Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group.

BACKGROUND: There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan. METHODS: A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined. RESULTS: No change in the decompression method, T3 cancer, negative postoperative complications (grades 0-1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors. CONCLUSIONS: Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

Clinical utility of 0.025-inch guidewire VisiGlide2TM in the endoscopic retrograde cholangiopancreatography-related procedures.

AIM: To examine the result of the use of 0.025-inch guidewire (GW) VisiGlide2TM as the first choice in the endoscopic retrograde cholangiopancreatography (ERCP)-related procedures without selecting the patient in a multicenter prospective study. METHODS: ERCP using 0.025-inch GW VisiGlide2TM as the first choice was conducted in patients who have needed ERCP, and its accomplishment rate of procedure, procedural time, incidence of accidental symptoms were compared with those of ERCP using 0.025-inch GW VisiGlideTM. RESULTS: The accomplishment rate of procedure was 97.5% (197/202), and procedural time was 23.930 ± 16.207 min. The accomplishment rate of procedure using 0.025-inch GW VisiGlideTM was 92.3% (183/195), and procedural time was 31.285 ± 19.122 min, thus the accomplishment rate of procedure was significantly improved and procedural time was significantly shortened (P < 0.05). Accidental symptoms by ERCP-related procedures were observed in 3.0% (6/202), and all were conservatively alleviated. CONCLUSION: When 0.025-inch GW VisiGlide2TM was used for ERCP-related procedure as the first choice, it showed high accomplishment rate of procedure and low incidence of accidental symptoms, suggesting it can be used as the universal GW. Clinical Trial Registry (UMIN0000016042).

Endoscopic management of unresectable malignant gastroduodenal obstruction with a nitinol uncovered metal stent: A prospective Japanese multicenter study.

AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction. METHODS: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, self-expandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline. RESULTS: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients (10.3%) in the form of mild pneumonitis. No other morbidities or mortalities were observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients (7.7%) on account of tumor growth. CONCLUSION: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients' quality of life.

Suspicion of superior mesenteric artery syndrome in a patient with severe gastric dilatation after catheter ablation.

Catheter ablation is a widely used treatment for atrial fibrillation. Gastric hypomotility due to periesophageal vagal plexus injury is a consequence of the extracardiac penetration of ablative energy. Some affected patients develop severe gastric dilatation requiring hospitalization. However, most previous reports have stated the cause of the subject's condition to be "unknown" or described the symptoms using obscure terms, such as "paralytic" or "gastroparesis." For example, one report stated that a few sites of severe gastric dilatation were secondary to "pyloric spasms;" however, no illustrations were provided in the paper. "Superior mesenteric artery syndrome" is a suspected cause of such dilatation.

Endoscopic papillary large balloon dilation for removal of bile duct stones.

AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study. METHODS: Lithotomy by EPLBD was conducted in 124 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. After endoscopic sphincterotomy, the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter. RESULTS: The success rate of first-time lithotomy was 86.3% (107/124) and the final lithotomy success rate was 100% (124/124). Lithotripsy was needed in 10 of the 124 (13.6%) patients. Adverse events due to the treatment procedure occurred in 6 (4.8%) patients, all of which were mild. Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy. CONCLUSION: It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.

Long-term outcome of the WallFlex partially covered stent for unresectable malignant biliary obstruction: a multicenter single-arm prospective study.

BACKGROUND/AIMS: Covered metallic stent was developed to prevent tumor ingrowth. However, procedural accidents due to its insertion often occur and migration after long-term insertion causes problems. The WallFlex partially covered stent (WF) with reduced axial force enables stenting along the bile duct. We examined the usefulness of WF placement in an unresectable malignant distal biliary obstruction. METHODOLOGY: We examined procedural accidents, stent obstruction rate, and patency period caused by WF insertion. RESULTS: Ninety-seven patients were analyzed; procedural accidents caused by WF insertion occurred in 8 patients (7.2%) composed of acute cholecystitis in 3 patients (3.2%), acute pancreatitis in 2 patients (2.1%), acute cholangitis in 1 patient (1%), and other in 1 patient (1%). The stent obstruction rate was 19.6% (19 patients), and obstruction cause includes sludge in 9 patients (9.3%), migration in 4 patients (4.1%), food impaction in 3 patients (3.1%), ingrowth in 1 patient (1%), overgrowth in 0 patients (0%), and unknown in 2 patients (2.1%). The mean stent patency period was 634.918 +/- 66.545 (7-946) days. CONCLUSIONS: WF has less procedural accidents when inserted into unresectable malignant biliary obstruction patients with reduced migration rate after a long period and low obstruction rate.

Can endoscopic sphincterotomy be performed safely in elderly patients aged 80 years or older with pancreatic and biliary diseases?

BACKGROUND/AIMS: The purpose of this study was to investigate whether endoscopic sphincterotomy (EST) can be usefully and safely performed in elderly patients aged 80 years or older. METHODOLOGY: The eligible patients with pancreatic and biliary diseases who required EST were divided into two groups depending on their age: under 80 (group A) and 80 or older (group B). Patient characteristics, EST success rate and incidence of the related complications were evaluated. RESULTS: Of the 720 patients who required EST, 522 patients were in group A and 198 in group B. Group B incidences of patient characteristics at baseline disease and anticoagulant/antiplatelet therapy were significantly higher than in group A (p<0.05). The EST success rates were 97.1% (507/522) in group A and 96.5% (191/198) in group B. The incidences of the related complications were 8.8% (46/522) in group A and 4% (8/198) in group B, respectively, again without significant difference. CONCLUSIONS: The EST success rate and the incidence of related complications were comparable between patients in groups A and B, indicating that EST can be safely performed even in the elderly aged 80 years or older.

Pancreatic duct guidewire-indwelling method for patients resistant to selective biliary cannulation and usefulness of pre-cut papillotomy following unsuccessful biliary cannulation with pancreatic duct guidewire-indwelling method.

BACKGROUND/AIMS: Pancreatic duct guidewire-indwelling method (P-GW) is effective when selective biliary cannulation (SBC) has failed, but neither its true success rate nor a salvage technique have been established. In this study, we examined the usefulness of pre-cut papillotomy employing a pancreatic duct guidewire as the salvage treatment after unsuccessful SBC under P-GW. METHODOLOGY: P-GW was conducted in 55 patients. When cannulation under P-GW was unsuccessful, pre-cut papillotomy was performed. Then, if SBC after trial was still unsuccessful, ERCP was tried again at a later date. The incidence of pancreatitis following ERCP in patients with difficult SBC, with and without pancreatic duct stenting was determined. RESULTS: P-GW resulted in successful SBC in 63.6% of patients. For the 20 patients in which SBC failed pre-cut papillotomy using the pancreatic duct guidewire was performed. Transpancreatic pre-cut papillotomy was performed in 17 patients; 3 patients underwent needle-knife pre-cut papillotomy. SBC was successful at first attempt in 89.1% and eventually in 96.4% of patients. Post-ERCP pancreatitis occurred in 7.3%, broken down into 0% for those with pancreatic duct stenting (p=0.03) and 16.7% for those without. CONCLUSIONS: Pre-cut papillotomy using a pancreatic duct guidewire was useful for patients with unsuccessful SBC with P-GW alone, and the risk for pancreatitis was reduced by pancreatic stenting.

Usefulness of peroral cholangioscopy in preoperative diagnosis of intraductal papillary neoplasm of the bile duct.

Surgical resection is considered the first-line treatment of intraductal papillary neoplasm of the bile duct (IPNB). Since some patients with IPNB have an unexpectedly superficially-spreading lesion, preoperative cholangioscopic diagnosis is very useful in determining the extent of resection. We report a patient with IPNB in whom preoperative peroral cholangioscopic evaluation was useful.

Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis.

AIM: To assess long-term outcome of endoscopic papillotomy alone without subsequent cholecystectomy in patients with choledocholithiasis and cholecystolithiasis. METHODS: Retrospective review of clinical records of patients treated for choledocholithiasis and cholecystolithiasis from 1976 to 2006. Of 564 patients subjected to endoscopic papillotomy and endoscopic stone extraction, 522 patients (279 men, 243 women; mean age 66.2 years) were followed up and predisposing risk factors for late complications were analyzed. RESULTS: The mean duration of follow up was 5.6 years. Cholecystitis and recurrent choledocholithiasis occurred in 39 (7.5%) and 60 (11.5%) patients, respectively. Cholecystitis, including one severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in one case. Pneumobilia was found to be a significant risk factor for cholecystitis (P = 0.019) and recurrent choledocholithiasis (P = 0.013). Biliary tract cancer occurred in 16 patients; gallbladder cancer in 13 and bile duct cancer in three. Gallbladder cancer developed within 2 years after endoscopic papillotomy in seven of the 13 patients (53.8%). CONCLUSION: Pneumobilia was the only significant risk factor for cholecystitis and recurrent choledocholithiasis in our study population. As for the long-term outcome, it was unclear whether endoscopic papillotomy contributed to the occurrence of biliary tract cancer.

Cholangiopancreatography troubleshooting: the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.

BACKGROUND: Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting. Although there are some procedures to retrieve the migrated stent, including surgical, percutaneous, and endoscopic approaches, endoscopy should be attempted first because it is least invasive. This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents. METHODS: Plastic stents that migrated in the bile duct (35 patients) or pancreatic duct (2) were retrieved with endoscopic retrograde cholangiopancreatography. Devices used were snare forceps, a basket catheter, grasping forceps, biopsy forceps, a balloon catheter, and the Soehendra stent retriever. RESULTS: Endoscopic retrieval of migrated stents was performed successfully in 36 (97.0%) of the 37 patients. The devices utilized for successful treatment were basket catheter (13 patients), grasping forceps (10), snare forceps (8), balloon catheter (3), biopsy forceps (1), and the Soehendra stent retriever (1). The unsuccessfully treated patient with chronic pancreatitis underwent surgery since the guide wire did not move forward due to bile duct stenosis, and there was also duodenal stenosis. One patient developed mild pancreatitis after withdrawal of the stent; the pancreatitis was relieved with conservative treatment. CONCLUSIONS: Endoscopic retrieval of migrated biliary and pancreatic stents appears to be useful because of its safety and low invasiveness. However, various forceps should be prepared for the retrieval of a migrated stent.

The successful use of peroral cholangioscopy for the diagnosis and treatment of the biliary tract lesions and giant bile duct stones in a 76-year-old man.

We encountered a case in whom peroral cholangioscopy was useful for the diagnosis and treatment of irregular biliary tract mucosa and giant bile duct stones. Peroral cholangioscopy seems to improve the diagnosis of biliary tract diseases and allow internal treatment. The proper diagnosis of biliary tract diseases may be further confirmed by the concomitant use of narrow band imaging and this endoscopic technology.

SiRNA of frizzled-9 suppresses proliferation and motility of hepatoma cells.

Frizzled (Fz), a receptor of Wnt ligands, plays key roles in liver carcinogenesis. Its expression was analyzed as part of a search for a target of molecular therapy for hepatocellular carcinoma (HCC) and hepatoblastoma (HB). Fz genes were analyzed by RT-PCR in HCC cell lines HLE, HLF, PLC/PRF/5, Huh-7 and Hep3B, HB cell lines Huh-6 and HepG2, HeLa cells, human normal fetal and adult liver. We transfected PLC/PRF/5, HLE, Huh-6, and HeLa cells with Fz9-small interfering RNA (Fz9-siRNA). Five days after transfection, cell proliferation was analyzed by MTS assay and cell motility by wound assay with H&E staining. Subsequently, the expressions of cyclin D1 and caspase-3 were analyzed by Western blot analysis. Fz9-siRNA decreased the expression of Fz9 gene in all cell lines. MTS assay showed that Fz9-siRNA significantly suppressed cell proliferation and cell motility in all cell lines. The expression of cyclin D1 was also suppressed by Western blotting. Cleaved caspase-3 did not appear and apoptosis was not observed in any of the cell lines tested. We demonstrated that Fz9 plays an essential role in carcinogenesis of HB and HCC, concluding that Fz9-siRNA could represent a useful therapeutic target for HB and HCC.

The usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and post-cholecystectomy bile leakage.

This study was conducted to examine the usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and postcholecystectomy bile leakage. Endoscopic transpapillary procedure was performed in 18 cases of post-cholecystectomy bile duct stricture and 6 cases of post-cholecystectomy bile leakage. In the bile duct stricture cases, the patients were assessed for the stricture by endoscopic retrograde cholangiography (ERC), and then underwent endoscopic sphincterotomy (EST) for tube stent insertion. The stents was replaced every 3 to 6 months, and the treatment was continued until the patients became stent-free. Successful therapy was defined as a stent-free condition without hepatic disorder. In the bile leakage cases, the leakage was located by ERC and EST was performed. Then, endoscopic nasobiliary drainage (ENBD) tube was inserted at the proximal side of the bile leakage, and the therapeutic outcome was defined as successful if disappearance of the leakage was confirmed by cholangiography at a later date. Endoscopic transpapillary procedure was 100% successful in both post-cholecystectomy bile duct stricture cases (18/18) and post-cholecystectomy bile leakage cases (6/6). There was no accident due to the treatment. Restricture occurred in 5.5% (1/18) of the patients, but additional therapy was successful and the stent was removed. Also, there was no accident due to endoscopic transpapillary procedure. Endoscopic transpapillary procedure in postcholecystectomy bile duct stricture and postcholecystectomy bile leakage was demonstrated to be a less invasive, safe, and useful method.

Clinical evaluation of endosonography-guided biliary drainage for patients with the difficulty with placing of internal drainage.

The methods for non-surgical biliary drainage for the treatment of obstructive jaundice generally include transpapillary one, or endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous one, or percutaneous transhepatic biliary drainage (PTBD). In placing internal drainage, a stent is frequently inserted through the route of the drainage. However, transpapillary approach may be infeasible in patients, if cannulation is difficult, drainage cannot reach the duodenal papilla, and percutaneous approach may be infeasible in patients, if the intrahepatic bile duct is not be expanded. Endosonography-guided biliary drainage (ESBD) is a new method enabling internal drainage of an obstructed bile duct. In this study, the transpapillary ESBD approach was successfully applied to a patient having obstructive jaundice due to cancer of the head of the pancreas during the treatment of ovarian cancer although internal drainage via transpapillary and percutaneous approach was not applicable to this patient. So far, few studies have reported the use of ESBD. Although a large-scale, multicenter study is required to investigate the indications and complications of ESBD, it is no doubt that we have now more treatment options for non-surgical biliary drainage.

Unconventional superconductivity and electron correlations in the cobalt oxyhydrate Na0.35CoO2.yH2O from nuclear quadrupole resonance.

We report a careful 59Co nuclear quadrupolar resonance measurement on the recently discovered cobalt oxyhydrate Na0.35CoO2.yH(2)O superconductor from T=40 K down to 0.2 K. We find that in the normal state the spin-lattice relaxation rate 1/T(1) follows a Curie-Weiss type temperature (T) variation, 1/T(1)T=C/(T-theta), with theta=-42 K, suggesting two-dimensional antiferromagnetic spin correlations. Below T(c)=3.9 K, 1/T(1) decreases with no coherence peak and follows a T(n) dependence with n approximately 2.2 down to approximately 2.0 K but crosses over to a 1/T(1) proportional to T variation below T=1.4 K, which suggests non-s-wave superconductivity. The data in the superconducting state are most consistent with the existence of line nodes in the gap function.