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EUS-guided gastroenterostomy (EUS-GE) is a minimally invasive technique for gastric outlet obstruction (GOO). EUS-guided balloon-occluded gastrojejunostomy bypass (EPASS) aims to improve stent deployment and minimize migration in EUS-GE. In this study, we evaluated the long-term outcomes of EPASS. We retrospectively analyzed 37 patients (mean age, 71 years; 21 men) with symptomatic, nonrefractory GOO who had undergone EPASS. EPASS achieved a 94.6% technical success rate (35/37), including 2 cases of stent misdeployment. The mean procedure time was 27.3 minutes, with a double-balloon tube insertion time of 10.4 minutes. Initial GOO scores improved from.43 to 2.14 and 2.60 at 7 and 28 days after EPASS, respectively. The clinical success rate was 89.2%. The rate of adverse events, including fever and abdominal pain, was 16.2%. The mean overall survival after EPASS was 193.5 days, with no stent occlusion or migration (100% patency). EPASS demonstrated safety and reliability in EUS-GE, offering a viable option for symptomatic malignant GOO treatment. (Clinical trial registration number: UMIN000011608.) [Display omitted] [ABSTRACT FROM AUTHOR]

The optimal electrosurgical unit (ESU) settings for endoscopic papillectomy (EP) have not been investigated. We conducted animal experiments to determine the optimal endoCUT settings with VIO (Erbe, Tübingen, Germany) ESUs and then conducted a small clinical study. Dedicated animal experimental models were created. To investigate the incision force, chicken meat was resected with a snare whose handle was a hung weight. To investigate the coagulation effect, a surgical needle electrode was inserted into a pig liver and energized, and to determine changes over time in the coagulation status, simulated EP was performed using a living pig. These experiments were performed using the knife-setting or snare-setting endoCUT modes and various effect, duration, and interval settings and compared with results for ICC (Erbe) ESUs. Based on the results, we performed EP in a small number of patients. The main factor affecting the incision force was duration. The coagulation effect was related to not only effect but also duration. In the endoCUT mode, knife-setting produced a higher incision force and lower coagulation effect. The nondischarge coagulation effect may cause deep ulceration. Based on the animal experiments, we concluded the ideal ESU setting for EP, "VIO EP mode," is knife-setting with high duration, lowest effect, and low interval settings. In the clinical study, there were no significant adverse events such as bleeding, pancreatitis, or perforation. "VIO EP mode" seems to afford optimal papillectomy. Larger scale clinical studies are needed to accumulate further data and make clinical comparisons with the ICC ESU. [Display omitted] [ABSTRACT FROM AUTHOR]

To evaluate the success of a patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA) practice for prostate cancer patients across multiple institutions using a questionnaire survey. The IMRT QA practice involves different methods of dose distribution verification and analysis at different institutions. Two full-arc volumetric modulated arc therapy (VMAT) plan and 7 fixed-gantry IMRT plan with DMLC were used for patient specific QA across 22 institutions. The same computed tomography image and structure set were used for all plans. Each institution recalculated the dose distribution with fixed monitor units and without any modification. Single-point dose measurement with a cylindrical ionization chamber and dose distribution verification with a multi-detector or radiochromic film were performed, according to the QA process at each institution. Twenty-two institutions performed the patient-specific IMRT QA verifications. With a single-point dose measurement at the isocenter, the average difference between the calculated and measured doses was 0.5 ± 1.9%. For the comparison of dose distributions, 18 institutions used a two or three-dimensional array detector, while the others used Gafchromic film. In the γ test with dose difference/distance-to-agreement criteria of 3%−3 mm and 2%−2 mm with a 30% dose threshold, the median gamma pass rates were 99.3% (range: 41.7%–100.0%) and 96.4% (range: 29.4%–100.0%), respectively. This survey was an informative trial to understand the verification status of patient-specific IMRT QA measurements for prostate cancer. In most institutions, the point dose measurement and dose distribution differences met the desired criteria. [ABSTRACT FROM AUTHOR]

• Clarify the inter-planner variation of knowledge-based plan (KBP) quality. • Ninety VMAT plans were created using the RapidPlan by nine planners. • Single optimization with only priority modification was performed. • Large variation of plan quality was observed in beginner planners. • Inter-planner variation remains for complicated plans even though using KBP. This study aimed to clarify the inter-planner variation of plan quality in knowledge-based plans created by nine planners. Five hypofractionated prostate-only (HPO) volumetric modulated arc therapy (VMAT) plans and five whole-pelvis (WP) VMAT plans were created by each planner using a knowledge-based planning (KBP) system. Nine planners were divided into three groups of three planners each: Senior, Junior, and Beginner. Single optimization with only priority modification for all objectives was performed to stay within the dose constraints. The coefficients of variation (CVs) for dosimetric parameters were evaluated, and a plan quality metric (PQM) was used to evaluate comprehensive plan quality. Lower CVs (<0.05) were observed at dosimetric parameters in the planning target volume for both HPO and WP plans, while the CVs in the rectum and bladder for WP plans (<0.91) were greater than those for HPO plans (<0.17). The PQM values of HPO plans for Cases1–5 (average ± standard deviation) were 41.2 ± 7.1, 40.9 ± 5.6, and 39.9 ± 4.6 in the Senior, Junior, and Beginner groups, respectively. For the WP plans, the PQM values were 51.9 ± 6.3, 47.5 ± 4.3, and 40.0 ± 6.6, respectively. The number of clinically acceptable HPO and WP plans were 13/15 and 11/15 in the Senior group, 13/15 and 10/15 plans in the Junior group, and 8/15 and 2/15 plans in the Beginner group, respectively. Inter-planner variation in the plan quality with RapidPlan remains, especially for the complicated VMAT plans, due to planners' heuristics. [ABSTRACT FROM AUTHOR]

Purpose This study evaluated whether RapidPlan based plans (RP plans) created by a single optimization, are usable in volumetric modulated arc therapy (VMAT) for patients with prostate cancer. Methods We used 51 previously administered VMAT plans to train a RP model. Thirty RP plans were created by a single optimization without planner intervention during optimization. Differences between RP plans and clinical manual optimization (CMO) plans created by an experienced planner for the same patients were analyzed (Wilcoxon tests) in terms of homogeneity index (HI), conformation number (CN), D 95% , and D 2% to planning target volume (PTV), mean dose, V 50Gy , V 70Gy , V 75Gy , and V 78Gy to rectum and bladder, monitor unit (MU), and multi-leaf collimator (MLC) sequence complexity. Results RP and CMO values for PTV D 95% , PTV D 2% , HI, and CN were significantly similar ( p < 0.05 for all). RP mean dose, V 50Gy , and V 70Gy to rectum were superior or comparable to CMO values; RP V 75Gy and V 78Gy were higher than in CMO plans ( p < 0.05). RP bladder dose-volume parameter values (except V 78Gy ) were lower than in CMO plans ( p < 0.05). MU values were RP: 730 ± 55 MU and CMO: 580 ± 37 MU ( p < 0.05); and MLC sequence complexity scores were RP: 0.25 ± 0.02 and CMO: 0.35 ± 0.03 ( p < 0.05). Conclusions RP plans created by a single optimization were clinically acceptable in VMAT for patient with prostate cancer. Our simple model could reduce optimization time, independently of planner’s skill and knowledge. [ABSTRACT FROM AUTHOR]

Abstract A rare pediatric case of pancreaticobiliary maljunction (PBM) with pancreas divisum is reported. The case showed extremely rare arrangement of the biliary tree and pancreatic duct; the common channel usually seen in PBM did not exist and the common bile duct was connected to the dorsal pancreatic duct via a dilated intermediary duct, in which a large protein plug had formed. The common bile duct was not dilated at all. All of these anomalies may have been caused by abnormal development of the ventral and dorsal pancreatic ducts at an early gestational age. We report a very rare pediatric case of pancreaticobiliary maljunction (PBM) complicated with pancreas divisum. In this case, the common bile duct showed a normal caliber and it was connected to the dorsal pancreatic duct through an intermediary dilated duct, which contained a protein plug that dammed up bile and pancreatic juice flow. This anomaly is very similar to type IIIc3 choledochal cyst, whose classification was addressed by Komi et al. (1), but it differed in the following point; in our case, the common bile duct did not connect to the duodenum through the ampulla of Vater (the common channel was absent) and bile was drained to the duodenum through Santorini duct. These quite rare anomalies might have been caused in the fetus by some kind of maldevelopment of the ventral and dorsal pancreatic ducts. [ABSTRACT FROM AUTHOR]

Purpose To investigate optimal bladder volumes at treatment planning (TP) in prostate cancer patients who undergo volumetric modulated arc therapy (VMAT). Methods and materials To determine the minimum value, 122 patients were classified into 6 groups according to the bladder volume at TP: < 100 mL (group 1), 100-149 mL (group 2), 150-199 mL (group 3), 200-249 mL (group 4), 250-299 mL (group 5), and ≥ 300 mL (group 6). Bladder volumes receiving more than 70 Gy (V 70Gy ) and V 50Gy were calculated in each subgroup and compared with the bladder dose-volume constraints specified in our institution. To determine the maximum value, 64 patients who underwent uniform nursing interventions were classified into the same 6 groups. Bladder volumes on cone beam computed tomography (CBCT) images were measured once weekly during treatment, for a total of 8 measurements. Relative bladder volumes (bladder volume on CBCT image [mL]/bladder volume at TP [mL] × 100%) were evaluated in each of the 6 subgroups. Results The upper bounds of the 95% confidence intervals of the mean V 70Gy and V 50Gy values in group 1 exceeded the dose constraints at our institution. The mean relative bladder volumes were 104%, 91%, 77%, 81%, 63%, and 59% in groups 1, 2, 3, 4, 5, and 6, respectively. The institutional criterion of 70% for the mean relative bladder volume was achieved in groups 1-4, but it could not be achieved in groups 5-6. Therefore, the patients in groups 2-4 met both institutional dose constraints for the bladder at TP and the institutional criterion for the mean relative bladder volume during treatment. Conclusions The optimal bladder volumes at TP were between 100 and 250 mL in this setting. Nursing intervention needs to be implemented before treatment planning to ensure that patients achieve the optimal bladder volume range. [ABSTRACT FROM AUTHOR]

Background Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent. Objective We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma. Design Retrospective case series. Setting Single tertiary referral medical center. Patients We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital. Interventions EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent. Main Outcome Measurements Technical success, clinical success, and adverse event. Results The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success rates of EUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days). Limitations Small sample size and no control group. Conclusions EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma. [ABSTRACT FROM AUTHOR]

Background Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent. Objective We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma. Design Retrospective case series. Setting Single tertiary referral medical center. Patients We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital. Interventions EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent. Main Outcome Measurements Technical success, clinical success, and adverse event. Results The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success rates of EUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days). Limitations Small sample size and no control group. Conclusions EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma. [ABSTRACT FROM AUTHOR]

Abstract: The cutting temperature of a cutting tool are required to be low during bone machining for preventing damage to bone cells. However, conventional tools are practically the same as those used for metal cutting, and many operational limitations have been reported. In this study, a dedicated cutting tool was designed for reducing cutting force and temperature. A short contact between the workpiece and the cutting edge leads to a reduction in the cutting force. Furthermore, a straight-line edge improves surface roughness. The effectiveness was evaluated using bovine bone, and the cutting force was found to be decreased by about 40%. [Copyright &y& Elsevier]

Background: Tubular plastic and metal stents have inherent shortcomings when used for transenteric drainage of fluid collections. Objective: To evaluate a novel lumen-apposing, self-expandable metal stent for EUS-guided drainage of pancreatic pseudocysts and the gallbladder. Design: Retrospective case series. Setting: Tertiary-care academic medical center. Patients: This study involved 15 patients (median age 54 years) with symptomatic pancreatic pseudocysts who underwent 12 transgastric and 3 transduodenal pseudocyst drainage procedures. Five patients (median age 69.5 years) with acute cholecystitis underwent 4 cholecystoduodenostomies and 1 cholecystogastostomy. Intervention: Stent deployment under EUS guidance, passage of an endoscope through the stent lumen for pseudocystoscopy or cholecystoscopy, transenteric endoscopy-guided interventions including biopsy, necrosectomy, and stone removal. Main Outcome Measurements: Technical and clinical success. Results: All stents were successfully deployed without complication, with a median time to removal of 35 days. All pseudocysts resolved after a single drainage procedure. One stent migrated into the stomach, and the remaining 14 were found to be patent at the time of removal. There was no pseudocyst recurrence during the 11.4-month median follow-up period. One gallbladder stent remains indwelling and fully patent at 12 months. Resolution of acute cholecystitis was observed immediately after stent implantation. No recurrence of symptoms was observed during a median follow-up period of 9 months. Limitations: Retrospective study, small sample size, lack of control patients. Conclusion: Transenteric drainage of pancreatic pseudocysts and the gallbladder by using a novel, lumen-apposing, metal stent was accomplished with high technical and clinical success in this pilot observational study. Further studies are warranted. [ABSTRACT FROM AUTHOR]

Background: Tubular plastic and metal stents have inherent shortcomings when used for transenteric drainage of fluid collections. Objective: To evaluate a novel lumen-apposing, self-expandable metal stent for EUS-guided drainage of pancreatic pseudocysts and the gallbladder. Design: Retrospective case series. Setting: Tertiary-care academic medical center. Patients: This study involved 15 patients (median age 54 years) with symptomatic pancreatic pseudocysts who underwent 12 transgastric and 3 transduodenal pseudocyst drainage procedures. Five patients (median age 69.5 years) with acute cholecystitis underwent 4 cholecystoduodenostomies and 1 cholecystogastostomy. Intervention: Stent deployment under EUS guidance, passage of an endoscope through the stent lumen for pseudocystoscopy or cholecystoscopy, transenteric endoscopy-guided interventions including biopsy, necrosectomy, and stone removal. Main Outcome Measurements: Technical and clinical success. Results: All stents were successfully deployed without complication, with a median time to removal of 35 days. All pseudocysts resolved after a single drainage procedure. One stent migrated into the stomach, and the remaining 14 were found to be patent at the time of removal. There was no pseudocyst recurrence during the 11.4-month median follow-up period. One gallbladder stent remains indwelling and fully patent at 12 months. Resolution of acute cholecystitis was observed immediately after stent implantation. No recurrence of symptoms was observed during a median follow-up period of 9 months. Limitations: Retrospective study, small sample size, lack of control patients. Conclusion: Transenteric drainage of pancreatic pseudocysts and the gallbladder by using a novel, lumen-apposing, metal stent was accomplished with high technical and clinical success in this pilot observational study. Further studies are warranted. [Copyright &y& Elsevier]

Abstract: Background: Extraction of bile duct stones in patients who have undergone Roux-en-Y anastomosis can be challenging. Recently, large balloon dilation following endoscopic sphincterotomy has been shown to be useful for the removal of bile duct stones. Aim: We retrospectively evaluated the feasibility and safety of endoscopic sphincterotomy large balloon dilation for the removal of bile duct stones in patients with Roux-en-Y anastomosis. Methods: Large balloon papillary dilation following EST for the removal of bile duct stones was performed on the intact papilla in 15 patients with Roux-en-Y anastomosis at our institution. When we could not use the long-type accessories, a conventional forward-viewing upper endoscope passed through the over tube of the single-balloon or double-balloon enteroscope for the use of short-type accessories. Following endoscopic sphincterotomy, a large balloon catheter was positioned across the main duodenal papilla. The size of large balloon used ranged from 15mm to 20mm. Results: Complete clearance of bile duct stones was achieved in all cases in the initial session without any adverse events. A mechanical lithotriptor for crushing stones was used in one patient (6.7%). Conclusion: Large balloon papillary dilation following EST appears to be an effective and safe treatment for difficult-to-remove bile duct stones in patients with Roux-en-Y anastomosis . [Copyright &y& Elsevier]

Background: Recently, endoscopic biliary sphincterotomy (EBS) followed by large-diameter balloon dilation has been used for the removal of large bile duct stones. A limitation is the need for 2 accessories: a sphincterotome and a dilating balloon. Objective: To evaluate a new device, a combination of a large-diameter dilating balloon and sphincterotome (LDDBS). Design: Retrospective study. Setting: University hospital. Patients: Eighteen patients with large bile duct stones. Interventions: After performing EBS by using the LDDBS, the catheter was then advanced into the bile duct and balloon dilation was performed by gradual inflation with diluted contrast medium under endoscopic and fluoroscopic guidance until it reached a diameter adequate to allow stone removal. Main Outcome Measurements: Feasibility and efficacy of stone removal by using an LDDBS. Results: Technical success of large-diameter balloon dilation after EBS was achieved in all cases. Bile duct clearance was accomplished in 94% (17/18) of cases in the first session. Bile duct clearance was eventually completed in all patients. Mechanical lithotripsy was required in 4 patients (22%). There were no major intraprocedural or postprocedural complications. Limitations: Single-institution study, small sample size. Conclusions: The prototype LDDBS is safe and effective to facilitate the removal of large bile duct stones by using one accessory. [Copyright &y& Elsevier]

Background: In the clinical setting, endosonographers acknowledge that not only the size and characteristics of EUS-guided FNA needles but also several conditions affect the acquisition of adequate samples. Objective: To compare the characteristics of the 19-gauge Tru-cut, 19-gauge aspiration, 22-gauge aspiration, and 25-gauge aspiration EUS needles under several conditions by using a bench simulator designed to provide standardized, reproducible, comparative performance data in combination with evaluation by 3 endosonographers of needle-insertion resistance. Design: Laboratory simulations that compare resistance to needle advancement under several conditions (straight and angulated endoscope position, endoscopic tip angulation, and the use of the elevator) by using both diagnostic and therapeutic EUS scopes. These varied conditions cause a range of resistance to the advancement of the needle through the endoscope. Setting: Research laboratory. Main Outcome Measurement: The mean (SD) for advancement resistance (N) to each EUS needle. Needle resistance was evaluated individually by endosonographers and divided into 5 levels (0 [no resistance] to 5 [impossible for needle to be advanced]). Results: Endosonographers concluded that the needle-advancement resistance was moderate with a pressure resistance to the needle of 5 N or more and high at 8 N or more, and that it was impossible to advance the needle when the resistance to it was 11 N or more. Instrumentational evaluation showed that, with the 25-gauge and 22-gauge needles, needle resistance was approximately less than 2 N and 3 N, respectively. In the straight endoscope position, the 19-gauge aspiration or Tru-cut needle resistance when using upward angulation of the endoscope or the elevator was more than 8 N and 10 N, respectively. In the angulated endoscope position, the resistance to the 19-gauge aspiration or Tru-cut needle when using upward angulation was more than 10 N and 20 N, respectively. Limitations: All data were collected ex vivo, and clinical validity remains to be determined. Conclusions: The 22-gauge or 25-gauge EUS-guided FNA needles are suitable for insertion into the target regions if tight angulation is necessary. [Copyright &y& Elsevier]

Although single-balloon enteroscopy (SBE)-assisted or short-type SBE (short SBE)-assisted ERCP has been reported as useful in patients with surgically altered anatomy, most studies had small sample sizes or single-center designs. This study aimed to evaluate the efficacy and factors affecting the procedure results of short SBE–assisted ERCP in patients with surgically altered anatomy. This multicenter, retrospective study was conducted at 8 tertiary referral care centers in Japan. The data of patients who underwent ERCP-related procedures using short SBE between September 2011 and August 2019 at each facility were analyzed. Overall, 1318 patients were included in this analysis. The enteroscopy (reaching the target site), cannulation, and total procedural success rates were 87.9% (95% confidence interval [CI], 86.1%-89.6%), 87.0% (95% CI, 84.9%-88.8%), and 74.9% (95% CI, 72.5%-77.2%), respectively. Adverse events occurred in 7.7% of patients (95% CI, 6.4%-9.3%). Multiple logistic regression analysis indicated that age (≥75 years), Roux-en-Y reconstruction, pancreatic indication, and malignancy were factors affecting the total procedural failure. This large-scale study proved that short SBE–assisted ERCP in patients with surgically altered anatomy was effective. Moreover, it clarified factors affecting procedure results. Proficiency with alternative treatment techniques is required in difficult cases. (Clinical trial registration number: UMIN00004045.) [ABSTRACT FROM AUTHOR]

Background: Endoscopic papillectomy (EP) has been recognized as a safe and reliable treatment for tumor of the duodenal papilla. For complete resection, precise assessment of not only the intraductal extent but also the lateral margins of the tumor is mandatory before resection. Objective: Our purpose was to prospectively assess the enhancement of the lateral margins of tumor of the duodenal papilla for the treatment of EP by comparing narrow-band imaging (NBI) and indigo carmine (IC) chromoendoscopy. Design: Prospective study. Setting: This procedure was performed in Tokyo Medical University Hospital. Patients: Fourteen consecutive cases of tumors of the major duodenal papilla. Intervention: All patients underwent EP after evaluation by NBI and IC. Main Outcome Measurement: Histologic evaluation of diagnosis of NBI and IC by comparison with en bloc tissue. Results: In all lesions, either IC or NBI were superior to conventional white-light imaging except in 1 IC case. The ability of NBI observation to emphasize the tumor margin was statistically significantly better than IC observation (P < .05). The en bloc EP was endoscopically successful in all cases, without fatal adverse events. En bloc tissue revealed 13 adenomas and 1 adenoma with focal adenocarcinoma. There was no residual adenoma in lateral margin specimens, either endoscopically or histologically. Limitations: The lesions resected were all relatively small. This was not a blinded randomized study. Conclusion: This study demonstrated the feasibility and a certain degree of efficacy of NBI for enhancement of the tumor margin of duodenal papilla. Further blinded randomized studies involving large duodenal papillary tumors are required. [Copyright &y& Elsevier]

Background: In patients with acute cholecystitis and at high risk for surgery, decompression of the gallbladder by percutaneous transhepatic gallbladder drainage (PTGBD) or aspiration (PTGBA) is needed as salvage therapy. However, we sometimes encounter patients in whom puncture cannot be performed for several reasons. Recently, endoscopic transpapillary gallbladder drainage (ETGD) has been reported to be safe and effective for acute cholecystitis. Objective: Our purpose was to evaluate the clinical efficacy and safety of ETGD for acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible. Design: Retrospective case study. Setting: This procedure was performed in Tokyo Medical University Hospital. Patients: Forty-three patients with acute cholecystitis, including 32 patients taking anticoagulation or antiplatelet drugs, 4 cases of Chilaiditi syndrome, 2 each of acute leukemia, marked ascites, and anatomic abnormality, and 1 case of hemophilia A. Intervention: All patients underwent ETGD. A 5F nasobiliary-drainage catheter was placed into the gallbladder. In case of failed ETGD, PTGBD or PTGBA was performed subsequently. Main Outcome Measurement: Efficacy and safety of this technique. Results: ETGD was achieved in 36 patients (84%) without any serious procedure-related complications. A clinically favorable response for ETGD was seen in 35 patients (97%). In 7 patients in whom ETGD was unsuccessful and 1 patient in which it was ineffective, a percutaneous transhepatic approach was performed with severe hemorrhage biloma in the former and uncontrolled hemorrhage cholecystitis, leading to death in the latter. Limitations: Difficulty of maneuvering the guidewire and drainage tube into the gallbladder. Conclusions: Although comparative studies are needed to define the appropriate role of ETGD and percutaneous transhepatic approach, ETGD can be useful in patients with acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible. [Copyright &y& Elsevier]

Background: Endoscopic biliary drainage has been established as providing effective treatment for acute obstructive jaundice and cholangitis. A recently developed ultrathin transnasal videoendoscope is less invasive, even for patients who were critically ill, and can be performed without conscious sedation. Objective: To evaluate the clinical efficacy and safety of biliary drainage (BD) by using transnasal videoendoscopy (TNE) without conscious sedation. Design: Case series. Setting: This procedure was performed at Tokyo Medical University Hospital. Patients: Three patients with bile-duct stones and acute cholangitis and with a previous biliary endoscopic sphincterotomy (ES) were included in this study. Intervention: All patients underwent BD by using a front-viewing TNE. Two 5F stents were placed into the bile duct across the major papilla. Main Outcome Measurement: The efficacy and safety of the TNE technique. Results: Transnasal insertion of a TNE endoscope was feasible in all patients, without epistaxis. TNE BD was achieved in all patients. Abdominal pain, fever, and jaundice improved 24 hours after the procedure in all patients. Despite the absence of intravenous conscious sedation, all patients would agree to undergo the procedure again, if necessary. Limitations: Maneuverability of the TNE endoscope; limited to patients with a previous ES. Conclusions: In this small series, unsedated TNE can be used to successfully drain the biliary system in patients with a previous ES. Additional studies to validate this hypothesis are needed. [Copyright &y& Elsevier]

Background: It is very important to determine the extent of intraductal mucinous neoplasms (IPMNs), because this can greatly affect the determination of the indications of surgery. Peroral pancreatovideoscopy (POPS) has been recognized as a new diagnostic tool for clear imaging of IPMN. Recently, narrow-band imaging (NBI) has made it possible to emphasize certain image features, such as mucosal structures and capillary vessels. Objective: To evaluate the clinical usefulness of POPS by using NBI for the diagnosis of IPMN. Design: Case reports. Setting: This procedure was performed at Tokyo Medical University Hospital. Patients: Three patients with IPMN. Intervention: All patients underwent POPS with NBI. Main Outcome Measurement: Efficacy and safety of this technique. Results: POPS with NBI was performed in 3 patients, without procedure-related complications. Identification of the surface structure and the capillary vessels by NBI observation was better than by conventional observation. Furthermore, NBI identified skip tumor lesions in the tail of pancreas, which were not detected by conventional POPS. Limitations: Because none of the patients in the 3 cases underwent surgical resection, a comparison to clarify total agreement between the preoperative POPS findings and the resected specimen was not possible. Conclusions: POPS with NBI may facilitate the observation of both fine mucosal structures and capillary vessels in patients with IPMN, although further study is necessary to fully establish the clinical benefit. [Copyright &y& Elsevier]

Background: Narrow-band imaging (NBI) makes it possible to emphasize the imaging of certain features, such as mucosal structures and mucosal microvessels in GI-tract diseases. Recently, video peroral cholangioscopy (POCS) was developed as a diagnostic modality for better visualization of bile-duct lesions; however, there is no report on POCS by using NBI. Objective: To evaluate the clinical usefulness of POCS by using NBI for the diagnosis of biliary-tract diseases. Design: Prospective case study. Setting: This procedure was performed at Tokyo Medical University Hospital. Patients: Twelve consecutive patients with biliary-tract diseases, including 7 bile-duct cancers and 5 benign biliary diseases, which revealed 6 bile-duct strictures and 6 filling defects by ERCP. Intervention: All patients underwent POCS by using NBI. Main Outcome Measurement: Efficacy and safety of this technique. Results: Twenty-one lesions were evaluated by using POCS with conventional white light imaging and NBI. Although visualization of only 2 lesions (9.5%) was “excellent” by conventional observation, visualization of 12 lesions (57.4%) was “excellent” by NBI observation. Identification of the surface structure and vessels of the lesions by NBI observation was significantly better than with conventional observation (P < .01 and P < .05, respectively). Limitations: Maneuverability and fragility of POCS. The current POCS is not equipped with magnification. Conclusions: POCS by using NBI may be helpful for the observation of both fine mucosal structures and tumor vessels. [Copyright &y& Elsevier]

Purpose This study aimed to compare bowel and urinary health-related quality of life (HRQOL) between prostate-only (PO) volumetric modulated arc therapy (VMAT) and whole-pelvis (WP) VMAT in patients with localized prostate cancer. Methods and materials A total of 234 patients treated with definitive VMAT to 78 Gy in 39 fractions were enrolled. Of these, 108 patients received PO-VMAT and 126 patients received initial WP-VMAT to 46.8 Gy in 26 fractions using a simultaneous integrated boost technique. HRQOL was prospectively assessed before radiation therapy (baseline), and 3, 6, 12, and 24 months after treatment using the Expanded Prostate Cancer Index Composite (EPIC). Results Baseline HRQOL scores did not differ significantly between the 2 groups. No significant between-group differences in HRQOL change from baseline were observed for all bowel and urinary EPIC domains. The proportion of patients showing a clinically relevant decrease in bowel and urinary HRQOL scores from baseline was similar between the groups throughout the follow-up period. An analysis of individual HRQOL items showed that patients undergoing WP-VMAT were more likely to report moderate/big problems with bloody stools ( P = .039) and overall bowel problems ( P = .008) than those undergoing PO-VMAT at 12 months. There was no significant between-group difference in any individual items at 24 months, however. Conclusions Bowel and urinary HRQOL is largely similar for patients receiving PO-VMAT and WP-VMAT during 24 months of follow-up, with the only differences seen in responses to specific bowel HRQOL items at 12 months. [ABSTRACT FROM AUTHOR]