Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: prospective randomized study.

BACKGROUND AND STUDY AIMS: Difficult biliary cannulation and unintentional pancreatic duct cannulation are thought to be important contributors to pancreatitis occurring after endoscopic retrograde cholangiopancreatography. Our aim was to compare and evaluate the rates of success and complications of transpancreatic precut papillotomy (TPPP) and the double-guidewire technique (DGT), both with prophylactic pancreatic stenting. PATIENTS AND METHODS: From April 2011 to March 2014, patients with difficult biliary cannulation, in whom we planned to first position a guidewire in the pancreatic duct, were enrolled, and 68 patients were prospectively randomly allocated to two groups (TPPP 34, DGT 34). We evaluated the rates of success and complications for each group. RESULTS: TPPP had a significantly higher success rate (94.1 %) than DGT (58.8 %). The rate of post-ERCP pancreatitis was 2.9 % in both groups. There was no significant difference between the two groups in the overall rate of complications related to cannulation. CONCLUSION : If biliary cannulation cannot be achieved, TPPP should be selected first after unintentional pancreatic duct cannulation.

Preoperative assessment of longitudinal extension of cholangiocarcinoma with peroral video-cholangioscopy: a prospective study.

BACKGROUND AND AIM: Preoperative assessment of longitudinal extension of cholangiocarcinoma (CCA) is essential for making decisions concerning surgical resection and selecting operative procedures. We evaluated the accuracy of peroral video-cholangioscopy (PVCS) in diagnosing longitudinal extension of CCA. METHODS: Patients with CCA who underwent preoperative PVCS were considered for this study. We evaluated the accuracy of PVCS in diagnosing longitudinal extension of perihilar cholangiocarcinoma (PCCA) and distal extrahepatic cholangiocarcinoma (DCCA) to the secondary biliary radicles and confluence of the hepatic ducts, respectively, on the hepatic side and to the intrapancreatic common bile duct on the papillary side. Diagnostic accuracy was determined by comparing the results with those of histopathological analyses of surgical specimens. RESULTS: Forty-three consecutive patients were enrolled. The cholangioscope could not be advanced into the hepatic side in eight of the 25 patients with PCCA and in five of the 18 patients with DCCA. The accuracy of PVCS in diagnosing longitudinal extension of CCA on the hepatic and papillary sides was 82.4% and 92.0%, respectively, in patients with PCCA and 92.3% and 100%, respectively, in patients with DCCA. PVCS accurately detected longitudinal extension of CCA to the hepatic and papillary sides that was not detected previously by endoscopic retrograde cholangiography in 20.0% and 11.6% patients, respectively. CONCLUSIONS: PVCS proved useful for the preoperative assessment of longitudinal extension of CCA. Therefore, it can aid surgeons in deciding surgical resectability and selecting operative procedures. This, in turn, may impact overall patient prognosis.

Old age is associated with increased severity of complications in endoscopic biliary stone removal.

BACKGROUND AND AIM: Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. METHODS: This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. RESULTS: Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). CONCLUSIONS: Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Factors affecting the accuracy of endoscopic transpapillary sampling methods for bile duct cancer.

BACKGROUND AND AIM: Various methods for endoscopic transpapillary sampling have been developed. However, the factors affecting the accuracy of these methods for bile duct cancer are unknown. The aim of the present study was to determine the factors affecting the accuracy of endoscopic transpapillary sampling methods. METHODS: We reviewed the results from 101 patients with bile duct cancer who underwent transpapillary sampling by aspiration bile cytology, brushing cytology, and fluoroscopic forceps biopsy. The final diagnosis of bile duct cancer was made on the basis of pathological evaluation of specimens obtained at surgery and the clinical course over at least 1 year in patients not operated on. We carried out subgroup analyses for the factors affecting the accuracy of each transpapillary sampling method. RESULTS: Aspiration bile cytology was carried out 238 times in 77 patients, brushing cytology was carried out 67 times in 60patients, and fluoroscopic forceps biopsy was carried out 64 times in 53 patients. Accuracies of aspiration bile cytology were significantly higher for longer (≥15 mm) biliary cancerous lesions than for shorter (<15 mm) lesions (30% vs 18%, respectively, P = 0.049). Accuracies of brushing cytology and fluoroscopic forceps biopsy were significantly higher for non-flat than for flat-type biliary cancerous lesions (brushing: 58% vs 38%, respectively, P = 0.032; forceps biopsy: 60% vs 33%, respectively, P = 0.043). CONCLUSION: Endoscopic transpapillary sampling methods are more accurate for longer or elevated (non-flat) biliary cancerous lesions than for shorter or flat lesions.

Comparison of the diagnostic accuracy of peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings for indeterminate biliary lesions: a prospective study.

BACKGROUND: The diagnostic accuracy of peroral video-cholangioscopy for indeterminate biliary lesions has not been determined in a prospective study. OBJECTIVE: To evaluate and compare the diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions with that of the cholangioscopy-guided forceps biopsy findings. DESIGN: Prospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: Patients who showed indeterminate biliary lesions on endoscopic retrograde cholangiography underwent peroral video-cholangioscopy for diagnosis. INTERVENTION: Each patient underwent peroral video-cholangioscopy with cholangioscopy-guided forceps biopsy. MAIN OUTCOME MEASUREMENTS: The accuracy of diagnosis by the peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings compared with that of the final diagnosis by other methods (malignant or benign). RESULTS: Thirty-three patients were enrolled, and the final diagnoses revealed that the lesions were malignant in 21 patients. All procedures were technically successful, and fine views were obtained in all patients. Procedure-related complications occurred in 2 patients (6.1%), but these complications were mild. The sensitivity, specificity, and accuracy were 100%, 91.7%, and 97.0%, respectively, for the peroral video-cholangioscopic visual findings and 38.1%, 100%, and 60.6%, respectively, for the cholangioscopy-guided forceps biopsy findings, and a significant difference was observed in the accuracy (P = .0018). LIMITATIONS: This was not a blinded study. No comparison was made with other diagnostic modalities involving tissue sampling. CONCLUSION: The diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions was excellent and significantly higher than that of the cholangioscopy-guided forceps biopsy findings. The accuracy of the cholangioscopy-guided forceps biopsy was insufficient, but the technique had an excellent specificity.

Clinical usefulness of doripenem (DRPM), a carbapenem antimicrobial drug, for the treatment of patients with acute cholangitis: retrospective study.

AIM: We investigated the usefulness of doripenem (DRPM), a carbapenem antimicrobial drug, for the treatment of acute cholangitis. METHODS: 28 patients who received a diagnosis of moderate or severe cholangitis were included in this investigation. 23 patients had moderate cholangitis; 5 patients had severe cholangitis. When moderate or severe cholangitis was diagnosed, administration of DRPM and endoscopic drainage were performed. The dose of DRPM was fixed at 0.5 g, 3 times daily. Evaluation of clinical findings (abdominal pain and body temperature) and blood test findings (WBC, CRP, ALT, ALP, and T-Bil) was performed before and on Day 5 after administration. RESULTS: Endoscopic drainage was successful in all patients. After administration of DRPM, a significant improvement was observed in all endpoints of both clinical findings and blood test findings (p < 0.05). No adverse events due to administration of DRPM were observed. CONCLUSION: It was suggested that administration of DRPM may be clinically useful for the treatment of moderate and severe cholangitis.

Endoscopic sphincterotomy combined with large balloon dilation for removal of large bile duct stones.

BACKGROUND/AIMS: Recently, there have been sporadic reports of lithotomy using endoscopic sphincterotomy combined with large balloon dilation (EPLBD) against large or multiple bile duct stones. However, there are not many reports so far concerning this procedure. Therefore, we decided to discuss the results of EPLBD against large or multiple bile duct stones. METHODOLOGY: Stone retrieval using EPLBD was performed with 59 patients of choledocholithiasis, A) with 13 mm or more in shortest dimension, or B) multiple (≥3) bile duct stones, with the smallest more than 10 mm in shortest dimension. The papilla treated with endoscopic sphincterotomy (EST) was dilated using a 12-20 mm balloon suitable for the biliary ductal size. RESULTS: The success rate for the first lithotomy for choledocholithiasis was 83.1% (49/59). The final lithotomy rate was 100% (59/59). The time required for lithotomy was 43.7 (12-125) minutes and the number of treatment was 1.3 (1-4) on average. Lithotripsy was needed in 13.6% (8/59). The incidence of coincidental events associated with the procedure was 6.8% (4/59). No pancreatitis was noted. CONCLUSIONS: An endoscopic treatment using EST plus large balloon dilation against large or multiple bile duct stones was suggested to be safe and effective.

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.

Two salvage techniques using a large dilation balloon: Endoscopic recovery of a migrated biliary metal stent and endoscope passage through a difficult duodenal stricture in combination with a duodenal stent.

There have been several reports of endoscopic removal of biliary metal stents using forceps or stent-in-stent techniques. Nishikawa and colleagues describe the endoscopic recovery of a proximally migrated biliary metal stent using a large dilation balloon and endoscope passage through a difficult duodenal stricture in combination with a duodenal stent.

Current situation of endoscopic treatment for common bile duct stones.

BACKGROUND/AIMS: The progression of endoscopy and devices as well as newly developed treatment methods have enabled endoscopic lithotomy. In this study, we examined to what degree is it possible to endoscopically treat patients who are diagnosed as having common bile duct stones. METHODOLOGY: Lithotomy was conducted using a backward side-viewing endoscope for patients without surgical history of upper gastrointestinal tract and patients with stomach reconstructed with Billroth-I method, using an ordinary endoscope for patients with stomach reconstructed with Billroth-II method (Bil-II) and using a double balloon endoscope for patients with difficulty in reaching the papilla or patients of Roux-en-Y anastomosis (R-Y). As for treatment methods, we selected endoscopic sphincterotomy as the first choice for papilla treatment and selected endoscopic papillary balloon dilation for patients with bleeding tendency or patients of Bil-II or R-Y. For patients with multiple stones or giant stones, lithotripsy was selected depending on judgment of the endoscopist. RESULTS: Endoscopic complete lithotomy was successful in 97.7% (168/172). An accidental disease was observed in 2.9% (5/172). In one patient with the perforated gastrointestinal tract, a surgery was performed but others were mild. CONCLUSIONS: Common bile duct stones can be endoscopically treated safely with high rate.

Endoscopic selective biliary stenting and reintervention using metal stents with a slim delivery system in a patient with complexly altered digestive anatomy.

Nishikawa and colleagues describe a case of endoscopic multiple stenting for malignant biliary stenosis in a patient with complexly altered digestive anatomy following hepaticojejunostomy with Roux-en-Y anastomosis and gastrojejunostomy with Braun enterostomy. Furthermore, reintervention for malignant stenosis extending from the intrahepatic bile duct to the intestinal tract was successfully completed.

Fully Printed PEDOT:PSS-based Temperature Sensor with High Humidity Stability for Wireless Healthcare Monitoring.

Facile fabrication and high ambient stability are strongly desired for the practical application of temperautre sensor in real-time wearable healthcare. Herein, a fully printed flexible temperature sensor based on cross-linked poly(3,4-ethylenedioxythiophene):poly(styrenesulfonate) (PEDOT:PSS) was developed. By introducing the crosslinker of (3-glycidyloxypropyl)trimethoxysilane (GOPS) and the fluorinated polymer passivation (CYTOP), significant enhancements in humidity stability and temperature sensitivity of PEDOT:PSS based film were achieved. The prepared sensor exhibited excellent stability in environmental humidity ranged from 30% RH to 80% RH, and high sensitivity of -0.77% °C-1 for temperature sensing between 25 °C and 50 °C. Moreover, a wireless temperature sensing platform was obtained by integrating the printed sensor to a printed flexible hybrid circuit, which performed a stable real-time healthcare monitoring.

Printed Strain Sensor with High Sensitivity and Wide Working Range Using a Novel Brittle-Stretchable Conductive Network.

There are few reports on resistive strain sensors that exhibit both high sensitivity and a wide working range under stretching. We have newly developed a high-performance strain sensor based on a brittle-stretchable conductive network that consists of both brittle and stretchable conductive layers and is fabricated on a stretchable substrate using the screen-printing method. Adding strain usually generates structural cracks in brittle conductive layers leading to a significant increase in resistance, while a stretchable conductive layer bridges these cracks to maintain the conductive pathways under high-strain conditions. This novel conductive network endows superior electrical-mechanical performance to the strain sensors, which possess high sensitivity (gauge factor > 870) over the entire working range (∼100%). Additionally, the developed sensors showed unique anisotropic bend-sensing characteristics, which could be used to detect the bending directions. This high degree of comprehensive performance results in a strain sensor with the capability for full-range human motion detection and robotic motion sensing.

Difference in gating and doping effects on the band gap in bilayer graphene.

A band gap is opened in bilayer graphene (BLG) by applying an electric field perpendicular to the layer, which offers versatility and controllability in graphene-based electronics. The presence of the band gap has been confirmed using double-gated BLG devices in which positive and negative gate voltages are applied to each side of BLG. An alternative method to induce the electric field is electron and hole doping of each side of BLG using electron-transfer adsorbates. However, the generation of the band gap by carrier doping is still under investigation. Here, we determined whether the electron/hole doping can produce the electric field required to open the band gap by measuring the temperature dependence of conductivity for BLG placed between electron-donor self-assembled monolayers (SAMs) and electron-acceptor molecules. We found that some devices exhibited a band gap and others did not. The potentially irregular and variable structure of SAMs may affect the configuration of the electric field, yielding variable electronic properties. This study demonstrates the essential differences between gating and doping.

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).