Measuring optimal ultrasound speed using endoscopic ultrasound in patients with chronic pancreatitis, including early stage.

OBJECTIVES: Ultrasound speed (USS) correction improves image quality by estimating the optimal USS correcting the deviation from a predetermined USS. This study assessed USS differences between chronic pancreatitis (CP), early CP (ECP), and normal pancreas when using endoscopic ultrasound (EUS). The usefulness of measuring optimal USS was evaluated for patients with CP, including early stage patients. METHODS: This study enrolled 116 consecutive patients for whom USS was measured using an EUS system. The USS correction principle is generation of a B-mode image by changing the USS in all ranges while correcting the delay in the received data. Final diagnoses were made according to the Japanese diagnostic criteria for CP in 2019. They were classified as CP, ECP, or normal. We compared USS applied for these three groups. RESULTS: The medians and ranges of USS values for patients in the normal, ECP, and CP groups were 1506.0 (1407-1600) m/s, 1580.0 (1520-1630) m/s, and 1574.0 (1537-1610) m/s, respectively. The USS values of the ECP and CP groups were significantly higher than those of the normal group (P < 0.001). Analyses of the receiver operating characteristic curve in the normal pancreas, ECP, and CP revealed the area as 0.957, with specificity and sensitivity of 95.9% and 87.5%, respectively, using the USS of 1535 m/s as a cut-off. CONCLUSION: Measurement of USS might be particularly useful for distinguishing between normal and ECP imaging.

Endoscopic ultrasound-guided coil deployment with sclerotherapy for isolated gastric varices: Case series of feasibility, safety, and long-term follow-up.

The purpose of the present study is to report our experience of endoscopic ultrasound-guided coil deployment with sclerotherapy (EUS-CS) for isolated gastric varices (IGV) through a case series. Eight consecutive patients who had risky IGV were prospectively enrolled. EUS-CS was performed according to the following procedures: (i) several coils were first deployed in the IGV under EUS guidance; (ii) contrast medium was subsequently injected without removing the needle; (iii) if the infused contrast medium stayed in the IGV and feeding vein, sclerosant was then injected to obliterate the IGV and feeders. Coil deployment in the IGV was successfully performed in all cases. Sclerosant was injected both into the IGV and feeders in seven patients (87.5%). There was no adverse event during the procedure. During a median follow-up of 57 months, one patient who could not inject the sclerosant into IGV and feeders had an early hemorrhagic recurrence. Our case series showed that EUS-CS could be a feasible and safe procedure for the treatment of IGV.

Multicenter, prospective, crossover trial comparing the door-knocking method with the conventional method for EUS-FNA of solid pancreatic masses (with videos).

BACKGROUND AND AIMS: There are currently no prospective, controlled trials of needle puncture speed in EUS-guided FNA (EUS-FNA). In this study, we prospectively evaluated the accuracy of histological diagnosis and the tissue acquisition rate of EUS-FNA by using the door-knocking method (DKM) with a standard 22-gauge needle. METHODS: From November 2013 to August 2014, 82 patients who had solid pancreatic masses underwent EUS-FNA in which the conventional method (CM) and DKM with 2 respective passes in turn were used. The primary outcomes of this study were the accuracy of histological diagnosis and the rates of tissue acquisition in 2 FNA procedures by using these 2 methods. RESULTS: Although the successful tissue acquisition rate for histology was not significantly different with the DKM and CM (91.5% vs 89.0%, P = .37), the high cellularity tissue acquisition rate for histology with the DKM was significantly superior to that with the CM (54.9% vs 41.5%, P = .03). However, adequate quality rate and accuracy were not different in the DKM and CM (78.0% vs 80.5%, P = .42 and 76.8% vs 78.0%, P = .50, respectively). In the transgastric puncture group, although the adequate quality rate and accuracy were similar in the DKM and CM (84.1% vs 79.4%, P = .30 and 84.1% vs 76.2%, P = .11, respectively), the tissue acquisition rate tended to be higher with the DKM than the CM (93.7% vs 85.7%, P = .06). Moreover, the high cellularity tissue acquisition rate was significantly better with the DKM than the CM (63.5% vs 39.7%, P = .002). On the other hand, in the transduodenal puncture group, although the tissue acquisition rate was similar with the DKM and CM (84.2% vs 100%, P = .13), the adequate quality rate and accuracy were significantly lower with the DKM than with the CM (57.9% vs 84.2%, P = .03 and 52.6% vs 84.2%, P = .02, respectively). CONCLUSION: EUS-FNA by using a 22-gauge needle with the DKM did not improve the accuracy of histological diagnosis, but enabled acquisition of a larger amount of tissue specimen by using transgastric puncture. ( TRIAL REGISTRATION: http://www.umin.ac.jp/english/: UMIN000012127.).

Guide Wire Selection (Straight vs. Angled) in Endoscopic Retrograde Cholangiopancreatography Using a Normal Contrast Catheter Performed by a Trainee: A Single-Center Prospective Randomized Controlled Cross-Over Study.

INTRODUCTION: Wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is a selective biliary cannulation technique aimed at improving the successful selective biliary cannulation rate and reducing the rate of post-ERCP pancreatitis (PEP) incidence. This study aimed to evaluate the effectiveness of angled-tip guidewires (AGW) vs. straight-tip guidewires (SGW) for biliary cannulation via WGC by a trainee. METHODS: We conducted a prospective, single-center, open-labeled, randomized, and controlled trial. Fifty-seven patients were enrolled in this study and assigned randomly to two groups (Group A to S and Group S to A). In this study, we started selective biliary cannulation via WGC with an AGW or an SGW for 7 min. If cannulation was unsuccessful, the other guidewire was used, and cannulation was continued for another 7 min (cross-over method). RESULTS: The selective biliary cannulation success rate over 14 min was significantly higher with an AGW compared with an SGW over 14 min (57.8% vs. 34.3%, p = 0.04) and for the second 7-min segment (36.4% vs. 0%, p = 0.04). No significant difference was found for adverse events such as pancreatitis between the two guidewires. CONCLUSIONS: Our results suggest that an AGW is recommended for WGC performed by a trainee.

A case of obstructive jaundice caused by metastasis of breast cancer to the intra/extrahepatic bile duct.

A 38-year-old woman was admitted to our hospital for a detailed examination of jaundice. Three years before, she had undergone a right total mastectomy and axillary lymph node dissection of her right breast because of cancer. Histopathological evaluation revealed invasive ductal carcinoma. Postoperatively, because multiple bone metastases were found, she underwent chemoradiotherapy. Endoscopic retrograde cholangiopancreatography was performed, which revealed widespread multiple stenoses with a smooth surface from the intrahepatic to the extrahepatic bile duct. A transpapillary biliary biopsy was performed. Histopathological examination revealed adenocarcinoma extending into the subepithelium of the bile duct. The obtained cancer cells were similar to those of the earlier invasive breast cancer. This rare case demonstrates bile duct metastasis of breast cancer with specific endoscopic retrograde cholangiopancreatography findings.

Diagnosing chronic pancreatitis by endoscopic ultrasound assessing the association between ultrasound and pathological findings: A narrative review.

Endoscopic ultrasound (EUS) is widely recognized for its non-invasiveness and for its usefulness in chronic pancreatitis (CP) diagnosis, including early CP. Although it is desirable to obtain a definitive diagnosis of CP by tissue sampling with EUS-guided fine needle aspiration, histopathological changes in CP are heterogeneous in terms of the extent and the distribution of lesions. Therefore, histopathological diagnosis of appropriate tissue sampling by EUS-fine needle aspiration is expected to be difficult. Furthermore, it is virtually impossible to match EUS images with pathological sections, making direct contrast between EUS findings and pathology difficult. This narrative review presents a discussion of the diagnosis of CP/early CP by EUS, particularly assessing the association between ultrasound and pathological findings. Recently, the histological corroboration and correlation of EUS findings related to CP have been clarified by surgical specimens, including those obtained from animal studies. Furthermore, remarkable advances have occurred in the objective and quantitative diagnosis of pancreatic fibrosis by EUS-elastography. Future technological advances in EUS are expected to improve the accuracy of diagnosis of pancreatic fibrosis at earlier stages.

A case in which the tip of a plastic stent placed to prevent recurrence of walled-off necrosis penetrated the bile duct and formed a stent-stone complex.

A woman in her 60s underwent endoscopic sphincterotomy for choledocholithiasis. Unfortunately, post-endoscopic retrograde cholangiopancreatography pancreatitis occurred. In addition, huge walled-off necrosis (WON) appeared as a late complication. For the infected WON, endoscopic ultrasound-guided fistuloplasty and endoscopic necrosectomy were performed, and a double pigtail plastic stent (PS) (7Fr, 7 cm) was placed to prevent a recurrence. Plain computed tomography conducted two years later showed that the stent implanted for WON had deviated. The distal end of the stent was found to have migrated into the bile duct. In addition, common bile duct stones with stents as nuclei were observed. Upon performing endoscopic retrograde cholangiography, it was revealed that the stent tip perforated the distal bile duct just above the papilla. After removal of the stent using grasping forceps, we made an incision between the duodenal - bile duct fistula and bile duct orifice using a sphincterotome. Then, the stone was removed by a balloon catheter. Although such late adverse events are rare occurrences, placement of long-term PS after treatment of WON should be followed up regularly with imaging examination, and if there is no recurrence for several months, removal of the PS at that point may be considered.

The Risk Factors for Progression to Chronic Pancreatitis in Patients with Past-History of Acute Pancreatitis: A Retrospective Analysis Based on Mechanistic Definition.

BACKGROUND: According to the mechanistic definition, the history of acute pancreatitis (AP) is a risk factor for chronic pancreatitis (CP). However, the etiology and severity of previous AP involved in the progression to CP have not been clarified. Here, we investigated risk factors for the progression to CP in patients with past-history of AP. METHODS: Sixty-four patients with AP who were followed-up for at least two years at our institution between April 2009 and March 2017 were enrolled. The multivariate analysis was performed based on the risk factors extracted by univariate analysis. RESULTS: Among the 64 patients, 13 patients (20.3%) progressed to CP (PCP group), while 48 did not (non-PCP group). Regarding the etiology of AP, rate of alcohol AP was significantly higher in the PCP group (76.9% vs. 33.3%, p = 0.003). In univariate analysis, smoking, number of previous AP, and alcohol consumption and drinking habits (Alcohol Use Disorders Identification Test-Concise; AUDIT-C) were identified as factors associated with progression to CP. Furthermore, multivariate analysis showed that AUDIT-C ≥ 6 points (male) and 4 points (female) after AP was a significant risk factor for CP (p = 0.003). CONCLUSIONS: Our results indicated that AUDIT-C ≥ 6 points (male) and 4 points (female) after AP was a risk factor in the process of progression to CP in patients with past-history of AP.

The Risk of Bleeding in Small/Straight Esophageal Varices with Red Color Sign on Endoscopy: A Retrospective Analysis from the Natural Course.

Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012−29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group's bleeding rate was 10% (5/49). The follow-up group's bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274−1582] days vs. 105 [1−336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.

The impact of endoscopic sphincterotomy incision size on common bile duct stone recurrence: A propensity score matching analysis.

BACKGROUND/PURPOSE: The aim of this study is to clarify the relation between the incision size for endoscopic sphincterotomy (EST) and common bile duct stone (CBDS) recurrence. METHODS: Patients who underwent elective endoscopic treatment for CBDS between January 2013 and December 2017 were enrolled, excluding those who met the exclusion criteria. The clinical characteristics were investigated using propensity score matching analysis. RESULTS: A total of 243 patients were investigated. Propensity scores were calculated using multinomial logistic regression with five relevant variables (age, gender, follow-up time, maximum stone size, and bile duct diameter), which led to extraction of 188 cases to compose cohorts of the small and medium EST incision groups. The CBDS recurrence rate was 17.0% in the small incision group and 6.4% in the medium incision group. Multivariate analysis identified the medium incision as an independent predictor of CBDS recurrence (hazard ratio 0.350, 95% confidence interval 0.133-0.922, P = .034). The CBDS non-recurrence rate of the medium incision group was significantly higher than that of the small incision group (log-rank test P = .019). CONCLUSIONS: Our findings suggest that the CBDS recurrence rate was lower in EST with medium incision size than with small incision size.

Salvage Endoscopic Submucosal Dissection for Local Recurrence of Superficial Esophageal Squamous Cell Cancer after Photodynamic Therapy.

Photodynamic therapy is useful as organ-preservation salvage therapy for residual recurrence of esophageal squamous cell carcinoma after chemoradiation therapy. However, the high residual recurrence rate of photodynamic therapy poses a problem. We herein report a patient who underwent photodynamic therapy for recurrence of superficial esophageal squamous cell carcinoma after chemoradiation therapy. The patient later exhibited another episode of recurrence of superficial esophageal squamous cell carcinoma, and R0 curative resection was obtained with endoscopic submucosal dissection. This suggests that endoscopic submucosal dissection may be an effective treatment option that can achieve R0 resection even for residual superficial cancer after salvage photodynamic therapy.

Usefulness of Adding Maspin Staining to p53 Staining for EUS-FNA Specimens of Pancreatic Ductal Adenocarcinoma.

Background: Endoscopic ultrasound-guided puncture aspiration biopsy (EUS-FNA) of pancreatic ductal adenocarcinoma (PDAC) is highly diagnostic, but it is difficult to distinguish from benign disease. Our objective was to determine the usefulness of maspin staining, in addition to conventional p53 staining, in the diagnosis of PDAC by EUS-FNA. Methods: Of the patients who underwent EUS-FNA and were diagnosed with PDAC, we retrospectively identified 90 cases in which both maspin and p53 staining were performed. In addition, we identified 28 cases of benign pancreatic disease diagnosed using EUS-FNA and these were selected as a control group. For analysis of EUS-FNA specimens, Cohen's Kappa (κ) coefficient and the prevalence and bias adjusted Kappa statistic (PABAK) were applied to assess the significance of sensitivity and specificity, comparing p53, maspin, p53+maspin. Results: The sensitivity and specificity of p53 staining were 48.9% and 100%. The κ coefficient was 0.31 (95%CI 0.18−0.44) (p < 0.01) and the PABAK coefficient was 0.22 (95%CI 0.03−0.40). The results for maspin staining were 88.9% and 92.9%. The κ coefficient was 0.72 (95%CI 0.54−0.90) (p < 0.01) and the PABAK coefficient was 0.78 (95%CI 0.64−0.88). The results for the combination of maspin and p53 staining were 94.4% and 92.2%. The κ coefficient was 0.82 (95%CI 0.64−1.00) (p < 0.01) and the PABAK coefficient was 0.86 (95%CI 0.74−0.94). Conclusion: Adding maspin staining to p53 staining showed high sensitivity and specificity. Our results demonstrated the usefulness of their combined use that might contribute to the improvement of tissue diagnostic performance of PDAC by EUS-FNA.

Advanced Endoscopy for Benign Esophageal Disease: A Review Focused on Non-Erosive Reflux Disease and Eosinophilic Esophagitis.

Advanced endoscopy (AVE) techniques include image-enhanced endoscopy methods, such as narrow-band imaging (NBI), and types of microscopic endoscopy, such as endocytoscopy. In the esophagus, AVE first showed diagnostic utility in the diagnosis of superficial esophageal cancer and was then applied to inflammatory disease. This review focuses on non-erosive reflux disease (NERD) and eosinophilic esophagitis (EoE), which sometimes show no abnormal findings on standard white light endoscopy alone. Studies have demonstrated that advanced endoscopy, including NBI magnification endoscopy and endocytoscopy, improved the diagnostic performance of white-light endoscopy alone for NERD and EoE. In this review, we explain why advanced endoscopy is needed for the diagnosis of these esophageal inflammatory diseases, summarize the study results, and discuss future perspectives.

Association of long-term endoscopic biliary stent placement with choledocholithiasis: a literature review.

Endoscopic stone removal is currently the first-line procedure for the treatment of common bile duct stones. Advances in equipment and treatment techniques have expanded the scope of application of endoscopic treatment to include stones that have previously been difficult to remove endoscopically, such as stacked stones and large stones. For the treatment of common bile duct stones in elderly patients in particular, long-term placement of a biliary stent is increasingly being selected. Although periodic stent replacement is required, some reports have stated that biliary stenting is useful in terms of treatment-associated invasiveness and the incidence of accidental complications. To date, various opinions have been presented on whether the treatment of bile duct stones should aim for complete removal of stones or adopt the biliary stenting approach. Findings in previous reports suggest that both the approach for complete stone removal and the long-term stenting approach are associated with advantages and disadvantages. In this study, we reviewed previous reports on the significance of placing a stent and implementing careful monitoring rather than stone removal in patients with bile duct stones.

Whole circumferential endoscopic submucosal dissection of superficial adenocarcinoma in long-segment Barrett's esophagus: A case report.

BACKGROUND: Esophageal adenocarcinoma (EAC) derived from long-segment Barrett's esophagus (LSBE) is extremely rare in Asia. LSBE-related EAC is often difficult to diagnose in the horizontal extent. If the tumor has spread throughout the LSBE, whole circumferential endoscopic submucosal dissection (ESD) should be performed, which is difficult to complete safely. Additionally, whole circumferential ESD can bring refractory postoperative stenosis. We hereby report a case of EAC involving the whole circumference of the LSBE, achieving complete endoscopic removal without complications. CASE SUMMARY: An 85-year-old man with the chief complaint of dysphagia underwent esophagogastroduodenoscopy. We suspected a flat-type cancerous lesion that extended the whole circumference of the LSBE (C 3.5, M 4.0) using narrow-band imaging magnification endoscopy (NBI-M). We achieved circumferential en bloc resection of the lesion safely with special ESD techniques. Histology of the ESD specimens demonstrated that the superficial EAC extended the whole circumference of the LSBE, and papillary or well-differentiated tubular adenocarcinoma was confined in the lamina propria mucosa showing a vertical negative margin. To prevent post-ESD stenosis, we performed endoscopic local injection of steroids, followed by oral administration of steroids. There was no evidence of esophageal refractory stenosis or tumor recurrence 30 mo after ESD. In summary, we experienced a rare case of LSBE-related EAC. The horizontal tumor extent was accurately diagnosed by NBI-M. Additionally, we achieve whole circumferential ESD safely without postoperative refractory stenosis. CONCLUSION: NBI-M, ESD, and steroid therapy enabled the curative resection of superficial full circumferential LSBE-related EAC without refractory postoperative stenosis.

Pilot Study of Acupuncture's Antispasmodic Effect on Upper Gastrointestinal Tract during Endoscopic Submucosal Dissection for Early Gastric Cancer: Controlled Clinical Trial.

A prospective study was conducted in patients with early-stage gastric cancer to determine the efficacy and safety of acupuncture stimulation as an antispasmodic compared with conventional medication during the procedure of endoscopic submucosal dissection (ESD) of the upper gastrointestinal tract. This study was a prospective single blinded quasi-randomized controlled trial. Seventy-three patients who were scheduled to undergo ESD for gastric cancer at Aizu Medical Center between 19 February 2016 and 30 June 2016 were assessed for eligibility for the study. Sixty out of 73 patients were included in the study and assigned into two intervention groups: medication group (MG) and acupuncture group (AG). Ease of the procedure was evaluated using modified NIWA classification (MNC) by endoscopist considering the frequency and amplitude of the upper gastrointestinal peristalsis. For the statistical analysis, Mann-Whitney test was used to compare the differences of MNC values (baseline and end of procedure) between two groups. The difference of MNC found in the AG (-2.00 (-3.0 to -2.0)) was significantly greater than that in the MG (-1.00 (-2.0 to -1.0), p < 0.0001, Mann-Whitney test). We consider that acupuncture to the abdomen could be an alternative antispasmodic method during upper gastrointestinal endoscopic procedure.