Background: EUS-guided pancreatic duct drainage (EUSPDD) is an endoscopic procedure which is indicated in symptomatic patients with evidence of pancreatic duct obstruction after failure of transpapillary drainage or impossibility to perform EWSL in the contest of chronic pancreatitis or altered anatomy causes (Whipple or Roux-en-Y surgery for example). Nowadays, it is a challenging procedure performed by few endoscopist. Clinical and technical success rate is still lacking and heterogenous, therefore acquisition of new data and experience is necessary. Material & Methods: This is a retrospective observational single-center study including patients (pts) undergone EUSPDD from March 2018 to July 2023 using plastic stent (7Fr 10cm), delivered with an electrocautery-enhanced catheter, after transpapillary drainage failure. Also, it was evaluated exocrine pancreatic function by fecal elastase (FE-1) and nutritional markers (prealbumin and magnesium). Results: Total of 15 pts (M:F=11:4) with median age of 72 years old. 13 pts (86.6%) had a chronic pancreatitis diagnosis with radiological evidence duct pancreatic alterations (5 stenosis, 3 lithiasis, 4 both, 1 duct rupture); 2 pts had a post-surgical stenosis. All pts were symptomatic: 6 pts (40%) shows multiple episodes of acute pancreatitis and 9 (60%) had abdominal pain non responder to medical therapy. Pancreatic duct had median dilatation of 7 mm (4-15.6 mm). Every transmural access was performed through gastric wall with single plastic stent (7Fr 10cm) placement. Technical success was obtained in 11 pts (73%) of which 2 pts had early stent migration and in 4 pts (26.6%) EUSPDD was failed. No other adverse events. 13 (86.6%) had a condition of pancreatic exocrine insufficiency with FE-1 < 200 µg/g in 8 pts and < 100 µg/g in 5 pts under pancreatic enzyme replacement therapy. Magnesium median value was 0.74 mmol/L (0.5-0.8 mmol/L) and prealbumin median value was 0.22 g/L (0.11-0.26 g/L), both at the low normal serum level. During clinical follow up, pts undergone to EUSPDD had no pain, improvement of general quality of life and nutritional markers. Conclusion: EUSPDD still remain a challenging endoscopic procedure indicated only for selected cases and performed by expert endoscopist. However, EUSPDD seems to have a reasonable clinical success rate but we need further data to improve endoscopic experience and clinical awareness.

INTRODUCTION Endoscopic ultrasound (EUS)-guided pseudocyst drainage is nowadays a a standard first-line therapy procedure with minimal morbidity and mortality. Although the use of EUS Doppler techniques has enhanced the safety of transmural puncture by helping avoid major vessels, immediate complications such as bleeding still occur in 1-2% of cases, due to the fact that vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler. CASE REPORT A 63-year-old man was referred to our hospital with abdominal pain and distension resulting from a history of pancreatic pseudocyst (PPC). Abdominal contrast-enhanced computed tomography, MRCP and endoscopic ultrasound examinations showed a pseudocyst in the tail of pancreas. Good adhesion was noted between the cyst wall and the posterior gastric wall. EUS imaging was used to determine the cyst puncture site and confirm the lack of intervening vessels. A 19-gauge needle was employed to perform the primary PPC puncture and access the cavity, which helped to create a fistula between the PPC and gastric lumen. A 0.035 in hydrophilic guidewire was inserted through the needle and then coiled into the cyst cavity. The needle was withdrawn, while the guidewire remained in the cyst. Next, a 6F cystotome was utilized to dilate the fistula. Unfortunately, after we removed the cystotome, an acute hemorrhage surrounding the fistula occurred. Under EUS, we noted a significant spurting (pulsatile) arterial bleeding started from the puncture level inside the pseudocyst, being easily visible on the gray-scale mode, with minimal intragastric bleeding and the blood flow was similar to a stream. The electrocautery-assisted cystotome was replaced and used to cauterize the bleeding vessel, successfully stopping the hemorrhage. In our case, the sudden spurting arterial bleeding was most probably caused by the blade which extends in the tip of the 19G trocar, probably by damaging concealed vessels at the internal wall of the pseudocyst, which were not visible initially, but were probably decompressed during EUS-guided drainage Conclusion Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler. Electrocautery-assisted cystotomes may represent a useful tool for the successful treatment of bleeding during EUS-guided drainage.Video case available

Introduction and Objectives: Pancreatic collections (PC) are a common local complication of acute pancreatitis (AP), often requiring drainage if symptomatic or infected. Management of symptomatic PC involves surgical, percutaneous, and endoscopic drainage. The study aimed to evaluate the effectiveness and safety of Endoscopic ultrasound (EUS) - guided drainage using metallic stents for managing PC. Material: This retrospective study included adult patients with symptomatic PC who underwent EUS–guided drainage with a LAMS at our hospital between 2017 and first 6 months of 2024. Evaluation variables included demographic data, imaging findings, technical success (correctly placement of LAMS), clinical success (symptomatic resolution and reduction in PC size), number of additional interventions, stent removal time, and complication rates. Results: The study included 13 patients (8 male; mean age 66 ± 12,61 years), with a total of 14 metallic stents placed (3 pseudocysts and 10 encapsulated necrotic collections). The most common indications for intervention were infection, followed by abdominal pain and gastric outlet obstruction. The mean size of the collections was 15 ± 6,43 cm. The largest walled-off necrosis (WON) (30 cm) required sequential placement of 2 metallic stents. Stent types included 5 Hot AXIOS®, 2 NAGI®, and 7 Hot SPAXUS®. The technical success rate was 100%, and the clinical success rate was 71.43%. Necrosectomy sessions were performed in 8 patients, averaging 1,86 sessions per patient. The mean time to stent removal was 34 days. Within 3 months post-stent removal, 1 patient required endoscopic placement of plastic stents. Complications occurred in 2 patients: one case of intra-gastric stent migration and one mild acute pancreatitis episode. There were no procedure-related mortalities. Additionally, two patients required surgical intervention: one underwent necrosectomy, and unfortunately, one patient died before surgery. Conclusions: Our study showed that LAMS are effective and safe for endoscopic drainage of PC. The high technical success rate and favorable clinical outcomes, coupled with a relatively low incidence of adverse events, highlight LAMS as a reliable option in managing symptomatic PC. The importance of timely stent removal to minimiza potential complications is emphasized. Moving forward, we plan to conduct a multicenter study to validate these findings across diverse patient populations.

Introduction: Endoscopic ultrasound-guided tissue sampling plays a central role in the accurate diagnosis of solid pancreatic lesions and is considered currently the safest and most efficient diagnostic technique. The aim of our study was to compare the diagnostic yield of FNA needles with FNB needles in solid pancreatic lesions. Aims & Methods: We conducted a retrospective and analytical study between January 2022 and June 2024. We included all patients with solid pancreatic lesions who underwent an endoscopic ultrasound-guided sampling. Three types of needles were used: 1- 22G fine needle aspiration (FNA) needles, 2- 19G FNA needles and 3- newer generation 20G fine needle biopsy (FNB) needles. For each patient, we performed an average of two needle passes, with fanning systematically performed. Additionally, suction was used during sampling with FNA needles and we evaluated the quality of all the samples by Macroscopic On-Site Evaluation (MOSE) (presence of white core tissue). Results: 54 patients were included in our study. The mean age was 59.6 +/- 15 years. The sex ratio was 1.5. 23 patients underwent UES-FNA, while 31 patients underwent EUS-FNB. In our series, the overall diagnostic yield of EUS-guided sampling was 63.6%. 88.2% of biopsies performed using FNB needles were conclusive compared to 31.7% when FNA needles were used. The diagnostic accuracy of 19G FNA needles was 81%. In pairwise comparison, the presence of adequate tissue core was significantly higher in the FNB group (p-value=0.006). In multivariate analysis, after adjusting for covariates (age, sex, size of the pancreatic mass on endoscopic ultrasound examination, and type of needle used), only the size of the lesion (p=0.04) and the use of newer generation FNB needles (p=0.03) were associated with obtaining a positive histopathological diagnosis. The anatomical location of the lesion (head/body/tail) did not influence the diagnostic accuracy (p value = 0,5). No complications were reported in both techniques. Conclusion: Newer generation FNB needles appear to offer a greater diagnostic performance in the sampling of solid pancreatic masses when Rapid On-Site Evaluation is not available. These results have immediate clinical practice implications and could help endoscopists meet the quality indicator threshold of having a sensitivity that equals or exceeds 85%, as advocated by European and American societies of gastroenterology.

Introduction Hepatic hydatid cyst usually runs asymptomatically, while clinical symptoms, are usually due to complications that supervene. The most commonly encountered complication is rupture into the biliary tree with secondary biliary obstruction by intracystic material and cholangitis. The aim of our study is to evaluate the contribution of endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnostic and particularly therapeutic management of ruptured liver hydatid cysts in the bile ducts. Methods We conducted an ambispective descriptive study, from January 2014 to June 2024, which included 55 patients with a hydatid cyst fistulized in the bile ducts. ERCP and endoscopic sphincterotomy were performed in all patients. Overall success was defined by definitive vacuity of the main bile duct. Results Among the ERCPs performed in our department during the study period, 4.2% (n = 55) were for a hepatic hydatid cyst communicating with the bile ducts. The mean age was 46.1 ±14.8 years with a male predominance of 66%. For our 55 patients included in the study, ERCP was performed in 56% of cases before surgical management of hydatid cyst, and in 44% postoperatively. ERCP was indicated for acute cholangitis in 44.9% of the cases and for persistent external biliary fistula in 34% of the cases. The median bile duct diameter was 10mm[7-14] and the median cyst diameter was 35mm[26-47]. Sphincterotomy was performed in 96% of patients allowing extraction of hydatid material by balloon or Dormia in 87.8% of the cases. Nevertheless 20% required naso-biliary drainage and 8% benefited from biliary stent placement. The overall success rate was 97% (n=53). The immediate complication rate was 7%(n=4), 1 patient had hemobilia and 3 patients had edge bleeding. The evolution was marked by the disappearance of jaundice after 5 to 10 days and by the drying up of the external biliary fistula after 10 days. Conclusion Our study confirms that endoscopic treatment of ruptured hydatid cyst in the bile ducts is an effective therapeutic procedure, with a low rate of immediate complications and a good long-term evolution.

Introduction Dilated commun bile duct is frequently found on abdominal ultrasound of CT scans. Endoscopic ultrasonography (EUS) is an effective diagnostic tool that enables direct vizualisation of the CBD and adjacent biliopancreatic structures. The aim of this study was to review the role of endoscopic ultrasonography (EUS) in assessing the etiology of unexplained common bile duct dilatation when conventional imaging was non conclusive. Methods This is a retrospective descriptive study conducted from January 2015 to June 2024, including 59 patients with intra-and/or extra-hepatic bile duct dilatation in the absence of any obstructive lesion. TODANI classification was considered for common bile duct (CBD) cystic dilatations. Results We enrolled 59 patients responding to inclusion criteria, which represented 10% of all indications of EUS. The mean age of our patients was 60±12,30 years, with a female predominance. EUS showed a dilated CBD in 56,9% of cases with a double duct sign in 5,9% of cases. The main diagnoses revealed were a cystic dilatation of CBD in 43,1%, predominated by type Ia and Ib in 38,1% and 4% respectively, a choledocholithiasis in 5.9% of the cases, an ampulloma in 3,9% of cases, and papillomatosis of the bile ducts in 2% of cases. The pancreatic head cancer was suspected during echo-endoscopy and then confirmed histologically in 3% of patients. However, EUS examination allowed us to exclude the diagnosis of biliary ducts dilatation in 41% of our patients. No complications were recorded secondary to the procedure. Conclusion EUS is a minimally-invasive safe tool with a good diagnostic accuracy in CBD dilations without obvious etiology on conventional imaging.