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The identification of bleeding sites of ruptured hepatocellular carcinoma (HCC) is important for immediate treatment. We experienced a case of ruptured HCC readily treated with transarterial embolization (TAE) after identification of the bleeding site using contrast-enhanced ultrasonography (CEUS) with Sonazoid. We report the case of a 61-year-old male with multiple HCCs caused by alcohol-related cirrhosis, who was admitted for rapid development of abdominal fullness. The diagnosis was established by hemorrhagic ascites by abdominal paracentesis. No clear extravasation was found on contrast-enhanced computed tomography. CEUS using the re-injection method in the post-vascular phase showed active bleeding from a lesion close to the S5 gallbladder bed. Abdominal angiography was urgently performed. Based on CEUS findings, selective cannulation of the cystic artery was performed. Cystic angiography findings with carbon dioxide showed extravasation. He was treated by TAE. Our case had multiple HCCs, but CEUS was useful for the identification of bleeding sites.

This case report concerns a 40-year-old male who had previously been treated for an esophageal varix rupture, at the age of 30 years. The medical examination at that time revealed occlusion of the inferior vena cava in the proximity of the liver, leading to the diagnosis of the patient with Budd-Chiari syndrome. The progress of the patient was therefore monitored in an outpatient clinic. The patient had no history of drinking or smoking, but had suffered an epileptic seizure in 2004. The patient's family history revealed nothing of note. In February 2012, color Doppler ultrasonography (US) revealed a change in the blood flow in the right portal vein branch, from hepatopetal to hepatofugal, during deep inspiration. Arrival time parametric imaging (At-PI), using Sonazoid-enhanced US, was subsequently performed to examine the deep respiration-induced changes observed in the hepatic parenchymal perfusion. US images captured during deep inspiration demonstrated hepatic parenchymal perfusion predominantly in red, indicating that the major blood supply was the hepatic artery. During deep expiration, the portal venous blood flow remained hepatopetal, and hepatic parenchymal perfusion was displayed predominantly in yellow, indicating that the portal vein was the major source of the blood flow. The original diagnostic imaging results were reproduced one month subsequently by an identical procedure. At-PI enabled an investigation into the changes that were induced in the hepatic parenchymal perfusion by a compensatory mechanism involving the hepatic artery. These changes occurred in response to a reduction in the portal venous blood flow, as is observed in the arterialization of hepatic blood flow that is correlated with the progression of chronic hepatitis C. It has been established that the peribiliary capillary plexus is important in the regulation of hepatic arterial blood flow. However, this case demonstrated that the peribiliary capillary plexus also regulates acute changes in portal venous blood flow, in addition to the chronic reduction in blood flow that is observed in patients with chronic hepatitis C.

Self-expanding metal stents (EMS) have gained widespread popularity for the palliative treatment of various stenoses in blood vessels, biliary ducts, bronchi, and the gastrointestinal tract. Regarding stenoses of the upper gastrointestinal tract, EMS insertion for gastric outlet and duodenal stenoses is considerably more difficult than for esophageal stenoses. We describe a reliable EMS insertion technique for malignant gastric outlet and duodenal stenoses.

Endoscopic biliary stenting is a useful way to treat distal malignant biliary strictures that are not eligible for surgery. A 10-Fr plastic or metal stent is used for stenting. Typically, endoscopic sphincterotomy (EST) has often been carried out as a way to prevent pancreatitis after stent placement given the ease of stent insertion, but EST has flaws such as bleeding and stent migration.The present study describes the need for EST prior to stent placement.

The short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) to treat gastric varices were evaluated by using computed tomography (CT) and gastroscopy (GF). The subjects were 77 patients who underwent BRTO to treat gastric varices. The short-term effects of BRTO were investigated with regard to ascites, pleural effusion, venous thrombus, and esophageal varices by comparing the findings of CT and GF performed within one month before and after BRTO. The mean duration of followup was 960.1 days. Ascites and pleural effusion were exacerbated after BRTO in 26 (33.8%) and 31 (40.3%), respectively. A significant difference in ascites exacerbation was noted in patients with hypoalbuminemia and a high Child-Pugh score, and a significant difference in exacerbation of pleural effusion was noted in patients with hypoalbuminemia. Venous thrombus was noted in 7 patients (9.1%). Esophageal varices were exacerbated in 14 (21.2%) of the 66 patients. The 2-year survival rate was 720 days, and significant differences were noted in the Child-Pugh classification and the concomitance of hepatocellular carcinoma (HCC) on multivariate analysis of prognosis-related factors. Conclusion. The frequencies of exacerbation of ascites, pleural effusion, and esophageal varices after BRTO were high but these may not be related to survival.

In patients with unresectable malignant biliary obstruction (MBO), anticancer treatment is often administered. The impact of anticancer treatment on recurrent biliary obstruction in covered self-expandable metallic stents (SEMS) has not been fully elucidated. Data on 279 patients enrolled in a multicenter prospective cohort study of two different covered SEMS for distal MBO, WATCH study (141 partially covered WallFlex stents and 138 partially covered Wallstents) were retrospectively analyzed. The rates and causes of recurrent biliary obstruction (stent occlusion or migration) were compared between anticancer treatment group (n = 173) and best supportive care alone (BSC) group (n = 106). Cumulative time and prognostic factors for recurrent biliary obstruction were analyzed, using a proportional hazards model with death without recurrent biliary obstruction as a competing risk. The overall rate (43 vs. 25 %, P = 0.002) and the cumulative incidence (16.1 vs. 8.2, 27.9 vs. 18.9 and 44.1 vs. 26.6 % at 3, 6 and 12 months, P = 0.030 by Gray’s test) of recurrent biliary obstruction were significantly higher in anticancer treatment group compared with BSC group. The multivariate analysis revealed anticancer treatment [subdistribution hazard ratio (SHR) 1.93, P = 0.007) as well as the use of a partially covered WallFlex stent (SHR 0.65, P = 0.049) as prognostic factors. Anticancer treatment was a risk factor for recurrent biliary obstruction in covered SEMS for distal MBO. The superiority of a partially covered WallFlex stent was again confirmed in this competing risk analysis; UMIN-CTR: UMIN000002293.

In this study, the aim was to determine the demographic characteristics of elderly patients with gastroduodenal ulcer who had undergone endoscopic hemostasis by comparing them with younger patients.A total of 353 patients with Forrest class I-IIa hemorrhagic gastroduodenal ulcer who underwent endoscopic hemostasis at our hospital between December 2004 and May 2010 were divided into two groups: one for those 75 years or older (old-old group; n = 71; age ≥75 years) and one for those younger than 75 years (younger group; n = 282; age75 years). Then, their demographic characteristics were compared.There were significantly more female patients, patients with underlying chronic renal failure and patients using non-steroidal anti-inflammatory drugs in the old-old group than in the younger group. In addition, the prevalence of open-type atrophy in the background gastric mucosa was significantly higher in the old-old group. Although more than half the patients in each group were infected with Helicobacter pylori, the prevalence was significantly higher in the younger group. Of the patients who underwent endoscopic hemostasis only once, those in the old-old group constituted a significantly higher medical cost than those in the younger group. Comparison of deaths between the two groups revealed that the old-old patients were more likely to develop severe complications associated with hematemesis, such as aspiration pneumonia.The observed lower prevalence of Helicobacter pylori infection among the elderly patients compared to the younger patients with hemorrhagic gastroduodenal ulcer suggests that other factors, such as non-steroidal anti-inflammatory drugs use and chronic renal failure, predispose the elderly to hemorrhagic ulcer.

We previously reported that detection of desmoplastic reaction (DR) in pretreatment biopsy specimens was useful for predicting the depth of submucosal invasion (SM depth) in nonpedunculated early colorectal cancers (ECRCs) in a retrospective study. Here, we performed a prospective multicenter study for verification of our previous findings. Subjects were diagnosed with ECRC by endoscopy, and with adenocarcinoma from the biopsy specimens. Eleven institutions affiliated with the Japanese Society for Cancer of the Colon and Rectum participated in this collaborative study. A total of 112 patients with ECRC were enrolled. For nonpedunculated ECRCs, presence of DR was significantly correlated with SM depth. The sensitivity and specificity of detection of DR for prediction of pSM2 (tumor invasion ≥1000 µm) in nonpedunculated ECRCs were 68.6% and 92.0%, respectively. Evaluation of DR in pretreatment biopsy specimens may be useful for the clinicopathological diagnosis of colorectal carcinoma with massive invasion into the submucosal layer.

Esophageal squamous cell carcinoma (ESCC) is considered one of the most aggressive cancers with poor prognosis. The high molecular weight cytokeratin 34βE12 (CK34βE12) is recognized by the antibody, that is expressed in the cytoplasm of epithelial basal cells, and has been considered as a potential marker for prostate cancer, breast cancer, and basaloid carcinoma of the lung. However, there are no clinicopathological studies investigating CK34βE12 expression at the invasive front of ESCC. In this study, we examined 170 surgically resected cases of ESCC to clarify the clinicopathological significance of CK34βE12 expression. CK34βE12 expression was found in 85.3% (145/170) of ESCC cases and was significantly correlated with lymph node metastasis (66.2% [96/145], P = 0.034), depth of tumor invasion (57.9% [84/145], P = 0.042), and differentiation (82.1% [119/145], P = 0.013). These results indicated that CK34βE12 expression is a good indicator of lymph node metastasis, depth of tumor invasion, and differentiation in case of ESCC.

AIM: To clarify the strategy for early diagnosis of pancreaticobiliary maljunction (PBM) without biliary dilatation and to pathologically examine gallbladder before cancer develops. METHODS: The anatomy of the union of the pancreatic and bile ducts was assessed by using endoscopic retrograde cholangiopancreatography (ERCP). Patients with a long common channel in which communication between the pancreatic and bile ducts was maintained even during sphincter contraction were diagnosed as having PBM. Of these, patients in which the maximal diameter of the bile duct was less than 10 mm were diagnosed with PBM without biliary dilatation. The process of diagnosing 54 patients with PBM without biliary dilatation was retrospectively investigated. Histopathological analysis of resected gallbladder specimens from 8 patients with PBM without biliary dilatation or cancer was conducted. RESULTS: Thirty-six PBM patients without biliary dilatation were diagnosed with gallbladder cancer after showing clinical symptoms such as abdominal or back pain (n = 16) or jaundice (n = 12). Radical surgery for gallbladder cancer was only possible in 11 patients (31%) and only 4 patients (11%) survived for 5 years. Eight patients were suspected as having PBM without biliary dilatation from the finding of gallbladder wall thickening on ultrasound and the diagnosis was confirmed by ERCP and/or magnetic resonance cholangiopancreatography (MRCP). The median age of these 8 patients was younger by a decade than PBM patients with gallbladder cancer. All 8 patients underwent prophylactic cholecystectomy and bile duct cancer has not occurred. Wall thickness and mucosal height of the 8 resected gallbladders were significantly greater than controls, and hyperplastic changes, hypertrophic muscular layer, subserosal fibrosis, and adenomyomatosis were detected in 7 (88%), 5 (63%), 7 (88%) and 5 (63%) patients, respectively. Ki-67 labeling index was high and K-ras mutation was detected in 3 of 6 patients. CONCLUSION: To detect PBM without biliary dilatation before onset of gallbladder cancer, we should perform MRCP for individuals showing increased gallbladder wall thickness on ultrasound.

Peritoneal malignant mesothelioma is a rare disorder with a poor prognosis, and a standard treatment for it has not yet been established. Therefore, treatment of this disorder tends to be selected according to pleura malignant mesothelioma. We analyzed case reports in Japan. The median survival time(MST)with this disease was 12 months and the 1-year survival rate was 47. 3% in the chemotherapy group. It was found through a case-series study that platinum pharmaceutical plus antimetabolite are effective against peritoneal malignant mesothelioma. A gemcitabine(GEM)plus cisplatin(CDDP)regimen had been selected as a conventional treatment, but subsequently, pemetrexed(MTA)was covered by health insurance for pleural malignant mesothelioma in 2007, and the MTA plus CDDP regimen became the standard treatment. However, a phase III trial of GEM plus CDDP regimen and MTA plus CDDP regimen was not performed. There is a need to perform these phase III trials in the future. In our institution, the MTA plus CDDP regimen was the first-line treatment, and the GEM plus CDDP regimen was the second-line treatment against peritoneal malignant mesothelioma. Palonosetron hydrochloride and aprepitant should be used actively in treatment. Also, carboplatin(CBDCA)is effective as an alternative therapy of the CDDP against renal disorder case, but hematotoxicity requires attention.

Recently, the progress of endoscopy has made it possible to evaluate bile duct mucosa by peroral cholangioscopy. Herein, we report a case of immunoglobulin G4-related sclerosing cholangitis accompanying autoimmune pancreatitis in a patient who improved with treatment by steroid therapy and endoscopic biliary stenting, and observed the bile duct mucosa by peroral cholangioscopy before and after treatment.

Autoimmune pancreatitis (AIP) is a newly described entity of pancreatitis in which the pathogenesis appears to involve autoimmune mechanisms. Based on histological and immunohistochemical examinations of various organs of AIP patients, AIP appears to be a pancreatic lesion reflecting a systemic "IgG4-related sclerosing disease". Clinically, AIP patients and patients with pancreatic cancer share many features, such as preponderance of elderly males, frequent initial symptom of painless jaundice, development of new-onset diabetes mellitus, and elevated levels of serum tumor markers. It is of uppermost importance not to misdiagnose AIP as pancreatic cancer. Since there is currently no diagnostic serological marker for AIP, and approach to the pancreas for histological examination is generally difficult, AIP is diagnosed using a combination of clinical, serological, morphological, and histopathological features. Findings suggesting AIP rather than pancreatic cancer include: fluctuating obstructive jaundice; elevated serum IgG4 levels; diffuse enlargement of the pancreas; delayed enhancement of the enlarged pancreas and presence of a capsule-like rim on dynamic computed tomography; low apparent diffusion coefficient values on diffusion-weighted magnetic resonance image; irregular narrowing of the main pancreatic duct on endoscopic retrograde cholangiopancreatography; less upstream dilatation of the main pancreatic duct on magnetic resonance cholangiopancreatography, presence of other organ involvement such as bilateral salivary gland swelling, retroperitoneal fibrosis and hilar or intrahepatic sclerosing cholangitis; negative work-up for malignancy including endoscopic ultrasound-guided fine needle aspiration; and steroid responsiveness. Since AIP responds dramatically to steroid therapy, accurate diagnosis of AIP can avoid unnecessary laparotomy or pancreatic resection.

BACKGROUND/AIMS Gastric cancer is the most common cancer in Japan. Genome-wide gene expression in the jejunal pouch mucosa was examined using a DNA microarray and quantitative real-time PCR (qPCR) to evaluate the safety, especially with regard to carcinogenic changes, of the jejunal pouch in patients who showed long-term survival. METHODOLOGY Biopsy samples of jejunal pouch and jejunal conduit were collected from four patients who had undergone gastrectomy 9 to 13 years previously. Total RNA was extracted, amplified to give complementary RNA, labeled with Cyanine 3-CTP and hybridized with a whole human genome oligo microarray (44k). Gene expression was confirmed partly by qPCR. RESULTS Although some changes in the expression of 417 reported cancer genes were observed with the DNA microarray, crucial changes related to small intestinal adenocarcinoma were not observed. Changes in the expression of eight genes related to small intestinal adenocarcinoma were also not detected by qPCR. CONCLUSIONS Crucial changes in the expression of genes related to small intestinal adenocarcinoma were not observed in the jejunal pouch of these four patients with gastric cancer by either DNA microarray or qPCR. The present results support the safety of the use of a jejunal pouch with a food pooling function in patients who show long-term survival after gastrectomy.

Purpose. It has been reported that Th2 cytokines downregulate antitumor immunity, while activation of type T cells promotes antitumor immunity. The aim of this paper was to evaluate host immunity in liver cirrhosis (LC) patients with advanced hepatocellular carcinoma (aHCC) receiving sorafenib therapy.Methods. Forty-five adult Japanese LC patients received sorafenib for aHCC between 2009 and 2011 at our hospital. Sorafenib was administered at a dose of 200–800 mg/day for 4 weeks. Blood samples were collected before and after treatment.Results. Eleven patients were treated with sorafenib at 200 mg/day (200 group), 27 patients received sorafenib at 400 mg/day (400 group), and 7 patients were given sorafenib at 800 mg/day (800 group). There was no significant change in the percentage of Th1 cells after treatment in any group. However, the percentages of Th2 cells and regulatory T cells were significantly decreased after treatment in the 400 group and 800 group compared with before treatment, although there was no significant change after treatment in the 200 group.Conclusions. These results indicate that treatment with sorafenib might induce Th1 dominance and prevent the escape of tumor cells from the host immune system in LC patients with aHCC.

Background and Aims. For distal malignant biliary obstruction in cases with short life expectancy, occlusion of plastic stents (PSs) does not usually occur before death, and the application of such a procedure is considered adequate from the viewpoint of cost-effectiveness. Methods and Setting. A new commercially available DLS with side holes, a conventional DLS, and, uncovered self-expanding metal stents (SEMSs) were retrospectively evaluated in patients with jaundice due to unresectable distal malignant biliary obstruction. Results. A total of 64 patients received endoscopic biliary stenting (23 patients with the new DLS, 24 patients with conventional DLS, and 17 patients with uncovered SEMS) from December 2002 to August 2009. Median patency time was found to be 198 days for the new DLS group and 99 days for the conventional DLS group, revealing a significant difference between devices. There was, however, no significant difference in median patency time between the new DLS and the uncovered SEMS (198 days versus 344 days). Conclusion. The new DLS is efficient and safe and may be considered the first choice for unresectable distal malignant obstruction in cases with short life expectancy.

Duodenal stenting has been gradually established in recent years because it is less invasive than standard surgical procedures and produces a rapid therapeutic response. For palliation of both duodenal and biliary stenoses, double stenting may be performed. Duodenal stents offer a great advantage in allowing endoscopic retrograde cholangiopancreatography (ERCP) without the need for balloon dilation. When biliary stent dysfunction occurs, the patient undergoes diagnostic and/or therapeutic ERCP across the duodenal stent. We encountered a duodenal stent fracture in a patient who required repeated ERCPs for stent dysfunction. Duodenal stent fractures have not previously been reported. The damaged stent was successfully repaired by using a cutting wire filament and placing another duodenal stent coaxially with the first. Clinicians should be aware of the possibility of stent fracture following endoscopic procedures, such as an ERCP, that require passage through the stent. The procedure described in this report would be of significant benefit if a gastrointestinal stent is fractured and occluded by a broken part.

Background/aims Evaluation of bile acids (BA) is useful for assessing the changes of intestinal flora in patients with ulcerative colitis (UC). During enterohepatic circulation, the intestinal micro flora cause 7 alpha-dehydroxylation of cholic acid (CA) and chenodeoxycholic acid (CDCA), yielding deoxycholic acid(DCA) and lithocholic acid, respectively. The aim of the present study was to investigate the effects of probiotics in patients with UC by examining changes of the serum BA profile. Methodology Twenty-seven patients were divided into the following 2 groups based on endoscopic findings: Fifteen patients with distal UC (dUC group) and 12 patients with pancolitis (pUC group). After treatment with mesalazine or salazosulfapyridine (5-ASA), all patients achieved remission. Then they were given 5-ASA plus the probiotic Clostridium butyricum Miyairi (3.0 g/day) for 4 weeks. Results After 4 weeks of probiotic treatment, %CDCA was significantly higher and %DCA was significantly lower in the pUC group than in the HV group. In contrast, the dUC group showed no significant differences of %CDCA or %DCA from the HV group after 4 weeks. Conclusions Probiotic therapy restored intestinal flora involved in 7 alpha-dehydroxylation in the dUC group, but not in the pUC group.

Background/aims Comparison of Parametric Imaging (PI) using Sonazoid-enhanced ultrasonography (US) and microflow imaging (MFI) to determine the possibility of hepatic hemangioma diagnosis using PI. Methodology Twenty-two hepatic hemangioma nodules (mean±SD diameter: 31.6±19.1mm) undergoing Sonazoid-enhanced US between February 2008 and March 2009. After Sonazoid-enhanced US, COMMUNE ultrasonographic image analysis software was used for analysis of tumor imaging dynamics in the vascular phase using PI and MFI. In PI, 0s was set as the time contrast agent reached the tumor. Imaging within the tumor after 0s was color-coded according to time, and the images were displayed in color. In MFI, 0s was set as the time contrast agent reached the tumor. The path of microbubbles as it flowed through blood vessels was superimposed on the original B-mode images. Three trained physicians used these methods to analyze tumor imaging dynamics. Results All physicians concluded all cases were hepatic hemangioma regardless of method used. However, compared to MFI, PI allowed determination of more detailed blood flow dynamics in high-flow hepatic hemangioma, where blood flow speed was faster than in normal hepatic hemangioma. Conclusions It is possible to diagnose hepatic hemangioma using PI using sonazoid-enhanced US.

No study has compared covered metallic stents with Tannenbaum stents. We evaluated the efficacy of the DoubleLayer stent (DLS) and Covered Wallstent (CWS) in patients with pancreatic head cancer (PHC).This was a multicenter, prospective randomized study. Between October 2005 and December 2007, we enrolled 113 patients (58 DLS, 55 CWS) with unresectable PHC with distal biliary obstructions and observed them for at least 6 months.No significant difference in patient survival was found between groups, with a median survival of 231 and 248 days in the DLS and CWS groups, respectively. The cumulative stent patency was significantly higher (P = 0.0072) in the CWS group. The respective mean and median stent patency was 202 and 133 days in the DLS group and 285 and 419 days in the CWS group. The incidence of DLS occlusion (53.5%) was significantly higher than that of CWS (23.6%; P = 0.0019). The respective causes of occlusion were tumor overgrowth (0, 1), ingrowth (0, 2), sludge (24, 2), food impaction (3, 5), kinking bile duct (2, 0), and other (2, 3). Other complications were cholecystitis (0, 4), pancreatitis (0, 1), migration (1, 5), liver abscess (2, 0), and other (1, 2). No significant difference in the incidence of complications between groups was observed.CWS had significantly longer patency than DLS for the management of PHC with obstructive jaundice. The incidence of complications other than stent occlusion was higher in CWS, but this difference did not reach significance.

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Background Covered self-expandable metal stents (CSEMSs) were developed to prevent tumor ingrowth, but stent migration is one of the problems with CSEMSs. Objective To evaluate a new, commercially available CSEMS with flared ends and low axial force compared with a commercially available CSEMS without the anti-migration system and high axial force. Design Multicenter, prospective study with a historical cohort. Setting Twenty Japanese referral centers. Patients This study involved patients with unresectable distal malignant biliary obstruction. Intervention Placement of a new, commercially available, partially covered SEMS. Main Outcome Measurements Recurrent biliary obstruction rate, time to recurrent biliary obstruction, stent-related complications, survival. Results Between April 2009 and March 2010, 141 patients underwent partially covered nitinol stent placement, and between May 2001 and January 2007, 138 patients underwent placement of partially covered stainless stents as a historical control. The silicone cover of the partially covered nitinol stents prevented tumor ingrowth. There were no significant differences in survival (229 vs 219 days; P = .250) or the rate of recurrent biliary obstruction (33% vs 38%; P = .385) between partially covered nitinol stents and partially covered stainless stents. Stent migration was less frequent (8% vs 17%; P = .019), and time to recurrent biliary obstruction was significantly longer (373 vs 285 days; P = .007) with partially covered nitinol stents. Stent removal was successful in 26 of 27 patients (96%). Limitations Nonrandomized, controlled trial. Conclusion Partially covered nitinol stents with an anti-migration system and less axial force demonstrated longer time to recurrent biliary obstruction with no tumor ingrowth and less stent migration. (Clinical trial registration number: UMIN000002293.)

Purpose of review Autoimmune pancreatitis (AIP) is a peculiar type of pancreatitis with a presumed autoimmune etiology. AIP is frequently associated with stenosis of the bile duct in the form of IgG4-related sclerosing cholangitis. This article reviews recent advances in clinicopathological findings for AIP and IgG4-related sclerosing cholangitis. Recent findings AIP is currently diagnosed based on characteristic radiological findings (irregular narrowing of the main pancreatic duct and enlargement of the pancreas) in combination with serological findings (elevated serum IgG4 and presence of autoantibodies) and histopathological findings (dense infiltration of IgG4-positive plasma cells and lymphocytes with fibrosis and obliterative phlebitis in the pancreas). Other clinical characteristics include preponderance toward elderly men, common initial symptoms of obstructive jaundice, and favorable response to steroid therapy. Differentiation of AIP from pancreatic cancer is crucial. As AIP is frequently associated with various sclerosing extrapancreatic lesions showing the same peculiar histological findings seen in the pancreas, AIP is currently considered to represent a pancreatic manifestation of IgG4-related sclerosing disease. Considering the age of onset, associated diseases, cholangiography, serum IgG4 levels, and steroid responsiveness, IgG4-related sclerosing cholangitis differs from primary sclerosing cholangitis. Summary AIP and associated extrapancreatic lesions are considered to represent clinical manifestations of IgG4-related sclerosing disease.

The incidence of local recurrence of hypervascular hepatocellular carcinoma (HCC) (15 mm or less) was compared retrospectively between a group treated with radiofrequency ablation (RFA) using cool-tip (Radionics, USA) 10-mm electrodes and a group treated with percutaneous ethanol injection (PEI).There were 23 patients who were treated for a total of 25 tumors during a 3-year period at our hospital. Ten of the tumors (11.1 +/- 2.7mm) were treated with RFA using cool-tip 10-mm electrodes and 15 tumors (10.6 +/- 2.7 mm) were treated with PEI. After treatment, progression was evaluated in enhanced CT scans every 3-6 months to confirm presence or absence of local recurrence.The number of recurrences, mean observation period, and mean recurrence period in the RFA group were 2 (20%), 6.6 months, and 6 months. The number of recurrences, mean observation period, and mean recurrence period in the PEI group were 2 (13.3%), 19.1 months, and 18 months. The period between treatment and recurrence tended to be longer in the PEI group than in the RFA group to be significant p0.05.The results suggest that PEI treatment is more effective in local treatment of hypervascular HCC with tumor diameters of 15 mm or less.

An invasive micropapillary variant (IMPV) has recently been described in several organs but has not been reported in the gallbladder. It has been mentioned to have aggressive behavior with a high propensity for lymphovascular invasion, lymph node metastasis and poor clinical outcome. We analyzed the clinicopathologic findings of IMPV and compared them with those of a conventional adenocarcinoma in the gallbladder to clarify the highly aggressive potential of IMPV of gallbladder carcinoma. Ninety consecutive cases of surgically resected gallbladder carcinomas were studied for age, gender, type, depth of invasion and lymph node and distant metastases. Histologically, IMPV of gallbladder carcinoma was characterized by a small cluster of tumor cells lying within clear stromal spaces. This pattern mimicked extensive lymphatic invasion, but the cluster of tumor cells showed a distinctive retraction artifact from the surrounding stroma. In total, 20 (22.2%) cases had foci of IMPV, which ranged from 5% to 10% of the primary tumor tissue. Of those 20 cases, 17 (85.0%) carcinomas with IMPV also included lymph node metastasis, which was more frequent than in conventional carcinoma (32.8%, P < 0.001). Carcinomas with IMPV had a more advanced tumor status and showed severe lymphatic invasion (P = 0.001, P < 0.001, respectively). A multivariate regression analysis demonstrated that the presence of IMPV is an independent predictor of regional nodal metastasis (Odds ratio: 9.995, 95% confidence interval: 1.996-50.052, P = 0.005). IMPV is a useful predictor of regional lymph node metastasis in gallbladder adenocarcinoma.

Background: Intraductal papillary-mucinous neoplasm (IPMN) is an intraductal tumor in which the mucin-producing epithelium shows proliferated papillary and a wide variety of pathological changes ranging from hyperplasia to adenocarcinoma. Therefore, it is important to determine whether an IPMN is benign or malignant. In the present study of patients with IPMN, the protrusion was observed by a peroral pancreatoscopy (PPS) using a small-diameter videoscope and narrow-band imaging (NBI). We carried out the differential diagnosis of benign lesion to malignant lesion. Methods: Between April 2003 and May 2009, PPS using a small-diameter videoscope by means of NBI was carried out on 21 hospitalized patients with IPMN (10 cases of adenocarcinoma, 11 cases of adenoma or hyperplasia; 14 males and seven females, with a mean age of 69.4 years). Results: Fifteen focal lesions of the 16 cases in the head of the pancreas (93.7%) and four focal lesions of the five cases in the pancreatic body (80%) were observable, whereas two lesions (adenocarcinoma in the pancreatic body, and adenoma in the uncus of pancreas) were not observable. Endoscopically, seven cases were classified as villous type and two cases as vegetative type, and nine cases were diagnosed as adenocarcinoma. Ten cases with sessile type or semipedunculated type were diagnosed as adenoma or hyperplasia. Vascular patterns and protrusions were detected more clearly in the NBI images than under white light observation. Conclusions: When combined with a videoscope and NBI, pancreatoscopy provided a clear image and was useful for evaluating whether the IPMN was benign or malignant.

Objective Endoscopic sphincterotomy (ES) is a well-established standard method for treating common bile duct stones. However, biliary sphincter function is impaired after the treatment, and this may influence the long-term outcomes. In this study, we aimed to compare the long-term outcomes after ES with those after endoscopic papillary balloon dilation (EPBD) because the latter procedure is expected to preserve biliary sphincter function better than ES. Design A prospective follow-up of the original cohort in a previously randomized, controlled trial to compare the early outcomes after ES and EPBD. Setting Eleven centers, including 6 clinical practices and 5 academic institutions. Patients A total of 282 patients with common bile duct stones were randomly selected to undergo ES (n = 144) or EPBD (n = 138) in the previous study. Interventions ES or EPBD. Main Outcome Measurements Complications after ES or EPBD occurring during long-term follow-up. Results The patients were followed up annually after the treatment. The median duration of the follow-up was 6.7 years. Morbidity was observed in 36 (25.0%) and 14 (10.1%) of the patients who underwent ES and EPBD, respectively ( P = .0016). Kaplan-Meier analysis revealed a significantly higher incidence of biliary complications in the ES group than in the EPBD group ( P = .0011). Multivariate analysis showed that ES, periampullary diverticulum, and in situ gallbladder stones were independent risk factors for stone recurrence. Conclusions During long-term follow-up, patients who underwent ES had significantly more biliary complications than those who underwent EPBD. The biliary sphincter dysfunction after ES results in additional late complications.

We have previously shown that continuous intra-arterial combination chemotherapy (IACC) might be more effective for advanced hepatocellular carcinoma (aHCC) in patients with HCV-related liver cirrhosis (C-LC) or alcoholic liver cirrhosis (A-LC) than in patients with HBV-related LC (B-LC). However, it is still unknown whether IACC actually improves the prognosis of aHCC patients with liver cirrhosis (LC), because it is difficult to perform a randomized controlled trial for patients with a poor prognosis. The aim of this study was to retrospectively assess the influence of IACC on the prognosis of aHCC. Fifty-eight adult Japanese patients who had aHCC and LC underwent repeated trans-arterial chemoembolization (TACE) without IACC between 1990 and 1997 at our hospital (group T), while 43 patients with aHCC and LC received IACC between 2000 and 2008 after undergoing several TACE sessions (group R). The Japan Integrated Staging score (JIS score) of each patient was ≥ 3 at the time of presentation, except for patients with tumor thrombi involving the first or subsequent portal vein branches or those with tumor invasion of the inferior vena cava. The same IACC regimen was repeated for as long as possible in group R. In group T, 13 patients had B-LC, 37 patients had C-LC, and 8 patients had A-LC, while the respective numbers were 14, 21, and 8 in group R. The median survival time (MST) was 248 days for patients with C-LC in group T and 708 days for those in group R, while it was 253 days for patients with A-LC in group T and 593 days for those in group R. There were significant differences of survival between the two groups. However, MST was 369 days for patients with B-LC in group T and 782 days for those in group R, without a significant difference. In group R, a complete or partial response was achieved after 4 weeks of chemotherapy in 14.3% of patients with B-LC versus 42.9% of patients with C-LC and 37.5% of patients with A-LC. In LC patients with a JIS score > 3 at diagnosis, multimodal therapy with IACC after TACE prolongs the MST of C-LC or A-LC patients compared with TACE alone, although it does not improve the MST of patients with B-LC.

CHF-B260 has thinner diameters, and the quality of the endoscopic images has improved. Recently, narrow band imaging (NBI) system has been developed for high-contrast observation of mucosal structures and vascular patterns. It is available to diagnose for the bile duct cancer endoscopically and it is useful for desciding of surgical margin before operation. As for its applicability to investigating the progression of superficially infiltrated bile duct cancer, additional cases must be examined in the future.

A 62-year-old man was admitted to our hospital complaining of sore throat and epigastralgia. Laboratory tests revealed leukocytosis and an elevated CRP level. CT showed a low density area in the right hypopharynx, wall thickening of the esophageal and gastric wall with an intramural low density area. Phlegmonous esophagogastritis associated with hypopharyngeal abscess was diagnosed. The infection was extension and his condition was serious because of his accompanying poorly controlled diabetes. He was successfully treated by antibiotics and drainage of the hypopharyngeal abscess. CT was useful for early diagnosis, confirmation of the extent of inflammation and follow-up.

From June, 1987 to November, 1989, 11 patients with malignant bile duct stenosis, which was later confirmed by surgery or autopsy, were examined by percutaneous transhepatic cholangioscopy (PTCS) and by an endoscopic biopsy. The endoscopic findings obtained with the usual observation methods and methylene blue staining and the histological findings of the biopsy specimens were compared. A fine vascular proliferation was seen in all of the patients and a granular appearance was noted in patients with carcinoma of the major papilla. The papillary appearance was noted in one case each of pancreatic carcinoma, bile duct carcinoma and carcinoma of the major papilla. Marginal protrusion was not noted in patients with pancreatic carcinoma. A distorted narrow segment was seen only in cases of pancreatic carcinoma. The presence of a granular appearance indicated that the carcinoma was exposed on the surface. A high degree of fine vascular proliferation and a papillary appearance tended to indicate a carcinoma which invaded mainly into the fibromuscular layer without invasion of the mucosa. The methylene blue staining method was simple and effective for better visualization of the surface structure of the abnormal area, normal mucosa and the border zone.

Regional lymph node metastasis in gastric cancer is a definitive indicator of the patient’s prognosis. The goal of this study was to identify the predictors for lymph node metastasis among all the possible histopathological parameters, especially by conducting an objective discrimination of the lymphatic and blood vessels. A total of 210 resected primary gastric cancers with or without lymph node metastasis were evaluated based on the conventional histopathological parameters together with immunohistochemistry using antisera-recognizing lymphatic endothelial hyaluronan receptor-1 (LYVE-1), von Willebrand factor, and lymphangiogenesis promoter vascular endothelial growth factor-C (VEGF-C) antibodies. A multivariate regression analyses of the results indicated that only lymphatic invasion was a significant independent predictor of lymph node metastasis at any stage of cancer invasion. VEGF-C expression was partially related to lymph node metastasis in early gastric cancer. The identification of lymphatic invasion by LYVE-1 antibody is therefore useful to predict regional lymph node metastasis in gastric cancer.

A retrospective multicenter survey was performed to evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) as a treatment of pancreatic stones.A survey was sent to 11 institutions belonging to the Japanese Association of Extracorporeal Shock Wave Lithotripsy in Digestive Diseases, and data were collected on 555 patients who underwent ESWL for pancreatic stones between January 1990 and September 2002. The male:female ratio was 5.2:1, and the mean age was 52.5 years. The etiology was alcohol related in 425 patients (76.6%) and idiopathic in 111 patients (20.0%); 204 patients (36.8%) had a single stone and 470 patients (84.7%) were symptomatic.Mean frequency of the procedure was 5.0 times (range, 1-29). Fragmentation of stones was achieved in 513 patients (92.4%), and the complete stone clearance rate after ESWL alone or in combination with interventional endoscopy was 72.6%. Symptom relief was achieved in 428 (91.1%) of 470 patients. Thirty-five patients (6.3%) developed complications, including 30 patients (5.4%) who developed acute pancreatitis. Five hundred four (90.8%) patients were followed for a mean of 44.3 months, during which 122 (22.0%) suffered stone recurrence (mean time to recurrence, 25.1 months). Twenty-two (4.1%) of the 504 patients who were followed required surgery. Pancreatic exocrine function improved in 65 patients (38.0%), was unchanged in 49 patients (28.7%), and progressed in 57 patients (33.3%). Pancreatic endocrine function improved in 44 patients (24.3%), was unchanged in 85 patients (47.0%), and progressed in 52 patients (28.7%).ESWL is the treatment of choice for clearing pancreatic stones.