Endotherapy in Biliopancreatic Diseases: ERCP Meets EUS: Two Techniques for One Vision

Foreword
Acknowledgement
Contents
Part I: ERCP and EUS: Armamentarium and Surroundings
	1: ERCP/EUS Room
		1.1	 ERCP Room
			1.1.1	 Introduction
		1.2	 Some Definitions
		1.3	 The Room
			1.3.1	 Requirements
				1.3.1.1	 Postanesthetic Care Area
			1.3.2	 Infection Control
			1.3.3	 The Cleaning of the Room
			1.3.4	 Staffing
		1.4	 Technical Rules According to European Legislation
			1.4.1	 Technical Plant and Electrical Safety
		1.5	 Technological Layout Guidelines
			1.5.1	 Ceiling Pendant Technology
			1.5.2	 Gases Centralized
			1.5.3	 Multimedia Integrated Network
			1.5.4	 Auxiliary Displays
			1.5.5	 Use of Laser Instruments
			1.5.6	 Net Connection Point
		1.6	 EUS Room
			1.6.1	 Introduction
		1.7	 Requirements
			1.7.1	 Room
				1.7.1.1	 Leaded Walls
			1.7.2	 Equipment Support Tools
			1.7.3	 Staffing
		References
	2: X-Rays in Endoscopy
		2.1	 When Were X-Rays Discovered?
		2.2	 Benefits of X-Rays
		2.3	 Why X-Rays in Endoscopy?
		2.4	 Which Radiological Instruments Were Used in the Past?
		2.5	 Change
	3: Ultrasound Equipment
		3.1	 Fujifilm
		3.2	 Olympus-Aloka
		3.3	 Pentax-Hitachi
	4: Endoscopes
		4.1	 Endoscopes
		4.2	 Duodenoscopes
		4.3	 Echoendoscopes
		4.4	 EUS Processors
		4.5	 ERCP Instruments
		4.6	 EUS Instruments
		References
	5: ERCP Standard and Special Devices
		5.1	 Introduction
		5.2	 Armamentarium for a Standard ERCP Procedure
			5.2.1	 Duodenoscopes
			5.2.2	 Cannulation Catheters
			5.2.3	 Guidewires
			5.2.4	 Standard Sphincterotome, Pre-cut Sphincterotome and the Needle Knife
			5.2.5	 Balloon Catheters
			5.2.6	 Dormia Baskets
			5.2.7	 Dilatation Catheters and Bougies
			5.2.8	 Biopsy Forceps and Brush Cytology
			5.2.9	 Lithotripsy
			5.2.10	 Biliary Stenting
			5.2.11	 Devices for ERCP in the Surgically Altered GI Tract
		5.3	 Special Devices for Therapeutic ERCP Interventions
			5.3.1	 Radiofrequency Ablation (RFA)
			5.3.2	 Photodynamic Therapy (PDT)
			5.3.3	 Cholangioscopy
		5.4	 Conclusion
		References
	6: EUS Standard Devices
		6.1	 EUS-FNA Devices
			6.1.1	 Overall Concepts
			6.1.2	 Types of Needles
				6.1.2.1	 Access Needle
				6.1.2.2	 Celiac Plexus Blockade and Neurolysis
			6.1.3	 EUS-FNA Technique
				6.1.3.1	 Application of Suction and Use of the Stylet
				6.1.3.2	 EUS-FNA/FNB Adverse Events
			6.1.4	 Through-the-Needle Devices
				6.1.4.1	 Cytology Brush
				6.1.4.2	 Microforceps
				6.1.4.3	 Needle-Based Confocal Laser Endomicroscopy Probe
				6.1.4.4	 Fiducial Placement
		6.2	 Interventional EUS
			6.2.1	 EUS-Guided Drainage of Intra-abdominal Fluid Collections
			6.2.2	 EUS-Guided Biliary Drainage
				6.2.2.1	 EUS-Guided Choledochoduodenostomy
				6.2.2.2	 EUS-Guided Hepaticogastrostomy
				6.2.2.3	 EUS-Guided Rendezvous Technique
				6.2.2.4	 EUS-Guided Antegrade Biliary Stenting
				6.2.2.5	 EUS-BD Versus ERCP
		References
	7: Deep Sedation and Anesthesia for Advanced Gastrointestinal Endoscopy: Challenging a Continuum
		7.1	 Introduction
		7.2	 Sedation in Digestive Endoscopy: A Continuum from Deep Sedation to General Anesthesia
		7.3	 Location [10]
		7.4	 The Anesthesia Staff
		7.5	 Drugs
		7.6	 Equipment
		7.7	 Monitoring
		7.8	 Patient Assessment
		7.9	 The Challenge
		7.10	 Coming to a Conclusion: Sedation, the Proceduralist, and the Anesthesiologist
		References
	8: Anatomy of the Biliary Tree
		8.1	 Overview
		8.2	 Intrahepatic Biliary Anatomy
			8.2.1	 Right Anterior Sectoral Ducts (Segments 5 and 8)
				8.2.1.1	 Segment 5
				8.2.1.2	 Segment 8
			8.2.2	 Right Posterior Sectoral Ducts (Segments 6 and 7)
				8.2.2.1	 Segment 6
				8.2.2.2	 Segment 7
			8.2.3	 Bile Ducts from Segments 2 and 3 (Left Lateral Sector)
			8.2.4	 Bile Ducts from Segment 4 (Left Medial Sector)
			8.2.5	 Bile Ducts from Segments 1 and 9 (Right Paracaval Region)
		8.3	 Extrahepatic Biliary Anatomy
			8.3.1	 Right Hepatic Duct
			8.3.2	 Left Hepatic Duct
			8.3.3	 Biliary Confluence
			8.3.4	 Common Hepatic Duct and Common Bile Duct
			8.3.5	 Gallbladder and Cystic Duct
		References
	9: Anatomy of the Pancreas
		9.1	 Introduction
		9.2	 Morphology of the Pancreas
		9.3	 Blood Supply
		9.4	 Lymphatic Drainage and Innervation
		9.5	 Ductal Anatomy
			9.5.1	 Normal Ductal Anatomy
			9.5.2	 Pancreas Divisum
			9.5.3	 Incomplete Pancreas Divisum
			9.5.4	 Abnormal Pancreatobiliary Junction
			9.5.5	 Annular Pancreas
			9.5.6	 Ansa Pancreatica
			9.5.7	 Dominant Dorsal Duct
		9.6	 Conclusion
		References
	10: CT: What We Need to Know to Start to Interpret Radiological Pictures
		10.1	 Computed Tomography Imaging Technique
		10.2	 CT Imaging of the Biliary System
			10.2.1	 Choledocholithiasis
			10.2.2	 Mirizzi Syndrome
			10.2.3	 Cholangitis: Biliary Tract Infection and Inflammation
				10.2.3.1	 Acute Cholangitis
				10.2.3.2	 Recurrent Pyogenic Cholangitis
				10.2.3.3	 Primary Sclerosing Cholangitis
				10.2.3.4	 Autoimmune Pancreatitis-Related Cholangitis
			10.2.4	 Cholangiocarcinoma
			10.2.5	 Biliary Injuries
				10.2.5.1	 Bile Leaks
				10.2.5.2	 Biliary Necrosis
				10.2.5.3	 Hemobilia
		10.3	 CT Imaging of the Pancreas
			10.3.1	 Acute Pancreatitis
				10.3.1.1	 Interstitial Oedematous Pancreatitis Versus Necrotizing Pancreatitis
				10.3.1.2	 Pancreatic and Peripancreatic Collections
				10.3.1.3	 Infection and Other Local Complications
			10.3.2	 Chronic Pancreatitis
				10.3.2.1	 Autoimmune Pancreatitis
				10.3.2.2	 Paraduodenal Pancreatitis
			10.3.3	 Solid Pancreatic Lesions
				10.3.3.1	 Pancreatic Adenocarcinoma
				10.3.3.2	 Pancreatic Neuroendocrine Tumours
		References
	11: MR: What We Need to Know to Start to Interpret Radiological Pictures
		11.1	 Magnetic Resonance Cholangiopancreatography
			11.1.1	 Imaging Protocol
			11.1.2	 MRCP Technique
			11.1.3	 Secretin-Enhanced MRCP
		11.2	 MR Imaging of the Biliary System
			11.2.1	 Congenital Diseases of Biliary System
				11.2.1.1	 Choledochal Cysts
				11.2.1.2	 Anomalous Pancreaticobiliary Junction
			11.2.2	 Choledocholithiasis
			11.2.3	 Biliary Stricture
				11.2.3.1	 Benign Biliary Stricture
					Iatrogenic Causes
					Primary Sclerosing Cholangitis
				11.2.3.2	 Malignant Biliary Stricture
					Cholangiocarcinoma
					Ampullary Carcinoma
		11.3	 MR Imaging of the Pancreatic Ducts
			11.3.1	 Congenital Pancreatic Anomalies
				11.3.1.1	 Pancreas Divisum
				11.3.1.2	 Santorinicele
				11.3.1.3	 Annular Pancreas
			11.3.2	 Pancreatitis
				11.3.2.1	 Acute Recurrent Pancreatitis
					Sphincter of Oddi Dysfunction
				11.3.2.2	 Chronic Pancreatitis
			11.3.3	 Solid Pancreatic Lesions
				11.3.3.1	 Pancreatic Adenocarcinoma
				11.3.3.2	 Pancreatic Neuroendocrine Tumours
			11.3.4	 Cystic Pancreatic Lesions
				11.3.4.1	 Pseudocyst
				11.3.4.2	 Intraductal Papillary Mucinous Neoplasm
				11.3.4.3	 Serous Cystadenoma
				11.3.4.4	 Mucinous Cystadenoma
				11.3.4.5	 Solid Pseudopapillary Tumour
		References
	12: Patient Management before and after EUS/ERCP
		12.1	 Pre-endoscopy Considerations
		12.2	 Informed Consent
		12.3	 Conscious Sedation (see also Chap. 7)
		12.4	 Radiation Protection and Patient Position
		12.5	 “Team-Time-Out”
		12.6	 Patient Management Before and During ERCP/EUS
		12.7	 Intra- and Postprocedural Considerations
		12.8	 Monitoring After ERCP/EUS, Postprocedural Complications
		12.9	 Discharge
		12.10	 Conclusion/Summary: Patient Management Before and After ERCP/EUS
		References
Part II: ERCP: What and How
	13: Cannulation Techniques
		13.1	 Accessing the Papilla
		13.2	 Pre-cannulation
		13.3	 Cannulation
			13.3.1	 Double-Wire Technique
			13.3.2	 When to Stop/Cut
		13.4	 Special Situations
			13.4.1	 Previous Sphincterotomy
			13.4.2	 Ampullary Tumor
			13.4.3	 Impacted Stone
			13.4.4	 Diverticulum
			13.4.5	 Altered Anatomy
	14: Biliary Sphincterotomy and Precut
		14.1	 Introduction
		14.2	 Biliary Sphincterotomy
			14.2.1	 Technique and Devices
			14.2.2	 Procedure
			14.2.3	 Indications and Contraindications
			14.2.4	 Adverse Events
		14.3	 Precut
			14.3.1	 Devices
			14.3.2	 How and When
			14.3.3	 Adverse Events
		References
	15: Pancreatic Sphincterotomy
		15.1	 Introduction
		15.2	 Endoscopic Technique
			15.2.1	 Patient Preparation
			15.2.2	 Pancreatic Duct Cannulation
			15.2.3	 Pull-Type Sphincterotomy
			15.2.4	 Needle-Knife Sphincterotomy
			15.2.5	 Precut Sphincterotomy
			15.2.6	 Post-sphincterotomy Plastic Stent Placement
		15.3	 Indications for Pancreatic Sphincterotomy
			15.3.1	 Pancreatic Sphincterotomy as Primary Therapy
			15.3.2	 SOD
			15.3.3	 Chronic Pancreatitis
			15.3.4	 IPMN-Associated Recurrent Pancreatitis
			15.3.5	 Post-distal Pancreatectomy Fistula
			15.3.6	 Pancreatic Sphincterotomy as Precursor of Other Endotherapy
		15.4	 Complications
		15.5	 Minor Papilla Sphincterotomy
			15.5.1	 Minor Papilla Identification
			15.5.2	 Dorsal Duct Cannulation
			15.5.3	 Pull-Type Sphincterotomy
			15.5.4	 Needle-Knife Sphincterotomy
			15.5.5	 Wire-Assisted Sphincterotomy
			15.5.6	 Precut Sphincterotomy
			15.5.7	 Post-sphincterotomy Plastic Stent Placement
			15.5.8	 Complications
		References
	16: Biliary Stones Extraction
		16.1	 Introduction: “Difficult” Biliary Stones
		16.2	 Bile Ducts Anatomy and Biliary Stones
			16.2.1	 Narrowing of the Distal Common Bile Duct
			16.2.2	 Bile Duct Angulation
			16.2.3	 Cystic Duct Stones
			16.2.4	 Intrahepatic Stones
		16.3	 Biliary Stones Extraction: Technical Points
			16.3.1	 The Sphincterotomy
			16.3.2	 The Axis and the Traction
			16.3.3	 Fogarty Balloon or Dormia Basket?
			16.3.4	 “Soft” and “Hard” Stones
			16.3.5	 Endoscopic Papillary Large Balloon Dilatation (EPLBD) and Mechanical Lithotripsy: When and How
		References
	17: Intraductal Lithotripsy
		17.1	 Introduction
		17.2	 Mechanical Lithotripsy
		17.3	 Cholangioscopy-Guided Lithotripsy
		17.4	 Cholangioscopy-Guided Laser Lithotripsy and Electrohydraulic Lithotripsy
			17.4.1	 Technical Background
		17.5	 General Tips and Tricks for Successful Lithotripsy
		17.6	 Conclusion
		References
	18: Biliary and Pancreatic ESWL
		18.1	 General Principles About ESWL
		18.2	 Technical Principles of ESWL
		18.3	 Specific Issues on Pancreatic ESWL
		18.4	 Specific Tools on Biliary ESWL
		18.5	 Conclusions
		References
	19: Biliary Stenting
		19.1	 Introduction
		19.2	 Plastic Stents
		19.3	 Self-Expandable Metal Stents
		19.4	 Multiple Biliary Stenting
		References
	20: Endoscopic Papillectomy
		20.1	 Clinical Features
		20.2	 Classification and Staging
		20.3	 Indication of Endoscopic Papillectomy
		20.4	 Staging
		20.5	 Techniques
		20.6	 Complications
		20.7	 Surveillance
		References
	21: Ductoscopy
		21.1	 History and Technical Background
			21.1.1	 Technical Details
		21.2	 Current Indications for Biliary Ductoscopy
			21.2.1	 Indeterminate Biliary Strictures
			21.2.2	 Bile Duct Stones
			21.2.3	 Other Indications for Cholangioscopy
		21.3	 Indications for Pancreatoscopy
		21.4	 Retrograde Cholangioscopy
			21.4.1	 Sphincter Management
			21.4.2	 Cannulation and Manoeuvrability
			21.4.3	 Safety
			21.4.4	 Limitations
		21.5	 Anterograde (Percutaneous) Cholangioscopy
			21.5.1	 Limitations
			21.5.2	 Safety of Anterograde Cholangioscopy
		References
	22: Intraductal Ablation Techniques
		22.1	 Introduction
		22.2	 Radiofrequency Ablation
		22.3	 Photodynamic Therapy
		22.4	 Argon Plasma Coagulation (APC)
		22.5	 Summary
		References
	23: Stent Removal (Plastic and Metal)
		23.1	 Indications for Removal
		23.2	 Removal Techniques of Biliary Stents
		23.3	 Removal of Proximally Migrated Stents
		23.4	 Complications from Stent Removal
		23.5	 Indications for Removal of Pancreatic Stents
		23.6	 Removal Techniques of Pancreatic Stents
		23.7	 Removal of Migrated Pancreatic Stents
		23.8	 Complications of Pancreatic Stent Removal
		23.9	 Conclusion
		References
	24: ERCP in Altered Anatomy
		24.1	 Surgical Reconstruction
		24.2	 Increased Incidence of Biliopancreatic Disease Requiring ERCP
		24.3	 Preparation for ERCP
		24.4	 Reaching the Papilla and/or Ductal Anastomosis
		24.5	 Device-Assisted ERCP, DAERCP
		24.6	 EUS-Guided Methods
		24.7	 Alternatives in RYGB/ ERCP via Gastrostomy
		24.8	 Laparoscopy-Assisted ERCP
		24.9	 Cannulation, Sphincterotomy, and Other Interventions
		24.10	 Adverse Events
		24.11	 Conclusion
		References
	25: PTC and PTC-ERCP Rendezvous Procedures
		25.1	 Introduction
		25.2	 Technique of PTCD
		25.3	 Patient Preparation
		25.4	 Procedure of PTCD
		25.5	 PTCD-ERCP Rendezvous
		25.6	 Indication for PTCD-ERCP Rendezvous
		References
Part III: EUS: What and How
	26: EUS Diagnostic Puncture
		26.1	 Indications
			26.1.1 What Can I Puncture?
		26.2	 Contraindications
		26.3	 Starting the Exam
		26.4	 Scope Positioning to Perform Puncture
		26.5	 Puncturing: How to Perform It Step-by-Step
		26.6	 Choosing the Needle
		26.7	 Additional Tips and Tricks to Get More and Higher-Quality Material
		26.8	 Cytopathology
			26.8.1 Cytology or Histology?
		26.9	 Markers in Pancreatic Cystic Fluid
		26.10	 Complications
		26.11	 What to Remember After the Puncture
		26.12	 Future Perspectives in EUS Diagnostic Punctures
			26.12.1 Confocal Laser Endomicroscopy (CLE)
			26.12.2 Microbiopsy Forceps
			26.12.3 Cytology Brush
			26.12.4 Fine Needle Vein Puncture
		References
	27: Ancillary Diagnostic Techniques in EUS
		27.1	 EUS Elastography
		27.2	 Contrast-Enhanced EUS
		27.3	 Endoscopic Ultrasound-Guided Needle-Based Confocal Laser Endomicroscopy
		References
	28: EUS-Guided Transenteric Pancreatic Duct Drainage
		28.1	 Technical Considerations
		28.2	 Clinical Algorithm
		28.3	 Conclusion
		References
	29: EUS-Assisted Ablation Techniques
		29.1	 Introduction
		29.2	 Indications
			29.2.1	 Pancreatic Adenocarcinoma
			29.2.2	 Pancreatic Neuroendocrine Tumours
			29.2.3	 Pancreatic Cystic Lesions
			29.2.4	 Extra-Pancreatic Indications
		29.3	 Ablative Techniques
			29.3.1	 Radiofrequency Ablation
				29.3.1.1	 Mechanism of Action
				29.3.1.2	 Clinical Data
			29.3.2	 Cryothermablation
				29.3.2.1	 Mechanism of Action
				29.3.2.2	 Clinical Data
			29.3.3	 Photodynamic Treatment
				29.3.3.1	 Mechanism of Action
				29.3.3.2	 Clinical Data
			29.3.4	 Neodymium-Doped Yttrium Aluminium Garnet Laser Ablation
				29.3.4.1	 Mechanism of Action
				29.3.4.2	 Clinical Data
			29.3.5	 Ethanol Injection
				29.3.5.1	 Mechanism of Action
				29.3.5.2	 Clinical Data
			29.3.6	 Chemotherapy Injection
				29.3.6.1	 Mechanism of Action
				29.3.6.2	 Clinical Data
					Chemotherapy
					Cytoimplant
					Dendritic Cells (DCs)
					Adenovirus ONYX-015
					Tumour Necrosis Factor Alpha (TNF-α)
					BC-819
		29.4	 Future Perspectives
		References
	30: Intraductal US
		30.1	 Introduction
		30.2	 Technical Consideration
		30.3	 Normal Endosonographic Imaging
		30.4	 Biliary Tree: Indications
			30.4.1	 Choledocholithiasis
			30.4.2	 Bile Duct Strictures
			30.4.3	 Staging of Malignancy
			30.4.4	 Evaluation of Idiopathic Acute or Recurrent Pancreatitis
			30.4.5	 Gallbladder Lesions
				30.4.5.1	 Ampulla
				30.4.5.2	 Pancreas
		30.5	 Other Nonconventional Indications
			30.5.1	 Primary Sclerosing Cholangitis, IgG-4-Related Cholangitis
			30.5.2	 Directed Endoscopic Biliary Procedures
			30.5.3	 Portal Hypertensive Biliopathy
		30.6	 Conclusions
		References
Part IV: Complications: Prevention, Diagnosis and Management
	31: Post-ERCP Acute Pancreatitis
		31.1	 Acute Post-ERCP Pancreatitis
		31.2	 Diagnosis
		31.3	 Pathogenesis of PEP
		31.4	 Risk Factors
		31.5	 Prevention
			31.5.1	 Patient Selection
			31.5.2	 Pharmacological Prophylaxis
			31.5.3	 Periprocedural Fluid Replacement
			31.5.4	 Guidewire Cannulation
			31.5.5	 Cannulation Attempts and Precut
			31.5.6	 Pancreatic Duct Stents
		31.6	 Management
		References
	32: Bleeding
		32.1	 ERCP-Related Bleeding
		32.2	 EUS-Related Bleeding
		32.3	 Risk Factors - Preventive Measures
		32.4	 Management
		32.5	 Conclusion
		References
	33: ERCP-Related Perforations
		33.1	 Epidemiology and Types of Perforation
		33.2	 Mechanisms of Perforation and Risk Factors
		33.3	 Diagnosis
		33.4	 Prevention
		33.5	 Therapy
			33.5.1	 Type 1 Perforations
				33.5.1.1	 Endoscopy
				33.5.1.2	 Surgery
			33.5.2	 Type 2 and 3 Perforations
				33.5.2.1	 Conservative Treatment
				33.5.2.2	 Endoscopy
				33.5.2.3	 Surgery
			33.5.3	 Type 4 Perforations
		33.6	 Summary
		References
	34: Miscellany Complications of ERCP
		34.1	 Infectious Adverse Events
			34.1.1	 Cholangitis
			34.1.2	 Cholecystitis
			34.1.3	 Duodenoscope-Related Infections
		34.2	 Hepatic Hematoma
		34.3	 Hepatic Abscess
		34.4	 Stent-Related Complication
		34.5	 Splenic Injury
		34.6	 Cardiopulmonary Adverse Events
			34.6.1	 Air Embolism
		References
	35: EUS Complications
		35.1	 Introduction
		35.2	 Complications of Diagnostic EUS
		35.3	 Complications of EUS-FNA
			35.3.1	 Infection
			35.3.2	 Pancreatitis
			35.3.3	 Hemorrhage
			35.3.4	 Tumor Seeding
			35.3.5	 Bile Peritonitis
		35.4	 Complications of EUS Fine-Needle Injection Procedures
		35.5	 Complications of Pancreatic Fluid Collection Drainage
			35.5.1	 Perforation
			35.5.2	 Bleeding
			35.5.3	 Buried LAMS
			35.5.4	 Stent Migration
			35.5.5	 Maldeployment
			35.5.6	 Direct Endoscopic Necrosectomy (DEN)
		35.6	 Complications of EUS-Guided Biliary Drainage
			35.6.1	 Bile Leak
			35.6.2	 Stent Migration and Maldeployment
		35.7	 Complication of EUS-Guided Gallbladder Drainage
		References
Part V: Biliopancreatic Diseases: Clinical Results
	36: Common Bile Duct Stones
		36.1	 Introduction
		36.2	 Etiology and Risk Factors
		36.3	 Clinical Spectrum of Common Bile Duct Stones
			36.3.1	 Symptomatic Bile Duct Stones with Cholestasis
			36.3.2	 Symptomatic Bile Stones Without Cholestasis
			36.3.3	 Asymptomatic Bile Duct Stones
			36.3.4	 Recurrent Common Bile Duct Stones
			36.3.5	 Acute Cholecystitis and Common Bile Duct Stones
			36.3.6	 Mirizzi Syndrome
		36.4	 Diagnosis of Common Bile Duct Stones
			36.4.1	 Laboratory Evaluation
			36.4.2	 Transabdominal Ultrasound
			36.4.3	 Endoscopic Ultrasound
			36.4.4	 Magnetic Resonance Imaging (MRI/MRCP)
			36.4.5	 Computed Tomography (CT)
			36.4.6	 Endoscopic Retrograde Cholangiopancreatography (ERCP)
		36.5	 Indication for Treatment of Common Bile Duct Stones
			36.5.1	 CBDS in Elderly Patients
		36.6	 Extraction Techniques
			36.6.1	 ERCP
				36.6.1.1	 Cannulation of the Papilla
				36.6.1.2	 Endoscopic Sphincterotomy
				36.6.1.3	 Pre-cut Sphincterotomy and Fistulotomy
				36.6.1.4	 Large Balloon Dilatation of the Papilla
			36.6.2	 Stone Extraction
				36.6.2.1	 Stone Extraction Balloon
				36.6.2.2	 Stone Extraction Basket
				36.6.2.3	 Mechanical Lithotripsy
			36.6.3	 Prophylactic Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones
				36.6.3.1	 Stent Placement
				36.6.3.2	 Intraductal Lithotripsy
			36.6.4	 Cholangioscopy with Lithotripsy
			36.6.5	 Extracorporeal Shock Wave Lithotripsy (ESWL)
			36.6.6	 Percutaneous Transhepatic Cholangiography (PTC)
				36.6.6.1	 Cholecysto-Choledocholithiasis
		References
	37: Intrahepatic Stones
		37.1	 Introduction
		37.2	 Diagnosis
		37.3	 Treatment
			37.3.1	 ERCP
			37.3.2	 Cholangioscopy
			37.3.3	 Endoscopic Ultrasound-Guided Drainage
			37.3.4	 Extracorporeal Shock Wave Lithotripsy (ESWL)
			37.3.5	 Surgical Treatment
		References
	38: Acute Cholangitis
		38.1	 Introduction
		38.2	 Symptoms
		38.3	 Diagnosis of Cholangitis
		38.4	 Initial Management
			38.4.1	 Grade III (Severe Acute Cholangitis)
			38.4.2	 Grade II (Moderate Acute Cholangitis)
			38.4.3	 Grade I (Mild Acute Cholangitis)
		38.5	 Antimicrobial Therapy [6]
		38.6	 Biliary Decompression
		References
	39: Papillectomy: Clinical Results
		39.1	 Indications
		39.2	 Contraindications
		39.3	 Clinical Results
		39.4	 Results in Relation to EP Techniques
		39.5	 Adverse Events
		39.6	 Surveillance for Residual or Recurrent Neoplastic Tissue
		39.7	 Treatment of Residual or Recurrent Endobiliary Neoplastic Tissue
		39.8	 Ablative Therapies
		39.9	 Comparison of EP and Surgery
		References
	40: Endoscopic Management in Malignant Biliary Strictures: Tips and Tricks
		40.1	 Tips and Tricks for Malignant Biliary Strictures
		40.2	 Distal Malignant Biliary Stricture (DMBO)
			40.2.1 Surgery Versus Endoscopic Approach
			40.2.2 Is the ERCP the First Choice Compared to EUS-BD?
			40.2.3 How to Treat Patients in Case of ERCP Failure?
			40.2.4 EUS-BD: Intrahepatic (HGS) Versus Extrahepatic (CDS) Approach. Which Is the Best?
			40.2.5 EUS-BD Versus PTBD After Failed ERCP: The Winner Is
				40.2.5.1	 When Percutaneous Biliary Drainage Should Be Used?
			40.2.6 Do We Need to Perform ES Before SEMS Placement?
			40.2.7 Is There a Greater Risk of Cholecystitis After Placing an FCSEMS?
			40.2.8 Treatment of Malignant Bilioduodenal Obstruction (Type II GOO); Is It Always Possible to Place a Stent?
			40.2.9 Which Stent: Plastic Versus Metal?
			40.2.10 ESGE Recommends SEMS Insertion for Palliative Drainage of Malignant Extrahepatic Biliary Obstruction
				40.2.10.1	 Which Metal Stent Should Be Used: USEMS Versus PCSEMS Versus CSEMS? A Battle of Superiority?
			40.2.11 How to Drain DMBO of Unconfirmed Etiology
			40.2.12 Preoperative Biliary Drainage (PBD) in DMBO
				40.2.12.1	 Which Route of PBD Is Preferred? PTBD Versus ERCP
				40.2.12.2	 Which Stent Should Be Placed in Case of PBD?
			40.2.13 Proximal Malignant Biliary Stricture (Hilar) (HMBO)
				40.2.13.1	 Introduction
				40.2.13.2	 Diagnosis
				40.2.13.3	 Treatment
				40.2.13.4	 Endoscopic Versus Percutaneous Approach
				40.2.13.5	 Is the Drainage of Advanced Hilar Stricture for All?
			40.2.14 Endoscopic Stenting
				40.2.14.1	 Should We Perform ES Before Stent Placement? Yes. We Should Do
				40.2.14.2	 Which Stent for Hilar Malignant Stricture? Plastic Versus Metal
				40.2.14.3	 Do We Need to Perform Unilateral or Bilateral Drainage?
				40.2.14.4	 Complete Versus Incomplete Drainage
				40.2.14.5	 How Do You Drain?
				40.2.14.6	 How to Perform Biliary Drainage?
				40.2.14.7	 Is There a Role of CSEMS in the Hilar Tumor?
			40.2.15 Stent in Stent (SIS) Versus Side by Side (SBS): Which Is the Best Technique?
				40.2.15.1	 How to Treat Stent Dysfunction?
				40.2.15.2	 Preoperative Biliary Drainage (PBD): Is There a Role
				40.2.15.3	 How to Perform PBD?
				40.2.15.4	 Which Stent Should Be Used for PBD?
				40.2.15.5	 Which Length? Is the Length Important?
				40.2.15.6	 Is There a Role of Drug-Eluting SEMS?
				40.2.15.7	 Endoscopic Adjuvant Treatment of Biliary Obstruction: Advance Beyond the SEMS
				40.2.15.8	 Radiofrequency Ablation
		References
	41: Results of EUS Transmural Biliary Drainage
		41.1	 Introduction
		41.2	 Techniques
			41.2.1	 Intrahepatic Approach
			41.2.2	 Extrahepatic Approach
			41.2.3	 Algorithm for EUS-BD Guidance
		41.3	 Summary
		References
	42: Postoperative Biliary Stricture
		42.1	 Epidemiology and Risk Factors
		42.2	 Classifications
		42.3	 Clinical Presentation and Diagnosis
		42.4	 Endoscopic Therapy
		42.5	 Non-endoscopic Therapies
		References
	43: Biliary Complications After Liver Transplantation
		43.1	 Introduction
		43.2	 Considering Surgical Technique Before Starting Endoscopic Treatment
		43.3	 Diagnostics Before Interventional Treatment
		43.4	 Stricturing Disease After Liver Transplantation
		43.5	 Bile Duct Leaks
		43.6	 Adverse Events from Bile Duct Content
		43.7	 Bilioma and Liver Abscess Formation
		43.8	 Summary and Diagnostic Algorithm
		References
	44: Biliary Leaks: Role of ERCP in Post-operative Biliary Complications
		44.1	 Introduction
		44.2	 ERCP in Bile Duct Injury
		44.3	 Evaluation and Subsequent Treatment of Bile Duct Injury
		44.4	 Other Post-operative Complications
		44.5	 Summary
		References
	45: Primary Sclerosing Cholangitis
		45.1	 Introduction
		45.2	 Symptoms and Diagnosis
		45.3	 Variants of PSC and Differential Diagnosis
		45.4	 Medical Therapy
		45.5	 Role of ERCP
		45.6	 Role of Cholangioscopy, EUS, and Intraductal Ultrasound
		45.7	 Surgery and Liver Transplantation
		45.8	 Conclusion
		References
	46: Acute Cholecystitis
		46.1	 Introduction
		46.2	 Diagnosis
		46.3	 Treatment
		46.4	 Percutaneous Cholecystostomy
		46.5	 Endoscopic Transpapillary Gallbladder Drainage (ETGBD)
		46.6	 EUS-Guided Gallbladder Drainage (EUS-GBD)
		46.7	 Comparison Between Non-surgical Drainage Techniques
		References
	47: Acute Pancreatitis
		47.1	 Introduction
		47.2	 Symptoms and Diagnosis
		47.3	 Scoring Systems for Severity Prediction
		47.4	 Fluid Resuscitation
		47.5	 Nutrition
		47.6	 Role of ERCP in Biliary Pancreatitis
		47.7	 Antibiotic Therapy
		47.8	 Cholecystectomy and Prevention of Relapse
		47.9	 Necrosectomy and Peripancreatic Fluid Collections
		47.10	 Conclusion
		References
	48: Chronic Pancreatitis
		48.1	 Introduction
		48.2	 Main Pancreatic Duct Drainage
			48.2.1	 Main Pancreatic Duct Drainage by ERCP
				48.2.1.1	 Clinical Results
					Stricture-Predominant Disease
						Single Plastic Stenting
						Multiple Plastic Stenting
						Self-Expandable Metal Stenting
					Stone(s)-Predominant Disease
				48.2.1.2	 Factors Predictive of Clinical Results
			48.2.2	 Main Pancreatic Duct Drainage by EUS
		48.3	 Common Bile Duct Drainage
			48.3.1	 Common Bile Duct Drainage by ERCP
				48.3.1.1	 Clinical Results
					Single Plastic Stenting
					Multiple Plastic Stenting
					Self-Expandable Metal Stenting
				48.3.1.2	 Factors Associated with Clinical Success
					Pancreatic Calcifications in the Head of Pancreas
					Concomitant Acute Pancreatitis
					Stricture Length
			48.3.2	 Common Bile Duct Drainage by EUS
		48.4	 Conclusions
		References
	49: Pancreatic Fistulas
		49.1	 Initial Diagnosis: Symptoms
		49.2	 Management of Pancreatic Fistula
		49.3	 Biliary and Pancreatic Leaks
		49.4	 General Principles of Fluid Circulation
		49.5	 Endoscopic Management of Pancreatic Fistulas
		49.6	 Endotherapy Complications
		49.7	 Surgical Treatment
		49.8	 Conclusion
		References
Part VI: The Cytopathologist’s Point of View
	50: EUS Tissue Sampling: What Are We Talking About?
		50.1	 Introduction
		50.2	 Handling of Aspirated Samples
			50.2.1	 Fixation of Slides
			50.2.2	 Rapid On-Site Diagnostic Evaluation (ROSE)
			50.2.3	 Cell Block
		50.3	 Handling of Core Biposy Specimens
		50.4	 Diagnostic Role of EUS-Guided Sampling
		50.5	 Conclusions
		References
	51: Molecular Biology of Biliopancreatic Lesions
		51.1	 Molecular Biology of Biliopancreatic Lesions
		51.2	 Deep Sequencing of PDAC
		51.3	 Most Commonly Mutated Genes in Biliopancreatic Lesions
			51.3.1	 KRAS
			51.3.2	 TP53
			51.3.3	 SMAD4
			51.3.4	 CTNNB1
			51.3.5	 GNAS
			51.3.6	 CDKN2A
				51.3.6.1	 Other Genetic Alterations
		51.4	 Techniques
		References
Part VII: Clinical Algorithms
	52: Suspected Common Bile Duct Stones (Algorithm)
		Bibliography
	53: Acute Cholangitis (Algorithm)
		Bibliography
	54: Diagnosis of Etiology in Acute Pancreatitis
		References
	55: Periampullary Biliary Strictures (Algorithm)
	56: Hilar Strictures: Algorithm
		References
	57: Diagnosis of Pancreatic Cyst: Algorithm
		Bibliography