Does endoscopic sphincterotomy contribute to the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis after endoscopic biliary stenting for malignant biliary obstruction? A multicenter prospective cohort study.

BACKGROUND: There is no consensus on the necessity of endoscopic sphincterotomy (ES) to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after endoscopic stenting in patients with malignant biliary obstruction. We investigated the incidence of PEP after endoscopic biliary stenting for malignant biliary obstruction with or without ES in a multicenter prospective cohort study. METHODS: We enrolled 807 patients who underwent endoscopic biliary stenting for malignant biliary obstruction with a native papilla at 36 hospitals between April 2017 and March 2018. The incidence of PEP in patients with or without ES was compared for subgroups based on stent type, placement method, and patient background. Univariate and multivariate analysis was performed to investigate the incidence of PEP in all stenting patients. RESULTS: Plastic and metal stents (MS) were inserted in 598 and 209 patients, respectively. The incidence of PEP in patients with or without ES was 7.9% and 7.4%, respectively among all stenting patients. The incidences of PEP with or without ES in plastic stent insertion patients, patients with MS insertion, stent insertions across the papilla, stent insertions across the papilla in patients without main pancreatic duct obstruction, and fully covered MS insertions across the papilla were compared. There was no overall significant difference in the incidence of PEP between those with or without ES. Multivariate logistic regression analysis for the incidence of PEP in all stenting patients revealed obstruction of the main pancreatic duct at the pancreatic head and epinephrine spraying on the papilla were significant factors; there was no significant difference in the incidence of PEP between patients with or without ES. CONCLUSION: Endoscopic sphincterotomy may not contribute to the prevention of PEP after endoscopic biliary stenting for malignant biliary obstruction, even in cases of insertion with a fully covered MS across the papilla.

Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin.

BACKGROUND/PURPOSE: The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM). METHODS: In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting. RESULTS: Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR = 8.3, P < .01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P < .01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P = .41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR = 0.23, P = .01). CONCLUSIONS: While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.

History of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis and Acute Pancreatitis as Risk Factors for Post-ERCP Pancreatitis.

BACKGROUND: Previous pancreatitis is a definite patient-related risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis: PEP). However, the effects of differences in the history of PEP and acute pancreatitis on the occurrence of PEP have not been fully investigated. We examined the relationship between previous PEP or previous acute pancreatitis and procedural factors associated with PEP. METHODS: Clinical data on 1,334 consecutive patients undergoing ERCP between April 2006 and June 2010 were collected. A multivariate logistic regression analysis was conducted to assess the relationship between PEP and the cannulation time (<15 min vs. ≥15 min) or total procedure time (<30 min vs. ≥30 min) according to previous pancreatitis (previous PEP: pPEP or previous acute pancreatitis: pAP), with adjustments for clinical characteristics. RESULTS: Longer cannulation times (≥15 min) correlated with the occurrence of PEP in the pPEP group (OR=2.97; 95% CI=1.10 to 8.43, P=0.03) and in patients without previous pancreatitis (non-preP group) (OR=2.43; 95% CI=1.41 to 4.14, P= 0.002), but not in the pAP group (OR=2.78; 95% CI=0.50 to 22.42, P= 0.25). In contrast, longer procedure times correlated with the occurrence of PEP in the pAP group (OR=3.93; 95% CI=1.11 to 16.5, P= 0.03), but not in the pPEP group (OR=2.79; 95% CI=0.92 to 9.18, P= 0.068) or non-preP group (OR=0.71; 95% CI=0.39 to 1.24, P= 0.23). CONCLUSIONS: A higher risk of PEP with previous PEP was associated with longer cannulation times, whereas a higher risk of PEP with previous acute pancreatitis was associated with longer procedure times.

A case of lymphoepithelial cyst of pancreas with unique "cheerios-like" appearance in EUS.

Lymphoepithelial cyst (LEC) of the pancreas is a rare benign lesion, which is difficult to diagnose preoperatively. We describe a case of a 60-year-old male, incidentally diagnosed as having LEC of the pancreas, which was managed by laparoscopic distal pancreatectomy. Most of the reported cases of LEC were asymptomatic and diagnosed incidentally. A high index of suspicion under EUS may help in making a diagnosis and avoiding unnecessary surgery in asymptomatic patients. In particular, the unique "cheerios-like" appearance of the lesion in EUS, which was also found in this case, might be helpful in the differential diagnosis of pancreatic cystic lesions.

Sphincter of Oddi disorder: what is the clinical issue?

Sphincter of Oddi disorder (SOD) is a functional disorder of the sphincter of Oddi (SO) and is pathophysiologically equivalent to functional gastrointestinal disorder (FGID) of the digestive tract. SOD is important as a cause of biliary pain of unknown origin and idiopathic acute recurrent pancreatitis; however, the concept of SOD has not generally spread in the same way as FGID. SOD is diagnosed using ROME III criteria which were revised in 2006 to reduce the number of unnecessary and potentially risky procedures. Many cases of SOD still need SO manometry (SOM) which is performed during endoscopic retrograde cholangiopancreatography (ERCP). It is problematic that SOD patients, who already have a high risk of post-ERCP pancreatitis, require SOM for a definitive diagnosis. SOM is an invasive examination that is accompanied by a high risk of post-procedure pancreatitis and can be performed only at a limited number of institutions because of technical difficulties. In the treatment of SOD, the effectiveness of the drugs is uncertain, and the role of drug therapy in the management of SOD has not yet been established. In recent years, endoscopic sphincterotomy (EST) has been recognized as standard treatment for SOD; however, the effect of EST is not yet clear. The development of less invasive diagnostic techniques is desirable in the future. Furthermore, patient eligibility criteria for EST and the long-term prognosis after EST should be clarified.

[Successful treatment for advanced hepatocellular carcinoma by hepatic arterial infusion of CDDP powder as second-line chemotherapy].

A 72-year-old man with type C liver cirrhosis had suffered from hepatocellular carcinoma (HCC) since April, 2001. HCC spread diffusely all over the right lobe of his liver, and the serum alpha-fetoprotein (AFP) value increased up to 42,696 ng/ml in June of 2004. He was implanted with a port-catheter system, and hepatic arterial infusion chemotherapy (HAIC) using low-dose of CDDP and 5-FU was started. However, it was not effective and after 4 months, the serum AFP level increased up to 755,030 ng/ml, ascites appeared, and gastro-esophageal varices also spread. No definite metastasis was detected, then we started to second-line chemotherapy. He was then given HAIC using CDDP powder for intraarterial use (CDDP 50 mg/m(2)/20 min, monthly). After 3 courses, the serum AFP level decreased to 9 10 ng/ml, and abdominal CT revealed that the main tumor had regressed and ascites had disappeared. After one more course, the serum AFP value decreased to 8 ng/ml and complete response was achieved on abdominal CT imaging. There was no major complication related to the chemotherapy. HAIC for advanced HCC using LFP has been reported to achieve favorable results, but no other regimens have been proved to the standard for HCC. HAIC using CDDP powder for advanced HCC may be beneficial as the second-line chemotherapy.

[Outcomes of treatment with gemcitabine for unresectable pancreatic cancer].

The efficacy and safety of gemcitabine were investigated in 16 patients with unresectable pancreatic cancer (Arm A), compared with 16 patients who received chemotherapy without gemcitabine (Arm B) and 44 patients who received best supportive care (Arm C). A gemcitabine 30 min i.v. infusion at a starting dose of 1,000 mg/m2 was administered once a week for 3 weeks with a 1 week rest. Dose reduction and cycle delay were applied because of toxicity in 62.5% of the cases in the first cycle and 31.3% in the second cycle. Hematological toxicity was observed in 81.3%, nausea/vomiting in 37.5% and fatigue in 18.8%. Clinical benefit response was observed in 25.0% in Arm A, as compared with the lower rate of 6.25% in Arm B. Response rates were comparable. The median time of outpatient treatment was 98.5 days in Arm A and 34.0 days in Arm B, respectively. The median survival time was 200 days in Arm A, 121 days in Arm B and 82.5 days in Arm C, respectively. In Arm A, the higher dose intensity showed a longer survival time. The results show that gemcitabine can be administered in outpatient clinics with dose reduction and cycle delay, and that higher dose intensity generates clinical benefit, survival advantage and prolonged outpatient treatment time.