Relapse rate and predictors of relapse after cessation of glucocorticoid maintenance therapy in type 1 autoimmune pancreatitis: a multicenter retrospective study.

BACKGROUND: Type 1 autoimmune pancreatitis responds well to glucocorticoid therapy with a high remission rate. Moreover, glucocorticoid maintenance therapy can help prevent relapse. However, the relapse rate following cessation of long-term glucocorticoid therapy is unknown. The aim of this study was to clarify the relapse rate and predictors of relapse following long-term glucocorticoid therapy cessation. METHODS: We analyzed 94 patients who achieved remission after undergoing glucocorticoid therapy, discontinued treatment after at least 6 months of maintenance therapy, and were subsequently followed up for at least 6 months. The patients were divided into three groups based on treatment duration (< 18, 18-36, and ≥ 36 months), and their relapse rates were compared. Univariate and multivariate analyses of clinical factors were conducted to identify relapse predictors. RESULTS: After discontinuing glucocorticoid therapy, relapse was observed in 43 (45.7%) patients, with cumulative relapse rates of 28.2% at 1 year, 42.1% at 3 years, 47.0% at 5 years, and a plateau of 77.6% at 9 years. Of the 43 patients who relapsed, 25 (58.1%) relapsed within 1 year after after cessation of glucocorticoid therapy. Relapse and cumulative relapse rates did not differ significantly according to treatment duration. In the multivariate analysis, an elevated serum IgG4 level at the time of glucocorticoid cessation was found to be an independent predictor of relapse (hazard ratio, 4.511; p < 0.001). CONCLUSIONS: A high relapse rate occurred after cessation of glucocorticoid maintenance therapy, regardless of the duration of maintenance therapy, especially within the first year after cessation. However, the normalization of long-term serum IgG4 levels may be a factor in considering cessation.

Diagnostic Ability and Safety of Repeated Pancreatic Juice Cytology Using an Endoscopic Nasopancreatic Drainage Catheter for Pancreatic Ductal Adenocarcinoma: A Multicenter Prospective Study.

Pathological examination is essential for the diagnosis and treatment of pancreatic ductal adenocarcinoma (PDAC). Moreover, a reliable pathological diagnosis is extremely important for improving prognosis, especially in early-stage PDAC. This study prospectively evaluated the usefulness of repeated pancreatic juice cytology (PJC) using an endoscopic nasopancreatic drainage (ENPD) catheter for the diagnosis of PDAC. We enrolled 82 patients suspected of having resectable PDAC, based on imaging studies, and judged the necessity for cytology. The diagnostic yield of up to six repeated PJCs and the incidence of complications, such as pancreatitis, was evaluated. A total of 60 patients were diagnosed with PDAC. The overall sensitivity and specificity were 46.7% and 95.5%, respectively. The cumulative positivity rate increased with the number of sampling sessions, reaching 58.3% in the sixth session. The sensitivity was significantly higher in the pancreatic head than in the pancreatic tail (p = 0.043). Additionally, it was 100% in four patients with a tumor size ≤10 mm. Pancreatitis occurred in six patients (7.3%), all of whom were treated conservatively. In the diagnosis of PDAC, repeated PJC using an ENPD catheter revealed a cumulative effect of sensitivity up to six times and an excellent diagnostic yield for small PDAC.

Needle tract seeding after endoscopic ultrasound-guided tissue acquisition of pancreatic tumors: A nationwide survey in Japan.

OBJECTIVES: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) plays a crucial role in the diagnosis of pancreatic tumors. The present study aimed to investigate the current status of needle tract seeding (NTS) after EUS-TA of pancreatic tumors based on a nationwide survey in Japan. METHODS: Patients who underwent surgical resection of primary pancreatic tumors after EUS-TA performed between April 2010 and March 2018 were surveyed. The incidence rates of NTS were determined, and compared in patients with pancreatic ductal adenocarcinomas (PDACs) and other tumors, and in patients who underwent transgastric and transduodenal EUS-TA of PDACs. The detailed features and prognosis of patients with NTS were also assessed. RESULTS: A total of 12,109 patients underwent surgical resection of primary pancreatic tumors after EUS-TA. The overall incidence rate of NTS was 0.330%, and the NTS rate was significantly higher in patients with PDAC than in those with other tumors (0.409% vs. 0.071%, P=0.004). NTS was observed in 0.857% of patients who underwent transgastric EUS-TA, but in none of those who underwent transduodenal EUS-TA. Of the patients with NTS of PDACs, the median time from EUS-TA to occurrence of NTS and median patient survival were 19.3 and 44.7 months, respectively, with 97.4% of NTS located in the gastric wall and 65.8% of NTS resected. The patient survival was significantly longer in patients who underwent NTS resection than in those without NTS resection (P=0.037). CONCLUSIONS: NTS appeared only after transgastric not after transduodenal EUS-TA. Careful follow-up provides an opportunity to remove localized NTS lesions by gastrectomy.

Mixed neuroendocrine non-neuroendocrine neoplasm: a case report and review.

Mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN) of the pancreas is a rare entity, and obtaining a preoperative diagnosis is difficult. We present a 70-year-old man in whom the possibility of MiNEN was successfully discovered preoperatively by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Immunostaining revealed positive results for the neuroendocrine markers chromogranin A and synaptophysin. We considered the possibility for MiNEN before surgery. He underwent distal pancreatectomy with splenectomy. Immunohistochemical examination of the tumor cells showed a wide range of positivity for trypsin as well as for chromogranin A and synaptophysin. Considering that ≥ 30% tumors ware positive for both acinar and neuroendocrine markers, the patient was diagnosed with MiNEN. MiNEN is a malignant tumor that requires early detection and treatment but is a rare disease for which no method has been established. We found that EUS-FNA and immunostaining are effective diagnostic methods for MiNEN.

Clinical Analysis of Early-Stage Pancreatic Cancer and Proposal for a New Diagnostic Algorithm: A Multicenter Observational Study.

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is challenging but essential for improving its poor prognosis. We established a multicenter study to clarify the clinicopathological features, and to propose new algorithm for early diagnosis of PDAC. Ninety-six patients with stage 0 and IA PDAC were enrolled from 13 high-volume centers. Overall, 70% of the patients were asymptomatic. The serum pancreatic enzyme levels were abnormal in half of the patients. The sensitivity of endoscopic ultrasonography (EUS) for detecting small PDAC was superior to computed tomography and magnetic resonance imaging (MRI) (82%, 58%, and 38%, respectively). Indirect imaging findings were useful to detect early-stage PDAC; especially, main pancreatic duct stenosis on MRI had the highest positive rate of 86% in stage 0 patients. For preoperative pathological diagnosis, the sensitivity of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatic juice cytology was 84%. Among the stage IA patients, EUS-guided fine-needle aspiration revealed adenocarcinoma in 93% patients. For early diagnosis of PDAC, it is essential to identify asymptomatic patients and ensure close examinations of indirect imaging findings and standardization of preoperative pathological diagnosis. Therefore, a new diagnostic algorithm based on tumor size and imaging findings should be developed.

Step-up approach combined with negative pressure wound therapy for the treatment of severe necrotizing pancreatitis: a case report.

A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.

A single institution experience of the treatment of pancreatic ductal carcinoma: The demand and the role of radiation therapy.

We aimed to demonstrate a single institution experience of treatment of pancreatic ductal carcinoma and to identify the role of radiation therapy. We assessed all patients who were diagnosed with pancreatic ductal carcinoma from January 2011 to December 2017. A total of 342 patients were enrolled. Thirteen, 131, 36, and 162 patients had stage I, II, III, and IV disease, respectively (UICC TNM, 7th edition). Among the patients with stages I-III disease, 94 underwent surgery, and the median overall survival (OS) was 33 months. Of patients with stages I-III disease who were not suitable for surgery, 58 patients received chemotherapy, and the median OS was 12 months. Among them, 17 patients received chemoradiotherapy added on chemotherapy and their OS was significantly better than that of patients who received chemotherapy alone. Of patients with stage IV disease, 111 received chemotherapy, and the median OS was 6 months. This study evaluated the demand, role, and outcome of each treatment modality and demonstrated a single institution experience of treatment of pancreatic ductal carcinoma. The demand and role of radiation therapy remained small; however, radiation therapy might have some importance as a local treatment.

Impact of sclerosing dacryoadenitis/sialadenitis on relapse during steroid therapy in patients with type 1 autoimmune pancreatitis.

OBJECTIVES: Steroids are the first-line drugs for induction of remission in patients with type 1 autoimmune pancreatitis (AIP), and the usefulness of steroid maintenance therapy to prevent relapse has recently been reported. However, even during steroid therapy, a relatively large percentage of patients relapse and the predictive factors for relapse have not yet been elucidated. The aim of this study was to clarify the predictive factors for relapse of AIP patients during steroid therapy. MATERIALS AND METHODS: The medical records of 76 patients with type 1 AIP with continued steroid therapy after induction of remission were analyzed retrospectively. The relapse rate during steroid therapy was evaluated, and the risk factors for relapse were investigated by univariate and multivariate analysis of clinical factors. RESULTS: Relapse occurred in 28.9% (22/76) of the patients. The cumulative relapse rates were 10.5% at 1 year, 25.0% at 3 years, 34.9% at 5 years, and 43.0% at 10 years. In multivariate analysis, presence of sclerosing dacryoadenitis/sialadenitis at the time of initial diagnosis of AIP was an independent risk factor for relapse (HR 3.475, p = .009). The cumulative relapse rates of patients with sclerosing dacryoadenitis/sialadenitis reached 21.4% at 1 year, 56.0% at 3 years, and 78.0% at 5 years. CONCLUSIONS: Sclerosing dacryoadenitis/sialadenitis was a predictive factor for relapse in type 1 AIP during steroid therapy; in such cases, strict follow-up is necessary with relapse in mind.

Lymphoepithelial cyst of the pancreas: A case report and summary of imaging features of pancreatic cysts.

INTRODUCTION: A lymphoepithelial cyst (LEC) of the pancreas is a benign and rare lesion that is difficult to diagnose preoperatively based on imaging studies. PRESENTATION OF CASE: We report a case of a 49-year-old man who presented with weight loss and diarrhea. The serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were slightly elevated to 6.7 ng/mL (reference value <5.0 ng/mL) and 45 U/mL (reference value <37 U/mL), respectively. Computed tomography showed a large cystic mass with internal septa in the pancreatic tail. The cystic wall and the septa showed enhancement while the cystic contents remained unenhanced. Magnetic resonance imaging (MRI) demonstrated a multiple-ball-like lesion with low signal intensity on T1-weighted image and high signal intensity on T2-weighted image. Diffusion-weighted MRI showed high signal intensity in the central and iso-signal intensity in the peripheral portions of the cystic lesion. The cystic wall and septa showed high signal intensity, and the cystic contents showed low signal intensity on an enhanced MRI. Endoscopic ultrasonography showed a cyst with multiple high-echoic lesions in the pancreatic tail. A mucinous cystic neoplasm and branch duct intraductal papillary mucinous neoplasm were considered among the differential diagnoses, and we performed distal pancreatectomy with concomitant splenectomy and lymphadenectomy for both diagnostic and therapeutic purposes. Histopathological findings revealed that the cystic wall was lined by stratified squamous epithelium, and several lymphoid follicles and a few sebaceous glands were observed within the cystic wall without hair follicles, leading to the final diagnosis of an LEC. CONCLUSION: We report a rare case of a pancreatic LEC, which was difficult to be diagnosed and summarize the imaging features of pancreatic cysts to differentiate from the malignancy preoperatively.

Clinical and Pathological Features of Solid Pseudopapillary Neoplasms of the Pancreas: A Nationwide Multicenter Study in Japan.

OBJECTIVE: The aim of this study was to evaluate the clinicopathological features of solid pseudopapillary neoplasms (SPNs). METHODS: In this retrospective study, 288 SPNs were analyzed. RESULTS: Overall, 214 patients (74%) were female. Distant metastases occurred in 4 patients, and splenic vein tumor thrombus occurred in 1 patient. Although imaging findings showed large (>2.0 cm) SPNs with clear, regular border, and heterogeneous internal structure, small SPNs appeared as almost entirely solid. Surgical resection was performed in 278 cases. The 5-year survival rate was 98.8%. Six patients had tumor recurrence after the initial resection. The detection rate in typical pathological findings was low for small SPNs. Tumor extension to the pancreatic parenchyma was detected in greater than 70% of the cases. Tumor invasion to adjacent organs was detected in 13 cases. One was given a diagnosis of apparent high-grade malignant transformation. CONCLUSIONS: The proportion of male cases was higher than that in previous studies, and there were statistically significant differences in the onset age and tumor diameter between male and female patients. Therefore, women seemed to have an early occurrence of SPNs, suggesting a difference in the developmental stage between men and women. Images and pathological findings of SPNs varied according to tumor size. Our findings indicated that SPN patients have excellent survival after margin-negative surgical resection.

Indication and Usefulness of Bile Juice Cytology for Diagnosis of Gallbladder Cancer.

AIM: We examined the effectiveness of bile juice cytology for distinguishing between benign and malignant gallbladder lesions of the protruding type with various sampling points, sampling methods, and macroscopic forms in order to discuss the effectiveness of the endoscopic transpapillary gallbladder drainage (ETGD) cytology. METHODS: We studied 162 cases of patients with a lesion localized within the gallbladder. At first, we examined the effectiveness for diagnosis of ETBD cytology using ERC and then that of the first ETGD cytology after placing the ETGD. Next, we examined the diagnostic effectiveness of the washed ETGD cytology by using the ETGD. Finally, we examined complications. RESULTS: In the final diagnoses, we identified 33 cases of adenocarcinoma, 10 cases of adenoma, 63 cases of ADM, 35 cases of nonneoplastic polyp, and 21 cases of chronic cholecystitis. It was found that the sensitivity of ETBD cytology was 3.6% and that of ETGD cytology was 59.1%. In the comparison of diagnostic effectiveness of cytologic diagnosis using samples of bile juice from the gallbladder collected by different methods, the sensitivities were 38.9% and 73.3% for the first and washed ETGD cytologies, respectively. In the comparison of the diagnostic effectiveness of gallbladder bile juice cytology using samples collected for different forms of lesion and by different methods, the sensitivities were 38.9% and 73.3%, respectively, for the first and washed ETGD cytologies for flat gallbladder wall thickening, while it was impossible to diagnose for lesions of GB polyp. CONCLUSION: For diagnosis of gallbladder cancer, we consider that the ETGD cytology should be taken into consideration for lesions of flat gallbladder wall thickening, for which it is difficult to distinguish between benign and malignant lesions.

Multicenter study of early pancreatic cancer in Japan.

BACKGROUND/OBJECTIVES: The diagnosis of early-stage pancreatic ductal adenocarcinoma (PDAC) is still challenging. We conducted a multicenter study to clarify the clinical features of early-stage PDAC in Japan. METHODS: We collected patients with stage 0 and stage I PDAC according to the sixth edition of the Japanese Classification of Pancreatic Carcinoma. We retrospectively analyzed the clinical profiles including opportunities for medical examination, imaging modalities and findings, methods of cytological diagnosis, and prognosis according to the stages at diagnosis. RESULTS: Two hundred cases with Stage 0 and stage I PDAC were reported from 14 institutions, which accounted for approximately 0.7% and 3% of all PDAC cases, respectively. Overall, 20% of the early-stage PDAC cases were symptomatic. Indirect imaging findings such as dilatation of the main pancreatic duct were useful to detect early-stage PDAC. In particular, local fatty changes may be specific to early-stage PDAC. For preoperative pathologic diagnosis, cytology during endoscopic retrograde cholangiopancreatography was more commonly applied than endoscopic ultrasound fine-needle aspiration. Although the overall prognosis was favorable, new PDAC lesions developed in the remnant pancreas in 11.5% cases. CONCLUSIONS: This multicenter study revealed several key points concerning the diagnosis and management of early-stage PDAC, including screening of asymptomatic cases, importance of indirect imaging findings, application of cytology during endoscopic retrograde cholangiopancreatography, and the risk of carcinogenesis in the remnant pancreas.

A case of sclerosing angiomatoid nodular transformation of the spleen with increased accumulation of fluorodeoxyglucose after 5-year follow-up.

INTRODUCTION: Sclerosing angiomatoid nodular transformation (SANT) of spleen is a new entity defined as a benign pathologic lesion. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) shows weak accumulation, thereby ruling out the malignancy in preoperative diagnosis is difficult. Herein, we reported a case of shrinking SANT with increased FDG accumulation during a 5-year follow-up period, which was treated by laparoscopic splenectomy. PRESENTATION OF CASE: A 64-year-old female had been referred to our hospital for the evaluation of a splenic tumor. Initial contrast-enhanced computed tomography (CT) showed a well-defined, and ovoid hypoattenuating lesion, measuring 52mm in diameter in the spleen. Initial PET/CT revealed accumulation of FDG in the tumor (maximum standardized uptake value [SUVmax]: 2.8). The mass was diagnosed as SANT, and the patient was followed-up every 6-12 months for 5 years. Follow-up PET/CT revealed increased accumulation of FDG (SUVmax: 3.5). As it was suspicious considering the differential diagnosis, including malignant lymphoma and inflammatory pseudotumor, she underwent laparoscopic splenectomy. The pathological results showed three types of vessels including capillaries, ectatic small veins, and sinusoids-like vessels, consistent with the features of SANT. DISCUSSION: A SANT may have features that resemble those of malignancy, including the growing mass and the increase of FDG accumulation. CONCLUSION: Although the preoperative diagnosis of SANT is difficult, it is necessary to make a diagnosis of SANT comprehensively, even when accumulation of FDG increased slightly during the follow-up period and suggested the possibility of malignant diseases.

Use of 4-Fr versus 6-Fr Nasobiliary Catheter for Biliary Drainage: A Prospective, Multicenter, Randomized, Controlled Study.

Background and Aim. Endoscopic nasobiliary drainage (NBD) effects according to diameter remain unclear. We aimed to assess the drainage effects of the 4-Fr and 6-Fr NBD catheters. Methods. This prospective, multicenter, randomized, controlled study was conducted at Hiroshima University Hospital and related facilities within Hiroshima Prefecture. Endoscopic retrograde cholangiopancreatography (ERCP) in 246 patients revealed acute cholangitis, obstructive jaundice, and/or extrahepatic cholestasis; 4-Fr or 6-Fr NBD catheters were randomly allocated and placed in these patients. The primary endpoint was the efficacy of NBD based on the technical success rate and clinical success (rates of change in blood test and amount of bile output). Secondary endpoints included the spontaneous catheter displacement rate and nasal discomfort. Results. The technical success rate and clinical success did not differ significantly between groups. No spontaneous catheter displacement was noted in either group. Nasal discomfort due to catheter placement was significantly lower in the 4-Fr group versus the 6-Fr group (24 h after ERCP: 2.4 versus 3.5 cm, P = 0.005; 48 h after ERCP: 2.2 versus 3.1 cm, P = 0.01). Conclusion. The 4-Fr NBD catheter was not inferior to 6-Fr NBD catheter in terms of clinical success; the 4-Fr NBD catheter was useful to reduce nasal discomfort.

A comparison of 4-Fr with 5-Fr endoscopic nasopancreatic drainage catheters: A randomized, controlled trial.

BACKGROUND AND AIM: Although endoscopic nasopancreatic drainage (ENPD) is useful for collecting samples for pancreatic juice cytology and for treating leakage of pancreatic juice and occlusive pancreatitis, placement of the ENPD catheter is associated with complications such as post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We investigated whether an ENPD catheter with a smaller diameter could reduce the incidence of complications. METHODS: Patients requiring placement of an ENPD catheter (n = 254) were enrolled and randomly assigned to one of two catheter-size groups: the 4-Fr group or the 5-Fr group. The incidence of PEP, cholangitis, and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples were compared between groups. In addition, univariate and multivariate analyses were conducted on factors associated with PEP. RESULTS: The incidence of PEP was significantly lower in the 4-Fr group compared with the 5-Fr group (4.1% vs 12.4%, respectively; P = 0.021). The rate of cholangitis and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples did not differ between groups. Multivariate analysis revealed that the risk of PEP was 3.7 times higher when using a 5-Fr catheter than when using a 4-Fr catheter (P = 0.019). In addition, the risk of PEP was 4.1 times higher in patients with an intraductal papillary mucinous neoplasm than in those without (P = 0.0049) and 4.6 times higher in patients aged <65 than in those aged ≥65 (P = 0.0033). CONCLUSIONS: A 4-Fr catheter is as useful as a 5-Fr catheter and is associated with a significantly lower incidence of PEP.

Preoperative Biliary Drainage in Cases of Borderline Resectable Pancreatic Cancer Treated with Neoadjuvant Chemotherapy and Surgery.

Objective. To elucidate the optimum preoperative biliary drainage method for patients with pancreatic cancer treated with neoadjuvant chemotherapy (NAC). Material and Methods. From January 2010 through December 2014, 20 patients with borderline resectable pancreatic cancer underwent preoperative biliary drainage and NAC with a plastic or metallic stent and received NAC at Hiroshima University Hospital. We retrospectively analyzed delayed NAC and complication rates due to biliary drainage, effect of stent type on perioperative factors, and hospitalization costs from diagnosis to surgery. Results. There were 11 cases of preoperative biliary drainage with plastic stents and nine metallic stents. The median age was 64.5 years; delayed NAC occurred in 9 cases with plastic stent and 1 case with metallic stent (p = 0.01). The complication rates due to biliary drainage were 0% (0/9) with metallic stents and 72.7% (8/11) with plastic stents (p = 0.01). Cumulative rates of complications determined with the Kaplan-Meier method on day 90 were 60% with plastic stents and 0% with metallic stents (log-rank test, p = 0.012). There were no significant differences between group in perioperative factors or hospitalization costs from diagnosis to surgery. Conclusions. Metallic stent implantation may be effective for preoperative biliary drainage for pancreatic cancer treated with NAC.

Long term persistence of NS5A inhibitor-resistant hepatitis C virus in patients who failed daclatasvir and asunaprevir therapy.

Although interferon-free antiviral treatment is expected to improve treatment of hepatitis C, it is unclear to what extent pre-existing drug-resistant amino acid substitutions influence response to therapy. The impact of pre-existing drug-resistant substitutions on virological response to daclatasvir and asunaprevir combination therapy was studied in genotype 1b hepatitis C virus (HCV)-infected patients. Thirty-one patients were treated with daclatasvir and asunaprevir for 24 weeks. Twenty-six patients achieved sustained virological response (SVR), three patients experienced viral breakthrough, and two patients relapsed. Direct sequencing analysis of HCV showed the existence of daclatasvir-resistant NS5A-L31M or -Y93H/F variants in nine out of 30 patients (30%) prior to treatment, while asunaprevir-resistant NS3-D168 mutations were not detected in any patient. All 21 patients with wild-type NS5A-L31 and -Y93 achieved SVR, whereas only four out of nine patients (44%) with L31M or Y93F/H substitutions achieved SVR (P = 0.001). Ultra-deep sequencing analysis showed that treatment failure was associated with the emergence of both NS5A-L31/Y93 and NS3-D168 variants. NS5A-L31/Y93 variants remained at high frequency through post-treatment weeks 103 through 170, while NS3-D168 variants were replaced by wild-type in all patients. In conclusion, pre-existence of NS5A inhibitor-resistant substitutions compromised the response to daclatasvir and asunaprevir combination therapy, and treatment failure was associated with the emergence of both NS5A-L31/Y93 and NS3-D168 variants. While asunaprevir-resistant variants that emerged during therapy returned to wild-type, daclatasvir-resistant variants tended to persist in the absence of the drug.

Evaluation of antibiotic use to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis.

BACKGROUND/AIMS: The purpose of this study was to evaluate the relationship between prophylactic antibiotic use and complications following endoscopic retrograde cholangiopancreatography (ERCP). METHODOLOGY: We retrospectively evaluated 605 consecutive patients who underwent ERCP in our hospital between September 2009 and November 2011. The antibiotic group included patients who underwent their procedure before October 2010, while the control group included patients after October 1, 2010, who did not receive antibiotics. We compared the incidence of postoperative pancreatitis and cholangitis between the groups. RESULTS: There were no significant differences in the backgrounds of the 304 control and the 301 antibiotic-treated patients. The incidence of post-ERCP pancreatitis was 4.9% in the control group and 4.3% in the antibiotic group (p = 0.72). The incidence of postoperative cholangitis was 2.0% in the control group and 1.7% in the antibiotic group (p = 0.99). Choledocholithiasis, pancreatic duct injection, and female gender were detected as significant risk factors for postoperative pancreatitis by multivariate analysis; sclerosing cholangitis and incomplete biliary drainage were significant risk factors for postoperative cholangitis. Even in cases with these risk factors, prophylactic antibiotic use did not influence the incidence of pancreatitis or cholangitis. CONCLUSION: Prophylactic antibiotics do not reduce the incidence of either pancreatitis or cholangitis following ERCP.

Occupational Radiation Exposure during Endoscopic Retrograde Cholangiopancreatography and Usefulness of Radiation Protective Curtains.

Objective. To evaluate the effectiveness of radiation protective curtains in reducing the occupational radiation exposure of medical personnel. Methods. We studied medical staff members who had assisted in 80 consecutive therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedures. Use of radiation protective curtains mounted to the X-ray tube was determined randomly for each procedure, and radiation doses were measured with electronic pocket dosimeters placed outside the protective apron. Results. When protective curtains were not used, the mean radiation doses to endoscopists, first assistants, second assistants, and nurses were 340.9, 27.5, 45.3, and 33.1 µSv, respectively; doses decreased to 42.6, 4.2, 13.1, and 10.6 µSv, respectively, when protective curtains were used (P < 0.01). When the patient had to be restrained during ERCP (n = 8), the radiation dose to second assistants without protective curtains increased by a factor of 9.95 (P < 0.01) relative to cases in which restraint was not required. Conclusions. During ERCP, not only endoscopists, but also assistants and nurses were exposed to high doses of radiation. Radiation exposure to staff members during ERCP was reduced with the use of protective curtains.