Evaluation of a Novel Easy Loop-Forming Guidewire to Reduce Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis for Serial Pancreatic Juice Aspiration Cytologic Examination: A Propensity Score Matching Analysis.

OBJECTIVE: This study aimed to investigate whether a novel, easy loop-forming guidewire could reduce post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients undergoing endoscopic nasopancreatic drainage tube placement for serial pancreatic juice aspiration cytologic examination (SPACE). METHODS: We evaluated patients with suspected pancreatic cancer who underwent SPACE at our institution between January 2015 and April 2023 retrospectively. The patients were divided into 2 groups based on the type of guidewire used, namely, easy loop-forming and control groups. Propensity score matching was used to compare the incidence of PEP between the groups. RESULTS: We included 101 patients, with 51 and 50 in the easy loop-forming and control groups, respectively. After propensity score matching, 29 pairs of patients were selected from each group. Intraductal ultrasonography of the pancreas was performed more frequently in the easy loop-forming group than in the control group (27.6% vs 0%; P = 0.004); however, PEP incidence was significantly lower in the easy loop-forming group than in the control group (3.4% vs 27.6%; odds ratio, 0.097; 95% confidence interval, 0.002-0.82; P = 0.025). CONCLUSIONS: The use of the novel easy loop-forming guidewire decreased PEP occurrence in patients who underwent endoscopic nasopancreatic drainage tube placement for SPACE.

Safety of early oral intake after endoscopic ultrasound-guided hepaticoenterostomy.

BACKGROUND: Techniques and devices for endoscopic ultrasound (EUS)-guided hepaticoenterostomy (EUS-HES) procedures, including EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided hepaticojejunostomy (EUS-HJS), have been developed; however, the optimal timing to begin oral intake after EUS-HES remains unknown. This study aimed to evaluate the safety of early oral intake after EUS-HES. METHODS: We retrospectively investigated patients who underwent EUS-HES (EUS-HGS or EUS-HJS) between March 2015 and March 2022. Patients who had no problems with the results of blood tests and computed tomography examinations on the morning of day 1 after EUS-HES were classified as either the early intake group (started oral intake on day 1 after EUS-HES) or the late intake group (started oral intake on day 2 or later after EUS-HES). Patients' characteristics, procedure characteristics, and early postprocedural adverse events (within 14 days after the procedure) were compared between groups. RESULTS: Fifty patients were enrolled in this study. Forty-three patients had no problems with the results of examinations performed on the morning of day 1 after EUS-HES. Twenty-one patients comprised the early intake group and 22 comprised the late intake group. Adverse events that developed within 14 days after EUS-HES were not significantly different between groups (early 4.7% vs. late 9.0%; odds ratio, 0.50; 95% confidence interval, 0.0080-10.49; P = 1.00). CONCLUSIONS: Starting oral intake on day 1 after EUS-HES did not increase postprocedural adverse events compared with starting oral intake on day 2 or later after EUS-HES.

Transferring a naso-gallbladder drainage tube to the mouth for re-examination of a gallbladder lesion.

Conventional gallbladder re-intervention along the naso-gallbladder drainage tube may result in dislocation of the tube during scope insertion or failure of guidewire insertion into the gallbladder. Mandai et al report a simple method for transferring a transpapillary naso-gallbladder drainage tube to the mouth that facilitates reliable re-intervention for gallbladder lesions.

Transpapillary biliary drainage using a long plastic stent: Preventing early stent dysfunction in pancreatic cancer with duodenal invasion.

Highlight Duodenal invasion has been reported to be a risk factor for early biliary stent dysfunction in patients with pancreatic cancer. Mandai and colleagues describe their method of transpapillary biliary drainage using a long plastic stent as a potentially useful treatment option to avoid early stent dysfunction in such patients.

Risk for Colorectal Cancer in Patients with Serially Positive Fecal Immunochemistry Test in an Annual Screening Program.

OBJECTIVES: There are patients who do not undergo colonoscopy even if the fecal immunochemistry test (FIT) results are positive and even with repeated positive test results the following year. We aimed to investigate colorectal cancer (CRC) risk in examinees with positive FIT results in our annual screening program. METHODS: We analyzed patients who underwent initial colonoscopy from April 2010 to March 2017 because of positive FIT results using an endoscopy database in our hospital. We investigated the difference in the risk of advanced colorectal neoplasia as a surrogate marker of CRC between those who had an initial positive test and those who had repeated positive tests. RESULTS: A total of 748 patients were included in this analysis. The advanced neoplasia detection rates were 7.6% (50/656) and 18.5% (17/92) for the initial and repeated positive test groups, respectively. Subgroup analysis of those with repeated positive tests revealed that the detection rates in examinees with positive tests 1-2 and >2 years ago were 16.7% (6/36) and 19.6% (11/56), respectively. The odds ratios for advanced neoplasia detection in patients with positive tests 1-2 and >2 years ago compared with those in the initial positive test group were 2.72 (95% confidence interval [CI], 1.04-7.10) and 3.09 (95% CI, 1.47-6.48), respectively. CONCLUSIONS: The risk of CRC appears more than doubled in patients with a repeated positive FIT result. Prompt colonoscopy is recommended for FIT-positive cases.

Ischemic Colitis Caused by Bowel Preparation for Colonoscopy.

BACKGROUND: Ischemic colitis is an adverse event which may occur during bowel preparation for colonoscopy. This study aims to clarify both the incidence and the risk factors of this complication. METHODS: This was a single-center, retrospective, observational study. All outpatients who were prescribed standardized preparation drugs for colonoscopy at the Kyoto Second Red Cross Hospital between November 2011 and March 2020 were included in the study. A split bowel preparation was carried out as follows; magnesium citrate with or without sodium picosulfate hydrate was/were used as a preparation drug on the day before the colonoscopy, and polyethylene glycol electrolyte solution or sodium phosphate was used on the morning of the endoscopic procedure. Patients were extracted from the electronic medical records and matched with the endoscopy database by examination date and hospital identification number. Following the endoscopic findings, both the incidence and risk factors for ischemic colitis arising after bowel preparation were examined. RESULTS: Among the 14,924 patients analyzed, ischemic colitis was observed in 14 patients (0.09%). Multivariate analysis revealed that old age (≥ 75 years old) and strong preparation (magnesium citrate with sodium picosulfate and polyethylene glycol electrolyte solution) for constipated patients were independent risk factors for ischemic colitis (odds ratio: 3.64 (95% confidence interval (CI): 1.36 - 9.77) and 4.27 (95% CI: 1.45 - 12.53), respectively). CONCLUSIONS: The age 75 years and above and strong preparation for patients with constipation were independent risk factors for ischemic colitis prior to colonoscopy. Careful attention should be paid to bowel preparation before colonoscopy for patients aged ≥ 75 years and for those with constipation.

EUS-guided antegrade pancreatic guidewire placement for double-guidewire technique in single-balloon enteroscope-assisted ERCP.

Highlight Mandai and colleagues describe EUS-guided antegrade pancreatic guidewire placement followed by the double-guidewire technique in balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography in a patient with recurrent gastric cancer. This case suggests that EUS-guided antegrade pancreatic guidewire placement can be useful for the subsequent double-guidewire technique when EUS-guided biliary access has failed.

Endoscopic ultrasound-guided treatment for malignant afferent loop obstruction after Roux-en-Y reconstruction.

The usefulness of endoscopic ultrasound (EUS)-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent (LAMS) has been reported. However, LAMS is not available in many countries and is more expensive than a conventional fully covered self-expandable metal stent (FCSEMS). We treated cases of malignant afferent loop obstruction after Roux-en-Y reconstruction: three patients underwent EUS-guided hepaticoenterostomy (EUS-HES) and one patient underwent EUS-GJ with a conventional biliary FCSEMS, instead of EUS-GJ with a LAMS. In two of the cases, EUS-GJ or EUS-guided jejunojejunostomy was not indicated because the afferent loop was far from the stomach or jejunum, and EUS-HES was performed. In one case, in which both EUS-HES and EUS-GJ were feasible, EUS-HES was performed because of unavailability of LAMS for EUS-GJ in Japan. In another case, EUS-HES was not indicated because of massive ascites around the liver, and thus, EUS-GJ using a 10 mm FCSEMS combined with a 7 Fr large-loop double-pigtail plastic stent was performed. In all four cases, the patients' symptoms improved without any adverse events. Stent occlusion did not occur in three of the four cases until the patients died of advanced cancer progression. EUS-GJ using a 10 mm FCSEMS with a 7 Fr large-loop double-pigtail plastic stent or EUS-HES is likely safe and effective for managing malignant afferent loop obstruction.

Significance of fecal hemoglobin concentration for predicting risk of colorectal cancer after colonoscopy.

BACKGROUND AND AIM: As the significance of the quantitative fecal immunochemical test (FIT) in patients who previously underwent a colonoscopy is unknown, this study aimed at investigating the association between fecal hemoglobin concentration and the risk of colorectal cancer (CRC). METHODS AND RESULTS: We retrospectively analyzed FIT-positive patients who underwent a colonoscopy through our opportunistic annual screening program from April 2010 to March 2017 at the Kyoto Second Red Cross Hospital. We stratified them into no colonoscopy and past colonoscopy (>5 years or ≤5 years) groups based on whether they had a history of undergoing a colonoscopy and analyzed the correlation between fecal hemoglobin concentration and advanced neoplasia or invasive cancer detection in each group. We analyzed 1248 patients with positive FIT results. There were 748 (59.9%), 198 (15.9%), and 302 (24.2%) patients in the no colonoscopy, past colonoscopy (>5 years), and past colonoscopy (≤5 years) groups, respectively. In the no colonoscopy group, the advanced neoplasia detection rate significantly increased with the fecal hemoglobin concentration (P < 0.001). However, no significant trend was observed in the past colonoscopy (both >5 years and ≤5 years) group (P = 0.982). No invasive cancer was detected in the past colonoscopy (≤5 years) group. CONCLUSION: The risk of CRC might be low even if fecal hemoglobin concentration was high, especially in those who underwent colonoscopy within 5 years.

Efficacy and Safety of Short-type Single Balloon Enteroscopy-assisted Peroral Direct Cholangioscopy Using an Ultra-slim Endoscope in Patients With Surgically Altered Anatomy.

BACKGROUND: The efficacy and safety of peroral direct cholangioscopy (PDCS) in patients with surgically altered anatomy (SAA) are unclear. The present study aimed to evaluate the efficacy and safety of short-type single balloon enteroscope (s-SBE)-assisted PDCS using an ultra-slim endoscope in patients with SAA. MATERIALS AND METHODS: We retrospectively analyzed 12 sessions of PDCS performed in 8 patients with surgically altered gastrointestinal or pancreatobiliary anatomy between November 2017 and September 2019 at our institution. Endoscopic retrograde cholangiopancreatography using s-SBE was initially performed. Subsequently, the s-SBE was exchanged for an ultra-slim endoscope through an overtube with an inflated balloon to perform PDCS. We analyzed the success rates and adverse events resulting from the procedure. RESULTS: Six patients had biliary stones and 2 had biliary strictures. The types of reconstruction were Roux-en-Y choledochojejunostomy (n=5), Billroth II gastrectomy (n=2), and Roux-en-Y gastrectomy (n=1). Biliary insertion of the ultra-slim endoscope was successful in all 12 sessions. Biliary interventions included electronic hydraulic lithotripsy in 5 sessions, stone removal using basket catheter in 3 sessions, biopsy in 2 sessions, and diagnosis of no residual stones in 2 sessions. Complete stone removal was finally achieved in all 6 patients with biliary stones. Biliary strictures in 2 patients were diagnosed as adenocarcinoma following a biopsy. The adverse events were cholangitis of mild severity in 3 sessions. CONCLUSION: S-SBE-assisted PDCS using an ultra-slim endoscope was useful and safe in patients with SAA, although care should be taken to avoid adverse events.

Association between hyperechogenic pancreas and pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasms.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) may independently occur in the pancreas separate from an intraductal papillary mucinous neoplasm (IPMN). Therefore, identifying the characteristics of patients with IPMN who will likely develop PDAC is clinically important. Although a recent study found that fatty pancreas correlated with PDAC, no reports have examined this matter in patients with IPMN. A previous study showed that fatty pancreas increased the echogenicity; hence, this study aimed to investigate the association between hyperechogenic pancreas and PDAC in patients with IPMN. METHODS: We retrospectively collected data of patients with IPMN who underwent endoscopic ultrasonography (EUS) between January 2012 and November 2018. A case-control analysis was performed between patients with IPMN concomitant with PDAC (cases) and those without PDAC (controls). We identified controls by matching age and sex with cases. The echogenicity of the pancreas was determined using EUS by comparing it with the left kidney or spleen. Echogenicity was determined using transabdominal ultrasonography by comparison with that of the liver when it was difficult to determine using EUS. RESULTS: Among 400 patients with IPMN, 23 cases and 92 controls were identified. The proportion of patients with hyperechogenic pancreas was significantly greater in cases than in controls (91.3% vs. 65.2%, P = 0.02). Multivariate analysis, including family history of pancreatic cancer, multifocal cysts, and hyperechogenic pancreas, showed that hyperechogenic pancreas was correlated with PDAC concomitant with IPMN (odds ratio = 7.07; 95% confidence interval = 1.48-33.80; P = 0.01). CONCLUSION: Our analysis demonstrated that hyperechogenic pancreas was associated with concomitant PDAC in patients with IPMN.