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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. [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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endoscopic nasobiliary drainage (NBD) for the treatment of acute cholangitis is an accepted method. A recently developed ultrathin transnasal videoendoscope is minimally invasive, even for patients who are critically ill. OBJECTIVE: To evaluate the clinical efficacy and safety of 1-step NBD by transnasal videoendoscopy (TNE). DESIGN: Prospective case study. SETTING: This study was performed at Tokyo Medical University Hospital. PATIENTS: Twenty patients with acute cholangitis who had previously undergone an endoscopic sphincterotomy (ES); including 10 with bile-duct stones, 8 with pancreatic cancers, 1 with chronic pancreatitis, and 1 with benign biliary stricture, were enrolled in this study. An indwelling self-expandable metallic stent (SEMS) was placed in all patients with pancreatic cancers. INTERVENTION: All patients underwent NBD via front-viewing TNE. A 5F NBD catheter was placed into the bile duct. MAIN OUTCOME MEASUREMENT: The efficacy and safety of this technique. RESULTS: The transnasal insertion of TNE was feasible in all patients, and none had epistaxis. Abdominal pain, fever, and jaundice were improved at 24 hours after the procedure in the majority of patients. The mean procedural time was 18.1 minutes. One patient pulled out the NBD catheter. None of the patients died. TNE-NBD was achieved in 19 patients (95%). LIMITATIONS: Maneuverability of the TNE, limited to patients with a previous ES or the placement of an SEMS. CONCLUSIONS: NBD that uses TNE may be a useful and novel technique for the treatment of acute cholangitis in patients with previous ES. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [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 © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

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.

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.

Background: It is often difficult to distinguish gallbladder cancers (GBC) from benign gallbladder diseases, which show thickened walls., Objectives: To evaluate the efficacy of bile cytology using endoscopic transpapillary gallbladder drainage (ETGD) and CT., Design: Retrospective study., Setting: Division of Gastroenterology, Tokyo Medical University, Tokyo, Japan., Patients and Interventions: Eighty-five patients with gallbladder diseases, consisting of 27 GBC and 58 benign gallbladder diseases, were reviewed. A pigtail-type nasobilliary drainage tube was left indwelling in the gallbladder, and through this drainage tube washing cytology was performed with an ETGD tube., Main Outcome Measurements: Diagnostic accuracy of CT and cytology. Complications and outcome were also evaluated., Results: CT and cytology with the ETGD tube had 81% and 81% sensitivity, 91% and 83% specificity, and 88% and 82% accuracy, respectively (P > .05). Looking only at the 71 successful ETGD cases, CT and ETGD cytology had 82% and 100% sensitivity, 92% and 98% specificity, and 89% and 99% accuracy, respectively (P = .036 and .025, respectively). Four patients with GBC in whom CT showed benign findings underwent open cholecystectomy because ETGD cytology revealed malignant findings. In contrast, 4 patients with benign diseases in whom CT suggested malignant finding underwent LC because the findings of ETGD cytology suggested benign disease., Conclusions: Cytology using an ETGD tube is very useful in the diagnosis and management of gallbladder diseases.