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

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

Evaluation of ultrasonic fibrosis diagnostic system using convolutional network for ordinal regression.

PURPOSE: Diagnosis of liver fibrosis is important for establishing treatment and assessing the risk of carcinogenesis. Ultrasound imaging is an excellent diagnostic method as a screening test in terms of non-invasiveness and simplicity. The purpose of this study was to automatically diagnose liver fibrosis using ultrasound images to reduce the burden on physicians. METHODS: We proposed and implemented a system for extracting regions of liver parenchyma utilizing U-Net. Using regions of interest, the stage of fibrosis was classified as F0, F1, F2, F3, or F4 utilizing CORALNet, an ordinal regression model based on ResNet18. The effectiveness of the proposed system was verified. RESULTS: The system implemented using U-Net had a maximum mean Dice coefficient of 0.929. The results of classification of liver fibrosis utilizing CORALNet had a mean absolute error (MAE) of 1.22 and root mean square error (RMSE) of 1.60. The per-case results had a MAE of 1.55 and RMSE of 1.34. CONCLUSION: U-Net extracted regions of liver parenchyma from the images with high accuracy, and CORALNet showed effectiveness using ordinal information to classify fibrosis in the images. As a future task, we will study a model that is less dependent on teaching data.

Esophageal cancer responsive to the combination of immune cell therapy and low-dose nivolumab: two case reports.

BACKGROUND: Blocking the programmed death 1 pathway by immune checkpoint inhibitors induces dramatic antitumor activity in patients with malignant tumors. However, the clinical response to immune checkpoint inhibitors remains limited owing to the patients' immunological status, such as the number of lymphocytes, programmed death ligand 1 expression, and tumor mutation burden. In this study, we successfully treated two patients with advanced esophageal cancer who responded to the combination of adoptive immune cell therapy and a low-dose immune checkpoint inhibitor, nivolumab. CASE PRESENTATION: Two Asian (Japanese) patients with advanced esophageal cancer who were resistant to conventional chemoradiation therapy were referred to our hospital for immune therapy. Case 1 was a 66-year-old woman who was diagnosed as having esophageal cancer. She received concurrent chemoradiation therapy and then underwent subtotal esophagectomy, after which she became cancer free. However, she relapsed, and cancer cells were found in the lung and lymph nodes 6 months later. She enrolled in a clinical trial at our institution (clinical trial number UMIN000028756). She received adoptive immune cell therapy twice at a 2-week interval followed by low-dose nivolumab with adoptive immune cell therapy four times at 2-week intervals. A follow-up computed tomography scan showed partial response, with mass reduction of the metastatic lung and mediastinal lesions. Case 2 was a 77-year-old man. He received concurrent chemoradiation therapy with fluoropyrimidine/platinum, and gastroscopy revealed complete remission of esophageal cancer. He was disease free for 5 months, but routine computed tomography revealed multiple metastases in his lungs and lymph nodes. He visited our clinic to receive adoptive immune cell therapy and immune checkpoint inhibitor combination therapy. Radiographic evidence showed continuous improvement of lesions. There was no evidence of severe adverse events during the combination therapy. CONCLUSION: The combination of adoptive immune cell therapy and an immune checkpoint inhibitor might be a possible treatment strategy for advanced esophageal cancer. Trial registration UMIN000028756. Registered 14 September 2017.

[Use of EUS-FNA in the diagnosis of hilar schwannoma:a case report].

Upon abdominal ultrasonography, a woman in her 36 years old was diagnosed with a hypoechoic tumor with a diameter of 60mm surrounding the bile duct in the hepatic portal region. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed a tumor-like mass in the bile duct. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) confirmed the diagnosis of schwannoma. Considering the lesion location, it appeared to rise from the hepatoduodenal ligament. She was unwilling to undergo tumor resection;however, a year after the diagnosis, no change was observed in the tumor. Here, we report a case of schwannoma in the hepatoduodenal ligament, wherein EUS-FNA was useful for establishing a diagnosis and determining a treatment strategy.

A case of miriplatin-induced lung injury.

A 69-year-old man with an 8-year history of hepatocellular carcinoma (HCC) was hospitalized for treatment of recurrent tumour. In 2010, the first transcatheter arterial chemoembolization (TACE) using miriplatin with agents (Lipiodol Ultra-Fluid) was performed and did not occur any adverse events. In 2014, since his HCC recurred, the TACE using miriplatin with agents was performed. Following this therapy, pyrexia occurred on day 3, followed by respiratory failure with cough and dyspnea on day 5. Chest radiography revealed scattered infiltration in the right upper lung fields, and chest computed tomography revealed ground grass attenuations, indicating fibrotic non-specific interstitial pneumonia. These findings progressively deteriorated, and a diagnosis of miriplatin-induced lung injury was made. His respiratory failure also progressively deteriorated. Treatment with pulse methylprednisolone therapy resulted in a dramatic improvement in both patient symptoms and radiological abnormalities.

[A case of acute progressive primary inflammatory fibrosarcoma of the retroperitoneum].

A 70-year-old man with liver cirrhosis presented to us with abdominal distention. Computed tomography revealed a giant retroperitoneal tumor. Examination of a biopsy specimen led to a diagnosis of primary inflammatory fibrosarcoma of the retroperitoneum. However, disease progression was rapid, and the patient died 6 weeks after the onset of the disease. Autopsy revealed that the tumor arose from the retroperitoneum and infiltrated the omentum and mesentery. Prognosis of inflammatory fibrosarcoma is poor if resection is incomplete. Establishment of treatment for unresectable cases is necessary.

Liver abscess of Actinomyces israelii in a hemodialysis patient: case report and review of the literature.

We had encountered a 74-year-old woman on hemodialysis therapy suffering from liver abscess of Actinomyces israelii. Percutaneous drainage of the abscess before starting antimicrobial therapy followed by correct microbiological identification and susceptibility test led us to determine long treatment with ampicillin and to a successful outcome. Periodontitis was thought to be a possible entry of actinomyces. Hepatic actinomycosis should be recognized as one of the important infectious diseases among patients of end-stage renal disease.