Guralwar, Chinmay

Background: The optimal self-expandable metallic stent (SEMS) choice for endoscopic drainage of unresectable extrahepatic malignant biliary obstruction (MBO) with endoscopic retrograde cholangiopancreatography (ERCP) remains unclear due to limited randomized controlled trial (RCT) evidence. Prior meta-analyses have relied on observational data, introducing heterogeneity and bias. To overcome these limitations, an RCT-only network meta-analysis (NMA) was performed to evaluate the efficacy and safety of SEMS types. Methods: A literature search was conducted to identify RCTs assessing fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and/or uncovered SEMS (UCSEMS) for ERCP drainage of unresectable extrahepatic MBO. Study outcomes included recurrent biliary obstruction (RBO), specific causes of RBO, overall survival (OS), and adverse events (AEs). A frequentist NMA was performed to estimate hazard ratios (HRs) and incidence rate ratios (IRRs) with their 95% confidence intervals and overall P-scores. Results: Ten RCTs (1,659 patients) were included. There were no significant differences in time to RBO, incidence of any RBO, or OS between stent types. UCSEMS had the lowest rates of stent migration, tumor overgrowth, and sludge occlusion, whereas FCSEMS most effectively prevented tumor ingrowth. AE rates were similar across groups; however, only FCSEMS, but not PCSEMS, had significantly higher rates of acute cholecystitis than UCSEMS in patients with an intact gallbladder. Conclusion: There were no differences in RBO, OS, or AE excluding acute cholecystitis between each SEMS type, although each type has its advantages and disadvantages. FCSEMS was associated with a higher risk of acute cholecystitis, emphasizing careful patient selection, particularly regarding gallbladder status.

Abstract Background and Aims EUS-guided gastroenterostomy (EUS-GE) is an effective option to palliate symptoms of gastric outlet obstruction (GOO). While the jejunum is conventionally targeted (EUS-GJ), targeting the duodenum (EUS-GD) may offer clinical advantages. Outcomes were compared for EUS-GJ and EUS-GD. Methods Adult patients who underwent EUS-GE for GOO between 2020 and 2024 were included and categorized as an EUS-GD if the stent entered the transverse or ascending duodenum or an EUS-GJ if the stent entered more distally. The primary outcome was clinical success (soft diet tolerance at 7 days). Secondary outcomes included adverse events (AEs), stent misdeployment, and unplanned endoscopic reintervention. Baseline demographic variables and outcomes were compared with statistical significance at p < 0.05. Results Of the 139 included patients (median age 67 years (IQR 61–74); 41% female), 105 underwent EUS-GJ and 34 underwent EUS-GD. Clinical success was 98% for EUS-GJ and 94% for EUS-GD (p = 0.25). The misdeployment rate was 7% for EUS-GJ and 0% for EUS-GD (p = 0.19). The AE rate was 22% for EUS-GJ and 12% for EUS-GD (p = 0.23). There were no significant differences for stent obstruction (EUS-GJ 12% vs. EUS-GD 6%), bleeding (2% vs. 6%), perforation (4% vs. 0%), stent migration (1% vs. 0%), infection (3% vs. 0%), and unplanned reintervention (14% vs. 9%). Conclusion Both EUS-GJ and EUS-GD demonstrate high clinical success with no significant differences in adverse event rates. These data can support intraprocedural decision-making for endoscopists performing EUS-GE.

Abstract Endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition is the cornerstone for assessment of suspected malignant biliary strictures. Conventional techniques, including biliary brush cytology and transpapillary forceps biopsy, are highly specific but are limited by modest sensitivity for detection of malignancy, often leaving a substantial proportion of individuals without a definitive diagnosis. To improve diagnostic sensitivity for cancer, several adjunctive approaches have been integrated into ERCP-based sampling. Peroral cholangioscopy (POC)-guided biopsies have become a reliable ERCP-based adjunctive modality, allowing direct visualization and targeted sampling, particularly in individuals with prior nondiagnostic procedures. Fluorescence in situ hybridization (FISH) is a technique used to improve diagnostic yield with biliary brushings by detecting chromosomal abnormalities, but is limited to specialized centers due to the need for specialized processing and training. Next-generation sequencing provides high sensitivity and can enable identification of actionable genomic alterations, while methylated DNA markers represent a promising, scalable molecular approach with strong diagnostic performance. Additional techniques include artificial intelligence–augmented direct visualization by POC and bile-based liquid biopsy. Current guidelines recommend multimodal ERCP-based sampling, combining at least two modalities where feasible, to optimize diagnostic accuracy. This review highlights the clinical performance, strengths, and limitations of established and emerging ERCP-guided techniques, emphasizing their evolving role in improving the diagnosis and management of malignant biliary strictures.

ABSTRACT Glucagon-like peptide-1 receptor agonists (GLP-1RA) are generally avoided in patients with a history of pancreatitis due to concerns about potential associated risk of acute pancreatitis (AP). However, their role in managing severe hypertriglyceridemia (HTG) remains underexplored. We present a case of a 42-year-old woman with recurrent HTG-induced AP who was initiated on GLP-1RA and achieved 15% weight loss, sustained triglyceride reduction, and remained AP-free while on that therapy. This case highlights a potential new role for the use of GLP-1RAs for HTG-AP.

Abstract Background: Acute coronary syndrome (ACS) remains a major cause of mortality worldwide, with India reporting approximately three million cases annually. This study aims to assess the demographics, risk factors, and treatment patterns of ACS patients in Central India while exploring challenges related to pre-hospital delays and financial constraints. Materials and Methods: A cross-sectional, questionnaire-based study was conducted at a tertiary care hospital. Data from patients with ACS were collected through face-to-face interviews using a self-designed, semi-structured, open-ended questionnaire. Results: Among the 90 participants, 86.6% were diagnosed with an acute ST-segment elevation myocardial infarction (STEMI), with a male predominance (81.1%). Common risk factors included smoking, diabetes, hypertension, and a history of cardiovascular events. The primary reasons for delays in seeking medical care were a lack of recognition of symptom severity (37%), prolonged travel times (21%), and unavailability of suitable transportation (21%). Chest pain was the most frequently reported initial symptom (73.3%), with symptom onset occurring most often in the morning (43.3%). Males were more likely to experience anterior wall MI, while females predominantly presented with inferior or posterior wall MI. Emergency medical service (EMS) utilization was low, with most patients relying on personal vehicles for transportation. Additionally, rural patients required at least one additional hospital visit before reaching the tertiary care center compared to their urban counterparts. Thrombolysis was the primary treatment modality, administered to 76.67% of participants, with an average door-to-needle time of 78 ± 63 min. Conclusion: Multiple hospital referrals and inadequate EMS utilization hinder optimal ACS management. This study underscores the need for a streamlined referral process, enhanced EMS infrastructure, reduced door-to-needle time, and targeted interventions to mitigate financial barriers to ACS care in India.