusions
For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

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Efficacy of hemostasis by gastroduodenal covered metal stent placement for hemorrhagic duodenal stenosis due to pancreatobiliary cancer invasion: a retrospective study: Yasunari Sakamoto, Taku Sakamoto, Akihiro Ohba, Mitsuhito Sasaki, Shunsuke Kondo, Chigusa Morizane, Hideki Ueno, Yutaka Saito, Yasuaki Arai, Takuji Okusaka; Clin Endosc 2024;57(5):628-636. Published online June 14, 2024; DOI: https://doi.org/10.5946/ce.2023.155

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.
Methods
Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.
Results
The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20–220 days) and 66.5 days (range, 31–220 days), respectively.
Conclusions
Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.

Citations

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Clinical significance of peritoneal lavage cytology in duodenal cancer
Yuya Miura, Katsuhisa Ohgi, Ryo Ashida, Yoshiyasu Kato, Shimpei Otsuka, Hideyuki Dei, Katsuhiko Uesaka, Teiichi Sugiura
Surgery.2025; 181: 109256. CrossRef
Clinical effect of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice
Shoulin Zhang, Shaopeng Huang, Zheng Xing, Youwen Song, Fujian Yuan
BMC Surgery.2025;[Epub] CrossRef

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Outcomes of partially covered self-expandable metal stents with different uncovered lengths in endoscopic ultrasound-guided hepaticogastrostomy: a Japanese retrospective study: Takeshi Okamoto, Takashi Sasaki, Tsuyoshi Takeda, Tatsuki Hirai, Takahiro Ishitsuka, Manabu Yamada, Hiroki Nakagawa, Takafumi Mie, Takaaki Furukawa, Akiyoshi Kasuga, Masato Ozaka, Naoki Sasahira; Clin Endosc 2024;57(4):515-526. Published online May 10, 2024; DOI: https://doi.org/10.5946/ce.2023.142

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO).
Methods
Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared.
Results
Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS.
Conclusions
No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Citations

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Migration of covered expandable metal stents after endoscopic ultrasound-guided hepaticogastrostomy: stent covering versus stent design?
Todd H. Baron
Clinical Endoscopy.2024; 57(4): 471. CrossRef

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1 Crossref

Reviews

Colon stenting as a bridge to surgery in obstructive colorectal cancer management: Dong Hyun Kim, Han Hee Lee; Clin Endosc 2024;57(4):424-433. Published online March 8, 2024; DOI: https://doi.org/10.5946/ce.2023.138

Abstract PDF PubReader ePub

Colonic stent placement is a commonly used bridging strategy for surgery in patients with obstructive colorectal cancer. The procedure involves the placement of a self-expandable metallic stent (SEMS) across the obstructive lesion to restore intestinal patency and alleviate the symptoms of obstruction. By allowing patients to receive surgery in a planned and staged manner with time for preoperative optimization and bowel preparation, stent placement may reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes. This review focuses on the role of colon stenting as a bridge to surgery in the management of obstructive colorectal cancer. SEMS as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful; however, further research is needed for its application in cases of right-sided colon cancer. Colon stent placement also has limitations and potential complications including stent migration, re-obstruction, and perforation. However, the timing of curative surgery after SEMS placement remains inconclusive. Considering the literature to date, performing surgery at an interval of approximately 2 weeks is considered appropriate. Therefore, colonic stent placement may be an effective strategy as a bridge to surgery in patients with obstructive colorectal cancer.

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Chitosan Approaches in Colon Cancer Therapy: Understanding its Macromolecular Interactions and Structure-Property Relationships
Sankha Bhattacharya, Dilpreet Singh
Journal of Macromolecular Science, Part B.2025; : 1. CrossRef
Development of colonic stent simulator using three-dimensional printing technique: a simulator development study in Korea
Hyundam Gu, Suyoung Lee, Sol Kim, Hye-Lim Jang, Da-Woon Choi, Kyu Seok Kim, Yu Ri Shin, Dae Young Cheung, Bo-In Lee, Jin Il Kim, Han Hee Lee
Clinical Endoscopy.2024; 57(6): 790. CrossRef
Self-Expandable Metal Stents for Obstructing Colon Cancer and Extracolonic Cancer: A Review of Latest Evidence
Pedro Marílio Cardoso, Eduardo Rodrigues-Pinto
Cancers.2024; 17(1): 87. CrossRef

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Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy: Sun Gyo Lim, Chan Gyoo Kim; Clin Endosc 2024;57(5):571-580. Published online February 23, 2024; DOI: https://doi.org/10.5946/ce.2023.160

Abstract PDF PubReader ePub

Malignant gastric outlet obstruction (GOO) is a condition characterized by blockage or narrowing where the stomach empties its contents into the small intestine due to primary malignant tumors or metastatic diseases. This condition leads to various symptoms such as nausea, vomiting, abdominal pain, and weight loss. To manage malignant GOO, different treatment options have been employed, including surgical gastrojejunostomy (SGJ), gastroduodenal stenting (GDS) using self-expandable metallic stent (SEMS), and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ). This review focuses on comparing the clinical outcomes of endoscopic stenting (GDS and EUS-GJ) with SGJ for malignant GOO. Studies have shown that GDS with SEMS provides comparable clinical outcomes and safety for the palliation of obstructive symptoms. The choice between covered and uncovered SEMS remains controversial, as different studies have reported varying results. EUS-GJ, performed via endoscopic ultrasound guidance, has shown promising efficacy and safety in managing malignant GOO, but further studies are needed to establish it as the primary treatment option. Comparative analyses suggest that GDS has higher recurrence and reintervention rates compared to EUS-GJ and SGJ, with similar overall procedural complications. However, bleeding rates were lower with GDS than with SGJ. Randomized controlled trials are required to determine the optimal treatment approach for malignant GOO.

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Palliative management for malignant biliary obstruction and gastric outlet obstruction from pancreatic cancer
Pengfei Wu, Kai Chen, Jin He
Annals of Gastroenterological Surgery.2025; 9(2): 218. CrossRef
Aortoenteric Fistula Formation From Chronic Erosion of an Axios Gastroduodenal Stent in a Patient With a History of Radiation
Caleb M Glover, Adam Bowen, Claire Russell, Ali Rida, Alexandra Davies, Edward Cay, John Walling
Cureus.2025;[Epub] CrossRef

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Original Articles

Impact of sarcopenia on biliary drainage during neoadjuvant therapy for pancreatic cancer: Kunio Kataoka, Eizaburo Ohno, Takuya Ishikawa, Kentaro Yamao, Yasuyuki Mizutani, Tadashi Iida, Hideki Takami, Osamu Maeda, Junpei Yamaguchi, Yukihiro Yokoyama, Tomoki Ebata, Yasuhiro Kodera, Hiroki Kawashima; Clin Endosc 2024;57(1):112-121. Published online July 18, 2023; DOI: https://doi.org/10.5946/ce.2022.278

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Since the usefulness of neoadjuvant chemo(radiation) therapy (NAT) for pancreatic cancer has been demonstrated, recurrent biliary obstruction (RBO) in patients with pancreatic cancer with a fully covered self-expandable metal stent (FCSEMS) during NAT is expected to increase. This study investigated the impact of sarcopenia on RBO in this setting.
Methods
Patients were divided into normal and low skeletal muscle index (SMI) groups and retrospectively analyzed. Patient characteristics, overall survival, time to RBO (TRBO), stent-related adverse events, and postoperative complications were compared between the two groups. A Cox proportional hazard model was used to identify the risk factors for short TRBO.
Results
A few significant differences were observed in patient characteristics, overall survival, stent-related adverse events, and postoperative complications between 38 patients in the normal SMI group and 17 in the low SMI group. The median TRBO was not reached in the normal SMI group and was 112 days in the low SMI group (p=0.004). In multivariate analysis, low SMI was the only risk factor for short TRBO, with a hazard ratio of 5.707 (95% confidence interval, 1.148–28.381; p=0.033).
Conclusions
Sarcopenia was identified as an independent risk factor for RBO in patients with pancreatic cancer with FCSEMS during NAT.

Citations

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Endeavors to prevent stent malfunction: new insights into the risk factors for recurrent biliary obstruction
Sung-Jo Bang
Clinical Endoscopy.2024; 57(1): 56. CrossRef
Skeletal muscle status and survival among patients with advanced biliary tract cancer
Shinya Takaoka, Tsuyoshi Hamada, Naminatsu Takahara, Kei Saito, Go Endo, Ryunosuke Hakuta, Kota Ishida, Kazunaga Ishigaki, Sachiko Kanai, Kohei Kurihara, Hiroki Oyama, Tomotaka Saito, Tatsuya Sato, Tatsunori Suzuki, Yukari Suzuki, Shuichi Tange, Yurie Tok
International Journal of Clinical Oncology.2024; 29(3): 297. CrossRef

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A novel fully covered metal stent for unresectable malignant distal biliary obstruction: results of a multicenter prospective study: Arata Sakai, Atsuhiro Masuda, Takaaki Eguchi, Keisuke Furumatsu, Takao Iemoto, Shiei Yoshida, Yoshihiro Okabe, Kodai Yamanaka, Ikuya Miki, Saori Kakuyama, Yosuke Yagi, Daisuke Shirasaka, Shinya Kohashi, Takashi Kobayashi, Hideyuki Shiomi, Yuzo Kodama; Clin Endosc 2024;57(3):375-383. Published online July 10, 2023; DOI: https://doi.org/10.5946/ce.2023.035

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Endoscopic self-expandable metal stent (SEMS) placement is currently the standard technique for treating unresectable malignant distal biliary obstructions (MDBO). Therefore, covered SEMS with longer stent patency and fewer migrations are required. This study aimed to assess the clinical performance of a novel, fully covered SEMS for unresectable MDBO.
Methods
This was a multicenter single-arm prospective study. The primary outcome was a non-obstruction rate at 6 months. The secondary outcomes were overall survival (OS), recurrent biliary obstruction (RBO), time to RBO (TRBO), technical and clinical success, and adverse events.
Results
A total of 73 patients were enrolled in this study. The non-obstruction rate at 6 months was 61%. The median OS and TRBO were 233 and 216 days, respectively. The technical and clinical success rates were 100% and 97%, respectively. Furthermore, the rate of occurrence of RBO and adverse events was 49% and 21%, respectively. The length of bile duct stenosis (<2.2 cm) was the only significant risk factor for stent migration.
Conclusions
The non-obstruction rate of a novel fully covered SEMS for MDBO is comparable to that reported earlier but shorter than expected. Short bile duct stenosis is a significant risk factor for stent migration.

Citations

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The anti‐migration effect of partially covered self‐expandable metal stents for unresectable malignant distal biliary obstruction: A multicenter comparative study
Shinya Kohashi, Arata Sakai, Keisuke Furumatsu, Takeshi Ezaki, Takao Iemoto, Takeshi Tanaka, Masahiro Tsujimae, Takashi Kobayashi, Atsuhiro Masuda, Yuzo Kodama
DEN Open.2025;[Epub] CrossRef
Endeavors to prevent stent malfunction: new insights into the risk factors for recurrent biliary obstruction
Sung-Jo Bang
Clinical Endoscopy.2024; 57(1): 56. CrossRef
Understanding mechanical properties of biliary metal stents for wise stent selection
Seok Jeong
Clinical Endoscopy.2023; 56(5): 592. CrossRef

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Endoscopic ultrasound-guided gastrojejunostomy with a direct technique without previous intestinal filling using a tubular fully covered self-expandable metallic stent: Hakan Şentürk, İbrahim Hakkı Köker, Koray Koçhan, Sercan Kiremitçi, Gülseren Seven, Ali Tüzün İnce; Clin Endosc 2024;57(2):209-216. Published online July 3, 2023; DOI: https://doi.org/10.5946/ce.2023.022

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Endoscopic ultrasonography-guided gastrojejunostomy is a minimally invasive method for the management of gastric outlet obstruction. Conventionally, a lumen-apposing metal stent (LAMS) is used to create an anastomosis. However, LAMS is expensive and not widely available. In this report, we described a tubular fully covered self-expandable metallic stent (T-FCSEMS) for this purpose.
Methods
Twenty-one patients (15 men [71.4%]; median age, 66 years; range, 40–87 years) were included in this study. A total of 19 malignant (12 pancreatic, 6 gastric, and 1 metastatic rectal cancer) and 2 benign cases were observed. The proximal jejunum was punctured with a 19 G needle. The stomach and jejunum walls were dilated with a 6 F cystotome, and a 20×80 mm polytetrafluoroethylene T-FCSEMS (Hilzo) was deployed. Oral feeding was initiated after 12 to 18 hours and solid foods after 48 hours.
Results
The median procedure time was 33 minutes (range, 23–55 minutes). After two weeks, 19 patients tolerated oral feeding. In patients with malignancy, the median survival time was 118 days (range, 41–194 days). No serious complications or deaths occurred. All patients with malignancy tolerated oral food intake until they expired.
Conclusions
T-FCSEMS is safe and effective. This stent should be considered as an alternative to LAMS for gastric outlet obstruction.

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Tubular fully covered self-expandable metallic stents for endoscopic ultrasound-guided gastrojejunostomy: moving forward or taking a step back?
Rami G. El Abiad, Mouen A. Khashab
Clinical Endoscopy.2024; 57(2): 193. CrossRef
Advances in self-expandable metal stents for endoscopic ultrasound-guided interventions
Dong Kee Jang, Dong Wook Lee, Seong-Hun Kim, Kwang Bum Cho, Sundeep Lakhtakia
Clinical Endoscopy.2024; 57(5): 588. CrossRef
Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy
Sun Gyo Lim, Chan Gyoo Kim
Clinical Endoscopy.2024; 57(5): 571. CrossRef

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Systematic Review and Meta-analysis

No difference in outcomes with 15 mm vs. 20 mm lumen-apposing metal stents for endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a meta-analysis: Shyam Vedantam, Rahil Shah, Sean Bhalla, Shria Kumar, Sunil Amin; Clin Endosc 2023;56(3):298-307. Published online May 22, 2023; DOI: https://doi.org/10.5946/ce.2022.299

Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: We compared outcomes between use of 15 vs. 20 mm lumen-apposing metal stents (LAMSs) in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction.
Methods
Databases were queried for studies that used LAMS for EUS-GE to relieve gastric outlet obstruction, and a proportional meta-analysis was performed.
Results
Thirteen studies were included. The 15 mm and 20 mm LAMS had pooled technical success rates of 93.2% (95% confidence interval [CI], 90.5%–95.2%) and 92.1% (95% CI, 68.4%–98.4%), clinical success rates of 88.6% (95% CI, 85.4%–91.1%) and 89.6% (95% CI, 79.0%–95.1%), adverse event rates of 11.4% (95% CI, 8.1%–15.9%) and 14.7% (95% CI, 4.4%–39.1%), and reintervention rates of 10.3% (95% CI, 6.7%–15.4%) and 3.5% (95% CI, 1.6%–7.6%), respectively. Subgroup analysis revealed no significant differences in technical success, clinical success, or adverse event rates. An increased need for reintervention was noted in the 15 mm stent group (pooled odds ratio, 3.59; 95% CI, 1.40–9.18; p=0.008).
Conclusions
No differences were observed in the technical, clinical, or adverse event rates between 15 and 20 mm LAMS use in EUS-GE. An increased need for reintervention is possible when using a 15 mm stent compared to when using a 20 mm stent.

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Benign biliary stricture caused by transduodenal lumen-apposing metal stent placement for pancreatic acute necrotic collection
Shuhei Shintani, Takuya Okamoto, Kosuke Hiroe, Hidenori Kimura, Hiroto Inoue, Atsushi Nishida, Osamu Inatomi
International Journal of Gastrointestinal Intervention.2025; 14(1): 24. CrossRef
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Chi-Ying Yang, Wen-Hsin Huang, Hsing-Hung Cheng
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Miaomiao Zhang, Jianqi Mao, Jia Ma, Shuqin Xu, Yi Lyu, Xiaopeng Yan
BMC Gastroenterology.2024;[Epub] CrossRef
Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy
Dimitrios Ziogas, Thomas Vasilakis, Christina Kapizioni, Eleni Koukoulioti, Georgios Tziatzios, Paraskevas Gkolfakis, Antonio Facciorusso, Ioannis S. Papanikolaou
Medical Sciences.2024; 12(1): 9. CrossRef
Lumen-apposing metal stents: A primer on indications and technical tips
Sridhar Sundaram, Suprabhat Giri, Kenneth Binmoeller
Indian Journal of Gastroenterology.2024; 43(5): 886. CrossRef
Advances in self-expandable metal stents for endoscopic ultrasound-guided interventions
Dong Kee Jang, Dong Wook Lee, Seong-Hun Kim, Kwang Bum Cho, Sundeep Lakhtakia
Clinical Endoscopy.2024; 57(5): 588. CrossRef
Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy
Sun Gyo Lim, Chan Gyoo Kim
Clinical Endoscopy.2024; 57(5): 571. CrossRef
III BRAZILIAN CONSENSUS STATEMENT ON ENDOSCOPIC ULTRASOUND
Ricardo Rangel de Paula PESSOA, Alexandre Moraes BESTETTI, Victor Lira de OLIVEIRA, Wladimir Campos de ARAUJO, Simone GUARALDI, Rodrigo Roda RODRIGUES SILVA, Francisco Antonio Araujo OLIVEIRA, Maria Sylvia Ierardi RIBEIRO, Fred Olavo Aragão Andrade CARNEI
Arquivos de Gastroenterologia.2024;[Epub] CrossRef
The Role of Luminal Apposing Metal Stents on the Treatment of Malignant and Benign Gastric Outlet Obstruction
Mihai Rimbaș, Kar Wai Lau, Giulia Tripodi, Gianenrico Rizzatti, Alberto Larghi
Diagnostics.2023; 13(21): 3308. CrossRef

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Original Article

Evaluation of the mechanical properties of current biliary self-expandable metallic stents: axial and radial force, and axial force zero border: Wataru Yamagata, Toshio Fujisawa, Takashi Sasaki, Rei Ishibashi, Tomotaka Saito, Shuntaro Yoshida, Shizuka No, Kouta Inoue, Yousuke Nakai, Naoki Sasahira, Hiroyuki Isayama; Clin Endosc 2023;56(5):633-649. Published online April 10, 2023; DOI: https://doi.org/10.5946/ce.2022.201

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Mechanical properties (MPs) and axial and radial force (AF and RF) may influence the efficacy and complications of self-expandable metallic stent (SEMS) placement. We measured the MPs of various SEMSs and examined their influence on the SEMS clinical ability.
Methods
We evaluated the MPs of 29 types of 10-mm SEMSs. RF was measured using a conventional measurement device. AF was measured using the conventional and new methods, and the correlation between the methods was evaluated.
Results
A high correlation in AFs was observed, as measured by the new and conventional manual methods. AF and RF scatterplots divided the SEMSs into three subgroups according to structure: hook-and-cross-type (low AF and RF), cross-type (high AF and low RF), and laser-cut-type (intermediate AF and high RF). The hook-and-cross-type had the largest axial force zero border (>20°), followed by the laser-cut and cross types.
Conclusions
MPs were related to stent structure. Hook-and-cross-type SEMSs had a low AF and high axial force zero border and were considered safest because they caused minimal stress on the biliary wall. However, the increase in RF must be overcome.

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Evaluation of the effect of metal stents on dose perturbation in the carbon beam irradiation field
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Dae Sung Ryu, Hyeonseung Lee, Seung Jin Eo, Ji Won Kim, Yuri Kim, Seokin Kang, Jin Hee Noh, Sanghee Lee, Jung-Hoon Park, Kun Na, Do Hoon Kim
Biomaterials.2025; 320: 123265. CrossRef
The anti‐migration effect of partially covered self‐expandable metal stents for unresectable malignant distal biliary obstruction: A multicenter comparative study
Shinya Kohashi, Arata Sakai, Keisuke Furumatsu, Takeshi Ezaki, Takao Iemoto, Takeshi Tanaka, Masahiro Tsujimae, Takashi Kobayashi, Atsuhiro Masuda, Yuzo Kodama
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Reviews

Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction: Partha Pal, Sundeep Lakhtakia; Clin Endosc 2023;56(2):143-154. Published online February 17, 2023; DOI: https://doi.org/10.5946/ce.2022.198

Abstract PDF PubReader ePub

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

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Feasibility of Endoscopic Ultrasound-Guided Hepaticogastrostomy for Malignant Hilar Biliary Obstruction
Akihisa Ohno, Nao Fujimori, Toyoma Kaku, Yuzo Shimokawa, Tsukasa Miyagahara, Yuta Suehiro, Anthony Gerodias, Shotaro Kakehashi, Kazuhide Matsumoto, Masatoshi Murakami, Keijiro Ueda, Yoshihiro Ogawa
Digestive Diseases and Sciences.2025; 70(1): 419. CrossRef
Percutaneous transhepatic cholangioscopy with cholangiography-guided choledochojejunostomy: a bridge drainage technique for distal common bile duct stenosis after Begerʼs operation
Rui Chen, Jingyi Zhang, Tianhao Chen, Jie Zhang, Rongxing Zhou
Endoscopy.2025; 57(S 01): E304. CrossRef
Novel approach to bilateral biliary drainage: EUS-guided hepaticoduodenodenostomy plus hepaticogastrostomy in malignant hilar biliary obstruction
Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Shota Harai, Daiki Agarie, Daiki Yamashige, Kohei Okamoto, Shin Yagi, Soma Fukuda, Yasuhiro Komori, Masaru Kuwada, Yutaka Saito, Takuji Okusaka
Endoscopy International Open.2025;[Epub] CrossRef
Endoscopic Management of Malignant Biliary Obstruction
Woo Hyun Paik, Do Hyun Park
Gastrointestinal Endoscopy Clinics of North America.2024; 34(1): 127. CrossRef
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Hiroki Sato, Hidemasa Kawabata, Mikihiro Fujiya
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Gang Tang, Jingyi Zhang, Rui Chen, Jie Zhang, Rongxing Zhou
Endoscopy.2024; 56(S 01): E724. CrossRef
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Role of radiofrequency ablation in advanced malignant hilar biliary obstruction: Mamoru Takenaka, Tae Hoon Lee; Clin Endosc 2023;56(2):155-163. Published online January 16, 2023; DOI: https://doi.org/10.5946/ce.2022.218

Abstract PDF PubReader ePub

Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment for biliary malignancies. However, the majority of patients with MHO cannot undergo surgery on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and the quality of life. Among the drainage methods, endoscopic biliary drainage is the current standard for palliation of unresectable advanced MHO. In addition, combined with endoscopic drainage, additional local ablation therapies, such as photodynamic therapy or radiofrequency ablation (RFA), have been introduced to prolong stent patency and survival. Currently, RFA is commonly used as palliative therapy, even for advanced MHO. This literature review summarizes recent studies on RFA for advanced MHO.

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Radiation-emitting metallic stent for unresectable Bismuth type III or IV perihilar cholangiocarcinoma: a multicenter randomized trial
Qi Chen, Nai-Jian Ge, Yu-Liang Li, Ming Huang, Wen-Hui Li, Dong Lu, Ning Wei, Peng-Hua Lv, Jian-Fei Tu, Cheng-Jian He, Wu-Jie Wang, Rong Ding, Bo Peng, Xue-Jun Wang, Fu-An Wang, Guang-Yu Zhu, Yong Wang, Li Chen, Jie Min, Jin-He Guo, Gao-Jun Teng, Jian Lu
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Milan Sigdel, Chengzhi Zhang, Rongna Hou, Mengyao Song, Zhanguo Sun, Dechao Jiao
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Percutaneous endobiliary radiofrequency ablation with stent placement in type IV hilar cholangiocarcinoma: A prospective comparison with stent placement alone
Kun Yung Kim, Chang Jin Yoon, Jae Hwan Lee, Chong-Ho Lee, Jin-Hyeok Hwang, Jaihwan Kim
European Journal of Radiology.2024; 176: 111516. CrossRef
Intraductal ablation therapy for malignant biliary obstruction
Qiyu Zhang, Yanchao Dong, Hongtao Niu
Langenbeck's Archives of Surgery.2024;[Epub] CrossRef
Metastatic Cholangiocarcinoma Presenting as Colonic Obstruction
Yianni Protopapadakis, Kevin Lamm, Joseph Baber
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Is endoscopic radiofrequency ablation plus stent placement superior to stent placement alone for the treatment of malignant biliary obstruction? A systematic review and meta-analysis
Chenming Liu, Jiaming Dong, Yuxing Liu, Siyuan Zhang, Ruanchang Chen, Haijun Tang
Journal of International Medical Research.2023;[Epub] CrossRef

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Original Article

Endoscopic Stenting for Malignant Biliary Obstruction: Results of a Nationwide Experience: Jeanne Lubbe, Gabriel Sandblom, Urban Arnelo, Eduard Jonas, Lars Enochsson; Clin Endosc 2021;54(5):713-721. Published online May 31, 2021; DOI: https://doi.org/10.5946/ce.2021.016

Abstract PDF PubReader ePub

Background
/Aims: Many unanswered questions remain about the treatment of malignant hilar obstruction. We investigated endoscopic stenting for malignant biliary strictures, as reported in a nationwide registry.
Methods
All endoscopic retrograde cholangiopancreatography (ERCP) procedures entered in the Swedish Registry of Gallstone Surgery and ERCP from January 2010 to December 2017 in which stenting was performed for malignant biliary stricture management were included in this study. Patency was estimated by determining the time to reintervention.
Results
Endoscopic stenting was performed for malignant stricture management in 4623 ERCP procedures, of which 1364 (29.5%) were performed for hilar strictures. Of the hilar strictures, 320 (23.5%) were intrahepatic strictures (Bismuth–Corlette III–IV). Adverse events were more common after hilar stenting than after distal stenting (17.2% vs. 12.0%, p<0.0001). The 6-month reintervention rate was 73.4% after hilar stenting compared with 55.9% after distal stenting (p<0.0001). The 6-month reintervention rates for Bismuth–Corlette types I, II, IIIa, IIIb, and IV were 70.4%, 75.6%, 90.0%, 87.5%, and 85.7%, respectively. In multivariate analysis, the risk for reintervention was three times higher after hilar stenting than after distal stenting (hazard ratio 3.47, 95% confidence interval 2.01–6.00, p<0.001).
Conclusions
This study with a relatively large patient cohort undergoing endoscopic stenting confirms that stenting for malignant hilar obstruction has more adverse events and lower patency than stenting for distal malignant obstruction.

Citations

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Risks and use of ERCP during the diagnostic workup in a national cohort of biliary cancer
Anna Forslund, Erik Haraldsson, Erik Holmberg, Peter Naredi, Magnus Rizell
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Yousuke Nakai
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Focused Review Series: Recent Updates on the Role of EUS in Pancreatobiliary Disease

What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy: Tanyaporn Chantarojanasiri, Thawee Ratanachu-Ek, Nonthalee Pausawasdi; Clin Endosc 2021;54(3):301-308. Published online May 28, 2021; DOI: https://doi.org/10.5946/ce.2021.103

Abstract PDF PubReader ePub

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

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Partha Pal, Sundeep Lakhtakia
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Junichi Nakamura, Takeshi Ogura, Saori Ueno, Atsushi Okuda, Nobu Nishioka, Yuki Uba, Mitsuki Tomita, Kimi Bessho, Nobuhiro Hattori, Hiroki Nishikawa
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Original Article

Survival Benefit of Intraductal Radiofrequency Ablation for Malignant Biliary Obstruction: A Systematic Review with Meta-Analysis: Byung Hyo Cha, Myoung-Jin Jang, Sang Hyub Lee; Clin Endosc 2021;54(1):100-106. Published online January 15, 2021; DOI: https://doi.org/10.5946/ce.2020.254

Abstract PDF PubReader ePub

Background
/Aims: Cholangiocarcinoma (CCA) is a rare but aggressive disease with a poor survival. Recent trials have shown improved survival with intraductal radiofrequency ablation (RFA) therapy. We performed a systematic review with meta-analysis to determine the survival benefit of endoscopic RFA for unresectable extrahepatic CCA with malignant biliary obstruction (MBO).
Methods
A systematic search from 1970 to 2020 was performed in MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials. gov. We selected eligible studies reporting relative risks, hazard ratios (HRs), or odds ratios, adjusted by controlling for confounding factors of survival rate and stent patency duration, among patients with extrahepatic CCA with MBO treated with RFA with stent insertion or stent insertion only.
Results
A total of eight trials (three randomized and five nonrandomized) with a total of 420 patients were included in the metaanalysis. Pooled overall survival analysis favored RFA treatment with stent insertion (HR, 0.47; 95% confidence interval [CI], 0.34– 0.64; I²=47%; p=0.09); however, no significant difference was found in the duration of stent patency between the groups (HR, 0.79; 95% CI, 0.57–1.09; I²=7%; p=0.36).
Conclusions
RFA therapy with stent insertion may confer a survival benefit compared with stent insertion only in patients with CCA and MBO.

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Case Report

Early Lumen-Apposing Metal Stent Dysfunction Complicating Endoscopic Ultrasound-Guided Gastroenterostomy: A Report of Two Cases: Janine B. Kastelijn, Veronique Van der Voort, Alderina Bijlsma, Leon M. G. Moons, Matthijs P. Schwartz, Frank P. Vleggaar; Clin Endosc 2021;54(4):603-607. Published online January 13, 2021; DOI: https://doi.org/10.5946/ce.2020.201

Abstract PDF PubReader ePub

Endoscopic ultrasonography-guided gastroenterostomy using a lumen-apposing metal stent has emerged as a novel technique in the palliative treatment of malignant gastric outlet obstruction. Endoscopic ultrasonography-guided gastroenterostomy seems to have the potential to provide long-lasting patency in a minimally invasive manner. Low reintervention rates have been described. We report two cases with early lumen-apposing metal stent dysfunction, compromising patency. One case showed food impaction after three weeks, and hyperplastic tissue overgrowth with a buried distal flange six weeks after stent placement. The latter was successfully treated by argon plasma coagulation, stent removal, and deployment of a larger-diameter lumen-apposing metal stent. The second case showed a narrowed luminal diameter of the stent and jejunal pressure ulcerations after three weeks. The narrowing was successfully treated by balloon dilation. Eight weeks later, hyperplastic tissue overgrowth at the distal flange of the stent and a gastro-colonic fistula were diagnosed, followed by extensive reconstructive surgery.

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Endoscopy.2022; 54(02): 185. CrossRef

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Original Article

Cholecystitis after Placement of Covered Self-Expandable Metallic Stents in Patients with Distal Malignant Biliary Obstructions: Masafumi Watanabe, Kosuke Okuwaki, Jun Woo, Mitsuhiro Kida, Hiroshi Imaizumi, Tomohisa Iwai, Hiroshi Yamauchi, Toru Kaneko, Rikiya Hasegawa, Takahiro Kurosu, Naoki Minato, Hiroki Haradome, Wasaburo Koizumi; Clin Endosc 2021;54(4):589-595. Published online November 17, 2020; DOI: https://doi.org/10.5946/ce.2020.136

Abstract PDF PubReader ePub

Background
/Aims: Cholecystitis can occur after the placement of covered self-expandable metallic stents for distal malignant biliary obstructions. We aimed to identify risk factors for cholecystitis following covered self-expandable metallic stent placement.
Methods
We investigated risk factors related to cholecystitis following covered self-expandable metallic stent placement in 118 patients with distal malignant biliary obstructions between January 1, 2015 and April 30, 2019. Endoscopic assessments and tumor invasion to the arteries feeding the gallbladder were determined by a pancreaticobiliary endoscopist and a radiologist, respectively.
Results
The median patient age was 72 years (men, 61.0%). The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct were observed in 35 (29.7%) and 35 (29.7%) patients, respectively. During the observation period (median, 179 days), cholecystitis occurred in 18 (15.3%) patients. Multivariate analysis revealed the flow of the contrast agent into the gallbladder (p=0.023) and tumor involvement in the orifice of the cystic duct (p=0.005) as significant independent risk factors associated with cholecystitis.
Conclusions
The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct are potential independent risk factors for cholecystitis following the placement of covered self-expandable metallic stents. A follow-up prospective study is warranted to validate their influence.

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Naoki Minato, Kosuke Okuwaki, Masafumi Watanabe, Jun Woo, Takaaki Matsumoto, Masayoshi Tadehara, Toru Kaneko, Junro Ishizaki, Tomohisa Iwai, Hiroshi Imaizumi, Mitsuhiro Kida, Hiroki Haradome, Chika Kusano
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Focused Review Series: Endoscopic Ultrasound-Guided Therapeutic Intervention: Focus on Technique and Practical Tips

Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction: Ryosuke Tonozuka, Takayoshi Tsuchiya, Shuntaro Mukai, Yuichi Nagakawa, Takao Itoi; Clin Endosc 2020;53(5):510-518. Published online September 23, 2020; DOI: https://doi.org/10.5946/ce.2020.151

Abstract PDF PubReader ePub

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

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Case Report

Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review: Arata Sakai, Hideyuki Shiomi, Takao Iemoto, Ryota Nakano, Takuya Ikegawa, Takashi Kobayashi, Atsuhiro Masuda, Yuzo Kodama; Clin Endosc 2020;53(4):491-496. Published online March 3, 2020; DOI: https://doi.org/10.5946/ce.2019.145

Abstract PDF PubReader ePub

In this study, we assessed a series of our cases in which endoscopic self-expandable metal stents (SEMSs) were used to treat malignant afferent loop obstruction (ALO) that arose after pancreaticoduodenectomy (PD). We retrospectively examined the records of 7 patients who underwent endoscopic SEMS placement for malignant ALO following PD. Clinical success was achieved in all cases. The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion, and no procedure-related adverse events were encountered. All patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days). A re-intervention involving endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting was performed for obstructive jaundice and acute cholangitis in 1 case. In conclusion, endoscopic SEMS placement may be an effective and safe treatment for malignant ALO that arises after PD.

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Early and late effects of endoscopic interventions in patients with malignant afferent loop syndrome: A single‐center experience and literature review
Kenjiro Yamamoto, Takao Itoi, Yukitoshi Matsunami, Atsushi Sofuni, Takayoshi Tsuchiya, Shuntaro Mukai, Hiroyuki Kojima, Hirohito Minami, Ryosuke Nakatsubo, Ryosuke Tonozuka
Journal of Hepato-Biliary-Pancreatic Sciences.2024; 31(2): 120. CrossRef
Efficacy of endoscopic ultrasound‐guided gastroenterostomy using self‐expandable metallic stent for afferent loop syndrome: A single‐center retrospective study
Yuya Hagiwara, Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Akihiro Ohba, Yuki Kawasaki, Kotaro Takeshita, Tetsuro Takasaki, Daiki Agarie, Hidenobu Hara, Shin Yagi, Soma Fukuda, Masaru Kuwada, Daiki Yamashige, Kohei Okamoto, Mark Chatto, Shunsuke Kond
Journal of Gastroenterology and Hepatology.2024; 39(10): 2136. CrossRef
Successful metal stent placement using short single-balloon endoscope for afferent loop syndrome after pancreaticoduodenectomy
Takuto Furukawa, Yuichi Takano, Jun Noda, Masataka Yamawaki, Tetsushi Azami, Fumitaka Niiya, Fumiya Nishimoto, Naotaka Maruoka, Masatsugu Nagahama
Progress of Digestive Endoscopy.2024; 104(1): 98. CrossRef
Antegrade metallic stent placement using a slim cholangioscope for malignant afferent loop obstruction
Haruo Miwa, Ritsuko Oishi, Kazuki Endo, Hiromi Tsuchiya, Akihiro Funaoka, Yuichi Suzuki, Shin Maeda
Endoscopy.2024; 56(S 01): E774. CrossRef
The Role of Endoscopic Management in Afferent Loop Syndrome
Clement Chun Ho Wu, Elizabeth Brindise, Rami El Abiad, Mouen A. Khashab
Gut and Liver.2023; 17(3): 351. CrossRef
Simultaneous stent placement for biliary and afferent loop obstruction due to tumor recurrence after pancreatoduodenectomy
Tatsunori Satoh, Hirotoshi Ishiwatari, Kazuma Ishikawa, Hidenori Kimura, Hiroyuki Matsubayashi, Hiroyuki Ono
Endoscopy.2022; 54(09): E524. CrossRef
Extra-anatomic percutaneous stenting of a malignant afferent loop obstruction following pancreaticoduodenectomy
Stefan Lam, Sarah Khan, Robert Hutchins, Tim Fotheringham
International Journal of Gastrointestinal Intervention.2022; 11(2): 77. CrossRef
Endoscopic Transluminal Stent Placement for Malignant Afferent Loop Obstruction
Chinatsu Yonekura, Takashi Sasaki, Takafumi Mie, Takeshi Okamoto, Tsuyoshi Takeda, Takaaki Furukawa, Yuto Yamada, Akiyoshi Kasuga, Masato Matsuyama, Masato Ozaka, Naoki Sasahira
Journal of Clinical Medicine.2022; 11(21): 6357. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 684. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 509. CrossRef
Endoscopic Ultrasound-Guided Gastroenterostomy for Afferent Loop Syndrome
Hideyuki Shiomi, Arata Sakai, Ryota Nakano, Shogo Ota, Takashi Kobayashi, Atsuhiro Masuda, Hiroko Iijima
Clinical Endoscopy.2021; 54(6): 810. CrossRef
Percutaneous- and EUS-guided gastroenterostomy for malignant afferent limb syndrome
Dayyan Adoor, Zachary L. Smith
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111 Download
9 Web of Science
12 Crossref

Focused Review Series: The Roleses of Endoscopy in the Management of Colonic Obstruction and Perforation

Endoscopic Management of Malignant Colonic Obstruction: Seung Young Seo, Sang Wook Kim; Clin Endosc 2020;53(1):9-17. Published online January 7, 2020; DOI: https://doi.org/10.5946/ce.2019.051

Abstract PDF PubReader ePub

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

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S.A. Aliyev, E.S. Aliyev, T.K. Aliyev
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Ahmad F. Aboelezz, Mohamed O. Othman
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Efstathios T Pavlidis, Ioannis N Galanis, Theodoros E Pavlidis
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Challenges associated with low rectal malignant obstruction stenting: a case report
Victor Cabrera-Bou, Eddy P Lincango, Alessandra E Cabrera, Gabriel Diaz-Pagan, Nathan Kostick, Noah Sobel, Luis F Serrano, Philip Kondylis
Journal of Surgical Case Reports.2024;[Epub] CrossRef
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Alexander Worix, Rajesh N. Keswani
Gastroenterology Clinics of North America.2024; 53(4): 587. CrossRef
EVALUATION OF THE RESULTS OF USING ENDOSCOPIC METHODS AS THE FIRST STAGE OF TREATMENT OF PATIENTS WITH COMPLICATED FORMS OF COLON CANCER
M. A. Kubrak, S. M. Zavgorodnii, M. B. Danilyk
Bulletin of Problems Biology and Medicine.2024; 1(3): 149. CrossRef
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Saday A. Aliyev, Emil S. Aliyev
Russian Journal of Oncology.2024; 29(2): 130. CrossRef
USING OF ENDOSCOPIC METHODS IN THE TREATMENT OF PATIENTS WITH COMPLICATED FORMS OF COLON CANCER
M. A. Kubrak , S. M. Zavgorodnii , M. B. Danilyk
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Hideyuki Suzuki, Shingo Tsujinaka, Yoshihiro Sato, Tomoya Miura, Chikashi Shibata
World Journal of Clinical Oncology.2023; 14(1): 1. CrossRef
Effectiveness and early postoperative outcomes of palliative endoluminal stenting versus Hartmann’s procedure in acute malignant bowel obstruction in high-risk patients
Mohammed Fayek Mahfouz, Tamer M. Saeid Salama, Amr H. Afifi, Hany Mansour Khalil Dabous
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Silvia Inés Guerrero Macías, Ada Bustos-Guerrero, Andres Felipe Chaparro-Zaraza
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Predictors of clinical outcomes of self-expandable metal stent treatment for malignant colorectal obstruction
Bora Han, Ji-Yun Hong, Eun Myung, Hyung-Hoon Oh, Hee-Chan Yang, Sang-Wook Kim, Jun Lee, Seong-Jung Kim, Yeom-Dong Han, Geom-Seok Seo, Gun-Young Hong, Ho-Dong Kim, Hyun-Soo Kim, Young-Eun Joo
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Digestive Diseases and Sciences.2020; 65(10): 2789. CrossRef

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14 Crossref

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction: Su Jin Jeong, Jongha Park; Clin Endosc 2020;53(1):18-28. Published online October 24, 2019; DOI: https://doi.org/10.5946/ce.2019.058

Abstract PDF PubReader ePub

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

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Yusheng Feng, Yufeng Chen, Ying Chen, Xiaowen He, Yousef Khan, Hong Hu, Ping Lan, Yi Li, Xiaoqin Wang, Gang Li, David Kaplan
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Kristen M. Westfall, Robert K. Cleary
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James Emmanuel, Sattian Kollanthavelu, Fitjerald Henry, Lee Tiong See
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Mary R. Kwaan, Yang Ren, Yuqi Wu, Sudha Xirasagar
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11,274 View
374 Download
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9 Crossref

Review

Review of Simultaneous Double Stenting Using Endoscopic Ultrasound-Guided Biliary Drainage Techniques in Combined Gastric Outlet and Biliary Obstructions: Hao Chi Zhang, Monica Tamil, Keshav Kukreja, Shashideep Singhal; Clin Endosc 2020;53(2):167-175. Published online August 13, 2019; DOI: https://doi.org/10.5946/ce.2019.050

Abstract PDF PubReader ePub

Concomitant malignant gastric outlet obstruction and biliary obstruction may occur in patients with advanced cancers affecting these anatomical regions. This scenario presents a unique challenge to the endoscopist in selecting an optimal management approach. We sought to determine the efficacy and safety of endoscopic techniques for treating simultaneous gastric outlet and biliary obstruction (GOBO) with endoscopic ultrasound (EUS) guidance for biliary drainage. An extensive literature search for peer-reviewed published cases yielded 6 unique case series that either focused on or included the use of EUS-guided biliary drainage (EUS-BD) with simultaneous gastroduodenal stenting. In our composite analysis, a total of 51 patients underwent simultaneous biliary drainage through EUS, with an overall reported technical success rate of 100% for both duodenal stenting and biliary drainage. EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy was employed as the initial technique. In 34 cases in which clinical success was ascribed, 100% derived clinical benefit. The common adverse effects of double stenting included cholangitis, stent migration, bleeding, food impaction, and pancreatitis. We conclude that simultaneous double stenting with EUS-BD and gastroduodenal stenting for GOBO is associated with high success rates. It is a feasible and practical alternative to percutaneous biliary drainage or surgery for palliation in patients with associated advanced malignancies.

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Woo Hyun Paik, Do Hyun Park
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Kejie Mao, Binbin Hu, Feng Sun, Kaiming Wan
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Rajesh Krishnamoorthi, Shivanand Bomman, Petros Benias, Richard A. Kozarek, Joyce A. Peetermans, Edmund McMullen, Ornela Gjata, Shayan S. Irani
Endoscopy International Open.2022; 10(06): E874. CrossRef

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