From the editor — April 2026

Editor’s note — This is the online edition of the April 2026 newsletter. Comments are open at the bottom of the page. Scroll to the end for this month’s editorial discussion question on CHOLEBLADEUS vs the equivalence literature — I’d genuinely value the field’s view.

April 2026 produces a striking convergence of evidence around endoscopic-ultrasound-guided gallbladder drainage. CHOLEBLADEUS, the long-term follow-up of the original GALLBLADEUS cohort, reports a substantial 12-month patency advantage of EUS-GBD over EUS-CDS after failed ERCP — but a near-simultaneous 28-centre propensity-matched cohort and a fresh meta-analysis pool to equivalence, leaving CHOLEBLADEUS as an interesting outlier worth watching rather than a practice-defining result. Separately, three independent 2026 cohorts converge on the conclusion that EUS-GBD is feasible in contained gallbladder perforation — a scenario currently listed as a contraindication in ASGE 2024 and AGA 2023 guidance. A validated triage tool emerges for the very common UK problem of incidental CBD dilation, a new World Endoscopy Organization 2025 guideline reframes difficult biliary cannulation, and a video-based study identifies two pragmatic markers of post-ERCP pancreatitis risk in pancreatic guidewire cases. Across all searches, approximately 150 papers were reviewed; five are featured, nine are listed.

— Dr Venkat Mahesh, MRCP, FEBGH — Education & Media Lead, UKIEUS

Top 5 featured papers — April 2026

#1 — CHOLEBLADEUS: 12-month patency favours EUS-GBD over EUS-CDS after failed ERCP

Score 81/100 · Multicentre PSM cohort · Guideline-challenging

Debourdeau A, Albouys J, Privat J … Jacques J. CHOLEBLADEUS: long-term results of endoscopic ultrasound-guided gallbladder versus bile duct drainage of malignant biliary obstruction after failed ERCP: a propensity-matched study. Endoscopy 2026 (accepted 24 April 2026). DOI: 10.1055/a-2837-9342

CHOLEBLADEUS retrospectively compared two historical international cohorts of patients treated between March 2017 and May 2024. After 1:1 propensity score matching, 200 patients (100 per group) were analysed. Technical success was equivalent (100% EUS-GBD vs 97% EUS-CDS, P=0.25), as was clinical success (80.5% vs 90.6%, P=0.08). The primary outcome — 12-month biliary patency — favoured EUS-GBD (86.2%, 95%CI 74.2–92.9, vs 63.8%, 95%CI 49.5–75.0; P=0.01), and biliary reintervention-free survival was significantly longer (log-rank P<0.001). Periprocedural AEs (7% vs 10%), delayed AEs (27% vs 30%), reintervention rates (23% vs 26%) and overall survival were comparable.

Contextualising evidence. A companion April 2026 paper by Mangiavillano et al. (Dig Endosc 38(4):e70145) using a 28-centre international PSM cohort of 224 patients (112/group, also rescue after failed ERCP) found no significant differences in technical success (97.3% vs 91%, P=0.08), clinical success (83% vs 85.7%, P=0.17), AE rate (19.6% vs 12.5%, P=0.20), severe AEs (8.9% vs 6.2%) or median overall survival (5 months in both groups). The recently published Chandan systematic review and meta-analysis (Chandan SR et al., Gastrointest Endosc 2026, PMID 41786152) pooled five studies and 352 patients and similarly found no significant differences in technical success (RR 1.02), clinical success (RR 0.97), overall AEs (RR 0.93), severe AEs (RR 0.69) or stent dysfunction (RR 0.95). The current ASGE 2024 guideline still recommends EUS-CDS or EUS-HGS — not EUS-GBD — as the standard EUS-guided rescue route for MDBO after failed ERCP, citing low-to-moderate quality evidence.

Clinical bottom line. CHOLEBLADEUS provides the first comparative cohort showing a substantive 12-month patency advantage for EUS-GBD over EUS-CDS, but sits within a wider literature — including a 2026 SR/MA and a 28-centre PSM cohort — that finds the two techniques broadly equivalent on every other meaningful endpoint. The honest read: an interesting outlier worth watching, not yet a basis to displace EUS-CDS as the default rescue route. EUS-GBD remains particularly attractive when EUS-CDS is anatomically challenging (CBD <12 mm, deeply seated CBD, duodenal infiltration), and cystic duct patency must be confirmed pre-procedurally. Worth discussing at the MDT, not yet worth re-writing the unit protocol.

#2 — GCAL Score: which patients with unexplained CBD dilation actually benefit from EUS?

Score 67/100 · Prediction model — prospectively validated · Practice-informing

Kale A, Satai M, Giri S et al. Development and validation of ‘Gallbladder-CBD diameter-Age-Liver function score’ to determine the need for endoscopic ultrasound in patients with unexplained bile duct dilatation. Indian J Gastroenterol 2026 (published 30 April 2026). DOI: 10.1007/s12664-026-01987-5

The GCAL Score (Gallbladder–CBD diameter–Age–Liver function) was derived from a single-centre cohort of 142 patients with unexplained CBD dilatation, then prospectively validated in 230 further patients. The five-factor score integrates abnormal gallbladder findings, CBD diameter (with thresholds at 9–12 mm and >12 mm), age >55 years, and abnormal liver function tests. In the validation cohort the score achieved an AUC of 0.904 with 95.97% sensitivity and 94.68% overall accuracy for identifying patients in whom EUS revealed actionable pathology.

Contextualising evidence. The ASGE 2019 choledocholithiasis guideline classifies isolated CBD dilatation as an intermediate-risk feature warranting evaluation with either EUS or MRCP, but does not differentiate which patients benefit most from EUS. Incidental CBD dilatation is an extremely common imaging finding in UK practice — the GCAL Score offers the first validated framework for triaging these patients without unnecessary endoscopic procedures.

Clinical bottom line. Incidental CBD dilation is one of the most common reasons for unnecessary EUS referrals in UK practice. GCAL offers a first validated triage tool — readers should expect to verify its performance in their own population, but the score variables are pragmatic and available at the point of MDT discussion. Worth piloting against a unit’s recent CBD-dilatation EUS audit data.

#3 — Difficult biliary cannulation: TPS leads on success, precut fistulotomy on safety

Score 65/100 · Network meta-analysis · Pure ERCP

Wu YY, Shiu SI, Tung CF, Cheng HE, Ko CW. Systematic review and network meta-analysis: comparison of different techniques for difficult biliary cannulation. BMC Gastroenterol 2026 (published 30 April 2026). DOI: 10.1186/s12876-026-04849-8

The Wu network meta-analysis synthesised 17 RCTs and 2,189 patients across seven techniques for difficult biliary cannulation: controlled persistence, precut papillotomy, precut fistulotomy, delayed precut papillotomy and fistulotomy, transpancreatic sphincterotomy (TPS), and double-guidewire. Transpancreatic sphincterotomy was ranked highest on cannulation efficacy (OR 6.00 vs persistence). Precut fistulotomy was the only technique with a significantly lower overall complication rate (OR 0.61, 95%CI 0.40–0.93), particularly for PEP.

Contextualising evidence. The newly published World Endoscopy Organization 2025 guideline on ERCP biliary cannulation and sphincterotomy techniques (Crinò SF et al., Dig Endosc 37(10):1029–1053, PMID 40518920) provides the most current international guidance on technique selection and PEP prevention. ESGE has historically recommended needle-knife fistulotomy as the preferred precut technique and early precut over prolonged persistent cannulation attempts. Wu’s findings are directionally consistent with both: TPS for highest success, fistulotomy for lowest complications.

Clinical bottom line. When difficult biliary cannulation is encountered, the choice of rescue technique should be driven by what matters most for that patient: TPS for highest cannulation success when an established centre and immediate pancreatic stenting are available; precut fistulotomy when minimising complication risk is the priority. The 2025 WEO guideline is now the most current authoritative reference for unit cannulation protocols.

#4 — Two pre-procedural markers of PEP risk in pancreatic guidewire cannulation

Score 62/100 · Video-based retrospective analysis · Pure ERCP

Takeshita K, Asai Y, Matsuo K et al. Video-Based Analysis of Risk Factors for Post-ERCP Pancreatitis in Pancreatic Guidewire-Assisted Biliary Cannulation. Dig Dis Sci 2026. DOI: 10.1007/s10620-026-09943-1

Takeshita and colleagues retrospectively analysed video recordings of 178 ERCP cases where the pancreatic guidewire (PGW) technique was used as the rescue method for difficult biliary cannulation. Multivariate analysis identified two independent risk factors for post-ERCP pancreatitis: cannulation time ≥20 minutes (OR 3.53) and short oral protrusion of the papilla <10 mm (OR 3.01). Both are identifiable before the PGW manoeuvre is committed to.

Contextualising evidence. The 2025 WEO guideline on ERCP cannulation (Crinò SF et al., Dig Endosc 37(10):1029–1053, PMID 40518920) and the ACG 2024 acute pancreatitis guideline both recommend rectal NSAIDs for all patients undergoing ERCP, with prophylactic pancreatic duct stenting strongly recommended in high-risk patients. The landmark SVI trial (Elmunzer BJ et al., Lancet 2024;403:450–458) established that indomethacin plus pancreatic stent is superior to indomethacin alone (PEP 11.3% vs 14.9%, P=0.011) in high-risk ERCP. The double-wire and PGW techniques are explicitly listed as risk factors warranting prophylactic stent placement.

Clinical bottom line. Two pragmatic, identifiable markers — cannulation time approaching 20 minutes and a short oral protrusion of the papilla — should trigger heightened PEP vigilance and prompt prophylactic pancreatic stent placement following PGW cannulation. The PGW technique is already a high-risk scenario; these two markers identify which of those high-risk cases is highest-risk.

#5 — EUS-GBD in contained gallbladder perforation: three converging 2026 cohorts

Score 67/100 · Prospective cohort · Contraindication-challenging

Vanella G, Guilabert L, Frigo F … Capurso G, Arcidiacono PG. Endoscopic ultrasound-guided gallbladder drainage in acute cholecystitis with contained perforation: a prospective cohort study. Endoscopy 2026 (dated 30 April 2026). DOI: 10.1055/a-2848-3876

Between January 2021 and March 2025 at San Raffaele Milan, 23 patients with acute cholecystitis and contained gallbladder perforation (Niemeier classification type 2) underwent EUS-GBD — representing 39.7% of the centre’s overall EUS-GBD cohort. 87% had underlying malignancy and 65.2% had prior ERCP with metal biliary stents in situ. Technical success was 100% (95%CI 85.7–100), clinical success 87.0% (95%CI 67.9–95.5), AE rate 21.7% (95%CI 9.7–41.9). The AE rate did not differ significantly from a contemporaneous intact-gallbladder cohort, but two fatal events occurred exclusively in the contained-perforation group.

Contextualising evidence. Two further 2026 studies independently address the same scenario. Chon et al. (Endoscopy 2026, PMID 41702549) reported a five-centre Korean retrospective cohort of 22 patients with Niemeier type II perforation: 100% technical and 100% clinical success, three AEs (biloma, stent migration, recurrent cholecystitis), 0% 30-day mortality, and Kaplan–Meier stent patency 90.9% at median follow-up 350 days. Godat et al. (J Gastroenterol Hepatol 2026, PMID 42128424) reported 12 high-surgical-risk patients with gallbladder perforation from a single Lausanne centre: 100% technical and 91.7% clinical success, one AE (pneumoperitoneum managed conservatively). Together these three independent 2026 papers represent 57 patients with broadly congruent outcomes, despite the ASGE 2024 and AGA 2023 guidelines listing gallbladder perforation as a contraindication or scenario where percutaneous drainage is preferred.

Clinical bottom line. The three independent 2026 cohorts together represent the first meaningful evidence that EUS-GBD is technically feasible in Niemeier type II contained perforation — challenging a guideline contraindication that was formulated before any of these data existed. Free perforation (Niemeier type I with biliary peritonitis) remains a clear contraindication. For carefully selected patients with contained perforation in expert centres, EUS-GBD is now a defensible option to discuss at the MDT alongside percutaneous and surgical alternatives. The fatal events in the Vanella cohort are a reminder that this is a uniquely high-risk population — patient selection matters more than technique.

Also published — April 2026

1. [Therapeutic EUS] EUS-guided WON drainage: nasocystic drain plus metal stent confers no benefit over metal stent alone — small RCT pilot (n=40). Randomised pilot trial of 40 patients with symptomatic walled-off necrosis comparing LAMS with nasocystic drain vs LAMS alone. Addition of nasocystic drain did not improve clinical outcomes. Negative finding from a pragmatic single-centre randomised design — informs practice for centres routinely placing nasocystic drains alongside LAMS. DOI: 10.1097/MPA.0000000000002659 · PMID: 42053102

2. [Cholangioscopy] SPY-SCREEN: prospective utility of digital single-operator cholangioscopy for surveillance of intraductal neoplasms after stone removal — 181 patients. Prospective cohort using D-SOC for risk-enriched detection of intraductal neoplasms of the bile duct after stone removal. Practice-informing for centres considering surveillance protocols. Adds to the developing case for D-SOC beyond stone clearance and indeterminate strictures. DOI: 10.1007/s10620-026-09863-0 · PMID: 42043470

3. [ERCP] Spontaneous CBD stone passage between MRCP and ERCP — 481 patients, Helsinki. Retrospective cohort identifying predictors of spontaneous CBD stone passage in the interval between MRCP confirmation and planned ERCP — 25% had no stones at ERCP. Reinforces the case for selective ERCP and the value of accurate inter-imaging triage in patients with non-urgent stone disease. DOI: 10.1080/00365521.2026.2661981 · PMID: 42037064

4. [Therapeutic EUS] Evolution of gallbladder drainage: comprehensive review from percutaneous to EUS-guided approaches. Comprehensive narrative review of the development of gallbladder drainage from PT-GBD through ET-GBD to EUS-GBD. A useful reference paper for trainees, MDT colleagues and unit protocols — synthesises the current state of the literature on technique selection. DOI: 10.1007/s00535-026-02417-1 · PMID: 42029728

5. [Therapeutic EUS] EUS-GBD using a 19G Franseen needle and a modified slim metal stent: simplified technique series (n=18, Aichi). Single-centre series of EUS-GBD using a 19G Franseen needle combined with a modified slim FCSEMS. Technical innovation potentially relevant in centres without access to dedicated electrocautery-enhanced LAMS. Small cohort — useful for proof-of-concept and technique sharing rather than practice change. DOI: 10.1111/den.70152 · PMID: 41947675

6. [Endoscopy in CP] Chronic pancreatitis: the role of endoscopic procedures — comprehensive review (Cleveland Clinic). Narrative review of the role of endoscopic procedures in chronic pancreatitis covering ductal decompression, stone clearance, stricture management, and emerging applications of EUS-guided therapy. Useful synthesis for unit MDT discussions on endoscopy-first strategies in CP. DOI: 10.1007/s10620-026-09895-6 · PMID: 42043472

7. [EUS training] Training in diagnostic and interventional endoscopic ultrasound: state-of-the-art review (Gemelli Rome). Comprehensive state-of-the-art review of EUS training pathways, simulation, competency assessment, and the emerging field of interventional EUS training. Directly relevant to UK higher-specialist training pathway discussions and reflects current European training models. DOI: 10.1080/17474124.2026.2662559 · PMID: 41996095

8. [EUS diagnostic] High-frequency miniprobe endoscopic ultrasonography across the GI tract — narrative review. Narrative review of applications of high-frequency miniprobe EUS across the upper and lower GI tract, including subepithelial lesions, oesophageal and gastric wall assessment, and biliary applications. Useful reference for units developing miniprobe services. DOI: 10.3390/diagnostics16091316 · PMID: 42122019

9. [FNB] Comparative assessment of 22G Franseen vs 20G antegrade core trap EUS-FNB needles in solid pancreatic lesions — prospective intra-patient comparison (n=50). Prospective same-patient comparison of two FNB needle designs for solid pancreatic lesions. Diagnostic accuracy 86% (Franseen) vs 66% (antegrade core trap), p=0.019; faster puncture time. Methodologically strong intra-patient design. Pairs with the March 2026 Gadour FNB SEL paper to support Franseen as default for solid lesion tissue acquisition. DOI: 10.1159/000551930

Editorial discussion — April 2026

The CHOLEBLADEUS question — over to the field.

CHOLEBLADEUS is the first comparative cohort to show a substantive 12-month patency advantage for EUS-GBD over EUS-CDS after failed ERCP — 86.2% vs 63.8%, with significantly longer reintervention-free survival. But it sits within a wider 2026 literature that pools to equivalence: the Mangiavillano 28-centre PSM cohort and the Chandan SR/MA both find no significant differences across technical success, clinical success, AE rates, or overall survival.

So the question — how are you and your unit interpreting this?

1. Practice change now, on the strength of a 22-percentage-point patency advantage in a 200-patient PSM cohort?
2. Watchful interest, given the equivalence signal from larger pooled data and the unchanged ASGE 2024 position?
3. Selective adoption — EUS-GBD specifically when EUS-CDS is anatomically unfavourable (CBD <12 mm, deeply seated duct, duodenal infiltration), retaining EUS-CDS as default otherwise?
4. Something else — what’s driving your unit’s decision-making?

Equally interested in views on the contained-perforation EUS-GBD evidence in Paper #5: three independent 2026 cohorts now describe outcomes in a scenario currently listed as a guideline contraindication. At what point does the evidence base justify a guideline revision request?

Reply below — anonymous handles are welcome, first comments are moderated, subsequent ones publish automatically. I’ll respond to every substantive comment, and the most interesting threads will be summarised (anonymised) in next month’s editorial.

— VM

© UKIEUS 2026. Editorial commentary by Dr Venkat Mahesh, MRCP, FEBGH. Paper titles and abstracts cited from PubMed with DOI attribution; no copyrighted full text reproduced. Primary literature identified via PubMed systematic search; broader clinical context verified through structured evidence synthesis; all references independently confirmed via PubMed prior to inclusion. For educational use only. www.ukieus.co.uk

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