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Background/aims: Covered metallic stent was developed to prevent tumor ingrowth. However, procedural accidents due to its insertion often occur and migration after long-term insertion causes problems. The WallFlex partially covered stent (WF) with reduced axial force enables stenting along the bile duct. We examined the usefulness of WF placement in an unresectable malignant distal biliary obstruction., Methodology: We examined procedural accidents, stent obstruction rate, and patency period caused by WF insertion., Results: Ninety-seven patients were analyzed; procedural accidents caused by WF insertion occurred in 8 patients (7.2%) composed of acute cholecystitis in 3 patients (3.2%), acute pancreatitis in 2 patients (2.1%), acute cholangitis in 1 patient (1%), and other in 1 patient (1%). The stent obstruction rate was 19.6% (19 patients), and obstruction cause includes sludge in 9 patients (9.3%), migration in 4 patients (4.1%), food impaction in 3 patients (3.1%), ingrowth in 1 patient (1%), overgrowth in 0 patients (0%), and unknown in 2 patients (2.1%). The mean stent patency period was 634.918 +/- 66.545 (7-946) days., Conclusions: WF has less procedural accidents when inserted into unresectable malignant biliary obstruction patients with reduced migration rate after a long period and low obstruction rate.

Background/aims: The purpose of this study was to investigate whether endoscopic sphincterotomy (EST) can be usefully and safely performed in elderly patients aged 80 years or older., Methodology: The eligible patients with pancreatic and biliary diseases who required EST were divided into two groups depending on their age: under 80 (group A) and 80 or older (group B). Patient characteristics, EST success rate and incidence of the related complications were evaluated., Results: Of the 720 patients who required EST, 522 patients were in group A and 198 in group B. Group B incidences of patient characteristics at baseline disease and anticoagulant/antiplatelet therapy were significantly higher than in group A (p<0.05). The EST success rates were 97.1% (507/522) in group A and 96.5% (191/198) in group B. The incidences of the related complications were 8.8% (46/522) in group A and 4% (8/198) in group B, respectively, again without significant difference., Conclusions: The EST success rate and the incidence of related complications were comparable between patients in groups A and B, indicating that EST can be safely performed even in the elderly aged 80 years or older.

Background/aims: Few studies have compared endoscopic biliary stenting and endoscopic nasobiliary drainage for preoperative biliary drainage in patients with malignant distal biliary obstruction. We aimed to evaluate their safety and efficacy in such patients awaiting pancreaticoduodenectomy., Methodology: Seventy-six of 80 patients (40 with pancreatic cancer, 26 with distal bile duct cancer, and 14 with ampullary cancer) who underwent endoscopic preoperative biliary drainage were included, and we evaluated whether endoscopic biliary stenting or endoscopic nasobiliary drainage provided a safer and more effective drainage for patients awaiting pancreaticoduodenectomy. We also determined whether the type of cancer influenced tube dysfunction., Results: No significant differences in the overall rate of catheter-related complications, the rate of tube dysfunction, or the median interval from preoperative biliary drainage to the time of tube dysfunction were observed between the two groups. Tube dysfunction was observed significantly more frequently in patients with pancreatic cancer than in those with distal bile duct or ampullary cancer., Conclusions: Both endoscopic biliary stenting and endoscopic nasobiliary drainage provided safe and effective drainage for patients awaiting pancreaticoduodenectomy. Tube dysfunction was associated with preoperative biliary drainage significantly earlier in patients with pancreatic cancer than in those with distal bile duct cancer or ampullary cancer.

Background/aims: Recently, there have been sporadic reports of lithotomy using endoscopic sphincterotomy combined with large balloon dilation (EPLBD) against large or multiple bile duct stones. However, there are not many reports so far concerning this procedure. Therefore, we decided to discuss the results of EPLBD against large or multiple bile duct stones., Methodology: Stone retrieval using EPLBD was performed with 59 patients of choledocholithiasis, A) with 13 mm or more in shortest dimension, or B) multiple (≥3) bile duct stones, with the smallest more than 10 mm in shortest dimension. The papilla treated with endoscopic sphincterotomy (EST) was dilated using a 12-20 mm balloon suitable for the biliary ductal size., Results: The success rate for the first lithotomy for choledocholithiasis was 83.1% (49/59). The final lithotomy rate was 100% (59/59). The time required for lithotomy was 43.7 (12-125) minutes and the number of treatment was 1.3 (1-4) on average. Lithotripsy was needed in 13.6% (8/59). The incidence of coincidental events associated with the procedure was 6.8% (4/59). No pancreatitis was noted., Conclusions: An endoscopic treatment using EST plus large balloon dilation against large or multiple bile duct stones was suggested to be safe and effective.

Background/aims: The progression of endoscopy and devices as well as newly developed treatment methods have enabled endoscopic lithotomy. In this study, we examined to what degree is it possible to endoscopically treat patients who are diagnosed as having common bile duct stones., Methodology: Lithotomy was conducted using a backward side-viewing endoscope for patients without surgical history of upper gastrointestinal tract and patients with stomach reconstructed with Billroth-I method, using an ordinary endoscope for patients with stomach reconstructed with Billroth-II method (Bil-II) and using a double balloon endoscope for patients with difficulty in reaching the papilla or patients of Roux-en-Y anastomosis (R-Y). As for treatment methods, we selected endoscopic sphincterotomy as the first choice for papilla treatment and selected endoscopic papillary balloon dilation for patients with bleeding tendency or patients of Bil-II or R-Y. For patients with multiple stones or giant stones, lithotripsy was selected depending on judgment of the endoscopist., Results: Endoscopic complete lithotomy was successful in 97.7% (168/172). An accidental disease was observed in 2.9% (5/172). In one patient with the perforated gastrointestinal tract, a surgery was performed but others were mild., Conclusions: Common bile duct stones can be endoscopically treated safely with high rate.

Background/aims: Transpancreatic precut papillotomy (TPPP) is considered as an effective method in patients with difficulty in selective biliary cannulation. However, the use of placing a pancreatic duct stent as a measure against post-ERCP pancreatitis has not been clarified. Here we examine the methods of implementing TPPP safely., Methodology: TPPP was conducted on patients with difficulty in selective biliary cannulation. The incidence of pancreatitis was compared between group P(+) in which a spontaneous dislodgement type pancreatic duct stent was placed and group P(-) without a duct stent., Results: The success rate of biliary cannulation was 83.3% at the first ERCP and finally 93.9%. Post-ERCP pancreatitis was observed in 9.09% of patients. The success rate of placement of pancreatic duct stent in the P(+) group was 100%. The incidence of pancreatitis in the P(+) group was 4.1% and the mean post-ERCP amylase level was 340.071 ±420.035IU/L. The incidence of pancreatitis in the P(-) group was 23.5% and the mean post-ERCP amylase level was 661.250±772.285IU/L. The incidence of pancreatitis and the mean post-ERCP amylase level were significantly lower in the P(+) group (p<0.05)., Conclusions: In the patients with difficulty in selective biliary cannulation, TPPP is a useful technique for biliary cannulation. The placement of a spontaneous dislodgement type pancreatic duct stent after TPPP may be useful for prevention of post-ERCP pancreatitis.

Background/aims: To examine the utility of placement of pancreatic duct spontaneous dislodgement stents for prevention of post-ERCP pancreatitis in patients with difficulty in selective biliary cannulation., Methodology: The incidence of pancreatitis was compared between the group with P(+) pancreatic duct spontaneous dislodgement stent placed for prevention of post-ERCP pancreatitis and the group without P(-) in patients with difficulty in selective biliary cannulation., Results: The final success rate of selective biliary cannulation was 94.45%. Post-ERCP pancreatitis was observed at 7.07%. The success rate of placement of pancreatic duct stent in the P(+) group was 99.0%. The incidence of pancreatitis in 99 patients in the P(+) group was 3.0%, that of abdominal pain was 3.0%, that of hyperamylasemia was 16.2%, and the mean post-ERCP amylase level was 353.031 +/- 520.792 IU/L. The incidence of pancreatitis in the P(-) group was 11.1%, that of abdominal pain was 20.2%, that of hyperamylasemia was 33.3%, and the mean post-ERCP amylase level was 541.204 +/- 771.843 IU/L. Comparing between the P(+) group and P(-) group, the incidence of pancreatitis, that of abdominal pain, that of hyperamylasemia and the mean post-ERCP amylase level were significantly decreased in the P(+) group (p<0.05)., Conclusion: Placement of pancreatic duct spontaneous dislodgement stent in patients with difficulty in selective biliary cannulation could be useful for prevention of post-ERCP pancreatitis.

Background/aims: Pancreatic duct guidewire-indwelling method (P-GW) is effective when selective biliary cannulation (SBC) has failed, but neither its true success rate nor a salvage technique have been established. In this study, we examined the usefulness of pre-cut papillotomy employing a pancreatic duct guidewire as the salvage treatment after unsuccessful SBC under P-GW., Methodology: P-GW was conducted in 55 patients. When cannulation under P-GW was unsuccessful, pre-cut papillotomy was performed. Then, if SBC after trial was still unsuccessful, ERCP was tried again at a later date. The incidence of pancreatitis following ERCP in patients with difficult SBC, with and without pancreatic duct stenting was determined., Results: P-GW resulted in successful SBC in 63.6% of patients. For the 20 patients in which SBC failed pre-cut papillotomy using the pancreatic duct guidewire was performed. Transpancreatic pre-cut papillotomy was performed in 17 patients; 3 patients underwent needle-knife pre-cut papillotomy. SBC was successful at first attempt in 89.1% and eventually in 96.4% of patients. Post-ERCP pancreatitis occurred in 7.3%, broken down into 0% for those with pancreatic duct stenting (p=0.03) and 16.7% for those without., Conclusions: Pre-cut papillotomy using a pancreatic duct guidewire was useful for patients with unsuccessful SBC with P-GW alone, and the risk for pancreatitis was reduced by pancreatic stenting.

Surgical resection is considered the first-line treatment of intraductal papillary neoplasm of the bile duct (IPNB). Since some patients with IPNB have an unexpectedly superficially-spreading lesion, preoperative cholangioscopic diagnosis is very useful in determining the extent of resection. We report a patient with IPNB in whom preoperative peroral cholangioscopic evaluation was useful.

The methods for non-surgical biliary drainage for the treatment of obstructive jaundice generally include transpapillary one, or endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous one, or percutaneous transhepatic biliary drainage (PTBD). In placing internal drainage, a stent is frequently inserted through the route of the drainage. However, transpapillary approach may be infeasible in patients, if cannulation is difficult, drainage cannot reach the duodenal papilla, and percutaneous approach may be infeasible in patients, if the intrahepatic bile duct is not be expanded. Endosonography-guided biliary drainage (ESBD) is a new method enabling internal drainage of an obstructed bile duct. In this study, the transpapillary ESBD approach was successfully applied to a patient having obstructive jaundice due to cancer of the head of the pancreas during the treatment of ovarian cancer although internal drainage via transpapillary and percutaneous approach was not applicable to this patient. So far, few studies have reported the use of ESBD. Although a large-scale, multicenter study is required to investigate the indications and complications of ESBD, it is no doubt that we have now more treatment options for non-surgical biliary drainage.

This study was conducted to examine the usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and postcholecystectomy bile leakage. Endoscopic transpapillary procedure was performed in 18 cases of post-cholecystectomy bile duct stricture and 6 cases of post-cholecystectomy bile leakage. In the bile duct stricture cases, the patients were assessed for the stricture by endoscopic retrograde cholangiography (ERC), and then underwent endoscopic sphincterotomy (EST) for tube stent insertion. The stents was replaced every 3 to 6 months, and the treatment was continued until the patients became stent-free. Successful therapy was defined as a stent-free condition without hepatic disorder. In the bile leakage cases, the leakage was located by ERC and EST was performed. Then, endoscopic nasobiliary drainage (ENBD) tube was inserted at the proximal side of the bile leakage, and the therapeutic outcome was defined as successful if disappearance of the leakage was confirmed by cholangiography at a later date. Endoscopic transpapillary procedure was 100% successful in both post-cholecystectomy bile duct stricture cases (18/18) and post-cholecystectomy bile leakage cases (6/6). There was no accident due to the treatment. Restricture occurred in 5.5% (1/18) of the patients, but additional therapy was successful and the stent was removed. Also, there was no accident due to endoscopic transpapillary procedure. Endoscopic transpapillary procedure in postcholecystectomy bile duct stricture and postcholecystectomy bile leakage was demonstrated to be a less invasive, safe, and useful method.

Background/aims: The purpose of this study was to examine the clinical utility of peroral cholangioscopy for mucin-producing bile duct tumor., Methodology: Peroral cholangioscopy was performed in seven cases of mucin-producing bile duct tumor to decide the course of treatment based on the results. All seven cases were evaluated by peroral cholangioscopy and examined by a transpapillary biopsy. Five out of the seven cases (71.4%) were adequately observed. Because abundant mucin could not be removed in 2 cases (28.6%), one of them underwent PTCS after PTBD, and the other had surgery for EBD insertion without PTBD at the patient's request. A stent was placed by surgery in five out of the seven cases and by a transpapillary method in two cases., Results: Among the five cases that could be evaluated by peroral cholangioscopy, the excised specimens were compared with the findings obtained from peroral cholangioscopy in three cases that underwent surgery, while the results of transpapillary mapping biopsy were compared with the findings obtained from peroral cholangioscopy in two inoperable cases, showing that the evaluation by peroral cholangioscopy agreed with the results of tumor staging in all the five cases., Conclusions: This study suggested the possibility that the use of peroral cholangioscopy for mucin-producing bile duct tumor could be useful in deciding the course of treatment.

Background/aims: Malignant intraductal papillary mucinous neoplasm of the pancreas (IPMN) has a very poor prognosis, and there is no useful biomarker for an early diagnosis at present. A biomarker is expected to allow an early diagnosis of IPMNs and consequently lead to an improvement of the patients' prognosis. Recent advances in proteomic analysis are remarkable; therefore we explored novel biomarkers for IPMN using Surface-Enhanced Laser Desorption and Ionization (SELDI) Mass Spectrometry., Methodology: We collected pancreatic juice samples from 33 patients with IPMNs, 54 patients with pancreatic ductal carcinoma, and 31 with chronic pancreatitis. We analyzed the pancreatic juice samples using a SELDI ProteinChip system (Ciphergen Biosystems, Fremont, CA)., Results: We identified a 6240-Da peak whose expression in pancreatic juice from patients with IPMNs was significantly higher compared with that in other pancreatic diseases (P<0.01). This 6240-Da protein was partially purified and was identified as pancreatic secretory trypsin inhibitor (PSTI) by amino acid sequencing. The pancreatic juice PSTI levels, as measured by radioimmunoassay, were significantly higher in the IPMN group than in the other groups (P<0.001). When the diagnostic cutoff value of PSTI in pancreatic juice was set at 25000 ng/mL, the positive predictive value, negative predictive value, sensitivity, and specificity were respectively 89%, 83%, 48%, and 98%., Conclusions: PSTI levels of pancreatic juice in patients with IPMN were significantly higher than those in patients with other pancreatic diseases. The PSTI level in pancreatic juice may be useful for the diagnosis of IPMN.

Background/aims: The aim of this study was to investigate whether exogenous dehydrocholic acid (DHCA) was useful to enhance the delineation of hepatolithiasis., Methodology: Our study population comprised 9 patients. Magnetic resonance cholangiopancreatography (MRCP) was acquired before and after the administration of DHCA. Two different MRCP snap-shot techniques were applied: thick-slab two-dimensional (2D) (coronal) single shot turbo spin echo T2-weighted sequences and multisection thin-slab, 2D (coronal) single shot turbo spin echo T2-weighted sequences with three-dimensional (3D) maximum intensity projection (MIP) post processing., Results: DHCA provided a better visualization of hepatolithiasis in 8 of 9 cases (88.9%)., Conclusions: It was suggested that administration of DHCA could enhance the delineation of the hepatolithiasis on MRCP images.

In this study, the authors report the case of a 35-year-old man diagnosed preoperatively as having adenocarcinoma of the jejunum using a conventional endoscopy, usually used for the examination of the large intestine.

Background/aims: Polyarteritis nodosa (PN) has been classified into polyarteritis (PA) and microscopic polyarteritis (MA) histologically. To clarify of the characteristics of upper gastrointestinal bleeding lesions in PN, we investigated the patients of PN with rapidly progressive glomerulonephritis (RPGN) presenting with upper gastrointestinal bleeding., Methodology: The subjects of this study were 21 patients of PN with RPGN (PA: 11, MA: 10) who presented with upper gastrointestinal bleeding. The bleeding lesions and their locations were examined endoscopically in the study subjects, and the relationship of the bleeding to the severity of renal failure, the necessity of hemodialysis (HD), presence/ absence of H. pylori infection and the gender of the patients were analyzed., Results: The bleeding lesions were endoscopically identified as esophageal ulcers in 2 cases, gastric ulcers in 15 cases and duodenal ulcers in 4 cases, respectively. In 10 of the 15 cases with gastric ulcers, the ulcer assumed the form of Dieulafoy's lesions affecting the gastric body, and the underlying disease was PA in all the 10 cases. In the remaining 5 cases of gastric ulcers and 2 cases of esophageal ulcer with underlying MA or 4 cases of duodenal ulcers, in whom assumed the bleeding form of oozing from the marginal zone of ulcers. In all of the 4 cases of duodenal ulcers, and the 1 case with underlying PA and the other cases with MA, no correlation was found between the onset of the upper gastrointestinal bleeding and the severity of renal failure or the necessity for HD, presence of H. pylori infection, or the gender of the patients., Conclusions: Dieulafoy's lesions are the most frequent sources of upper gastrointestinal bleeding in cases of PA.

Background/aims: The aim of this study was to investigate whether exogenous dehydrocholic acid (DHCA) was useful to enhance the delineation of the biliary tree., Methodology: Our study population comprised 14 patients. Magnetic resonance cholangiopancreatography was acquired before and after the administration of DHCA. Two different MRCP snap shot techniques were applied: thick-slab two-dimensional (2D) (coronal) single shot turbo spin echo T2-weighted sequences and multisection thin-slab, 2D (coronal) single shot turbo spin echo T2-weighted sequences with three-dimensional (3D) maximum intensity projection (MIP) post processing. Volume rendering was prepared based on the source images, and the pixel size was visually adjusted to the biliary area of MRCP to measure the biliary tree volume., Results: DHCA increased the bile duct volume in 13 of the 14 patients. It provided a better visualization of the biliary tree in 11 patients. The three patients without improvement in visualization included 1 patient with liver cirrhosis secondary to portoenterostomy for congenital biliary dilatation and 2 patients with cholecystectomy who had the bile ducts filled with bile by the time of the administration., Conclusions: It was suggested that administration of DHCA could enhance the delineation of the biliary tree on MRCP images.

Mucin-producing bile duct tumor is a rare biliary tract tumor. Despite the development of modern diagnostic technologies such as ultrasonography, and angiography, the precise determination of this tumor is difficult because of ambiguity caused by the abundant mucin secreted by the tumor and/or by the superficial mucosal spread of the tumor along the bile duct. Given these problems, selective percutaneous transhepatic biliary drainage (PTBD) and percutaneous transhepatic cholangioscopy (PTCS) are indispensable for the accuracy staging of this cancer. But, PTCS has a risk of a rare but serous complications, seeding metastasis at the sinus tract of PTBD, whereas the retrograde approach minimizes this risk. We report the case of a patient who underwent the successful resection of a mucin-producing bile duct tumor. The tumor was diagnosed preoperatively as originating in the left caudate lobe after ERC and peroral cholangioscopy (POCS).

Background/aims: The aim of this study was to investigate whether exogenous dehydrocholic acid (DHCA) was useful to enhance the delineation of anastomotic site., Methodology: DHCA is a cholagogue which produces an immediate effect by acting directly on liver cells. Its choleretic effect is strong, appearing 1 to 3 minutes after intravenous injection, reaching the maximum level in 20 to 30 minutes. Our study population comprised 9 patients. Magnetic resonance cholangiopancreatography (MRCP) was acquired before and after the administration of DHCA. Two different MRCP snap-shot techniques were applied: thick-slab two-dimensional (2D) (coronal) single-shot turbo spin echo T2-weighted sequences and multisection thin-slab, 2D (coronal) single shot turbo spin echo T2-weighted sequences with three-dimensional (3D) maximum intensity projection (MIP) post processing., Results: DHCA provided a better visualization of the anastomotic site in 7 patients (77.8%). The two patients without improvement in visualization of anastomotic site included 1 patient with liver cirrhosis secondary to portoenterostomy for congenital biliary dilatation and 1 patient, who was not eligible for the evaluation because of motion artifact caused by the difficulty of breath holding motion artifact., Conclusions: It was suggested that administration of DHCA could enhance the delineation of the anastomotic site on MRCP images.

Background/aims: To assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) and examine the indications for endoscopic retrograde cholangiopancreatography (ERCP)., Methodology: MRCP was performed in 185 patients with hepatobiliary disease in whom abdominal ultrasonography (US) had not been of diagnostic value. These patients were selected for MRCP in view of their abdominal symptoms, high levels of hepatobiliary enzymes, and pancreatic/bile duct dilatation found by abdominal US. Based on MRCP findings, 75 patients were selected for ERCP., Results: ERCP provided new findings in 14 (18.%) patients. In 110 patients subjected to only MRCP and follow-up as well as in 75 patients with MRCP followed by ERCP, MRCP-based diagnosis corresponded with the final diagnosis. In our study, patients who would have conventionally required ERCP, such as those with natural passed choledocholithiasis and postoperative bile duct dilatation, could be followed up without ERCP. These results the importance of considering indications for ERCP., Conclusions: MRCP can be an alternative to ERCP at least for diagnosis.