Endoscopic ultrasound (EUS) plays a key role in the diagnosis and treatment of biliopancreatic and gastrointestinal diseases. The aim of this study was to assess the training needs of endoscopists in EUS through an anonymous survey and to identify the main challenges in order to guide the development of appropriate training programs. Materials and Methods: We conducted a cross-sectional, prospective, descriptive, and analytical study using an anonymous online survey completed by over 100 endoscopists practicing or training in EUS.Training needs were assessed using the FGP grid (Frequency, Gravity, Problems) across seven items.Each item was evaluated based on its frequency (scored 0–2), severity (0–2), and related difficulties in knowledge, skills, and attitudes (0, 2, 4). Data were analyzed using Jamovi software,version 2.4. Results: A total of 72 responses from 23 countries across five continents were analyzed. Among participants, 59.7% were male. The majority(51.4%)were aged between 30–40years, and 31.9% were between 40–50 years.While 47.2% had over 10 years of endoscopy experience, only 36.1% had more than 5 years of experience in EUS. EUS equipment was available in 87.5% of training centers; however, only 56.9% of participants had received formal training. Reported training modalities included: hands-on training with patients (66.7%), university or inter-university diplomas (50%), webinars or online courses (38.9%), hands-on training using models or animals (31.9%), and certification programs (26.4%).The most preferred methods were hands-on training with patients (86.1%) and university diplomas (44.4%).More than half of respondents (55.6%) considered their training insufficient. According to the FGP grid, the most commonly reported difficulties involved practical skills, followed by theoretical knowledge,particularly in EUS image interpretation. Interventional procedures and image interpretation were the most challenging area. Participants who had received hands-on training with patients reported fewer practical difficulties compared to those who did not. Conclusion: EUS is a crucial diagnostic and therapeutic tool, especially for biliopancreatic diseases.Our international survey highlighted significant training needs, particularly in interventional EUS and image interpretation. The findings emphasize the importance of practical exposure, with hands-on training proving to be the most effective and preferred method.

AIMS: We report our experience on EUS-guided portal pressure gradient measurement (EUS-PPGm). METHODS Prospective study of patients referred for EUS-PPGm. A 25G dedicated needle was used. A 19G FNA needle was used for EUS-guided bilobar liver biopsy (EUS-BLB). Following baseline EUS-PPGm, 0.15 mg/kg of body weight, propranolol was administered intravenously by continuous infusión and the EUS-PPGm repeated 15 minutes later. RESULTS EUS-PPGm was performed in 70 patients. Indications: Assessment of MASLD in morbid obese patients: 43. Portal hypertension (PH): 20. Evaluation for curative therapy in hepatocellular carcinoma (HCC): 3. Acute response to intravenous propranolol: 4. Additional procedures were performed in the same endoscopic session: Fifty-one (73%) EUS-BLB, 3 band ligation for esophageal varices and 1 EUS-guided coil therapy for gastric varices. EUS-PPGm was obtained in 63/70 patients (90%). In 12/43 morbid obese patients (28%) the EUS-PPGM was >6 mmHg without varices nor fibrosis on EUS-BLB. In morbid obese patients, there was a statistically significant difference in the S3 score of steatosis in the group of portal hypertension (33%) in comparison with the no portal hypertension group (4%). Patients were treated accordingly with the results of EUS-PPGm. A significant reduction of PPG in 2 patients treated with intravenous propranolol [10.5 mmHg to 4.75 mmHg (22%) and 10 mmHg to 2 mmHg (20%), respectively] was observed. In the other two the PPG was normal, avoiding chronic use of beta-blockers. In 7 cases (10%) EUS-PPGm was not obtained. For rapid breathing movements (1 case) and for non-reliable pressure measurements (6 cases). In one case the 25G needle passed in close proximity to the hepatic artery. We experienced difficulty in punction the hepatic and the portal vein in one and two cases, respectively. In one case the 25G needle failed to transverse the liver capsule. Mean time to obtain EUS-PPGm 24±2 minutes for EUS-BLB 17±2 minutes and for combined EUS-PPGm plus EUS-BLB 45±2 minutes. Three adverse events were observed: 1 mild epigastric pain, 1 self-limited bleeding from the cardias and 1 atrial fibrillation. CONCLUSIONS EUS-PPGm, even combined with EUS-BLB, seems safe, providing relevant clinical information. A notewhorty proportion of morbid obese patients were precociously diagnosed of portal hypertension in early reversible stages without liver fibrosis on EUS-BLB. Acute response to intravenous propranolol can be obtained with EUS-PPGm

Background Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an established treatment for malignant gastric outlet obstruction (GOO), but its role in benign GOO remains less defined. Methods: We performed a retrospective analysis of a prospectively maintained national database of patients who underwent EUS-GE for benign GOO from 2022 to 2025. Primary outcome was technical success; secondary outcomes included clinical success (measured by the Gastric Outlet Obstruction Scoring System), time to oral intake, and adverse events (AEs). Results: Ten patients (6 females; median age: 48 years) with benign GOO were included. Etiologies were acute pancreatitis (n=3), superior mesenteric artery syndrome (n=2), duodenal peptic stricture (n=2), duodenal tuberculosis (n=1), pancreatic serous cystadenoma (n=1), and angulation of the Roux limb after subtotal gastrectomy (n=1). Technical and clinical success were 100%, with all patients achieving a GOO score of 3 at 48 hours and 30 days (P<0.01). No early AEs (<30 days) occurred; one late AE (>30 days) a gastro-entero-colic fistula requiring surgical intervention. Median time to oral intake was 9 hours. All patients were followed for >3 months with no reinterventions. Lumen-apposing metal stents (LAMS) used were 15 mm (n=7) and 20 mm (n=3). Conclusion:EUS-GE is a safe and effective option for managing benign GOO in varied clinical contexts.

Background: Endoscopic ultrasound- guided gastroenterostomy (EUS-GE) is a new treatment modality for gastric outlet obstruction, demonstrating advantages over enteral stenting and surgical bypass. The procedure is used also for new indications such as afferent loop syndrome. The majority of reported procedures have been performed with only one electrocautery- enhanced lumen-apposing stent (LAMS) and data about other LAMSs are scarce. Aim: To evaluate the safety and efficacy of EUS-GE using a novel electrocautery- enabled LAMS (Niti-S Hot SPAXUS, Taewoong Medical, Goyang, South Korea). Primary endpoints were adverse events (AEs) and factors associated with their occurrence. Secondary endpoints were technical success (establishment of an anastomosis), clinical success (tolerating semisolid food at 48 hours), procedure time, hospital stay and long term follow up data on symptom relief. Methods: Retrospective single center study over a 2-year period. Demographic characteristics, procedure-related and follow-up data were collected. Results: Thirty-seven patients were included. The most common indication was malignancy (81.1%). Technical success was achieved in 100%. Stent misdeployment occurred in 8.1% and was more frequent in younger and female patients (p=0.0068; p=0.0079 respect.). No association with etiology, site of obstruction, technique, shape of target loop, presence of ascites, previous interventions or surgically altered anatomy was found. All the cases were salvaged endoscopically. Stent misdeployment did not prolong the hospital stay (p= 0.481). There were no immediate AEs (<7 days) reported. The rate of short-term AEs (<30 days) was 12.5% (n=4) occurring more frequently in the presence of ascites (p=0.078). Long-term AEs (>30 days) were reported in 17.9% with higher frequency in benign indications. The clinical success was 94.6% with 63.9% remaining alive at follow-up and 57.6% of them still tolerating regular diet. At six months 81.8% are still eating normally. Conclusions: EUS-GE using a novel electrocautery- enabled LAMS is a safe and effective procedure. Many patients tolerate normal diet at long term follow-up. Stent misdeployment does not affect the outcome and is most probably related with the learning curve.

INTRODUCTION Endoscopic ultrasound (EUS) is an important tool for the diagnosis and characterization of esophageal lesions, but impassable upper esophageal strictures may limit its use. OBJECTIVE This case describes an innovative use of EUS to characterize an esophageal lesion located just below the upper esophageal sphincter. DISCUSSION We report the case of a 66-year-old man with an esophageal stricture located 22 cm from the incisors, impassable with a standard endoscope but passable using an ultrathin endoscope. The stricture had a millimetric diameter and length, with normal-appearing mucosa, suggestive of extrinsic compression. Initial histology was inconclusive. Complementary imaging (CT, ¹⁸F-FDG PET, and MRI) revealed circumferential wall thickening suggestive of a metabolically active esophageal neoplasm at the cervical–thoracic esophageal junction. Due to complete dysphagia caused by the stricture, a surgical gastrostomy was performed. Simultaneously, a retrograde upper gastrointestinal EUS was carried out via the gastrostomy, with the aim of characterizing the lesion. Advancement to the level of the stricture revealed a hypoechoic, hypovascular lesion (21 × 17.8 mm) with a predominantly blue elastography pattern, suggesting extraluminal growth and disruption of the esophageal wall layers. FNA (25G) and FNB (22G) needle biopsies were performed, and adequate material was obtained. Histopathological analysis showed multiple small fragments of esophageal mucosa with esophagitis and glycogenic acanthosis, without evidence of malignancy. The cell-block and immunocytochemistry showed bundles of smooth muscle tissue (AML+), with no epithelial cells observed. Subsequent sampling via EBUS revealed findings compatible with esophageal squamous cell carcinoma. CONCLUSION This case illustrates an innovative application of EUS, and according to the authors' literature review, it is the first reported case of retrograde upper gastrointestinal EUS, including illustrative iconography. A multidisciplinary approach was crucial to overcome anatomical limitations and to enable the use of this essential diagnostic tool for an esophageal neoplastic stricture

Background: Endoscopic ultrasound-guided elastography (EUS-elastography) is a non-invasive method for assessing tissue stiffness, with potential utility in differentiating pancreatic lesions. The two main semi-quantitative approaches are Strain Ratio (SR) and Strain Histogram (SH). This study aims to compare their diagnostic accuracy in distinguishing pancreatic adenocarcinoma (PDAC) from pancreatic neuroendocrine tumor (pNET). Methods: A prospective, single-center study enrolled patients undergoing EUS-elastography as part of standard evaluation for solid pancreatic lesions between October 2024 and March 2025. Only cases with confirmed PDAC or pNET were included. Each patient underwent SR and SH analysis and fine-needle biopsy (FNB). Diagnostic cut-offs used were SR >10 and SH <50 as indicative of malignancy. Results: Eighteen patients were included (median age 65.5 years; M:F = 6:12), with 9 PDAC and 9 pNET. Lesions predominantly appeared blue on qualitative analysis (66.6%), with an average of 3.6 images acquired per case. Mean SR was higher in PDAC (12.57 ± 5.96) than in pNET (9.02 ± 5.69), but not statistically significant (p = 0.13). In contrast, SH was significantly lower in PDAC (19.39 ± 9.76) than in pNET (47.59 ± 25.94; p = 0.006). Using standard cut-offs, 77.8% of PDAC and 33.3% of pNET exceeded SR >10, while SH <50 was observed in 100% of PDAC and 77.8% of pNET. ROC analysis showed superior performance for SH (AUC = 0.89) over SR (AUC = 0.72), though the difference was not statistically significant (ΔAUC = 0.173; p = 0.245), likely due to small sample size. Conclusion: Preliminary results suggest that EUS-elastography, particularly SH analysis, may aid in differentiating PDAC from pNET. While SH demonstrated better diagnostic accuracy than SR, further studies with larger cohorts are needed to validate these findings and assess clinical applicability.

Cholecystectomy is the gold standard for acute cholecystitis, but in patients with contraindications or failed surgery, alternative drainage approaches are required. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as an effective minimally invasive option in high-risk patients. We report a case of a 54-year-old woman with acute cholecystitis complicated by a dense phlegmon, who underwent two failed surgical attempts. A prolonged percutaneous drain resulted in a persistent cholecysto-cutaneous fistula. Given the chronic inflammation and persistent fistula, the multidisciplinary team proposed EUS-GBD. The procedure required technical adaptations due to a collapsed gallbladder and active fistula. Fistula occlusion using a balloon allowed for gallbladder distension and successful placement of a 15 x 10 mm lumen-apposing metal stent (LAMS). After initial improvement, LAMS migration occurred, requiring endoscopic removal and return to percutaneous drainage. Definitive management included surgical closure of the fistula. This case illustrates that EUS-GBD may serve as a viable rescue strategy after surgical failure. Prior drains and altered anatomy present challenges but can also facilitate access. A tailored approach and advanced expertise are essential, as complications such as stent migration may limit success.

Metastatic lesions to the pancreas are rare, accounting for 3–5% of all pancreatic lesions. In lung cancer, pancreatic metastasis occurs in approximately 1% of patients with distant spread, most often from adenocarcinoma; squamous cell histology is even less common. Diagnosis is challenging, as these lesions can mimic primary pancreatic tumors. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is the gold standard in the diagnosis. We present a 56-year-old man with a history of stage IIIB squamous cell carcinoma of the lung, treated with chemoradiotherapy. On follow-up PET-CT, there was evidence of disease progression with a hypermetabolic left lung mass, mediastinal lymphadenopathy, and a 52 mm hypermetabolic lesion in the pancreatic body-tail (SUVmax 11.4). EUS revealed a large, predominantly hypoechoic mass in the pancreatic body-tail, measuring 48 mm, with blue/green elastography pattern and splenic vessel involvement. Three transgastric passes were performed using a 22G needle with the slow-pull technique. Cytology demonstrated squamous cell carcinoma (p40+,p63+), confirming pancreatic metastasis from lung cancer. PD-L1 expression was positive. The patient was started on first-line metastatic therapy (carboplatin+paclitaxel+pembrolizumab). Pancreatic metastases from squamous cell lung carcinoma are exceedingly rare and may be radiologically indistinguishable from primary pancreatic cancer. EUS-FNB allows definitive diagnosis and is essential for guiding management.

Lumen-apposing metal stents (LAMSs) are widely used for endoscopic ultrasound (EUS)-guided drainage of pancreatic collections (PCs), yet the optimal timing for stent removal remains unclear. We conducted a retrospective multicenter study of patients undergoing LAMS placement for symptomatic PCs across three Portuguese hospitals (2018–2024), comparing early (<4 weeks) versus late (≥4 weeks) removal. Demographic, clinical, and procedural variables, as well as outcomes, were analysed. Forty-seven patients were included (mean age 65.9 ± 13.6 years), with biliary pancreatitis as the predominant etiology. Forty-eight LAMSs were placed, 72.3% for walled-off necrosis (WON) and 27.7% for pseudocysts (PC), with a mean collection size of 12.8 ± 5.5 cm. Technical success was 97.8%. In the early removal group (n=26), the mean dwell time was 19.1 days. Adverse events occurred in 11.5% of patients, with a clinical success rate of 92.3%. Collections averaged 11.5 cm in diameter, with WON in 62.5% and PC in 23.8% of cases. In the late removal group (n=21), the mean dwell time was 45.9 days. Adverse events occurred in 5.5% of patients, with a clinical success rate of 60%. Collections were larger (mean 15.4 cm), with WON in 85.7% and PC in 14.3% of cases, and extension to the paracolic gutters in 95.2%. Although early removal was associated with higher clinical success, late removal cases involved larger, more complex collections, which likely contributed to the lower success despite similar AE incidence. Adverse event rates did not differ significantly between groups (p>0.05). These findings suggest that removal timing alone does not determine clinical outcomes and should be interpreted alongside baseline disease severity. An individualized, patient-tailored approach—rather than adherence to fixed temporal thresholds—appears most appropriate.

Background and Aim: Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is an advanced, minimally invasive procedure primarily indicated in patients with malignant gastric outlet obstruction (GOO) as an alternative to traditional enteral stenting or surgery. EUS-GE are generally performed in expert centers with a technical success rate ranging from 92% to 100%, a clinical success rate of around 90%, and 11%–12% of adverse events (AEs). However, this study aims to describe our experience in a single peripherical center. Methods: Retrospective evaluation of the results of EUS-GE performed in a single peripherical center from November 2021 to November 2024, including EUS-direct trans-enteric endoscopic retrograde cholangiopancreatography (EDEE). Wireless endoscopic simplified technique (WEST) and direct technique over a guidewire (DTOG) for EUS-GE are applied. Results: A total of 20 patients (15:5,M:F), median age of 76 years old (36-90) were included. All patients were symptomatic with nausea, vomiting, and inappetence with evidence of GOO. In 15 cases (75%), EUS-GE was performed in an advanced oncological setting: 6 patients presenting with pancreatic cancer, 4 with gastric cancer (including 1 EDEE in a recurrence case after Roux-en-Y gastrectomy), 3 with ampullary/duodenal cancer, 2 with carcinosis due to colon cancer. The remaining 5 patients underwent EUS-GE for EDEE (1 case) or refractory benign GOO: 2 due to stenosing peptic ulcer not responding to other treatments; 2 due to pancreatitis-related duodenal strictures. WEST was used in 18 cases and DTOG in 2. A 20x10 mm lumen apposing metal stent (LAMS) was used in all cases. Technical success was reached without AEs in 90% of cases (18). In 2 cases (10%) a distal flange maldeployment (both DTOG) was recognized and solved in the same session: prolonging the LAMS with an esophageal fully covered metal stent in one case and bridging with another LAMS performing natural orifice transluminal endoscopic surgery in the other one. Median EUS-GE procedural time was 55 minutes (40-200). Clinical success was 100%. Six patients (30%) died for oncological progression after a median of 135 days (30-510). Conclusion: EUS-GE is a challenging endoscopic procedure with high technical and clinical success described in tertiary care centers. Our results showed reasonable technical and clinical success even in peripheral centers if capable of recognizing and managing intra-procedural complications.