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Additional file 1. Table S1. Comparison of diagnostic accuracy between two needles.

Additional file 2. Table S2. Comparison of diagnostic accuracy in each pancreatic location between two needles.

BACKGROUND AND AIM Several experts of direct peroral videocholangioscopy (D-PVCS) using a conventional ultraslim endoscope have reported its usefulness for the diagnosis and therapy of biliary tract diseases. We have additionally developed a dedicated double-bending D-PVCS technique for freehand scope insertion. In this study, we developed an ex vivo training model for the freehand double-bending D-PVCS technique and compared it with the technique using a conventional ultraslim endoscope. METHODS The ex vivo model was made for training using a U-shape insertion pattern. A third prototype endoscope and an ultraslim upper gastrointestinal endoscope were used. Two experts and nine non-experts performed D-PVCS using the freehand technique. RESULTS The two experts could not advance the tip of the endoscope to the hilar portion using the freehand technique, but they could achieve technical successful insertion to the hilar portion with the third prototype cholangioscope using the freehand technique alone. The non-experts could not advance the tip of the endoscope to the bile duct using the freehand technique. On the other hand, two (22.2%) non-experts could advance the tip of the third prototype cholangioscope using the freehand technique before the training conducted by the experts. After the training, all the non-experts could advance the tip of the third prototype cholangioscope to the hilar portion. CONCLUSIONS The novel ex vivo model using a third prototype cholangioscope was useful for training in the use of the freehand D-PVCS technique.

Background and Aims There are currently no prospective, controlled trials of needle puncture speed in EUS-guided FNA (EUS-FNA). In this study, we prospectively evaluated the accuracy of histological diagnosis and the tissue acquisition rate of EUS-FNA by using the door-knocking method (DKM) with a standard 22-gauge needle. Methods From November 2013 to August 2014, 82 patients who had solid pancreatic masses underwent EUS-FNA in which the conventional method (CM) and DKM with 2 respective passes in turn were used. The primary outcomes of this study were the accuracy of histological diagnosis and the rates of tissue acquisition in 2 FNA procedures by using these 2 methods. Results Although the successful tissue acquisition rate for histology was not significantly different with the DKM and CM (91.5% vs 89.0%, P = .37), the high cellularity tissue acquisition rate for histology with the DKM was significantly superior to that with the CM (54.9% vs 41.5%, P = .03). However, adequate quality rate and accuracy were not different in the DKM and CM (78.0% vs 80.5%, P = .42 and 76.8% vs 78.0%, P = .50, respectively). In the transgastric puncture group, although the adequate quality rate and accuracy were similar in the DKM and CM (84.1% vs 79.4%, P = .30 and 84.1% vs 76.2%, P = .11, respectively), the tissue acquisition rate tended to be higher with the DKM than the CM (93.7% vs 85.7%, P = .06). Moreover, the high cellularity tissue acquisition rate was significantly better with the DKM than the CM (63.5% vs 39.7%, P = .002). On the other hand, in the transduodenal puncture group, although the tissue acquisition rate was similar with the DKM and CM (84.2% vs 100%, P = .13), the adequate quality rate and accuracy were significantly lower with the DKM than with the CM (57.9% vs 84.2%, P = .03 and 52.6% vs 84.2%, P = .02, respectively). Conclusion EUS-FNA by using a 22-gauge needle with the DKM did not improve the accuracy of histological diagnosis, but enabled acquisition of a larger amount of tissue specimen by using transgastric puncture. (Trial Registration: http://www.umin.ac.jp/english/: UMIN000012127.)

A 58-year-old Japanese woman came to our institution because of leg edema and abdominal distention. She had developed acute pancreatitis 5 times in the past 3 years. Dilation of the bile duct and main pancreatic duct without obstruction was observed on computed tomography and magnetic resonance cholangiopancreatography. The presence of Strongyloides stercoralis was highly suspected from the biopsy sample from the duodenal papilla. Polymerase chain reaction amplification and sequencing of small subunit rDNA from paraffin-embedded specimens identified the worm as S. stercoralis. All of the symptoms were considered to be associated with S. stercoralis infection. Therefore, the patient was treated with oral administration of ivermectin. Subsequently, symptoms and laboratory data improved. There has been no recurrence of the symptoms to date.

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-choice treatment for patients with obstructive jaundice. However, there are patients in whom bile duct access is not possible. In these patients, percutaneous transhepatic biliary drainage (PTBD) may be performed as an alternative biliary drainage method. PTBD is reportedly associated with a moderate mortality rate. In recent years, endoscopic ultrasonography-guided biliary drainage (EUS-BD) in patients with failed ERCP has been reported as an alternative to PTBD. EUS-BD is classified into three techniques: (1) EUS-guided choledocoduodenostomy (EUS-CDS); (2) EUS-guided hepatogastrostomy (EUS-HGS); and (3) EUS-guided antegrade (EUS-AG) approach. Herein, we focus on the current status of EUS-BD in light of these techniques.

Background Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent. Objective We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma. Design Retrospective case series. Setting Single tertiary referral medical center. Patients We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital. Interventions EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent. Main Outcome Measurements Technical success, clinical success, and adverse event. Results The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success rates of EUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days). Limitations Small sample size and no control group. Conclusions EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma.

There are currently no plastic pancreatic duct stents that have been designed for endoscopic ultrasonography (EUS)-guided placement. This study prospectively evaluated the feasibility and efficacy of a new, single-pigtail, plastic stent. Eight patients with main pancreatic duct stricture or stenotic pancreatojejunostomy underwent EUS-guided placement of the pancreatic duct stent. The stent was placed successfully in all cases (8/8). Treatment success was achieved in all cases (8/8). A mild adverse event associated with the procedure was observed in one patient but there were no other adverse events during a mean follow-up of 7.4 months. This new pancreatic duct stent appears to be feasible and effective for EUS-guided stenting.

Endoscopic transpapillary gallbladder drainage (ETGBD) is a difficult procedure to perform, and its technical success rate is reportedly lower than that of percutaneous transhepatic gallbladder drainage (PTGBD). Therefore, ETGBD is regarded and positioned as an alternative to PTGBD, and advanced techniques and tips are often needed for a successful ETGBD. ETGBD is classified into two types, namely, endoscopic naso-gallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS). The selection of ENGBD or EGBS should be decided after carefully considering the situation and status of the patient as well as after a detailed examination and treatment planning for the patient. Importantly, prospective studies involving a large number of patients for long-term EGBS are needed. ETGBD is a useful alternative to PTGBD and should be performed at institutions with skilled endoscopists. In this section, we describe the status of ETGBD and provide valuable technical tips in effectively performing ETGBD.

Several experts of direct peroral videocholangioscopy (D-PVCS) using a conventional ultraslim endoscope have reported its usefulness for the diagnosis and therapy of biliary tract diseases. We have additionally developed a dedicated double-bending D-PVCS technique for freehand scope insertion. In this study, we developed an ex vivo training model for the freehand double-bending D-PVCS technique and compared it with the technique using a conventional ultraslim endoscope.The ex vivo model was made for training using a U-shape insertion pattern. A third prototype endoscope and an ultraslim upper gastrointestinal endoscope were used. Two experts and nine non-experts performed D-PVCS using the freehand technique.The two experts could not advance the tip of the endoscope to the hilar portion using the freehand technique, but they could achieve technical successful insertion to the hilar portion with the third prototype cholangioscope using the freehand technique alone. The non-experts could not advance the tip of the endoscope to the bile duct using the freehand technique. On the other hand, two (22.2%) non-experts could advance the tip of the third prototype cholangioscope using the freehand technique before the training conducted by the experts. After the training, all the non-experts could advance the tip of the third prototype cholangioscope to the hilar portion.The novel ex vivo model using a third prototype cholangioscope was useful for training in the use of the freehand D-PVCS technique.

Background and Aim Endoscopic sphincterotomy (ES) combined with large balloon dilation (ESLBD) can be useful for extracting large and multiple bile duct stones. Although there are many studies on the feasibility and short-term outcome, there are few reports about mid- to long-term outcome after ESLBD. The aim of our study is to prospectively evaluate the mid-term outcome of ESLBD. Methods One hundred eighty-three patients who underwent ESLBD between November 2006 and May 2012 were included. The patients were followed up periodically after the procedure until April 2013. Papillary dilation was performed at the time of initial ES or prior ES. Early and late adverse events and stone recurrence were evaluated in this study. Results The patients' mean age was 76.6 ± 10.7 years. Surgically altered anatomy was present: Billroth I gastrectomy (2), Billroth II gastrectomy (13), and gastrectomy with Roux-en Y reconstruction (18). Seventy-eight (42.6%) patients had periampullary diverticulum. Prior ES had been performed in 40 (21.9%) patients. The mean follow-up period was 43.5 ± 19.7 months (range 11–78). Eight (4.4%) patients had stone recurrence. There was rare stone recurrence after initial ESLBD treatment and native gastrointestinal anatomy. Univariate and multivariate analyses showed that prior ES and previous history of stone recurrence were predictive of stone recurrence (P

Recently, a novel fully covered and biflanged metal stent (BFMS)dedicated to the drainage of walled-off necrosis(WON) was developed. The aim of this study was to retrospectively evaluate the safety, efficacy, and cost performance of drainage of WON using the novel BFMS compared with a traditional plastic stent.A total of 70 patients with symptomatic WON were treated under endoscopic ultrasound (EUS) guidance. Initial drainage was conducted using the single gateway technique with placement of one or more plastic stents or a single BFMS.If drainage was unsuccessful,direct endoscopic necrosectomy (DEN)was performed.There were no statistically significant differences in rates of technical success, clinical success,and adverse events between plastics stents and BFMS, despite the size of WON in the BFMS group being significantly larger than that in the plastic stent group (105.6 vs. 77.1 mm; P=0.003).The mean procedure times for the first EUS-guided drainage and for re-intervention were significantly shorter in the BFMS group than in the plastic stent group (28.8±7.1 vs. 42.6±14.2, respectively,for drainage, P0.001; and 34.9±8.5 vs.41.8±7.6, respectively, for re-intervention, P0.001). There was no statistically significant difference in the total cost between plastic stent and BFMS use in the treatment of WON ($5352vs. $6274; P=0.25).Plastic stents and BFMS were safe and effective for the treatment of WON. In particular,BFMS placement appeared to be preferable for initial EUS-guided drainage and additional reintervention(e.g. DEN) as it reduced the procedure time. Prospective randomized controlled trials are warranted.

Minimally invasive interventions for choledocholithiasis are preferable in elderly patients because they tend to have multiple underlying disorders or a decreased activity of daily living. Endoscopic sphincterotomy and endoscopic papillary balloon dilation have been recognized as first-line treatments for choledocholithiasis excluding difficult cases such as large stones or multiple stones. Recently, the safety and efficacy of endoscopic papillary large balloon dilation (EPLBD) for difficult choledocholithiasis cases have been reported, although scarcely in elderly patients. To investigate whether EPLBD can be safety and effectively performed in patients aged 75 years or older. The medical records of 165 patients who underwent EPLBD from November 2006 to August 2013 were analyzed retrospectively. The patients were divided into 2 groups: Group A (≥75 years); Group B (

Background and study aims: 19-gauge (19G) needles are used for EUS-guided tissue acquisition and interventions. The aim of the current study was to compare the functional characteristics of 19G EUS needles by means of using various echoendoscopes in a bench simulator. Methods: The angles achieved for 19G needles (EchoTip: ET-19G, EchoTip Flex: ExF-19G, Expect: Ex-19G, and ProCore: PC-19G) and for the distal tip of the echoendoscope were evaluated for maximal angulation settings of the distal tip and the elevator. Also the resistance to advancement of the 19G needles at these endoscope settings was assessed. All evaluations were done with endoscopes in a straight and in a curved position. Results: There was no large discrepancy for scope and needle angles among all echoendoscopes except for the slim Pentax scope (EG-3270UK). The ExF-19G and PC-19G needles showed better optimal angles in various conditions compared to standard 19G needles. In straight scope position, out of the 20 conditions (5 endoscopes × 2 positions of the distal tip × 2 elevator positions) the numbers of optimal angulations achieved for the Ex-19G, ExF-19G, ET-19G, and PC-19G, were 11 /20 (55 %), 20 /20 (100 %), 14 /20 (70 %) and 18 /20 (90 %), respectively. However, regarding resistance, it was impossible to advance theneedle with 14 /20 settings (70 %) for the Ex-19G, 3 /20 (15 %) for the ExF-19G, 10 /20 (50 %) for the ET-19G and 7 /20 (35 %) for the PC-19G. When the scopes were bent, with regard to the force needed to advance the needle, the numbers of optimal settings, for the Ex-19G, ExF-19G, ET-19G, and PC-19G, were 1 (5 %), 13 (65 %), 6 (30 %) and 8 (40 %), respectively. The mean maximum resistance to advancement was less for the ExF-19G than for the other needless in almost all scope and angle conditions (p

Background and Aims Pancreatic duct guidewire placement (P-GW) techniques include both the injection cannulation technique with a contrast medium and wire-guided cannulation without contrast injection for selective biliary cannulation; the latter is the so-called “double-guidewire technique” (D-GW). The aim of this study was to compare the outcomes between P-GW and D-GW for biliary cannulation. Methods The procedures for biliary cannulation with a naive papilla were performed in a total of 363 cases. We divided the patients chronologically, according to the time period during which the procedures were performed, into two groups: group A, P-GW performed from March 2008 to June 2009; and group B, D-GW performed from July 2009 to December 2010. The success rates and complication rates were evaluated in each group. Results Biliary cannulation was successful in 31 (81.6%) patients in the P-GW group and 34 patients (82.9%) in the D-GW group. The onsets of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) occurred in the P-GW and D-GW groups were four (10.5%) and three (7.3%) patients, respectively, and all were mild cases (P = 0.616). The frequency of hyperamylasemia and the serum amylase level tended to be lower in the D-GW group than in the P-GW group (P = 0.213). There was a statistically significant difference on the onsets of PEP in the GW and non-GW groups (P = 0.04, 8.9% and 1.1%, respectively). Conclusions Both the D-GW and P-GW techniques were equally effective for difficult biliary cannulation. Furthermore, the complication rates, including PEP, were similar in both techniques. A prospective randomized trial is warranted.

Biliary self-expandable metallic stent (SEMS) is the preferred and first-line therapy for unresectable malignant biliary obstruction. To date, several reports have revealed the relatively high incidence of acute complications such as pancreatitis and cholecystitis due to mechanical stent compression. In the present case, we encountered fatal pancreatitis following fully covered metal stent placement. An 85-year-old man had middle bile duct strictures due to cholangiocarcinoma. A 10-mm diameter fully covered SEMS was placed across the papilla for biliary decompression. Laboratory data and physical evidence the following day revealed acute pancreatitis. Therefore, antibiotics and protein degeneration enzyme inhibitors were given. However, his condition did not improve. Two days after the procedure, we removed the stent and returned him to his original hospital. Serum amylase level decreased below 400 mg/dL 6 h after the procedure. However, the acute pancreatitis worsened. Although we treated the patient in the intensive care unit, he died 32 days after the second admission.

Background and Objectives: There have been few studies to date evaluating the effectiveness of contrast-enhanced endoscopic ultrasound (CE-EUS) for detecting mural nodules in patients with branch duct-type intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas. We aim to evaluate the effectiveness of CE-EUS for detecting mural nodules in BD-IPMN. Patients and Methods: Of the 427 BD-IPMN patients, 21 patients (4.9%) in whom the presence of mural nodules was suggested by CE computed tomography (CT) or magnetic resonance imaging (MRI), or in whom the presence of nodule-like lesions as shown by fundamental EUS, were examined by CE-EUS. Results: The mean diameter of cystic lesions was 29.8 ± 12.8 mm. The mean diameter of mural nodules was 9.5 ± 5.7 mm. BD-IPMN was detected in the pancreatic head in 16 cases, pancreatic body in 2 cases, and pancreatic tail in 3 cases. The mean follow-up period was 17.2 ± 11.9 months. The detection rates of mural nodule-like lesions in BD-IPMN patients on CT, MRI, and fundamental EUS were 36.8%, 63.2%, and 100%, respectively. The detection rates of true mural nodules in BD-IPMN patients on CT, MRI, and fundamental EUS were 85.7%, 71.4%, and 100%, respectively. The echo levels of mural nodule-like lesions on fundamental EUS were hyperechoic in 6 patients, isoechoic in 9 patients, and hypoechoic in 6 patients. The final diagnosis was mucus lumps in 14 patients and mural nodules in 7 patients. The contrast patterns observed were avascular, isovascular, and hypervascular in 14, 3, and 4 patients, respectively. No patients showed a hypovascular pattern. Fourteen patients showing an avascular pattern were diagnosed as having mucus lumps, and they were able to avoid surgical resection. Of the 7 patients who were diagnosed as having mural nodules, 5 underwent surgical resection. The pathological findings were adenocarcinoma in 2 patients and adenoma in 3 patients. Of the 3 adenoma patients, fundamental EUS demonstrated a hypoechoic area in 1 patient and an isoechoic area in 2 patients. Of the 2 adenocarcinoma patients, 1 each showed a hypoechoic area and a hyperechoic area. It was difficult to distinguish between patients with adenoma and patients with adenocarcinoma using the echo levels obtained from fundamental EUS. Conclusions: CE-EUS may be useful for avoiding the overdiagnosis of BD-IPMN with mural nodule-like lesions. However, it has difficulty in distinguishing between clearly benign and malignant lesions in BD-IPMN.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been carried out as an alternative to the percutaneous or surgical approach when endoscopic retrograde cholangiopancreatography fails. However, there is no standard technique or device for EUS-BD. In this review, we focus on how we choose the stents and described our tips on this EUS-BD technique. The plastic stent (PS) and the self-expandable metallic stent (SEMS) are used for EUS-BD. The latter is further divided into the fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and uncovered SEMS (UCSEMS) types. Although PS is not expensive, the duration of stent patency is short. SEMS is expensive but the duration of stent patency is long. With UCSEMS, basically there is no stent malpositioning; however, if the gap between the bile duct and the GI tract becomes displaced, bile leakage from the mesh of the stent is likely to occur. Though there is no bile leakage with FCSEMS, the side branch of the bile duct may become occluded, and migration and dislocation sometimes occur. PCSEMS is basically similar to FCSEMS. When EUS-BD was first developed, drainage by PS was common, although reports on drainage by SEMS have increased recently.

There are few reports on the histological diagnostic ability of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in a large-series of pancreatic masses. In the present study therefore we retrospectively evaluated the histological diagnostic ability of EUS-FNA in pancreatic masses without on-site cytopathologist. In 355 patients with pancreatic solid masses, EUS-FNA was carried out. EUS-FNA histology showed accuracy, 90.7%; sensitivity, 89.5%; specificity, 95.6%; positive predict value, 98.8%; negative predict value, 68.8% by intention-to-treat analysis. Except for 10 with inadequate materials, EUS-FNA histology showed accuracy, 93.3%; sensitivity, 91.8%; specificity, 100%; positive predict value, 100%; negative predict value, 77.6%. The mean number of puncture was 2.88 (range 1 to 8). There was two (0.6%) procedure-related bleeding. In conclusion, diagnostic ability of EUS-FNA by histological materials was similar to previous literature on the EUS-FNA without on-site cytopathologist.

Background Extraction of bile duct stones in patients who have undergone Roux-en-Y anastomosis can be challenging. Recently, large balloon dilation following endoscopic sphincterotomy has been shown to be useful for the removal of bile duct stones. Aim We retrospectively evaluated the feasibility and safety of endoscopic sphincterotomy large balloon dilation for the removal of bile duct stones in patients with Roux-en-Y anastomosis. Methods Large balloon papillary dilation following EST for the removal of bile duct stones was performed on the intact papilla in 15 patients with Roux-en-Y anastomosis at our institution. When we could not use the long-type accessories, a conventional forward-viewing upper endoscope passed through the over tube of the single-balloon or double-balloon enteroscope for the use of short-type accessories. Following endoscopic sphincterotomy, a large balloon catheter was positioned across the main duodenal papilla. The size of large balloon used ranged from 15 mm to 20 mm. Results Complete clearance of bile duct stones was achieved in all cases in the initial session without any adverse events. A mechanical lithotriptor for crushing stones was used in one patient (6.7%). Conclusion Large balloon papillary dilation following EST appears to be an effective and safe treatment for difficult-to-remove bile duct stones in patients with Roux-en-Y anastomosis .

Self-expandable metallic stent (SEMS) placement is a widely used, effective therapy for unresectable malignant stricture of the lower bile duct.We evaluated the short-term outcome of the newly developed WallFlex(®) Biliary RX Partially Covered Stent in patients with malignant lower and middle biliary stricture in five tertiary referral centers.The subjects of this study were 52 patients in whom WallFlex(®) Biliary RX Stents were inserted into the bile duct for malignant stenosis of the middle and lower bile duct at five medical facilities between April 2009 and November 2009.The stent placement success rate was 100%. Effective biliary decompression was achieved in all patients. The incidence of early complications was 7.7% (4/52). Stent occlusion occurred in two patients (3.8%) (one dislocation, one migration); cholecystitis occurred in two patients (3.8%). Neither acute pancreatitis nor stent kinking in the bile duct occurred.The present results revealed that the new WallFlex(®) Biliary RX Partially Covered SEMSs were useful for the short-term relief of biliary obstruction due to unresectable distal biliary malignancies.

膵疾患において血流動態を加味したCE-USは，鑑別診断および進展度診断に有用とされている．しかし高音圧性の超音波造影剤Levovist®を用いたCE-USでは限界があり問題点も明らかとなってきた．そのためより精密な描出や評価が可能となる第2世代低音圧性超音波造影剤Sonazoid®や新しく開発された造影超音波手法を用い，これまでのLevovist®を用いたCE-USとの比較検討をおこなった．結果では，総じてSonazoid®がLevovist®より緻密な画像が得られ，これまで以上に正確な染影評価が可能であった．Sonazoid®を使用することでLevovist®では映像化が困難であった微小血管内でのマイクロバブルの細かい動きをリアルタイムに繰り返し可視化することができた．特に悪性腫瘤では腫瘤内部の微小血管に一致してマイクロバブルが不規則に揺れ動く，いわゆるirregular rolling signが特徴的で良悪性の鑑別に有用であった．膵疾患においてSonazoid®を用いたCE-USは従来のLevovist®以上に診断能の向上が得られ，鑑別診断に有用であった．

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage method in patients with obstructive jaundice. EUS-BD is divided into EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD). The aim of this review is to focus on the current status and limitations of EUS-BD. A systematic review was performed to evaluate EUS-BD. MEDLINE, EMBASE and manual searches were performed to identify the pertinent English language full articles. The high success rate without fatal adverse events for EUS-CDS (93%; 28/30) and EUS-HGS (97%; 28/29) suggest the feasibility and safety of the procedures in high-volume endoscopic centers adopting various procedural techniques. Although the number of reported cases was very small, the success rate of EUS-GBD was high (100%; 14/14), without serious adverse events. Although all procedures require further assessment in a larger cohort of patients, including comparative studies between EUS-CDS or EUS-HGS versus PTBD, and EUS-GBD versus PTGBD, EUS-BD may be a promising procedure for the treatment of obstructive jaundice. However, dedicated devices for EUS-guided drainage are needed for reliable procedures.

A 51-year-old man was hospitalized because of close examination for liver dysfunction. drip infusion cholangiography-computed tomography (DIC-CT) revealed a stricture located at the middle bile duct but normal biliary scintigraphy. Endoscopic retrograde cholangiopancreatography (ERCP) showed obstruction of bile duct. Although we tried to pass the stricture using several kinds of guidewire under direct vision of peroral cholangioscopy, recanalization could not be achieved. Then percutaneous transhepatic biliary drainage (PTBD) was conducted. Cholangioscopy using narrow band imaging showed no tumor vessel or irregular mucosa. The biopsy specimens obtained from both distal and proximal sides of stricture showed no malignancy. Eventually, a rendezvous technique was tried using guidewire under percutaneous transhepatic cholangioscopy (PTCS) direct vision. Fortunately, since a guidewire could advance into a tiny hole at the center of a scar and an endoscopic nasobiliary drainage (ENBD) tube could be placed across the biliary stricture. One week after placement of ENBD tube, a 10 Fr plastic stent was inserted and the PTBD tube was removed without procedure-related complication. Eight months later, the stent was removed and the chief complaint disappeared without liver dysfunction.

We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones.Retrospective analysis.A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P0.05).ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.

Background In the clinical setting, endosonographers acknowledge that not only the size and characteristics of EUS-guided FNA needles but also several conditions affect the acquisition of adequate samples. Objective To compare the characteristics of the 19-gauge Tru-cut, 19-gauge aspiration, 22-gauge aspiration, and 25-gauge aspiration EUS needles under several conditions by using a bench simulator designed to provide standardized, reproducible, comparative performance data in combination with evaluation by 3 endosonographers of needle-insertion resistance. Design Laboratory simulations that compare resistance to needle advancement under several conditions (straight and angulated endoscope position, endoscopic tip angulation, and the use of the elevator) by using both diagnostic and therapeutic EUS scopes. These varied conditions cause a range of resistance to the advancement of the needle through the endoscope. Setting Research laboratory. Main Outcome Measurement The mean (SD) for advancement resistance (N) to each EUS needle. Needle resistance was evaluated individually by endosonographers and divided into 5 levels (0 [no resistance] to 5 [impossible for needle to be advanced]). Results Endosonographers concluded that the needle-advancement resistance was moderate with a pressure resistance to the needle of 5 N or more and high at 8 N or more, and that it was impossible to advance the needle when the resistance to it was 11 N or more. Instrumentational evaluation showed that, with the 25-gauge and 22-gauge needles, needle resistance was approximately less than 2 N and 3 N, respectively. In the straight endoscope position, the 19-gauge aspiration or Tru-cut needle resistance when using upward angulation of the endoscope or the elevator was more than 8 N and 10 N, respectively. In the angulated endoscope position, the resistance to the 19-gauge aspiration or Tru-cut needle when using upward angulation was more than 10 N and 20 N, respectively. Limitations All data were collected ex vivo, and clinical validity remains to be determined. Conclusions The 22-gauge or 25-gauge EUS-guided FNA needles are suitable for insertion into the target regions if tight angulation is necessary.

Background In patients with acute cholecystitis and at high risk for surgery, decompression of the gallbladder by percutaneous transhepatic gallbladder drainage (PTGBD) or aspiration (PTGBA) is needed as salvage therapy. However, we sometimes encounter patients in whom puncture cannot be performed for several reasons. Recently, endoscopic transpapillary gallbladder drainage (ETGD) has been reported to be safe and effective for acute cholecystitis. Objective Our purpose was to evaluate the clinical efficacy and safety of ETGD for acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible. Design Retrospective case study. Setting This procedure was performed in Tokyo Medical University Hospital. Patients Forty-three patients with acute cholecystitis, including 32 patients taking anticoagulation or antiplatelet drugs, 4 cases of Chilaiditi syndrome, 2 each of acute leukemia, marked ascites, and anatomic abnormality, and 1 case of hemophilia A. Intervention All patients underwent ETGD. A 5F nasobiliary-drainage catheter was placed into the gallbladder. In case of failed ETGD, PTGBD or PTGBA was performed subsequently. Main Outcome Measurement Efficacy and safety of this technique. Results ETGD was achieved in 36 patients (84%) without any serious procedure-related complications. A clinically favorable response for ETGD was seen in 35 patients (97%). In 7 patients in whom ETGD was unsuccessful and 1 patient in which it was ineffective, a percutaneous transhepatic approach was performed with severe hemorrhage biloma in the former and uncontrolled hemorrhage cholecystitis, leading to death in the latter. Limitations Difficulty of maneuvering the guidewire and drainage tube into the gallbladder. Conclusions Although comparative studies are needed to define the appropriate role of ETGD and percutaneous transhepatic approach, ETGD can be useful in patients with acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible.

It has been reported that circulating tumor cells (CTCs) can be used to predict survival in metastatic breast cancer. In this preliminary study, we examined the level of CTCs in pancreatic cancer (PC) patients to elucidate whether we could predict survival in PC. The eligible subjects, at Tokyo Medical University Hospital, were 26 patients with PC, 11 with chronic pancreatitis, and 10 healthy volunteers. Three PC patients underwent surgery, 18 patients (who were stage IV) were treated with gemcitabine (GEM), and 5 patients received best supportive care (BSC). The CTC count was 1/7.5 ml blood or higher (defined as positive) in 11 of the 26 patients (42%; mean, 16.9/7.5 ml blood; range, 1-105/7.5 ml blood). Gemcitabine was administered to 6 of the 11 CTC-positive patients (3.8 courses on average). The treatment was continued for more than three courses in 2 patients, in both of whom the CTC count was only 1/7.5 ml blood. Operation was performed in 1 of the 11 CTC-positive patients. The remaining 4 patients of the 11 CTC-positive patients received only BSC. CTC was negative in 15 patients with PC (stage II, 1; stage III, 1; stage IVa, 7; and stage IVb, 6) and in the subjects with benign conditions. The median survival times (MSTs) of the CTC-positive and-negative patients were 110.5 and 375.8 days (P < 0.001). When the analysis was limited to the 14 stage-IVb patients, the MSTs of the CTC-positive and-negative patients were 52.5 and 308.3 days (P < 0.01). The present study demonstrated that the detection of CTCs in peripheral blood may be useful to predict prognosis in patients with PC.

Background It is very important to determine the extent of intraductal mucinous neoplasms (IPMNs), because this can greatly affect the determination of the indications of surgery. Peroral pancreatovideoscopy (POPS) has been recognized as a new diagnostic tool for clear imaging of IPMN. Recently, narrow-band imaging (NBI) has made it possible to emphasize certain image features, such as mucosal structures and capillary vessels. Objective To evaluate the clinical usefulness of POPS by using NBI for the diagnosis of IPMN. Design Case reports. Setting This procedure was performed at Tokyo Medical University Hospital. Patients Three patients with IPMN. Intervention All patients underwent POPS with NBI. Main Outcome Measurement Efficacy and safety of this technique. Results POPS with NBI was performed in 3 patients, without procedure-related complications. Identification of the surface structure and the capillary vessels by NBI observation was better than by conventional observation. Furthermore, NBI identified skip tumor lesions in the tail of pancreas, which were not detected by conventional POPS. Limitations Because none of the patients in the 3 cases underwent surgical resection, a comparison to clarify total agreement between the preoperative POPS findings and the resected specimen was not possible. Conclusions POPS with NBI may facilitate the observation of both fine mucosal structures and capillary vessels in patients with IPMN, although further study is necessary to fully establish the clinical benefit.

Surgical gastrojejunostomy (GJ), which has been the standard palliative treatment for malignant gastric outlet obstruction (MGOO), is associated with good functional outcome and the long-term relief of symptoms. Endoscopic placement of a metal stent for MGOO treatment has been gaining popularity as an alternative to surgical GJ because of its high technical success rates and less invasiveness. Interestingly, several investigators have attempted endoscopic GJ as ‘endoscopic bypass’ for longer efficacy while maintaining a less invasive procedure.1 We previously reported on the feasibility and safety of EUS-guided GJ (EUS-GJ) using a lumen-apposing metal stent (LAMS)2 ,3 and a special double-balloon enteric tube in an animal model and a pilot clinical study.3 Herein, we describe the first prospective clinical study of EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a LAMS (figure 1). We performed EPASS in 20 patients with MGOO. The double-balloon tube (figure 2) was correctly inserted into the jejunum across from the stomach in all cases. The technical success rate of stent placement was 90%. Figure 1 Schema of EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a lumen-apposing metal stent. Figure 2 Double-balloon enteric tube allows the filling-water between two balloons. EPASS was performed in 20 patients with MGOO between March 2014 and March 2015 (10 male) (supplementary tables 1 and 2). The median intubation time of the double-balloon tube insertion was 10.5 min (range 6–28 min). The technical success rate of stent placement was 90% (18/20) (figure 3 and supplementary table 3). The median intubation time from the double-balloon tube intubation to stent placement was 25.5 min (range 10–39 min). In the two failed cases, we recognised the maldeployment of the distal flange immediately after deployment of the proximal flange by the presence of pneumoperitonium on fluoroscopy and endoscopic visualisation of the abdominal cavity through the LAMS. Post-treatment gastric outlet obstruction …

Background and Aims Balloon enteroscopy–assisted ERCP has provided a marked improvement in the success rate of reaching the papilla and consecutive ERCP procedures in patients with surgically altered anatomy in the Roux-en-Y reconstruction setting. However, limited data are available on the outcome of balloon enteroscopy–assisted ERCP in patients with Roux-en-Y anatomy who have naive papillae. We retrospectively evaluated the feasibility of balloon enteroscopy–assisted ERCP in Roux-en-Y reconstruction after total or subtotal gastrectomy (RYG) with native papillae. Methods We performed 123 ERCP procedures in 109 patients with RYG. Among these patients, 90 consecutive ERCPs in 90 patients with native papillae were included. When selective biliary cannulation failed, the double-guidewire technique, the precut technique, or the rendezvous technique were performed as advanced cannulation methods. Results The overall success rate of reaching the papilla was 93.5% (115/123). The total procedure success rate was 88.1% (96/109). The adverse event rate was 7.3% (8/109). The success rate of the standard cannulation of the intact papilla was 67.8% (61/90). The final cannulation success rate was 95.6% (86/90) by using advanced cannulation methods. Conclusions Standard cannulation of the intact papilla in RYG cases remains challenging and uncertain. The use of various advanced cannulation methods improves the deep cannulation rate. Once selective cannulation succeeds, the treatment success rate is very high.

Introduction: Biliary stricture can occur following surgeries of the biliary tract and can cause biliary congestion and cholangitis. Recently, fully covered self-expandable metal stent (FCSEMS) has been utilized for postoperative hilar and anastomotic strictures that have conventionally been considered difficult to treat. On the other hand, there is no solid evidence regarding optimal metal stent placement period. Method: Retrospective review of patients treated for postoperative benign biliary stricture using a FCSEMS at our hospital between 2013 and 2015. Results: We performed a total of 14 metal stent placements for 12 patients with postoperative benign biliary stricture. In all the patients, the metal stents were placed endoscopically and removed safely after the placement. The mean duration of stent placement was 47.9 days (28-144), and there was no retrograde cholangitis observed during metal stent placement. Following metal stent removal, the stricture improved in 9 patients. Recurrence developed in 3 patients, recurring bile duct stones in 2 patients, and cholangitis in 1 patient. Adverse events included post-ERCP pancreatitis in 2 patients, which was alleviated by stent removal the following day and conservative treatment in 1 patient, and conservative treatment only in the other patient. Distal stent migration was observed in 2 patients. Conclusion: The present results suggest that stricture improvement can be expected in a shorter period by metal stent placement in patients with refractory postoperative biliary stricture. In patients with bile duct stones, lithectomy can be safely and effectively performed following metal stent expansion; however, further studies are required.

Wire-guided cannulation has become a common biliary cannulation technique worldwide. Different guidewires with various tip shapes and materials have been reportedly used for wire-guided cannulation. However, there are apparently no studies reporting changes in the biliary cannulation rate according to the type of guidewire used. We evaluated the effectiveness of the J-tip guidewire for biliary cannulation. We conducted a prospective, multicenter, controlled study involving patients with a native papilla who required biliary cannulation. We allocated the patients to the J-tip guidewire or angled-tip guidewire groups (groups J and A, respectively). If biliary cannulation was not achieved within 10 min, the GW was changed and cannulation was continued. Groups J and A consisted of 66 and 65 enrolled patients, respectively. The biliary cannulation rate with a single guidewire for the first 10 min was 84.8 % (56/66) for group J and 80.0 % (52/65) for group A. The final success rate for biliary cannulation was 100 % in both groups. The mean times necessary for biliary cannulation were 285.8 and 267.6 s in group J and group A, respectively. The incidence rates of complications (i.e., all mild pancreatitis) were 3.0 % (2/66) and 6.2 % (4/65) in group J and group A, respectively. The mean amylase concentrations were 168.0 and 297.7 IU/L in group J and group A, respectively. There were no significant differences in any results between both groups. The biliary cannulation rate of the J-tip guidewire was not significantly different from those of standard guidewires.

Background There are currently no dedicated plastic stents for EUS-guided hepaticogastrostomy (EUS-HGS). Objective We prospectively evaluated the feasibility and the technical and functional success rates of our newly designed plastic stent for EUS-HGS. Design Prospective preliminary feasibility study. Setting A tertiary-care referral center. Patients Twenty-three consecutive patients were treated. The reasons for requiring EUS-HGS were periampullary tumor invasion (n = 9), altered anatomy (n = 7), failed duodenal intubation (n = 3), and previous ERCP failure (n = 4). Interventions An 8F single-pigtail plastic stent with 4 flanges was placed for EUS-HGS. Main Outcome Measurements Technical success, clinical success, and adverse events according to the American Society for Gastrointestinal Endoscopy lexicon. Results All stents were successfully deployed without procedural adverse events (100% technical success rate). Bleeding from the punctured gastric wall occurred in 1 patient 3 days postoperatively. We exchanged the plastic stent for a fully covered self-expandable metal stent. A mild adverse event of self-limited abdominal pain occurred in 3 patients. Treatment success was achieved in all patients. The occlusion rate was 13.7% (3/22) during the median follow-up period (5.0 months, range 0.5-12.5 months). The median duration of stent patency was 4.0 months (range 0.5-9.0 months). There was no stent migration or dislocation during the follow-up period. Limitations Small number of patients and lack of a control group. Conclusions This newly designed single-pigtail plastic stent dedicated for EUS-HGS was technically feasible and can possibly be used for highly selected patients with advanced malignancy or benign stricture. (Trial Registration: http://www.umin.ac.jp/english/: UMIN000012993.)

To evaluate the safety and clinical application of high-intensity focused ultrasound (HIFU) therapy for unresectable pancreatic cancer (PC).Thirty PC patients (16 cases in stage III and 14 cases in stage IV) with visualized pancreatic tumors were admitted for HIFU therapy as an optional local therapy in addition to systemic chemotherapy or chemoradiotherapy. Informed consent was obtained. This study began at the end of 2008 and was approved by the ethics committee of our hospital [Institutional Review Board (IRB): 890]. The HIFU device used was the FEP-BY02 (Yuande Bio-Medical Engineering, Beijing, China).The mean tumor size after HIFU therapy changed to 30.9 ± 1.7 mm from 31.7 ± 1.7 mm at pre-therapy. There were no significant changes in tumor size, mean number of treatment sessions (2.7 ± 0.1 mm), or mean total treatment time (2.4 ± 0.1 h). The rate of symptom relief effect was 66.7%. The effectiveness of primary lesion treatment was as follows: complete response, 0; partial response, 4; stable disease, 22; progressive disease, 4. Treatment after HIFU therapy included 2 operations, 24 chemotherapy treatments, and 4 best supportive care treatments. Adverse events occurred in 10% of cases, namely pseudocyst formation in 2 cases and mild pancreatitis development in 1. However, no severe adverse events occurred in this study.We suggest that HIFU therapy is safe and has the potential to be a new method of combination therapy for PC.

Endoscopic sphincterotomy (ES) combined with large balloon dilation (ESLBD) can be useful for extracting large and multiple bile duct stones. Although there are many studies on the feasibility and short-term outcome, there are few reports about mid- to long-term outcome after ESLBD. The aim of our study is to prospectively evaluate the mid-term outcome of ESLBD.One hundred eighty-three patients who underwent ESLBD between November 2006 and May 2012 were included. The patients were followed up periodically after the procedure until April 2013. Papillary dilation was performed at the time of initial ES or prior ES. Early and late adverse events and stone recurrence were evaluated in this study.The patients' mean age was 76.6 ± 10.7 years. Surgically altered anatomy was present: Billroth I gastrectomy (2), Billroth II gastrectomy (13), and gastrectomy with Roux-en Y reconstruction (18). Seventy-eight (42.6%) patients had periampullary diverticulum. Prior ES had been performed in 40 (21.9%) patients. The mean follow-up period was 43.5 ± 19.7 months (range 11-78). Eight (4.4%) patients had stone recurrence. There was rare stone recurrence after initial ESLBD treatment and native gastrointestinal anatomy. Univariate and multivariate analyses showed that prior ES and previous history of stone recurrence were predictive of stone recurrence (P 0.001).At mid-term outcome, ESLBD is associated with a low rate of recurrent bile duct stones, although long-term follow up is needed.

Recently, several endoscopists have described the usefulness of the endoscopic ultrasonography (EUS)-guided, single transluminal gateway technique (SGT) using transmural placement of single or multiple plastic stents or metal stents for a pancreatic pseudocyst (PC) and walled-off necrosis (WON). Moreover, the uses of the multiple transluminal gateway technique (MTGT) and single transluminal gateway transcystic multiple drainages (SGTMD) for complicated pancreatic walled-off necrosis have recently been reported. The aim of this study is to evaluate retrospectively the feasibility and efficacy of endotherapy for the treatment of complicated PC and WON cases.Eighty-nine patients with a PC (n = 14) and WON (n = 75) were treated under EUS guidance.In a total of 89 cases using SGT in combination with MTGT or SGTMD, the present study showed a technical success rate of 100 %, a final clinical success rate of 97.8 %, an adverse event during procedure rate of 0 %, an early adverse event rate of 12.4 %, and a mortality rate of 2.2 %.Even complicated WON cases can be treated using combination endotherapies, although a surgical approach as well as a percutaneous approach should be considered in the cases refractory to endoscopic therapies.

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux-en Y (R-Y). A 73-year-old man who had total gastrectomy with R-Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre-cutting, the ultraslim endoscope was replaced with a conventional forward-viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure-related complication.

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large-balloon dilation in combination with pancreatic sphincterotomy. A 63-year-old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire-guided pull-type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20-mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure-related complication.

To evaluate the usefulness of real-time virtual sonography (RVS) in biliary and pancreatic diseases.This study included 15 patients with biliary and pancreatic diseases. RVS can be used to observe an ultrasound image in real time by merging the ultrasound image with a multiplanar reconstruction computed tomography (CT) image, using pre-scanned CT volume data. The ultrasound used was EUB-8500 with a convex probe EUP-C514. The RVS images were evaluated based on 3 levels, namely, excellent, good and poor, by the displacement in position.By combining the objectivity of CT with free scanning using RVS, it was possible to easily interpret the relationship between lesions and the surrounding organs as well as the position of vascular structures. The resulting evaluation levels of the RVS images were 12 excellent (pancreatic cancer, bile duct cancer, cholecystolithiasis and cholangiocellular carcinoma) and 3 good (pancreatic cancer and gallbladder cancer). Compared with conventional B-mode ultrasonography and CT, RVS images achieved a rate of 80% superior visualization and 20% better visualization.RVS has potential usefulness in objective visualization and diagnosis in the field of biliary and pancreatic diseases.