Akio Katanuma

Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial

BACKGROUND AND STUDY AIMS No prospective comparison of endoscopic ultrasonography-guided direct celiac ganglia neurolysis (EUS - CGN) vs. EUS-guided celiac plexus neurolysis (EUS - CPN) has been reported. The aim of the current study was to compare the effectiveness of EUS - CGN and EUS - CPN in providing pain relief from upper abdominal cancer pain in a multicenter randomized controlled trial. PATIENTS AND METHODS Patients with upper abdominal cancer pain were randomly assigned to treatment using either EUS - CGN or EUS - CPN. Evaluation was performed at Day 7 postoperatively using a pain scale of 0 to 10. Patients for whom pain decreased to ≤ 3 were considered to have a positive response, and those experiencing a decrease in pain to ≤ 1 were considered to be completely responsive. Comparison between the two groups was performed using intention-to-treat analysis. The primary endpoint was the difference in treatment response rates between EUS - CGN and EUS - CPN at postoperative Day 7. Secondary endpoints included differences in complete response rates, pain scores, duration of pain relief, and incidence of adverse effects. RESULTS A total of 34 patients were assigned to each group. Visualization of ganglia was possible in 30 cases (88 %) in the EUS - CGN group. The positive response rate was significantly higher in the EUS - CGN group (73.5 %) than in the EUS - CPN group (45.5 %; P = 0.026). The complete response rate was also significantly higher in the EUS - CGN group (50.0 %) than in the EUS - CPN group (18.2 %; P = 0.010). There was no difference in adverse events or duration of pain relief between the two groups. CONCLUSIONS EUS - CGN is significantly superior to conventional EUS - CPN in cancer pain relief. CLINICAL TRIAL REGISTRATION http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000002536).

Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): Covered Wallstent versus DoubleLayer stent.

Background:  No study has compared covered metallic stents with Tannenbaum stents. We evaluated the efficacy of the DoubleLayer stent (DLS) and Covered Wallstent (CWS) in patients with pancreatic head cancer (PHC).

Mucin-Secreting Bile Duct Adenoma – Clinicopathological Resemblance to Intraductal Papillary Mucinous Tumor of the Pancreas

We describe a case of mucin-secreting biliary adenoma associated with obstructive jaundice due to mucin production. Duodenal endoscopy revealed mucin secretion through an enlarged papilla of Vater. On the cholangiogram, large filling defects caused by mucin were observed in the dilated bile duct. Granular and/or papillary mucosa was noted from the hilar to the common bile duct by using percutaneous transhepatic cholangioscopy. Biopsy specimens taken from the papillary mucosa revealed slightly papillary projection without any evidence of malignancy. This lesion was diagnosed as mucin-secreting superficial adenoma and pancreatoduodenectomy was performed according to the malignant behavior. Using a histologic examination of the specimen, pure adenoma was documented. Since the surgical margin was positive, radiation was added for the residual adenoma in the intrahepatic bile ducts. The patient has been well without any evidence of recurrence for 21 months since her operation. It is only recently that the term ‘intraductal papillary mucinous tumor (IPMT)’, which is accepted as a distinct disease entity of pancreas, has begun to be used for mucin-secreting bile duct tumor. This case also seemed to clinicopathologically resemble an IPMT of the pancreas.

Development of transient thyroid disease and reaction during treatment of chronic hepatitis C with interferon

Six of 50 (12%) patients with chronic hepatitis C who were treated with interferon developed thyroid disease or an autoimmune thyroid reaction while undergoing treatment. One patient developed silent thyroiditis, with an increase in serum tri-iodothyronine (T3), thyroxine (T4), free T3, free T4, and markedly suppressed thyroid-stimulating hormone (TSH) levels, accompanied by the appearance of both antithyroglobulin (TgAb) and antimicrosomal antibodies (McAb). One patient developed hypothyroidism in association with moderately elevated TSH levels and high titers of McAb. TSH, TgAb, and McAb levels returned to the initial values at least 4 months after the end of interferon treatment (9 months of follow up). Four patients whose TgAb and/or McAb levels were elevated during treatment with interferon had been diagnosed as having subclinical autoimmune thyroiditis; however, their thyroid function remained in the normal range. These results suggested that treatment with interferon can cause a transient autoimmune thyroid reaction and disease as a side effect.

Indication of Endoscopic Papillectomy for Tumors of the Papilla of Vater and Its Problems

Discussions have just started in Japan as to the indication, technique and complication of endoscopic papillectomy for tumors of the papilla of Vater.

Large balloon dilation for the treatment of recurrent bile duct stones in patients with previous endoscopic sphincterotomy: preliminary results

Abstract Objective. Endoscopic sphincterotomy (ES) is an established method to treat common bile duct (CBD) stones. Inevitable sequence after ES is a substantial risk of recurrent choledocholithiasis and occasional difficulty in removal of large or multiple CBD stones after ES even when mechanical lithotripsy (ML) is employed. In turn, a new endoscopic technique, large balloon dilation (LBD) after ES, has been introduced. The objective was to analyze the efficacy and safety of LBD in patients with recurrent bile duct stones who have previously undergone ES. Patients and methods. From December 2007 to November 2009, 24 patients with recurrent choledocholithiasis and a history of ES were treated with LBD without additional ES. The size of the balloon for LBD was 15–20 mm and the duration of balloon dilation was 30 s. Results. Successful stone removal and complications such as perforation, pancreatitis, and bleeding were evaluated as procedure-related outcomes. Postoperative CBD stone recurrence was evaluated as the short term outcome. Complete duct clearance rate without using ML was 96% (23/24 patients) and all stone removal was achieved in one session. Failure to remove stones occurred in one (4.2%) patient. There were no procedure-related complications although one case of aspiration pneumonia occurred after the endoscopy. Recurrent choledocholithiasis after LBD was observed in 12.5% (3/24) of the cases overall. Conclusions. LBD is an effective and safe method in patients with recurrent choledocholithiasis not only to treat large stones but also to prevent further recurrence.

Clinical Features and Natural History of Serous Cystic Neoplasm of the Pancreas

Aims: To clarify the clinical features and the natural history of serous cystic neoplasm (SCN) of the pancreas. Methods: We retrospectively analyzed data from 30 patients affected by SCN. SCNs were classified as (1) microcystic type, (2) micro- and macrocystic type, and (3) macrocystic type according to the modified WHO classification. Eighteen patients who underwent serial radiographic imaging were identified, and tumor growth rate in these patients was evaluated. Results: The median age was 62 years, and the female:male ratio was 2:1. Twenty-five patients (83%) were asymptomatic and 5 (17%) were symptomatic. The median tumor size was 2.6 cm. Fifteen cases (50%) had the microcystic type, 7 (23%) the micro- and macrocystic type, and 8 (27%) the macrocystic type. Age, gender, symptoms, location or tumor size did not differ significantly among the three subtypes. Eighteen patients were followed up for a median of 58 months. Morphological changes were observed in 3 patients (17%) and enlargement of tumor size in 9 patients (50%) during the follow-up. The growth rate was 0.29 cm per year and doubling time was 3.5 years; these rates did not differ among morphological subtypes or size of tumors. Conclusions: In asymptomatic patients with a clear imaging diagnosis of SCN, nonoperative management with a careful follow-up should be recommended. Surgery should be suggested in only symptomatic patients, those with giant tumors (>10 cm), rapid growing or when the presence of a potentially malignant tumor cannot be excluded.

Efficacy, Safety, and Long-Term Follow-Up Results of EUS-Guided Transmural Drainage for Pancreatic Pseudocyst

Background and Aim. EUS-guided transmural drainage (EUS-GTD) is now considered a minimally invasive and effective alternative to surgery for drainage of symptomatic pancreatic pseudocysts. However, the technique is rather difficult, and sometimes serious complications occur to patients undergoing this procedure. We retrospectively evaluated efficacy, safety, and long-term follow-up results of EUS-GTD for pancreatic pseudocyst. Methods. Sixty-seven patients with pancreatic pseudocyst who underwent EUS-GTD from April 2000 to March 2011 were enrolled. We retrospectively evaluated (1) technical success, (2) clinical success, (3) adverse event of procedure, and (4) long-term follow-up results. Results. Total technical success rate was 88%. Ninety-one percent of external drainage, 79% of internal drainage, and 66% of puncture and aspiration only achieved clinical success. There was only one case with an adverse event, perforation (1.5%). The case required emergency operation. Total recurrence rate was 23.9%. Median follow-up period was 33.9 months. The recurrence rates in the cases of stent remaining, spontaneously dislodged, removed on schedule, external tube removal, and aspiration only were 10.0%, 12.5%, 42.9%, 50%, and 0%, respectively. Conclusion. EUS-GTD is a relatively safe and effective therapeutic method. However, further analysis should be done by larger series to determine the method of EUS-GTD for pancreatic pseudocyst.

Endoscopic treatment of difficult common bile duct stones.

Recent developments in treatment devices and advancements in technology have made endoscopic treatment the first choice for bile duct stones. In endoscopic treatment, the stones are removed after expanding the papilla with endoscopic sphincterotomy or endoscopic papillary balloon dilatation. The devices used to remove bile duct stones include basket catheters, balloon catheters and mechanical lithotripters, and their employment varies depending on the clinical situation. Stone removal by endoscopy is superior to other options, although treatment can be difficult in some cases. The reasons are mainly large stones, a history of gastric surgery, and Mirizzi syndrome. For such difficult cases, various adjuvant treatments such as extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and lasers are recommended rather than using just a mechanical lithotripter. Recently, large‐diameter biliary orifice balloon dilation, a method in which the papilla is expanded using a large‐diameter balloon, allowing the stones to be removed, has been reported and is attracting increasing attention.

Lack of Independent Association Between Fatty Pancreas and Incidence of Type 2 Diabetes: 5-Year Japanese Cohort Study

OBJECTIVE Previous cross-sectional studies have shown that attenuation in the pancreas seen on unenhanced computed tomography (CT) scans was inversely correlated with histologic pancreatic fat, and that fatty pancreas was associated with type 2 diabetes mellitus (T2DM). However, no longitudinal study has evaluated whether fatty pancreas increases the incidence of T2DM. We conducted a cohort study to investigate the association between fatty pancreas and the incidence of T2DM. RESEARCH DESIGN AND METHODS A total of 813 participants without diabetes underwent health checks by unenhanced CT scanning in 2008 and 2009, and were observed for a median follow-up period of 5.06 (interquartile range 3.01–5.92) years. Attenuation in three regions of the pancreas seen on an unenhanced CT scan was measured, and the mean pancreatic attenuation was calculated to evaluate fatty pancreas at baseline; the more severe the fatty pancreas, the lower the mean pancreatic attenuation. The incident T2DM hazard ratios (HRs) for the association between fatty pancreas and T2DM incidence were estimated by Cox proportional hazards models adjusted for age, sex, BMI, liver attenuation seen on unenhanced CT scan, and alcohol intake of ≥20 g/day. RESULTS T2DM occurred in 62 participants (7.6%) during the follow-up period. The higher pancreas attenuation (i.e., less pancreatic fat) at baseline was associated with decreased T2DM incidence in a univariate analysis (crude HR 0.97 [95% CI 0.96–0.99]); and fatty pancreas (lower pancreas attenuation) was positively associated with increased T2DM incidence. However, the association was substantially explained by the confounders (multivariate HR 1.00 [95% CI 0.98–1.02]). CONCLUSIONS Fatty pancreas was not independently associated with future T2DM.