Clinical Features Focusing on Extraintestinal Manifestations in Japanese Patients with Inflammatory Bowel Diseases: Far East 1000.

BACKGROUND: Patients with inflammatory bowel diseases (IBD) can develop extraintestinal manifestations (EIMs) during the disease course, which sometimes impact their quality of life. OBJECTIVES: This study aimed to clarify the prevalence and types of EIMs using a hospital-based IBD cohort in Japan. METHODS: A patient cohort with IBD was established in 2019, as participated by 15 hospitals in Chiba Prefecture of Japan. Using this cohort, the prevalence and types of EIMs, which are defined based on previous reports and the Japanese guidelines, were investigated. RESULTS: This cohort enrolled 728 patients, including 542 ulcerative colitis (UC) and 186 Crohn's disease (CD). Of these patients with IBD, 10.0% were identified with one or more EIMs (57 (10.5%) with UC and 16 (8.6%) with CD). Arthropathy and arthritis were the most common EIM in 23 (4.2%) patients with UC, followed by primary sclerosing cholangitis (PSC) (2.6%). Arthropathy and arthritis were also the most common in patients with CD, but no cases of PSC were observed. EIMs were more frequently observed in patients with IBD treated by specialists than in those treated by non-specialists (12.7% vs. 5.5%, p = 0.011). The incidence of EIMs in patients with IBD was not significantly different over time. CONCLUSIONS: The prevalence and types of EIMs in our hospital-based cohort in Japan did not significantly differ from those reported in previous or Western studies. However, the incidence might be underestimated due to the limited ability of non-IBD specialists to discover and describe EIMs in patients with IBD.

Diagnostic value of peroral cholangioscopy in addition to computed tomography for indeterminate biliary strictures.

BACKGROUND: Peroral cholangioscopy (POCS) has been used to overcome the difficulty in diagnosing indeterminate biliary stricture or tumor spread. However, the value of adding POCS to computed tomography (CT) remains unclear. Our aim was to evaluate the diagnostic value of adding POCS to CT for indeterminate biliary stricture and tumor spread by interpretation of images focusing on the high diagnostic accuracy of visual findings in POCS. METHODS: We retrospectively identified 52 patients with biliary stricture who underwent endoscopic retrograde cholangiography (ERC) at our institution between January 2013 and December 2018. Two teams, each composed of an expert endoscopist and surgeon, performed the interpretation independently, referring to the CT findings of the radiologist. The CT + ERC + POCS images (POCS group) were evaluated 4 weeks after the evaluation of CT + ERC images (CT group). A 5-point scale (1: definitely benign to 5: definitely malignant) was used to determine the confident diagnosis rate, which was defined as an evaluation value of 1 or 5. Tumor spread was also evaluated. RESULTS: In the evaluation of 45 malignant diagnoses, the score was significantly closer to 5 in the POCS group than in the CT group in both teams (P < 0.001). The confident diagnosis rate was significantly higher for the POCS group (92% and 73%) than for the CT group (25% and 12%) in teams 1 and 2, respectively (P < 0.001). We found no significant difference in diagnostic accuracy for tumor spread between the groups. CONCLUSION: Visual POCS findings confirmed the diagnosis of biliary strictures. POCS was useful in cases of indefinite diagnosis of biliary strictures by CT.

Liver cirrhosis is a risk factor for poor prognosis of acute cholangitis caused by choledocholithiasis.

INTRODUCTION AND OBJECTIVES: Acute cholangitis, which is characterized by biliary infection and acute liver injury, may impact cirrhosis prognosis. However, the prognosis itself remains unclear. MATERIALS AND METHODS: This multicenter retrospective cohort study compared the mortality and liver function change between patients with and without cirrhosis who underwent endoscopic treatment for acute cholangitis caused by choledocholithiasis between January 2004 and December 2019. RESULTS: We analyzed 699 patients, 44 of whom had cirrhosis. The cirrhotic group had a significantly higher 30-day mortality rate than the noncirrhotic group (14% vs. 1%; P < 0.001). The cirrhotic group also had significantly lower total bilirubin and albumin recovery. However, all patients with cirrhosis who survived achieved total-bilirubin recovery, and 91% achieved albumin recovery within 90 days. In multivariable Cox regression analysis, the independent risk factors for total-bilirubin recovery included cirrhosis (hazard ratio, 0.37; 95%CI, 0.24‒0.58; P < 0.001) and high total-bilirubin level (0.46; 95%CI, 0.34‒0.60; P < 0.001), whereas those for albumin recovery were cirrhosis (0.51; 95%CI, 0.33‒0.79; P = 0.002), high age (0.62; 95%CI, 0.47‒0.82; P < 0.001), organ dysfunction (0.62; 95%CI, 0.39‒0.96; P = 0.03), low albumin level (0.57; 95%CI, 0.36‒0.91; P = 0.02), and high C-reactive protein level (0.73; 95%CI, 0.56‒0.95; P = 0.02). CONCLUSIONS: Patients with cirrhosis complicated with acute cholangitis had poor prognosis. Recovery of liver function after endoscopic treatment was slow; nevertheless, most patients who survived could recover within 90 days.

Uncovered versus covered metallic stents for the management of unresectable malignant distal biliary obstruction: a randomized multicenter trial.

OBJECTIVE: The treatment result of the uncovered metallic stent (uncovered MS) and covered metallic stent (covered MS) for unresectable malignant distal biliary obstruction is controversial. This time, we conducted this study to compare the efficacies and complication rates of uncovered MS and covered MS in unresectable malignant distal biliary obstructions at a prospective randomized multicenter trial. MATERIALS AND METHODS: From April 2014 to September 2018, patients with unresectable malignant distal biliary obstruction were randomly assigned to 2 groups: the uncovered MS group and the covered MS group. RESULTS: 92 treatment results patients were discussed. 48 patients were assigned to the uncovered MS group and 44 cases were assigned to the covered MS group. Both groups showed a drainage effect. No significant difference was found in the drainage effect between the 2 groups. The number of stent occlusion was significantly greater (p = .0467) in uncovered MS (43.8%) comparing with those in covered MS (22.7%). As the cause of stent occlusion, tumor ingrowth was significantly greater (p < .001) in the uncovered MS group (35.4%) than in the covered MS group (2.3%). The median stent patency period was significantly longer (p = .0112) in the covered MS group (455 days) than that of the uncovered MS group (301 days). A significant difference in the median survival period was not found between the 2 groups. CONCLUSIONS: Covered MS showed the possibility of extending the stent patency period by suppressing tumor ingrowth more than uncovered MS does. The UMIN Clinical Trial Registry number is UMIN000015093.

Immunohistochemical analysis of IMP3 and p53 expression in endoscopic ultrasound-guided fine needle aspiration and resected specimens of pancreatic diseases.

BACKGROUND: Insulin-like growth factor II messenger ribonucleic acid-binding protein 3 (IMP3) is a valuable marker that distinguishes malignant from benign lesions and predicts prognosis. METHODS: First, we evaluated IMP3 expression in 77 resected specimens of pancreatic ductal adenocarcinoma (PDAC), intraductal papillary mucinous neoplasm (IPMN), and chronic pancreatitis (CP). Eleven PDAC patients preoperatively underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Survival analysis of IMP3 and clinicopathological factors was performed. IMP3 and p53 expression was evaluated in another 127 EUS-FNA samples of solid pancreatic masses to compare the diagnostic value of routine and immunohistochemical staining. RESULTS: IMP3 expression was detected in 72.3%, 50%, 20%, and 0% of PDAC, malignant IPMN, benign IPMN, and CP, respectively. Evaluation of IMP3 expression in EUS-FNA specimens coincided with that in resected specimens in 10 of 11. IMP3 expression correlated with tumor differentiation in PDAC samples (p = .006) and with poor prognosis through univariate analysis (p = .045). Tumor differentiation and lymph node metastasis were significantly associated with poor prognosis through multivariate analysis. In EUS-FNA specimens, the sensitivity, specificity, and accuracy of cytohistological analysis were 80.8%, 100%, and 85.0%, respectively. IMP3 and p53 expression were detected in 80.8% and 44.9% of malignant and 0% and 5% of benign lesions. Combined with IMP3 immunostaining, the sensitivity, specificity and accuracy of cytohistological analysis significantly increased to 87.9%, 100%, and 90.8% (p = .016), respectively. Meanwhile, p53 staining had no impact on the results. CONCLUSIONS: IMP3 immunohistochemical staining can improve the diagnostic accuracy of EUS-FNA for malignant pancreatic tumors.

Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: prospective randomized study.

BACKGROUND AND STUDY AIMS: Difficult biliary cannulation and unintentional pancreatic duct cannulation are thought to be important contributors to pancreatitis occurring after endoscopic retrograde cholangiopancreatography. Our aim was to compare and evaluate the rates of success and complications of transpancreatic precut papillotomy (TPPP) and the double-guidewire technique (DGT), both with prophylactic pancreatic stenting. PATIENTS AND METHODS: From April 2011 to March 2014, patients with difficult biliary cannulation, in whom we planned to first position a guidewire in the pancreatic duct, were enrolled, and 68 patients were prospectively randomly allocated to two groups (TPPP 34, DGT 34). We evaluated the rates of success and complications for each group. RESULTS: TPPP had a significantly higher success rate (94.1 %) than DGT (58.8 %). The rate of post-ERCP pancreatitis was 2.9 % in both groups. There was no significant difference between the two groups in the overall rate of complications related to cannulation. CONCLUSION : If biliary cannulation cannot be achieved, TPPP should be selected first after unintentional pancreatic duct cannulation.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy.

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Prognostic relevance of apparent diffusion coefficient obtained by diffusion-weighted MRI in pancreatic cancer.

BACKGROUND: Diffusion-weighted magnetic resonance imaging (DW-MRI) is utilized as a method of oncologic imaging for predicting treatment outcomes. This study explored the role of DW-MRI in the treatment of patients with resected pancreatic cancer by comparing apparent diffusion coefficient (ADC) values with clinicopathological findings and survival rates. MATERIALS AND METHODS: Records of 54 patients in whom DW-MRI at 1.5T was performed (b values: 0 and 1000 mm(2) /s) before macroscopically curative resection were analyzed. ADC values were then calculated and compared with clinicopathological factors including age, gender, serum carcinoembryonic antigen levels, serum carbohydrate antigen 19-9 levels, lymph node metastasis, primary tumoral location, size, differentiation, resectability, and pT stage. A survival analysis of clinicopathological factors and ADC values was performed using the Kaplan-Meier method, and the results were evaluated with the log-rank test. Prognostic significance was assessed using the Cox proportional hazard model. RESULTS: Significant associations were found between tumor differentiation and ADC values (P = 0.001). In a univariate analysis of overall survival, tumor differentiation (P = 0.037) and ADC values (P = 0.002) were identified as significant prognostic factors. However, age, gender, carcinoembryonic antigen levels, carbohydrate antigen 19-9 levels, lymph node metastasis, primary tumoral location, size, resectability, and pT stage were not associated with overall survival. In a multivariate analysis of overall survival, only ADC values were identified as significant prognostic factors (hazard ratio 2.293, 95% confidence interval 1.147-4.585, P = 0.019). CONCLUSION: ADC values were found to be associated with prognosis in patients with resected pancreatic cancer.

Preoperative assessment of longitudinal extension of cholangiocarcinoma with peroral video-cholangioscopy: a prospective study.

BACKGROUND AND AIM: Preoperative assessment of longitudinal extension of cholangiocarcinoma (CCA) is essential for making decisions concerning surgical resection and selecting operative procedures. We evaluated the accuracy of peroral video-cholangioscopy (PVCS) in diagnosing longitudinal extension of CCA. METHODS: Patients with CCA who underwent preoperative PVCS were considered for this study. We evaluated the accuracy of PVCS in diagnosing longitudinal extension of perihilar cholangiocarcinoma (PCCA) and distal extrahepatic cholangiocarcinoma (DCCA) to the secondary biliary radicles and confluence of the hepatic ducts, respectively, on the hepatic side and to the intrapancreatic common bile duct on the papillary side. Diagnostic accuracy was determined by comparing the results with those of histopathological analyses of surgical specimens. RESULTS: Forty-three consecutive patients were enrolled. The cholangioscope could not be advanced into the hepatic side in eight of the 25 patients with PCCA and in five of the 18 patients with DCCA. The accuracy of PVCS in diagnosing longitudinal extension of CCA on the hepatic and papillary sides was 82.4% and 92.0%, respectively, in patients with PCCA and 92.3% and 100%, respectively, in patients with DCCA. PVCS accurately detected longitudinal extension of CCA to the hepatic and papillary sides that was not detected previously by endoscopic retrograde cholangiography in 20.0% and 11.6% patients, respectively. CONCLUSIONS: PVCS proved useful for the preoperative assessment of longitudinal extension of CCA. Therefore, it can aid surgeons in deciding surgical resectability and selecting operative procedures. This, in turn, may impact overall patient prognosis.

Old age is associated with increased severity of complications in endoscopic biliary stone removal.

BACKGROUND AND AIM: Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. METHODS: This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. RESULTS: Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). CONCLUSIONS: Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Factors affecting the accuracy of endoscopic transpapillary sampling methods for bile duct cancer.

BACKGROUND AND AIM: Various methods for endoscopic transpapillary sampling have been developed. However, the factors affecting the accuracy of these methods for bile duct cancer are unknown. The aim of the present study was to determine the factors affecting the accuracy of endoscopic transpapillary sampling methods. METHODS: We reviewed the results from 101 patients with bile duct cancer who underwent transpapillary sampling by aspiration bile cytology, brushing cytology, and fluoroscopic forceps biopsy. The final diagnosis of bile duct cancer was made on the basis of pathological evaluation of specimens obtained at surgery and the clinical course over at least 1 year in patients not operated on. We carried out subgroup analyses for the factors affecting the accuracy of each transpapillary sampling method. RESULTS: Aspiration bile cytology was carried out 238 times in 77 patients, brushing cytology was carried out 67 times in 60patients, and fluoroscopic forceps biopsy was carried out 64 times in 53 patients. Accuracies of aspiration bile cytology were significantly higher for longer (≥15 mm) biliary cancerous lesions than for shorter (<15 mm) lesions (30% vs 18%, respectively, P = 0.049). Accuracies of brushing cytology and fluoroscopic forceps biopsy were significantly higher for non-flat than for flat-type biliary cancerous lesions (brushing: 58% vs 38%, respectively, P = 0.032; forceps biopsy: 60% vs 33%, respectively, P = 0.043). CONCLUSION: Endoscopic transpapillary sampling methods are more accurate for longer or elevated (non-flat) biliary cancerous lesions than for shorter or flat lesions.

Usefulness of Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Procedures for Gallstone Pancreatitis.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are said to be useful procedures for gallstone pancreatitis. However, there have been few reports on a large number of patients to whom they were used. The clinical usefulness of ERCP and EST is herein examined retrospectively. METHODS: ERCP and EST were performed to evaluate their clinical usefulness and safety in 108 patients who had gallbladder stones from December 1985 to October 2017 and were diagnosed as having gallstone pancreatitis. Of 108 patients, 83 were mild, and 25 were severe. Following the procedures, clinical courses were observed for three years in 108 patients who underwent the treatments. RESULTS: Cholangiogram was successfully conducted in 108 patients. Bile duct stones were noted in 90 patients, and the stones were removed after EST. Of 18 patients who did not show bile duct stone in cholangiogram, 13 patients underwent EST, while five patients taking anticoagulants completed procedures only with cholangiogram. Accidental symptom was hemorrhage in three patients (2.7%; 3/108), but it was mild and conservatively resolving. During the three-year observation period, acute cholangitis was noted in three patients (2.7%; 3/108), but no relapsing pancreatitis was noted. CONCLUSIONS: It was suggested that ERCP and EST could be useful therapies for gallstone pancreatitis.

Usefulness of Elobixibat in Patients With Chronic Constipation After Cholecystectomy.

BACKGROUND: There have been reports that elobixibat improves bowel movements in patients with chronic constipation. However, no studies have been conducted to date to examine bowel movements after the administration of elobixibat in patients with chronic constipation in terms of the presence or absence of the gallbladder. In this study, we examined the frequency of bowel movements and stool forms in patients with gallbladders and post-cholecystectomy patients before and after the administration of elobixibat for chronic constipation. METHODS: Elobixibat 10 mg was administered to treat chronic constipation in 40 patients with gallbladders and 18 patients who underwent cholecystectomy. The frequencies of bowel movements one week before and after elobixibat administration were compared between the two groups, using the Bristol Stool Form Scale (BSFS). RESULTS: No significant difference in patient background with or without cholecystectomy was noted between the groups. In patients with gallbladders, the pre-dosing mean frequency of bowel movements was 2.389 ± 0.502 with BSFS of 2.179 ± 0.721 and the post-dosing mean frequency of bowel movements was 4.308 ± 1.151 with BSFS of 3.718 ± 1.521, indicating significant improvement in bowel movements (p < 0.001). In post-cholecystectomy patients, the pre-dosing mean frequency of bowel movements was 2.389 ± 0.502 with BSFS of 2.222 ± 0.647 and the post-dosing mean frequency of bowel movements was 4.222 ± 1.734 with BSFS of 3.333±1.237, indicating significant improvement in bowel movements (p < 0.001). No significant difference in bowel movements was noted between patients with or without the gallbladder. CONCLUSIONS: Elobixibat is useful in improving the bowel movements of patients with chronic constipation. No significant difference was noted in the improvement of bowel movements due to cholecystectomy. It was suggested that even post-cholecystectomy patients could obtain therapeutic effects similar to patients with gallbladders.

Natural history of asymptomatic gallbladder stones in clinic without beds: A long-term prognosis over 10 years.

BACKGROUND: Several studies have explored the long-term prognosis of patients with asymptomatic gallbladder stones. These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases. AIM: To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities. METHODS: We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022. When symptoms developed, patients were transferred to hospitals where appropriate treatment was possible. We investigated the asymptomatic and survival periods during the follow-up. RESULTS: Among the 237 patients, 214 (90.3%) remained asymptomatic, with a mean asymptomatic period of 3898.9279 ± 46.871 d (50-4111 d, 10.7 years on average). Biliary complications developed in 23 patients (9.7%), with a mean survival period of 4010.0285 ± 31.2788 d (53-4112 d, 10.9 years on average). No patient died of biliary complications. CONCLUSION: The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable. When the condition became symptomatic, the patients were transferred to hospitals with beds that could address it; thus, no deaths related to biliary complications were reported. This finding suggests that follow-up care in clinics without beds is possible.

Assessing outcomes and complications of secondary hepatolithiasis after choledochoenterostomy: A nationwide survey in Japan.

BACKGROUND: This study aimed to evaluate the outcomes and complications of secondary hepatolithiasis following choledochoenterostomy to guide suitable management. METHODS: The study analyzed 127 patients from a 2017 national survey conducted by the Ministry of Health, Labor, and Welfare. The 2023 cohort study assessed residual stones, recurrences, cholangitis, cholangiocarcinoma, and prognosis. RESULTS: The median follow-up duration was 48 months. Balloon endoscopy-assisted endoscopic retrograde cholangiography (BE-ERC) was the most common treatment, achieving complete stone clearance in 84.4% of patients. Anatomical hepatectomy was the most common surgery. Predictors of residual stones were stone number ≥10 (odds ratio [OR], 7.480; p = .028) and stone diameter ≥10 mm (OR, 5.280; p = .020). Predictors of stone recurrence during follow-up were biliary strictures (hazard ratio [HR], 3.580; p = .005) and cholangitis (HR, 2.700; p = .037). Predictors of cholangitis during follow-up were biliary stricture (HR, 5.016; p = .006) and dilatation (HR, 3.560; p = .029). Any treatment for hepatolithiasis reduced cholangitis occurrence (HR, 0.168; p = .042). Balloon dilation combined with stenting for ≥3 months improved biliary strictures in 57.1% of patients. CONCLUSION: This study recommends BE-ERC as the first-choice treatment for secondary hepatolithiasis. Stone removal and relief of biliary strictures and dilatation are crucial to prevent stone recurrence and cholangitis after treatment.

A multi-institutional study designed by members of Tokyo Guidelines (TG) Core Meeting to elucidate the clinical characteristics and pathogenesis of acute cholangitis after bilioenteric anastomosis and biliary stent insertion with a focus on biliary obstruction: Role of transient hepatic attenuation difference (THAD) and pneumobilia in improving TG diagnostic performance.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

Use of F-18 fluorodeoxyglucose positron emission tomography with dual-phase imaging to identify intraductal papillary mucinous neoplasm.

BACKGROUND & AIMS: We investigated the usefulness of dual-phase F-18 fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) to differentiate benign from malignant intraductal papillary mucinous neoplasms (IPMNs) and to evaluate branch-duct IPMNs. METHODS: We used FDG-PET/CT to evaluate IPMNs in 48 consecutive patients who underwent surgical resection from May 2004 to March 2012. IPMNs were classified as benign (n = 16) or malignant (n = 32) on the basis of histology analysis. The ability of FDG-PET/CT to identify branch-duct IPMNs was compared with that of the International Consensus Guidelines. RESULTS: The maximum standardized uptake value (SUVmax) was higher for early-phase malignant IPMNs than that for benign IPMNs (3.5 ± 2.2 vs 1.5 ± 0.4, P < .001). When the SUVmax cutoff value was set at 2.0, early-phase malignant IPMNs were identified with 88% sensitivity, specificity, and accuracy. The retention index values for malignant and benign IPMNs were 19.6 ± 17.8 and -2.6 ± 12.9, respectively. When the SUVmax cutoff was set to 2.0 and the retention index value to -10.0, early-phase malignant IPMNs were identified with 88% sensitivity, 94% specificity, and 90% accuracy. In identification of branch-duct IPMNs, when the SUVmax cutoff was set to 2.0, the sensitivity, specificity, and accuracy values were 79%, 92%, and 84%, respectively. By using a maximum main pancreatic duct diameter ≥7 mm, the Guidelines identified branch-duct IPMNs with greater specificity than FDG-PET/CT. The Guidelines criteria of maximum cyst size ≥30 mm and the presence of intramural nodules identified branch-duct IPMNs with almost equal sensitivity to FDG-PET/CT. CONCLUSIONS: Dual-phase FDG-PET/CT is useful for preoperative identification of malignant IPMN and for evaluating branch-duct IPMN.

Comparison of the diagnostic accuracy of peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings for indeterminate biliary lesions: a prospective study.

BACKGROUND: The diagnostic accuracy of peroral video-cholangioscopy for indeterminate biliary lesions has not been determined in a prospective study. OBJECTIVE: To evaluate and compare the diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions with that of the cholangioscopy-guided forceps biopsy findings. DESIGN: Prospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: Patients who showed indeterminate biliary lesions on endoscopic retrograde cholangiography underwent peroral video-cholangioscopy for diagnosis. INTERVENTION: Each patient underwent peroral video-cholangioscopy with cholangioscopy-guided forceps biopsy. MAIN OUTCOME MEASUREMENTS: The accuracy of diagnosis by the peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings compared with that of the final diagnosis by other methods (malignant or benign). RESULTS: Thirty-three patients were enrolled, and the final diagnoses revealed that the lesions were malignant in 21 patients. All procedures were technically successful, and fine views were obtained in all patients. Procedure-related complications occurred in 2 patients (6.1%), but these complications were mild. The sensitivity, specificity, and accuracy were 100%, 91.7%, and 97.0%, respectively, for the peroral video-cholangioscopic visual findings and 38.1%, 100%, and 60.6%, respectively, for the cholangioscopy-guided forceps biopsy findings, and a significant difference was observed in the accuracy (P = .0018). LIMITATIONS: This was not a blinded study. No comparison was made with other diagnostic modalities involving tissue sampling. CONCLUSION: The diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions was excellent and significantly higher than that of the cholangioscopy-guided forceps biopsy findings. The accuracy of the cholangioscopy-guided forceps biopsy was insufficient, but the technique had an excellent specificity.