Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the “Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept”, has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain.

The evaluation of biliary strictures poses a challenge due to the low sensitivity of standard diagnostic approaches, but the advent of direct single-operator cholangioscopy (DSOC) has revolutionized this paradigm. Our study aimed to assess the diagnostic performance of DSOC and DSOC-targeted biopsies, intraductal ultrasound (IDUS), and standard brush cytology in patients with indeterminate biliary strictures (IBS). We reviewed patients who underwent advanced diagnostic evaluation for IBS at our endoscopy unit from January 2018 to December 2022, all of whom had previously undergone at least one endoscopic attempt to characterize the biliary stricture. Final diagnoses were established based on surgical pathology and/or clinical and radiological follow-up spanning at least 12 months. A total of 57 patients, with a mean age of 67.2 ± 10.0 years, were included, with a mean follow-up of 18.2 ± 18.1 months. The majority of IBS were located in the distal common bile duct (45.6%), with malignancy confirmed in 35 patients (61.4%). DSOC and IDUS demonstrated significantly higher accuracies (89.5% and 82.7%, respectively) compared to standard cytology (61.5%, p < 0.05). Both DSOC visualization and IDUS exhibited optimal diagnostic yields in differentiating IBS with an acceptable safety profile.

Evaluation of biliary strictures remains a challenge due to the low sensitivity of standard diagnostic work up, but the introduction of direct single-operator cholangioscopy (DSOC) changed this paradigm. Aim of our study was to evaluate diagnostic performance of DSOC and DSOC-targeted biopsies, intraductal ultrasound (IDUS) and brush cytology in patients with indeterminate biliary stricture (IBS). We evaluated patients who underwent advanced diagnostic work up for IBS in our endoscopy unit from ‘01/2018 to ‘12/2022; all patients had at least one previous attempt to characterize the biliary stricture. Final diagnosis was based on surgical pathology and/or clinical and radiological follow-up of at least 12 months. A total of 57 patients with a mean age of 67.2 ± 10.0 years were included, with a mean follow up of 18.2 ± 18.1 months. IBS were mostly located in the distal common bile duct (45.6%) and final diagnosis was consistent with malignancy in 35 patients (61.4%). DSOC and IDUS showed a significantly higher accuracy (89.5% and 82.7% respectively) compared to standard cytology (61.5%, p <0.05). In our experience, DSOC visualization and IDUS both demonstrated an optimal diagnostic yield in the differentiation of IBS, with an acceptable safety profile both quantitatively and qualitatively.

Aims Pre-operative biliary drainage (PBD) in patients undergoing hepato-pancreato-biliary surgery (HPBS) has a controversial impact on post-operative infectious complications (POICs): we report the related experience at our tertiary level centre. Methods We retrospectively reviewed patients who underwent HPBS from 2015 to 2022 including cases with available intraoperative bile samples. We compared patients who had PBD (group A, endoscopic stenting, plus group B, percutaneous stenting) to patients directly referred to surgery (group C), evaluating bile culture (BC) results, drug-sensitivity of isolated germs and the occurrence of POICs [1] [2]. Results We included 42 patients: 24 (57%) underwent PBD, while 18 (43%) directly received surgical treatment. Group A+B and group C were comparable for age, gender and underlying pathology (table 1). Positive BC was found in 20/24 (83%) stented patients and in 2/18 (11%) directly operated patients (p<0.01). In group A+B, most frequently detected germs were Enterococci (6/20, 30%), predominantly multi-drugs sensitive (MS, 5/6, 83%), and Gram -, predominantly E. Coli (4/20, 20%); we found multi-drugs resistant (MR) Klebsiella in two patients. All 3 cases of MR germs were reported in stented population (p=0.9). POICs occurred in 8/24 (33%) cases in group A+B and in 8/18 (44%) cases in group C (p=0.53); infected fluid collections were the most represented POICs (7/8 and 6/8 cases respectively; p=0.74), which were all successfully treated with antibiotic therapy ([Table 1]). Conclusions In our cohort the rate of bile contamination was significantly higher in PBD group compared to directly operated patients, but we did not observe any related increase of POICs. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Text We present a case of a 57-years old woman with a FNB diagnosis of insulinoma in the body of the pancreas with a size of 13 mm; during the diagnostic work up in MRI a pancreas divisum was discovered. Due to the small size of the lesion, a laparoscopic enucleation was planned. Before surgery she was referred for tattoing of the lesion in EUS to improve lesion’s localization. In the same session a prophylactic pancreatic duct stent was positioned to reduce the risk of duct damage, acute pancreatitis and the development of fistul [1]. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Text We present an 85 years-old-man case with abdominal pain, fever and elevation of inflammatory serum markers. He performed Abdominal-US and CT that showed acute cholecystitis and gallbladder entirely inhabited by stones. Patient was unfit for surgery; thus EUS-GBD was planned. After procedure there was a clinical improvement. Therefore, EUS-GBD with no fluid gallbladder and voluminous gallstone could be technically unfeasible. Stone mobilization could create the adequate space for LAMS releasing. In a frail patient the approach should be tailored in terms of LAMS removal or not, timing of LAMS removal, indication to cholecystolithotomy and/or cholecystolithotripsy. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany