Are Newer Extracorporeal Shock Wave Lithotripsy Models Truly Improving Pancreatolithiasis Lithotripsy Performance? A Japanese Single-Center Study Using Endoscopic Adjunctive Treatment.

Background/Aims: Many Japanese institutions use electromagnetic extracorporeal shock wave lithotripsy (ESWL) systems for treating pancreatic duct stones. However, there are no reports on direct comparisons between recent electromagnetic lithotripters. This study aimed to verify whether the new electromagnetic lithotripter can improve the efficiency of pancreatic stone fragmentation, and to clarify the role of combined endoscopic treatment on the clearance of pancreatic duct stones. Methods: We retrospectively identified 208 patients with pancreatolithiasis who underwent endoscopic adjunctive treatment after pancreatic ESWL at a single Japanese center over a 17-year period. We evaluated the outcome data of this procedure performed with SLX-F2 (last 2 years; group A) and Lithostar/Lithoskop (first 15 years; group B), as well as additional endoscopic treatments for pancreatolithiasis. We also performed logistic regression analysis to detect various factors associated with the procedure. Results: For pancreatic head stones, ESWL disintegration was achieved in 93.7% of group A patients and 69.0% of group B patients (p=0.004), and adjunctive endoscopic treatment removed stones in 96.8% of group A patients and 73.0% of group B patients (p=0.003). Multivariate analysis revealed that lithotripter type (odds ratio, 6.99; 95% confidence interval, 1.56 to 31.33; p<0.01) and main pancreatic duct stricture (odds ratio, 2.87; 95% confidence interval, 1.27 to 6.45; p<0.01) were significant factors for ESWL fragmentation. Conclusions: The SLX F2 showed high performance in fragmenting the pancreatic duct stones. In addition, endoscopic adjunctive treatment improved the overall success rate of the procedure. The improved ESWL lithotripter has many advantages for patients undergoing pancreatic lithotripsy treatment.

Focal pancreatic ductal change induced by 10-Fr S-type plastic stent in chronic pancreatitis.

BACKGROUND AND AIM: Stent-induced ductal change (SIDC) is a complication of endoscopic pancreatic stenting (EPS) in patients with chronic pancreatitis (CP). However, the evaluation of SIDC associated with S-type pancreatic plastic stent (PS) and large-caliber PS, such as 10 Fr, is limited. This study aimed to analyze the SIDC of the main pancreatic duct (MPD) associated with 10-Fr S-type PS in patients with CP. METHODS: Between January 2008 and December 2021, 132 patients with CP in whom a 10-Fr S-type PS had been installed by EPS were retrospectively reviewed. The SIDC incidence rate was examined, and the clinical features of patients with and without SIDC were investigated, including the outcomes for detected SIDC. RESULTS: Stent-induced ductal change during EPS was confirmed in 41 patients (31.1%) of 132 patients at a site coincident with the PS tip or distal flap in the MPD. All patients were asymptomatic during the development of SIDC. Morphological changes in the MPD were detected as elevated (75.6%) or bearing stricture changes (24.4%). A total of 90.2% of SIDC developed after the first 10-Fr PS installation. No significant differences were noted between the patients with and without SIDC. The outcomes of continued PS installment for SIDC showed persistence and secondary change. CONCLUSIONS: Stent-induced ductal change-associated 10-Fr PS installation was performed in just under one-third of the patients, indicating a substantial incidence rate and a possible development of SIDC from early stages onwards. More emphasis should be placed on SIDC as the complication.

Endoscopic therapy for recurrent pancreatitis complicated with pancreatolithiasis in a case of annular pancreas.

Annular pancreas is a congenital abnormality in which part of the pancreatic head completely or partially surrounds the duodenum in a ring-like manner. The condition is thought to be an abnormality of the ventral pancreatic bud. While pancreatitis is a common complication of the annular pancreas, its recurrence may be prevented by improving the outflow of pancreatic juice. The present case report describes a 23-year-old woman who had been referred to our hospital for recurrent pancreatitis since childhood. An endoscopic incision was made on the orifice of the annular pancreas, after which pancreatitis of the annular pancreas did not recur for 6 years. The patient subsequently exhibited pancreatolithiasis in the dorsal pancreatic duct, which was successfully treated with endoscopic treatment. Endoscopic pancreatic sphincterotomy may prevent the recurrence of pancreatitis and avoid further surgical interventions by improving the flow of pancreatic juice.

Peroral Pancreatoscopy with Videoscopy and Narrow-Band Imaging in Intraductal Papillary Mucinous Neoplasms with Dilatation of the Main Pancreatic Duct.

BACKGROUND/AIMS: Endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMNs) is useful in determining whether the lesions are benign or malignant. This study aimed to examine the usefulness of peroral pancreatoscopy (POPS) in determining the prognosis of IPMNs. METHODS: POPS with videoscopy was performed using the mother-baby scope technique. After surgery, computed tomography/magnetic resonance cholangiopancreatography or ultrasonography and blood tests were performed every 6 months during the follow-up. RESULTS: A total of 39 patients with main pancreatic duct (MPD)-type IPMNs underwent POPS using a videoscope, and the protrusions in the MPD were observed in 36 patients. The sensitivity and specificity of cytology/biopsy performed at the time of POPS were 85% and 87.5%, respectively. Of 19 patients who underwent surgery, 18 (95%) patients had negative surgical margins and 1 (5%) patient had a positive margin. CONCLUSION: In IPMNs with dilatation of the MPD, POPS is considered effective if the lesions can be directly observed. The diagnosis of benign and malignant lesions is possible depending on the degree of lesion elevation. However, in some cases, slightly elevated lesions may increase in size during the follow-up or multiple lesions may be simultaneously present; therefore, careful follow-up is necessary.

[A case of diverticulitis in the horizontal part of the duodenum].

A 38-year-old woman was referred to our department to investigate epigastric discomfort. Laboratory studies showed increases in the peripheral white blood cell count and the level of C-reactive protein. Abdominal computed tomography depicted inflammation and a mass in the horizontal part of the duodenum. To observe it directly, we performed esophagogastroduodenoscopy (EGD), but it was very difficult to reach the lesion. Therefore, we performed enteroscopy by using SIF-H290S (Olympus Europa SE & Co. KG, Hamburg, Germany), which revealed a diverticulum containing food residue in the horizontal part of the duodenum. Using grasping forceps, we removed the food residue. The patient recovered over the next several days. Endoscopic therapy was thus effective for duodenal diverticulitis caused by food residue, but attention to technique was necessary.

Successful treatment of advanced pancreatic leiomyosarcoma treated with gemcitabine plus nab-paclitaxel: a case report and literature review.

Pancreatic leiomyosarcoma (PLMS) is an extremely rare tumor that accounts for 0.1% of pancreatic malignancies, and its chemotherapy has yet to be established. Generally, soft-tissue sarcoma chemotherapy is standard treatment with doxorubicin (DXR) alone. However, the effectiveness of gemcitabine (GEM) plus docetaxel (DOC) has been shown in uterine leiomyoma. In contrast, the GEM plus nab-paclitaxel (PTX) regimen has been established as first-line chemotherapy for unresectable pancreatic cancer. For this study, we selected the GEM plus nab-PTX regimen for patients with PLMS, achieving success in approximately 10 months. From a search on PubMed, we found only 12 cases of PLMS (including this case) that underwent chemotherapy. Our case is the first reported patient to have survived more than 2 years with chemotherapy alone. In a nude mouse model, the GEM plus DOC regimen was shown to significantly decrease tumor size when compared with DXR in leiomyosarcoma, and the GEM plus nab-PTX regimen was reported to significantly reduce necrosis when compared with DXR alone, GEM alone, DOC alone, nab-PTX alone and GEM plus DOC in soft-tissue sarcoma. GEM plus nab-PTX therapy might therefore be the first choice for soft-tissue sarcoma and leiomyosarcoma. This is the first reported case of PLMS treated with GEM plus nab-PTX.

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones.

AIM: Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures. METHODS: Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis. RESULTS: Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p = 0.03). CONCLUSION: The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.

Assessment in steroid trial for IgG4-related sclerosing cholangitis.

PURPOSE: Response to steroids is included in the diagnostic criteria for IgG4-related sclerosing cholangitis (IgG4-SC). To assess how to appropriately conduct steroid trials for IgG4-related SC, we examined the clinical pictures of steroid responsiveness in IgG4-SC patients. MATERIAL AND METHODS: A total of 29 patients with IgG4-SC (lower bile duct involvement, n=29; hilar/intrahepatic bile duct involvement, n=6) initially treated with steroids were enrolled in this study. Blood biochemistry was examined at about 5, 10 and 15 days after commencing steroid therapy. Endoscopic retrograde cholangiography (ERC) and magnetic resonance cholangiopancreatography (MRCP) were performed after steroid administration in 18 and 25 patients, respectively. RESULTS: In 19 patients without biliary drainage, elevated serum levels of total bilirubin, alanine aminotransferase, and alkaline phosphatase were halved in 50%, 25%, and 44% of patients at about 5 days after starting steroids, and in 17%, 38%, and 44% at about 10 days. Responsiveness to steroids could be evaluated at 1-2 weeks on ERC or MRCP, but response was lower in the hilar/intrahepatic bile duct than in the lower bile duct. CONCLUSIONS: Steroid responsiveness of IgG4-SC is recommended to be assessed by blood biochemistry at 5 and 10 days and on MRCP and/or ERC at 1-2 weeks after starting steroid.

Comparison of percutaneous radiofrequency ablation and CyberKnife(®) for initial solitary hepatocellular carcinoma: A pilot study.

AIM: To compare therapeutic outcomes and adverse events in initial solitary hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) and CyberKnife(®). METHODS: Seventy three consecutive patients with initial solitary HCC treated with RFA (38 patients; RFA group) and CyberKnife(®) (35 patients; CK group) were enrolled in this study. Background factors were compared between the two groups. Local and intrahepatic distant recurrence control, and cumulative survival rates were compared between the two groups. These were determined using the Kaplan-Meier method, and the significance of differences was analyzed by log-rank test. The presence of more grade 3 on CTCAE ver. 4.0 early and late adverse events was investigated. RESULTS: In background factors, age was significantly higher (P = 0.005) and the tumor diameter was significantly larger (P = 0.001) in the CK group. The 1-year local recurrence control rates were 97.4% and 97.1% in the RFA and CK groups, respectively (P = 0.71); the 1-year intrahepatic distant recurrence control rates were 85.6% and 86.1%, respectively (P = 0.91); and the 1-year cumulative survival rates were 100% and 95.2%, respectively (P = 0.075), showing no significant difference in any rate between the two groups. There were no late adverse event in the RFA group, but 11.4% in the CK group had late adverse events. In the CK group, the Child-Pugh score at 12 mo after treatment was significantly higher than that in the RFA group (P = 0.003) and significantly higher than the score before treatment (P = 0.034). CONCLUSION: The occurrence of adverse events is a concern, but CyberKnife(®) treatment is likely to become an important option for local treatment of early HCC.

Efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy, and additional electrohydraulic lithotripsy using the SpyGlass direct visualization system or X-ray guided EHL as needed, for pancreatic lithiasis.

INTRODUCTION: To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. METHODS: For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. RESULTS: Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). CONCLUSIONS: In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

Endosonographic preoperative evaluation for tumors of the ampulla of vater using endoscopic ultrasonography and intraductal ultrasonography.

BACKGROUND/AIMS: In recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy. METHODS: The subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors. RESULTS: The diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging. CONCLUSIONS: EUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System.

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum ß-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Necessity for endoscopic sphincterotomy for biliary stenting in cases of malignant biliary obstruction.

Endoscopic biliary stenting is a useful way to treat distal malignant biliary strictures that are not eligible for surgery. A 10-Fr plastic or metal stent is used for stenting. Typically, endoscopic sphincterotomy (EST) has often been carried out as a way to prevent pancreatitis after stent placement given the ease of stent insertion, but EST has flaws such as bleeding and stent migration.The present study describes the need for EST prior to stent placement.

Duct of Luschka diagnosed by sonography in a patient with bile duct carcinoma and intrahepatic bile duct dilatation.

The bile duct of Luschka (BDL) is an anatomic anomaly that is an important cause of bile leakage after bile duct surgery. We report a case of bile duct carcinoma with dilated BDL that was diagnosed by ultrasonography (US). An 83-year-old man presented with an obstructive jaundice. US on admission revealed the presence of a solid hypoechoic mass in the bile duct at the hepatic duct confluence and a branch of the bile duct, about 2-4 mm in diameter, distinct from the dilated right anterior hepatic duct slightly upstream of the tumor. This branch had a spiral structure, extended along the gallbladder bed on the surface of segment 5 (S5) of the liver, and emanated small branches that entered the hepatic parenchyma. There has been no previous report of delineation of BDL by preoperative US.

Right hepatic artery pseudoaneurysm complicating acute pancreatitis: a case report.

OBJECTIVE: To report a rare case of right hepatic artery pseudoaneurysm complicating acute pancreatitis based upon imaging findings obtained before and after the development of pseudoaneurysm. CLINICAL PRESENTATION AND INTERVENTION: A 32-year-old male with a history of acute pancreatitis 1 year prior was readmitted for acute pancreatitis. Computed tomography (CT) and angiography after admission revealed pseudoaneurysm of the right hepatic artery. Transcatheter arterial embolization with coils was used to successfully treat the pseudoaneurysm. A CT and angiography 1 year earlier did not reveal any pseudoaneurysm. CONCLUSION: This patient with a rare right hepatic artery pseudoaneurysm complicating acute pancreatitis was successfully treated with coil embolization.

Heterotopic Pancreas of the Jejunum Incidentally Detected by Preoperative Abdominal CT: Report of Two Cases and Review of the Literature.

Heterotopic pancreas (HP) is typically an asymptomatic malformation that can present anywhere along the gastrointestinal tract. It is often detected incidentally on surgery for other diseases or autopsy. We encountered 2 patients with jejunal HP incidentally detected by computed tomography (CT) performed for close evaluation of other diseases. In a 57-year-old woman diagnosed with reactive lymphoid hyperplasia on the dorsal portion of the pancreas head, CT detected a 15 mm oval-shaped submucosal lesion at the jejunum. In an 87-year-old woman diagnosed with type 2 adenocarcinoma occupying the sigmoid colon, CT detected a round-shaped submucosal tumor 15 mm in diameter in the jejunum. Both cases were histologically diagnosed as type 1 HP according to the classification by Heinrich. Contrast-enhanced CT revealed that the CT analyses of HP and pancreatic parenchyma were nearly identical in the arterial phase, but in the equilibrium phase, contrast enhancement persisted longer in HP than in the pancreatic parenchyma. There has been no report of asymptomatic jejunal HP preoperatively diagnosed by CT. These cases are presented with a review of the literature, particularly focusing on CT findings.

Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer.

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Efficacy of the new double-layer stent for unresectable distal malignant biliary obstruction: a single-center retrospective study.

Background and Aims. For distal malignant biliary obstruction in cases with short life expectancy, occlusion of plastic stents (PSs) does not usually occur before death, and the application of such a procedure is considered adequate from the viewpoint of cost-effectiveness. Methods and Setting. A new commercially available DLS with side holes, a conventional DLS, and, uncovered self-expanding metal stents (SEMSs) were retrospectively evaluated in patients with jaundice due to unresectable distal malignant biliary obstruction. Results. A total of 64 patients received endoscopic biliary stenting (23 patients with the new DLS, 24 patients with conventional DLS, and 17 patients with uncovered SEMS) from December 2002 to August 2009. Median patency time was found to be 198 days for the new DLS group and 99 days for the conventional DLS group, revealing a significant difference between devices. There was, however, no significant difference in median patency time between the new DLS and the uncovered SEMS (198 days versus 344 days). Conclusion. The new DLS is efficient and safe and may be considered the first choice for unresectable distal malignant obstruction in cases with short life expectancy.

Case of immunoglobulin G4-related cholangitis accompanying autoimmune pancreatitis: diagnosis by peroral cholangioscopy and treatment by endoscopic biliary stenting.

Recently, the progress of endoscopy has made it possible to evaluate bile duct mucosa by peroral cholangioscopy. Herein, we report a case of immunoglobulin G4-related sclerosing cholangitis accompanying autoimmune pancreatitis in a patient who improved with treatment by steroid therapy and endoscopic biliary stenting, and observed the bile duct mucosa by peroral cholangioscopy before and after treatment.