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Objectives: The placement of plastic stents (PS), including intraductal PS (IS), is useful in patients with unresectable malignant hilar biliary obstruction (UMHBO) because of patency and ease of endoscopic reintervention (ERI). However, the optimal stent replacement method for PS remains unclear. Methods: This retrospective study included 322 patients with UMHBO. Among them, 146 received PS placement as initial drainage (across‐the‐papilla PS [aPS], 54; IS, 92), whereas 75 required ERI. Eight bilateral aPS, 21 bilateral IS, and 17 bilateral self‐expandable metallic stent (SEMS) placements met the inclusion criteria. Rates of technical and clinical success, adverse events, recurrent biliary obstruction (RBO), time to RBO (TRBO), overall survival, and secondary ERI were compared. Results: There were no significant intergroup differences in rates of technical or clinical success, adverse events, RBO occurrence, or overall survival. The median TRBO was significantly shorter in the aPS group (47 days) than IS (91 days; P = 0.0196) and SEMS (143 days; P < 0.01) groups. Median TRBO did not differ significantly between the IS and SEMS groups (P = 0.44). On Cox multivariate analysis, the aPS group had the shortest stent patency (hazard ratio 2.67 [95% confidence interval 1.05–6.76], P = 0.038). For secondary ERI, the median endoscopic procedure time was significantly shorter in the IS (22 min) vs. SEMS (40 min) group (P = 0.034). Conclusions: Bilateral IS and SEMS placement featured prolonged patency after first ERI. Because bilateral IS placement is faster than SEMS placement and IS can be removed during secondary ERI, it may be a good option for first ERI. [ABSTRACT FROM AUTHOR]

Background: Although intraductal plastic stent (IS) placement is an effective treatment for unresectable malignant hilar biliary obstruction (UMHBO), the effectiveness of unilateral and bilateral IS drainage remains controversial. This retrospective study investigated the effectiveness of bilateral IS placement for UMHBO using the propensity score matching method. Methods: Patients who underwent transpapillary endoscopic stenting for UMHBO were analyzed for technical and clinical success, adverse events, and time to recurrent biliary obstruction (TRBO). Results: A total of 321 patients were enrolled in the study with 27 patients in each unilateral and bilateral IS group in the propensity score‐based cohort. Technical success was 100%, while clinical success was 93% and 96% in the unilateral and bilateral IS groups, respectively (p = 1.0). Cholecystitis occurred in 4% and 7%, respectively (p = 1.0). The median TRBO was shorter in the unilateral group (129 [5–383] days) than that in the bilateral group (226 [16–563] days) (p =.0281). Bilateral IS placement was an independent long TRBO factor (hazard ratio [HR] 0.46; 95% confidence interval [CI]: 0.21–0.97; p =.041). Conclusions: Unilateral and bilateral IS placement had high technical and clinical success rates in primary stent placement. However, bilateral IS placement showed a longer TRBO. Bilateral IS placement may be a good option for initial UMHBO drainage. [ABSTRACT FROM AUTHOR]

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled‐off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound‐guided transluminal drainage combined with on‐demand endoscopic necrosectomy (i.e. the step‐up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen‐apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound‐guided antegrade treatment (EUS‐AG) and balloon endoscopy‐assisted endoscopic retrograde cholangiopancreatography (BE‐ERCP) have emerged as useful procedures for managing bile duct stones (BDS) in patients with surgically altered anatomy. However, the comparison between these two procedures has not been well studied. The aim of our study was to compare the clinical outcomes of EUS‐AG and BE‐ERCP for managing BDS in patients with surgically altered anatomy. Methods: The database was retrospectively evaluated at two tertiary care centers to identify patients with surgically altered anatomy who underwent either EUS‐AG or BE‐ERCP for BDS. Clinical outcomes were compared between the procedures. The success rate of each procedure was evaluated in three steps: endoscopic approach, biliary access, and stone extraction. Results: Among the 119 identified patients, 23 had EUS‐AG, and 96 had BE‐ERCP. The overall technical success rates of EUS‐AG and BE‐ERCP were 65.2% (15/23) and 69.8% (67/96), respectively (P =.80). The comparison of each step between the procedures EUS‐AG versus BE‐ERCP was as follows: endoscopic approach, 100% (23/23) versus 88.5% (85/96) (P =.11); biliary access, 73.9% (17/23) versus 80.0% (68/85) (P =.57); stone extraction, 88.2% (15/17) versus 98.5% (67/68) (P =.10). The overall adverse event rate was 17.4% (4/23) versus 7.3% (7/96) (P =.22). Conclusions: Both EUS‐AG and BE‐ERCP are effective and relatively safe procedures in the management of BDS in patients with surgically altered anatomy. The challenging steps of each procedure might be different, which could help decide which one to use to manage BDS in patients with surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Background: During endoscopic ultrasound‐guided biliary drainage (EUS‐BD), a combination of a 19‐gauge needle and a 0.025‐inch guidewire is generally used. However, a 19‐gauge needle has poor maneuverability because of their stiffness and rigidity and might have poor penetrability in non‐dilated bile ducts because of their large bore. In contrast, the application of a 22‐gauge needle is expected to have improved maneuverability. However, only a 0.018‐inch guidewire, which has less supportability, is applicable in the subsequent guidewire selection. This study aimed to evaluate the feasibility and safety of a dedicated bougie dilator for a 0.018‐inch guidewire. Methods: From September 2019 to May 2020, 26 patients underwent fistula dilation using the dilator after accessing the bile duct using a 22‐gauge needle and a 0.018‐inch guidewire during EUS‐BD. The success and adverse event rates of EUS‐BD were evaluated. Results: Biliary access with a combination of a 22‐gauge needle and a 0.018‐inch guidewire was successful in all with a median bile duct diameter of 5 mm. Dilation of the fistula using the dedicated dilator was also successful in all cases. Subsequently, the dilator was successfully exchanged to an ERCP catheter that allowed for exchange to a 0.025‐inch guidewire, except in one case where the catheter did not cross the fistula and a dilation balloon was inserted for an exchange to a 0.025‐inch guidewire. The technical success rate of the EUS‐BD was 100%. The adverse event rate was 19%. Conclusion: The application of the dedicated dilator for a 0.018‐inch guidewire was considered feasible and safe for EUS‐BD. [ABSTRACT FROM AUTHOR]

Background: Endoscopic transpapillary gallbladder drainage (EGBD) has been reported as an effective gallbladder drainage treatment option for acute cholecystitis in high‐risk surgical patients. However, the long‐term outcomes such as cholecystitis' recurrence rate after placement of EGB stenting (EGBS) have not been well studied yet. Aims: The aim of the present study was to compare the long‐term outcome of EGBS and removal of gallbladder drainage after percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic nasogallbladder drainage (ENGBD) for acute cholecystitis in high‐risk surgical patients and clarify the usefulness of long‐term placement of EGBS. Methods: We retrospectively studied 180 high‐risk surgical patients with acute cholecystitis between January 2010 and December 2018. The patients were divided into two groups: EGBS group (long‐term placement of EGBS) or Removal group (removal of drainage tube after PTGBD or ENGBD). Clinical outcomes, including long‐term results, were compared between the groups. Results: The cumulative late adverse event (AE) rates were 5.0% and 22.1% in the EGBS and Removal group (P =.002), with a median follow‐up period of 375 and 307 days in the two groups, respectively. The cumulative cholecystitis recurrence rate was 5.0% (2/40) in the EGBS group and 16% (21/131) in the Removal group (P =.024), respectively. In the multivariate analysis for late AE, only EGBS was an independent risk factor with a decreasing value. Conclusion: The permanent EGBS in high‐risk surgical patients with acute cholecystitis was considered effective in reducing the risk of late AE. [ABSTRACT FROM AUTHOR]

Background/Purpose: Unresectable distal malignant biliary obstruction (DMBO) in patients with surgically altered anatomy is traditionally managed with percutaneous transhepatic biliary drainage (PTBD) and stenting because the anatomical features complicate the endoscopic approach to the biliary orifice. EUS‐guided approaches recently emerged as alternative treatments; however, limited data comparing the procedures are available. The aim of this study was to compare EUS–antegrade biliary stenting (ABS) with PTBD for DMBO in patients with surgically altered anatomy. Methods: The medical records of patients who underwent EUS‐ABS or PTBD for the management of DMBO and had a history of upper intestinal surgery at two tertiary centers between 2007 and 2019 were retrospectively evaluated. The study outcomes were technical, clinical, and internalization success rates and adverse event rates. Results: Of the 64 enrolled patients, 35 underwent EUS‐ABS and 29 had PTBD. Basic characteristics including age, sex, performance status, primary malignancy, and reconstruction method did not differ significantly between groups. The technical, clinical, and internalization success rates in the EUS‐ABS and PTBD groups were 97.1% vs 96.6% (P = 1.00), 97.1% vs 93.1% (P =.586), and 97.1% vs 75.9% (P =.01), respectively. The adverse event rate was 11.4% vs 27.6% (P =.119). No significant long‐term difference was seen in time to recurrent biliary obstruction and survival. Multivariate analysis confirmed EUS‐ABS was not an independent risk factor for survival. Conclusions: Similar to PTBD, EUS‐ABS can effectively and safely manage DMBO in patients with surgically altered anatomy. Further well‐designed trials are warranted to confirm these findings. [ABSTRACT FROM AUTHOR]

Background/Purpose: Endoscopic transpapillary gallbladder drainage (ETGBD), including endoscopic nasogallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS), has been reported to be an effective treatment for acute cholecystitis. However, ETGBD is considered to be more difficult than percutaneous transhepatic gallbladder drainage (PTGBD), and few studies have evaluated the factors that affect technical success of the procedure. We investigated the factors predicting its technical success from among patient characteristics and image findings before treatment. Methods: Three hundred twenty three patients who underwent ETGBD for acute cholecystitis from November 2006 to December 2018 were analyzed retrospectively. Results: The technical success rate was 72.8% (235/323). The technical success rate by cystic duct direction was as follows: proximal/distal, 65.9%/93.6%; right/left: 74.0%/65.2%; cranial/caudal, 83.5%/20.0%. The clinical response rate was 96.2% (226/235). Adverse events were encountered in 5.9% of cases (19/323), including cystic duct injury (11 patients), pancreatitis (five patients), and bleeding (three patients). In both univariate and multivariate analysis, presence of cystic duct stone, dilation of the common bile duct (CBD), and cystic duct direction (proximal and caudal branches) were identified as significant factors affecting technical failure of ETGBD. Conclusion: Although ETGBD was an effective and safe procedure for acute cholecystitis, it has a limited success rate. The presence of cystic duct stone, dilation of CBD, and cystic duct direction (proximal and caudal branches) can serve as important predictors of ETGBD difficulties. These findings should be considered before procedures and the necessary adaptation of ETGBD made. [ABSTRACT FROM AUTHOR]

Background and Aim: An antireflux metal stent (ARMS) for nonresectable distal malignant biliary obstruction (MBO) may prevent recurrent biliary obstruction (RBO) as a result of duodenobiliary reflux and prolong time to RBO (TRBO). Superiority of ARMS over conventional covered self‐expandable metal stents (SEMS) has not been fully examined. Methods: We conducted a multicenter randomized controlled trial to examine whether TRBO of an ARMS with a funnel‐shaped valve was longer than that of a covered SEMS in SEMS‐naïve patients. We enrolled 104 patients (52 patients per arm) at 11 hospitals in Japan. Secondary outcomes included causes of RBO, adverse events, and patient survival. Results: TRBO did not differ significantly between the ARMS and covered SEMS groups (median, 251 vs 351 days, respectively; P = 0.11). RBO as a result of biliary sludge or food impaction was observed in 13% and 9.8% of patients who received an ARMS and covered SEMS, respectively (P = 0.83). ARMS was associated with a higher rate of stent migration compared with the covered SEMS (31% vs 12%, P = 0.038). Overall rates of adverse events were 20% and 18% in the ARMS and covered SEMS groups, respectively (P = 0.97). No significant between‐group difference in patient survival was observed (P = 0.26). Conclusions: The current ARMS was not associated with longer TRBO compared with the covered SEMS. Modifications including addition of an anti‐migration system are required to use the current ARMS as first‐line palliative treatment of distal MBO (UMIN‐CTR clinical trial registration number: UMIN000014784). [ABSTRACT FROM AUTHOR]

Background: Bilateral self‐expandable metallic stent (SEMS) placement is effective for long‐term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well‐studied. This study aimed to evaluate ERI efficacy after stent‐in‐stent placement. Methods: Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed. Results: The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370–2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121–1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction. Conclusions: ABBS >104° and overgrowth were risk factors for ERI failure after stent‐in‐stent placement. In the decision‐making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases. [ABSTRACT FROM AUTHOR]

This Editorial refers to the article by Inoue et al., p 949–956 of this issue. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic sphincterotomy (ES) is a standard procedure for the treatment of common bile duct stones (CBDS). Endoscopic papillary large balloon dilation (EPLBD) is emerging as an effective method to treat difficult CBDS, providing several advantages over ES without increasing early adverse events (AE). However, the late AE of EPLBD have not yet been well studied. The aim of the present study was to compare late AE after EPLBD versus ES for the treatment of CBDS using a propensity score‐based cohort analysis. Methods: Propensity score matching was introduced to reduce the possible bias in baseline characteristics between two treatment groups and formed the matched cohort including 240 patients. Primary endpoint was cumulative as well as estimated 1‐year and 3‐year late AE rates. Secondary outcome was the incidence of early AE. Results: Cumulative late AE rates were 12.5% and 16.7% in the ELPBD and ES groups (P = 0.936) with a median follow‐up period of 915.5 and 1544.5 days, respectively. Estimated 1‐year and 3‐year late AE rates were 8.4% and 13.1% in the EPLBD group and 5.0% and 15.0% in the ES group, respectively. In multivariate analysis, ≥two procedures were identified as independent risk factors for late AE. Overall early AE rate did not differ between the groups. Conclusion: In the present study, late AE rate after EPLBD showed no significant difference compared with that after ES, which had a relatively long follow‐up period. Therefore, EPLBD could be used for the treatment of CBDS, if CBDS are considered difficult to treat. Clinical Trial Registry: UMIN000027798 [ABSTRACT FROM AUTHOR]

Background and Aim: Percutaneous transhepatic drainage is the most common method for non‐operative gallbladder drainage, but the technique does have several disadvantages because of its invasive nature and requirement for continuous drainage. To overcome these disadvantages, we developed a novel procedure, endoscopic gallbladder lavage followed by stent placement, carried out in a single endoscopic session. Our aim was to prospectively evaluate the efficacy and safety of this procedure in patients with acute cholecystitis. Methods: Patients diagnosed with moderate cholecystitis at four tertiary care centers were enrolled in this study. We initially placed a 5‐Fr tube to carry out gallbladder lavage. The tube was then cut to the optimal length and placed as a stent. Main outcomes were procedural and clinical success rates. Results: The procedure was attempted in 40 patients and was successful in 30 (75.0%). Minor adverse events occurred in two (5.0%) patients: perforation of the cystic duct by the guidewire in one patient and pancreatitis in the other. Among the 30 patients in whom the procedure was successfully done, clinical resolution was obtained in 29 (96.6%). Elective cholecystectomy was carried out in 37 patients (92.5%), with a median delay after drainage of 42 days (range, 12–138 days). There were no adverse events during the waiting period. Conclusions: Gallbladder rinsing followed by internal drainage using a 5‐Fr nasobiliary tube is considered an effective and safe alternative to other techniques, providing an acceptable success rate in patients with acute cholecystitis prior to elective surgery. Clinical trial information: http://www.umin.ac.jp/ctr/index.htm (ID: UMIN‐000009680). [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic retrograde cholangiography (ERCP) with biliary stenting for the treatment of unresectable malignant biliary obstruction (MBO) is challenging among patients with surgically altered anatomy. Endoscopic ultrasound-guided antegrade biliary stenting (EUS-ABS) was introduced as an alternative biliary drainage method, although it has not yet been well studied. In this single-center prospective pilot study, we aimed to evaluate the feasibility and safety of EUS-ABS for MBO in patients with surgically altered anatomy. Methods EUS-ABS for MBO was attempted in patients with surgically altered anatomy. In EUS-ABS, the bile duct in the left lobe was accessed from the intestine under EUS guidance, and a guidewire was placed. Thereafter, an uncovered metallic stent was deployed at the MBO through the fistula. All devices were then removed. Technical, clinical, and adverse event rates, as well as patient characteristics and procedure details, were evaluated. Results Twenty patients (10 women; median age, 69 years) were enrolled in the present study. Technical and clinical success rates of EUS-ABS were both 95% (19/20). In one patient, unsuccessful EUS-ABS as a result of failed visualization of the left lobe of the liver with EUS was salvaged with percutaneous biliary drainage. Rate of adverse events was 20% (4/20), including mild pancreatitis in three patients and mild fever in one patient, which were successfully managed conservatively. Conclusions EUS-ABS for MBO in patients with surgically altered anatomy was a feasible and safe procedure. Further large scale comparison studies are needed to confirm its efficacy (Clinical Trial Registration Number: UMIN000008589). [ABSTRACT FROM AUTHOR]

Background and Aim In patients with unresectable malignant distal biliary obstruction, covered self-expandable metallic stents (CSEMS) may remain patent longer than uncovered self-expandable metallic stents as a result of tumor ingrowth prevention. One main cause of recurrent biliary obstruction (RBO) in CSEMS is sludge formation, which can be prevented using a large-bore stent. Therefore, we developed a novel, 12-mm diameter fully covered SEMS (FCSEMS) and investigated its clinical safety, efficacy, and rate of adverse events. Methods This prospective, multicenter pilot study, which ran between June 2011 and November 2012, included 38 consecutive patients with unresectable malignant distal biliary obstruction. All patients underwent endoscopic insertion of our novel stent. Primary endpoint was non-RBO rate 6 months after placement. Results Technical and functional success rates of the procedures were 100%. Six-month non-RBO rate was 50%, and median time to RBO was 184 days. Median survival time was 241 days. Twelve patients died within 6 months after stent placement without RBO. RBO was observed in 10 patients (26%), with seven experiencing stent occlusion and three experiencing stent migration. Adverse events other than RBO (at <30 days) developed in six patients (16%; cholecystitis, one; pancreatitis, one; hyperamylasemia, one; pancreatic ductitis, one; abdominal pain, two). Stent removal for reintervention was successfully completed in eight patients. Conclusion Our novel FCSEMS may be safe and effective for managing malignant distal obstruction with an acceptable incidence of adverse events. [ABSTRACT FROM AUTHOR]

The present review compared unilateral versus bilateral stenting in order to determine the optimal stenting strategy for malignant hilar biliary strictures based on the previous literature. The role of preoperative biliary drainage prior to liver resection for hilar cholangiocarcinoma remains under discussion. However, in Japan, endoscopic placement of single nasobiliary drainage in the future remnant hepatic lobe is currently considered the most suitable method. In most unresectable cases, unilateral stenting appears to be adequate for ameliorating jaundice. It is technically easier and less expensive than bilateral stenting, with reintervention for stent dysfunction also being considerably easier. However, contrast medium injection into undrained bile ducts is associatedwith uncontrolled cholangitis and poor prognosis. To prevent this complication, bilateral stenting may be preferred to unilateral stenting. Additionally, previous studies have demonstrated bilateral stenting to be associated with longer stent patency as compared to unilateral stenting. We consider that further large-scale studies are required to clarify whether unilateral or bilateral stenting is a better therapeutic technique for malignant hilar biliary stricture. [ABSTRACT FROM AUTHOR]

Background: Endoscopic biliary stenting is a well-established palliative treatment for unresectable malignant biliary strictures, for which plastic tube stents (PSs) and self-expandable metallic stents (SEMSs) are most commonly used. The efficacy of these stents has been extensively described in distal biliary strictures, but not in hilar biliary strictures. The present study aimed to compare the efficacy of PSs and SEMSs for unresectable malignant hilar biliary strictures. Methods: From June 2004 to November 2008, 60 patients were enrolled and prospectively randomized into the PS or SEMS group. Results: The 6-month patency rate was significantly higher in the SEMS group than in the PS group (81 vs. 20%; p = 0.0012). Kaplan-Meier analysis showed significantly longer patency in the SEMS group than in the PS group ( p = 0.0002); the 50% patency period was 359 days in the SEMS group and 112 days in the PS group. There was no significant difference in the overall survival period between the PS and SEMS groups ( p = 0.2834). The mean number of reinterventions for stent failures was significantly lower in the SEMS group (0.63 times/patient) than in the PS group (1.80 times/patient) ( p = 0.0008). The overall total cost for the treatment was significantly lower in the SEMS group than in the PS group ( p = 0.0222). Conclusions: SEMSs were associated with a longer patency than PSs in patients with unresectable hilar biliary stricture. SEMSs were also more advantageous in reducing the number of reintervention sessions and the overall treatment cost. [ABSTRACT FROM AUTHOR]

Background and Aim: Currently, endoscopic intervention is widely attempted as the first-line treatment of benign biliary strictures because of its convenience and low morbidity. Plastic tube stents (PS) are usually used for such treatment; however, covered self-expandable metallic stents (C-SEMS) are becoming more commonly used at some institutions. The temporary placement of C-SEMS may lead to better outcomes because of their larger diameter and, therefore, better dilation of the stricture, especially in refractory cases. The aim of the present study was to evaluate the efficacy of the temporary placement of C-SEMS in the management of benign biliary strictures. Methods: We retrospectively reviewed our endoscopic retrograde cholangiopancreatography (ERCP) database (May 1996 to December 2010), and extracted the data of patients who underwent endoscopic treatment for benign biliary strictures. Then, the follow-up data from patient charts were reviewed to determine the long-term outcomes of those procedures. Results: All patients ( n = 56) initially had a PS placed, with or without balloon dilation. However, C-SEMS placement was later attempted in 12 patients because the stricture was refractory to placement of the PS. During their follow-up periods, two patients died of unrelated diseases after 15 and 17 months, and another two still had the C-SEMS in place after 9 and 50 months. In the remaining eight patients, the C-SEMS was removed after a median placement period of 6 months (range, 2-15). Seven patients in this group have not experienced a recurrence at a median follow-up time of 48 months. However, in one patient, stenosis did recur 8 months after the C-SEMS was removed. Conclusions: Temporary placement of C-SEMS can be a treatment option for benign biliary strictures, especially in refractory cases. [ABSTRACT FROM AUTHOR]

Background: Various types of self-expandable metallic stents (SEMSs) are commercially available. However, few reports have compared the performance of the various SEMSs. In addition to long-term patency, maneuverability during initial placement and feasibility of re-intervention for the stent occlusion are also very important. Methods: In this retrospective analysis, we compared the duration of stent patency and frequency of re-interventions in 96 patients diagnosed with unresectable hilar biliary strictures in whom initial 10-mm SEMSs were inserted between June 1999 and November 2008. Results: Based on Kaplan-Meier curves, significantly shorter patency duration was noted for SEMSs with moderate axial force (AF) than for other groups of SEMSs with low AF. Endoscopic re-interventions for SEMS occlusion were easier in a group of SEMSs with low AF and large cell width than in other groups of SEMSs. Conclusions: With respect to patency duration and the frequency of re-intervention required, we consider that SEMSs with low AF and large cell width are favorable for hilar biliary strictures. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) has recently become popular. However, this technique has not yet been standardized, and the available instruments have not been sufficiently developed. Therefore, it is difficult to determine the treatment strategy and the choice of devices. Aims: To evaluate the current status of EUS-PPD. Methods: Between May 2001 and February 2008, EUS-PPD was attempted in 26 patients. Initially, an external drainage was placed, which was replaced with an indwelling tube in cases where the discharge continued more than 2 weeks. The early and late outcomes of EUS-PPD were retrospectively analyzed. Results: Placement of a naso-cystic drainage was successful in 24 (92%) of the 26 patients. Insertion of the drainage tube failed in other 2 patients due to a thickened cystic wall. The pseudocyst was completely resolved after the placement in 23 patients, while the remaining patient underwent a surgical operation. Discharge of the cystic fluid was stopped and the naso-cystic tube was removed in 12 patients after a median duration of 14.5 days. In the remaining 11 patients, it was replaced with indwelling tubes due to continuous discharge after 2 weeks. Thereafter, the indwelling tubes were removed in all cases after a median duration of 4 months. Recurrence of the pseudocyst occurred in 4 patients during a median follow-up period of 48 months. All 15 patients without cystic infection were successfully treated by EUS-PPD, and 9 (60%) of them were treated by only an external drainage. On the other hand, one patient (11%) failed treatment by EUS-PPD and 5 patients (56%) required subsequent internal drainage among the 9 patients with cystic infection. Conclusions: Endoscopic ultrasound-guided pancreatic pseudocyst drainage is a promising treatment for a pancreatic pseudocyst. However, the insertion of the tube is difficult in cases with a thickened cystic wall. Infected pseudocysts are often difficult to treat by only short-term external drainage, thus additional treatments should be considered at an early stage. [ABSTRACT FROM AUTHOR]

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 < 0.0001). Moreover, the liver function 6 months after RFA was also better preserved in the ICSP group according to Child–Pugh grading, thus resulting in a better clinical outcome. Conclusions: ICSP through a nasobiliary tube is a potential intervention method to prevent biliary injury by percutaneous RFA. [ABSTRACT FROM AUTHOR]

Nonobese diabetic (NOD) mice, a model of type I diabetes mellitus, harbor certain unique defects in their immune system. The aim of this study was to investigate how NOD mice show hepatic injury and subsequent fibrogenic responses. Methods: Hepatic fibrosis was induced by intraperitoneal injections of dimethylnitrosamine (DMN), and assessed biochemically and histologically. Expressions of cytokine messenger RNA (mRNA) in the liver were determined. Results: In a model of liver cirrhosis induced by dimethylnitrosamine (DMN), we found that NOD mice had lower levels of hepatic fibrosis and better survival than control ICR mice. The resistance to DMN-induced lethality in NOD mice was independent of apoptosis and necrosis of hepatocytes, but apparently due to the prevention of hepatic fibrosis. We also found increased inductions of interferon-γ (IFN-γ) mRNA in the liver of NOD mice and of intracellular IFN-γ from intrahepatic T cells following DMN administration. Treatment with neutralizing anti-IFN-γ-antibody cancelled the inhibition of hepatic fibrosis in NOD mice. Conclusions: These results suggest that IFN-γ is effective for inhibiting hepatic fibrosis and that genetic host factors may be important in determining differential responses to injury. [ABSTRACT FROM AUTHOR]

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. The charts of 22 consecutive patients with benign biliary stricture treated endoscopically at our institutions between December 1995 and December 2002 were analyzed retrospectively. 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. 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The consensus‐based TOKYO criteria were proposed as a standardized reporting system for endoscopic transpapillary biliary drainage. The primary objective was to address issues arising from the inconsistent reporting of stent outcomes across studies, which has complicated the comparability and interpretation of study results. However, the original TOKYO criteria were not readily applicable to recent modalities of endoscopic biliary drainage such as biliary drainage based on endoscopic ultrasound or device‐assisted endoscopy. There are increasing opportunities for managing hilar biliary obstruction and benign biliary strictures through endoscopic drainage. Biliary ablation has been introduced to manage benign and malignant biliary strictures. In addition, the prolonged survival times of cancer patients have increased the importance of evaluating overall outcomes during the period requiring endoscopic biliary drainage rather than solely focusing on the patency of the initial stent. Recognizing these unmet needs, a committee has been established within the Japan Gastroenterological Endoscopy Society to revise the TOKYO criteria for current clinical practice. The revised criteria propose not only common reporting items for endoscopic biliary drainage overall, but also items specific to various conditions and interventions. The term “stent‐demanding time” has been defined to encompass the entire duration of endoscopic biliary drainage, during which the overall stent‐related outcomes are evaluated. The revised TOKYO criteria 2024 are expected to facilitate the design and reporting of clinical studies, providing a goal‐oriented approach to the evaluation of endoscopic biliary drainage. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]