Endoscopic biliary drainage using a 4-Fr catheter for biliary obstruction: a pilot study.

INTRODUCTION: Stent or endoscopic nasobiliary drainage (ENBD) catheter placement for a tight, complicated biliary stricture is still technically challenging. A thin, 4-Fr ENBD catheter (4-Fr catheter) has been developed to overcome this difficulty. The study aimed to evaluate the feasibility of the 4-Fr catheter for endoscopic biliary drainage (EBD). MATERIAL AND METHODS: We performed a retrospective review of 51 patients who underwent EBD with the 4-Fr catheter because placement of a conventional drainage catheter (CDC) had failed. RESULTS: The success rate of 4-Fr catheter placement was 96.1% (49/51). The median patency period of the catheter was 114 days (95% CI, 53-200). Among the 49 patients with successful placement of the catheter, adverse events occurred in five (10.2%) patients: post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), two patients; catheter dislocation, one patient; and kinking of the 4-Fr catheter, two patients. Both cases of PEP improved with conservative treatment, but all cases of catheter dislocation and kinking required reintervention with a 4-Fr catheter. Forty-three (87.8%) patients achieved clinical remission after EBD with a 4-Fr catheter. CONCLUSIONS: The newly developed 4-Fr catheter is safe and feasible for EBD in patients in whom CDC placement is difficult due to a tight, complicated biliary stricture.

A prospective multicenter study of endoscopic ultrasound-guided fine needle biopsy using a 22-gauge Franseen needle for pancreatic solid lesions.

BACKGROUND AND AIM: While encouraging data of endoscopic ultrasound (EUS)-guided fine-needle biopsy (EUS-FNB) using a 22-gauge Franseen needle have been reported, large-scale data of per pass and quantitative analyses are still lacking. METHODS: This was a multicenter prospective study of EUS-FNB using the 22-gauge Franseen needle for a pancreatic solid lesion. Cytological and histological analyses per pass were evaluated and semi-quantitative analyses were performed on core tissue and blood contamination. Primary end-point was diagnostic accuracy per session. Prognostic factors were analyzed for diagnostic accuracy, sensitivity, core tissue, and blood contamination. RESULTS: A total of 629 passes were performed in 244 cases at 14 centers between 2018 and 2019. The median tumor size was 29 mm, and the puncture was transduodenal in 43%. The median pass number was 2. Diagnostic accuracy per session, at a first pass, and per pass were 93%, 90%, and 88%. In 198 cases with pancreatic cancer, diagnostic sensitivity per session, at a first pass, and per pass were 94%, 89%, and 89%. The rates of core tissue score of 4 and blood contamination score of 3 were 50% and 47%. The adverse event rate was 1.6%. In the multivariate analysis, tumor size ≤20 mm (odds ratio [OR] of 0.46, P = 0.03), transduodenal puncture (OR of 0.53, P = 0.04), and suction (OR of 0.16, P = 0.01) were associated with lower diagnostic accuracy. CONCLUSIONS: The EUS-FNB using the 22-gauge Franseen needle for pancreatic solid lesions showed high per pass and overall diagnostic accuracy.

Adverse events of endoscopic ultrasound-guided fine-needle aspiration for histologic diagnosis in Japanese tertiary centers: Multicenter retrospective study.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is used for the histopathological diagnosis of any type of gastrointestinal disease. Few adverse events are experienced with this procedure; however, the actual rate of adverse events remains unclear. This study aimed to clarify the current status of cases that experienced adverse events related to the EUS-FNA procedure used for histopathologic diagnoses. METHODS: A retrospective analysis of cases with EUS-FNA-related adverse events in Japanese tertiary centers was conducted by assessing the following clinical data: basic case information, FNA technique, type of procedural adverse events, and prognosis. RESULTS: Of the 13,566 EUS-FNA cases overall, the total number of cases in which adverse events related to EUS-FNA occurred was 234. The incidence of EUS-FNA-related adverse events was ~1.7%. Bleeding and pancreatitis cases accounted for ~49.1% and 26.5% of all adverse events, respectively. Bleeding was the most common adverse event with only seven cases requiring blood transfusion. In cases with neuroendocrine tumors, pancreatitis was the most frequent adverse event. Needle tract seeding because of EUS-FNA was observed during the follow-up period in only ~0.1% of cases with pancreatic cancer. There was no mortality because of adverse events caused by EUS-FNA. CONCLUSIONS: This study revealed that the adverse events-related EUS-FNA for histopathologic diagnoses were not severe conditions, and had low incidence.

[A case of granulomatosis with polyangiitis with Crohn's disease-like findings].

A 22-year-old woman who was diagnosed with Crohn's disease experienced diarrhea and bloody stool. She was suspected of have aggravated Crohn's disease and was transferred to our hospital. Upper gastrointestinal endoscopy revealed multiple esophageal ulcers and erosive gastritis, while colonoscopy revealed multiple ulcers in the rectum to the sigmoid colon. Initially, the evidence suggested that the Crohn's disease had worsened, and consequently, prednisolone (PSL) therapy was initiated. However, the patient's condition was determined to be atypical inflammatory bowel disease, which was indicated by endoscopic findings and skin symptoms and because various test results did not meet the diagnostic criteria for Crohn's disease. As a result, her diagnosis was changed to granulomatosis with polyangiitis. Here, we report a case of granulomatosis with polyangiitis with gastrointestinal symptoms similar to Crohn's disease, both of which have been suggested to involve Th1/Th17 cells.

Antitumor effect of VEGFR2-targeted microbubble destruction with gemcitabine using an endoscopic ultrasound probe: In vivo mouse pancreatic ductal adenocarcinoma model.

BACKGROUND: Ultrasound-targeted microbubble destruction (UTMD) induces cellular inflow of drugs at low intensity, while high intensity eradicates tumor vessels. Since vascular endothelial growth factor receptor 2 (VEGFR2) is highly expressed in pancreatic ductal adenocarcinoma (PDAC), VEGFR2-targeted microbubble (MB) might additionally increase the tissue specificity of drugs and thus improve antitumor effects. In addition, fixing the dual pulse intensity could maximize MB properties. This study evaluated the one-off (experiment 1) and cumulative (experiment 2) treatment effect of UTMD by regulating the dual pulse output applied to PDAC using VEGFR2-targeted MB. METHODS: C57BL/6 mice inoculated with Pan-02 cells were allocated to five groups: VEGFR2-targeted MB+ gemcitabine (GEM), VEGFR2-targeted MB, non-targeted MB+GEM, GEM, and control groups. After injection of GEM or GEM and either VEGFR2-targeted or non-targeted MB, UTMD was applied for several minutes at low intensity followed by high intensity application. In experiment 1, mice were treated by the protocol described above and then euthanized immediately or at the tumor diameter doubling time (TDT). In experiment 2, the same protocol was repeated weekly and mice were euthanized at TDT regardless of protocol completion. Histological analysis by CD31 and VEGFR2 staining provided microvascular density (MVD) and VEGFR2 expression along vessels (VEGFR2v) or intra/peripheral cells (VEGFR2c). RESULTS: In experiment 1, TDT was significantly longer in the VEGFR2-targeted MB+GEM group compared to the non-targeted MB+GEM, GEM, and control groups, while the VEGFR2-targeted MB group showed no statistical significance. MVD and VEGFR2v in the immediate euthanasia was significantly lower in the VEGFR2-targeted MB+GEM and VEGFR2-targeted MB groups than other conditions. In experiment 2, the VEGFR2-targeted MB+GEM group produced significantly longer TDT than the GEM or control groups, whereas the VEGFR2-targeted MB group showed no significant difference. Histology revealed significantly reduced VEGFR2v and VEGFR2c in the VEGFR2-targeted and non-targeted MB+GEM groups, while only VEGFR2v was significantly less in the VEGFR2-targeted MB group. CONCLUSIONS: UTMD-mediated GEM therapy with the dual pulse application using VEGFR2-targeted MB substantially suppresses PDCA growth.

A novel second-generation multibending backward-oblique viewing duodenoscope in ERCP.

INTRODUCTION: Successful access to the papilla and cannulation of the desired duct can be technically challenging. A novel second-generation multi-bending backward-oblique viewing duodenoscope (2nd M-D scope) was developed to overcome this difficulty. The aim of the present study was to evaluate the utility of 2nd M-D scope during biliary ERCP. MATERIAL AND METHODS: This was a retrospective review of 53 patients with native papilla who underwent biliary ERCP with the 2nd M-D scope. RESULTS: Biliary cannulation and interventional procedures were successfully completed in all patients. In two of these patients, ERCP was initially attempted with a conventional single bending duodenoscope, but biliary cannulation was unsuccessful; one had Billroth-I gastrectomy, and the other had a Type III choledochal cyst. However, with the 2nd M-D scope, biliary cannulation and interventional procedures were successfully achieved. Finally, in nine patients, upward or downward angulation of the proximal bending portion in addition to the distal bending portion was used during ERCP, and the operator's comments demonstrated that it was helpful for obtaining an appropriate en face view to look up to the papilla and facilitate successful biliary cannulation. CONCLUSION: The newly developed 2nd M-D scope could safely facilitate biliary cannulation in selected patients during ERCP.

A double-blind, block-randomized, placebo-controlled trial to identify the chemical assistance effect of mesna submucosal injection for gastric endoscopic submucosal dissection.

BACKGROUND: Previous animal studies and a pilot clinical trial demonstrated that submucosal injection of a thiol compound called mesna could chemically soften connective tissues and thus facilitate endoscopic submucosal dissection (ESD). OBJECTIVE: To evaluate whether mesna injection could reduce procedural times for gastric ESD. DESIGN: Double-blind, block-randomized, controlled trial. SETTING: University hospital. PATIENTS: A total of 101 patients with superficial gastric cancer indicated for ESD were enrolled and randomly assigned to either the mesna or control (saline solution) group. INTERVENTION: Traditional ESD was performed with a single bolus injection of mesna or saline solution. MAIN OUTCOME MEASUREMENTS: Time for submucosal dissection (TSD). RESULTS: En bloc resection was achieved for all lesions in the mesna group (53/53) and 51 of 52 lesions (98.08%) in the control group. TSD was not statistically different between the groups (18.62 ± 13.9 [mean ± SD] minutes for the mesna group and 24.58 ± 24.55 [mean ± SD] minutes for the control group; P = .128), and there were fewer time-consuming cases (times over 30 minutes) in the mesna group compared with controls (7/53 vs 15/52; P = .049). Multivariate regression analysis demonstrated that use of mesna, specimen size, and the presence of fibrous scars were significantly correlated with TSD (P < .05). LIMITATIONS: Single-center study. CONCLUSION: TSD was not significantly different between the mesna and control injection groups, but multivariate analysis indicated that mesna injection reduced procedural challenges associated with the submucosal dissection. ( CLINICAL TRIAL REGISTRATION NUMBER: UMIN000003786.).

Contrast-enhanced harmonic endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening.

BACKGROUND AND AIMS: Differentiation of gallbladder (GB) carcinoma from benign GB wall thickening is challenging. The recent introduction of second-generation ultrasonic contrast agents has made contrast harmonic imaging with EUS possible. The aim of our study was to evaluate the utility of contrast-enhanced harmonic EUS (CH-EUS) for the differential diagnosis of GB wall thickening. METHODS: Thirty-six consecutive patients with GB wall thickening imaged by CH-EUS and then underwent surgery were enrolled in this study. After the lesions were observed with conventional harmonic EUS (H-EUS), CH-EUS was performed with intravenous injection of 0.015 ml/kg of Sonazoid. Three reviewers with various levels of experience of EUS (Reviewer A: experienced endosonographer, B: EUS trainee, C: experienced gastroenterologist with expertise in transabdominal ultrasound but no EUS experience) were blinded to findings of recorded video of H-EUS and CH-EUS. The diagnostic accuracy of H-EUS and CH-EUS for malignant GB wall thickening was compared. RESULTS: Final diagnoses based on surgical histology were GB carcinoma in 16, cholecystitis in 11, adenomyomatosis in 6 and cholesterolosis in 3. Overall sensitivity, specificity and accuracy for diagnosing malignant GB wall thickening of H-EUS and CH-EUS were 83.3 versus 89.6, 65 versus 98% (p < 0.001) and 73.1 versus 94.4% (p < 0.001). The inter-observer agreement for H-EUS was moderate (κ = 0.51), whereas that for CH-EUS was substantial (κ = 0.77). The inhomogeneous enhanced pattern on CH-EUS was a strong predictive factor of malignant GB wall thickening. CONCLUSION: CH-EUS has the potential to improve the preoperative diagnostic accuracy and inter-observer agreement in the differential diagnosis of GB wall thickening.

A comparison of diagnostic utility of new endoscopic scraper combined cell block method and conventional brush catheter for biliary tract cancer.

Background/Aims: The sensitivities of endoscopic trans-papillary pathologic diagnosis of biliary tract cancer (BTC) are unsatisfactory. Recently, the diagnostic utility of the endoscopic scraper device, Trefle for biliary stricture has been reported. The Trefle can be guided to the target biliary stricture over the guidewire and is as easy to use as the conventional brush catheter (CBC). This study evaluated the efficacy and safety of Trefle-assisted tissue acquisition combined cell block method and CBC cytology for biliary strictures due to BTCs. Methods: We retrospectively reviewed consecutive patients with biliary strictures in whom CBC cytology or Trefle-assisted tissue acquisition under endoscopic retrograde cholangiopancreatography was performed for suspected BTCs from January 2015 to June 2022 at our institution. Results: 173 patients (CBC group; n = 55, Trefle group; n = 118) were enrolled in this study. The sensitivity, specificity, and accuracy of CBC cytology for BTC were 68.3%/100%/76.4%. On the other hand, the sensitivity, specificity, and accuracy of Trefle-assisted tissue acquisition for BTC were 93.7%/95.7%/94.1%, showing superior sensitivity (p < 0.001) and accuracy (p = 0.002) compared to that of CBC. Conclusions: Compared to CBC cytology, Trefle-assisted tissue acquisition has superior diagnostic performance while maintaining procedural simplicity and is considered useful for diagnosing malignant biliary stricture.

Correlation between pathology and quantitative ultrasonographic evaluation of pancreatic fat with ultrasonographic classification.

PURPOSE: No studies of the relationship between grayscale sonographic findings and pancreatic fat content have been reported to date. This study aimed to investigate the correlation between echogenicity and fat content of resected specimens using quantitative analysis. METHODS: Forty-two consecutive patients who underwent pancreatoduodenectomy or distal pancreatectomy for pancreatic tumors were enrolled in this study. Ultrasonographic images were compared with quantitative pathological analysis. Subjective evaluation of echogenicity was classified as hypoechoic, isoechoic, hyperechoic, and super hyperechoic. The total and intralobular fat areas were measured. RESULTS: The mean, median, modal, minimum, and maximum ultrasound gray values correlated with the proportion of total fat area (r = 0.349; 0.357, 0.486, 0.466, and 0.347; p = 0.024, 0.020, 0.014, 0.019, and 0.089, respectively), but did not correlate with the proportion of intralobular fat area. Subjective classification was correlated with median gray value (p < 0.001), intralobular fat area (p = 0.118), and total fat area (p = 0.011). Cases were classified as hypoechoic (n = 3), isoechoic (n = 7), hyperechoic (n = 30), and super hyperechoic (n = 2). The subjective classification was correlated with the median gray value (p < 0.001) and total fat area (p = 0.005), and not correlated with the intralobular fat area (p = 0.118). Hyperechoic or super hyperechoic pancreatic parenchyma contains over 19.7% fat. Computed tomography values correlated with the proportion of intralobular fat area (r = - 0.479, p = 0.004) and total fat area (r = - 0.541, p < 0.001). CONCLUSION: Echogenicity classified based on subjective evaluation and image analysis were correlated with the proportion of fat in the pancreas.

Quantitative analysis of VEGF-C mRNA of extrahepatic cholangiocarcinoma with real-time PCR using samples obtained during endoscopic retrograde cholangiopancreatography.

OBJECTIVE: Vascular endothelial growth factor (VEGF)-C overexpression in extrahepatic cholangiocarcinoma (ECC) has been shown to be correlated with lymph node metastasis. The intensity of immunohistochemical staining of VEGF-C protein in surgical samples has been used as index of VEGF-C overexpression in previous studies. The aim of the study was to examine if VEGF-C overexpression in ECC could be preoperatively detected by using samples obtained during ERCP. METHODS: Consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary stricture during the study period were prospectively analyzed. VEGF-C mRNA was quantified by real-time PCR methods using endoscopic samples obtained during ERCP. The high intensity of immunohistochemical staining of VEGF-C protein in surgical samples was used for the reference standard of VEGF-C overexpression. The level of S100P mRNA which was a novel diagnostic marker of ECC was also quantified to evaluate whether the endoscopic samples contained ECC cells. RESULTS: Twenty-five patients were enrolled in this study. Eighteen patients were diagnosed as ECC and seven patients were diagnosed as benign biliary structure. Nine of eighteen patients with ECC, who showed positive S100P mRNA in endoscopic samples and received surgical resection, were finally analyzed. Receiver operating characteristics analysis yielded VEGF-C mRNA cut-off value of 3.85 for detection of VEGF-C overexpression, and the diagnostic performance of VEGF-C mRNA measurement in the endoscopic sample for VEGF-C overexpression reached sensitivity of 75.0%, specificity of 100%, and accuracy of 88.9%. CONCLUSION: The quantification of VEGF-C mRNA of ECC with real-time PCR using endoscopic samples was useful for preoperative detection of VEGF-C overexpression.

Is it safe to perform endoscopic band ligation for the duodenum? A pilot study in ex vivo porcine models.

AIM: In the digestive tract, endoscopic band ligation (EBL) has been routinely used for the treatment of variceal bleeding and superficial malignancies. In recent years, endoscopic treatments for duodenal varices, adenoma, and cancer have also actively incorporated EBL. Although there have been a number of reports on the risks associated with the use of EBL in the esophagus, stomach, and colon, few studies have focused on EBL in the duodenum. We performed EBL procedures to evaluate the risks associated with the use of EBL in the duodenum. MATERIAL AND METHODS: Overall, EBLs were performed at nine sites in duodenum sampled from a pig immediately after sacrifice. Submucosal saline injections were placed in three of the nine studied sites. RESULTS: Regardless of saline injection, the full thickness of the duodenal wall was ligated in all attempts. CONCLUSIONS: Routine EBL is not recommended in the duodenum because the risk of perforation is unacceptably high.

Diagnostic utility of quantitative analysis of microRNA in bile samples obtained during endoscopic retrograde cholangiopancreatography for malignant biliary strictures.

BACKGROUND: The sensitivity of bile cytology for malignant biliary strictures is not adequate. To overcome this limitation, we evaluated whether quantitative analysis of microRNAs (miRNAs) in bile can provide a precise diagnosis of malignant biliary strictures due to pancreatic cancer (PC) and biliary tract cancer (BTC). METHODS: This was a retrospective evaluation of miRNA levels in stored bile samples of patients with PC, BTC or benign biliary stricture obtained during biliary drainage from April 2019 to December 2021 at our institution. A total of 113 patients (PC; n = 40, BTC; n = 38, control; n = 35) were enrolled. The miRNA candidates to be quantified were determined with microarray analysis from each 3 patients with PC, BTC and controls. RESULTS: Using microarray analysis, we confirmed four significantly up-regulated miRNAs (miR-1275, miR-6891-5p, miR-7107-5p, miR-3197) in patients with PC and BTC compared to control patients. Quantitative PCR was then performed in 113 bile samples for these miRNAs. miR-1275 was significantly upregulated in PC (p = 0.003) and BTC (p = 0.049) compared to controls, miR-6891-5p was significantly upregulated in PC compared to controls (p = 0.025). In particular, a combination of bile cytology and miR-1275 in bile showed a sensitivity of 77.5% (95% CI, 70.7-77.5%), specificity of 100% (95% CI, 92.2-100%) and an area under the curve (AUC) of 0.93, and provided a significantly greater additional diagnostic effect than bile cytology alone (p = 0.014). CONCLUSIONS: This study suggest that bile miRNAs could be potential biomarkers for pancreato-biliary diseases, particularly miR-1275 and miR-6891-5p may be helpful in the diagnosis of PC and BTC.

The Usefulness of the Alpha-Retroflex Position in Biliary Cannulation on Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Roux-en-Y Gastrectomy: A Retrospective Study.

Introduction: Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is a useful therapeutic procedure that provides promising results in patients with surgically altered anatomy. However, biliary cannulation in BE-ERCP remains challenging. Therefore, in patients with Roux-en-Y gastrectomy, this study aimed to evaluate a BE-ERCP cannulation strategy that includes the newly developed alpha-retroflex scope position. Methods: This was a retrospective review of 52 patients with Roux-en-Y gastrectomy who underwent BE-ERCP at two centers between April 2017 and December 2022. In these patients, three types of scope position had been used for biliary cannulation: straight (S-position), J-retroflex (J-position), and alpha-retroflex (A-position). First, the S-position was used for biliary cannulation. Then, if biliary cannulation was difficult with this position, the J-position was used, followed by the A-position, if necessary. Results: The biliary cannulation success rate was 96.6% (50/52). The S-, J-, and A-positions achieved successful biliary cannulation in 24 (48%), 14 (28%), and 12 patients (24%), respectively. No adverse events, including post-ERCP pancreatitis and perforation, occurred. Conclusion: This was the first study of a cannulation strategy that included the A-position in addition to the S- and J-positions. The study showed that the A-position is feasible and safe in BE-ERCP in patients with Roux-en-Y gastrectomy.

A comparison of electronic radial and curvilinear endoscopic ultrasonography in the detection of pancreatic malignant tumor.

OBJECTIVE: There is no comparative study of electronic radial endoscopic ultrasonography (ER-EUS) and electronic curvilinear EUS (EC-EUS). The aim of this study was to compare the accuracy of ER-EUS and EC-EUS for detecting pancreatic malignancies. METHODS: This was a retrospective review of the patients who had EUS assessment from September 2008 to December 2011 for suspicious pancreatic tumors. Sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancies were calculated and compared between the ER-EUS and EC-EUS cohort. The final diagnosis of pancreatic malignancy was based on pathology, or the consensus of patient's clinical course and multimodal imaging tests. RESULTS: Two hundred twenty-one patients were included and divided into two cohorts: ER-EUS (n = 139) and EC-EUS (n = 82) cohorts. With propensity score matching method, 70 cases in each cohort were selected for the comparison. There was no significant difference in sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancy between ER-EUS and EC-EUS cohort (88.5 vs. 100%, 88.6 vs. 90.9%, 0.8855 vs. 0.9545). CONCLUSION: ER-EUS and EC-EUS provided similar accuracy for the detection of pancreatic malignancies. In view of similar diagnostic results of ER-EUS and EC-EUS for the detection of pancreatic malignancy, and the advantage of being able to perform FNA with EC-EUS, EC-EUS may be the preferred choice.

Novel quantitative perfusion analysis with contrast-enhanced harmonic EUS for differentiation of autoimmune pancreatitis from pancreatic carcinoma.

OBJECTIVE: Autoimmune pancreatitis (AIP) is often misdiagnosed as pancreatic carcinoma (PC) despite recent advances in imaging tests. The aim of the study was to evaluate whether the quantitative perfusion analysis using software "Time intensity curve" with contrast-enhanced harmonic EUS (CH-EUS) facilitate the differentiation of AIP from PC. METHODS: Consecutive patients with focal AIP and pancreatic carcinoma who underwent CH-EUS from January 2009 to September 2010 were analyzed. CH-EUS was performed with intravenous administration of an ultrasonographic contrast (Sonazoid) and electronic radial echoendoscope. The graph of time intensity curve (TIC) for pancreatic mass was generated to depict the changes in signal intensity over time within the region of interest (ROI). ROI was placed to cover an area with a pancreatic mass lesion. Based on the analysis of TIC, base intensity before injection (BI), peak intensity (PI), time to peak, and maximum intensity gain (MIG: PI-BI) were calculated. RESULTS: Eight patients with focal AIP and twenty-two patients with PC were evaluated by TIC. PI and MIG of mass lesion of AIP were significantly higher than that of PC (21.4 dB vs. 9.6 dB, 17.5 vs. 6.6). Receiver operating characteristics analysis yielded an optimal MIG cutoff value of 12.5 with high sensitivity and specificity. CONCLUSION: Pancreatic mass lesions of AIP and PC exhibited markedly different patterns with the TIC. This novel diagnostic modality using TIC generated by CH-EUS might offer an opportunity to improve accuracy in the differential diagnosis between pancreatic mass lesion of AIP and PC.

A pilot study of the novel offset-tip papillotome for selective biliary cannulation in ERCP.

INTRODUCTION: We developed a new offset-tip papillotome to facilitate biliary cannulation and reduce the incidence of unintended contrast injection into the pancreatic duct during ERCP. The aim of the present retrospective cohort study was to evaluate the utility of the novel offset-tip papillotome in achievement of biliary cannulation, and prevention of unintended contrast injection into the pancreatic duct during ERCP, compared with a standard straight-tip catheter. MATERIAL AND METHODS: Patients with native papilla who required biliary ERCP were retrospectively reviewed. Biliary ERCPs were performed by two experienced endoscopists using either the offset-tip papillotome or a standard catheter. Patients in whom ERCP involved fellows in training were excluded. RESULTS: Eighty-five patients were included and divided into two cohorts: The offset-tip papillotome (OT; n = 40) and the standard straight-tip cohort (ST; n = 45). Biliary cannulation success rates in OT and ST cohort were 92.5% and 88.9%, respectively. The frequency of unintended contrast injection into the pancreatic duct and time to biliary cannulation of the OT cohort during biliary cannulation were significantly less than those of the ST cohort (0.56 vs. 1.65 times and 103.3 vs. 287.9 seconds). CONCLUSION: The novel offset-tip papillotome could reduce the incidence of unintended contrast injection into the pancreatic duct and the time to biliary cannulation.

A pilot study on ultrasound-assisted liposuction of the greater omentum in porcine models.

The greater omentum is the largest depot of visceral fat, and recent studies implicate removal of omental fat as a therapeutic option for metabolic syndrome (MS). This study evaluated the technical feasibility of reducing omental fat by using ultrasound-assisted liposuction (UAL) in porcine models. We removed as much omental adipose tissues as possible with a novel ultrasonic aspirator specifically designed for visceral liposuction that was inserted into the peritoneal cavity via the bilateral hypochondrial trocars. The greater part of the omental surface was emulsified and suctioned within 12.4 ± 9.2 (mean ± SD) min. In the survival study, all animals survived for two weeks without clinically evident complications following UAL. Histological examinations confirmed a substantial reduction in omental fat in pigs subjected to UAL. In conclusion, the pilot animal study conducted here demonstrated the technical feasibility of omental liposuction. UAL thus has potential as a relatively non-invasive liposuction approach to treat MS by selectively reducing the visceral fat content of the greater omentum.

The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound.

The Asian Federation of Societies for Ultrasound in Medicine and Biology aimed to provide information on techniques and indications for contrast-enhanced harmonic endoscopic ultrasound (CH-EUS), and to create statements including the level of recommendation. These statements are based on current scientific evidence reviewed by a Consensus Panel of 15 internationally renowned experts. The reliability of clinical questions was measured by agreement rates after voting. Six statements were made on techniques, including suitable contrast agents for CH-EUS, differences between contrast agents, setting of mechanical index, dual imaging and duration and phases for observation. Thirteen statements were made on indications, including pancreatic solid masses, pancreatic cancer staging, pancreatic cystic lesions and mural nodules, detection of subtle pancreatic lesions, gallbladder sludge and polyps, hepatic lesions, lymph nodes, subepithelial lesions, visceral vascular diseases, guidance of fine needle aspiration and evaluation for local therapy. These international expert consensus guidelines will assist endosonographers in conducting CH-EUS according to evidence-based information.

Contrast-enhanced harmonic EUS with novel ultrasonographic contrast (Sonazoid) in the preoperative T-staging for pancreaticobiliary malignancies.

OBJECTIVE: Sonazoid is a new second-generation microbubble contrast for ultrasonography. In this pilot study, the diagnostic role of contrast-enhanced harmonic imaging endoscopic ultrasonography (CH-EUS) with Sonazoid was prospectively evaluated in preoperative T-staging of pancreaticobiliary malignancies. PATIENTS AND METHODS: Patients with suspected pancreaticobiliary malignancies underwent CH-EUS by a single examiner. After the lesions were observed carefully with conventional harmonic imaging EUS (H-EUS), CH-EUS was performed with intravenous injection of Sonazoid. A reviewer who was blinded reviewed the recordings of H-EUS and CH-EUS and assessed the T-staging. The accuracy of H-EUS and CH-EUS for T-staging was compared to the results of surgical histopathology in patients who underwent surgery. RESULT: Twenty-six patients underwent surgical resection and could be included in the study. The final diagnosis were pancreatic cancer in 11, bile duct cancer in 7, gallbladder cancer in 4 and ampullary cancer in 4. The overall accuracy of H-EUS and CH-EUS for T-staging were 69.2 (18/26) and 92.4% (24/26), respectively (p < 0.05). There were disagreement in six cases between H-EUS and CH-EUS. CH-EUS staged correctly in all of these six cases, whereas H-EUS misdiagnosed the depth of invasion in one case of gallbladder cancer and one case of ampullary cancer, and invasion of portal vein in two cases of pancreatic cancer and two cases of bile duct cancer. CONCLUSION: The depth of invasion of biliary cancer and vascular invasion of pancreatic and biliary cancer could be demonstrated more clearly with CH-EUS compared to H-EUS. CH-EUS has the potential to improve the diagnostic accuracy of preoperative T-staging of pancreaticobiliary malignancies.