Search

Biliary self-expandable metallic stent (SEMS) is the preferred and first-line therapy for unresectable malignant biliary obstruction. To date, several reports have revealed the relatively high incidence of acute complications such as pancreatitis and cholecystitis due to mechanical stent compression. In the present case, we encountered fatal pancreatitis following fully covered metal stent placement. An 85-year-old man had middle bile duct strictures due to cholangiocarcinoma. A 10-mm diameter fully covered SEMS was placed across the papilla for biliary decompression. Laboratory data and physical evidence the following day revealed acute pancreatitis. Therefore, antibiotics and protein degeneration enzyme inhibitors were given. However, his condition did not improve. Two days after the procedure, we removed the stent and returned him to his original hospital. Serum amylase level decreased below 400 mg/dL 6 h after the procedure. However, the acute pancreatitis worsened. Although we treated the patient in the intensive care unit, he died 32 days after the second admission.

There are few reports on the histological diagnostic ability of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in a large-series of pancreatic masses. In the present study therefore we retrospectively evaluated the histological diagnostic ability of EUS-FNA in pancreatic masses without on-site cytopathologist. In 355 patients with pancreatic solid masses, EUS-FNA was carried out. EUS-FNA histology showed accuracy, 90.7%; sensitivity, 89.5%; specificity, 95.6%; positive predict value, 98.8%; negative predict value, 68.8% by intention-to-treat analysis. Except for 10 with inadequate materials, EUS-FNA histology showed accuracy, 93.3%; sensitivity, 91.8%; specificity, 100%; positive predict value, 100%; negative predict value, 77.6%. The mean number of puncture was 2.88 (range 1 to 8). There was two (0.6%) procedure-related bleeding. In conclusion, diagnostic ability of EUS-FNA by histological materials was similar to previous literature on the EUS-FNA without on-site cytopathologist.

A 51-year-old man was hospitalized because of close examination for liver dysfunction. drip infusion cholangiography-computed tomography (DIC-CT) revealed a stricture located at the middle bile duct but normal biliary scintigraphy. Endoscopic retrograde cholangiopancreatography (ERCP) showed obstruction of bile duct. Although we tried to pass the stricture using several kinds of guidewire under direct vision of peroral cholangioscopy, recanalization could not be achieved. Then percutaneous transhepatic biliary drainage (PTBD) was conducted. Cholangioscopy using narrow band imaging showed no tumor vessel or irregular mucosa. The biopsy specimens obtained from both distal and proximal sides of stricture showed no malignancy. Eventually, a rendezvous technique was tried using guidewire under percutaneous transhepatic cholangioscopy (PTCS) direct vision. Fortunately, since a guidewire could advance into a tiny hole at the center of a scar and an endoscopic nasobiliary drainage (ENBD) tube could be placed across the biliary stricture. One week after placement of ENBD tube, a 10 Fr plastic stent was inserted and the PTBD tube was removed without procedure-related complication. Eight months later, the stent was removed and the chief complaint disappeared without liver dysfunction.

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux-en Y (R-Y). A 73-year-old man who had total gastrectomy with R-Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre-cutting, the ultraslim endoscope was replaced with a conventional forward-viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure-related complication.

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large-balloon dilation in combination with pancreatic sphincterotomy. A 63-year-old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire-guided pull-type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20-mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure-related complication.