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Background: Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound-guided CPN (EUS-CPN) was introduced and has enabled the performance of CPN under real-time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS-CPN in order to enable rational selection of the therapeutic strategy. Patients and Methods: Forty-seven consecutive patients who underwent EUS-CPN at our institutions were eligible for this study. Absolute ethanol containing a contrast medium was injected just above the origin of the celiac trunk from the aorta under real-time EUS guidance, and abdominal computed tomography was performed immediately after the procedure to evaluate the distribution of the injected ethanol. The efficacy in pain relief was evaluated based on the pain score at day 7 after EUS-CPN. Results: Pain relief was obtained in 32 patients (68.1%). Multivariate analysis using a multiple logistic regression model revealed that direct invasion of the celiac plexus and distribution of ethanol only on the left side of the celiac artery were significant factors for a negative response to EUS-CPN (odds ratio = 4.82 and 8.67, P = 0.0387 and 0.0224, respectively). Conclusion: EUS-CPN seems to be less effective in patients with direct invasion of the celiac plexus. Ethanol should be injected on both sides of the celiac axis to obtain greater pain relief.

症例は72歳の男性で，主訴は下血であった．平成9年10月に前立腺癌に対し，ホルモン療法，精巣摘除術，放射線療法，対症的局所切除術が施行された．平成17年12月，直腸狭窄を伴う腫瘤を認め，超音波内視鏡下穿刺吸引生検にて前立腺癌リンパ節再発と診断された．腸管通過障害に対し，双孔式S状結腸人工肛門を造設したが，直腸腫瘍部からの出血が持続するため，平成18年8月，Hartmann手術を施行した．摘出標本の病理組織像は，腺管状のadenocarcinomaであり導管癌と診断されたが，平成9年の初回手術時の前立腺生検標本も同様に導管癌の特徴を有していた．さらに，追加で行った各種免疫染色検査に対して，前立腺生検標本との染色性が類似していたことから，直腸粘膜下病変は前立腺導管癌の転移であると診断した．なお，PSAの値は全経過を通じて正常範囲内であった．前立腺導管癌においては，PSA低値であっても転移，再発を来しうることを念頭におく必要があると考え，報告した．

Background and Aim: Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC. Patients and Methods: The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study. Results: Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.

Background: Recently, endoscopic treatment has been attempted to counter benign biliary strictures. It is expected to be an alternative to surgical operation because of its lower morbidity and its convenience, but the long-term results have not yet been sufficiently elucidated. Here, we evaluate the short- and long-term results of endoscopic stenting in patients with benign biliary strictures, and also describe a new technique using a covered metallic stent (CMS) in the refractory cases. Methods: The charts of 22 consecutive patients with benign biliary stricture treated endoscopically at our institutions between December 1995 and December 2002 were analyzed retrospectively. Results: Stricture etiology was as follows: postoperative, nine; chronic pancreatitis, seven; primary sclerosing cholangitis (PSC), three; and other, three. The stent initially placed was a 7 Fr in 11 patients and a 10 Fr in 11 patients. Eighteen of 22 patients (82%) were successfully treated by the initial treatment, and stents were removed after a mean duration of 3.1 months (range: 1–14 months). In the remaining four patients, stents were exchanged once to four times after that, and a CMS was placed as the second endoprosthesis in two patients with chronic pancreatitis. These stents, including CMS, were finally removed from these four patients after a mean duration of 14.8 months (range: 8–22 months). Over a median follow-up period of 26 months (range: 6–78 months), one recurrence has been observed, in which case a CMS was placed in a patient with chronic pancreatitis. The CMS was removed successfully 6 months after the insertion, and no recurrence was observed during the 6-month follow-up period. Conclusions: Endoscopic stenting for benign biliary stricture is an alternative to surgery because it shows satisfactory results. Placement of a CMS would also be an option in refractory strictures, such as those due in chronic pancreatitis, if the certainty of removal is proven by cumulative experience with a large number of patients.

Background: Endoscopic drainage of pancreatic pseudocysts is becoming common. Recent techniques using endoscopic ultrasound (EUS) have made the procedure safer and easier. However, bleeding related to the procedure is sometimes still experienced and placement of the tube is also sometimes difficult in cases where the cystic wall is thick and hard. We describe a new technique of EUS-guided drainage using a large-channel echoendoscope, a conventional polypectomy snare and a high-frequency current generator with automatic controls. We also evaluate this technique's utility. Methods: Between May 2001 and December 2002, EUS-guided drainage was attempted in consecutive patients with symptomatic pancreatic pseudocysts that had resisted conservative treatments. The EUS device was a recently introduced large-channel linear scanning echoendoscope. A puncture was made with a 19 G needle under EUS guidance and a 0.035 inch guidewire was passed through the puncture and into the pseudocyst. Then, a conventional polypectomy snare was used to enlarge the puncture tract with the new current generator, and a 7 Fr pigtail-type nasocystic drain was placed. Results: The drainage was successful and insertion of the drain was easy in all 13 patients included in the study. No complications related to the procedure, such as bleeding and perforation, were observed. The clinical symptoms resolved after the procedure in all patients. In nine patients, the cyst completely disappeared and the discharge also stopped, allowing the tube to be removed after a mean of 15 days. The median follow-up period for these nine patients was 4 months and no recurrence has been observed. In two other patients, the cysts shrank but did not disappear completely 4 weeks or more after the procedure. Since both of these patients had had previous cystic infections, they were given surgical operations. In the remaining two cases, the cystic lumen completely disappeared but the discharge continued for 4 weeks, so we replaced the 7 Fr nasobiliary tube with a 10 Fr internal drainage tube. Conclusion: This method is an easy and effective treatment for pancreatic pseudocysts. It may also reduce the risk of bleeding related to the procedure.

Diagnosis of the upstream extent of extrahepatic bile duct cancer has been difficult via the transpapillary approach, due to the difficulty of obtaining a biopsy sample above the stricture. We developed a new biopsy technique that allows a sample to be taken above the stricture, and prospectively evaluated the new technique's utility. Twenty-four consecutive patients diagnosed as having possible extrahepatic bile duct cancer by endoscopic retrograde cholangiopancreatography and other imaging tests were included in the study. They initially underwent endoscopic placement of a nasobiliary drainage tube. After improvement of jaundice and cholangitis, the cholangiogram obtained via the tube was examined and transpapillary biopsy was performed using a double lumen catheter under fluoroscopic guidance. The biopsy sampling in the stricture was successful in all cases, and pathological diagnosis was confirmed in all cases. The success rate of the method of upstream diagnosis was also sufficient in cases in which stricture was located below the middle extrahepatic bile duct. However, it was relatively low in cases whose stricture was located in the upper extrahepatic bile duct. Biopsy sampling in the hepatic hilum was also difficult. The transpapillary biopsy technique is useful for determination of the upstream extent of extrahepatic bile duct cancer, especially in cases in which stricture is located in the lower extrahepatic bile duct. Compared to the percutaneous transhepatic approach, it is less invasive and can shorten the preoperative period. It was also seen to be relatively safe, easy and convenient.

Inflammatory pseudotumor (IPT) of the liver is a rare benign variant of hepatic masses, and its exact etiology has not been elucidated. We report a case of IPT associated with primary sclerosing cholangitis (PSC). The patient was a 50-year-old man admitted to our hospital because of jaundice. Abdominal ultrasonography (US) and computed tomography showed multiple dilations of the intrahepatic bile ducts and multiple masses in the liver. On magnetic resonance imaging, the masses were slightly hypointense on T1-weighted images and slightly hyperintense on T2-weighted images. On T1-weighted images after the bolus infusion of Gd chelate, the masses had no contrast enhancement, and they were hypointense in the arterial phase and portal venous phase. However, they were slightly enhanced and became almost isointense relative to the surrounding normal liver parenchyma in the delayed phase. Endoscopic retrograde cholangiography demonstrated multiple irregular strictures and dilations of the intrahepatic bile ducts. Angiography demonstrated no abnormal findings, but, interestingly, subsequent dynamic CO2-enhanced US showed a strongly hyperechoic string, indicating that an artery had penetrated through the hypoechoic mass. A US-guided percutaneous needle biopsy revealed that the lesions were morphologically comparable to IPT. After cholangiography and microscopic analysis of the tumor, the final diagnosis was determined to be IPT of the liver with PSC. A number of previous reports have suggested a possible relationship between IPT and PSC, based on pathological findings. This report confirmed, based on clinical findings, that PSC is one of the causes of hepatic IPT.

Background Endoscopic papillary balloon dilatation (EPBD) is generally considered a safe and effective technique for removal of common bile duct (CBD) stones. However, some reports have prompted concern about the risk of pancreatitis following the procedure, and it seems to be more difficult and to require adjunctive procedures more frequently in patients with large stones. Aims To analyse the factors influencing pancreatitis after the procedure, and to examine which is the more suitable adjunct for treating large stones, mechanical lithotripsy (ML) or extracorporeal shockwave lithotripsy (ESWL). Patients and methods EPBD was performed in 92 patients, including 40 with large stones (≥ 12 mm). These 40 patients were randomly assigned to two groups receiving ML or ESWL to fragment stones (20 patients each). Results Complete ductal clearance was obtained in all 92 patients. Significant elevation of the serum amylase level compared with the prior value (> 300 IU/I) was observed in 26 (28%), and eight (8.7%) developed clinical pancreatitis. To assess the influence of various factors on the amylase level, multivariate analysis was used. The number of stones and the time required for treatment had a significant influence on the incidence of increased amylase level (P < 0.05), and ML also significantly increased it (P < 0.05). On the other hand, the amylase level remained low in the ESWL group. ML caused elevation of amylase level in 11 patients (55%), while three (15%) had elevation after ESWL. Conclusions In patients with multiple stones, elevation of the amylase level is more frequent. This seems to be because repeated cannulation and much time is required for treatment. In patients with large stones, the rate was also high if ML was used, but was low when ESWL was used. ESWL may reduce the incidence of pancreatitis.

Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound-guided CPN (EUS-CPN) was introduced and has enabled the performance of CPN under real-time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS-CPN in order to enable rational selection of the therapeutic strategy.Forty-seven consecutive patients who underwent EUS-CPN at our institutions were eligible for this study. Absolute ethanol containing a contrast medium was injected just above the origin of the celiac trunk from the aorta under real-time EUS guidance, and abdominal computed tomography was performed immediately after the procedure to evaluate the distribution of the injected ethanol. The efficacy in pain relief was evaluated based on the pain score at day 7 after EUS-CPN.Pain relief was obtained in 32 patients (68.1%). Multivariate analysis using a multiple logistic regression model revealed that direct invasion of the celiac plexus and distribution of ethanol only on the left side of the celiac artery were significant factors for a negative response to EUS-CPN (odds ratio = 4.82 and 8.67, P = 0.0387 and 0.0224, respectively).EUS-CPN seems to be less effective in patients with direct invasion of the celiac plexus. Ethanol should be injected on both sides of the celiac axis to obtain greater pain relief.

The diagnosis of lymphadenopathy after treatment of malignancy is sometimes difficult, especially in patients whose treatment was deemed curative and without local recurrence or those who have increased serum levels of related tumor markers. We aimed to evaluate the effectiveness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as a diagnostic tool in patients with lymphadenopathy after curative treatment of malignancy.Consecutive patients with mediastinal, intraabdominal, or pelvic lymphadenopathy after curative treatment of malignancy who were referred to our hospital between October 2003 and September 2007 were enrolled in this study.A total of 62 patients were included. The lymph nodes were located at the mediastinum in 22 patients, intraabdomen in 38 patients, and intrapelvis in 2 patients. From the pathological findings of the FNA sample, 31 patients (50%) were confirmed to have recurrence of the prior malignancy, and 9 patients (15%) were diagnosed as having a different new malignancy. The remaining 22 patients (35%) were shown to have no recurrence or no other malignancies. However, 1 of them was later diagnosed with recurrence by open laparotomy. The overall sensitivity, specificity, accuracy, and positive and negative predictive values of the EUS-FNA were 97%, 100%, 98%, 100%, and 97%, respectively.Lymphadenopathy after treatment of malignancy is not a definitive sign of recurrence. Therefore, pathological sampling and diagnosis are essential for determining the appropriate treatment. For this purpose, EUS-FNA is a safe, convenient, and minimally invasive procedure with high diagnostic value.

Background/Aims: We assessed the usefulness of the Cornell Medical Index (CMI) and electroencephalogram (EEG) in the prediction and early detection of psychoneurological symptoms associated with interferon (IFN) therapy for chronic viral hepatitis. Methods: Forty-eight consecutive patients received IFN for chronic viral hepatitis for 8–24 weeks. CMI was measured before IFN therapy. Serial EEGs were recorded before IFN therapy, 2, 4 weeks, and thereafter every 4 weeks in the therapy. Results: Psychoneurological symptoms including insomnia, depression, and restlessness were seen in 11 (23%) of 48 patients. Five (13%) of 40 patients with CMI I and II and six (75%) of eight with CMI III developed psychoneurological symptoms (P

Background & Aims: Because impaired regeneration after surgical treatment of the liver is influenced by circulating endotoxin, the underlying molecular mechanism was investigated. Methods: Lipopolysaccharide (LPS) was injected intraperitoneally into mice, followed 24 hours later by 67% partial hepatectomy. We measured serum tumor necrosis factor (TNF) α levels as well as proliferating cell nuclear antigen labeling index, transforming growth factor (TGF) β expression, and plasma kallikrein (PLK) activities in regenerating livers. We also examined the effect of LPS, TNF-α, and PLK on latent TGF-β activation in homotypic and heterotypic cultures of rat or mouse hepatic stellate cells and Kupffer cells. Results: Serum TNF-α levels increased after LPS (500 ng/g body wt) injection and after partial hepatectomy, accompanying TGF-β–mediated suppression of hepatic proliferating cell nuclear antigen labeling index. This suppression was mimicked by a combination of preadministration of 50 ng/g body wt LPS and postoperative administration of 5 ng/g body wt TNF-α. In vitro, LPS stimulated Kupffer cells to secrete TNF-α, which enhanced PLK activity on the hepatic stellate cell surface through increasing PLK binding, thereby inducing proteolytic activation of latent TGF-β and its autoinduction. Blockade of TGF-β, TNF-α, or PLK activity prevented LPS-induced impaired regeneration in vivo. Conclusions: LPS provokes TNF-α/PLK–mediated proteolytic activation of latent TGF-β in hepatic stellate cells, leading to impaired liver regeneration after partial hepatectomy. GASTROENTEROLOGY 2002;123:352-364

Endoscopic papillary balloon dilation (EPBD) is considered to cause less trauma to the papilla than EST. However, it ha not been elucidated whether or not the preservation of papillary function is clinically meaningful. Aims: We compared papillary damage between post-EPBD and post-EST, and analyzed the incidence of later complications in each group. Methods:We evaluated the sphincter of Oddi function one year after treatment in each of 30 patients using a 4Fr. microtransducer catheter (Gaeltec Ltd.) via endoscopy.We also studied the incidence of pneumobilia and later complications in 171 post-EPBD patients and in 72 post-EST patients. Incidence of pneumobilia were detected by abdominal radiograph, ultrasonography, and computed tomography. Results: All manometric data, i.e., basal pressure, peak pressure and contraction frequency, was more reduced in post-EST patients than in post-EPBD patients, with a statistically significant difference. In 20 post-EST patients, the contraction wave had disappeared completely. The incidence of pneumobilia 1 year after the procedure was 8% (13/171) in post-EPBD patients and 47% (34/72) in post- EST patients. Recurrence of the stone was observed in 4% of post-EPBD patients and in 4% of post-EST patients in a period of one year, in 8% and in 6% for 2 years, in 8% and in 10% for 4 years, respectively. Cholangitis was observed in 0% of post-EPBD patients and in 3% (2/72) of post-EST patients. Gallbladder was preserved in 100 patients (58%) in the post- EPBD group and in 24 patients (33%) of the post-EST group, and cholecystitis was observed in 3% (3/100) and in 4% (1/24), respectively. Frequently recurrent cases (more than 3 times for 3 years) were observed in one post-EPBD patient and in 3 post-EST patients, and all of them presented pneumobilia. Conclusion: EPBD can preserve sphincter of Oddi function relative to the effects of EST. But it is still uncertain whether or not such preservations clinically meaningful.