Usefulness of a target sample check illuminator in the detection of target specimens in endoscopic ultrasound-guided fine-needle biopsy samples: Multicenter prospective study.

OBJECTIVES: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) uses a thin needle, rendering unclear whether the collected sample contains pathological evidence. We examined the usefulness of our target sample check illuminator (TSCI) through a multicenter prospective trial. METHODS: We included 52 consecutive patients. After assessing EUS-FNB samples by conventional (visual observation) and TSCI methods, we evaluated consistency with the histopathological diagnosis. We compared the target sample confirmation rate between conventional and TSCI methods and evaluated the diagnostic ability separately. RESULTS: Comparison between the conventional and TSCI methods revealed the following: (i) for all cases: sensitivity, 51.0% (25/49) vs. 95.9% (47/49) (P = 0.001); specificity, 100% (3/3) vs. 66.7% (2/3); positive predictive value (PPV), 100% (25/25) vs. 97.9% (47/48); and negative predictive value (NPV), 11.1% (3/27) vs. 50.0% (2/4) (P = 0.002); (ii) for pancreatic masses: sensitivity, 28.0% (7/25) vs. 96.0% (24/25) (P < 0.001); specificity, 100% (2/2) vs. 100% (2/2); PPV, 100% (7/7) vs. 100% (24/24); and NPV, 10.0% (2/20) vs. 66.7% (2/3) (P < 0.001) (the TSCI method showed significantly better sensitivity and NPV than the conventional method); and (iii) for lymph node tumors: sensitivity, 75.0% (18/24) vs. 95.8% (23/24) (P = 0.025); specificity, 100% (1/1) vs. 0% (0/1); PPV, 100% (18/18) vs. 95.8% (23/24); and NPV, 14.3% (1/7) vs. 0% (0/1). CONCLUSIONS: The TSCI improved the sensitivity, NPV, and accuracy of target sample confirmation for pancreatic mass EUS-FNB. Although the proportion of samples not including a target region was quite low, which could strongly influence our results, the TSCI method can be used in EUS-FNB when rapid on-site evaluation cannot be performed. (A multicenter prospective study for the utility of a target sample check illuminator, Clinical Trial ID: UMIN000023349).

[A case of distal bile duct carcinoma converted to neuroendocrine cancer and proliferated into the pancreas].

A woman in her 50s was referred due to a solid mass in the head of the pancreas. It was diagnosed as a neuroendocrine carcinoma (NEC) by endoscopic ultrasound-guided fine-needle aspiration. Consequently, pancreatoduodenectomy was performed. A well-differentiated adenocarcinoma component was revealed in the resected bile duct, suggesting a relationship with the NEC component in the pancreas. Genetic examination suggested that cholangiocarcinoma, but not coexisting carcinoma, was converted to NEC after the interstitial invasion. Finally, it was diagnosed as the NEC derived from the extrahepatic bile duct, which is rare at about 0.2-2% in gastrointestinal neuroendocrine neoplasms.

EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos).

BACKGROUND AND AIMS: Although balloon enteroscopy-assisted ERCP (BE-ERCP) is effective and safe for benign biliary diseases in patients with surgically altered anatomy (SAA), BE-ERCP is not always successful. Recently, EUS-guided antegrade intervention (EUS-AI) by using a 1-stage or 2-stage procedure has been developed for BE-ERCP failure cases. The aim of the present study was to evaluate the outcome of EUS-AI for benign biliary diseases in patients with SAA. METHODS: Of 48 patients in whom BE-ERCP failed, percutaneous transhepatic intervention was performed in 11. From November 2013 until November 2017, we retrospectively reviewed cases of an additional 37 patients with SAA who failed BE-ERCP and underwent EUS-AI for benign biliary diseases (common bile duct stones [n = 11], intrahepatic bile duct stones [n = 5], anastomotic strictures [n = 21]). RESULTS: The overall technical success of the creation of the hepatoenteric tract by EUS was 91.9% (34/37). Moderate adverse events were observed in 8.1% (biliary peritonitis [n = 3]). One-stage EUS-AI by EUS succeeded in 8 cases (100%) without any adverse events. In another 26 cases, 2-stage EUS-AI by ERCP was performed about 1 or 2 months later. Endoscopic antegrade therapy under fluoroscopy was successful in 6 cases. Per-oral cholangioscopy-assisted antegrade intervention was required in 19 cases (guidewire manipulation across the anastomotic stricture [n = 6], cholangioscopy-guided lithotripsy by using electrohydraulic lithotripsy [n = 13]). In 1 case, magnetic compression anastomosis was performed. The final clinical success rate of all EUS-AIs was 91.9%. CONCLUSIONS: EUS-AI for benign biliary diseases in patients with SAA appears to be a feasible and safe alternative procedure after BE-ERCP failure.

Ex vivo assessment of anchoring force of covered biflanged metal stent and covered self-expandable metal stent for interventional endoscopic ultrasound.

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS)-guided transmural drainage using a covered biflanged metal stent (CBFMS) and a conventional tubular biliary covered self-expandable metal stent (CSEMS) has recently been performed by EUS experts. However, appropriate traction force of the sheath to prevent the migration during stent deployment is well unknown. Herein, we assessed the anchoring force (AF) of the distal flange in CBFMSs and CSEMSs. METHODS: The AFs of four CBFMSs (Stents AX, NG, PL, and SX) and six CSEMSs (Stents BF, BP, EG, HN, SP, and WF) were compared in an ex vivo setting. We assessed the AF produced by each stent using an EUS-guided transmural drainage model and an EUS-guided hepaticogastrostomy model consisting of sheet-shaped specimens of the stomach, gelatin gel, and gelatin tubes. RESULTS: For CBFMSs, the maximum AF of Stent AX was significantly higher than those of Stents PL and SX (P < 0.05) in the porcine model. In the gelatin series, all stents except Stent NG showed a nearly similar AF. For CSEMSs, Stents HN, EG, BF, and WF showed gradual AF elevation in the porcine stomach. Stents SP and BP showed a lower AF than the other four stents. For the gelatin setting, the maximum AF of Stents HN, EG, and WF was higher than those of the other stents regardless of the type of specimens. CONCLUSIONS: The significance of the AF and traction distance according to the property of various CBFMSs and CSEMSs could be elucidated using ex vivo models.

Expanding the indication of endoscopic papillectomy for T1a ampullary carcinoma.

BACKGROUND AND AIM: Endoscopic papillectomy (EP) has been attempted not only for benign lesions but also for early ampullary carcinoma (AC). However, there is still no sufficient evidence or consensus regarding the effectiveness of EP for early AC. Herein, we evaluated the expanding indication of EP for early AC. METHODS: Between May 1999 and December 2016, 177 patients were diagnosed with ampullary tumor before undergoing EP, and their clinical and histopathological data were analyzed retrospectively. RESULTS: There were 27 Tis-T1a AC patients and four T1b AC patients who underwent EP. Mean tumor size was 14.1 mm for Tis-T1a AC and 17.0 mm for T1b AC. For the histological grade, 50% (2/4) of T1b AC were moderately differentiated, whereas 96.3% (26/27) of Tis-T1a AC were well differentiated and papillary. For lymphovascular invasion, one (25%) occurred in T1b AC but none occurred in Tis-T1a AC. There was no AC recurrence from the date of EP until a maximum of 5 years (Tis-T1a: mean period 48.5 months [5-60]; T1b: mean period 26.5 months [3-60]). CONCLUSIONS: Endoscopic papillectomy is useful and reliable for the curative treatment of T1a AC. Large-scale prospective studies with long-term follow up are needed.

Novel peroral direct digital cholangioscopy-assisted lithotripsy using a monorail technique through the overtube in patients with surgically altered anatomy (with video).

Efficacy of cholangioscopy-assisted lithotripsy for difficult stones such as huge stones, multiple large stones and an impacted stone in patients with non-altered anatomy has been reported. Herein, we describe peroral direct digital cholangioscopy (PDCS)-assisted electrohydraulic lithotripsy (EHL) with a new technique in patients with surgically altered anatomy. Five patients received PDCS-assisted EHL with the monorail technique due to failed conventional stone extraction. Balloon enteroscope was removed, leaving the stiff guidewire in the bile duct and an overtube with inflated balloons. The cholangioscope was then inserted into the bile duct over the wire through the overtube. After direct visualization of the stone, PDCS-assisted EHL was carried out. This technique was named the 'monorail technique'. Complete removal of biliary stones in one session was accomplished in four patients and only one case required two sessions. There was no adverse event in any of the cases. PDCS-assisted EHL using the monorail technique was effective and safe for difficult biliary stones in patients with surgically altered anatomy.

Novel ex vivo training model for freehand insertion using a double-bending peroral direct cholangioscope.

BACKGROUND AND AIM: Several experts of direct peroral videocholangioscopy (D-PVCS) using a conventional ultraslim endoscope have reported its usefulness for the diagnosis and therapy of biliary tract diseases. We have additionally developed a dedicated double-bending D-PVCS technique for freehand scope insertion. In this study, we developed an ex vivo training model for the freehand double-bending D-PVCS technique and compared it with the technique using a conventional ultraslim endoscope. METHODS: The ex vivo model was made for training using a U-shape insertion pattern. A third prototype endoscope and an ultraslim upper gastrointestinal endoscope were used. Two experts and nine non-experts performed D-PVCS using the freehand technique. RESULTS: The two experts could not advance the tip of the endoscope to the hilar portion using the freehand technique, but they could achieve technical successful insertion to the hilar portion with the third prototype cholangioscope using the freehand technique alone. The non-experts could not advance the tip of the endoscope to the bile duct using the freehand technique. On the other hand, two (22.2%) non-experts could advance the tip of the third prototype cholangioscope using the freehand technique before the training conducted by the experts. After the training, all the non-experts could advance the tip of the third prototype cholangioscope to the hilar portion. CONCLUSIONS: The novel ex vivo model using a third prototype cholangioscope was useful for training in the use of the freehand D-PVCS technique.

Serum Metabolomic Profiles for Human Pancreatic Cancer Discrimination.

This study evaluated the clinical use of serum metabolomics to discriminate malignant cancers including pancreatic cancer (PC) from malignant diseases, such as biliary tract cancer (BTC), intraductal papillary mucinous carcinoma (IPMC), and various benign pancreaticobiliary diseases. Capillary electrophoresismass spectrometry was used to analyze charged metabolites. We repeatedly analyzed serum samples (n = 41) of different storage durations to identify metabolites showing high quantitative reproducibility, and subsequently analyzed all samples (n = 140). Overall, 189 metabolites were quantified and 66 metabolites had a 20% coefficient of variation and, of these, 24 metabolites showed significant differences among control, benign, and malignant groups (p < 0.05; Steel-Dwass test). Four multiple logistic regression models (MLR) were developed and one MLR model clearly discriminated all disease patients from healthy controls with an area under receiver operating characteristic curve (AUC) of 0.970 (95% confidential interval (CI), 0.946-0.994, p < 0.0001). Another model to discriminate PC from BTC and IPMC yielded AUC = 0.831 (95% CI, 0.650-1.01, p = 0.0020) with higher accuracy compared with tumor markers including carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), pancreatic cancer-associated antigen (DUPAN2) and s-pancreas-1 antigen (SPAN1). Changes in metabolomic profiles might be used to screen for malignant cancers as well as to differentiate between PC and other malignant diseases.

Balloon enteroscopy-assisted ERCP in patients with Roux-en-Y gastrectomy and intact papillae (with videos).

BACKGROUND AND AIMS: Balloon enteroscopy-assisted ERCP has provided a marked improvement in the success rate of reaching the papilla and consecutive ERCP procedures in patients with surgically altered anatomy in the Roux-en-Y reconstruction setting. However, limited data are available on the outcome of balloon enteroscopy-assisted ERCP in patients with Roux-en-Y anatomy who have naïve papillae. We retrospectively evaluated the feasibility of balloon enteroscopy-assisted ERCP in Roux-en-Y reconstruction after total or subtotal gastrectomy (RYG) with native papillae. METHODS: We performed 123 ERCP procedures in 109 patients with RYG. Among these patients, 90 consecutive ERCPs in 90 patients with native papillae were included. When selective biliary cannulation failed, the double-guidewire technique, the precut technique, or the rendezvous technique were performed as advanced cannulation methods. RESULTS: The overall success rate of reaching the papilla was 93.5% (115/123). The total procedure success rate was 88.1% (96/109). The adverse event rate was 7.3% (8/109). The success rate of the standard cannulation of the intact papilla was 67.8% (61/90). The final cannulation success rate was 95.6% (86/90) by using advanced cannulation methods. CONCLUSIONS: Standard cannulation of the intact papilla in RYG cases remains challenging and uncertain. The use of various advanced cannulation methods improves the deep cannulation rate. Once selective cannulation succeeds, the treatment success rate is very high.

A newly designed plastic stent for EUS-guided hepaticogastrostomy: a prospective preliminary feasibility study (with videos).

BACKGROUND: There are currently no dedicated plastic stents for EUS-guided hepaticogastrostomy (EUS-HGS). OBJECTIVE: We prospectively evaluated the feasibility and the technical and functional success rates of our newly designed plastic stent for EUS-HGS. DESIGN: Prospective preliminary feasibility study. SETTING: A tertiary-care referral center. PATIENTS: Twenty-three consecutive patients were treated. The reasons for requiring EUS-HGS were periampullary tumor invasion (n=9), altered anatomy (n=7), failed duodenal intubation (n=3), and previous ERCP failure (n=4). INTERVENTIONS: An 8F single-pigtail plastic stent with 4 flanges was placed for EUS-HGS. MAIN OUTCOME MEASUREMENTS: Technical success, clinical success, and adverse events according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS: All stents were successfully deployed without procedural adverse events (100% technical success rate). Bleeding from the punctured gastric wall occurred in 1 patient 3 days postoperatively. We exchanged the plastic stent for a fully covered self-expandable metal stent. A mild adverse event of self-limited abdominal pain occurred in 3 patients. Treatment success was achieved in all patients. The occlusion rate was 13.7% (3/22) during the median follow-up period (5.0 months, range 0.5-12.5 months). The median duration of stent patency was 4.0 months (range 0.5-9.0 months). There was no stent migration or dislocation during the follow-up period. LIMITATIONS: Small number of patients and lack of a control group. CONCLUSIONS: This newly designed single-pigtail plastic stent dedicated for EUS-HGS was technically feasible and can possibly be used for highly selected patients with advanced malignancy or benign stricture. ( TRIAL REGISTRATION: http://www.umin.ac.jp/english/: UMIN000012993.).

Initial evaluation of a new plastic pancreatic duct stent for endoscopic ultrasonography-guided placement.

There are currently no plastic pancreatic duct stents that have been designed for endoscopic ultrasonography (EUS)-guided placement. This study prospectively evaluated the feasibility and efficacy of a new, single-pigtail, plastic stent. Eight patients with main pancreatic duct stricture or stenotic pancreatojejunostomy underwent EUS-guided placement of the pancreatic duct stent. The stent was placed successfully in all cases (8/8). Treatment success was achieved in all cases (8/8). A mild adverse event associated with the procedure was observed in one patient but there were no other adverse events during a mean follow-up of 7.4 months. This new pancreatic duct stent appears to be feasible and effective for EUS-guided stenting.

Endoscopic ultrasound-guided placement of plastic vs. biflanged metal stents for therapy of walled-off necrosis: a retrospective single-center series.

BACKGROUND AND STUDY AIMS: Recently, a novel fully covered and biflanged metal stent (BFMS)dedicated to the drainage of walled-off necrosis(WON) was developed. The aim of this study was to retrospectively evaluate the safety, efficacy, and cost performance of drainage of WON using the novel BFMS compared with a traditional plastic stent. PATIENTS AND METHODS: A total of 70 patients with symptomatic WON were treated under endoscopic ultrasound (EUS) guidance. Initial drainage was conducted using the single gateway technique with placement of one or more plastic stents or a single BFMS.If drainage was unsuccessful,direct endoscopic necrosectomy (DEN)was performed. RESULTS: There were no statistically significant differences in rates of technical success, clinical success,and adverse events between plastics stents and BFMS, despite the size of WON in the BFMS group being significantly larger than that in the plastic stent group (105.6 vs. 77.1 mm; P=0.003).The mean procedure times for the first EUS-guided drainage and for re-intervention were significantly shorter in the BFMS group than in the plastic stent group (28.8±7.1 vs. 42.6±14.2, respectively,for drainage, P<0.001; and 34.9±8.5 vs.41.8±7.6, respectively, for re-intervention, P<0.001). There was no statistically significant difference in the total cost between plastic stent and BFMS use in the treatment of WON ($5352vs. $6274; P=0.25). CONCLUSIONS: Plastic stents and BFMS were safe and effective for the treatment of WON. In particular,BFMS placement appeared to be preferable for initial EUS-guided drainage and additional reintervention(e.g. DEN) as it reduced the procedure time. Prospective randomized controlled trials are warranted.

Relationship between the liver tissue shear modulus and histopathologic findings analyzed by intraoperative shear wave elastography and digital microscopically assisted morphometry in patients with hepatocellular carcinoma.

OBJECTIVES: Shear wave elastography is a novel noninvasive method for assessing liver fibrosis by measuring liver stiffness. This study was conducted to evaluate how pathologic changes could have an impact on measured elasticity values in both resected hepatocellular carcinomas and adjacent liver tissue. METHODS: Intraoperative shear wave elastography was performed in 7 patients who underwent liver resection at our institution; 7 hepatocellular carcinomas and adjacent liver tissue were subjected to elastographic measurements. A total of 48 circular regions of interest (ROIs; 3-8 mm in diameter) were located in the hepatocellular carcinomas (n = 37) and adjacent liver tissue (n = 11), and mean stiffness values were obtained from each ROI. All of the histologic images corresponding to the 48 ROIs after surgery were transformed into digital microscopic images by a scanning system, and histologic parameters, such as the proportions of nuclear areas, fatty areas, fibrous areas, and vessel areas, were quantitatively assessed. Relationships between the mean stiffness and the histologic parameters were investigated by the mixed effects model. RESULTS: By univariate analysis, the proportions of collagen fiber areas (P = .039), fibrous areas (P = .045), hepatocellular nuclear areas (P = .045), and nuclear areas other than hepatocellular and lymphoplasmacytic areas (P = .039) showed statistically positive associations with mean stiffness values. Multivariate analysis indicated that the proportion of collagen fiber areas was the strongest pathologic determinant of mean stiffness (P = .008), with hepatocellular nuclear areas also having a significant effect (P = .010). CONCLUSIONS: Fibrosis predictably affects elastographic estimation, but hepatocellular density (ie, hepatocellular nuclear areas) also alters elastographic assessment.

Creation of simulated papillae for endoscopic sphincterotomy and papillectomy training by using in vivo and ex vivo pig model (with videos).

BACKGROUND: There are few in vivo and ex vivo models for training in endoscopic sphincterotomy (ES) and endoscopic papillectomy (EP). OBJECTIVE: We describe in vivo and ex vivo training pig models that use a simulated papilla for hands-on teaching of ES and EP. DESIGN: Animal experiment. SETTING: A referral center. MATERIALS AND INTERVENTIONS: Hyaluronate solution (0.4%) was injected submucosally using a 25-gauge sclerotherapy needle to create a submucosal bleb by using porcine in vivo stomach, ex vivo stomach, and ex vivo rectum. ES and EP were then performed by using a pull-type sphincterotome and snare, respectively. MAIN OUTCOME MEASUREMENT: The feasibility of creating a simulated papilla for ES and EP procedures was tested by experienced and nonexperienced ERCP endoscopists. RESULTS: Creation of a hemispheroidal bulge was successful in 13 of 17 (76%) areas within an in vivo stomach, 13 of 16 (81%) areas of an ex vivo stomach, and 16 of 16 (100%) areas in an ex vivo rectum. In the in vivo stomach model, ES was successfully and realistically performed on the anterior wall of the stomach rather than in other walls. In the ex vivo stomach model, endoscopists experienced in ERCP and trainees performed ES without difficulty, whereas it was difficult or impossible for nonexperienced trainees to perform ES. In the ex vivo rectum model, all 3 endoscopists were able to complete not only ES but also EP. LIMITATIONS: Pilot study. CONCLUSIONS: Although further studies are necessary to evaluate the reproducibility and cost-effectiveness, this novel pig model appears useful for ES and EP training.

Is the double-guidewire technique superior to the pancreatic duct guidewire technique in cases of pancreatic duct opacification?

BACKGROUND AND AIMS: Pancreatic duct guidewire placement (P-GW) techniques include both the injection cannulation technique with a contrast medium and wire-guided cannulation without contrast injection for selective biliary cannulation; the latter is the so-called "double-guidewire technique" (D-GW). The aim of this study was to compare the outcomes between P-GW and D-GW for biliary cannulation. METHODS: The procedures for biliary cannulation with a naïve papilla were performed in a total of 363 cases. We divided the patients chronologically, according to the time period during which the procedures were performed, into two groups: group A, P-GW performed from March 2008 to June 2009; and group B, D-GW performed from July 2009 to December 2010. The success rates and complication rates were evaluated in each group. RESULTS: Biliary cannulation was successful in 31 (81.6%) patients in the P-GW group and 34 patients (82.9%) in the D-GW group. The onsets of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) occurred in the P-GW and D-GW groups were four (10.5%) and three (7.3%) patients, respectively, and all were mild cases (P = 0.616). The frequency of hyperamylasemia and the serum amylase level tended to be lower in the D-GW group than in the P-GW group (P = 0.213). There was a statistically significant difference on the onsets of PEP in the GW and non-GW groups (P = 0.04, 8.9% and 1.1%, respectively). CONCLUSIONS: Both the D-GW and P-GW techniques were equally effective for difficult biliary cannulation. Furthermore, the complication rates, including PEP, were similar in both techniques. A prospective randomized trial is warranted.

Urgent and early EUS-guided biliary drainage in patients with acute cholangitis.

BACKGROUND AND OBJECTIVES: EUS-guided biliary drainage (EUS-BD) has been reported as an effective alternative drainage technique. However, clinical data on EUS-BD for patients with acute cholangitis (AC) are limited. The aim of this study was to analyze the clinical outcomes of EUS-BD in patients with AC. PATIENTS AND METHODS: Nineteen patients with AC who underwent urgent or early drainage (within 96 h) by EUS-guided hepaticoenterostomy (EUS-HES) between January 2014 and November 2019 were retrospectively reviewed. Furthermore, the clinical outcomes of EUS-HES using a plastic stent in the AC group (n = 15) were compared to those in the non-AC group (n = 88). RESULTS: In the 19 AC cases, the technical and clinical success rate was 100% with 5.3% of moderate adverse events (biliary peritonitis [n = 1]). Regarding the comparison between the AC group and the non-AC group, the clinical success rate was 100% in both groups and the adverse event rate was not statistically significantly different (P = 0.88). Although the recurrent biliary obstruction (RBO) rate was not statistically significantly different (P = 0.43), the early RBO rate was statistically significantly higher in the AC group (26.7% vs. 3.4%, P < 0.001). Kaplan-Meier curves showed that AC was associated with a shorter time to RBO (P = 0.046). The presence of AC was found to be an independent risk factor of early RBO (odds ratio = 10.3; P = 0.005). CONCLUSIONS: Urgent or early biliary drainage (within 96 h) by EUS-BD can be a feasible and safe alternative procedure for patients with AC, although there is a tendency of early RBO.

Novel method for evaluating the indication for endoscopic papillectomy in patients with ampullary adenocarcinoma.

This study aimed to determine the clinicopathological features of the subtypes of ampullary carcinoma (AC) to explore the indications for endoscopic papillectomy (EP) in early AC. Fifty-seven patients with AC who underwent curative resection were retrospectively reviewed. The 0/IA stages were significantly more common in the intestinal type (I-type) than in the mixed and pancreatobiliary type (M&PB-type) (90.7% vs 35.7%, P < 0.001). Tis/T1a tumors limited to the ampulla [Tis/T1a(ampulla)] were significantly more likely to be I-type than M&PB-type (74.4% vs 14.3%, P = 0.002). The tub1 rate was significantly higher in the I-type than in the M&PB-type (81.4% vs 35.7%, P = 0.001). In the I-type, the tub1 rate was significantly higher for Tis/T1a(ampulla) than for T1a tumors limited to the sphincter of Oddi (100% vs 42.9%, P = 0.004). These observations suggest that I-type AC with tub1 is an indication for EP. The concordance rate of pathological subtypes between endoscopic biopsy and resected specimens was high (κ = 0.8053, P < 0.001). Tis/T1a(ampulla) showed no lymphovascular or perineural invasion. An endoscopic imaging finding of early AC with I-type and tub1 on biopsy could be an indication for EP. Identifying the pathological subtype of AC by endoscopic biopsy could be a novel preoperative approach for evaluating the indications for EP.

EUS-guided hepaticoenterostomy with using a dedicated plastic stent for the benign pancreaticobiliary diseases: A single-center study of a large case series.

BACKGROUND AND OBJECTIVES: EUS-guided biliary drainage (EUS-BD) has recently been used for the treatment of not only malignant pancreaticobiliary diseases, but also for benign diseases. In most previous studies, EUS-BD was performed using a fully covered self-expandable metallic stent (SEMS), and data focusing on the usability of plastic stents for benign diseases are limited. We previously developed a plastic stent dedicated to EUS-guided hepaticoenterostomy (EUS-HES), and achieved favorable results in a feasibility study, although most of the patients had malignant diseases. Therefore, the aim of the present study was to evaluate the usability of dedicated plastic stents for EUS-HES in patients with benign pancreaticobiliary diseases. PATIENTS AND METHODS: A total of 57 consecutive patients (28 men, median age: 68 years; range: 7-90 years) of normal and surgically altered anatomy with benign pancreaticobiliary diseases who underwent EUS-HES using the dedicated plastic stent between Jan. 2015 and Jun. 2020 were retrospectively analyzed. Results: The overall technical success rate of EUS-HES was 92.9% (53/57). Among the 4 cases of technical failure of plastic stent placement, a SEMS was placed in 1; percutaneous transhepatic biliary drainage was performed in 1; EUS-HES was reperformed 1 week later in 1; and observational management was selected in 1 patient. Adverse events associated with the procedure were seen in 15.7% (9/57) of the patients, namely, biliary peritonitis in 4, bleeding in 2, cholecystitis in 2, and pneumoperitoneum in 1 patient. Except for 1 patient who required blood transfusion owing to bleeding and 1 patient with cholecystitis who required percutaneous transhepatic gallbladder drainage, the other 7 patients were treated by conservative therapy. There were no intervention-associated deaths. CONCLUSION: Our results demonstrated that for patients with benign pancreaticobiliary diseases in whom conventional ERCP was unsuccessful, EUS-HES using a dedicated plastic stent was safe and feasible.