Hidemichi Imamura

Pancreatobiliary drainage using the EUS-FNA technique: EUS-BD and EUS-PD

The recent progression of endoscopic ultrasonography (EUS) enables EUS-guided transmural drainage based on the EUS-guided fine-needle aspiration biopsy technique. Prior to the development of EUS-guided drainage procedures, the options for treating obstruction of the pancreatobiliary system included surgical drainage, percutaneous drainage using ultrasound and radiological guidance, and endoscopic (non EUS-guidance) transmural drainage. Today, using EUS guidance and dedicated accessories, it is possible to create bilio- or pancreato-digestive anastomosis, EUS-guided biliary drainage (EUS-BD), and EUS-guided pancreatic drainage (EUS-PD). The recent literature describes that EUS-BD and EUS-PD have acceptable success and complication rates. These procedures are anticipated for use as alternatives to surgery or percutaneous drainage when endoscopic transpapillary procedures fail.

Two Cases of Retroperitoneal Liposarcoma Diagnosed Using Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA)

This report describes our experience with two cases that were ultimately diagnosed as retroperitoneal liposarcoma using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Case 1 is that of a 54-year-old woman with chief complaints of nausea and abdominal distention. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large (15 cm diameter) tumor, which was significantly compressing the stomach and apparently occupied the entire left abdominal cavity. Although advanced primary gastrointestinal stromal tumor (GIST) or retroperitoneal tumor was inferred as the differential diagnosis, a definitive diagnosis was difficult using imaging alone. After EUS-FNA was done, the tumor was diagnosed histopathologically as high-grade liposarcoma. Case 2 is that of a 73-year-old man. Abdominal ultrasonography and CT showed a 6 cm diameter tumor within the pelvic cavity. The tumor had high MRI signal-intensity on both T1 and T2 images. Endorectal EUS showed a hyperechoic mass. The images suggested lipoma or liposarcoma containing lipoma-like components. Myxoid liposarcoma was revealed by subsequent EUS-FNA. Performing EUS-FNA was clinically useful for determining the subsequent therapeutic strategy in these cases where a tumor of unknown origin existed in the retroperitoneum.

INTERVENTIONAL ENDOSCOPIC ULTRASONOGRAPHY: APPLICATIONS FOR CANCER RELATED TREATMENT

For tissue diagnosis in patients with abnormalities of various organs, endoscopic ultrasonography (EUS)‐guided fine needle aspiration (EUS‐FNA) has emerged as an effective technique. Subsequently, EUS‐guided fine needle injection (EUS‐FNI) has expanded the clinical utility of EUS. Several applications of EUS‐FNI for anti‐cancer efforts have included celiac nerve blocking and drug delivery into tumors, such as ablation, chemotherapy, gene therapy, and cytoimplantation. Furthermore, chemosensitivity tests with materials obtained using EUS‐FNA are available to produce tailor‐made medicines. Demonstrably, EUS‐guided intervention has opened new and exciting clinical applications for the management of malignancies.

Analysis of prognostic factors in patients with gastric varices after endoscopic treatment.

Background:  The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment.

Hemorrhagic duodenal varices treated successfully with endoscopic injection sclerotherapy using cyanoacrylate and ethanolamine-oleate: a case report.

We report a case of a 50-year-old man with a medical history of alcoholic cirrhosis, in addition to esophagogastric and duodenal varices (DV), who was transferred to our institution because of hemorrhagic DV. Emergent esophagogastroduodenoscopy showed hemorrhagic varices in the horizontal portion of the duodenum. Abdominal contrast-enhanced CT showed hemodynamics of DV derived from anastomosis between the superior mesenteric vein and right renal vein. Cyanoacrylate was injected into the DV. Subsequently, 5% ethanolamine-oleate was injected endoscopically as a sclerosant into the DV feeding vein. Radiographic fluoroscopic findings revealed that the injected cyanoacrylate and sclerosant remained, respectively, in the varices and its feeder. Five days later, CT showed that the injected cyanoacrylate occupied the DV, and thrombus formation of the afferent vein led to bifurcation of superior mesenteric vein. This case showed the usefulness of endoscopic injection sclerotherapy using cyanoacrylate and sclerosant for the management of DV.

A New Device for Dilation of the Fistula Tract Between Gastric and Cystic Wall in Performing EUS-Guided Pancreatic Pseudocyst Drainage

A New Device for Dilation of the Fistula Tract Between Gastric and Cystic Wall in Performing EUS-Guided Pancreatic Pseudocyst Drainage Hidemichi Imamura, Atsushi Irisawa, Manoop S. Bhutani, Takuto Hikichi, Goro Shibukawa, Tadayuki J. Takagi, Kyouko Katakura, Takeru Wakatsuki, Ai Sato, Katsutoshi Obara, Yukio Sato Background and Aim: In EUS-guided drainage of the pancreatic pseudocysts, there are two methods for the puncture, electrosurgical and non-electrical. Although the electrosurgical puncture using a needle knife is able to create a wide fistula tract between the gastric and cystic wall sufficiently, bleeding and leakage of the fluid to the peritoneal cavity are known complication of this procedure. On the other hand, although low complication rate in the non-electrical puncture have noted in the previous literatures, it was difficult to create a wide fistula tract using existing dilating device. Thus, long procedure time was required in non-electrical method. In order to solve this problem, we developed the new dilating device of the fistula tract. The purpose of this study was to evaluate whether EUS -guided cyst drainage by non-electrical method with the new dilating device could be feasible and successful, in comparison with the dilating method by existing dilating device. Patients and Methods: EUS-guided drainage of cystic lesions was attempted in 12 patients. The drainage sites were gastric in all cases. A fistula was created with a 19G needle (ECHOTIP) for EUS-FNA by non-electrical method, followed by dilation of the fistula tract using ERCP catheters (n Z 6) or a new dilating device (n Z 9). Our new device was a rather hard plastic tube which was tapered from 7Fr to 0.025 inch (just fitting in the 0.025 inch guide-wire on the tip of tube, made by Olympus). The drainage was done using 7-Fr stent or 6-Fr nasocystic drainage tube, and drainage tube was chosen in which with the character of the aspirated fluid. Results: In all patients, creation of a fistula and placement of the drain (naso-tube and stent) were successful. There were no immediate complications, especially bleeding. The mean procedure time (from insert to extract of the endoscope) in the case using ERCP catheter as a dilating device was 86 min, on the other hand, that in the case using new dilating device was 32.6 min. There was a significant difference between two groups. Conclusions: A new dilating device was useful for the drainage of the Abstracts

T1380 Chemosensitivity Testing to Predict Chemosensitivity for Gemcitabine Using the Biopsy Specimens Obtained by Endoscopic Ultrasonogrphy-Guided Fine-Needle Aspiration From Unresectable Pancreatic Cancer

Chemosensitivity Testing to Predict Chemosensitivity for Gemcitabine Using the Biopsy Specimens Obtained by Endoscopic Ultrasonogrphy-Guided FineNeedle Aspiration From Unresectable Pancreatic Cancer Takeru Wakatsuki, Atsushi Irisawa, Tadayuki Takagi, Goro Shibukawa, Hidemichi Imamura, Yuta Takahashi, Ai Sato, Masaki Sato, Tsunehiko Ikeda, Rei Suzuki, Takuto Hikichi, Katsutoshi Obara, Hiromasa Ohira

Endoscopic Feature of Gastric Varices Caused by Left-Sided Portal Hypertension due to Pancreatic Disease

Endoscopic Feature of Gastric Varices Caused by Left-Sided Portal Hypertension due to Pancreatic Disease Tadayuki J. Takagi, Atsushi Irisawa, Katsutoshi Obara, Ayako Saito, Goro Shibukawa, Go Yamamoto, Takuto Hikichi, Takeru Wakatsuki, Hidemichi Imamura, Yukio Sato Background: Left-sided portal hypertension was occurred by the stricture of splenic vein due to the infiltration of the pancreatic inflammation or carcinoma, and then gastric varices often developed. The aim of this study is to reveal the endoscopic feature of gastric varices caused by left-sided portal hypertension due to pancreatic disease. Patients and Methods: One hundred six patients with pancreatic disease (chronic pancreatitis;45, carcinoma;60, metastasis;2) who were undergone endoscopic examination in our hospital were enrolled. The pancreatic diseases were diagnosed by computed tomography, ultrasonography, ERCP, and EUS-FNA. The hemodynamics of gastric varices was evaluated utilizing 3dimentiomal computed tomography and/or angiography. Results: In 7 patients (chronic pancreatitis; 1, pancreatic carcinoma; 5,metastatic pancreatic carcinoma; 1), the gastric varices were visualized by endoscopy. The frequency of existence of the gastric varices was 2.3% in chronic pancreatitis and 8.3% in pancreatic carcinoma. The endoscopic features of those gastric varices were identified as the widespread tortuous gastric-varices locating from the cardia to lower gastric body. These findings were seen in all cases. Angiographic analysis of variceal hemodynamics revealed that these gastric varices were formed by two routes; 1: the collaterals from the short gastric vein to the portal vein via coronary veins, 2; the collaterals from short gastric vein to the portal vein via gastro-epiproic vein. Conclusion: The endoscopic feature of gastric varices in patient with left-sided portal hypertension due to the pancreatic disease was the widespread tortuous gastric-varices locating from the cardia to lower gastric body, reflecting the portovariceal hemodynamics.