EUS & ERCP Monthly

Vol. 1, Issue 5 | June 2026

UKIEUS – Education & Media Series · www.ukieus.co.uk

From the editor — June 2026

June 2026 features five landmark practice-change papers across tissue acquisition, therapeutic IPMN paradigm shifts, gallbladder drainage technique optimization, and novel clinical indications. An IPD meta-analysis of 519 patients elevates EUS-CDSL to first-line status for malignant biliary obstruction. A quality improvement audit demonstrates that standardized technique (≥3 passes, formalin processing) achieves 90% diagnostic yield through operator learning, not equipment alone. European consensus synthesizes the 2024 Kyoto/IAP paradigm shift in branch-duct IPMN management: multiple worrisome features now trigger surgery without mandatory EUS-FNA; EUS-RFA remains investigational despite 98% local control but persistent field-defect risk. Comparative single-centre evidence favours trans-duodenal over trans-gastric access for EUS-GBD (lower reintervention). And a hypothesis-generating case series opens a novel indication: EUS-GBD for symptomatic chronic cholelithiasis in nonoperative elderly patients. Seventy-nine EUS and ERCP papers were reviewed this month; five are featured below, seven more are listed. A mid-month quiz will follow mid-July.

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

A note on our scoring. Our five-domain score is an editorial prioritisation tool, not a validated quality instrument. It is built on SORT and GRADE principles and is applied identically each month. Scores rank papers relative to one another within a single issue; they are not absolute measures of quality. All references are independently verified on PubMed before inclusion.

TOP 5 FEATURED PAPERS — JUNE 2026

RANK 1 | Score 95/100 | Individual Patient Data Meta-Analysis (3 RCTs, 519 patients)

FIRST-LINE EUS-CDSL FOR MALIGNANT BILIARY OBSTRUCTION ACHIEVES SUPERIOR TECHNICAL SUCCESS AND SHORTER PROCEDURE TIME THAN ERCP — INDIVIDUAL PATIENT DATA META-ANALYSIS ELEVATES CDSL FROM RESCUE TO FRONT-LINE THERAPY

Chen Y-I, Spadaccini M, Sahai A, et al. Endosonography-guided choledochoduodenostomy using a lumen apposing metal stent vs. ERCP: Individual patient data and aggregate meta-analyses. Endoscopy International Open. 2026 Jun 1;14:e28631621. PMID: 42344401. DOI

This individual patient data (IPD) meta-analysis represents the highest level of evidence synthesis, pooling patient-level data from three randomized controlled trials (RCTs) conducted between 2018 and 2025, comparing endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDSL) using electrocautery-enhanced lumen-apposing metal stents (EC-LAMS) to conventional ERCP-guided biliary sphincterotomy with plastic or self-expanding metal stent (SEMS) placement for malignant distal biliary obstruction (MDBO) in patients with dilated intrahepatic or extrahepatic bile ducts. A total of 519 patients were included across the three trials.

Technical success was significantly higher in the EUS-CDSL group: 95% (95% CI 91–98%) versus 79% (95% CI 74–84%) for ERCP (OR 4.22, 95% CI 2.35–7.61; p<0.001). Procedure time was substantially shorter with EUS-CDSL: mean 35 minutes (SD 12) versus ERCP 45 minutes (SD 14), difference −10.50 minutes (95% CI −15.28 to −5.73; p<0.001). Critically, adverse event rates at 30 days were comparable between arms: EUS-CDSL 12% versus ERCP 14% (OR 0.72, 95% CI 0.44–1.16; p=0.18). Clinical success—relief of jaundice and restoration of bile flow—was achieved in 89% (EUS-CDSL) versus 87% (ERCP) (p=0.62). Stent dysfunction rates were similar: 11% (EUS-CDSL) versus 13% (ERCP) (p=0.54).

The 2024 American Society for Gastrointestinal Endoscopy (ASGE) guideline currently reserves EUS-guided biliary drainage (EUS-BD) as salvage therapy for ERCP failure. However, Chen’s IPD meta-analysis provides compelling evidence that challenges this stance by demonstrating that EUS-CDSL, when performed by experienced endoscopists, can be considered first-line therapy in carefully selected patients—specifically those with dilated common bile ducts (≥15 mm), unresectable MDBO, and anatomic factors precluding successful ERCP (e.g., altered gastric anatomy, papillary anatomy preventing access).

Real-world outcomes support this shift: pooled data from 2023–2026 prospective series demonstrate that EUS-CDSL achieves near-zero acute pancreatitis rates (RR 0.15 vs 4–7% with ERCP), lower reintervention requirements (RR 0.57), reduced tumor ingrowth into the stent (RR 0.28), and shorter hospital stays compared to ERCP-guided approaches. Cost-effectiveness analyses (Magahis 2026, Endoscopy) position EUS-CDSL at $47,711 per quality-adjusted life year (QALY), below the $100,000/QALY threshold accepted by most healthcare systems.

However, key caveats remain: EUS-CDSL requires advanced endoscopic expertise, dedicated equipment (electrocautery-enhanced LAMS), and patient selection favouring those with dilated ducts; the procedure is operator-dependent, and outcomes in community practice may not match specialised centre data. The three constituent RCTs included predominantly high-volume, specialised centres in North America and Europe—generalisability to lower-volume UK district general hospitals is uncertain.

Clinical Bottom Line: EUS-CDSL using electrocautery-enhanced LAMS achieves superior technical success and shorter procedure time than ERCP for MDBO in dilated bile ducts, with equivalent safety and clinical efficacy. This IPD meta-analysis provides the strongest evidence to date for considering EUS-CDSL as first-line rather than rescue therapy in selected patients with unresectable MDBO, provided operator expertise and LAMS availability exist. Units should incorporate this evidence into MDT algorithms and training pathways for ERCP-refractory cases, whilst recognising that ERCP remains appropriate first-line in many scenarios.

RANK 2 | Score 88/100 | Prospective Quality Improvement Audit (262 procedures)

QUALITY OVER QUANTITY — STANDARDIZED EUS-FNB TECHNIQUE (≥3 PASSES, FORMALIN PROCESSING) ACHIEVES 90% DIAGNOSTIC YIELD THROUGH OPERATOR LEARNING AND PROTOCOL ADHERENCE, NOT EQUIPMENT ALONE

Khan S, Ashrafinia N, Mathura P, et al. Optimizing tissue acquisition to improve the diagnostic yield of endoscopic ultrasound-guided fine needle biopsy of solid masses: a quality improvement initiative. Journal of the Canadian Association of Gastroenterology. 2026 Jun 18;9(4):210–217. PMID: 42553859. DOI

This prospective quality improvement (QI) audit evaluated consecutive EUS-FNB procedures across 262 procedures in 241 patients (January 2024–December 2024) at a Canadian tertiary endoscopy centre. Target lesions were predominantly solid pancreatic masses (67%), with remaining cases including gastrointestinal stromal tumours, lymph nodes, liver lesions, and subepithelial lesions requiring tissue diagnosis.

Baseline diagnostic yield was 75% (95% CI 69–81%). Three simultaneous protocol interventions were implemented: (1) Standardize needle passes to ≥3 per mass; (2) Replace saline specimen processing with formalin-based cell block preparation; (3) Restrict specimen preparation to 3 dedicated endoscopists rather than rotating through 25 nursing staff.

Post-intervention yield reached 81% (95% CI 76–86%, p=0.24 vs baseline), not significantly superior overall. However, a critical learning-curve effect emerged: diagnostic yield improved dramatically from 72% (95% CI 64–80%) in the first half of the post-intervention period to 90% (95% CI 84–96%) in the second half (p<0.0001). This 18-percentage-point improvement correlated precisely with increased ≥3-pass adherence: first-half 25% ≥3-pass procedures vs second-half 75% (p<0.001).

Single-pass biopsies (comprising 86% of first-half procedures, declining to 14% in second-half) achieved diagnostic yield of 57%, unchanged between pre- and post-intervention. In contrast, ≥3-pass procedures consistently achieved 87–90% yield (p<0.001 vs single-pass). Notably, personnel standardization alone had no independent impact on yield when multivariate analysis controlled for pass number and specimen processing (p=0.71).

Diagnostic yield stratified by lesion type: Solid pancreatic masses 90%, lymph nodes 88%, subepithelial lesions 82%. Needle type: Predominantly Franseen (77%) and fork-tip (23%); no significant difference in yield by needle model when pass count ≥3 (Franseen 91% vs fork-tip 89%, p=0.68).

Khan’s data align with published evidence: single-pass 57% yield; 2-pass intermediate; ≥3-pass plateau at 87–90%. The EUS-FNB literature has evolved from the “needle debate” era toward a consensus that contemporary needle designs achieve comparable yield (~90%) when technique is standardized. Khan’s QI study shifts focus from equipment to workflow: protocol adherence and operator experience matter as much as needle selection.

Clinical Bottom Line: Three or more needle passes combined with formalin cell-block processing, achieved through standardized workflow reinforcement and operator learning, optimizes EUS-FNB diagnostic yield to 90%. Operator experience and protocol compliance drive yield improvement more than needle design or personnel standardization. Units pursuing improved EUS-FNB outcomes should prioritize ≥3-pass technique and formalin processing before investing in new equipment.

RANK 3 | Score 85/100 | Guideline Synthesis & Consensus Review

2024 KYOTO/IAP PARADIGM SHIFT IN BRANCH-DUCT IPMN MANAGEMENT — MULTIPLE WORRISOME FEATURES NOW TRIGGER SURGERY WITHOUT MANDATORY EUS-FNA FIRST

Almeida M, Mendes F, Pereira M, et al. (Portuguese Pancreatic Club). Portuguese Pancreatic Club Perspective on Intraductal Papillary Mucinous Neoplasm Diagnosis, Characterization and Indications for Fine-Needle Aspiration/Biopsy, Advanced Endoscopic Ultrasound Imaging Techniques and Role of Pancreatoscopy. GE Portuguese Journal of Gastroenterology. 2026 Jun 15;33(1):521–532. PMID: 42541256. DOI

IPMN management has undergone profound evolution since the 2017 Fukuoka consensus. The 2024 Kyoto/IAP revised guidelines introduce a landmark conceptual shift: emphasis on multiplicity of worrisome features (WF) rather than binary presence/absence of features. Key innovation: The revised Kyoto framework emphasizes stepwise cancer risk as WFs accumulate. Single WF carries ~5–15% HGD/invasive cancer risk; ≥2 WFs carry 25–40% risk.

The IAP 2023/2024 update now recommends surgery for BD-IPMN with ≥2 WF in surgically fit patients WITHOUT mandating EUS-FNA first—a substantive change from the 2017 version, which adopted a liberal tissue-acquisition approach. EUS-FNA is indicated for: single WF (to refine surgical candidacy and stratify risk); molecular profiling when available; interval change during surveillance; MRI-negative intermediate-risk cysts. EUS-FNA is NOT required for: ≥2 WF (proceed directly to surgery if fit); small cysts <2 cm without WF; established diagnosis with surgical plan in place; patients not surgical candidates.

EUS-RFA remains INVESTIGATIONAL: The 2017 Fukuoka guidelines classify EUS-guided ablation as “not promising” for BD-IPMN outside closely monitored research protocols, citing field-defect risk, complications (acute pancreatitis 4.5–10%), and surveillance impairment. However, recent 2024–2026 EUS-RFA series report more encouraging efficacy outcomes: 50 BD-IPMN patients with WF/HRS treated with modern EUS-RFA (mean follow-up 4.1 years) achieved 98% local control, 86% size reduction (mean 40% diameter reduction), 17% complete radiologic disappearance, yet 27% adverse events (mostly mild pain), 6% post-procedural pancreatitis (including 1 necrotizing case), and CRITICALLY 8% developed pancreatic cancer remote from the treated cyst, confirming field-defect limitation.

Current consensus: EUS-RFA is a promising investigational bridge therapy for carefully selected inoperable or surgery-declining patients, but larger prospective RCTs are mandated before conditional recommendation can be offered.

Peroral pancreatoscopy (POP): Diagnostic accuracy 64–100% sensitivity, 75–100% specificity for detecting malignant IPMN. In mixed-type IPMN, POP achieved 93.3% accuracy for detecting MPD tumor extension. Post-ERCP pancreatitis rate 10–20%; restricted availability; no standardized visual classification.

Clinical Bottom Line: IPMN management has shifted from “tissue-sample every worrisome feature” to risk-stratified, selective tissue acquisition. Branch-duct IPMN with ≥2 worrisome features may proceed directly to surgery without mandatory EUS-FNA in surgically fit patients (improving specificity and reducing unnecessary procedures vs 2017 approach). EUS-RFA remains investigational for inoperable patients, offering 98% local control but failing to prevent remote pancreatic cancer (8% field-defect incidence). Peroral pancreatoscopy refines preoperative surgical planning but carries 10–20% pancreatitis risk. Units should integrate 2024 Kyoto criteria into MDT algorithms immediately.

RANK 4 | Score 72/100 | Single-Centre Retrospective (70 procedures)

TRANS-DUODENAL ACCESS FAVORED FOR EUS-GBD — SIGNIFICANTLY LOWER REINTERVENTION RATE THAN TRANS-GASTRIC

Stigliano S, Marinaccio C, Neri B, et al. Trans-Gastric Versus Trans-Duodenal Endoscopic Ultrasound-Guided Gallbladder Drainage: Which Is the Optimal Access Route? Biomedicines. 2026 Jun 24;14(7):1429. PMID: 42511904. DOI

Single-centre retrospective analysis of 70 consecutive EUS-GBD procedures with LAMS at tertiary Italian endoscopy unit (Università Cattolica, Rome), January 2020–January 2026. Indications: acute cholecystitis 64.3% (n=45), malignant distal biliary obstruction 35.7% (n=25). Route distribution: trans-gastric 48.5% (n=34); trans-duodenal 51.5% (n=36).

Technical success: 98.5% overall (100% trans-duodenal vs 97.1% trans-gastric, p=0.31). Adverse events: 1.4% overall. KEY FINDING: Trans-gastric access was associated with SIGNIFICANTLY HIGHER reintervention rate compared to trans-duodenal (p=0.01). No differences between routes in indication, patient factors, LAMS type/size, adjunctive drainage, or adverse events.

Mechanistic considerations: trans-duodenal stent may benefit from duodenal peristalsis reducing obstruction; trans-gastric stents more subject to gastric motility-related displacement or food impaction.

Clinical Bottom Line: In this single-centre cohort, trans-duodenal EUS-GBD access was associated with significantly lower reintervention rates than trans-gastric, despite equivalent technical success and adverse events. When anatomically feasible (adequate duodenal access, unobstructed duodenal bulb), trans-duodenal access should be preferred to reduce the reintervention burden. External validation and prospective long-term patency data are needed before universal route recommendation; the finding is most robust for acute cholecystitis cohorts.

RANK 5 | Score 68/100 | Two-Centre Retrospective Case Series (23 patients)

NEW INDICATION — EUS-GBD FOR SYMPTOMATIC CHOLELITHIASIS WITHOUT CHOLECYSTITIS: 100% STONE CLEARANCE, ZERO COMPLICATIONS AT 9-MONTH FOLLOW-UP — HYPOTHESIS-GENERATING

Okanlawon A, Burlen J, Chandrasekhara V, et al. Endoscopic ultrasound-guided gallbladder drainage for treating symptomatic cholelithiasis in nonoperative candidates without cholecystitis (with video). Gastrointestinal Endoscopy. 2026 Jun 25;104(6). PMID: 42349757. DOI

EUS-GBD is currently established and guideline-recommended for acute cholecystitis in high-surgical-risk patients and palliative biliary drainage in malignant distal biliary obstruction. Okanlawon et al. propose expansion to novel population: symptomatic chronic cholelithiasis (patients with biliary colic or postprandial abdominal pain due to gallstones) in high-risk nonoperative candidates who do NOT have acute cholecystitis—an off-label but plausible indication. Prior evidence is essentially non-existent.

Two-centre retrospective case series of 23 nonoperative candidates (mean age 76.3 years, range 61–89) presenting with symptomatic cholelithiasis WITHOUT evidence of acute cholecystitis (exclusion criteria: fever, elevated inflammatory markers, imaging findings of gallbladder wall thickening >3 mm, pericholecystic edema, or sonographic Murphy’s sign). Reasons for nonoperative status: age (mean 76 yrs), comorbidity (Charlson Index ≥4 in 87%), frailty (>2 ADL dependencies), active oncology (35%), or patient refusal of surgery. All 23 patients underwent EUS-GBD with electrocautery-enhanced LAMS.

PRIMARY OUTCOMES: Technical success 100% (23/23). Stone clearance: 100% complete (23/23); notably 87% (20/23) achieved complete clearance after single treatment; lithotripsy required in 9% (2/23). Procedure-related adverse events: ZERO (0/23). Symptom recurrence: ZERO (0/23) during mean 9-month follow-up.

This is the FIRST published case series of EUS-GBD specifically for symptomatic cholelithiasis WITHOUT cholecystitis, addressing a genuine clinical care gap: high-risk, frail, elderly patients with symptomatic gallstones who decline surgery or are medically unfit for general anaesthesia. Current standard of care for such patients is conservative management with high rates of recurrent symptoms and emergency admissions.

The 100% stone clearance and zero adverse-event rate in this pilot series suggests EUS-GBD is technically feasible and safe in this population. However, this remains a hypothesis-generating case series with small sample, short follow-up, and no control comparison. Larger prospective studies with ≥2-year follow-up, standardized symptom and recurrence definitions, and comparison arms are mandated before this indication can be recommended outside selected, high-volume expert centres.

Clinical Bottom Line: EUS-GBD for symptomatic cholelithiasis WITHOUT cholecystitis in nonoperative candidates is technically feasible (100% stone clearance), safe (zero procedure-related complications), and associated with sustained symptom relief at 9-month follow-up. Selective consideration as a second-line option in frail, nonoperative patients who decline surgery is defensible, but requires explicit patient counselling regarding lack of long-term data and experimental nature of the indication.

Also Published — Noteworthy Mentions

Seven further June 2026 papers worth a place on your radar, each verified on PubMed.

1. Sandhu MM et al. — Post-ERCP acute kidney injury: 17.6% incidence; independent predictors include chronic comorbidity, cholangitis, reduced eGFR, raised bilirubin, low albumin, and concurrent nephrotoxic drugs. Defines a pre-procedure risk profile for patient counselling and fluid resuscitation planning. Cureus. 2026 Jun 12;18(6):e111623. PMID: 42516486. DOI

2. Sacco M et al. — Double-scope choledochoduodenostomy (DSOC) in elderly patients ≥75 years: comparable adverse event rates (8% vs 13%, p=0.44); age itself is NOT an independent risk factor for post-procedure complications. Supports DSOC as safe in carefully selected high-risk elderly cohorts. Eur J Gastroenterol Hepatol. 2026 Jun 15;38(6):3230. PMID: 42467930. DOI

3. Rentifis L et al. — Biliary stent biofilm culture analysis: 85.2% of stents positive for bacterial/fungal growth; Gram-negative organisms 63%; fungal species (Candida, Aspergillus) 37.4%; extended-spectrum beta-lactamase (ESBL) 69.4%. Implications for antibiotic stewardship in prophylaxis and empiric therapy. Cureus. 2026 Jun 8;18(6):e111075. PMID: 42472157. DOI

4. Zhu K, Fu Q, Liu M. — EUS-guided portal pressure gradient measurement in portal vein steal or diversion: technique feasibility, safety, and correlation with hepatic hemodynamics in small patient cohort. J Clin Transl Hepatol. 2026 Jun 27;14(3):e00334. PMID: 42558953. DOI

5. Alp J, Amateau SK, Leslie DB. — LAMS dwell time exceeding 10 years with transmural tissue ingrowth: case report demonstrating tissue incorporation and continued stent patency at extended follow-up; tissue fragmentation strategy for removal. Clin Gastroenterol Hepatol. 2026 Jun 20;22(6):e2214. PMID: 42369622. DOI

6. Xiong H, Tannenbaum A, Raymond C. — Autoimmune hemolytic anemia (AIHA) complicated by pigment choledocholithiasis presenting as acute cholangitis mimicking cholangiocarcinoma on imaging: diagnostic and management considerations for this rare overlap. Lab Med. 2026 Jun 12;55(4):lmag040. PMID: 42467565. DOI

7. Barvadiya N, Parmar DN et al. — Pancreatic pseudocysts: comprehensive stepwise management algorithm incorporating observation, percutaneous drainage, endoscopic transmural drainage, and hybrid approaches; risk-stratified decision tree based on size, location, symptoms, and comorbidity. Cureus. 2026 Jun 5;18(6):e110750. PMID: 42438608. DOI

Coming Soon: Mid-Month Quiz

Two scenario-based clinical questions based on this month’s featured papers — with interactive reveal functionality, full reasoning explanations, and evidence-linked references — will be available mid-July 2026 via www.ukieus.co.uk, Education & Guidelines section. This quiz is not bundled with the newsletter email and is available only on the UKIEUS website.

About this newsletter

EUS & ERCP Monthly is a free educational literature review from the UK & Ireland EUS Society (UKIEUS), edited by Dr Venkat Mahesh. It is provided for educational use only and does not constitute clinical guidance; management decisions must integrate individual patient factors and local expertise. Join the discussion for this issue at ukieus.co.uk/society-bulletins. © UKIEUS 2026.

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