Long-term outcomes after EUS-guided antegrade intervention for benign bilioenteric anastomotic stricture.

BACKGROUND AND AIMS: Bilioenteric anastomotic stricture (BES) is a well-known adverse event after bilioenterostomy. Recently, EUS-guided antegrade intervention (EUS-AI) has been developed for cases that are difficult to treat by balloon enteroscopy-assisted ERCP. However, no data are available on the long-term outcomes after EUS-AI. The main goal of the present study was to clarify the long-term outcomes of EUS-AI in such patients. METHODS: Between November 2013 and November 2021, 34 patients who were followed for more than 1 year after EUS-AI for BES were identified. The primary endpoint was the rate of stricture resolution. Secondary endpoints were factors associated with stricture resolution, rate of BES recurrence, rate of conversion to surgery, and rate of hepatic fibrosis progression during follow-up. RESULTS: The median follow-up period was 56.7 months. Stricture resolution was achieved in 17 of 34 patients (50%). A multivariate analysis confirmed that the presence of bile duct stones (odds ratio, 9.473; 95% confidence interval, 1.66-53.98; P = .01) was significantly associated with stricture resolution. The stricture recurrence rate was 33%, and the median time from stent removal to recurrence was 31.2 months. Four patients underwent surgery because of recurrent cholangitis. During the median follow-up period of 56.7 months, 25% progressed to hepatic fibrosis based on the Fibrosis-4 index grade. Interestingly, patients without cholangitis during follow-up did not show progression of hepatic fibrosis. CONCLUSIONS: EUS-AI has achieved acceptable long-term clinical outcomes. EUS-AI can be a viable alternative treatment of choice before surgical treatment in patients who are difficult to treat by conventional approaches.

Optimal mode and power output of electrosurgical units for endoscopic papillectomy based on animal experiments and a preliminary clinical study (with videos).

BACKGROUND AND AIMS: The optimal electrosurgical unit (ESU) settings for endoscopic papillectomy (EP) have not been investigated. We conducted animal experiments to determine the optimal endoCUT settings with VIO (Erbe, Tübingen, Germany) ESUs and then conducted a small clinical study. METHODS: Dedicated animal experimental models were created. To investigate the incision force, chicken meat was resected with a snare whose handle was a hung weight. To investigate the coagulation effect, a surgical needle electrode was inserted into a pig liver and energized, and to determine changes over time in the coagulation status, simulated EP was performed using a living pig. These experiments were performed using the knife-setting or snare-setting endoCUT modes and various effect, duration, and interval settings and compared with results for ICC (Erbe) ESUs. Based on the results, we performed EP in a small number of patients. RESULTS: The main factor affecting the incision force was duration. The coagulation effect was related to not only effect but also duration. In the endoCUT mode, knife-setting produced a higher incision force and lower coagulation effect. The nondischarge coagulation effect may cause deep ulceration. Based on the animal experiments, we concluded the ideal ESU setting for EP, "VIO EP mode," is knife-setting with high duration, lowest effect, and low interval settings. In the clinical study, there were no significant adverse events such as bleeding, pancreatitis, or perforation. CONCLUSIONS: "VIO EP mode" seems to afford optimal papillectomy. Larger scale clinical studies are needed to accumulate further data and make clinical comparisons with the ICC ESU.

Metachronous intraductal papillary mucinous neoplasms disseminate via the pancreatic duct following resection.

Metachronous development of intraductal papillary mucinous neoplasms in the remnant pancreas following resection is a significant clinical burden. Our aim was to characterize the clinicopathological and molecular features of the patients with metachronous tumor development to identify predictive factors and the possible route(s) of dissemination. Seventy-four patients who underwent resection of intraductal papillary mucinous neoplasms with no invasive compartment or associated carcinoma were retrospectively analyzed. In patients with metachronous tumor development, targeted sequencing of 18 genes associated with pancreatic tumorigenesis and immunohistochemical detection of four proteins (p53, SMAD4, p16, and ß-catenin) were performed on both primary and metachronous tumors. The distributions of microscopic neoplastic lesions were examined at surgical margins and in apparently normal tissue apart from the primary tumor. During the median follow-up period of 52 months, 9 patients (12%) developed metachronous tumors in the remnant pancreas. Primary tumors located in the body/tail of the pancreas (odds ratio, 15; 95% confidence interval, 1.6-131) and of the pancreatobiliary type (odds ratio, 6.1; 95% confidence interval, 1.1-35.7) were identified as significant risk factors for subsequent metachronous tumor development. Eight of the nine patients shared molecular aberrations between their primary and metachronous tumors, suggesting migrations from the primary tumor to the pancreatic duct as the cause of metachronous tumor development. Our data suggest that these post-resection metachronous tumors develop by skip dissemination of the primary tumor, potentially via the pancreatic duct. The development of strategies to better predict and prevent this form of tumor progression is necessary.

Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing a pancreatic mass; however, EUS-FNA for patients with surgically altered upper gastrointestinal (UGI) anatomy has not yet been investigated sufficiently. Therefore, the feasibility and safety of EUS-FNA in these patients were retrospectively investigated. METHODS: Patients in whom EUS-FNA was performed between March 2008 and April 2017 were retrospectively investigated in terms of EUS-FNA technical success, procedure time, diagnostic accuracies of cytology and histology, and procedure-related adverse events. RESULTS: Twenty-five EUS-FNAs were performed for 15 pancreatic body-to-tail and 10 head lesions. All patients underwent EUS-FNA successfully; however, changing of the echoendoscope to a forward-viewing echoendoscope and preplacement of a nasobiliary catheter by balloon-assisted enteroscopy for guidance were needed in one and two cases, respectively. The median procedure time was 26 min (range, 16-70). The diagnostic accuracies were 76%, 84%, and 88% for cytology, histology, and combined use, respectively. Adverse events were not observed. CONCLUSIONS: Endoscopic ultrasound-guided FNA is a safe and efficient method for diagnosing a pancreatic mass even in patients with surgically altered UGI anatomy. Nevertheless, some sophisticated techniques are required for pancreatic head lesions if reaching the duodenum after passing through the jejunal limb is required for visualization of the pancreatic mass.

Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure.

Background and study aims Short-type single-balloon enteroscope (short SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is a promising alternative treatment in postsurgical altered anatomy. However, it is technically demanding, and factors affecting its technical difficulty have not yet been clarified. This study aimed to examine the procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure. Patients and methods A total of 117 consecutive patients (203 procedures) with surgically altered anatomy underwent ERCP using prototype short SBEs. The procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure were examined retrospectively. Results The enteroscopy success rate and procedural success rate were 92.6 % (95 % confidence interval [CI] 88.1 % - 95.8 %) and 81.8 % (95 %CI 75.8 % - 86.8 %), respectively. Multivariate analyses indicated that pancreatic indication (odds ratio [OR] 4.35, 95 %CI 1.67 - 11.4), first ERCP attempt (OR 6.03, 95 %CI 2.17 - 16.8), and no transparent hood (OR 4.61, 95 %CI 1.48 - 14.3) were potential risk factors for procedural failure. Conclusions Short SBE-assisted ERCP was effective in postsurgical altered anatomy. This large case series suggested the potential factors affecting procedural failure.

Rare case of transfusion-transmitted hepatitis E from the blood of a donor infected with the hepatitis E virus genotype 3 indigenous to Japan: Viral dynamics from onset to recovery.

AIM: The transfusion transmission of hepatitis E can occur even in non-endemic areas in the world as autochthonous hepatitis E has been increasingly reported in developed countries where the hepatitis E virus (HEV) is not prevalent. We investigated the post-transfusion transmission of hepatitis E in a patient by molecularly confirming its presence, and characterized the viral kinetics of HEV in this case. METHODS: A Japanese man underwent re-thoracotomy for hemostasis followed by platelet transfusion. After the transfusion, the blood donor was found to be HEV positive. The donated blood was re-examined and was found to contain HEV. Throughout the prospective follow up of the patient, we analyzed the viral kinetics, chronological anti-HEV antibody level changes and disease progression during the entire course of HEV infection from transfusion until the end of viremia. RESULTS: Sequence analysis of the strains isolated from both the donor and the patient who contracted acute hepatitis E showed an identical match for 326 nucleotides in open reading frame 1. Two strains belonged to HEV genotype 3 indigenous to Japan. CONCLUSION: To the best of our knowledge, this is the first detailed report on the entire natural course of hepatitis E from viral transmission, then clearance, to replication preceding liver injury caused by HEV genotype 3, which is responsible for autochthonous infection in developed countries. The findings provide valuable insights into the mechanism of the transfusion transmission of HEV and subsequent viral dynamics.

Recent progress in radiofrequency ablation therapy for hepatocellular carcinoma.

In order to attain better ablation and more effective management of hepatocellular carcinoma (HCC), new approaches and devices in radiofrequency ablation (RFA) therapy were presented and discussed in a workshop at the 50th Annual Meeting of the Liver Cancer Study Group of Japan. A novel bipolar RFA apparatus was introduced in Japan in January 2013. Hundreds of subjects with HCC were treated with multipolar RFA with varied devices and plans. Among these, no-touch ablation was one of the most useful procedures in the treatment of HCC with the apparatus. In RFA therapy, a few assisting devices and techniques were applied for convenience and improvement of the thermal ablation procedure. Contrast-enhanced ultrasonography and three-dimensional fusion imaging technique using volume data of CT or MRI could improve exact targeting and shorten the treatment time for RFA procedures under ultrasonographic guidance. A more complicated method using a workstation was also reported as being helpful in planning the ablated shape and volume in multineedle RFA. The effective use of sedatives and antianalgesics as well as a novel microwave apparatus with a cooled-tip electrode was also discussed.

Efficacy and long-term outcomes of radiofrequency ablation in the elderly with hepatocellular carcinoma.

AIM: The use of radiofrequency ablation (RFA) in elderly patients is increasing in those with hepatocellular carcinoma (HCC). This study compares the elderly (≥75 years old) to non-elderly patients (<75 years old) in the outcomes of the efficacy and safety of RFA. METHODS: Three hundred and thirty-five patients, 103 elderly and 232 non-elderly, with naive HCC who were treated with RFA from 1999 to 2012 were enrolled. Patient characteristics, complications, length of hospital stay, overall survival (OS), median survival time (MST), recurrence-free survival (RFS) and factors related to OS were analyzed. RESULTS: Median age was 79 years (range, 75-88) in the elderly group and 65 years (38-74) in the non-elderly group. The proportion of women (45.6% and 28.0%), hepatitis C virus infection (63.1% and 50.4%) and comorbidities (78.6% and 44.0%) in the elderly group compared to the non-elderly group, respectively, was significantly higher. No difference existed in the complications and length of hospital stay. The 5-year OS rates and MST were 67.3% and 90.5 months in the elderly group and 60.9% and 86.4 months in the non-elderly group, respectively (P = 0.486). The median RFS time was 20 months in the elderly group and 18.7 months in the non-elderly group (P = 0.429). In multivariate analysis, the Child-Pugh grade and tumor-node-metastasis stage were significantly associated with OS (P < 0.001, =0.003); age was not (P = 0.355). CONCLUSION: RFA in elderly patients is as effective and safe as in non-elderly patients for the treatment of HCC.

Potential versatile uses of a novel ultra-thin peroral cholangioscope.

Tonozuka and colleagues report the usefulness of a newly developed ultra-thin mother-baby type peroral cholangioscope with a tip external diameter of 2.3 mm for a case of biliary stricture in which conventional peroral cholangioscope insertion was challenging. The novel scope allows simple and low-cost peroral cholangioscopy, making it highly versatile.

Multicenter comparative study on the usefulness of the optimal electrosurgical unit setting in endoscopic papillectomy for ampullary neoplasms (with video).

BACKGROUND: Endoscopic papillectomy (EP) is less invasive than surgery but procedure-related adverse events (AEs) still frequently occur. This study compared the benefits of EP using a new optimal endoCUT setting on the VIO (Erbe) electrosurgical unit (VIO-EP) with those using the conventional electrosurgical unit setting (ICC-EP, Erbe). METHODS: This multicenter, retrospective, comparative cohort study included 57 patients who underwent VIO-EP and 91 who underwent ICC-EP. The primary outcome was occurrence of EP-related AEs. Secondary outcomes were pathological findings (the resection margins, the R0 resection, and residual lesions). RESULTS: Pancreatitis tended to be less common in the VIO-EP group (5.3% vs. 9.9%, p = .248). Evaluation of computed tomography images showed that pancreatitis was confined to the pancreatic head in 77.8% of cases in the ICC-EP group and in 33.3% of those in the VIO-EP group. After exclusion of cases of delayed bleeding, pancreatitis tended to be less common in the VIO-EP group; this finding was not statistically significant (2.3% vs. 8.2%, p = .184). In pathological findings, residual lesions were significantly less common in the VIO-EP group. CONCLUSIONS: The risks of pancreatitis and residual lesions after EP may be lower when the VIO electrosurgical unit is used with the optimal setting.

Endoscopic ultrasound-guided biopsy using a three-prong asymmetry tip needle for pancreatic tumors and peridigestive tract lesions: Retrospective single-center study.

BACKGROUND: Endoscopic ultrasound-guided tissue acquisition is vital for diagnosing pancreatic and peridigestive tract lesions. A new three-prong asymmetry tip needle has been developed for this procedure. In this study, we retrospectively assessed the diagnostic ability, tissue collection volume, and procedural adverse events of the three-prong asymmetry tip needle for solid pancreatic, subepithelial, and other organ lesions. METHODS: We analyzed the data of 58 consecutive patients who underwent endoscopic ultrasound-guided tissue acquisition using a three-prong asymmetry tip needle between August 2022 and April 2023 at a single care center. RESULTS: The tissue collection rate was 91.4% with 89.7% accuracy, 89.3% sensitivity, 100% specificity, 100% positive predictive value, and 25% negative predictive value. No significant differences in collection rates or diagnostic performance were observed based on the target organ, puncture route, or lesion size. Using our original assessment method, the average histological core tissue score was 3.1 ± 0.8, whereas the blood contamination volume was 2.5 ± 0.8. Only one of 58 patients (1.7%) developed a pancreatic fistula of moderate severity as an adverse event. CONCLUSIONS: The three-prong asymmetry tip needle demonstrated good diagnostic capability and adequate sample volume with safety for pancreatic, subepithelial, and other organ lesions.

A novel technique for one-step dilation followed by bile aspiration using an ultra-tapered bougie dilator with side holes to minimize bile leakage during EUS-guided hepaticogastrostomy.

Bile aspiration during endoscopic ultrasound-guided hepaticogastrostomy reduces the risk of bile leakage. Mukai and colleagues devised a method in which side holes for bile aspiration are created using a biopsy punch in a hard type ultra-tapered bougie dilator. Effective bile aspiration was achieved in all four cases attempted.

A novel peroral digital cholangioscope with a large accessory channel: An experimental study.

BACKGROUND/PURPOSE: A peroral cholangioscope (POCS) can allow direct visualization of the biliary mucosa and its use is becoming more widespread due to improvements in functionality, image quality, and operability, as well as the development of related devices. Recently, a novel mother-baby peroral cholangioscope (nMB-POCS) with a large (2-mm) accessory channel has been developed. In this study, we evaluated the feasibility of this novel POCS in a dry simulation and animal model. METHODS: We evaluated the ease of insertion and maneuverability of the nMB-POCS, the image quality, and the passage of the devices into the accessory channel and into the common bile duct in a dry and live porcine model. RESULTS: In both models, the nMB-POCS could be easily inserted into the duodenoscope and into the distal bile duct and hilum. The image quality was good, and it was possible to observe the surface structure and the vascular network of the bile duct mucosa in detail. CONCLUSIONS: The nMB-POCS with its larger accessory channel is expected to improve the efficiency of diagnosis and  treatment, and reduce the procedure time. Clinical studies in patients are warranted.

A novel tube placement technique in EUS-guided drainage for small pancreatic pseudocyst: Spinning lasso method.

This paper discusses a novel tube placement technique; the "spinning lasso method", in EUS-guided drainage for small pancreatic pseudocysts (PC) with video. In general, the placement of a drainage tube can be difficult in a small PC and the tube often deviates during attempted insertions into the cavity. The technique helps to mitigate this problem.

Endoscopic retrieval of a proximally migrated fully covered self-expandable metal stent using biopsy forceps with a guiding sheath cannula.

Transpapillary endoscopic biliary drainage is the gold standard for resolving malignant biliary obstruction. Stent migration occasionally occurs and is troublesome to retrieve. Yamamoto and colleagues report with accompanying video on the successful retrieval of a proximally migrated stent using biopsy forceps through a guiding sheath cannula.

Objective evaluation of the resistance forces of 22-gauge EUS-FNA and fine-needle biopsy needles.

Background and Objectives: EUS-guided tissue acquisition is routinely performed for the diagnosis of gastrointestinal tract and adjacent organ lesions. Recently, various types of needles have been developed. However, how the shape of the needle tip and echoendoscope tip angle affect puncturability, has not been clarified. The aim of this experimental study was to compare the puncturability of several 22-gauge EUS-FNA and EUS-guided fine-needle biopsy (EUS-FNB) needles, and to evaluate the effects of the needle tip shape and echoendoscope tip angle on tissue puncturability. Materials and Methods: The following six major FNA and FNB needles were evaluated: SonoTip® ProControl, EZ Shot 3 Plus, Expect™ Standard Handle, SonoTip® TopGain, Acquire™, and SharkCore™. The mean maximum resistance force against needle advancement was evaluated and compared under several conditions using an echoendoscope. Results: The mean maximum resistance force of the needle alone was higher for the FNB needles than for the FNA needles. The mean maximum resistance force of the needle in the echoendoscope with free angle demonstrated that the resistance forces were between 2.10 and 2.34 Newton (N). The mean maximum resistance force increased upon increases in angle of the tip of echoendoscope, particularly in the FNA needles. Among the FNB needles, SharkCore™ had the lowest resistance force (2.23 N). The mean maximum resistance force of the needle alone, the needle in the echoendoscope with free angle, and the needle in the echoendoscope with full-up angle for SonoTip® TopGain were all similar to that of Acquire™. Conclusion: SonoTip® TopGain had similar puncturability to Acquire™ in all tested situations. Regarding the puncturability, SharkCore™ is most suitable for insertion into target lesions, when tight echoendoscope tip angle is necessary.

A fatal case of massive hemobilia caused by invasive pancreatic cancer with median arcuate ligament syndrome: A case report.

INTRODUCTION: In median arcuate ligament syndrome (MALS), the celiac artery is compressed, causing an arcade to develop in the pancreatic head, leading to ischemic symptoms and aneurysms. PATIENT CONCERNS: The patient was diagnosed with borderline resectable pancreatic cancer (PC) and MALS. Endoscopic biliary drainage with a covered metal stent (CMS) was performed for the obstructive jaundice. After the jaundice improved, a modified FOLFIRINOX regimen was initiated. Several days later, cardiopulmonary arrest occurred after hematemesis occurred. Cardiopulmonary resuscitation was performed, his blood pressure stabilized, and emergent upper endoscopy was performed. The CMS was dislodged and active bleeding was observed in the papillae. The CMS was replaced, and temporary hemostasis was achieved. Contrast-enhanced computed tomography revealed a diagnosis of extravasation from the posterior superior pancreaticoduodenal artery (PSPDA) into the biliary tract. Transcatheter arterial embolization was performed. However, the patient was subsequently diagnosed with hypoxic encephalopathy and died on day 14 of hospitalization. DIAGNOSIS: Biliary hemorrhage due to invasion of pancreatic cancer from the PSPDA associated with MALS. INTERVENTION: None. OUTCOMES: Biliary hemorrhage from the PSPDA was fatal in the patient with invasive PC with MALS. LESSONS: Since MALS associated with PC is not a rare disease, the purpose of this study was to keep in mind the possibility of fatal biliary hemorrhage.

Impact of using scope holder on Interventional Endoscopy (with video).

Highlight Tsuchiya and colleagues developed a scope holder to maintain good scope positioning during interventional endoscopic ultrasound. The scope holder not only reduces the burden on the endoscopist but also reduces the radiation exposure of the caregiver. This is the first report on a scope holder for flexible endoscopes.

Endoscopic papillectomy for tumors of the minor duodenal papilla: A case series of six patients and literature review.

BACKGROUND/PURPOSE: Various tumors of the minor duodenal papilla have been reported, most of which are treated by laparotomy. Although early-stage tumors of the major papilla are increasingly being treated by endoscopic resection with relative ease and low invasiveness, there are only a few reports on endoscopic resection of tumors in the minor papilla. METHODS: Six patients with tumors in the minor papilla were treated by endoscopic papillectomy (EP), and their clinical and histopathological data were analyzed retrospectively. RESULTS: The final pathological diagnoses were carcinoma in adenoma in two patients and adenoma, neuroendocrine neoplasm (G1), hyperplastic lesion, and no neoplastic lesion (disappearance of adenoma after biopsy) in one patient each. En bloc resection was performed in five patients and piecemeal resection in one patient. There were no procedure-related adverse events, such as bleeding, pancreatitis, or perforation. There was one case with a residual lesion, which was treated by ablation therapy, and no recurrences during a mean follow-up of 12 ± 10.33 months (maximum, 28 months) from the date of EP. CONCLUSIONS: Endoscopic papillectomy appears to be an effective minimally invasive treatment for ampullary tumors of the minor duodenal papilla.