Search

Background Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP. Methods This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ⩾ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications. Results Initially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P < 0.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P < 0.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (P = 0.870) or compared with the conventional group (P = 0.125). Conclusions Based on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation. [ABSTRACT FROM AUTHOR]

Background/Aims: Epithelial-mesenchymal transition (EMT)-related proteins may exhibit differential expression in intestinal type or pancreatobiliary type ampulla of Vater carcinomas (AVCs). We evaluated the expression of E-cadherin, b-catenin, and S100A4 in intestinal and nonintestinal type AVCs and analyzed their relationships with clinicopathological variables and survival. Methods: A clinicopathological review of 105 patients with AVCs and immunohistochemical staining for E-cadherin, β-catenin, and S100A4 were performed. The association between clinicopathological parameters, histological type, and expression of EMT proteins and their effects on survival were analyzed. Results: Sixty-five intestinal type, 35 pancreatobiliary type, and five other types of AVCs were identified. The severity of EMT changes differed between the AVC types; membranous loss of E-cadherin and β-catenin was observed in nonintestinal type tumors, whereas aberrant nonmembranous β-catenin expression was observed in intestinal type tumors. EMT-related changes were more pronounced in the invasive tumor margin than in the tumor center, and these EMT-related changes were related to tumor aggressiveness. Among the clinicopathological parameters, a desmoplastic reaction was related to overall survival, and the reaction was more severe in nonintestinal type than in intestinal type AVCs. Conclusions: Dysregulation of E-cadherin, β-cadherin, and S100A4 expression may play a role in the carcinogenesis and tumor progression of AVCs. [ABSTRACT FROM AUTHOR]

Background and study aims: Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is rare but can cause high mortality. Our aim was to assess the clinical outcomes of these events. Method: A total of 59 patients who were diagnosed as having ERCP-related duodenal perforation at six institutions between 2000 and 2007 were enrolled in this multicenter retrospective study. We evaluated complications and mortality associated with ERCP-related duodenal perforation according to injury detection time (IDT), peritoneal irritation signs (PIS), systemic inflammation signs (SIS), and treatment modality in these patients. Results: Of the 59 patients, 41 (69.5 %) and 18 (30.5 %) underwent medical and surgical treatment, respectively. Duodenal perforation-related death was observed in five patients, who had received medical therapy (n=2) and surgical therapy (n=3). Among medically treated patients, seven patients (17.1 %) underwent endoscopic clipping immediately after the injury; surgery was not required as a salvage therapy and there were no complications or deaths among these patients. The remaining 34 patients received antibiotics combined with therapeutic fasting and intravenous hydration. Duodenal perforation-related complications depended significantly on IDT (P=0.0001), treatment modality (P=0.008), PIS (P=0.003), and SIS (P=0.010). The duodenal perforation- related mortality was significantly related to IDT (P=0.008) and PIS (P=0.001). Conclusions: IDT, PIS, and SIS appear to be important prognostic factors following ERCP-related duodenal perforation. Medical therapy can be suggested as an initial treatment strategy for ERCP-related duodenal perforation, and if possible, endoscopic clipping is strongly recommended. However, surgical treatment should be considered if the perforation is not expected to seal spontaneously, or if the continuing leakage causes PIS or SIS. [ABSTRACT FROM AUTHOR]

Background and study aims: After endoscopic papillectomy, pancreatic duct stenting is important in preventing pancreatitis, but duct cannulation can be difficult following conventional snare resection. Pancreatic duct wire-guided endoscopic snaring before resection can reduce the post-procedure stenting failure rate. We evaluated the usefulness of this approach. Patients and methods: Pancreatic duct wire-guided endoscopic papillectomy was performed in 72 patients with ampullary adenoma. The snare loop was passed over a guide wire inserted into the pancreatic duct. After resection, a pancreatic stent was immediately placed along or alongside the guide wire. Results: Pancreatic duct stentingwas successful in all patients after endoscopic papillectomy. Postprocedure pancreatitis occurred in 6/72 (8 %), but was mild and resolved with conservative treatment. Complete endoscopic resection of ampullary adenoma was achieved in 65/72 (90 %), with en bloc resection in 60/72 (83 %). There was no procedure-associated mortality. Follow-up (mean 23.7 months) showed recurrence in 5/65 (8 %) who had undergone complete resection. Conclusions: Pancreatic duct wire-guided endoscopic snare papillectomy for ampullary adenoma effectively facilitated pancreatic duct stenting to prevent severe post-procedure pancreatitis. [ABSTRACT FROM AUTHOR]

Acute colonic pseudo-obstruction (Ogilvie syndrome) associated with herpes zoster is extremely rare, and few cases have been reported. An 81-year-old woman diagnosed with herpes zoster was referred for accompanying colonic ileus. The diameter of the cecum was 7 cm and a computed tomographic scan showed no definite obstructive cause. Because the patient showed minimal improvement with conservative treatment, endoscopic colonic decompression was performed successfully. Previous studies revealed that the treatment of Ogilvie syndrome associated with herpes zoster does not differ from that of other conditions, and the role of the varicella-zoster virus in this syndrome is unclear. Here, we present the first case of Ogilvie syndrome associated with herpes zoster in Korea, which was improved by endoscopic colonic decompression. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic forceps biopsy (EFB) as the primary histological diagnosis of gastric epithelial neoplasia (GEN) is debated in the era of endoscopic resection (ER). Our aim was to investigate the diagnostic reliability of EFB in patients with GEN compared with ER specimens as the reference standard for the final diagnosis in a large consecutive series. Methods: This was a cross-sectional retrospective study at a tertiary-referral center. A total of 354 consecutive patients with 397 GENs underwent ER (endoscopic mucosal resection or endoscopic submucosal dissection). Discrepancy rates between the histological results from EFB and ER specimens were assessed. Discrepancies that could affect patient outcome or clinical care were considered major. Results: The overall histological discrepancy rate between EFB and ER specimens was 44.5% (95% confidence interval [CI], 39.7–49.5%) among the enrolled patients. The overall discrepancy rate was significantly higher in the intraepithelial neoplasia (IEN) group than in the carcinoma group (49.8% vs 25.6%, P < 0.001). The major discrepancy rate was also significantly higher in the IEN group than in the carcinoma group (36.6% vs 7.0%, P < 0.001). In subgroup analysis of the IEN group, a major histological discrepancy rate of 33.6% (70/208) for low-grade and 42.7% (44/103) for high-grade IEN was found, respectively. Conclusions: Endoscopic forceps biopsy was insufficient for a definitive diagnosis and therapeutic planning in patients with GEN. ER should be considered as not only definitive treatment but also a procedure for a precise histological diagnosis for lesions initially assessed as GEN by forceps biopsy specimens. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 57-year-old man who has undergone endoscopic retrograde cholangiopancreatography (ERCP) for multiple bile duct and gallbladder stones. The case outlines various endoscopic techniques that have been introduced for removing a proximally migrated pancreatic stent. It also notes the delayed removal following insertion of an additional stent that can help to make more space for inserting removal devices.

Background/Aims Intraductal papillary neoplasm of bile duct (IPNB) is a precursor of invasive carcinoma. However, it can be miss or underdiagnosed by cross-sectional imaging studies and/or cholangiography. Recently, as single operator peroral cholangioscopy (SO-POC) which is easy to maneuver in high image quality has been developed, SO-POC are emerging as one of the diagnostic methods of bile duct diseases. In this study, we evaluated the usefulness of SO-POC for diagnosis and management of IPNB. Methods Data from consecutive patients undergoing SO-POC and diagnosed as IPNB were analyzed. SO-POC was performed with direct POC using an ultra-slim endoscope and/or SpyGlass direct visualization system. All POC findings were reviewed by two experienced investigators. All of IPNB cases were diagnosed as IPNB according to the criteria of World Health Organization 2010 by one expert pathologist. Results A total of 30 patients with IPNB diagnosed by POCs was analyzed. In 16 patients (53.3%), IPNB was not observed in computed tomography and SO-POC was performed for the evaluation of dilated bile duct (n=7) and management of stones (n=7). In 17 patients (56.7%), direct POC with narrow band image and/or I-SCAN was used for evaluation of IPNB. Irregular tortuous and dilated vessels (p=0.012) was found to be significantly associated with invasiveness. POC-guided target biopsy was performed technically successful in all patient. In 11 patients (36.7%), management plan was changed after confirmation of IPNB extent by POC.Background/Aims Intraductal papillary neoplasm of bile duct (IPNB) is a precursor of invasive carcinoma. However, it can be miss or underdiagnosed by cross-sectional imaging studies and/or cholangiography. Recently, as single operator peroral cholangioscopy (SO-POC) which is easy to maneuver in high image quality has been developed, SO-POC are emerging as one of the diagnostic methods of bile duct diseases. In this study, we evaluated the usefulness of SO-POC for diagnosis and management of IPNB. Methods Data from consecutive patients undergoing SO-POC and diagnosed as IPNB were analyzed. SO-POC was performed with direct POC using an ultra-slim endoscope and/or SpyGlass direct visualization system. All POC findings were reviewed by two experienced investigators. All of IPNB cases were diagnosed as IPNB according to the criteria of World Health Organization 2010 by one expert pathologist. Results A total of 30 patients with IPNB diagnosed by POCs was analyzed. In 16 patients (53.3%), IPNB was not observed in computed tomography and SO-POC was performed for the evaluation of dilated bile duct (n=7) and management of stones (n=7). In 17 patients (56.7%), direct POC with narrow band image and/or I-SCAN was used for evaluation of IPNB. Irregular tortuous and dilated vessels (p=0.012) was found to be significantly associated with invasiveness. POC-guided target biopsy was performed technically successful in all patient. In 11 patients (36.7%), management plan was changed after confirmation of IPNB extent by POC. Conclusions SO-POC is useful to detect the IPNB which was not observed by cross-sectional imaging studies and decide the management plan of IPNB. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic management of complicated bile duct stones in patients with benign biliary stricture (BBS) is very challenging. Recently developed modified short length of fully covered self-expandable metallic stent (FCSEMS) can be inserted intraductally and easily removed by long lasso. Our aim was to evaluate the usefulness of short intraductal FCSEMS for endoscopic removal of complicated bile duct stones after relieving of biliary stricture. Methods Twenty-six patients (11 women; median age, 61.5 years [range, 23 to 84 years]) having retained bile duct stones with biliary stricture failed by conventional endoscopic removal included this study. Non-flared short FCSEMS (BONASTENT M-Intraductal) having 7 or 10 cm of lasso was intraductally inserted on stricture. After FCSEMS removal at 6months stenting period, endoscopic stone removal was tried. Primary outcome was complete stone clearance rate. Secondary outcomes were success rate of stent insertion and removal, relieving of biliary stricture rate, and procedure-related adverse events. Results Intraductal placement of FCSEMS was successful in all cases. There were three cases (11.5 %) of stent migration during follow-up. Intended stent removal was successful in other 23 patients. Improvement of biliary stricture revealed in all 23 patients. Complete stone clearance was achieved 22 of 26 patients (84.6%). There were no significant adverse event related to procedures. No stent-induced ductal change was observed in all patients. Conclusions Temporary intraductal placement of unflared FCSEMS may be an effective in endoscopic management of complicated bile duct stones in patients with biliary stricture minimizing stent induced adverse events. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic post-papillectomy bleeding occurs in 3% to 20% of cases and delayed bleeding within 1 week is also problematic. However, there was no definite guideline or consensus for prevention or reduction of delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed post-papillectomy bleeding and reduce the recurrence or persistence of residual tumors. Methods A prospective randomized pilot trial was performed at six tertiary referral centers. Patients with ampulla of Vater adenoma were enrolled from January 2016 to April 2018 and were randomized to either the prophylactic APC or non-APC group. The prophylactic APC group underwent APC on the resection margin. On the day after papillectomy, all patients underwent follow-up duodenoscopy to identify post-papillectomy bleeding and followed up with duodenoscopy at 1, 3, 6, and 12 months. The main outcome measurements were delayed (>24 hours) post-papillectomy bleeding rate and tumor persistent rate between the two groups. Results In total, 54 patients randomized into both group. Delayed bleeding rates in the prophylactic APC and non-APC groups were 30.8% (8/26) and 21.4% (6/28), respectively (p=0.434). Post-procedure pancreatitis rates were 23.1% (6/26) in the prophylactic APC and 35.7% (10/28) in the non-APC groups, respectively (p=0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, p=0.656), 3 months (4.2% vs 3.7%, p=1.00), 6 months (8.3% vs 3.7%, p=0.595), 12 months (0% vs 3.7%, p=1.00) (Table 1). Conclusions The prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding, and might not have an additive role on remnant tumor ablation effect immediately after papillectomy or during follow-up. [ABSTRACT FROM AUTHOR]

Background/Aims Direct peroral cholangioscopy (DPOC) using a conventional ultra-slim endoscope has been limited because of its low and inconsistent success rate in spite of several advantages such as high-quality endoscopic imaging with image-enhanced technology, and the relatively larger working channel. To overcome the technical difficulties of DPOC, a prototype multibending (MB) ultra-slim endoscope has been developed as a dedicated cholangioscope. In this study, we evaluated the clinical usefulness of the DPOC using a MB ultra-slim endoscope with a free-hand insertion of an endoscope into the bile duct. Methods A total of 145 patients with biliary diseases requiring diagnostic and/or therapeutic DPOC were enrolled prospectively. Initially, DPOC using a MB ultra-slim endoscope was tried without device assistance ("free-hand") in all patients up to 15 minutes. The primary outcome was the technical success of free-hand insertion of the MB endoscope during DPOC. Results Free-hand biliary insertion of the MB endoscope for DPOC was technically successful in 133 of 145 patients (91.7%). The procedure time (mean±standard deviation) of DPOC using a free-hand biliary insertion was 2.7±1.6 minutes. DPOC-guided target biopsy was performed in 38 patients (28.6%) and showed technical success in 36 patients (94.7%). Among 110 patients who had no stricture and/or suspicious malignant biliary lesions on previous radiological images, malignant lesion was diagnosed incidentally by DPOC-guided target biopsy in two patients (1.8 %). During the DPOC, total 69 therapeutic interventions were performed and technically successful in 65 patients (94.2%). Adverse events was observed in six patients (4.1%) and treated conservatively in all patients. Conclusions Free-hand biliary insertion of the MB ultra-slim endoscope showed a high technical success rate without severe adverse events. Therefore, the MB endoscope is considered to facilitate broadening the indications for DPOC in various biliary diseases. [ABSTRACT FROM AUTHOR]

Background/Aims In a recent, the endobiliary radiofrequency ablation (RFA) has been showed clinical efficacies in a palliative management of extrahepatic distal malignant biliary stricture. In this study, we evaluated the efficacy and safety of endoscopic stenting after the endobiliary RFA compared with stenting alone in a patients with inoperable hilar cholangiocarcinoma. Methods Total 42 patients diagnosed with inoperable hilar cholangiocarcinoma were enrolled prospectively. Twenty-one patients underwent endobiliary RFA using an automatically temperature controlled RFA catheter (ELRA, STARmed) before endobiliary stenting with plastic or metallic stents (RFA group). The primary outcome was stent patency duration. Results The clinical success rates were not statistically significantly different between the RFA and non-RFA groups (95.2% vs 90.5%, p=1.000). After 3 months, stent patency rates was significantly higher in RFA group than that of non-RFA group (95.2% vs 71.4%, p=0.047). The reintervention due to recurrent biliary obstruction in RFA and non-RFA groups was performed in 12 patients (57.1%) and 18 patients (85.7%), respectively (p=0.043). The median cumulative stent patency duration in RFA group was 8.0 months which was significantly longer than 4.0 months of non-RFA group (log-rank test, p=0.01). In a multivariate analysis, RFA was a favorable independent factor (adjusted hazard ratio, 0.416; 95% confidence interval, 0.198 to 0.876; p=0.021) for stent patency. Survival probability and adverse events were not different between the two groups. Conclusions The endobiliary RFA before endoscopic stenting is considered to be effective for improvement of stent patency in patients with inoperable hilar cholangiocarcinoma. Further randomized controlled trials using a large numbers of subjects are required to confirm the benefit and safety of the endobiliary RFA. [ABSTRACT FROM AUTHOR]

The author reflects on the study "Different strategies for transpancreatic septotomy and needle knife infundibulotomy due to the presence of unintended pancreatic cannulation in difficulty biliary cannulation," by Y. J. Lee and colleagues on the importance of confrontational strategy in the effectiveness of precut papillotomy (PP). Topics include post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), needle-knife infundibulotomy (NKI), and transpancreatic septotomy (TPS).

Background/Aims: The use of a self-expandable metal stent (SEMS) is recommended for unresectable malignant biliary obstruction (MBO). Stent-related adverse events might differ according to the position of the stent through the ampulla of Vater (AOV). We retrospectively evaluated SEMS patency and adverse events according to the position of the SEMS. Methods: In total, 280 patients who underwent endoscopic SEMS placement due to malignant distal biliary obstruction were analyzed retrospectively. Suprapapillary and transpapillary SEMS insertions were performed on 51 patients and 229 patients, respectively. Results: Between the suprapapillary group (SPG) and transpapillary group (TPG), the stent patency period was not significantly different (median [95% confidence interval]: 107 days [82.3 to 131.7] vs 120 days [99.3 to 140.7], p=0.559). There was also no significant difference in the rate of adverse events. In subgroup analysis, the stent patency for an MBO located within 2 cm from the AOV was found to be significantly shorter than that for an MBO located more than 2 cm from the AOV in the SPG (64 days [0 to 160.4] vs 127 days [82.0 to 171.9], p<0.001) and TPG (87 days [52.5 to 121.5] vs 130 [97.0 to 162.9], p<0.001). Patients with an MBO located within 2 cm from the AOV in both groups had a higher percentage of duodenal invasion (SPG: 40.0% vs 4.9%, p=0.002; TPG: 28.6% vs 2.9%, p<0.001) than patients with an MBO located more than 2 cm from the AOV. Conclusions: The SPG and TPG showed similar results in terms of stent patency and rate of adverse events. However, patients with an MBO located within 2 cm from the AOV had a higher percentage of duodenal invasion with shorter stent patency than those with an MBO located more than 2 cm from the AOV, regardless of stent position. [ABSTRACT FROM AUTHOR]

Background/Aims Although a long self-expandable metal stent (SEMS) with a sufficient intragastric portion is preferred for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), it can complicate endoscopic re-intervention for recurrent biliary obstruction (RBO). We evaluated the efficacy and safety of endoscopic re-intervention for RBO through the stent after EUS-HGS using a novel partially covered SEMS with an anchoring flange. Methods The covered SEMS featured a proximal uncovered portion measuring 1.5 cm in length and a resilient fold-back wide distal anchoring flange with a 2.0 cm diameter. Endoscopic re-interventions were performed through the stent lumen while the stent was in situ. The evaluated outcomes were the technical and clinical success of the endoscopic re-intervention, procedure time, and adverse events. Results In total, 35 re-interventions for RBO were performed in 19 patients. The overall technical and clinical success rates were 91.4% (32/35) and 85.7% (30/35). The re-intervention methods included stent cleaning (18.2%), additional HGS stent placement (33.3%), and antegrade stent placement (48.5%). Mild cholangitis occurred in 5.7% (2/35) of patients and was managed conservatively. Conclusion Various types of endoscopic re-interventions for RBO can be effectively and safely performed through the lumen of a new partially covered SEMS with an anchoring flange. [ABSTRACT FROM AUTHOR]

Background/Aims Newly developed image-enhanced endoscopies such as texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) can improve the assessment of obscure ampullary lesions. We aimed to explore the usefulness of TXI and RDI compared to narrow-band imaging (NBI) in differentiating ampullary lesions. Methods Consecutive patients with suspected ampullary lesions underwent sequential endoscopic observation using white-light imaging, NBI, TXI-1, TXI-2, and RDI-3. After the detection and characterization of the ampullary lesions, the final diagnosis was confirmed through histologic findings from forceps biopsy, endoscopic papillectomy, and/or surgery. The evaluated outcomes included the detection rate of endoscopic features suggesting neoplasms and diagnostic accuracy. Results Among the 31 ampullary lesions, 4 (12.9%) were adenocarcinomas, 7 (22.6%) were adenomas, and 20 (64.5%) were benign. TXI-1 demonstrated superior capability compared to NBI in detecting discoloration (41.9% vs. 9.7%, p=0.023), dotted microvessels (35.5% vs. 6.5%, p=0.032), and irregularly dilated and tortuous vessels (38.7% vs. 9.7%, p=0.048). Although the intergroup difference was not significant, RDI-3 showed a trend toward superiority over NBI in evaluating irregular villous arrangements (38.7% vs. 22.6%, p=0.812). NBI outperformed both TXI-1 and RDI-3 in distinguishing the demarcation with normal villi (NBI vs. TXI-1, 45.2% vs. 12.9%, p=0.032; NBI vs. RDI-3, 45.2% vs. 9.7%, p=0.011). In the receiver operating characteristic curve analysis, the combined use of TXI and RDI showed significantly higher accuracy (0.91) than NBI alone (0.74, p=0.021). Conclusion TXI and RDI can enhance the characterization of ampullary lesions, providing a more accurate diagnosis when used in conjunction with NBI. [ABSTRACT FROM AUTHOR]

Background/Aims Although early detection of intraductal neoplasms of the bile duct (IN-B) is crucial for the curative treatment of cholangiocarcinoma (CCA), current diagnostic modalities remain suboptimal. We aimed to evaluate whether disposable digital single-operator cholangioscopy (D-SOC) could be an effective tool for screening intraductal neoplasms of the bile duct in patients with bile duct stones. Methods Consecutive 181 patients who underwent D-SOC after endoscopic bile duct stone removal were enrolled. The primary outcome was the detection rate of intraductal neoplasms of the bile duct, and secondary outcomes were the technical success rates of D-SOC and D-SOC guided forceps biopsy, the diagnostic accuracy of D-SOC findings, adverse events, and the number of patients needed to screen to identify a single intraductal neoplasm. Results D-SOC was successfully performed in all patients, and 23 (13.5%) showed abnormal intraductal superficial lesions of the bile duct. The technical success rate of D-SOC guided forceps biopsy was 91.3% (21/23 patients). Pathological evaluation identified IN-Bs in 9 patients (42.9%) and benign lesions in 12 patients (57.1%); patients with IN-Bs were diagnosed with CCAs (n=2), intraductal papillary neoplasms of the bile duct (n=6), and adenomas with dysplasia (n=1). D-SOC findings afforded 87.5% sensitivity, 91.4% specificity, and 91.3% accuracy, respectively. Curative surgical resection was performed on 2 patients. Mild cholangitis occurred in 3 patients (1.7%) and was managed conservatively. The number of patients who needed to screen to detect a neoplastic bile duct lesion was calculated to be 20.1. Conclusion D-SOC can be a valuable tool for screening intraductal neoplasms of the bile duct, including CCAs, in patients with bile duct stones (NCT05600803). [ABSTRACT FROM AUTHOR]

Background/Aims: Treatment options for difficult bile duct stones are limited. Direct peroral cholangioscopy (POC)-guided lithotripsy may be an option. A newly developed multibending (MB) ultraslim endoscope has several structural features optimized for direct POC. We evaluated the utility of direct POC using an MB ultraslim endoscope for lithotripsy in patients with difficult bile duct stones. Methods: Twenty patients with difficult bile duct stones, in whom stone removal using conventional endoscopic methods, including mechanical lithotripsy, had failed were enrolled from March 2018 to August 2019. Direct POC-guided lithotripsy was performed by electrohydraulic lithotripsy or laser lithotripsy. The primary outcome was complete ductal clearance, defined as the retrieval of all bile duct stones after lithotripsy confirmed by balloon-occluded cholangiography and/or direct POC. Results: The technical success rate of direct POC was 100% (20/20), and the free-hand insertion rate was 95% (19/20). Direct POC-guided lithotripsy, attempted by electrohydraulic lithotripsy in nine patients (45%) and laser lithotripsy in 11 patients (55%), was successful in 95% (19/20) of the patients. Complete ductal clearance after direct POC-guided lithotripsy was achieved in 95% (19/20) of patients. Patients required a median of 2 (range, 1–3) endoscopic retrograde cholangiopancreatography sessions for complete stone removal. Adverse event was observed in one patient (5%) with hemobilia and was treated conservatively. Conclusions: Direct POC using an MB ultraslim endoscope was safe and effective for lithotripsy in patients with difficult bile duct stones. [ABSTRACT FROM AUTHOR]

Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is a first-line diagnostic modality for suspected malignant biliary stricture (MBS), the diagnostic yield of ERCP-based tissue sampling is insufficient. Peroral cholangioscopy-guided forceps biopsy (POC-FB) and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) are evolving as reliable diagnostic procedures for inconclusive MBS. This study aimed to evaluate the usefulness of a diagnostic approach using POC-FB or EUS-FNAB according to the stricture location in patients with suspected MBS.Methods: Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with transpapillary forceps biopsy (TPB) was performed initially. When malignancy was not confirmed by TPB, POC-FB using a SpyGlass direct visualization system or direct POC using an ultraslim endoscope was performed for proximal strictures, and EUS-FNAB was performed for distal strictures as a follow-up biopsy.Results: Among a total of 181 patients, initial TPB showed malignancy in 122 patients, and the diagnostic accuracy of initial TPB was 71.8 % (95 % confidence interval [CI] 65.3 % - 78.4 %]. Of the 59 patients in whom TPB was negative for malignancy, 32 had proximal biliary strictures and underwent successful POC. The remaining 27 patients had distal strictures and underwent successful EUS-FNAB. The accuracy of malignancy detection using POC-FB for proximal biliary strictures and EUS-FNAB for distal biliary strictures was 93.6 % (95 %CI 84.9 %-100 %) and 96.3 % (95 %CI 89.2 %-100 %), respectively. The overall diagnostic accuracy for the combination of TPB with either POC-FB for proximal strictures and EUS-FNAB for distal strictures was 98.3 % (95 %CI 95.9 %-100 %) and 98.4 % (95 %CI 95.3 %-100 %), respectively.Conclusions: An approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS. [ABSTRACT FROM AUTHOR]

Background/Aims: In suspected malignant biliary strictures (MBSs), the diagnostic yield of endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling is limited. Transpapillary forceps biopsy (TPB) under intraductal ultrasonography (IDUS) guidance is expected to improve the diagnostic accuracy in patients with indeterminate biliary strictures. We evaluated the usefulness of IDUS-guided TPB in patients with suspected MBS. Methods: Consecutive patients with suspected MBS were prospectively enrolled in the study. ERCP with IDUS was performed in all patients. Both conventional TPB and IDUS-guided TPB on fluoroscopy were performed in each patient. The primary outcome was the diagnostic accuracy of conventional TPB and IDUS-guided TPB. Results: The technical success rate of IDUS-guided TPB was 97.0% (65/67 patients). Of these 65 patients, the final diagnosis was malignancy in 61 patients (93.8%). On IDUS, the most common finding of IDUS was an intraductal infiltrating lesion in 29 patients (47.5%). The overall diagnostic accuracy was significantly higher using IDUS-guided TPB than that using conventional TPB (90.8% vs 76.9%, p=0.027). According to the subgroup analysis based on the tumor morphology, IDUS-guided TPB had a significantly higher cancer detection rate than conventional TPB for intraductal infiltrating lesions (89.6% vs 65.5%, p=0.028). Conclusions: IDUS-guided TPB appears to improve the accuracy of histological diagnosis in patients with MBS. [ABSTRACT FROM AUTHOR]

Background and study aims I-SCAN is a computed virtual chromoendoscopy (CVC) system designed to enhance surface and vascular patterns. In this study, we evaluated the usefulness of direct peroral cholangioscopy (POC) using I-SCAN compared with a conventional white-light image (WLI) to diagnose bile duct lesions. Patients and methods Patients with mucosal lesions in the bile duct detected during direct POC were enrolled prospectively. The quality of endoscopic visualization and the visual diagnosis were assessed using I-SCAN and WLI modes, respectively, during direct POC. Results A total of 20 patients (9 malignant and 11 benign lesions) underwent I-SCAN to evaluate lesions in the bile duct using direct POC. The quality of endoscopic visualization using direct POC with I-SCAN was significantly higher than that of WLI for surface structure (P = 0.04), surface microvascular architecture (P = 0.01), and margins (P = 0.02). Overall diagnostic accuracy of the visual diagnosis was not different between I-SCAN and WLI (90.0 % vs. 75.0 %; P = 0.20). Conclusion Direct POC using CVC by I-SCAN seems to be helpful for evaluating mucosal lesions of the bile duct, without the interference from bile.Clinical Trial Registration: UMIN000021009. [ABSTRACT FROM AUTHOR]

Background/Aims: Controversy still exists regarding the benefits of covered self-expandable metal stents (SEMSs) compared to uncovered SEMSs. We aimed to compare the patency and stent-related adverse events of partially covered SEMSs (PC-SEMSs) and uncovered SEMSs in unresectable malignant distal biliary obstruction. Methods: A total of 134 patients who received a PC-SEMS or uncovered SEMS for palliation of unresectable malignant distal biliary obstruction were reviewed retrospectively. The main outcome measures were stent patency, stent-related adverse events, and overall survival. Results: The median stent patency was 118 days (range, 3 to 802 days) with PC-SEMSs and 105 days (range, 2 to 485 days) with uncovered SEMSs (p=0.718). The overall endoscopic revision rate due to stent dysfunction was 36.6% (26/71) with PC-SEMSs and 36.5% (23/63) with uncovered SEMSs (p=0.589). Tumor ingrowth was more frequent with uncovered SEMSs (4.2% vs 19.1%, p=0.013), but migration was more frequent with PC-SEMSs (11.2% vs 1.5%, p=0.04). The incidence of stent-related adverse events was 2.8% (2/71) with PC-SEMSs and 9.5% (6/63) with uncovered SEMSs (p=0.224). The median overall survival was 166 days with PC-SEMSs and 168 days with uncovered SEMSs (p=0.189). Conclusions: Compared to uncovered SEMSs, PC-SEMSs did not prolong stent patency in unresectable malignant distal biliary obstruction. Stent migration was more frequent with PC-SEMSs. However, tumor ingrowth was less frequent with PC-SEMSs compared to uncovered SEMSs. [ABSTRACT FROM AUTHOR]

Background/Aims: Treatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS). Methods: EBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events. Results: Among 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days). Conclusions: EBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS. [ABSTRACT FROM AUTHOR]

Choledochal cysts are congenital anomalies of the biliary tract manifested by cystic dilatation of the extrahepatic and intrahepatic bile ducts. Choledochal cyst is not rare in far-East Asian countries. Type II choledochal cysts account for 2% of all such cysts. They are true diverticula of the extrahepatic bile duct and communicate with the bile duct through a narrow stalk. This condition is associated with significant complications, such as ductal strictures, stone formation, cholangitis, rupture and secondary biliary cirrhosis. We describe a case of a huge impacted stone in a diverticular choledochal cyst which masqueraded as an unusual cystic duct stone causing Mirizzi's syndrome.

A 70-year-old man had undergone pancreaticoduodenectomy due to a distal common bile duct malignancy. After the operation, serous fluid discharge decreased from two drain tubes in the retroperitoneum. Over four weeks, the appearance of the serous fluid changed to a greenish bile color and the patient persistently drained over 300 ml/day. Viewed as bile leak at the choledochojejunostomy, treatment called for endoscopic diagnosis and therapy. Cap-fitted forward-viewing endoscopy demonstrated that the distal tip of a pancreatic drain catheter inserted at the pancreaticojejunostomy site had penetrated the opposite jejunum wall. One of the drain tubes primarily placed in the retroperitoneum had also penetrated the jejunum wall, with the distal tip positioned near the choledochojejunostomy site. No leak of contrast appeared beyond the jejunum or anastomosis site. Following repositioning of a penetrating catheter of the pancreaticojejunostomy, four days later, the patient underwent removal of two drain tubes without additional complications. In conclusion, the distal tip of the catheter, placed to drain pancreatic juice, penetrated the jejunum wall and may have caused localized perijejunal inflammation. The other drain tube, placed in the retroperitoneal space, might then have penetrated the inflamed wall of the jejunum, allowing persistent bile drainage via the drain tube. The results masqueraded as bile leakage following pancreaticoduodenectomy.

Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor (NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.

Aim: To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for one-step endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) in a new experimental biliary dilatation porcine model., Methods: A novel dedicated device for one-step EUS-guided biliary drainage system (DEUS) introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation. A self-expandable metal stent, consisting of both uncovered and nitinol-covered portions, was preloaded into DEUS introducer. After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs, EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices., Results: One-step EUS-BD was technically successful in seven pigs [7/9 (77.8%) as intention to treat] without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic (n = 2) or common hepatic (n = 5) duct. Primary technical failure occurred in two cases that did not show adequate biliary dilatation. In seven pigs with a successful bile duct dilatation, the technical success rate was 100% (7/7 as per protocol). Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min (IQR; 8.9-18.1). There were no immediate procedure-related complications., Conclusion: Modified tapered metal tip and low profile introducer may be technically feasible for one-step EUS-BD in experimental porcine model.