Hidekazu Mukai

The diagnosis of pancreatic cancer by endoscopic ultrasonography.

Endoscopic ultrasonography was evaluated for detection of tumors of the pancreas. The technique was performed in 42 patients with cancer of the pancreas and 8 patients with nodular fibrosis of chronic pancreatitis. The lesions were clearly identified in all 50 patients, even when the size of the tumor was less than 20 mm in diameter. A tumor of the pancreas was usually visualized as a hypoechoic mass that had a characteristic image depending on the size. Ultrasonographic differentiation of malignant from benign tumors of the pancreas was possible in tumors larger than 30 mm in size but difficult in tumors less than 20 mm in size. Compared with conventional ultrasonography, endoscopic retrograde pancreatography, computed tomography, and angiography, endoscopic ultrasonography had the highest detection rate of tumors of the pancreas, especially in cases of small tumors under 20 mm in size. In cancer of the pancreas, endoscopic ultrasonography also proved to be valuable for the detection of vascular invasion.

Evaluation of endoscopic ultrasonography in the pre-operative staging of carcinoma of the ampulla of Vater and common bile duct.

Endoscopic ultrasonography (EUS) was performed in 23 patients with carcinoma of the ampulla of Vater (ampulla) and in 16 patients with common bile duct (CBD) carcinoma. These patients all underwent surgery. The layered structures of the duodenum, ampulla, and CBD, and the pancreas, portal vein, and regional lymph nodes were clearly identified by EUS using a transduodenal approach. With this technique, ampullary carcinoma appeared as a hypoechoic mass in 22 of 23 patients, and the 1 remaining cancer was not detected because of its small size. Carcinoma of the CBD also appeared as a hypoechoic mass in 12 of 16 patients. However, the remaining four appeared as hyperechoic masses. For these tumors, EUS had a high tumor detection rate (96 to 100%). In this regard, EUS was comparable to ERCP and was better than ultrasonography (US), CT, and angiography. Using EUS, we were also able to stage the extent of these tumors according to the involvement of the duodenal or CBD walls, invasion of the pancreas and portal vein, and spread to regional lymph nodes. The accuracy rates of cancer extent by EUS were 78% for ampullary carcinoma and 81% for CBD carcinoma when compared with surgical findings. We conclude that EUS is a valuable method for the detection and staging of tumors of the ampulla and CBD.

Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones

OBJECTIVE Endoscopic sphincterotomy (ES) is a well-established standard method for treating common bile duct stones. However, biliary sphincter function is impaired after the treatment, and this may influence the long-term outcomes. In this study, we aimed to compare the long-term outcomes after ES with those after endoscopic papillary balloon dilation (EPBD) because the latter procedure is expected to preserve biliary sphincter function better than ES. DESIGN A prospective follow-up of the original cohort in a previously randomized, controlled trial to compare the early outcomes after ES and EPBD. SETTING Eleven centers, including 6 clinical practices and 5 academic institutions. PATIENTS A total of 282 patients with common bile duct stones were randomly selected to undergo ES (n = 144) or EPBD (n = 138) in the previous study. INTERVENTIONS ES or EPBD. MAIN OUTCOME MEASUREMENTS Complications after ES or EPBD occurring during long-term follow-up. RESULTS The patients were followed up annually after the treatment. The median duration of the follow-up was 6.7 years. Morbidity was observed in 36 (25.0%) and 14 (10.1%) of the patients who underwent ES and EPBD, respectively (P = .0016). Kaplan-Meier analysis revealed a significantly higher incidence of biliary complications in the ES group than in the EPBD group (P = .0011). Multivariate analysis showed that ES, periampullary diverticulum, and in situ gallbladder stones were independent risk factors for stone recurrence. CONCLUSIONS During long-term follow-up, patients who underwent ES had significantly more biliary complications than those who underwent EPBD. The biliary sphincter dysfunction after ES results in additional late complications.

Covered self-expandable metal stents with an anti-migration system improve patency duration without increased complications compared with uncovered stents for distal biliary obstruction caused by pancreatic carcinoma: a randomized multicenter trial.

OBJECTIVES:The requirements of biliary stents used in the palliation of malignant biliary obstruction are a long duration of patency and minimal adverse effects. Covered self-expandable metal stents (SEMSs) have been shown to prevent tumor ingrowth, which is the most frequent complication of uncovered SEMSs. However, because they are prone to migration, the superiority of covered SEMS has yet to be convincingly demonstrated. The aim of this study was to evaluate the superiority of covered over uncovered SEMSs in the palliation of distal biliary obstruction due to unresectable pancreatic carcinoma, using both stent types with relatively low axial force and uncovered flared ends to prevent their migration.METHODS:From April 2009 to December 2010, 120 patients who were admitted to 22 tertiary-care centers because of distal biliary obstruction from unresectable pancreatic carcinomas were enrolled in this prospective randomized multicenter study. Patients were randomly assigned to receive a covered or uncovered SEMS deployed at the site of the biliary stricture during endoscopic retrograde cholangiopancreatography. Stent patency time, patient survival time, patient survival time without stent dysfunction (time to stent dysfunction or patient death), cause of stent dysfunction (ingrowth, overgrowth, migration, or sludge formation), and serious adverse events were compared between covered and uncovered SEMS groups.RESULTS:Patient survival time in the two groups did not significantly differ (median: 285 and 223 days, respectively; P=0.68). Patient survival time without stent dysfunction was significantly longer in the covered than in the uncovered SEMS group (median: 187 vs. 132 days; P=0.043). Stent patency was also significantly longer in the covered than in the uncovered SEMS group (mean±s.d.: 219.3±159.1 vs. 166.9±124.9 days; P=0.047). Reintervention for stent dysfunction was performed in 14 of 60 patients with covered SEMSs (23%) and in 22 of 60 patients with uncovered SEMSs (37%; P=0.08). Stent dysfunction was caused by tumor ingrowth, tumor overgrowth, and sludge formation in 0 (0%), 3 (5%), and 11 (18%) patients in the covered SEMSs group, and in 15 (25%), 2 (3%), and 6 (10%) patients in the uncovered SEMSs group, respectively. Stent migration was not observed in either group. Rates of tumor overgrowth and sludge formation did not significantly differ between the two groups, whereas the rate of tumor ingrowth was significantly lower in the covered than in the uncovered SEMS group (P<0.01). Acute pancreatitis occurred in only one patient in the covered SEMS group. Acute cholecystitis occurred in one patient in the covered SEMS group and in two patients in the uncovered SEMS group. There was no significant difference between the two groups in the incidence of serious adverse events.CONCLUSIONS:By preventing tumor ingrowth and migration, covered SEMSs with an anti-migration system had a longer duration of patency than uncovered SEMSs, which recommends their use in the palliative treatment of patients with biliary obstruction due to pancreatic carcinomas.

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).

Clinical significance of cathepsin E in pancreatic juice in the diagnosis of pancreatic ductal adenocarcinoma.

Background: It has been reported that cathepsin E (CTSE) is a non‐secretory and intracellular aspartic proteinase found in the superficial epithelial cells of the stomach and that it is also expressed in pancreatic ductal adenocarcinoma. We evaluated the diagnostic value of CTSE in the pancreatic juice in the diagnosis of pancreatic ductal adenocarcinoma compared with that of CA19–9, carcinoembryonic antigen (CEA) and K‐ras mutations.

COVERED WALLSTENT FOR PALLIATION OF MALIGNANT COMMON BILE DUCT STRICTURE: PROSPECTIVE MULTICENTER EVALUATION

Background:  Occlusion due to tumor ingrowth is a major drawback in self‐expandable metallic stents. Covering the stent is a probable solution to prevent tumor ingrowth. A manufactured covered self‐expandable metallic stent, Covered Wallstent, has become commercially available. We evaluated the Covered Wallstent in a prospective uncontrolled multicenter setting.

Role of percutaneous transhepatic gallbladder aspiration in the early management of acute cholecystitis

Early cholecystectomy is currently the gold standard treatment for acute cholecystitis (AC). However, the acceptability and safety of this strategy remain in dispute. The aim of this study was to clarify the role of percutaneous transhepatic gallbladder aspiration (PTGBA) in the early management of AC in a single center.

Complete response of a pancreatic adenosquamous carcinoma to chemoradiotherapy

A 51-year-old woman with an unresectable pancreatic tumor that was histologically diagnosed as an adenosquamous carcinoma underwent chemoradiotherapy with 5-fluourouracil (FU) and low-dose cisplatin (low-dose FP). Because we recognized a partial response to the chemoradiotherapy, we subsequently administered combined chemotherapy with S-1 and cisplatin. After one course of this combined chemotherapy, the tumor was further reduced in size and became difficult to discern on abdominal computed tomography (CT). We have continued to administer the S-1 and cisplatin combined chemotherapy, and the patient is still alive. After 20 months of treatment, the tumor has not recurred (as assessed by abdominal CT). Additionally, we have not seen elevation of tumor markers. This report presents the successful use of chemoradiotherapy with low-dose FP and additional combined chemotherapy with S-1 and cisplatin for unresectable pancreatic adenosquamous carcinoma.

Current role of percutaneous transhepatic gallbladder aspiration: from palliative to curative management for acute cholecystitis.

The present study assessed conservative management of acute cholecystitis (AC) with a focus on percutaneous transhepatic gallbladder aspiration (PTGBA).