[A case of duodenal perforation due to ingested fishbone with retroperitoneal abscess formation where surgical drainage was necessary after endoscopic removal].

A female in her 60s was referred to our institution with epigastric pain and abdominal fullness persisting for one week. She was afebrile and mild abdominal tenderness was found on physical examination. Computed tomography (CT) revealed free air, and the dirty fat sign outside the duodenal wall. Her previous CT had not shown causative findings such as duodenal diverticula. A slightly high-attenuated linear structure penetrating the duodenal wall at the second portion was suspected after review of present CT images. Based on the history of her current illness, the possibility of mackerel bone ingestion was considered. Esophagogastroduodenoscopy (EGD) revealed a fishbone sticking out of the duodenal wall, which was extracted with biopsy forceps. Although antibiotic treatment under fasting was continued, the formation of retroperitoneal abscess was detected by CT on the 6th postprocedural day. Given that she also developed a high fever, surgical drainage was performed. The patient was discharged on the 15th postoperative day. Thus, in cases of duodenal perforations, a fishbone should be taken into account as a possible cause. Even if endoscopic removal was initially selected, careful observation is mandatory and an additional treatment should be considered depending on the clinical course.

[A case of circumferential rectal wall thickening caused by prostate cancer invasion concomitant with ischemic colitis].

A man in his 70s presented to Kyojinkai Komatsu Hospital with lower left abdominal pain and hematochezia after repeated use of laxatives. Computed tomography (CT) revealed continuous bowel wall thickening from the descending colon to the rectum. The symptoms and CT findings were consistent with ischemic colitis. The patient's condition improved with conservative treatment. However, the patient was reexamined 3 months later because complaints of constipation and voiding difficulty continued. Colonoscopic findings revealed rectal stenosis and reddish edematous mucosa with nodular alterations. Although CT showed that the abnormality in the descending and sigmoid colon had resolved, the wall thickening and annular stricture of the rectum persisted. The prostate was irregularly enlarged, encircling and compressing the rectum. Rectal biopsy results did not reveal malignancy. However, moderately to poorly differentiated adenocarcinoma was detected by prostate biopsy. Consequently, the patient was diagnosed with prostate cancer with rectal involvement. The rectal wall thickening and the symptoms improved following hormone therapy. Thus, concomitant prostate cancer invasion should be considered when CT reveals continuous colon wall thickening up to the rectum in a patient suspected of ischemic colitis.

Overlapping attentional networks yield divergent behavioral predictions across tasks: Neuromarkers for diffuse and focused attention?

Attention is a critical cognitive function, allowing humans to select, enhance, and sustain focus on information of behavioral relevance. Attention contains dissociable neural and psychological components. Nevertheless, some brain networks support multiple attentional functions. In this study, we used the visual attentional blink (VAB) as a test of the functional generalizability of the brain's attentional networks. In a VAB task, attention devoted to a target often causes a subsequent item to be missed. Although frequently attributed to limitations in attentional capacity or selection, VAB deficits attenuate when participants are distracted or deploy attention diffusely. The VAB is also behaviorally and theoretically dissociable from other attention tasks. Here we used Connectome-based Predictive Models (CPMs), which associate individual differences in task performance with functional connectivity patterns, to test their ability to predict performance for multiple attentional tasks. We constructed visual attentional blink (VAB) CPMs, and then used them and a sustained attention network model (saCPM; Rosenberg et al., 2016a) to predict performance. The latter model had been previously shown to successfully predict performance across tasks involving selective attention, inhibitory control, and even reading recall. Participants (n â€‹= â€‹73; 24 males) underwent fMRI while performing the VAB task and while resting. Outside the scanner, they completed other cognitive tasks over several days. A vabCPM constructed from VAB task data (behavior and fMRI) successfully predicted VAB performance. Strikingly, the network edges that predicted better VAB performance (positive edges) predicted worse performance for selective and sustained attention tasks, and vice versa. Predictions from applying the saCPM to the data mirrored these results, with the network's negative edges predicting better VAB performance. The vabCPM's positive edges partially yet significantly overlapped with the saCPM's negative edges, and vice versa. Many positive edges from the vabCPM involved the default mode network, whereas many negative edges involved the salience/ventral attention network. We conclude that the vabCPM and saCPM networks reflect general attentional functions that influence performance on many tasks. The networks may indicate an individual's propensity to deploy attention in a more diffuse or a more focused manner.

Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding.

BACKGROUND AND AIMS: To prospectively evaluate the role of contrast-enhanced computed tomography (CE-CT) in the detection of colonic diverticular bleeding (CDB). PATIENTS AND METHODS: Consecutive patients who presented with hematochezia and were clinically suspected of CDB were prospectively enrolled. Those who could undergo both CE-CT and total colonoscopy, and who were finally diagnosed as CDB, were included in the analysis. RESULTS: Fifty-two cases were finally included in the analysis. The detection rate of CDB by CT was 15.4 % (8/52). Univariate analysis showed that the interval from the latest episode of hematochezia to the performance of CT and the presence of a past history of CDB were contributing factors for detection. The interval was 1.6 ± 4.6 h (mean ± SD) in patients detected by CT, and 3.4 ± 3.2 h in those without detection. The detection rate of CDB by total colonoscopy was 38.5 % (20/52). The overall detection rate was 46.2 % (24/52), which was superior to what CT or colonoscopy alone achieved. CONCLUSIONS: CE-CT may play a complementary role to colonoscopy in patients with suspected CDB, but is not recommended for all cases due to its low detection rate. Patients who can be examined within 2 h of last hematochezia would be candidates for urgent CT.

Therapeutic endoscopic retrograde cholangiography using a single-balloon enteroscope in patients with Roux-en-Y anastomosis.

BACKGROUND: The aim of the present study was to evaluate the usefulness of a single-balloon enteroscope (SBE) including a newly developed short SBE (SIF-Y0004) for therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y (R-Y) anastomosis. PATIENTS AND METHODS: Therapeutic ERC using a SBE was attempted in 19 cases (41 procedures) with R-Y anastomosis after gastrectomy. A standard SBE (working length of 200 cm, working channel of 2.8 mm) was used in 11 cases (Group L), and a short SBE (working length of 152 cm, working channel of 3.2 mm) was used in eight cases (Group S). RESULTS: Insertion of the scope up to the major papilla was achieved in 79% (15/19) of cases. Average insertion time was 37.0 ± 13.8 min (range, 19-62 min). Bile duct cannulation rate was 79% (11/14) after exclusion of the initial case in which scope exchange was unsuccessful. Average procedure time was78.8 ± 26.9 min (18-119 min). The scheduled therapeutic procedure was completed in 67% (10/15) of the cases (53% [10/19] on an intention-to-treat basis). Cardiorespiratory suppression due to sedative agents resulting in scope withdrawal developed in one procedure (2.4%; 1/41). Although there was no significant difference in therapeutic results between the two groups, the number of procedures was smaller (1.8 ± 1.3 vs 3.6 ± 3.1; P = 0.286) in Group S than in Group L. CONCLUSIONS: Therapeutic ERC using a SBE for patients with R-Y anastomosis is considered to be safe and effective. A short SBE appears to be promising for further improvement in therapeutic results.

Impact of technical modification of endoscopic papillectomy for ampullary neoplasm on the occurrence of complications.

AIM: To evaluate the usefulness of a modified technique of endoscopic papillectomy (EP) for lessening the occurrence of complications. METHODS: Indications for EP were adenoma or well-differentiated adenocarcinoma confined to the papilla of Vater (T1) without tumor spread into the bile/pancreatic duct. Sixteen patients underwent the modified technique, which consists of resection with the Endocut mode, followed by biliary/pancreatic sphincterotomy and stenting (Group A). Twelve patients who had undergone EP, using a cutting current, followed by pancreatic duct stenting were included as control (Group B). The frequency of complications and clinical outcomes were retrospectively compared between the two groups. RESULTS: Sixteen patients had adenoma, and 12 had adenocarcinoma. Early complications occurred in 36% of all patients (hemorrhage, 7; cholangitis, 3; perforation, 2; cholecystitis, 1). The frequency of early complications in Group A was significantly lower than that in Group B (6% vs 75%, odds ratio [OR] 0.022, 95% confidence interval [CI], 0.0020-0.25). Late complications occurred in 18% of the patients (bile duct stone, 3; hemorrhage, 1; pancreatitis, 1). There was no significant difference in the late complication rate between Group A and Group B (19% vs 17%). Local recurrences were found in 14% of the patients, without a significant difference between Group A and Group B (19% vs 8%) during a mean follow-up period. All recurrent tumors were successfully treated with argon plasma coagulation. CONCLUSIONS: The modified technique of EP for ampullary neoplasm contributed to lessening the occurrence of early complications. However, further refinement of this technique is necessary for improving the clinical outcome.

Efficacy of acetic acid-spraying method in diagnosing extension of Barrett's cancer under the squamous epithelium.

AIM: Endoscopic diagnosis of the lateral extension of Barrett's cancer under the squamous epithelium (BCUS) is sometimes difficult because the cancer is unobservable in the esophageal lumen. The aim of the present study was to clarify the endoscopic features of the extension of BCUS and verify the usefulness of the acetic acid-spraying method (AAS) for diagnosis. METHODS: A total of 25 patients with Barrett's cancer who had undergone endoscopic resection were included in this study. Histological examination of patients' resected specimens was performed to identify the presence of BCUS. Then, the endoscopic images of the BCUS cases were reviewed to summarize the findings and to evaluate the feasibility of diagnosing the extent of BCUS with each imaging technique. RESULTS: Of the 25 patients, 10 (40%) had BCUS. With white-light imaging, subtle reddish change was observed in the area of BCUS in 80% of the patients, and a flat elevated lesion was recognized in 30%. With narrow band imaging, slight brownish change was observed in the area of BCUS in 86% of the patients. Slight white changes were visualized in all cases with AAS. The extension of BCUS was correctly diagnosed by white-light imaging, narrow band imaging and AAS in 50%, 43% and 100% of the cases, respectively. Histology verified the opening of cancerous glands, which extended under the squamous epithelium, into the esophagus in the area showing slight white changes by AAS. CONCLUSION: AAS can be useful for diagnosing the extension of BCUS.

Prospective randomized controlled study comparing cell block method and conventional smear method for pancreatic juice cytology.

AIM: To elucidate the diagnostic efficacy of the cell block (CB) method by comparing it with that of conventional smear cytology for pancreatic juice obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial fashion. METHODS: A total of 170 patients with pancreatic lesions suspicious of being malignant who underwent pancreatic juice collection without giving secretin under ERCP were enrolled in this study. After sampling, the pancreatic juice was randomized to the CB method (n = 85) or to smear cytology (n = 85). CB sections were subjected to hematoxylin-eosin, periodic acid Schiff-Alcian blue, and immunohistochemical stains. Both Papanicolaou stain and Giemsa stain were used for smear cytology. RESULTS: The final diagnosis was malignancy in 54 patients: pancreatic cancer, 45; intraductal papillary-mucinous carcinoma, six; and endocrine tumor, three. The number of patients with a cytological borderline malignancy in the CB group (3.5%) was significantly smaller than that in the smear group (27.1%) (P < 0.001). The diagnostic accuracy of the CB method and that of smear cytology were 76.5% (65/85) and 74.1% (63/85), respectively (P = 0.72), and their respective sensitivities were 50% (14/28) and 38.5% (10/26) (P = 0.39). The sensitivity of the CB method (88.9%) was better than that of smear cytology (42.9%) for invasive ductal carcinoma in the pancreas head (P = 0.048). CONCLUSIONS: The CB method using immunostaining for pancreatic juice cytology showed a much lower rate of equivocal borderline malignancy and a tendency for a higher diagnostic yield compared with smear cytology. Its diagnostic sensitivity, however, was not satisfactory except for pancreatic-head cancer.

Brief Report: Emotional Picture and Language Processing in Adults with Autism Spectrum Disorder.

There is currently limited research and a lack of consensus on emotional processing impairments among adults with autism spectrum disorder (ASD). The present pilot study sought to characterize the extent to which adults with ASD are impaired in processing emotions in both words and pictures. Ten adults with ASD rated word and picture stimuli on emotional valence and arousal. Their ratings were compared to normative data for both stimuli sets using item-level correlations. Adults with ASD rank-ordered stimuli similarly to typically developing individuals, demonstrating relatively typical understanding of emotional words and pictures. However, they used a narrower range of the scales which suggests more subtle impairments affecting emotion-processing. Future directions arising from the findings of this pilot study are discussed.

Mediastinal emphysema after esophageal endoscopic submucosal dissection: its prevalence and clinical significance.

AIMS: To assess the prevalence and clinical significance of mediastinal emphysema (ME) after esophageal endoscopic submucosal dissection (ESD). METHODS: A total of 105 patients in whom assessment of ME was prospectively carried out with multi-detector row computed tomography (MDCT) after esophageal ESD were included in this study. ME was graded as follows: Grade-0, no ME; Grade-I, bubbles around the esophagus; Grade-II, ME around the thoracic aorta; Grade-III, ME extending around the heart or beyond the mediastinum into the neck; and Grade-IV, ME with pneumothorax or subcutaneous emphysema. MDCT grading was compared with the finding of conventional chest X-ray images (CXR) and clinical symptoms. RESULTS: CXR revealed the presence of ME in 6.6% of the subjects. On MDCT, ME was recognized in 62.9% (Grade-0, 37.1%; I, 46.7%; II, 10.5%; III, 5.7%; and IV, 0%), most (83.8%) being Grade-I or 0. CXR was able to visualize ME of Grade-II or greater. Exposure of the muscularis propria layer and location of the lesion were significant risk factors for development of ME of Grade-II or greater (P = 0.008 and P = 0.03, respectively). The duration of a fever of 37°C or higher was longer and the serum C-reactive protein level was higher in patients with a higher grade of ME. CONCLUSIONS: MDCT revealed the occurrence of ME in 62.9% of the patients who had undergone esophageal ESD, most of which, however, was clinically silent. Exposure of the muscular layer during ESD and location of the lesion were independent risk factors for the development of ME.

Intraductal ultrasonography in the diagnosis of bile duct stones: when and whom?

BACKGROUND AND AIM: Biliary intraductal ultrasonography (IDUS) is highly sensitive in visualizing bile duct stones (BDS). Indications for IDUS, however, in cases of suspected BDS have not yet been established. The aim of the present study was to elucidate adequate indications for IDUS in cases that undergo endoscopic retrograde cholangiopancreatography (ERCP) due to suspected BDS. METHODS: A total of 213 patients who were suspected of having BDS were included in this retrospective study. The patients were divided into two groups: Group A in which BDS was visualized by ERCP; and Group B in which BDS was demonstrated only by IDUS. Comparison between the groups was carried out. RESULTS: ERCP successfully visualized BDS in 166 patients. Forty-seven patients underwent IDUS, which revealed BDS and biliary sludge in 12 and eight patients, respectively. The diameter of the largest stone was 13 ± 6 mm in Group A and 5 ± 1 mm in Group B (P < 0.001). The sensitivity, specificity, and accuracy of ERCP in the diagnosis of BDS were 93%, 100%, and 94%, respectively. The sensitivity was influenced by the size of BDS: 100% in cases of stones ≥ 8 mm in size, but 74% in those with stones < 8 mm. In cases with stones < 8 mm, the sensitivity was significantly affected by the bile duct diameter (≥ 12 mm vs < 12 mm, P < 0.05). CONCLUSION: When ERCP fails to visualize stones in patients with suspected BDS, IDUS is recommended, especially in those with a bile duct ≥ 12 mm in diameter.

Lateral spread along the main pancreatic duct in branch-duct intraductal papillary-mucinous neoplasms of the pancreas: usefulness of intraductal ultrasonography for its evaluation.

BACKGROUND: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas tend to spread intraepithelially along the pancreatic duct wall. We evaluated histopathological intraductal lateral spread (LS) along the main pancreatic duct (MPD) from branch-duct IPMN and investigated the usefulness of intraductal ultrasonography (IDUS) for its preoperative diagnosis. PATIENTS AND METHODS: Twenty-four patients with branch-duct IPMN who had undergone preoperative IDUS and surgery were reviewed clinicopathologically. The prevalence and histological length of LS along the MPD from branch-duct IPMN, characteristics of the patients with LS, and efficacy of LS assessment by IDUS were examined. RESULTS: LS along the MPD was observed in 54% of the subjects. In the group of patients with LS, its mean length was 25.2±16.8mm (5-50mm) and the diameter of the MPD was 6mm or greater. Of the patients with LS, those in whom the length of LS along the MPD was longer than the diameter of the cystically dilated branch accounted for 30%. The diameter of the MPD in the group with LS was significantly greater than that in the group without LS (P=0.03). The sensitivity, specificity, and overall accuracy of IDUS in the detection of LS were 92%, 91%, and 92%, respectively. CONCLUSION: LS along the MPD was detected in about half of the resected cases of branch-duct IPMN. Preoperative transpapillary IDUS may be beneficial for the determination of the resection line, especially in those branch-duct IPMN patients in whom the MPD is 6 mm or greater in diameter.

Single-session endoscopic bilateral y-configured placement of metal stents for hilar malignant biliary obstruction.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. PATIENTS AND METHODS: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y-configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty-seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y-configured placement were endoscopically deployed in a partial stent-in-stent manner in one session. Technical success, early complications, and stent patency were evaluated. RESULTS: The technical success rate in the YMS group was 100%. Mild post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P=0.65). During a median follow-up period of 7.3months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P=0.028). Mean stent patency in the YMS group was 250days and that in the PS group was 115days (P=0.0061). Risk factors for stent occlusion were bile duct cancer (P=0.035) and the PS group (P=0.07) by multivariate analysis. CONCLUSION: Single-session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.

[A case of mucinous cystadenoma of the pancreas resected after a 10-year follow-up].

A 40-year-old woman was hospitalized because of acute pancreatitis. CT showed a monolocular cyst thought to be a pseudocyst. The patient was followed as an outpatient. The size of the cyst decreased 6 years later. Ultrasonography 10 years later demonstrated an enlarged cyst with a cyst-in-cyst formation. A tendency to increase in size and the irregular wall thickening indicated that the cyst was a malignant mucinous cystic neoplasm (MCN) and distal pancreatectomy was performed. The tumor was diagnosed histologically as a mucinous cystadenoma. A case of MCN resected after long-term follow-up is extremely rare. The present case is thought to be important for elucidation of the natural history of MCNs.

Transgastric transhepatic endosonography-guided biliary drainage: histological assessment of its sinus tract in an autopsy case.

Endosonography-guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.

A case of distal bile duct cancer with extensive intraepithelial spread diagnosed preoperatively by peroral cholangioscopy combined with narrow band imaging.

A 75-year-old woman with jaundice was given a diagnosis of bile duct cancer using several imaging modalities. The proximal and middle bile ducts were evaluated as normal by multidetector-row CT and intraductal ultrasonography. However, peroral cholangioscopy (POCS) with narrow band imaging (NBI) clearly revealed the intraepithelial extent of the bile duct cancer from the distal bile duct to the hilar bile duct, which was confirmed by histological examination of the resected specimen. POCS combined with NBI is expected to be useful for determining the resection margin in bile duct cancer cases.

[A case of giant esophageal leiomyoma successfully resected by endoscopic submucosal dissection followed by retrieval via laparotomy].

A 30-year-old woman with chest discomfort at swallowing and occasional vomiting was referred to our department with a diagnosis of esophageal submucosal tumor. CT visualized a mass 70 mm in diameter in the middle esophagus. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor, and endoscopic resection was considered. As the size of the tumor was so large, retrieval of the resected specimen via the stomach following incision, laparotomy was planned. En bloc resection by endoscopic submucosal dissection with a Hook-knife was performed. Retrieval of the resected specimen was carried out as planned. The specimen, which was 53×48×43mm in size with a distinct margin, was diagnosed as leiomyoma derived from the muscularis mucosae histologically. Her postprocedural course was uneventful. Endoscopic resection can be chosen when an esophageal submucosal tumor is pedunculated with abundant mobility, making it possible to avoid invasive surgery.

Impact of a transparent hood on the performance of total colonoscopy: a randomized controlled trial.

BACKGROUND: Clinical demand for total colonoscopy (TCS) is increasing. Improvement of the cecal intubation rate and shortening of the examination time would expand the capacity for TCS. OBJECTIVE: To assess the efficacy of a transparent hood attached to the tip of a colonoscope for cecal intubation in TCS. DESIGN: Prospective, randomized, controlled study. SETTING: Single tertiary-referral center. INTERVENTIONS: TCS. MAIN OUTCOME MEASUREMENTS: Cecal intubation time and rate, complications, patient discomfort, and detection rate of colonic polyps. METHODS: Patients who were to undergo screening and/or surveillance TCS for colorectal cancer were invited to participate in the study. Cecal intubation time and rate, complications, patient discomfort, and detection rate of colonic polyps were evaluated. RESULTS: A total of 592 patients enrolled in this study were randomly allocated to the hood group and no-hood group. The mean (SD) cecal intubation time in the hood group and the no-hood group was 10.2 +/- 12.5 minutes and 13.4 +/- 15.8 minutes, respectively (P = .0241). The effect of its use was more prominent in the expert endoscopists group compared with those with moderate experience. The cecal intubation rate and the detection rate of small polyps in the 2 groups were similar. The grade of patient discomfort was significantly lower in the hood group. No complications were encountered with the use of the hood. CONCLUSIONS: Use of a transparent hood on the tip of a colonoscope shortened the time required for cecal intubation and decreased patient discomfort; such use was more effective among experts in shortening the examination time.

Long-tube insertion with the ropeway method facilitated by a guidewire placed by transnasal ultrathin endoscopy for bowel obstruction: a prospective, randomized, controlled trial.

BACKGROUND: It is often difficult to insert a long intestinal tube in the small bowel of patients with bowel obstruction, and it often results in long procedure time and severe patient distress. OBJECTIVE: To assess the usefulness of the ropeway method by using a guidewire placed with the assistance of transnasal ultrathin endoscopy in long-tube insertion for patients with bowel obstruction. DESIGN: Prospective, randomized, controlled, single-center study. PATIENTS AND INTERVENTIONS: Thirty-four consecutive patients with bowel obstruction requiring decompression participated in the study and were randomized to the insertion of a long tube with the ropeway method (ILTR) group (ie, insertion along an endoscopically placed guidewire that was passed through only the distal 4 cm of the tube) or insertion by a conventional method group (C group). MAIN OUTCOME MEASUREMENTS: The time required for the procedure (main), success rate, x-ray exposure time, and intensity of patient distress measured with a visual analog scale of 1 to 5 (better to worse). RESULTS: The mean (+/- standard deviation) duration of the procedure in the successful cases in the ILTR group and the C group was 16.1 +/- 5.6 minutes and 26.4 +/- 13.8 minutes, respectively (P = .010). The success rate was 100% in the ILTR group and 88% in the C group (P = .48). The mean (+/- standard deviation) x-ray exposure time and intensity of patient distress were, respectively, 16.4 +/- 8.7 minutes and 33.2 +/- 12.3 minutes (P < .001) and 2.6 +/- 0.7 and 3.7 +/- 1.2 (P = .016). LIMITATIONS: Single-center study and small sample size to evaluate overall safety. CONCLUSIONS: Long-tube insertion for bowel obstruction with the ropeway method facilitated by transnasal ultrathin endoscopy was superior to conventional fluoroscopic placement with regard to overall procedure success, time required, and patient comfort.

Therapeutic endoscopic retrograde cholangiopancreatography using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy.

BACKGROUND: Prior Billroth II gastrectomy is an important factor presenting difficulties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. METHODS: Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls. RESULTS: The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no significant differences compared with the control group. CONCLUSIONS: Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.