Digestive Endoscopy最新文献

{"title":"Strengthening Data Validation in the Japan Endoscopy Database","authors":"Naoki Ishii, Yasutoshi Shiratori, Fumio Omata","doi":"10.1111/den.70328","DOIUrl":"10.1111/den.70328","url":null,"abstract":"","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149328012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Stone Removal, Drainage Alone, or No ERCP? Choosing a Strategy for Bile Duct Stones in the Very Elderly","authors":"Mamoru Takenaka, Masatoshi Kudo","doi":"10.1111/den.70310","DOIUrl":"10.1111/den.70310","url":null,"abstract":"<p>In aging societies, the number of very elderly patients with bile duct stones for whom endoscopic retrograde cholangiopancreatography (ERCP) must be considered has increased substantially. Patients aged 80 years and older are now commonly seen in the endoscopy unit. Because physiologic reserve declines with age, there is concern that older patients face both a higher risk of procedure-related adverse events and a higher risk that such events prove fatal. On the other hand, the tolerability of endoscopic procedures depends more on an individual's capabilities than on age. For example, some 80-year-olds retain a physiologic reserve comparable to that of a 60-year-old, whereas others have respiratory conditions that preclude sedation. Therefore, for very elderly patients with bile duct stones, there are two potential approaches: completely removing the stones, or performing only drainage using a plastic stent. The former offers the advantage of preventing subsequent biliary events but requires a lengthy procedure and imposes a considerable physical burden. The latter can be performed quickly and carries a lower immediate risk, yet it leaves the stones in place. Choosing between these options in routine clinical practice is often challenging.</p><p>In this issue, Hakuta et al. address this problem directly [<span>1</span>]. Based on a literature search through December 2025, the authors assembled the evidence on bile duct stones in patients aged 75 years and older and concluded that treatment decisions should not rest on chronological age alone but should incorporate a comprehensive assessment of overall physical condition, including frailty. They compared four frailty assessment tools with respect to whether each can be applied retrospectively, used at the bedside, and performed under emergency conditions, and they proposed an algorithm that assigns patients according to frailty, gallbladder status, stone size, and bleeding tendency rather than age.</p><p>These four tools differ in practical terms. The Hospital Frailty Risk Score is calculated from discharge diagnosis codes and can therefore be used only retrospectively, for database research rather than bedside decisions. The modified frailty index is based on comorbidities and allows prospective use, yet it reflects neither physical nor cognitive function. Comprehensive geriatric assessment yields the most information but takes the longest, a drawback when a patient presents with cholangitis at night. In contrast, the Clinical Frailty Scale [<span>2</span>] allows rapid bedside assessment and reflects physical status, making it potentially the most practical choice in such situations. Evidence linking frailty to ERCP outcomes nevertheless remains limited, and it is not yet clear which measure most accurately predicts outcomes in very elderly patients with bile duct stones.</p><p>The authors present age criteria without standardizing them, revealing that “elderly” is defined as 80, 85, or 90 yea","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70310","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149336223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Underwater Endoscopic Submucosal Dissection for Duodenal Tumors: Promise, Limitations, and When to Resurface","authors":"Masao Yoshida","doi":"10.1111/den.70321","DOIUrl":"10.1111/den.70321","url":null,"abstract":"<p>Since the introduction of underwater endoscopic mucosal resection without submucosal injection, endoscopic treatment in a liquid-filled environment has expanded to other applications [<span>1</span>]. In endoscopic submucosal dissection (ESD), buoyancy-induced natural countertraction, lower intraluminal pressure than under air insufflation, and improved access to the submucosal layer through irrigation may provide a favorable field for dissection. The duodenum poses particular challenges because of its thin wall and difficult endoscope maneuverability [<span>2</span>]. Because perforation can have serious consequences, clear visualization of the interface between the submucosal layer and the muscularis propria and maintenance of a safe dissection plane are important. Underwater ESD (U-ESD) may help expose this plane and facilitate dissection in the duodenum.</p><p>In this issue, Kirita et al. [<span>3</span>] report a systematic review and meta-analysis evaluating the clinical outcomes of U-ESD for duodenal tumors. Their analysis included four retrospective studies conducted in Japan, comprising 298 lesions, and yielded pooled rates of 99% for <i>en bloc</i> resection, 89% for R0 resection, 5% for intraoperative perforation, 1% for delayed perforation, and 2% for delayed bleeding. No surgical intervention for adverse events was reported. The high rates of <i>en bloc</i> and R0 resection in this technically demanding location support the feasibility of U-ESD at expert centers.</p><p>However, safety should not be judged solely on the pooled estimates. The 95% confidence interval for intraoperative perforation was wide, ranging from 1% to 23%, with substantial between-study heterogeneity (<i>I</i><sup>2</sup> = 88%). In fact, intraoperative perforation rates in the individual studies ranged from 0% to 25%. Lesion size and location, fibrosis, operator experience, and the devices used may have contributed to this variability. However, these factors were not adequately evaluated, and the sources of heterogeneity could not be established. Caution is therefore warranted when interpreting the pooled rate of 5% as a risk estimate directly applicable to individual institutions or operators.</p><p>The generalizability of these outcomes is another important consideration. All included studies were conducted in Japan, and the procedures were predominantly performed by highly experienced endoscopists at expert centers with substantial experience in duodenal ESD. In addition to the effects of the underwater environment, the favorable outcomes may reflect dissection skills acquired through conventional ESD, expertise in managing adverse events, and institutional support. Thus, the study does not demonstrate that U-ESD can be performed easily and safely by less experienced operators. Future studies should examine how outcomes vary with institutional and operator experience and evaluate the training and supervision required for safe adoption.</p><p>Numerical com","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70321","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149328013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Segment-Specific Occlusion of Retrieved Plastic Biliary Stents: Direct Quantification and Microbial and Material Determinants","authors":"Akihiro Matsumi,&nbsp;Kazuyuki Matsumoto,&nbsp;Kentaro Oki,&nbsp;Satoshi Kajitani,&nbsp;Ryosuke Sato,&nbsp;Tatsuya Kikuchi,&nbsp;Kazuya Miyamoto,&nbsp;Hiroyuki Terasawa,&nbsp;Yuki Fujii,&nbsp;Daisuke Uchida,&nbsp;Shigeru Horiguchi,&nbsp;Koichiro Tsutsumi,&nbsp;Toshiharu Mitsuhashi,&nbsp;Motoyuki Otsuka","doi":"10.1111/den.70324","DOIUrl":"10.1111/den.70324","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Plastic stents (PS) are widely used for biliary drainage, with occlusion mainly caused by biofilm formation and sludge accumulation. However, direct evaluation of luminal occlusion remains limited, and its spatial distribution is poorly understood. This study aimed to quantify luminal occlusion in retrieved PS and identify associated factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In this prospective observational study, 64 patients (196 stents) undergoing scheduled PS exchange at approximately 3-month intervals were included. Retrieved stents were divided into proximal, central, and distal segments, and occlusion was quantified using ImageJ. Clinical, microbiological, and device-related variables were analyzed. Multivariable linear regression was used to identify independent factors associated with occlusion.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The mean occlusion rate was 28.8% ± 29.8%. Occlusion was significantly higher in the proximal segment than in the central and distal segments (35.5% vs. 25.8% and 25.0%; <i>p</i> &lt; 0.05). Multivariable analysis showed that age &gt; 65 years (β = 11.62, <i>p</i> = 0.006), Enterococcus-positive bile culture (β = 16.00, <i>p</i> = 0.012), and probiotic use (β = 14.91, <i>p</i> = 0.007) were independently associated with increased occlusion. Stent brand was also associated with the degree of occlusion.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Plastic stent occlusion is segment-dependent, predominantly affecting the proximal portion, and is associated with microbiological and material-related factors. Direct quantification may help optimize stent design and management.</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13728814/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149328011","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"EUS-PPG Measured Distal to the Thrombus: A Reliable Way to Detect the Pressure Gradient in Patients With Cirrhosis and Portal Vein Thrombosis","authors":"Wei Wei,&nbsp;Laijuan Chen,&nbsp;Runya Ying,&nbsp;Meng Xue","doi":"10.1111/den.70325","DOIUrl":"10.1111/den.70325","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>In patients with portal vein thrombosis (PVT), hepatic venous pressure gradient (HVPG) does not accurately reflect portal pressure. This study aimed to evaluate the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) in cirrhotic patients with PVT.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In patients with cirrhosis who had gastroesophageal varices (GEV) and PVT were included. The PPG proximal to the PVT (Pro-PVT PPG), PPG distal to the PVT (Dis-PVT PPG), and gastric variceal pressure gradient (GVPG) were measured by puncturing the target vessels under the guidance of EUS. The pressure gradients measured using different methods were compared and correlated with clinical characteristics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 51 patients with GEV and PVT were included in the final analysis. There was a substantial agreement between Dis-PVT PPG and GVPG, with an intraclass correlation coefficient (ICC) of 0.693 (0.514–0.813). Dis-PVT PPG and GVPG were significantly higher in the patients with bleeding history than in those without (17.0 mmHg vs. 11.3 mmHg, and 18.0 mmHg vs. 7.0 mmHg, <i>p</i> &lt; 0.01 for both). In addition, patients with a Dis-PVT PPG ≥ 12 mmHg had a higher incidence of red sign (odds ratio [OR] = 5.6, 95% confidence interval [CI] = 1.6–20.2) and bleeding history (OR = 7.0, 95% CI = 2.0–26.4).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Dis-PVT PPG may be a preferred index that reflects the status of portal hypertension in cirrhotic patients with PVT and is associated with a bleeding history of GEV.</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13724997/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149328010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intracholecystic Gel Injection Facilitating Endoscopic Ultrasound-Guided Gallbladder Drainage With a Lumen-Apposing Metal Stent","authors":"Tadahisa Inoue,&nbsp;Eisuke Tsuzuki,&nbsp;Kiyoaki Ito","doi":"10.1111/den.70317","DOIUrl":"10.1111/den.70317","url":null,"abstract":"","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149302555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Correction to the “ePoster Presentation” for “Abstracts of ENDO 2026 – 5th World Congress of GI Endoscopy, 24–26 September 2026, Cape Town International Convention Centre (CTICC), Cape Town, South Africa”","authors":"","doi":"10.1111/den.70319","DOIUrl":"https://doi.org/10.1111/den.70319","url":null,"abstract":"<p>“ePoster Presentation.” <i>Digestive Endoscopy</i> 38 (2026): e70226. https://doi.org/10.1111/den.70226</p><p>The following abstract should be added.</p><p>\u0000 <b>Minimizing ionizing radiation in endoscopic retrograde cholangiopancreatography: the role of integrating transabdominal ultrasound and endoscopic ultrasound in a nonradiation procedure</b>\u0000 </p><p><span><b>Dr Hongbin Zhu</b></span>¹, Mr Zenghui Xi¹, Dr Dongxu Wang¹, Mr Jun Bai¹</p><p>\u0000 ^{\u0000 <i>1</i>\u0000}\u0000 <i>The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China</i>\u0000 </p><p><b>Introduction:</b> ERCP relies on fluoroscopy, exposing both patients and medical staff to ionizing radiation. It is imperative to minimize the use of fluoroscopy. Transabdominal ultrasound (TA-US) is a real-time imaging modality with the potential to supplant fluoroscopy for procedural guidance. This case shows the application of a novel approach combining TA-US and endoscopic ultrasound (EUS) in nonradiation endoscopic retrograde cholangiopancreatography ERCP (NR-ERCP).</p><p><b>Case Presentation:</b> A 66-year-old woman was admitted to our hospital for acute cholangitis associated with common bile duct (CBD) stones. EUS detected a stone in the lower dilated CBD (Figure A). The location and size of the stone were documented, and NR-ERCP was performed. Specifically, a guidewire was used to navigate a catheter into the CBD via the duodenal papilla. TA-US was then used to verify the guidewire position in the subcostal view, ensuring it did not enter the pancreatic duct or cystic duct. The guidewire appeared as a linear echoic stripe (white arrow, Figure B). Following endoscopic sphincterotomy, a stone retrieval balloon was inserted into the CBD. TA-US monitored its depth to confirm placement above the stone. Upon inflation, TA-US confirmed that the balloon fully occupied the lumen of the CBD.</p><p><b>Discussion:</b> In the context of NR-ERCP, there is a concern regarding the potential creation of a false tract and cannulation of the cystic duct during bile aspiration. Furthermore, a blinded balloon inflation may result in an improper fit in the CBD, which could be either excessively tight or inadequately loose. TA-US is effectively employed to confirm guidewire and device placement. However, it exhibits lower sensitivity in visualizing the lower CBD and is limited by image quality. In contrast, EUS demonstrates high sensitivity in diagnosing lesions of the CBD. By integrating dynamic TA-US with EUS, the rate of complete stone removal is maximized, thereby significantly reducing the risk of post-procedural recurrence.</p><p>We apologize for this error.</p>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 11","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70319","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149258690","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Usefulness of Endoscopic Ultrasound-Guided Pancreatogastrostomy and the Related Trans-Endosonographically Created Route Procedure for the Management of Refractory Pancreatic Stones (With Video)","authors":"Ko Tomishima,&nbsp;Hiroyuki Isayama,&nbsp;Shigeto Ishii,&nbsp;Akinori Suzuki,&nbsp;Yusuke Takasaki,&nbsp;Sho Takahashi,&nbsp;Shin Arii,&nbsp;Takumi Okuaki,&nbsp;Haruka Hagiwara,&nbsp;Yusuke Yamaguchi,&nbsp;Yasuhisa Jimbo,&nbsp;Ippei Ikoma,&nbsp;Daishi Kabemura,&nbsp;Hiroto Ota,&nbsp;Muneo Ikemura,&nbsp;Tomoya Takahashi,&nbsp;Taito Fukuma,&nbsp;Mako Ushio,&nbsp;Fumi Kurata,&nbsp;Toshio Fujisawa","doi":"10.1111/den.70314","DOIUrl":"10.1111/den.70314","url":null,"abstract":"<div>\u0000 \u0000 <p>Endoscopic management of symptomatic pancreatic stones (P-Stones) with main pancreatic duct (MPD) strictures due to chronic pancreatitis remains challenging. For refractory P-Stones, high-quality evidence for endoscopic treatment remains limited, and endoscopic ultrasound-guided pancreatogastrostomy (EUS-PGS) is considered a potential salvage option. This single-center retrospective study enrolled 16 consecutive patients with symptomatic refractory P-Stones who underwent EUS-PGS between June 2017 and June 2025, after failed transpapillary access or, in cases of surgically altered anatomy (SAA), with pancreatojejunal anastomotic stricture. Following EUS-PGS, procedures via the endosonographically created route (ESCR) and conversion to transpapillary approaches were used to manage stones and strictures, with multiple plastic stents placed to maintain ESCR patency. Technical success was defined as P-Stones treatment, and clinical success as symptom improvement after complete stone clearance. EUS-PGS achieved 100% technical and 93.8% clinical success. Complete stone removal was achieved in 15 of 16 cases (93.8%), with 1 case still under treatment. Early adverse events (AEs) occurred in 18.8% of cases (pancreatic leakage, mild pancreatitis), and late AEs in 12.5% (bleeding, stent migration). The median stone removal time was 350 days. Procedural times were similar between the normal anatomy and SAA groups, although the puncture-to-stent interval tended to be longer in the normal anatomy group (40 vs. 25 min, <i>p</i> = 0.05). EUS-PGS demonstrated high technical and clinical success for symptomatic P-Stones, with an acceptable AE rate. However, the long treatment period, often related to the absence of dedicated devices, remains a limitation that warrants improvement.</p>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 10","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149225255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"EUS-Based Prediction of Variceal Recurrence After EVL Plus APC: Endohepatology Innovation Cannot Substitute for Portal Hypertension Standard of Care","authors":"Antoine Debourdeau,&nbsp;Lucy Meunier","doi":"10.1111/den.70312","DOIUrl":"https://doi.org/10.1111/den.70312","url":null,"abstract":"<p>We read with interest the study by Tezuka et al. [<span>1</span>] demonstrating that perforating veins (PVs) detected by endoscopic ultrasonography (EUS) after endoscopic variceal ligation (EVL) combined with argon plasma coagulation (APC) independently predict esophageal variceal recurrence. While the competing risk framework and uniform protocol are methodological strengths, three limitations deserve consideration.</p><p>First, the study evaluates a treatment strategy not specifically recommended by current international guidelines while omitting the one that is. EVL combined with APC is not specifically endorsed by ESGE or Baveno VII guidelines; EVL alone remains the reference endoscopic treatment [<span>2, 3</span>]. Non-selective beta-blockers (NSBBs), prescribed to only 2/163 patients (1%), are guideline-recommended first-line therapy for secondary prophylaxis and routinely combined with EVL [<span>2, 3</span>]. This near-total absence of NSBBs undermines external validity: in Western practice where NSBB use exceeds 60%–70%, hemodynamic conditions and recurrence kinetics differ substantially. Whether PVs retain predictive value in NSBB-treated patients remains unknown.</p><p>Second, EUS was performed only after APC, without pretreatment assessment. Whether PVs represent a preexisting marker of advanced portal hypertension or persistent vessels reflecting incomplete mucosal obliteration—two mechanistically distinct entities—cannot be determined. The absence of paired pre/post-treatment EUS data also precludes assessment of the protocol's effect on collateral vessel architecture.</p><p>Third, the multivariable model includes six covariates for only 37 recurrence events (events-per-variable ratio approximately 6), below the recommended threshold of 10. The reported sub-distribution hazard ratio (SHR 3.97; 95% CI, 1.99–7.92) should be interpreted cautiously, and external validation is warranted before clinical translation.</p><p>Future studies should evaluate PV detection within a guideline-adherent framework including systematic NSBB therapy and hepatic venous pressure gradient assessment to establish the incremental value of EUS-based risk stratification.</p><p><b>Antoine Debourdeau:</b> conceptualization, writing – original draft, writing – review and editing. <b>Lucy Meunier:</b> writing – review and editing, critical revision for important intellectual content.</p><p>The authors have nothing to report.</p><p>The authors declare no conflicts of interest.</p><p>This article is linked to Tezuka et al. paper. To view this article, visit. https://doi.org/10.1111/den.70132.</p><p>Data sharing not applicable to this article as no datasets were generated or analysed during the current study.</p>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 10","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70312","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149258047","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond Removability: Can Multi-Hole Covered Metal Stents Overcome the Remaining Challenges in Malignant Hilar Biliary Obstruction?","authors":"Hirofumi Kogure","doi":"10.1111/den.70316","DOIUrl":"10.1111/den.70316","url":null,"abstract":"&lt;p&gt;Malignant hilar biliary obstruction (MHBO) remains one of the most technically demanding conditions in therapeutic pancreatobiliary endoscopy. Although bilateral drainage using uncovered self-expandable metal stents (UMSs) has conventionally been favored because of their prolonged patency and preservation of side-branch drainage, the non-removability of UMSs represents an increasingly important limitation. Improvements in systemic therapy have prolonged survival in patients with biliary tract and other malignancies, and recurrent biliary obstruction (RBO) after UMS placement is therefore encountered more frequently. Once the UMS becomes embedded in the bile duct wall due to tumor ingrowth or tissue hyperplasia, removal is generally impossible, and reintervention must be performed through or alongside the existing stent. This can restrict selective access to an undrained or newly obstructed segment, increase the complexity of repeated procedures, and leave a permanent metallic framework that may hinder subsequent modification of the drainage strategy or complicate conversion surgery. In this sense, removability is not simply a technical convenience: it preserves the option to reset the biliary anatomy at the time of reintervention.&lt;/p&gt;&lt;p&gt;Inoue et al. recently compared suprapapillary stent-by-stent deployment of 6-mm slim fully covered metal stents (FCMSs) with conventional UMS deployment for unresectable MHBO in a multicenter retrospective study [&lt;span&gt;1&lt;/span&gt;]. After propensity score matching, 52 patients were included in each group. Technical and clinical success rates were comparable, whereas the FCMS group had a significantly lower incidence of RBO than the UMS group (32.0% vs. 60.8%) and a significantly longer time to RBO. Importantly, FCMSs could be removed in all patients undergoing reintervention. The reintervention time was shorter, and both the total number of reinterventions and the proportion of patients requiring multiple reinterventions were lower with FCMSs. These findings are important because they link removability not only to device retrieval but also to the cumulative burden of longitudinal biliary management.&lt;/p&gt;&lt;p&gt;The study therefore raises a broader question: should MHBO drainage primarily pursue “permanent drainage,” with the ideal goal of zero reintervention, or “removable drainage,” which accepts that reintervention may occur but seeks to make it predictable and technically straightforward? These aims should not be viewed as mutually exclusive or as a competition between devices. Rather, they represent different priorities along a patient's anticipated clinical course. Durable drainage with the lowest possible probability of another procedure may be the dominant objective in a patient with limited life expectancy or high procedural risk. By contrast, removability may be especially valuable in patients expected to receive prolonged systemic therapy, those likely to require repeated interventions, or those in whom conver","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 10","pages":""},"PeriodicalIF":3.6,"publicationDate":"2026-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70316","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149225307","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}