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Background Recently, a new digital cholangiopancreatoscopy (DCPS) has been developed. The aim of this study is to retrospectively evaluate the utility of new DCPS in patients with pancreaticobiliary diseases. Methods Digital cholangiopancreatoscopy was used in 26 patients (16 men) with pancreaticobiliary diseases that could not be diagnosed and treated by standard endoscopic retrograde cholangiopancreatography (ERCP). The procedures included DCPS-guided tissue sampling and interventions. Technical success and adverse events were evaluated. Results Among the 26 patients, 19 patients were classified for diagnostic purposes and seven for therapeutic purposes. The detailed breakdown of the particular conditions and numbers of patients was as follows: indeterminate bile duct (BD) lesion, indeterminate pancreatic duct (PD) lesion, lithotripsy by yttrium aluminum garnet-laser or electrohydraulic lithotripsy, removal of migrated BD stent and PD stent, and guidewire passing across the biliary stricture. The overall technical success rates of visualizing the target lesions and therapeutic interventions were 100% and 85.7%, respectively. The incidence of procedure-related adverse events among the patients was 7.7% (2/26). Cholangitis developed in one of the patients and post-endoscopic sphincterotomy bleeding in one patient. All adverse events were successfully treated by conservative therapy. Conclusion Digital cholangiopancreatoscopy has a high potential for providing an accurate diagnosis and facilitating therapy in patients with pancreaticobiliary diseases.

Background and Aim Endoscopic sphincterotomy (ES) combined with large balloon dilation (ESLBD) can be useful for extracting large and multiple bile duct stones. Although there are many studies on the feasibility and short-term outcome, there are few reports about mid- to long-term outcome after ESLBD. The aim of our study is to prospectively evaluate the mid-term outcome of ESLBD. Methods One hundred eighty-three patients who underwent ESLBD between November 2006 and May 2012 were included. The patients were followed up periodically after the procedure until April 2013. Papillary dilation was performed at the time of initial ES or prior ES. Early and late adverse events and stone recurrence were evaluated in this study. Results The patients' mean age was 76.6 ± 10.7 years. Surgically altered anatomy was present: Billroth I gastrectomy (2), Billroth II gastrectomy (13), and gastrectomy with Roux-en Y reconstruction (18). Seventy-eight (42.6%) patients had periampullary diverticulum. Prior ES had been performed in 40 (21.9%) patients. The mean follow-up period was 43.5 ± 19.7 months (range 11–78). Eight (4.4%) patients had stone recurrence. There was rare stone recurrence after initial ESLBD treatment and native gastrointestinal anatomy. Univariate and multivariate analyses showed that prior ES and previous history of stone recurrence were predictive of stone recurrence (P

Recently, a novel fully covered and biflanged metal stent (BFMS)dedicated to the drainage of walled-off necrosis(WON) was developed. The aim of this study was to retrospectively evaluate the safety, efficacy, and cost performance of drainage of WON using the novel BFMS compared with a traditional plastic stent.A total of 70 patients with symptomatic WON were treated under endoscopic ultrasound (EUS) guidance. Initial drainage was conducted using the single gateway technique with placement of one or more plastic stents or a single BFMS.If drainage was unsuccessful,direct endoscopic necrosectomy (DEN)was performed.There were no statistically significant differences in rates of technical success, clinical success,and adverse events between plastics stents and BFMS, despite the size of WON in the BFMS group being significantly larger than that in the plastic stent group (105.6 vs. 77.1 mm; P=0.003).The mean procedure times for the first EUS-guided drainage and for re-intervention were significantly shorter in the BFMS group than in the plastic stent group (28.8±7.1 vs. 42.6±14.2, respectively,for drainage, P0.001; and 34.9±8.5 vs.41.8±7.6, respectively, for re-intervention, P0.001). There was no statistically significant difference in the total cost between plastic stent and BFMS use in the treatment of WON ($5352vs. $6274; P=0.25).Plastic stents and BFMS were safe and effective for the treatment of WON. In particular,BFMS placement appeared to be preferable for initial EUS-guided drainage and additional reintervention(e.g. DEN) as it reduced the procedure time. Prospective randomized controlled trials are warranted.

Minimally invasive interventions for choledocholithiasis are preferable in elderly patients because they tend to have multiple underlying disorders or a decreased activity of daily living. Endoscopic sphincterotomy and endoscopic papillary balloon dilation have been recognized as first-line treatments for choledocholithiasis excluding difficult cases such as large stones or multiple stones. Recently, the safety and efficacy of endoscopic papillary large balloon dilation (EPLBD) for difficult choledocholithiasis cases have been reported, although scarcely in elderly patients. To investigate whether EPLBD can be safety and effectively performed in patients aged 75 years or older. The medical records of 165 patients who underwent EPLBD from November 2006 to August 2013 were analyzed retrospectively. The patients were divided into 2 groups: Group A (≥75 years); Group B (

Background and Aims Pancreatic duct guidewire placement (P-GW) techniques include both the injection cannulation technique with a contrast medium and wire-guided cannulation without contrast injection for selective biliary cannulation; the latter is the so-called “double-guidewire technique” (D-GW). The aim of this study was to compare the outcomes between P-GW and D-GW for biliary cannulation. Methods The procedures for biliary cannulation with a naive papilla were performed in a total of 363 cases. We divided the patients chronologically, according to the time period during which the procedures were performed, into two groups: group A, P-GW performed from March 2008 to June 2009; and group B, D-GW performed from July 2009 to December 2010. The success rates and complication rates were evaluated in each group. Results Biliary cannulation was successful in 31 (81.6%) patients in the P-GW group and 34 patients (82.9%) in the D-GW group. The onsets of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) occurred in the P-GW and D-GW groups were four (10.5%) and three (7.3%) patients, respectively, and all were mild cases (P = 0.616). The frequency of hyperamylasemia and the serum amylase level tended to be lower in the D-GW group than in the P-GW group (P = 0.213). There was a statistically significant difference on the onsets of PEP in the GW and non-GW groups (P = 0.04, 8.9% and 1.1%, respectively). Conclusions Both the D-GW and P-GW techniques were equally effective for difficult biliary cannulation. Furthermore, the complication rates, including PEP, were similar in both techniques. A prospective randomized trial is warranted.

Endoscopic ultrasonography-guided (EUS)-guided pancreatic interventions have gained increasing attention. Here we review EUS-guided pancreatic duct (PD) access techniques and outcomes. EUS-guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS-guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS-guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS-PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been carried out as an alternative to the percutaneous or surgical approach when endoscopic retrograde cholangiopancreatography fails. However, there is no standard technique or device for EUS-BD. In this review, we focus on how we choose the stents and described our tips on this EUS-BD technique. The plastic stent (PS) and the self-expandable metallic stent (SEMS) are used for EUS-BD. The latter is further divided into the fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and uncovered SEMS (UCSEMS) types. Although PS is not expensive, the duration of stent patency is short. SEMS is expensive but the duration of stent patency is long. With UCSEMS, basically there is no stent malpositioning; however, if the gap between the bile duct and the GI tract becomes displaced, bile leakage from the mesh of the stent is likely to occur. Though there is no bile leakage with FCSEMS, the side branch of the bile duct may become occluded, and migration and dislocation sometimes occur. PCSEMS is basically similar to FCSEMS. When EUS-BD was first developed, drainage by PS was common, although reports on drainage by SEMS have increased recently.

Traditionally, either surgical or percutaneous drainage is recommended for liver abscess. Recently, several endoscopists have reported the endoscopic ultrasound (EUS)-guided liver abscess drainage. Herein, we report a case of tuberculous liver abscess in which endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was useful for the diagnosis and therapy. A 78-year-old woman suffered from continuous epigastric pain and fever up. Computed tomography (CT) showed a 70 mm multilocular and multiseptate cystic lesion around the head of pancreas and caudate lobe of the liver. After confirming liver abscess by EUS-FNA, EUS-guided liver abscess drainage was carried out. Finally, a 7 Fr straight stent and a 5 Fr nasocystic catheter were inserted into the cyst. Four weeks later, we found that cultured microorganism obtained using drainage catheter was Mycobacterium tuberculosis. Although he was doing well during 5 days after the procedure, CT showed the size of another abscess increased. Then, additional EUS-guided abscess drainage was carried out at the body of the stomach into the abscess of the left lobe. Two weeks later, CT showed disappearance of abscesses. Then, she discharged with the internal stent still in place.

Pancreatic carcinoma has one of the poorest prognoses among malignant tumors. Many pancreatic carcinoma patients who undergo common treatments, such as surgery, radio-chemotherapy and chemotherapy, gained little benefit because of the histological characteristics.HIFU is a new technique of noninvasive treatment for unresectable pancreatic carcinoma. HIFU has the ability to ablate the deep tissues inside body from an external source using high-intensity focused ultrasound. The effects of HIFU can result in cell destruction and tissue necrosis.Results from study in China in 251 patients with advanced pancreatic carcinoma suggested that HIFU treatment could reduce the size of tumors without causing complications and prolong survival. Moreover, according to some reports from China, HIFU treatment is suggested to be useful as the one of palliative treatments for unresectable pancreatic carcinoma. Our case of HIFU therapy for pancreatic carcinoma is presented including pathological findings in this paper. The results suggested that HIFU treatment might be effective in controlling local tumor.HIFU therapy may have the possibility of becoming one of the combination therapies for treating pancreatic carcinoma in the future.

Self-expandable metallic stent (SEMS) placement is a widely used, effective therapy for unresectable malignant stricture of the lower bile duct.We evaluated the short-term outcome of the newly developed WallFlex(®) Biliary RX Partially Covered Stent in patients with malignant lower and middle biliary stricture in five tertiary referral centers.The subjects of this study were 52 patients in whom WallFlex(®) Biliary RX Stents were inserted into the bile duct for malignant stenosis of the middle and lower bile duct at five medical facilities between April 2009 and November 2009.The stent placement success rate was 100%. Effective biliary decompression was achieved in all patients. The incidence of early complications was 7.7% (4/52). Stent occlusion occurred in two patients (3.8%) (one dislocation, one migration); cholecystitis occurred in two patients (3.8%). Neither acute pancreatitis nor stent kinking in the bile duct occurred.The present results revealed that the new WallFlex(®) Biliary RX Partially Covered SEMSs were useful for the short-term relief of biliary obstruction due to unresectable distal biliary malignancies.

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as an alternative drainage method in patients with acute cholangitis. Here, we describe two successful EUS-GBD cases and review the literature on this topic.EUS-GBD was conducted using a curved linear array echoendoscope and a 19-gauge needle.A 7-Fr double pigtail stent was successfully placed transgastrically in one patient and transduodenally in the other patient, without any serious early adverse events in either patient. No late complications or relapse of acute cholecystitis have been seen during the 3- to 6-month follow-up period.EUS-GBD holds high potential as an alternative gallbladder decompression procedure. However, because current experience is limited, multicenter trials for the accurate evaluation of this procedure appear to be necessary in the near future.

Extraction of large bile duct stones in patients who have undergone a Billroth II (B-II) gastrectomy can be challenging. Recently, a large balloon dilation performed after endoscopic sphincterotomy (ESLBD) was useful for the removal of large bile duct stones. The aim of our study was to evaluate the feasibility and safety of ESLBD for removal of bile duct stones in patients who have undergone a B-II gastrectomy. ESLBD for removal of bile duct stones were performed in 11 patients with a B-II gastrectomy at Tokyo Medical University Hospital. Immediately after EST, a large balloon catheter (maximum diameter 15 mm, 18 mm, or 20 mm) was passed over the guide-wire and positioned across the main duodenal papilla. Maximum stone size (short diameter) ranged from 7 to 30 mm with a median of 13.5 mm. The number of stones was 1-26 with a median of 4.8. The common bile duct diameter was 10 mm to 30 mm with a median of 18.1 mm. A mechanical lithotripter for crushing stones was used in two patients (18%). Papillary balloon dilation using variously sized balloons was performed in addition to endoscopic sphincterotomy. Complete clearance of bile duct stones was achieved in all cases at one session. There were no procedure-related adverse events such as acute pancreatitis or retroperitoneal perforation. ESLBD appears to be an effective and safe treatment for removal of difficult bile duct stones in patients who have undergone a B-II gastrectomy.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage method in patients with obstructive jaundice. EUS-BD is divided into EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD). The aim of this review is to focus on the current status and limitations of EUS-BD. A systematic review was performed to evaluate EUS-BD. MEDLINE, EMBASE and manual searches were performed to identify the pertinent English language full articles. The high success rate without fatal adverse events for EUS-CDS (93%; 28/30) and EUS-HGS (97%; 28/29) suggest the feasibility and safety of the procedures in high-volume endoscopic centers adopting various procedural techniques. Although the number of reported cases was very small, the success rate of EUS-GBD was high (100%; 14/14), without serious adverse events. Although all procedures require further assessment in a larger cohort of patients, including comparative studies between EUS-CDS or EUS-HGS versus PTBD, and EUS-GBD versus PTGBD, EUS-BD may be a promising procedure for the treatment of obstructive jaundice. However, dedicated devices for EUS-guided drainage are needed for reliable procedures.

We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones.Retrospective analysis.A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P0.05).ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.

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.

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.

It has been reported that circulating tumor cells (CTCs) can be used to predict survival in metastatic breast cancer. In this preliminary study, we examined the level of CTCs in pancreatic cancer (PC) patients to elucidate whether we could predict survival in PC. The eligible subjects, at Tokyo Medical University Hospital, were 26 patients with PC, 11 with chronic pancreatitis, and 10 healthy volunteers. Three PC patients underwent surgery, 18 patients (who were stage IV) were treated with gemcitabine (GEM), and 5 patients received best supportive care (BSC). The CTC count was 1/7.5 ml blood or higher (defined as positive) in 11 of the 26 patients (42%; mean, 16.9/7.5 ml blood; range, 1-105/7.5 ml blood). Gemcitabine was administered to 6 of the 11 CTC-positive patients (3.8 courses on average). The treatment was continued for more than three courses in 2 patients, in both of whom the CTC count was only 1/7.5 ml blood. Operation was performed in 1 of the 11 CTC-positive patients. The remaining 4 patients of the 11 CTC-positive patients received only BSC. CTC was negative in 15 patients with PC (stage II, 1; stage III, 1; stage IVa, 7; and stage IVb, 6) and in the subjects with benign conditions. The median survival times (MSTs) of the CTC-positive and-negative patients were 110.5 and 375.8 days (P < 0.001). When the analysis was limited to the 14 stage-IVb patients, the MSTs of the CTC-positive and-negative patients were 52.5 and 308.3 days (P < 0.01). The present study demonstrated that the detection of CTCs in peripheral blood may be useful to predict prognosis in patients with PC.

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 P 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.

Post endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis is the most common complication of ERCP, which can occasionally become serious or fatal. This preliminary study was to prospectively evaluate the efficacy of a temporary unflanged pancreatic duct stent (PS) to prevent post-ERCP pancreatitis.A total of 64 patients were randomly divided into a control group, which did not undergo stenting, and a stent group. The stent used was a 5-Fr pigtail PS without an inner flange.Placement of an unflanged PS was successful and without complications in all 32 patients. The rates of hyperamylasemia were 50.0% and 34.4% in the control and stent groups, respectively (P0.05), and the mean serum amylase levels were 456.2 and 257.9 IU/l, respectively (P = 0.035). The overall rates of post-ERCP pancreatitis diagnosed according to Cotton's criteria were 12.5% and 3.1% in the control and stent groups, respectively (P0.05). The severity of pancreatitis was severe in one patient, moderate in one, and mild in two in the control group, whereas in the stent group, the single case of pancreatitis was mild.Placement of an unflanged 5-Fr PS may be useful in preventing post-ERCP pancreatitis.

Aim: To evaluate prospectively the efficacy of endoscopic transpapillary naso-gallbladder drainage (ETGBD) after endoscopic sphincterotomy (ES) in patients with acute cholecystitis with choledocholithiasis. Patients: Twenty-six patients with acute cholecystitis and choledocholithiasis, but without pericholecystic liver abscess, were evaluated. After ES and extraction of stones, ETGBD was performed immediately. Results: In 24 of the 26 patients with ES, complete bile duct clearance was achieved. In the other two cases treated with ES, stones could be completely removed in an additional session after ETGBD. ETGBD was successfully performed in 23 patients (88%). In three patients with unsuccessful ETGBD, a percutaneous cholecystostomy (PC) was performed. Of the 23 patients that underwent ETGBD, a positive clinical response at 72 h was seen in 22 (96%) patients. In one patient who did not show a clinical response at 72 h, catheter drainage was continued and a positive clinical response was seen 5 days after the procedure. In three patients treated with PC, a clinical response at 72 h was seen in all cases (100%). No major procedure-related complications occurred. Conclusions: ETGBD after ES proved useful in the management of acute cholecystitis and choledocholithiasis.

We describe our methods and outcomes of multidisciplinary treatments in patients with unresectable hilar cholangiocarcinoma. Fifty-seven patients with a known outcome were enrolled. Thirty-four of 57 patients were treated and evaluated by salvage therapy. For salvage therapy, we used internal and external radiotherapy, photodynamic therapy, YAG laser therapy and microwave coagulation therapy. The median survival time was 548 days for the group receiving salvage therapy and 198 days for the group not receiving this treatment. In conclusion, although no randomization of the patients was performed in this retrospective study, our present data provide convincing evidence that salvage therapy is a useful therapeutic approach for unresectable hilar cholangiocarcinomas.

Endoscopic nasobiliary drainage (ENBD) plays an important role in the treatment of patients with obstructive jaundice. Nowadays, ENBD is widely performed for not only biliary drainage, but also for gallbladder, pancreatic duct, and pancreatic cyst drainage. Herein is presented the indications for ENBD and its technique.

F s h Urakami et al1 first reported a peroral direct cholangiosopy (PDCS) procedure 3 decades ago. Recently, PDCS using ltraslim upper endoscopes has been described for diagnosic and therapeutic purposes.2-9 However, those endoscopes re not dedicated cholangioscopes. This is the first report of he use of a dedicated prototype peroral direct cholangiocope to fragment a difficult bile duct stone.

Wire-guided cannulation has become a common biliary cannulation technique worldwide. Different guidewires with various tip shapes and materials have been reportedly used for wire-guided cannulation. However, there are apparently no studies reporting changes in the biliary cannulation rate according to the type of guidewire used. We evaluated the effectiveness of the J-tip guidewire for biliary cannulation. We conducted a prospective, multicenter, controlled study involving patients with a native papilla who required biliary cannulation. We allocated the patients to the J-tip guidewire or angled-tip guidewire groups (groups J and A, respectively). If biliary cannulation was not achieved within 10 min, the GW was changed and cannulation was continued. Groups J and A consisted of 66 and 65 enrolled patients, respectively. The biliary cannulation rate with a single guidewire for the first 10 min was 84.8 % (56/66) for group J and 80.0 % (52/65) for group A. The final success rate for biliary cannulation was 100 % in both groups. The mean times necessary for biliary cannulation were 285.8 and 267.6 s in group J and group A, respectively. The incidence rates of complications (i.e., all mild pancreatitis) were 3.0 % (2/66) and 6.2 % (4/65) in group J and group A, respectively. The mean amylase concentrations were 168.0 and 297.7 IU/L in group J and group A, respectively. There were no significant differences in any results between both groups. The biliary cannulation rate of the J-tip guidewire was not significantly different from those of standard guidewires.

To evaluate the safety and clinical application of high-intensity focused ultrasound (HIFU) therapy for unresectable pancreatic cancer (PC).Thirty PC patients (16 cases in stage III and 14 cases in stage IV) with visualized pancreatic tumors were admitted for HIFU therapy as an optional local therapy in addition to systemic chemotherapy or chemoradiotherapy. Informed consent was obtained. This study began at the end of 2008 and was approved by the ethics committee of our hospital [Institutional Review Board (IRB): 890]. The HIFU device used was the FEP-BY02 (Yuande Bio-Medical Engineering, Beijing, China).The mean tumor size after HIFU therapy changed to 30.9 ± 1.7 mm from 31.7 ± 1.7 mm at pre-therapy. There were no significant changes in tumor size, mean number of treatment sessions (2.7 ± 0.1 mm), or mean total treatment time (2.4 ± 0.1 h). The rate of symptom relief effect was 66.7%. The effectiveness of primary lesion treatment was as follows: complete response, 0; partial response, 4; stable disease, 22; progressive disease, 4. Treatment after HIFU therapy included 2 operations, 24 chemotherapy treatments, and 4 best supportive care treatments. Adverse events occurred in 10% of cases, namely pseudocyst formation in 2 cases and mild pancreatitis development in 1. However, no severe adverse events occurred in this study.We suggest that HIFU therapy is safe and has the potential to be a new method of combination therapy for PC.

Recently, several endoscopists have described the usefulness of the endoscopic ultrasonography (EUS)-guided, single transluminal gateway technique (SGT) using transmural placement of single or multiple plastic stents or metal stents for a pancreatic pseudocyst (PC) and walled-off necrosis (WON). Moreover, the uses of the multiple transluminal gateway technique (MTGT) and single transluminal gateway transcystic multiple drainages (SGTMD) for complicated pancreatic walled-off necrosis have recently been reported. The aim of this study is to evaluate retrospectively the feasibility and efficacy of endotherapy for the treatment of complicated PC and WON cases.Eighty-nine patients with a PC (n = 14) and WON (n = 75) were treated under EUS guidance.In a total of 89 cases using SGT in combination with MTGT or SGTMD, the present study showed a technical success rate of 100 %, a final clinical success rate of 97.8 %, an adverse event during procedure rate of 0 %, an early adverse event rate of 12.4 %, and a mortality rate of 2.2 %.Even complicated WON cases can be treated using combination endotherapies, although a surgical approach as well as a percutaneous approach should be considered in the cases refractory to endoscopic therapies.

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux-en Y (R-Y). A 73-year-old man who had total gastrectomy with R-Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre-cutting, the ultraslim endoscope was replaced with a conventional forward-viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure-related complication.

To date, several endoscopic ultrasonography (EUS)-guided interventions have been reported. Of these interventions, EUS-guided pancreatic duct (PD) intervention seems to be the most difficult and challenging procedure to accomplish. We provide suggestions for EUS-guided PD intervention, which includes PD stenting and the rendezvous technique following EUS-guided pancreatography. PD stenting is performed between the PD and the gastrointestinal tract (stomach, duodenum, or jejunum). The rendezvous technique is performed using a guidewire across the papilla or anastomotic site for retrograde stent insertion. EUS-guided PD intervention is still challenging because it is not established yet. Thus, although EUS-guided PD intervention seems to be promising, it should be performed in selected patients such as those of failed standard endoscopic retrograde cholangiopancreatography.

Background Although peroral direct cholangioscopy (PDCS) is emerging as an alternative to traditional mother-daughter cholangioscopy, it is associated with high failure rates. The aim of the present study was to evaluate the ability to insert and carry out interventions using a prototype multi-bending PDCS. Patients and Methods Prospective, observational clinical feasibility study was done in 41 patients with a variety of biliary diseases. A multi-bending PDCS prototype was inserted using a free-hand technique, a guidewire alone, or with a 5-Fr diameter anchoring balloon. Diagnostic and therapeutic procedures were carried out. Results The free-hand direct insertion technique failed in all attempted cases (n = 7). Of the remaining 34 cases, successful rate of PDCS insertion into the distal bile duct was achieved by passing the PDCS over a guidewire alone (n = 6) and/or with a guidewire plus anchoring balloon (n = 28) for an overall successrate of 88.2% (30/34). In 13 (92.9%) patients without an underlying biliary stricture, PDCS insertion proximal to the bifurcation was possible. In 25 cases, biliary interventions were attempted including biopsy (n = 13), stone removal (n = 6), stent removal (n = 1), and intraductal electrohydraulic lithotripsy (n = 2) and were successful in 22 (88%). Other than two patients with procedure-related cholangitis with a mild grade of severity, no complications were observed. Conclusions Using a novel multi-bending prototype peroral direct cholangioscope, cholangioscopy had a high diagnostic and therapeutic success rate only when passed over a guidewire and anchoring balloon but not with the free-hand insertion technique. Comparative studies of direct cholangioscopy are warranted.

Background/aims Recently, controllable biopsy forceps (MTW, D°sseldorf, Germany) have been developed. This biopsy forceps were 90° adjustable. In the present study, the feasibility and efficacy of the controllable biopsy forceps were compared with those of conventional biopsy forceps in patients with biliary tract disease. Methodology A total of 27 patients with biliary tract lesions were enrolled. We evaluated the procedure time, the sample tissue size and the diagnostic accuracy. In addition, the physicians performing the procedure rated their impressions about operability into 3 classes: excellent, fair and poor. Results The sensitivity in distinguishing benign from malignant lesions was 71.4% (15/21) for the 90° adjustable type and 66.7% (14/21) for the conventional type. The accuracy rate was 77.8% (21/27) for the 90° adjustable type and 74.0% (20/27) for the conventional type. In terms of operability as rated by each physician, the 'excellent' rate was given more frequently to the 90° adjustable type 25.9% than for the conventional type 11.1% (p=0.047). Conclusions This preliminary study showed that controllable biopsy forceps compared to conventional type biopsy forceps, despite a larger diameter, enables biopsy in a similar procedure time and its ease of use was rated better.

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.

To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents (SEMS).All SEMS had been placed for distal biliary strictures. Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS (one uncovered and 18 covered) removal had been attempted, and 8 patients in whom stent trimming using argon plasma coagulation (APC) had been attempted at Tokyo Medical University Hospital. The APC settings were: voltage 60-80 W and gas flow at 1.5 L/min.The mean stent indwelling period for all patients in whom stent removal had been attempted was 113.7 ± 77.6 d (range, 8-280 d). Of the 19 patients in whom removal of the SEMS had been attempted, the procedure was successful in 14 (73.7%) without procedure-related adverse events. The indwelling period in the stent removable group was shorter than that in the unremovable group (94.9 ± 71.5 d vs 166.2 ± 76.2 d, P = 0.08). Stent trimming was successful for all patients with one minor adverse event consisting of self-limited hemorrhage. Trimming time ranged from 11 to 16 min.Although further investigations on larger numbers of cases are necessary to accumulate evidence, the present data suggested that stent removal and stent trimming is feasible and effective for stent-related complications.

Severe bleeding following endoscopic biliary sphincterotomy (EBS) can sometimes be difficult to manage, resulting in the need for an invasive intervention. The aim of this study was to retrospectively evaluate the feasibility and efficacy of endoscopic hemostasis using covered self-expandable metallic stents (SEMSs) for severe post- EBS bleeding. Eleven patients with bile duct stones underwent standard EBS using a standard sphincterotome-based technique at 4 endoscopic units of a university-affiliated hospital and a general hospital. Monotherapy or combined therapy were used to achieve hemostasis with either balloon tamponade, hypertonic saline epinephrine injection, or endoclip placement. When active bleeding could not be controlled, covered SEMSs were placed across the major papilla. Emergency endoscopy was performed on the day of admission or the subsequent day (ranging from 6 to 35 h after admission). Bleeding was classified as mild in 6 cases (54.5 %) and moderate in 5 (45.5 %). A covered SEMS 10mm in diameter and 6 cm long was placed across the papilla. After placement, complete hemostasis was achieved. The mean duration of stent placement was 8.2 days (range 5–10 days), and the SEMS was successfully removed in all cases. Although the present study has the limitations of a small sample size and lack of control patients, covered SEMS placement for endoscopic hemostasis may be useful in selected patients with uncontrolled post-EBS bleeding.

Magnetic compression anastomosis (MCA) is a revolutionary, minimally invasive method of performing choledochoenterostomy or choledochocholedochostomy without using surgical techniques in patients with biliary stricture or obstruction. Herein, we describe a case series of MCA for severe biliary stricture or obstruction, which could not be treated with conventional therapies. Two patients with biliary obstruction were treated using MCA for choledochocholedochostomy and choledochoenterostomy at Tokyo Medical University Hospital and Tokyo Medical University Hachioji Medical Center. Endoscopically, a samarium–cobalt (Sm–Co) rare-earth magnet was placed at the superior site of obstruction through the percutaneous transhepatic biliary drainage route and another Sm–Co magnet was placed at the inferior site of obstruction. A comprehensive computer-aided literature search for MCA was performed up to September 2009 by using MEDLINE and EMBASE. MCA techniques enabled complete anastomosis in both cases without procedure-related complications. The MCA technique is a revolutionary method of performing choledochocholedochostomy and choledochoenterostomy interventionally in patients with biliary obstruction, for whom the conventional endoscopic procedure is not available, or in candidates who are deemed unsuitable for surgery.

The aim of this study is to evaluate a prototype variable stiffness duodenoscope (VSD) for diagnostic and therapeutic ERCP in comparison with standard duodenoscopes. We performed retrospective analysis on the success rate of intubation of the second duodenum, overall procedural success rate, and comparative frequency of the necessity to change duodenoscopes from standard JF-260V and TJF 260V or to change stiffness using the VSD. A total of 213 nonconsecutive procedures in 196 patients with pancreaticobiliary diseases. There was no statistically significant difference in endoscope intubation rate or technical success rate between the different duodenoscopes. In one patient with severe duodenal stenosis, the VSD using the moderately stiff mode allowed the major papilla to be reached when the TJF-260V endoscope could not. There were no serious procedure-related adverse events. In conclusion, while the VSD performed well, the present models do not appear to offer obvious advantages over the standard duodenoscopes for routine diagnostic and therapeutic ERCP. Prospective studies may be warranted to identify those patients who would benefit from this new technology.

Endoscopic therapy of pancreatic duct (PD) strictures using balloon dilation and pancreatic duct stent (PS) placement has been reported to improve the severity of abdominal pain in selected patients with chronic pancreatitis (CP). However, some strictures are refractory and require frequent PS exchange to control symptoms. We describe two cases of successful endoscopic PD incision for difficult PD stricture using a wire-guided snare. The snare is partially opened within the strictured pancreatic duct while applying current, thus incising the duct. Although both cases were successful without complications we do not advocate that this method be used routinely because of the potential for severe complications, e.g. bleeding, ductal perforation or pancreatic parenchymal damage. In order to prevent these complications, we developed a wire-guided technique under fluoroscopic control. We think this procedure may be useful in patients with short, straight PD strictures. Although further study is required, this approach may have potential for selected patients with refractory PD strictures due to CP.

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.

The acute angulation of Roux-en-Y (R-Y) limb precludes endoscopic access for endoscopic retrograde cholangiopancreatography (ERCP) even using a balloon enteroscopy. Here, we describe a case of successful single balloon enteroscopy (SBE)-assisted ERCP using a rendezvous technique in a patient with sharply angulated R-Y limb in a 79-year-old woman who had bile duct stones. Method. At first, a guidewire was passed antegradely through the major papilla after the needle puncture using percutaneous transhepatic biliary drainage technique. A hydrophilic guidewire with an ERCP catheter was antegradely advanced beyond the Roux limb. After a guidewire was firmly grasped by a snare forceps, it was pulled out of the body, resulting that the enteroscope could advance to the papilla. After papillary dilation, complete removal of bile duct stones was achieved without any procedure-related complication. In conclusion, although further study is needed, SBE-assisted ERCP using a rendezvous technique may have a potential for selected patients.

The aim of this study was to evaluate the usefulness of single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy (B-II) or Roux-en-Y anastomosis (R-Y).Thirteen SBE procedures were performed in 2 patients with B-II and 11 patients with R-Y at Tokyo Medical University Hospital. SBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. This is a retrospective cohort study.In all cases but one (92.3%, 12/13), the papilla or anastomotic site could be reached with the SBE. The rate for B-II and R-Y were 100% (2/2) and 90.9% (10/11), respectively. The mean time required to reach the papilla or anastomotic site was 33.3 min (range, 5-86 min). In cases of R-Y, the mean time required to reach the papilla or anastomotic site was 35.5 min (range, 12-76 min). The overall success rate of the therapeutic ERCP on the first session was 76.9% (10/13). In patients with an intact papilla, the success rate on the first session was 72.3% (8/11). With regard to the type of surgery, the success rate of the procedure in patients with B-II and R-Y was 100% (2/2) and 72.3% (8/11), respectively. The mean procedural time for 10 successful groups on the first session was 66.4 min (range, 25-152 min). No adverse events occurred.SBE-assisted ERCP using an overtube-assisted technique appears to be promising for performing therapeutic ERCP in patients with B-II or R-Y.

Background There have been a few previous reports on attempted double-balloon endoscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis and an intact papilla. This study was designed to evaluate the usefulness of DBE-assisted ERCP in patients with Roux-en-Y anastomosis and an intact papilla of Vater. Methods Thirteen DBE procedures were performed in nine patients who had undergone Roux-en-Y reconstruction combined with eight total gastrectomies and one partial gastrectomy. Both short-type and long-type DBE were used. Long-type DBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. Technical success rate, measurement of procedure times, and adverse events were evaluated in the retrospective study. Results In all cases, the scopes could reach the papilla. The mean time required to reach the papilla was 48 (range, 13–90) min. There was a statistically significant difference with the short and long scope (29.0 ± 19.2 min vs. 64.8 ± 24.7 min, respectively; P = 0.044). The success rate of bile duct cannulation, resulting in achieving therapeutic ERCP on the first session was 66.7% (6/9). The mean procedural time in the successful cases was 128 (range, 47–183) min. Finally, therapeutic ERCP was achieved in all nine cases. There was one adverse event in which retroperitoneal perforation during lithotripsy, but that was successfully treated by conservative therapy alone. Conclusion DBE-assisted ERCP seems to be a promising option to perform therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis.

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.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.Prospective study.This procedure was performed in Tokyo Medical University Hospital.Fourteen consecutive cases of tumors of the major duodenal papilla.All patients underwent EP after evaluation by NBI and IC.Histologic evaluation of diagnosis of NBI and IC by comparison with en bloc tissue.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.The lesions resected were all relatively small. This was not a blinded randomized study.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.

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.

Endoscopic ultrasonography-guided fine needle aspiration biopsy (EUS-FNA) is a safe and accurate procedure for the diagnosis of pancreatic lesions. However, in general, surgically altered anatomy excluding Billroth I gastrectomy is considered a relative contraindication to EUS-FNA. Herein, we described a successful case of EUS-FNA in a patient with prior Billroth II gastrectomy. A 78-year-old man, who had previously undergone Billroth II gastrectomy for duodenal ulcer, undertook EUS-FNA using a curved linear echoendoscope. An echoendoscope was advanced into the duodenum and EUS-FNA could be carried out using a 22-gauge needle without procedure-related adverse event.