Electrohydraulic Lithotripsy for Pancreatic Duct Stones Under Digital Single-Operator Pancreatoscopy (with Video).

BACKGROUND: Recently, a digital single-operator cholangiopancreatoscope (DSOC) has become available. This system allows the performance of electrohydraulic lithotripsy (EHL) even within the main pancreatic duct (MPD). However, there are only few reports of EHL for MPD stones using SPY-DS. AIMS: The aim of this study was to evaluate the technical feasibility and efficacy of EHL for MPD stones under DSOC guidance. METHODS: Between October 2016 and August 2017, patients with MPD stones were retrospectively enrolled in this study. The presence of MPD stones was diagnosed by endoscopic ultrasound and MRCP. The patients' baseline characteristics and those of the stones, including their size, number, and site in the MPD, number of EHL procedures, and adverse events, were reviewed. RESULTS: A total of 21 patients were retrospectively enrolled. The etiologies of chronic pancreatitis were idiopathic (n = 4) and alcohol induced (n = 17). The pancreatic stone was variously located in the head (n = 6), body (n = 11), tail (n = 1), head and body (n = 2), and body and tail (n = 1) of the pancreas. Median pancreatic stone size was 12 mm, and the mean number of ERCP sessions was 1.29 (range 1-3). EHL was successfully performed in 15 patients (85.7%, 18/21), and the rate of complete stone clearance was 88.2% (18/21). Severe adverse events were not seen in any of the patients, although one patient developed mild acute pancreatitis. CONCLUSIONS: In conclusion, although additional case reports and prospective studies are needed, EHL under DSOC may be an option to treat MPD stones.

Prospective histological evaluation of a 20G core trap with a forward-cutting bevel needle for EUS-FNA of pancreatic lesions.

BACKGROUND: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been established as a method to obtain tissues of various organs. To obtain sufficient tissue has clinical impact to facilitate the diagnosis by clinical pathologists, the assessment and subtyping of various neoplasms, and for further immunohistochemical investigations of tumor type. Recently, a novel 20G core trap with a forward-cutting beveled FNA needle (ProC-F) has become available. The aim of this prospective study was to evaluate the feasibility and diagnostic yield of EUS-FNA for pancreatic lesions using this needle. PATIENTS AND METHOD: In this study, the first puncture was performed using the ProC-F. Only tissue obtained with the first puncture using the ProC-F was used to evaluate diagnostic yield of ProC-F. The second puncture was performed using a 22G standard FNA needle using the same technique as for the first puncture. Second puncture was performed if the endosonographer did not feel that sufficient tissue had not been obtained by first puncture. RESULTS: Fifty-three consecutive patients who underwent EUS-FNA for pancreatic lesions were prospectively enrolled. The technical success rate of EUS-FNA using the ProC-F was 98.1% (52/53). The rate of adequate tissue obtained by ProC-F was 96.2% (50/52). On the other hand, the rate of adequate tissue obtained by the standard needle was 71.1%. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of the ProC-F and the standard needle were 92.5, 100, 100, 76.9, and 94.0%, and 85.2, 100, 100, 55.6, and 87.5%, respectively. Diagnostic yield of ProC-F about sensitivity (P = 0.027), NPV (P = 0.035), and accuracy (P = 0.004) was significantly higher than of standard needle. Adverse events were not seen in any patients. CONCLUSIONS: Although only tissue obtained by the first puncture was evaluated, the rate of adequate tissue and the histologic diagnostic yield for pancreatic lesions were extremely high using the ProC-F.

Prospective clinical study of endoscopic ultrasound-guided biliary drainage using novel balloon catheter (with video).

BACKGROUND AND AIM: On endoscopic ultrasound (EUS)-guided biliary drainage, fistula dilation may be accompanied by leakage of bile juice, potentially along with bacteria or air, so this procedure should be kept as simple and short as possible. To date, various techniques to dilate the fistula have been reported. This prospective, single-center, single-arm study evaluated the technical feasibility and safety of EUS-guided biliary drainage using novel balloon catheters. METHODS: Tip of novel balloon catheters is only 3 Fr and tapered, and the catheters also show favorable push ability. First, biliary tract was punctured using 19-G fine needle aspiration needle. Next, we immediately inserted the novel balloon catheter, and the biliary tract and intestinal wall were dilated. Then, we performed metallic stent placement without any dilation fistula. RESULTS: A total of 20 patients were prospectively enrolled in this study. Technical success rate was 100%. Eleven patients underwent EUS-guided choledochoduodenostomy, and nine patients underwent EUS-guided hepaticogastrostomy. Median procedure time was only 11 min (range, 8-16 min) for EUS-guided choledochoduodenostomy and 14 min (range, 11-18 min) for EUS-guided hepaticogastrostomy. Adverse events were seen in 15% (3/20; self-limited abdominal pain n = 2, peritonitis n = 1). CONCLUSIONS: Although additional cases and a randomized controlled comparison with another dilation technique such as the graded dilation or cystotome dilation technique are needed, our technique may be helpful for EUS-guided biliary drainage.

Evaluation of the safety of endoscopic radiofrequency ablation for malignant biliary stricture using a digital peroral cholangioscope (with videos).

BACKGROUND AND AIM: The clinical impact of catheter-based radiofrequency ablation (RFA) under endoscopic retrograde cholangiopancreatography (ERCP) guidance has recently been reported; however, severe adverse events have also been noted. If tumor is not present in the biliary tract, severe adverse events such as perforation or bleeding as a result of vessel injury around the biliary tract may occur. In addition, the effectiveness of RFA may not be sufficient based solely on radiographic guidance. The aim of the present study was to evaluate the actual feasibility of intraductal RFA by peroral cholangioscope (POCS) evaluation before/after RFA. METHODS: In this retrospective study carried out between July and September 2016, consecutive patients who underwent RFA for malignant biliary stricture and POCS evaluation before/after RFA were enrolled. Primary endpoint of this study was technical feasibility of RFA, which was evaluated by POCS. Secondary endpoints were rates and types of adverse event. RESULTS: A total of 12 consecutive patients were retrospectively enrolled in this study. Stent placement using uncovered metal stents had been previously done in six patients before RFA. Tumor was seen in the biliary tract in all patients. RFA was technically successful in all patients, and clinical success was confirmed in all patients by POCS imaging. Adverse events were seen in only one patient. Median stent patency was 154 days. CONCLUSIONS: RFA for malignant biliary stricture may be safe. To confirm the feasibility and efficacy of RFA, additional cases, prospective studies, and a comparison study between with and without endobiliary RFA are needed.

Prospective evaluation of digital single-operator cholangioscope for diagnostic and therapeutic procedures (with videos).

BACKGROUND AND AIM: Recently, the digital single-operator cholangioscope (SPY-DS) has become available. This system may allow diagnosis by direct visualization and allow performance of various therapeutic procedures. The aim of the present study was to prospectively evaluate the clinical utility of DSOCS for diagnostic and therapeutic procedures for biliary disease. METHODS: Technical success was defined as successful visualization of target lesions in the biliary tract and carrying out forceps biopsy as a diagnostic procedure, and successfully carrying out treatment such as guidewire insertion for the area of interest, electrohydraulic lithotripsy (EHL), or migrated stent removal. Also, the present study aimed at investigating diagnostic yield of the cholangioscopic findings and biopsy specimens. RESULTS: A total of 55 consecutive patients were prospectively enrolled in this study; a diagnostic procedure was done in 33 patients, and a therapeutic procedure was done in 22 patients. Overall accuracy of visual findings was 93%, with a sensitivity of 83%, a specificity of 89%, positive predictive value (PPV) of 83%, and negative predictive value (NPV) of 100%. However, the overall accuracy of forceps biopsy was 89%, with a sensitivity, specificity, and PPV of 100%, and NPV of 90%. Overall technical success rate of therapeutic procedures such as selective guidewire insertion, EHL or migrated stent removal was 91% (20/22). Finally, adverse events were seen in two cases in the diagnostic group, but were not seen in the therapeutic group. CONCLUSION: Although additional cases and a randomized, controlled study with another cholangioscope are needed, diagnostic and therapeutic procedures using SPY-DS appear to be feasible and safe.

Percutaneous transhepatic sclerotherapy for recurrent bleeding ileal varices diagnosed by capsule endoscopy and computed tomography during percutaneous transhepatic venography.

We report a case of acute uncontrolled gastrointestinal bleeding in a patient with liver cirrhosis. A 64-year-old man was admitted to our hospital for further investigation of blood in stools. Preliminary examination by computed tomography (CT) as well as upper and lower endoscopy could not detect the bleeding source. Exploratory laparotomy was considered difficult due to potential easy bleeding and adhesions caused by past abdominal surgery. The hemoglobin level was normalized by blood transfusion. Capsule endoscopy (CE) identified ileal varices. The top of these ileal varices was red, prompting their identification as the source of bleeding. Percutaneous transhepatic venography (PTV) confirmed the presence of many varices in the branch of the superior mesenteric vein, although the bleeding source could not be identified. CT during PTV identified varices protruding into the ileal lumen, which were managed subsequently by percutaneous transhepatic sclerotherapy (PTS). The procedure stopped the bleeding completely. CE proved less invasive and effective in detecting obscure gastrointestinal bleeding. CT during PTV followed by PTS is suitable for diagnosis and treatment of bleeding varices in patients with portal hypertension.

Multicenter clinical experience with recombinant soluble thrombomodulin for disseminated intravascular coagulation associated with severe acute cholecystitis.

BACKGROUND: Severe acute cholecystitis (AC) is defined by the association of organ dysfunction, including hematological dysfunction, with AC. Severe AC is often complicated by disseminated intravascular coagulation (DIC), the diagnostic criteria of which overlap with AC-associated hematological dysfunction. Since the diagnosis of DIC often delays definitive surgical management of severe AC, treatment of DIC in this setting is clinically important. Recombinant human soluble thrombomodulin (rTM) is a new agent that has proven clinically useful for treating DIC. However, the relevance of rTM to sepsis-induced DIC caused by AC has not been clinically evaluated. This retrospective multicenter study aimed to determine the clinical impact of rTM on sepsis-induced DIC caused by AC. METHODS: This retrospective multicenter study initially included 68 consecutive patients and proceeded between July 2014 and December 2017. The inclusion criterion was sepsis-induced DIC caused by severe AC due to benign disease. Sixteen of the 68 patients were excluded in this study due to having advanced malignant tumors. Finally, 42 patients were enrolled in this study. We treated DIC with AC using Recomodulin® Injection (rTM) at doses of 130 or 380 U/kg/day. RESULTS: 17 and 25 patients were treated with and without rTM, respectively. Values on days 3 and 7 did not significantly differ between the groups for PT-INR (P = 0.38 and P = 0.16, respectively) and FDP (P = 0.06 and P = 0.08, respectively), and PLT was significantly increased in the rTM group at day 7 (P = 0.03). Resolution rates of DIC on day 7 were significantly higher in the group treated with, than without rTM (94.1% [16/17] vs. 68.0% [17/25], P = 0.04). Two patients in each group died of sepsis-induced DIC associated with severe AC, and thus mortality rates did not significantly differ. CONCLUSIONS: rTM can may be improve the resolution rate of sepsis-induced DIC due to severe AC. Future studies should include more patients to validate our findings.

A feasibility study of digital single-operator cholangioscopy for diagnostic and therapeutic procedure (with videos).

Recently, the novel SpyGlass DS Direct Visualization system (SPY DS) has become available. This system offers several advantages over the conventional SPYGlass system. This study evaluated the clinical feasibility and efficacy of diagnostic and therapeutic procedures for biliary disorder using SPY DS.In this retrospective study, consecutive patients who had biliary disorder were enrolled between November 2015 and February 2016. All patients could not be diagnosed or treated by standard endoscopic retrograde cholangiopancreatography in our hospital or at another hospital.A total of 28 consecutive patients (21 men and 7 women; median age, 73 years; age range, 55-87 years) were retrospectively enrolled in this study. Among them, diagnostic procedure was performed in 20 patients, and 8 patients underwent therapeutic procedures. The technical success rate for diagnostic procedures was 100% (20/20). Diagnostic accuracy was 100% (19/19). The technical success rate for therapeutic procedures was 88% (7/8). Among these 8 patients, 4 patients with common bile duct stones underwent electrohydraulic lithotripsy. One patient successfully underwent guidewire insertion to remove a migrated plastic stent. The 3 remaining patients underwent SPY DS to insert a guidewire for left bile duct obstruction and for posterior bile duct branch. In the patient who underwent guidewire insertion for left hepatic bile duct obstruction cause by primary sclerosing cholangitis, we could not advance the guidewire into the left hepatic bile duct. No adverse events were seen. Median SPY DS insertion time was 21 min (range, 8-32 min).Single-operator cholangioscopy using SPY DS was feasible and had a marked clinical impact in patients with biliary disease. Additional case reports and prospective studies are needed to examine further applications of this system.

Multicentric solid pseudopapillary neoplasms of the pancreas diagnosed by endoscopic ultrasound-guided fine needle aspiration: a case report.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor. This neoplasm usually arises as a single mass; multicentricity is exceptionally rare. We report the preoperative diagnosis of multicentric SPNs by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 32-year-old woman presented to the hospital with a pancreatic tumor that was detected on abdominal echography. Contrast-enhanced computed tomography (CT) scans revealed a 5-mm low-density mass in the body of the pancreas and a 10-mm mass in the tail of the pancreas. Magnetic resonance imaging (MRI) also revealed two tumors in the body and tail of the pancreas. On endoscopic ultrasonography (EUS), two indistinct and heterogeneous echogenic masses were found, and EUS-FNA was performed for each of these tumors. Cytological analysis revealed that the two masses were highly cellular with papillary groups of small, uniform, oval cells surrounding a fibrovascular core. Immunohistochemistry was positive for α-1 antitrypsin, vimentin, neuron-specific enolase (NSE), CD10, and progesterone receptor. These features confirmed the preoperative diagnosis of multicentric SPNs. The patient underwent laparoscopic distal pancreatectomy with splenectomy. The final pathologic diagnosis was multicentric SPNs. During 2 years of follow-up, she has not developed any recurrence.

[A case of mucosal Schwann cell hamartoma].

A 40-year-old man was referred to our hospital because of a positive fecal occult blood test. Colonoscopy revealed many small whitish nodules in the mucosa of the sigmoid colon. Specimens endoscopically resected from the lesions revealed spindle cell proliferation in the lamina propria. Immunohistochemical study revealed strong and diffuse positivity for S-100 protein. Results of staining for neurofilament protein and epithelial membrane antigen were negative. The neurogenic tumors were diagnosed as mucosal Schwann cell hamartoma. No clinical features of multiple endocrine neoplasia type 2B or neurofibromatosis type 1 were found in the present case.