Search

Background and Aims ERCP is a difficult procedure to perform in Billroth II gastrectomy patients because of altered anatomy. We investigated the outcomes and risk factors for adverse events with ERCP using a cap-fitted forward-viewing endoscope with endoscopic papillary balloon dilation (EPBD) in Billroth II gastrectomy patients. Methods The records for Billroth II gastrectomy patients who underwent ERCP using a cap-fitted forward-viewing endoscope with EPBD at 5 institutions between August 2008 and April 2014 were retrospectively reviewed. The outcomes and risk factors for adverse events resulting from this treatment were analyzed. Results In total, 165 patients were identified. ERCP was technically successful in 144 patients (87.3%) and clinically successful in 141 patients (85.5%). Adverse events occurred in 38 patients (23.0%): perforation in 3 cases (1.8%), pancreatitis in 13 cases (7.9%), and asymptomatic hyperamylasemia in 22 patients (13.3%). In univariate analysis, ≥2 ERCP sessions, periampullary diverticulum, and common bile duct (CBD) stone size ≥ 12 mm were found to be associated with ERCP-related adverse events. In multivariate analysis, ≥2 ERCP sessions (odds ratio [OR], 4.762; 95% confidence interval [CI], 1.472-15.402; P = .009) and a CBD stone size ≥ 12 mm (OR, 3.213; 95% CI, 1.140-9.057; P = .027) were significant. Conclusions ERCP using a cap-fitted forward-viewing endoscope with EPBD is feasible in Billroth II gastrectomy patients. In patients with ≥2 ERCP sessions or a CBD stone size ≥ 12 mm, special attention should be paid to the possible occurrence of significant adverse events.

Background EUS-guided radiofrequency ablation (EUS-RFA) could be used as an adjunct and effective alternative mode of treatment for unresectable locally advanced and nonmetastatic pancreatic adenocarcinoma. However, its translation into clinical practice has been restricted because of limited data and high procedure-related risk. Objective To evaluate the feasibility, efficacy, and safety of EUS-RFA in the normal porcine pancreas. Design Prospective, endoscopic, experimental study in a porcine model. Setting Tertiary-care referral center animal laboratory. Patients Animal study. Intervention EUS-RFA of the pancreas was attempted on 10 adult mini pigs. An 18-gauge endoscopic RFA electrode was used to puncture the body and tail of the pancreas, with an output power of 50 W for 5 minutes. Main Outcome Measurements The feasibility, efficacy, and safety of EUS-RFA. Results A spherical necrotic lesion surrounded by fibrous tissue localized in the pancreatic parenchyma was observed on histopathologic examination. The mean diameter of the ablated tissue was 23.0 ± 6.9 mm. No major procedure-related complications were noted, and all pigs survived without any distress behavioral pattern for 7 days until autopsy. Limitations Small sample size with short-term observation and the lack of evaluation of the head of the pancreas. Conclusion EUS-RFA of the pancreatic body and tail was feasible, effective, and relatively safe in a porcine model. More animal studies to assess damage to adjacent organs are required before human trials can be conducted.

Background Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications. Objective We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent. Design A multicenter, prospective comparative pilot study. Setting Two tertiary referral centers. Patients A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21). Interventions Predefined duration of placement and removal of FCSEMSs. Results After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration ( P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n=22 in the AF group and n=17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty. Limitations Short-term follow-up after the removal of FCSEMSs. Conclusions With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. (Clinical trial registration number: NCT00945516.)

Background EUS-guided biliary drainage (EUS-BD) with the use of a fully covered metal stent can result in a large-diameter fistula between the bile duct and the duodenum or stomach. This sustainable fistula may constitute a new endoscopic route to the bile duct. Objective To assess the feasibility of performing endoscopic procedures through EUS-guided choledochoduodenostomy or hepaticogastrostomy with a fully covered self-expandable metal stent (FCSEMS). Design Observational pilot study. Setting Tertiary-care referral center. Patients This study involved 3 consecutive patients who underwent EUS-BD with an FCSEMS for biliary decompression. Interventions One to four weeks after EUS-BD with an FCSEMS, endoscopic procedures for the bile duct were performed through the sinus tract to evaluate and manage intrabiliary lesions. Main Outcome Measurements Technical success and procedural complications of endoscopic procedures through EUS-BD with an FCSEMS. Results Endoscopic procedures were completed through the sinus tract of EUS-BD. Two patients underwent photodynamic therapy for tumor bleeding in the common bile duct and argon plasma coagulation on the biliary intraductal papillary mucinous neoplasm repeatedly under direct visual guidance. In the other patient, photodynamic therapy was performed on the malignant hilar stricture through EUS-guided hepaticogastrostomy with an FCSEMS. Limitations Small sample size, pilot study. Conclusions EUS-BD with an FCSEMS may result in a large-diameter sustainable fistula. Endoscopic intervention through this fistula seems to be feasible and useful for the management of intrabiliary lesions.

Anthracosis is a black pigment discoloration located mainly in the bronchi because of inhalation of dust or particulates. 1 Extrapulmonary anthracosis that includes the esophagus is very rare, and its etiology is not well established. 2,3 We present a case of esophageal anthracosis presenting as a submucosal tumor (SMT) complicated by mediastinal tuberculous lymphadenitis.

Background: Radiofrequency ablation (RFA) has become a widespread treatment option for primary or metastatic tumor of liver. However, there is limitation to approach pancreas by percutaneous method. EUS has emerged as an essential diagnostic and therapeutic tool in pancreatic disease. The purposes of this study are to evaluate in vivo feasibility, efficacy and safety of EUS-guided RFA on porcine pancreas. Materials and Methods: Ex vivo RFA was performed using bovine liver to find out the optimal length of electrode, optimal duration and power of RFA. Then in vivo EUS-guided RFA was performed on the pancreas using 40 kg adult mini-pigs. A 18-gauge RFA electrode with 1 cm in length and a VIVA RF system (STARmed, Korea) were used. One week after RFA, laparotomy was done and ablated areas and possible complications were evaluated. Results: EUS-guided RFA was technically successful in 10 pigs. The RFA electrode was visible on the EUS view and electrode needle was deployed or retracted without difficulty. Pancreatic tissue ablation was achieved within 6 minutes with 50 Watts of power. There was no immediate complication. Laparotomy revealed a discrete, well-defined round ablation of pancreas measuring about 20mm in diameter and without injury to surrounding pancreas parenchyma or adjacent organs. Ablated lesion was demarcated from normal parenchyme by fibrous wall. However, some omental adhesions were observed. Conclusion: EUS-guided RFA of porcine pancreas was technically feasible and effective ablation was accomplished without causing serious complication. EUS-guided RFA may have therapeutic potential for human pancreatic tumors.