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We investigated the presence of occult pancreaticobiliary reflux in patients with a morphologically normal pancreaticobiliary ductal arrangement by measuring biliary amylase levels and compared histopathological findings of the gallbladder between groups with high and low biliary amylase levels.In 178 patients with a normal pancreaticobiliary ductal arrangement who had undergone endoscopic retrograde cholangiopancreatography (ERCP), we sampled bile from the bile duct and measured amylase levels. Then we compared clinical features and histological findings of the gallbladder between high (HALG) and low amylase level groups (LALG).A high biliary amylase level was observed in 25.8% (46/178) of the patients. The prevalence of a high biliary amylase level was high in patients with gallbladder carcinoma (40%) and in those with choledocholithiasis (28.4%). The level of amylase in bile was high in patients with gallbladder carcinoma, adenomyomatosis of the gallbladder, and chronic cholecystitis. A strong correlation between the levels of amylase and lipase in bile and the dominance of amylase of pancreatic origin in bile were confirmed by isozyme analysis. Thickening of the gallbladder mucosa was a significant manifestation in HALG. Histological examination of the gallbladder mucosa showed that incidences of metaplastic change and atypical epithelium and Ki67-LI in were higher in HALG than in LALG.Occult pancreaticobiliary reflux is observed in a considerable number of ERCP candidates. Those who show an extremely high biliary amylase level, at least, may be at high risk for biliary malignancies.

We report a case of superficial bile duct carcinoma showing extensive intraductal spread without dilatation of the bile duct in which diagnosis was established preoperatively by transpapillary forceps biopsy and intraductal ultrasonography. A 78-year-old man was given a diagnosis of acute cholecystitis, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. Cholangiography via the PTGBD tube revealed a tiny irregularity in the hilar bile duct. Transpapillary intraductal ultrasonography showed that this irregularity extended from the intrahepatic bile duct to the middle of the bile duct. Bile duct biopsy revealed malignancy, and thus bile duct resection and hepaticojejunostomy were performed. Histological examination verified a well-differentiated adenocarcinoma confined to the epithelium and the fibromuscular layer.

Background Endoscopic papillectomy is performed in selected patients with ampullary neoplasm, and, thus, accurate preoperative tumor staging is indispensable for its application. Design Prospective and histopathologically controlled study. Setting Single center. Patients and Interventions EUS and transpapillary intraductal US (IDUS) were performed in 40 patients with ampullary neoplasm before surgery (n = 30) or endoscopic papillectomy (n = 10). Ductal infiltration by a tumor into the bile duct (BD) or the pancreatic duct (PD) was also evaluated. The indication for endoscopic papillectomy was determined by findings obtained by EUS and IDUS. These findings were compared with histologic features of the resected specimens. Main Outcome Measurements and Results Thirty-three patients had adenocarcinoma (14 pT1, 11 pT2, 8 pT3-4) and 7 had adenoma. Tumor depiction by EUS and IDUS was achieved in 95% and 100% of the patients, respectively. The diagnostic accuracy of EUS and IDUS in T staging was 62% and 86% in adenoma and pT1, 45% and 64% in pT2, and 88% and 75% in pT3-4, respectively. The overall accuracy by EUS and IDUS in T staging was 63% and 78%, respectively ( P = .14). In 10 patients who underwent endoscopic papillectomy, the accuracy of IDUS in T staging with EUS and IDUS was 80% and 100%, respectively. Ductal infiltration into the BD and the PD was correctly assessed in 88% and 90% by EUS and in both BD and the PD in 90% by IDUS, respectively. Ductal infiltration was correctly diagnosed by EUS and IDUS in all patients who had a papillectomy. Conclusion Although IDUS had a tendency of overestimation in tumor staging for ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for endoscopic papillectomy.

The aim of this study was to evaluate histopathologically the frequency, direction, and length of intraductal spread (IS) along the main pancreatic duct from the main tumor of small pancreatic cancer.Resected specimens from 20 cases of pTS1 (histologically 2 cm or less in diameter) pancreatic cancer (September 1983 to December 2005) were examined histopathologically. As controls, 40 resected specimens from cases of pTS2 (more than 2 cm and less than 4 cm in diameter) or larger sized pancreatic cancer (pTS2or=) were examined in the same manner. The specimens were evaluated histopathologically as to (1) the prevalence of IS, (2) the direction and length of IS, and (3) the positive rates of transpapillary cytology of pure pancreatic juice (TPC) and biopsy of the main pancreatic duct (TPB), performed preoperatively.IS was observed in 45% of pTS1 and 13% of pTS2or= cases. In 88% of cases of pTS1, IS was observed in the direction of the ampullary side. In 40% of cases of pTS2or=, IS toward the ampullary side was seen. The mean length of IS in pTS1 and pTS2or= cases was 11.8 mm and 7.2 mm, respectively. Positive rates of TPC and TPB in pTS1 cases were 70% and 75%, respectively, and in pTS2or= cases, 50% and 44%, respectively.The frequency of IS was high in pTS1 cases, which suggests there is potential for improvement in establishing the histocytological diagnosis of small pancreatic cancer via the transpapillary approach with the development of adequate tools.

We investigated the mode of progression of intraductal papillary-mucinous neoplasm of the pancreas (IPMN) in patients who underwent follow-up in order to elucidate the characteristics of malignancy and to establish an effective treatment strategy.Fifty-one patients with IPMN (branch-duct type, 47; main-duct type, 4) who had undergone follow-up study by endoscopic ultrasonography (EUS) were included (mean follow-up duration, 41.0+/-32.3 months; average number of EUS examinations performed during follow-up, 4.4). Chronological changes in EUS findings and histological findings of resected specimens were evaluated.Of the patients with the branch-duct type, only 2% showed enlargement of the dilated branches. In the main-duct-type group, an increase in size of the main pancreatic duct (MPD) was observed in 75% of the patients. In 14 patients with papillary protrusions, an increase in size and lateral spread was observed in 71% and 43%, respectively. No patients developed invasive cancer. In 15 patients who had thick septum-like structures (TSS), the development of papillary protrusions and that of invasive cancer were observed in 53% and 13%, respectively. Twenty-nine patients who had thin septum-like structures showed no change. Two patients with dense multilocular large cysts and TSS developed invasive cancer without change in the cystic lesions. One patient developed carcinoma with multifocal stromal invasion.Patients with branch-duct type IPMNs without papillary protrusions or TSS are not immediate candidates for surgery. Those who have small papillary protrusions have a benign course. It is recommended that patients with the large branch-duct type with TSS should undergo surgery. Attention should be paid to the entire pancreas when performing follow-up examinations in patients with branch-duct type IPMN, as invasive ductal adenocarcinoma can develop at a site in the pancreas different from that of the IPMN.

This study was performed to determine and compare the effectiveness and incidence of complications of percutaneous cholecystostomy and gallbladder aspiration in cases of severe acute cholecystitis. SUBJECTS AND METHODS. Fifty-eight patients with severe acute cholecystitis who did not improve after antibiotic treatment were included in this study. The patients were randomized into either the percutaneous cholecystostomy group (n = 30) or the gallbladder aspiration group (n = 28). Under sonographic guidance, percutaneous cholecystostomy was performed in the usual manner using a 6.5- or 7-French catheter. Gallbladder aspiration was carried out with a 21-gauge needle under sonographic guidance. The technical success, clinical response, and complications in each group were evaluated.Percutaneous cholecystostomy and gallbladder aspiration were technically successful in 30 patients (100%) and 23 patients (82%), respectively (not statistically significant). In five patients (18%) of the gallbladder aspiration group, aspiration was unsuccessful because of replacement of bile with dense biliary sludge or pus. Good clinical response was obtained in 27 patients (90%) of the percutaneous cholecystostomy group and in 14 patients (61%) of the gallbladder aspiration group (p0.05). As for complications, dislodgment of the catheter occurred in one patient of the percutaneous cholecystostomy group and minor bleeding in one patient after gallbladder aspiration. No major complications or procedure-related deaths occurred in either group.For severe acute cholecystitis, percutaneous cholecystostomy was superior to gallbladder aspiration in terms of clinical effectiveness and had the same complication rate as gallbladder aspiration.

We herein report a case of pancreatic serous cystadenoma in a patient who presented with jaundice, and we provide a review of the literature. A 53-year-old man was admitted with complaints of jaundice and weight loss. With a preoperative diagnosis of pancreatic serous cystadenoma with obstructive jaundice, he underwent pylorus-preserving pancreatoduodenectomy. A cystic tumor partially protruding into the bile duct was observed in the pancreatic head. Histology verified serous cystadenoma of the pancreas. Histologically, no atypia was proven in the epithelium. There have been only eight case reports dealing with serous cystadenoma of the pancreas with obstructive jaundice. Although serous cystadenoma of the pancreas has essentially a benign nature, pylorus-preserving pancreatoduodenectomy is the treatment of choice when available to avoid the recurrence of obstructive jaundice.

Background: Some patients with autoimmune pancreatitis (AIP) suffer from disease progression during follow-up with no medication or from relapse after steroid treatment. Aim: To elucidate the proportion of patients with AIP showing disease progression or relapse and its predictive factors. Patients: Thirty-eight patients with AIP based on HISORt criteria from 1988 to 2010 were included in this study. Results: Of the 38 patients, 10 with histologically confirmed AIP after resection were followed-up conservatively with no medication. One patient (10%) developed relapse of AIP in the remnant pancreas. Of the other 28 patients, 14 were followed up without surgery or medication (median follow-up period: 1525 days), 2 of which (14.3%) showed disease progression and received steroid treatment. The remaining 14 patients received steroid treatment (initial dose: 30-60 mg/day) because of symptoms, and all of them achieved remission. In 7 of these 14 patients, steroid treatment was stopped (period to discontinuance of the treatment: 23-1366 days), and 4 of these 7 (57.1%) developed relapse (period to relapse: 19-737 days). The remaining 7 patients received maintenance treatment with low-dose steroid (period of maintenance treatment: 155-2749 days), 1 of which (14.3%) developed relapse after 265 days from initial steroid administration. Sex, age, diabetes mellitus (DM), icterus, serum IgG4 level, diffuse pancreatic swelling, other organ involvement (OOI), steroid treatment, and maintenance treatment with low-dose steroid were investigated with univariate analysis in 30 patients of AIP who had been followed up for more than 6 months to evaluate the predictive factors for disease progression or relapse, the results being as follows: male (p=0.623, OR: 1.1, 95%CI: 0.2-7.5), age less than 70 y.o. at onset (p=0.004), icterus (p=0.288, OR: 3.3, 95%CI: 0.3-32.3), DM (p=0.659, OR: 1.0, 95%CI: 0.2-5.0), serum IgG4 level >500 mg/dl (p=0.651, OR: 1.1, 95%CI: 0.28.1), diffuse pancreatic swelling (p=0.223, OR: 2.9, 95%CI: 0.5-16.4), OOI (p=0.541, OR: 1.4, 95%CI: 0.2-9.2), steroid treatment (p=0.195, OR: 2.9, 95%CI: 0.6-15.6) and maintenance treatment with low-dose steroid (p=0.480, OR: 2.1, 95%CI: 0.2-20.8). Multivariate analysis including age, diffuse pancreatic swelling and steroid treatment, which showed p

Su1438 Efficacy and Safety of a Newly Developed Fully Covered Biliary Metallic Stent in Comparison With the Partially Covered WallFlex Biliary RX Stent for Unresectable Malignant Biliary Stricture Takahisa Ogawa, Kei Ito, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Takashi Obana, Jun Horaguchi, Shinsuke Koshita, Yoshihide Kanno Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and aim: Endoscopic self-expandable metallic stent (SEMS) placement is widely accepted as a palliative therapy in patients with unresectable malignant biliary stricture. Although a covered SEMS has been reported to have a longer stent patency than an uncovered SEMS, complications such as stent migration and kinking of the bile duct can occur after deployment. A newly developed fully covered biliary metallic stent (ZEOSTENT Covered (ZEO), Zeon Medical Inc., Tokyo, Japan) which has an uneven outer surface, a low shortening ratio, and a low axial force might reduce such complications. The aim of this study was to evaluate the efficacy and safety of this new covered biliary stent in comparison with the partially covered WallFlex Biliary RX Stent (Wall) (Boston Scientific, Co., Ltd., Natic, MA, USA). Patients and methods: Between March 2010 and November 2010, endoscopic placement of a ZEO was performed in 24 patients (mean age, 77 10 yrs; 10 males, 14 females) with unresectable malignant biliary stricture. Fifteen patients had pancreatic cancer, 4 had bile duct cancer, 2 had gallbladder cancer, 2 had ampullary cancer and 1 had lymph node metastases from other cancers. Main outcome measurements were success rate of the procedure, early complications, late complications, and stent patency. Early complications were defined as those which occurred within 3 days after stent placement. Such data were compared with those of 24 patients (mean age, 75 12 yrs; 13 males, 11 females) who had undergone endoscopic placement of a Wall between April 2009 and July 2010. Results: Mean follow-up duration of the ZEO group and the Wall group were 77 days and 124 days, respectively (P 0.024). Stent placement was successful and improvement of jaundice was obtained in all patients of both groups. ZEO and Wall were transpapillarily placed in 18 and 22 patients, respectively. Transduodenal and transgastric stent placement utilizing the endosonography-guided biliary drainage route was performed in 5 and 2 patients, respectively. Early complications occurred in 1 patient in the ZEO group (pancreatitis, 1) and in 4 in the Wall group (pancreatitis, 3; cholecystitis,1) (P 0.17). Late complications occurred in 5 patients of the ZEO group (stent occlusion, 4; stent migration, 1; cholecystitis, 1) and in 6 of the Wall group (stent occlusion, 1; stent migration, 2; cholecystitis, 3; cholangitis without stent occlusion, 1) (P 1.00). In 3 cases of the ZEO group, tumor ingrowth occurred due to breakage of the cover, whereas there were no such cases in the Wall group. Mean stent patency duration of the ZEO group and the Wall group were 243 days and 382 days, respectively (P 0.20). Conclusion: The short-term efficacy and safety of ZEO were comparable with those of Wall. However, improvement of the cover of the ZEO is indispensable for prevention of tumor ingrowth.

患者は78歳の男性.黄疸を主訴に当科へ紹介となった.腹部超音波検査では，膵頭部に辺縁不整な低エコー腫瘤が指摘された.肝外，肝内胆管拡張，および肝内に多数の低エコー腫瘤を認めた.胆道ドレナージを目的にERCPを試みたが，癌浸潤に伴う十二指腸狭窄にて不成功で，胃内から肝外胆管を標的胆管として，超音波内視鏡ガイド下胆道ドレナージ（ESBD：Endosonography-guided biliary drainage）を施行した.肝転移により手術適応無く，減黄後gemcitabine化学療法を導入した.その後，十二指腸狭窄が増悪し食事摂取が困難となったために，内視鏡下に十二指腸ステント留置を行った.内視鏡治療により良好なQOLが得られたが，初診から約6ヶ月後に原病死となった.化学療法の進歩した現在，全身状態の改善をめざした悪性胆道·消化管狭窄に対する内視鏡的interventionは，積極的に試みるべきと考えられた.

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting. CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Endosonography-guided biliary drainage (ESBD) is a new method enabling internal drainage of an obstructed bile duct. However, the histological conditions associated with fistula development via the duodenum to the bile duct have not been reported. We performed ESBD 14 d preoperatively in a patient with an ampullary carcinoma and histologically confirmed changes in and around the fistula. The female patient developed no complications relevant to ESBD. Levels of serum bilirubin and hepatobiliary enzymes declined quickly, and pancreatoduodenectomy was carried out uneventfully. The resected specimen was sliced and stained with hematoxylin-eosin. Histological evaluation of the puncture site in the duodenum and bile-duct wall, and the sinus tract revealed no hematoma, bile leakage, or abscess in or around the sinus tract. Little sign of granulation, fibrosis, and inflammatory cell infiltration was observed. Although further large-scale confirmatory studies are needed, the findings here may encourage more active use of ESBD as a substitute for percutaneous transhepatic drainage in cases with failed/difficult endoscopic biliary stenting.

To assess optimum endoscopic biliary drainage (EBD) in cases with unresectable pancreatic cancer in the era of gemcitabine (GEM).Thirty patients with unresectable pancreatic cancer, who presented with jaundice and underwent chemotherapy using GEM after EBD were included in this study (GEM group). Fifteen cases with the same clinical manifestation and stage of pancreatic cancer treated with EBD alone were also included as controls. A covered metallic stent (CMS) or a plastic stent (PS) was used for EBD. The mean survival time (MST) in each group, risk factors of survival time, type of stent used and associated survival time, occlusion rate of stent, patency period of stent, and risk factors of stent occlusion were evaluated.MST in the GEM group was longer than that in the control (9.9 mo vs 6.2 mo). In the GEM group, the survival time was not different between those who underwent metallic stenting and those who underwent plastic stenting. Stent occlusion occurred in 60% of the PS group and 7% of the CMS group. The median stent patency in the PS-GEM group and the CMS-GEM group was 5 mo and 7.5 mo, respectively. Use of a PS was the only risk factor of stent occlusion.A CMS is recommended in cases presenting with jaundice due to unresectable pancreatic cancer, since the use of a CMS makes it possible to continue chemotherapy using GEM without repetition of stent replacement.