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Background: Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound-guided CPN (EUS-CPN) was introduced and has enabled the performance of CPN under real-time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS-CPN in order to enable rational selection of the therapeutic strategy. Patients and Methods: Forty-seven consecutive patients who underwent EUS-CPN at our institutions were eligible for this study. Absolute ethanol containing a contrast medium was injected just above the origin of the celiac trunk from the aorta under real-time EUS guidance, and abdominal computed tomography was performed immediately after the procedure to evaluate the distribution of the injected ethanol. The efficacy in pain relief was evaluated based on the pain score at day 7 after EUS-CPN. Results: Pain relief was obtained in 32 patients (68.1%). Multivariate analysis using a multiple logistic regression model revealed that direct invasion of the celiac plexus and distribution of ethanol only on the left side of the celiac artery were significant factors for a negative response to EUS-CPN (odds ratio = 4.82 and 8.67, P = 0.0387 and 0.0224, respectively). Conclusion: EUS-CPN seems to be less effective in patients with direct invasion of the celiac plexus. Ethanol should be injected on both sides of the celiac axis to obtain greater pain relief.

Background and Aim: Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC. Patients and Methods: The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study. Results: Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.

Background: Recently, endoscopic treatment has been attempted to counter benign biliary strictures. It is expected to be an alternative to surgical operation because of its lower morbidity and its convenience, but the long-term results have not yet been sufficiently elucidated. Here, we evaluate the short- and long-term results of endoscopic stenting in patients with benign biliary strictures, and also describe a new technique using a covered metallic stent (CMS) in the refractory cases. Methods: The charts of 22 consecutive patients with benign biliary stricture treated endoscopically at our institutions between December 1995 and December 2002 were analyzed retrospectively. Results: Stricture etiology was as follows: postoperative, nine; chronic pancreatitis, seven; primary sclerosing cholangitis (PSC), three; and other, three. The stent initially placed was a 7 Fr in 11 patients and a 10 Fr in 11 patients. Eighteen of 22 patients (82%) were successfully treated by the initial treatment, and stents were removed after a mean duration of 3.1 months (range: 1–14 months). In the remaining four patients, stents were exchanged once to four times after that, and a CMS was placed as the second endoprosthesis in two patients with chronic pancreatitis. These stents, including CMS, were finally removed from these four patients after a mean duration of 14.8 months (range: 8–22 months). Over a median follow-up period of 26 months (range: 6–78 months), one recurrence has been observed, in which case a CMS was placed in a patient with chronic pancreatitis. The CMS was removed successfully 6 months after the insertion, and no recurrence was observed during the 6-month follow-up period. Conclusions: Endoscopic stenting for benign biliary stricture is an alternative to surgery because it shows satisfactory results. Placement of a CMS would also be an option in refractory strictures, such as those due in chronic pancreatitis, if the certainty of removal is proven by cumulative experience with a large number of patients.

Background: Endoscopic drainage of pancreatic pseudocysts is becoming common. Recent techniques using endoscopic ultrasound (EUS) have made the procedure safer and easier. However, bleeding related to the procedure is sometimes still experienced and placement of the tube is also sometimes difficult in cases where the cystic wall is thick and hard. We describe a new technique of EUS-guided drainage using a large-channel echoendoscope, a conventional polypectomy snare and a high-frequency current generator with automatic controls. We also evaluate this technique's utility. Methods: Between May 2001 and December 2002, EUS-guided drainage was attempted in consecutive patients with symptomatic pancreatic pseudocysts that had resisted conservative treatments. The EUS device was a recently introduced large-channel linear scanning echoendoscope. A puncture was made with a 19 G needle under EUS guidance and a 0.035 inch guidewire was passed through the puncture and into the pseudocyst. Then, a conventional polypectomy snare was used to enlarge the puncture tract with the new current generator, and a 7 Fr pigtail-type nasocystic drain was placed. Results: The drainage was successful and insertion of the drain was easy in all 13 patients included in the study. No complications related to the procedure, such as bleeding and perforation, were observed. The clinical symptoms resolved after the procedure in all patients. In nine patients, the cyst completely disappeared and the discharge also stopped, allowing the tube to be removed after a mean of 15 days. The median follow-up period for these nine patients was 4 months and no recurrence has been observed. In two other patients, the cysts shrank but did not disappear completely 4 weeks or more after the procedure. Since both of these patients had had previous cystic infections, they were given surgical operations. In the remaining two cases, the cystic lumen completely disappeared but the discharge continued for 4 weeks, so we replaced the 7 Fr nasobiliary tube with a 10 Fr internal drainage tube. Conclusion: This method is an easy and effective treatment for pancreatic pseudocysts. It may also reduce the risk of bleeding related to the procedure.

Diagnosis of the upstream extent of extrahepatic bile duct cancer has been difficult via the transpapillary approach, due to the difficulty of obtaining a biopsy sample above the stricture. We developed a new biopsy technique that allows a sample to be taken above the stricture, and prospectively evaluated the new technique's utility. Twenty-four consecutive patients diagnosed as having possible extrahepatic bile duct cancer by endoscopic retrograde cholangiopancreatography and other imaging tests were included in the study. They initially underwent endoscopic placement of a nasobiliary drainage tube. After improvement of jaundice and cholangitis, the cholangiogram obtained via the tube was examined and transpapillary biopsy was performed using a double lumen catheter under fluoroscopic guidance. The biopsy sampling in the stricture was successful in all cases, and pathological diagnosis was confirmed in all cases. The success rate of the method of upstream diagnosis was also sufficient in cases in which stricture was located below the middle extrahepatic bile duct. However, it was relatively low in cases whose stricture was located in the upper extrahepatic bile duct. Biopsy sampling in the hepatic hilum was also difficult. The transpapillary biopsy technique is useful for determination of the upstream extent of extrahepatic bile duct cancer, especially in cases in which stricture is located in the lower extrahepatic bile duct. Compared to the percutaneous transhepatic approach, it is less invasive and can shorten the preoperative period. It was also seen to be relatively safe, easy and convenient.