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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.

Recently, the usefulness of endoscopic ultrasound (EUS) elastography has been reported for the diagnosis of pancreatic lesions. In the present study, we retrospectively assessed EUS elastography as a diagnostic tool by evaluating tissue elasticity distribution and elasticity semiquantification, using the strain ratio (SR) of tissue elasticity, in patients with pancreatic masses. One hundred and nine patients who underwent EUS elastography between September 2006 and May 2009 were retrospectively evaluated. The final diagnosis was chronic pancreatitis (CP) in 20 patients [6 with non-mass-forming pancreatitis, 7 with mass-forming pancreatitis (MFP), and 7 with autoimmune pancreatitis (AIP)], pancreatic cancer (PC) in 72, pancreatic neuroendocrine tumor (PNET) in 9, and normal pancreas in 8. The tissue elasticity distribution calculation was performed in real time, and the results were represented in color in fundamental B-mode imaging. In addition, we performed quantification using the SR (non-mass area/mass area). Elastography for all PC patients showed intense blue coloration, indicating malignant lesions. In contrast, MFP presented with a mixed coloration pattern of green, yellow, and low-intensity blue. Normal controls showed an even distribution of green to red. The mean SR was 23.66 ± 12.65 for MFP and 39.08 ± 20.54 for PC (P

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.

Advanced Cu-40mass%Zn alloys with a high tensile strength and excellent machinability have been developed via a powder metallurgy (P/M) process. They are environmentally benign because fine graphite particles are included instead of lead (Pb) to improve their machinability. The effect of the content and particle size of the graphite on the mechanical properties and machinability are investigated in this paper. When applying a conventional P/M process consisting of the cold compaction and hot extrusion to consolidate elementally premixed mixture of Cu-40mass%Zn and graphite powder, the addition of 1 mass% graphite particles with m in diameter is suitable to obtain a high tensile strength and good machinability at the same time.

A method for practical preparation of pinacolborane from borane-diethylaniline and pinacol was newly developed. Aromatic C–H borylation of arenes with pinacolborane or bis(pinacolato)diboron catalyzed by 1/2[Ir(OMe)(COD)]2-(4,4′-di-tert-butyl-2,2′-bipyridine) at 25 °C in hexane to give arylboronic esters was directly followed by cross-coupling with aromatic bromides at 60 °C in the presence of PdCl2(dppf) (3.0 mol %) and K3PO4 in DMF. This one-pot, two-step procedure provided a variety of unsymmetrical biaryls in high yields.

By using pure titanium powder coated with unbundled multiwall carbon nanotubes (MWCNTs) via wet process, powder metallurgy (P/M) titanium matrix composite (TMC) reinforced with the CNTs was prepared by spark plasma sintering (SPS) and subsequently hot extrusion process. The microstructure and mechanical properties of P/M pure titanium and reinforced with CNTs were evaluated. The distribution of CNTs and in situ formed titanium carbide (TiC) compounds during sintering was investigated by optical and scanning electron microscopy (SEM) equipped with EDS analyzer. The mechanical properties of TMC were significantly improved by the additive of CNTs. For example, when employing the pure titanium composite powder coated with CNTs of 0.35 mass%, the increase of tensile strength and yield stress of the extruded TMC was 157 MPa and 169 MPa, respectively, compared to those of extruded titanium materials with no CNT additive. Fractured surfaces of tensile specimens were analyzed by SEM, and the uniform distribution of CNTs and TiC particles, being effective for the dispersion strengthening, at the surface of the TMC were obviously observed.

916 Endoscopic Ultrasound-Guided Pancreatic Duct Rendezvous in Child With Traumatic PD Disruption Kentaro Ishii*, Takao Itoi, Atsushi Sofuni, Fumihide Itokawa, Takayoshi Tsuchiya, Toshio Kurihara, Shujiro Tsuji, Nobuhito Ikeuchi, Junko Umeda, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Fuminori Moriyasu Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan Background and Patient: Endoscopic retrograde cholangiopancreatography (ERCP) for a patient with traumatic pancreatic duct (PD) disruption is minimally invasive but always challenging. Here, we describe the successful PD stenting in a 9-year-old boy in whom the PD was disrupted by trauma and the initial ERCP failed. The boy fell down and seriously hurt his abdomen on the way home from school. He later developed pancreatic injury and complete PD disruption. Transpapillary PD stenting failed in the previous hospital. Endoscopic Methods: ERCP was re-attempted in our hospital. Endoscopic retrograde pancreatography revealed the complete PD disruption and pooling of contrast medium at the pancreatic body. A guidewire (GW) could not be advanced into the distal PD. Thus, a therapeutic curved linear array echoendoscope was positioned in the stomach. After excluding the blood vessels by Doppler ultrasonography, the distal PD was punctured transluminally using a 22-guage fine needle aspiration (FNA) needle under endoscopic ultrasound (EUS) guidance. PD access was confirmed by EUS imaging and fluoroscopy. A contrast agent was injected via the FNA needle. Then, a 0.018-inch GW was inserted into the PD. However, the GW could not be advanced to the proximal PD from the PD disruption site even with a hydrophilic GW. Therefore, the GW was left in the disruption cavity as long as possible and the echoendoscope was removed. The echoendoscope was then advanced to the major papilla. Thereafter, the GW could be grasped with a biopsy forceps and pulled out through the working channel. A 9-Fr dilation catheter was inserted into the PD over the rendezvous GW, and another wire could be inserted into the distal PD through the dilation catheter (i.e., over-thewire double GW technique). Finally, a 5-Fr PD stent was retrogradely inserted into the distal PD across the disruption cavity. The PD stent was changed every 1 or 2 months, and removed after 7 months. The patient has remained symptom-free. Clinical Implications: EUS-PD rendezvous appears to be useful even in a child in whom the PD was disrupted by trauma and the initial ERCP failed.

Background Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are associated with substantially increased risk of malignant transformation when compared to other types of pancreatic lesions such as serous cystadenoma (SCA) and mucinous cystadenoma (MCA). A recent study suggests that detection of a mutation in codon 201 of GNAS in pancreatic cyst fluid DNA may be able to distinguish IPMN from other lesions of the pancreas, including both MCA and SCA [1]. This study found the detection of a GNAS mutation to be 100% specific, and the presence of either a GNAS or KRAS mutation to be 96% sensitive for IPMN. We examined the diagnostic significance of GNAS mutations in a cohort of pancreatic cyst fluid specimens and correlated the results with the associated diagnostic information. Methods 200 residual pancreatic cyst fluid DNA specimens from 198 distinct patients were retrieved from specimen archives and tested. These specimens were chosen so that there was an equal mix of KRAS mutated and wildtype results, and a range of CEA results above and below 192 ng/mL. DNA was amplified with primers targeting the codon 201 region, and sequenced using capillary electrophoresis and Sanger sequencing. The clonality of the mutation was identified as the ratio of mutant to wildtype, with a limit of detection of 10%. IPMN was determined to be present if there was duct dilation or connectivity to the duct system together with observation of mucinous characteristics of the fluid (e.g. gross mucin, mucin stain, elevated CEA, etc.). Results GNAS mutations were found in 50/200 (25%) specimens. A significant association between the presence of KRAS mutation and GNAS mutation was found, with more GNAS mutations present among KRAS-mutated than KRASwildtype cysts (odds ratio=4, p=7.0e-5). There was no significant difference in mean CEA values between according to GNAS mutation status. Two small ( CAT) that has not been previously reported in IPMN; this mutation was present in only that one specimen. In 20/50 (40%) of GNAS mutated-specimens neither duct dilation nor cyst communication with the duct system was observed. Conclusions Based on the present evaluation, GNAS is found to be mutated in a significant number of cases lacking the classic features of IPMNs. Further work is needed to better understand the role of GNAS in discriminating IPMNs from other cystic neoplasms of the pancreas and in evaluating the malignant potential of either; additional surgical outcomes would be valuable for this assessment. 1. Sci. Transl. Med. 3, 92ra66 (2011).

Endoscopic biliary stenting for malignant biliary obstruction is currently the gold standard for biliary drainage. Biliary cancer treatment is crucial. Cases of gastric outlet obstruction that includes the duodenum because of cancer invasion and biliary obstruction are seldom observed. The required treatment for such cases is simple biliary stenting and a different treatment for duodenal obstruction. Hence, double stenting for bile duct and duodenal obstruction has drawn attention. In the present review, we state different treatment strategies for malignant duodenal obstruction and then describe double stenting in biliary obstruction that also includes non-biliary cancer malignant lesions and duodenal obstruction.

AIM: To examine the coexistence of metachronous and synchronous cancer in branch duct intraductal papillary mucinous neoplasms of the pancreas (IPMN). METHODS: We reviewed the records of 145 patients with branch duct IPMN between January 1991 and April 2008 and assessed the relationship between IPMN and intra- or extra-pancreatic carcinoma and the outcome of IPMN. RESULTS: The mean observation period was 55.9 ± 45.3 mo. Among the 145 patients, the frequency of extra-pancreatic cancer was 29.0%. The frequency of gastric cancer, colon cancer, breast cancer, and pancreatic cancer were 25.5%, 15.7%, 13.7%, and 9.8%, respectively. Twenty (13.8%) of the patients died. The cause of death was extra-pancreatic carcinoma in 40%, pancreatic cancer in 25%, IPMN per se in 20%, and benign disease in 15% of the patients. CONCLUSION: The prognosis for IPMN depends not on the IPMN per se, but on the presence of intra- or extra-pancreatic cancer.

Sepharose 4B conjugated with phosphorylated myosin light chains was used in affinity chromatography of a partially purified preparation of gizzard myosin light-chain phosphatase (MLCP) (Onishi et al. (1979) J. Biochem. 86, 1283-1290). The MLCP preparation thus purified contained, according to SDS gel electrophoresis, three components of 67,000 (67 K), 54,000 (54 K), 34,000 (34 K) daltons. In an accompanying report, Uchiwa et al. (J. Biochem. 91, 273-282 (1982)) described the purification of gizzard myosin light-chain kinase, which consisted of two subunits; 130 K and 17 K daltons. Using the purified preparations of MLCP and MLCK, it was demonstrated a) that reversible changes in the ATPase and superprecipitation activities occur as myosin light chains are enzymatically phosphorylated and dephosphorylated, and b) that addition of a very low concentration of Ca2+ and its removal cause reversible changes in the turbidity of actomyosin suspensions as well as in the state of phosphorylation of myosin light chains only when MLCK and MLCP are both present. These results provide strong support for the proposal (see Ikebe et al. (1977) J. Biochem. 80, 299-302) that MLCK and MLCP play a key role in the Ca2+ regulation in gizzard.