Transnasal endoscopic retrograde chalangiopancreatography using an ultrathin endoscope: a prospective comparison with a routine oral procedure.

AIM: To investigate if transnasal endoscopic retrograde cholangiopancreatography (n-ERCP) using an ultrathin forward-viewing scope may overcome the disadvantages of conventional oral ERCP (o-ERCP) related to the large-caliber side-viewing duodenoscope. METHODS: The study involved 50 patients in whom 25 cases each were assigned to the o-ERCP and n-ERCP groups. We compared the requirements of esophagogastroduodenoscopy (EGD) prior to ERCP, rates and times required for successful cannulation into the pancreatobiliary ducts, incidence of post-procedure hyperamylasemia, cardiovascular parameters during the procedure, the dose of a sedative drug, and successful rates of endoscopic naso-biliary drainage (ENBD). RESULTS: Screening gastrointestinal observations were easily performed by the forward-viewing scope and thus no prior EGD was required in the n-ERCP group. There was no significant difference in the rates or times for cannulation, or incidence of hyperamylasemia between the groups. However, the cannulation was relatively difficult in n-ERCP when the scope appeared U-shape under fluoroscopy. Increments of blood pressure and the amount of a sedative drug were significantly lower in the n-ERCP group. ENBD was successfully performed succeeding to the n-ERCP in which mouth-to-nose transfer of the drainage tube was not required. CONCLUSION: n-ERCP is likely a well-tolerable method with less cardiovascular stress and no need of prior EGD or mouth-to-nose transfer of the ENBD tube. However, a deliberate application is needed since its performance is difficult in some cases and is not feasible for some endoscopic treatments such as stenting.

Autonomic nervous function in upper gastrointestinal endoscopy: a prospective randomized comparison between transnasal and oral procedures.

BACKGROUND: Transnasal esophagogastroduodenoscopy (EGD) using an ultrathin endoscope is less stressful to the cardiovascular system with less elevation of systolic blood pressure (BP) than oral procedures. To elucidate the mechanism of such beneficial cardiovascular responses, we performed a prospective patient-centered randomized study in which BP and pulse rate (P), as well as autonomic nervous functions, were estimated during transnasal EGD compared with those in oral procedures using the same ultrathin endoscope. METHODS: The study involved 781 patients, among whom 55 and 56 cases were assigned to transnasal and oral EGD groups, respectively. The autonomic nervous responses were determined employing power spectral analysis (PSA) of heart-rate variations on electrocardiogram. PSA data were based on two peaks in low frequency (LF) and high-frequency (HF) ranges. HF power and the ratio of LF power/HF power represented parasympathetic and sympathetic nervous activities, respectively. RESULTS: Our study confirmed the lesser elevation of BP and P in patients undergoing transnasal EGD than in those undergoing oral procedures. PSA revealed a lower increase in LH power/HF power in transnasal EGD than in oral EGD. However, both endoscopic procedures equally suppressed HF power. Significant correlations were found between the parameters of cardiovascular response (P and BP) and autonomic functions (LF power/HF power ratio and HF power). CONCLUSIONS: This is the first study demonstrating less sympathetic stimulation in patients undergoing transnasal EGD, leading to lesser elevation of BP and P.

A novel technique for the internal drainage of extrahepatic biloma complicating transarterial embolization of hepatocellular carcinoma.

Biloma is an infrequent complication of nonsurgical treatments of hepatocellular carcinoma (HCC), including transarterial embolization (TAE), and it is often associated with ischemic injuries of the biliary tract after therapy. We here report on a case featuring successful internal drainage of an extrahepatic biloma into the duodenum by a route via the cholecyst, cholecystic duct, and common bile duct under fluoroscopic control. An extrahepatic biloma developed after urgent TAE for ruptured HCC and became contaminated. Radiography with contrast medium through the percutaneous drainage tube revealed a fistula between the biloma and gallbladder. The drainage catheter was introduced into the gallbladder through the fistula, from where it subsequently reached the duodenum via the cholecystic and common bile ducts. The internal drainage route played a major role in the rapid elimination of the biloma, which did not recur after the tube was withdrawn. To our knowledge, this is the first report of internal drainage of a biloma through the cholecystic and common bile ducts.