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The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Background and Aim Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). Methods One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. Results Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliarycannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3–30). Conclusions DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.

A metal stent has a longer stent patency than a plastic stent in patients with unresectable malignant distal biliary stricture. However, treatment for stent dysfunction of a metal stent remains unresolved. A review of reported articles regarding reintervention for metal stent dysfunction showed that causes of stent dysfunction included tumor ingrowth/overgrowth, stone/sludge/food impaction, and stent migration. Cleaning of the stent is associated with an early relapse of stent dysfunction. Additional placement of a covered metal stent is expected to have a longer stent patency than that of other stents such as uncovered metal stents or plastic stents. It is recommended that occluded covered metal stents be removed if possible. Stent trimming with argon plasma coagulation is sometimes useful for the treatment of stent displacement. No strategy for occluded metal stents has been established yet. Further clinical trials regarding proper treatments are necessary.

Background and Aim: Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self-expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD. Methods: Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio-enteric anastomosis (BEA) method. SEMS was deployed with the one-step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated. Results: One-step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.

Aim: To elucidate the diagnostic efficacy of the cell block (CB) method by comparing it with that of conventional smear cytology for pancreatic juice obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial fashion. Methods: A total of 170 patients with pancreatic lesions suspicious of being malignant who underwent pancreatic juice collection without giving secretin under ERCP were enrolled in this study. After sampling, the pancreatic juice was randomized to the CB method (n = 85) or to smear cytology (n = 85). CB sections were subjected to hematoxylin-eosin, periodic acid Schiff–Alcian blue, and immunohistochemical stains. Both Papanicolaou stain and Giemsa stain were used for smear cytology. Results: The final diagnosis was malignancy in 54 patients: pancreatic cancer, 45; intraductal papillary-mucinous carcinoma, six; and endocrine tumor, three. The number of patients with a cytological borderline malignancy in the CB group (3.5%) was significantly smaller than that in the smear group (27.1%) (P

Aim: To evaluate the usefulness of a modified technique of endoscopic papillectomy (EP) for lessening the occurrence of complications. Methods: Indications for EP were adenoma or well-differentiated adenocarcinoma confined to the papilla of Vater (T1) without tumor spread into the bile/pancreatic duct. Sixteen patients underwent the modified technique, which consists of resection with the Endocut® mode, followed by biliary/pancreatic sphincterotomy and stenting (Group A). Twelve patients who had undergone EP, using a cutting current, followed by pancreatic duct stenting were included as control (Group B). The frequency of complications and clinical outcomes were retrospectively compared between the two groups. Results: Sixteen patients had adenoma, and 12 had adenocarcinoma. Early complications occurred in 36% of all patients (hemorrhage, 7; cholangitis, 3; perforation, 2; cholecystitis, 1). The frequency of early complications in Group A was significantly lower than that in Group B (6% vs 75%, odds ratio [OR] 0.022, 95% confidence interval [CI], 0.0020–0.25). Late complications occurred in 18% of the patients (bile duct stone, 3; hemorrhage, 1; pancreatitis, 1). There was no significant difference in the late complication rate between Group A and Group B (19% vs 17%). Local recurrences were found in 14% of the patients, without a significant difference between Group A and Group B (19% vs 8%) during a mean follow-up period. All recurrent tumors were successfully treated with argon plasma coagulation. Conclusions: The modified technique of EP for ampullary neoplasm contributed to lessening the occurrence of early complications. However, further refinement of this technique is necessary for improving the clinical outcome.

Background: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas tend to spread intraepithelially along the pancreatic duct wall. We evaluated histopathological intraductal lateral spread (LS) along the main pancreatic duct (MPD) from branch-duct IPMN and investigated the usefulness of intraductal ultrasonography (IDUS) for its preoperative diagnosis. Patients and Methods: Twenty-four patients with branch-duct IPMN who had undergone preoperative IDUS and surgery were reviewed clinicopathologically. The prevalence and histological length of LS along the MPD from branch-duct IPMN, characteristics of the patients with LS, and efficacy of LS assessment by IDUS were examined. Results: LS along the MPD was observed in 54% of the subjects. In the group of patients with LS, its mean length was 25.2 ± 16.8 mm (5–50 mm) and the diameter of the MPD was 6 mm or greater. Of the patients with LS, those in whom the length of LS along the MPD was longer than the diameter of the cystically dilated branch accounted for 30%. The diameter of the MPD in the group with LS was significantly greater than that in the group without LS (P = 0.03). The sensitivity, specificity, and overall accuracy of IDUS in the detection of LS were 92%, 91%, and 92%, respectively. Conclusion: LS along the MPD was detected in about half of the resected cases of branch-duct IPMN. Preoperative transpapillary IDUS may be beneficial for the determination of the resection line, especially in those branch-duct IPMN patients in whom the MPD is 6 mm or greater in diameter.

Background: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y-configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty-seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y-configured placement were endoscopically deployed in a partial stent-in-stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow-up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single-session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.

Endosonography-guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.

Transpapillary endoscopic biliary drainage is a well-accepted technique for patients with biliary obstruction. However, transpapillary access to the bile duct is not always possible, especially in patients with duodenal stenosis or difficult cannulation of the bile duct during endoscopic retrograde cholangiopancreatography. Percutaneous transhepatic biliary drainage or surgical bypass has been performed in cases of unsuccessful endoscopic retrograde cholangiopancreatography. Recently, endosonography-guided biliary drainage (ESBD) has been developed as a new biliary drainage technique. Current issues regarding ESBD are discussed in this article. Proper indications for ESBD should be established for widespread performance. Technical standardization and dedicated instruments for ESBD are also mandatory.

Aim: For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy. Methods: Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long-tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty-three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls. Results: The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 ± 8.1 min and 48.7 ± 25.3 min, respectively, with a statistically significant difference (P

Endosonography-guided biliary drainage (ESBD) is a new option that allows establishment of biliary drainage. Due to the diameter of the working channel of an echoendoscope, it is necessary to replace a small caliber stent with a larger one to lessen the risk of stent occlusion. However, insertion of a guidewire into the bile duct via the hole of the sinus tract following direct removal of a previously placed stent is not always possible, resulting in guidewire passage outside the fistula and bile leakage. Cannulation of the previously deployed stent, guidewire insertion into the bile duct via the cannula and the stent, and removal of the stent with the snare over the guidewire leaving the guidewire in place (the snare-over-the-wire technique [SOW]) for stent exchange following ESBD was attempted. Four patients who required stent exchange following ESBD were included in the present study to evaluate the feasibility and usefulness of SOW. SOW was successful in all the cases. A new stent was also successfully deployed over the guidewire in all the cases. No complications were encountered. The snare-over-the-wire technique is feasible and useful in stent exchange following ESBD for the reduction of the risk of guidewire migration.

Endosonography-guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography-guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm-long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD.

Aim: We evaluated the diagnostic efficacy of transpapillary intraductal ultrasonography before biliary drainage (IDUS-BD) and transpapillary biopsy (TPB) for the assessment of the longitudinal extent of bile duct cancer. Methods: Between November 1999 and January 2005, we performed IDUS-BD and TPB preoperatively in 27 patients with carcinoma of the extrahepatic bile duct. Following IDUS-BD, TPB was performed under fluoroscopic guidance immediately after endoscopic sphincterotomy. The diagnostic efficacy of IDUS-BD and TPB for the longitudinal extent of the cancer and the complications which accompanied the procedure were evaluated. Results: The overall success rate of sampling and the diagnostic accuracy of bile duct cancer by TPB were 85.3% (192/225) and 85% (23/27), respectively. The sensitivity, specificity and accuracy of the assessment of the longitudinal extent of cancer on the hepatic and duodenal sides by IDUS-BD were 82%, 70%, 78% and 85%, 43%, 70%, respectively. Those by a combination of IDUS-BD and TPB were 88%, 80%, 85% and 77%, 86%, 80%, respectively. Overestimation of the longitudinal extent of BD cancer by IDUS-BD was mainly due to inflammation and obscure images, especially resulting from collapse of the bile duct on the duodenal side of the tumor, and was corrected by TPB in four of five patients. No serious complications occurred following the combination of IDUS-BD and TPB. Conclusions: TPB is useful for preoperative histological diagnosis of bile duct cancer. The combination of IDUS-BD and TPB is practical for evaluation of its longitudinal extent; basically, IDUS-BD is sufficient on the hepatic side of the tumor, but concomitant TPB is recommended on the duodenal side.

Endoscopic biliary drainage (e.g. endoscopic biliary stenting [EBS]) is the treatment of choice in the management of obstructive jaundice due not only because of its lesser invasiveness and greater safety as compared with surgical drainage or percutaneous transhepatic biliary drainage (PTBD), but also due to its ability to maintain the physiological flow of bile. EBS, however, is not always possible, and surgical drainage or PTBD have been performed in such cases with difficult cannulation of the bile duct or difficult intubation of the duodenum with a duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP).Recently,the role of endoscopic ultrasonography (EUS),or endosonography (ES),has expanded from simply obtaining cross-sectional images of the gut wall or surrounding organs and tissue samples by fine-needle aspiration cytology/biopsy to therapeutic applications. Endosonography-guided biliary drainage (ESBD) is one of such therapeutic applications of ES and reports on this procedure are increasing. In the present article, technical aspects and the current status of ESBD are discussed.As in EBS,ESBD makes it possible to recover physiological bile flow without pain following the procedure.Therefore,ESBD is expected to soon be widely accepted as a new option for difficult cases of not only EBS but also PTBD with obstructive jaundice, and may become the treatment of choice in selected cases. Development of relevant devices will expand its indications and accelerate its spread.

Endoscopic retrograde cholangiopancreatography (ERCP) is accepted as a safe, direct technique for evaluating pancreatobiliary diseases. Since the introduction of endoscopic sphincterotomy (EST), ERCP has evolved from a diagnostic procedure to a therapeutic one. ERCP with EST and stone removal is a valuable therapeutic modality in choledocholithiasis. Herein are reviewed the complications of EST in cases of choledocholithiasis along with a discussion of the risk management of this particular procedure. Pancreatitis is the most common ERCP-related complication. Hemorrhage is primarily a complication related to sphincterotomy. Other complications include perforation, cholangitis, cholecystitis, and sedation-related cardiopulmonary complications. Endoscopists who perform ERCP should have appropriate training and be knowledgeable of such complications.

Intraductal ultrasonography (IDUS) is useful for evaluating the horizontal spread along the main pancreatic duct in cases of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, thus providing valuable information for the determination of the resection line at surgery. Differentiation between benign and malignant IPMN is also indispensable for management decisions. Measurement of the height of mural nodules by IDUS is expected to be useful for differential diagnosis of IPMN. Because IDUS cannot always demonstrate whole lesions, especially in branch duct IPMN, endoscopic ultrasonography plays a complementary role in such cases.

Aim: To assess the influence of juxtapapillary diverticula on endoscopic treatment of bile duct stones. Methods: Two hundred and fifty-eight consecutive patients with bile duct stones who had undergone endoscopic treatment at our department were included in this study. Comparison was done between a group that had a juxtapapillary diverticulum (Group D) and a group that did not (Group N). Results: Deep cannulation was achieved in 98% and 100% of Group D and Group N, respectively. The time required for cannulation was 18 min in both groups. Deep cannulation of the bile duct tended to be difficult in cases with the papilla located at the edge of or in the diverticulum in Group D. Complete removal of stones was achieved in 97.7% and 96.9% of the respective groups. The number of sessions and the total time required for removal of stones in Group D and Group N were 1.6 and 47 min, and 1.5 and 47 min, respectively (n.s.). The occurrence rate of complications was not statistically different (12.4%vs 10.1%); however, it was higher (50%) in those who had a papilla inside the diverticulum. Conclusions: Although the presence of juxtapapillary diverticula has only a subtle influence on endoscopic treatment of bile duct stones, caution is necessary when treating patients with a papilla in a diverticulum because of the high incidence of complications in such patients.

Pedunculated polypoid cancer of the gallbladder ordinarily shows cancer spread within the polyp consisting mainly of adenoma. We experienced a case of pedunculated mucosal cancer associated with flat-type cancer of the gallbladder without an adenomatous component, the details of which are reported herein. The lesion was first detected by transabdominal ultrasonography (US) as a polypoid lesion of the gallbladder, 5 mm in size. Distinct growth of the lesion was revealed at follow-up US after a year. Endoscopic ultrasonography showed not only a pedunculated polypoid lesion, 9 mm in size, with a solid internal echo pattern and a nodular surface, but also slight thickening of the surrounding gallbladder wall. Cholecystectomy was performed with a preoperative diagnosis of early gallbladder cancer, and a pedunculated polypoid lesion, 8 × 8 × 3 mm in size with a thin stalk and a nodular contour, surrounded by a widely spreading flat lesion with a coarse-granular surface, was confirmed. Microscopically, the stalk was 700 µm in size, and both the pedunculated polypoid lesion and flat lesion consisted of well-differentiated tubular adenocarcinoma limited to the mucosa, without an adenomatous component.

Background: Biopsy diagnosis of gastric mucinous carcinoma (GMC) is sometimes difficult. Endoscopic ultrasonography (EUS) can visualize the change in the gastric wall in detail. We reviewed the EUS images and histological findings of cases of GMC and evaluated the correlation between them to identify the characteristic findings of GMC on EUS. Methods: Thirty-one GMC patients who had undergone both preoperative EUS and surgery were studied. The EUS images of these patients and the histological findings were compared with those for other histological types of gastric cancer (OGC). Results: The tumor echo showed high echoic in GMC cases more frequently than that in OGC. The frequency of visualization of the layer structure above the tumor was higher compared with OGC. Histology verified the presence of fine septa composed of thin fibrotic tissue and floating cancer cells in the mucus lake. The mucus lake was often located in the submucosa and the tumor was covered with cancerous mucosa of other histological types with preserved lamina muscularis mucosae. Conclusions: The EUS findings of GMC are characteristic and reflect its histological changes well, and would complement the preoperative diagnosis of this tumor.

Clinical diagnosis of chronic cholecystitis is made based on diffuse hyperechoic thickening of the gallbladder wall as shown by ultrasonographic examination. We herein report three cases of chronic cholecystitis showing localized hypoechoic thickening of the gallbladder wall that mimicked gallbladder cancer by ultrasonography. Histologically, hypertrophy of the muscularis propria was a common characteristic finding in these three patients. A smooth surface of the inner hypoechoic layer of the thickened wall was considered to be a reliable finding in the differential diagnosis between this type of chronic cholecystitis and gallbladder cancer.

Background and Aim: Biliary intraductal ultrasonography (IDUS) is highly sensitive in visualizing bile duct stones (BDS). Indications for IDUS, however, in cases of suspected BDS have not yet been established. The aim of the present study was to elucidate adequate indications for IDUS in cases that undergo endoscopic retrograde cholangiopancreatography (ERCP) due to suspected BDS. Methods: A total of 213 patients who were suspected of having BDS were included in this retrospective study. The patients were divided into two groups: Group A in which BDS was visualized by ERCP; and Group B in which BDS was demonstrated only by IDUS. Comparison between the groups was carried out. Results: ERCP successfully visualized BDS in 166 patients. Forty-seven patients underwent IDUS, which revealed BDS and biliary sludge in 12 and eight patients, respectively. The diameter of the largest stone was 13 ± 6 mm in Group A and 5 ± 1 mm in Group B (P

Although endoscopic transpapillary treatment of chronic pancreatitis (CP) is gaining acceptance, it is not always possible, especially in patients with inflammatory stenosis of the duodenum due to CP or with a history of a Whipple's procedure. Linear array echoendoscopes (ES) provide high-quality images of the pancreas along with adjacent organs and allow therapeutic applications. echoendoscope-related procedures, such as ES-guided pancreatic duct drainage (ESPD) are feasible and useful in selected patients with CP suffering from PD stricture in whom conventional endoscopic retrograde cholangiopancreatography (ERCP) is impossible.