Hirofumi Kogure

Preliminary report on a new, fully covered, metal stent designed for the treatment of pancreatic fluid collections

BACKGROUNDnEndoscopic transluminal treatment of pancreatic fluid collections (PFC) has been reported as an effective alternative approach to surgical treatment. A wide, short stent with an anti-migration system has been developed.nnnOBJECTIVEnTo evaluate a newly developed, fully covered, self-expandable metal stent (FCSEMS) customized for cystogastrostomy.nnnDESIGNnRetrospective case series.nnnSETTINGnTertiary-care academic medical centers and affiliated hospitals.nnnPATIENTSnNine patients who underwent endoscopic treatment of PFCs (5 with pseudocysts and 4 with walled-off pancreatic necrosis).nnnINTERVENTIONnStent deployment after endoscopic US-guided puncture. Irrigation and necrosectomy were performed at the discretion of the endoscopist.nnnMAIN OUTCOME MEASUREMENTSnTechnical and clinical success rate, complications, and removability.nnnRESULTSnThe FCSEMS was inserted successfully in all cases (9/9, 100%). Clinical success was achieved in 7 of 9 cases (77.8%). No early complications associated with the procedure were observed. Late complications were observed in 2 cases (bleeding and asymptomatic migration). The FCSEMS was removed without any complications in all 6 cases where it was attempted after the procedure had been completed (100%).nnnLIMITATIONSnThis was a retrospective evaluation of a small number of cases. The FCSEMS was always inserted via the transgastric route. Follow-up duration was short.nnnCONCLUSIONnThe endoscopic approach that uses this new FCSEMS is feasible for the treatment of PFCs. However, further evaluation is required.

Slow Pull Versus Suction in Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Solid Masses

BackgroundEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic masses is an established procedure for obtaining a pathological specimen. However, application of suction during EUS-FNA is still controversial and the efficacy of the slow-pull technique was recently reported for new core biopsy needles.AimThe purpose of this study was to compare the suction and slow-pull techniques using regular FNA needles.MethodsThe diagnostic yield of the suction and slow-pull techniques was retrospectively studied for patients who underwent EUS-FNA for pancreatic solid lesions.ResultsA total of 367 passes (181 by suction and 186 by the slow-pull technique) were performed during 97 EUS-FNA procedures for 93 patients with pancreatic solid lesions. The slow-pull technique resulted in lower scores for cellularity (≥2 for 37.5xa0% vs. 76.7xa0%) but scores for contamination with blood were lower (≥2 for 25.0xa0% vs. 66.7xa0%) and sensitivity of diagnosis of malignancy was higher (90.0xa0% vs. 67.9xa0%) when a 25-gauge FNA needle was used. There were no significant differences between the two techniques when a 22-gauge needle was used. In multivariate analysis of 82 cases with malignancy, the slow-pull technique (odds ratio (OR) 1.92, Pxa0=xa00.028), tumor size ≥25xa0mm (OR 4.64, Pxa0<xa00.001), and tumor location in the body or tail (OR 2.82, Pxa0<xa00.001) were associated with greater sensitivity.ConclusionThe slow-pull technique was associated with less contamination with blood and can potentially increase the diagnostic yield compared with the suction technique in EUS-FNA of pancreatic solid masses, especially with a 25-gauge FNA needle.

Risk factors for pancreatitis following transpapillary self-expandable metal stent placement

BackgroundPancreatitis is one of complications after self-expandable metal stent (SEMS) placement. The purpose of this study was to evaluate risk factors for pancreatitis after endoscopic SEMS placement for malignant biliary obstruction (MBO).MethodsWe retrospectively reviewed 370 consecutive patients who underwent initial transpapillary SEMS placement for biliary decompression. The characteristics of inserted SEMSs were classified according to axial and radial force.ResultsPancreatitis following SEMS insertion was observed in 22 patients (6%). All of them were mild according to consensus criteria. Univariate analysis indicated that injections of contrast into the pancreatic duct (frequency of pancreatitis, 10.3%), the placement of an SEMS with high axial force (8.3%), and nonpancreatic cancer (16.1%) significantly contributed to the development of pancreatitis, whereas female gender, a younger age, a covered SEMS, and a SEMS with high radial force or without a biliary sphincterotomy did not. In a multivariate risk model, SEMSs with high axial force (odds ratio [OR], 3.69; pxa0=xa00.022) and nonpancreatic cancer (OR, 5.52; pxa0<xa00.001) were significant risk factors for pancreatitis.ConclusionsSEMSs with high axial force and an etiology of MBO other than pancreatic cancer were strongly associated with a high incidence of pancreatitis following transpapillary SEMS placement in patients with distal MBO.

Acoustic radiation force impulse elastography for noninvasive assessment of chronic pancreatitis.

BackgroundEndoscopic ultrasonography or real-time elastography has been applied for the diagnosis of chronic pancreatitis. Acoustic radiation force impulse (ARFI) imaging is another tissue strain imaging technology, and recent technological advances have enabled quantification of the stiffness of some tissues by measuring the shear wave velocity (SWV) during routine B-mode ultrasonography.MethodsARFI elastography was performed in 52 healthy volunteers and 46 patients with chronic pancreatitis. SWV was measured in the head, body, and tail of the pancreas. The diagnostic performance was assessed using receiver-operating characteristic (ROC) curves.ResultsSWV in patients with chronic pancreatitis was significantly higher than that in healthy volunteers in each part of the pancreas, although the measurement was difficult in the tail of the pancreas. The area under the ROC curve was 0.78 in the body of the pancreas, with an optimal cut-off value of 1.40xa0m/s, and the sensitivity, specificity, positive predictive value, and negative predictive value were 75, 72, 69, and 78%, respectively. In the patients with chronic pancreatitis, alcoholic etiology and decreased body mass index (BMI) were associated with high SWV.ConclusionsARFI elastography of the pancreas showed high elasticity in chronic pancreatitis compared to findings in the normal pancreas. This modality is feasible to use for the diagnosis of chronic pancreatitis.

Risk factors for post-ERCP pancreatitis in wire-guided cannulation for therapeutic biliary ERCP

BACKGROUNDnWire-guided cannulation (WGC) was reported to decrease post-ERCP pancreatitis (PEP), but risk factors for PEP in WGC are not fully elucidated.nnnOBJECTIVEnTo evaluate the incidence and risk factors of PEP in WGC.nnnDESIGNnSingle-center retrospective study.nnnSETTINGnAcademic center.nnnPATIENTSnA total of 800 consecutive patients with a native papilla.nnnINTERVENTIONSnBiliary therapeutic ERCP by using WGC.nnnMAIN OUTCOME MEASUREMENTSnThe rate of PEP and its risk factors.nnnRESULTSnBiliary cannulation was successful by using WGC alone in 70.5%, and the final cannulation rate was 96.1%. Unintentional guidewire insertion and contrast material injection into the pancreatic duct (PD) during cannulation occurred in 55.3% and 21.8%, respectively. The incidence of PEP was 9.5% (mild 5.6%, moderate 2.9%, severe 1.0%). Multivariate analysis revealed a common bile duct (CBD) diameter ofxa0<9xa0mm (odds ratio [OR] 2.03; Pxa0= .006) and unintentional guidewire insertion into the PD (OR 2.25; Pxa0= .014) as risk factors for PEP. PD opacification was not a risk factor for PEP (OR 1.15; Pxa0= .642), but the incremental increase of the PEP rate was seen in patients with CBDsxa0<9xa0mm: 4.6% without any PD manipulation, 8.3% with contrast material alone, 16.9% with guidewire alone, and 22.1% with both contrast material and guidewire.nnnLIMITATIONSnRetrospective design in a single center.nnnCONCLUSIONnUnintentional PD manipulation was not uncommon in WGC. Guidewire insertion into the PD and a small CBD were risk factors for PEP in biliary therapeutic ERCP with the use of WGC.

Management of malignant gastric outlet obstruction with a modified triple-layer covered metal stent

BACKGROUNDnA high incidence of migration with covered metal stents has been reported in malignant gastric outlet obstruction (GOO). A newly modified, partially covered, triple-layer nitinol stent was developed that has a longer uncovered portion (5-15 mm) to prevent stent migration.nnnOBJECTIVEnTo estimate the efficacy and safety of the modified covered, triple-layer metal stent.nnnDESIGNnMulticenter, prospective cohort study.nnnSETTINGnThree tertiary referral centers.nnnPATIENTSnFifty consecutive patients (26 with pancreatic carcinoma, 14 with gastric carcinoma, 9 with cholangiocarcinoma, 1 with a metastatic node) who presented with symptomatic unresectable malignant GOO between April 2007 and March 2010.nnnINTERVENTIONSnEndoscopic placement of the modified covered, triple-layer metal stent.nnnMAIN OUTCOME MEASUREMENTSnThe primary endpoint was to improve the GOO scoring system (GOOSS) score. Secondary endpoints were success rate, patency, and complications.nnnRESULTSnThe median GOOSS score improved significantly (P < .0001) after stenting (from 0 to 3). The technical and clinical success rates were 100% and 90%, respectively. Stent occlusion by tumor overgrowth or ingrowth at the uncovered portion developed in 5 patients (10%). Asymptomatic stent migration occurred in 3 patients (6%) receiving chemotherapy at 95, 230, and 553 days after stent placement, but these patients tolerated solid food 68, 260, and 142 days after stent migration, respectively. Other complications occurred in 1 patient with insufficient expansion, cholangitis, and pancreatitis. No procedure-related deaths occurred.nnnLIMITATIONSnA single-arm study in tertiary-care centers.nnnCONCLUSIONSnThe modified covered, triple-layer metal stent was effective and safe for managing malignant GOO and can prevent tumor ingrowth and stent migration. (nnnCLINICAL TRIAL REGISTRATION NUMBERnUMIN000004566.).

Transmural Biliary Drainage Can Be an Alternative to Transpapillary Drainage in Patients with an Indwelling Duodenal Stent

BackgroundSelf-expandable metal stents (SEMS) are widely utilized to relieve symptoms of malignant gastric outlet obstruction (GOO), but GOO is frequently complicated by nonresectable distal biliary obstruction. The optimal endoscopic approach to biliary drainage in this setting remains controversial and has yet to be resolved.AimsTo compare the safety and efficacy of endoscopic ultrasound-guided transmural biliary drainage (EUS-BD) and transpapillary drainage in patients with an indwelling duodenal SEMS.MethodsPatients who underwent EUS-BD or transpapillary drainage for distal malignant biliary obstruction with an indwelling duodenal SEMS between June 2007 and August 2012 at three Japanese tertiary referral centers were identified retrospectively. We compared times to stent dysfunction, causes of dysfunction, and procedural related complications between these two groups.ResultsTwenty patients were included in the study (7 EUS-BD and 13 transpapillary drainage). EUS-BD was performed via hepaticogastrostomy using a SEMS in three patients and via choledochoduodenostomy using a SEMS or a plastic stent in two patients each. Transpapillary drainage was performed using a SEMS in all patients. The stent patency rate in the EUS-BD group was higher than that in the transpapillary drainage group (100 vs. 71xa0% at 1xa0month and 83 vs. 29xa0% at 3xa0months, respectively). The rate of stent dysfunction in the EUS-BD group tended to be lower than that in the transpapillary group (14 vs. 54xa0%; Pxa0=xa00.157). Complication rates were similar between the groups (Pxa0=xa01.000), with moderate bleeding in one patient in the EUS-BD group and mild pancreatitis in one patient in the transpapillary group.ConclusionEndoscopic ultrasound-guided transmural biliary drainage is an alternative to transpapillary drainage in patients with an indwelling duodenal SEMS.

High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction

Endoscopic bilateral self‐expandable metallic stent (SEMS) placement in a stent‐in‐stent method for malignant hilar biliary obstruction is technically challenging. Technical difficulties in the initial placement and reinterventions for stent occlusion are disadvantages inherent to this stent‐in‐stent method. We previously reported the feasibility of Niti‐S large cell D‐type biliary stents (LCD). This multicenter prospective consecutive study evaluated the efficacy of bilateral SEMS placement using modified LCD with large and uniform cells, a slimmer delivery system and high radial force.

Prognostic nomogram for nonresectable pancreatic cancer treated with gemcitabine-based chemotherapy

Background:A nomogram is progressively being used as a useful predictive tool for cancer prognosis. A nomogram to predict survival in nonresectable pancreatic cancer treated with chemotherapy has not been reported.Methods:Using prospectively collected data on patients with nonresectable pancreatic cancer receiving gemcitabine-based chemotherapy at five Japanese hospitals, we derived a predictive nomogram and internally validated it using a concordance index and calibration plots.Results:In total, 531 patients were included between June 2001 and February 2013. The American Joint Committee on Cancer (AJCC) TNM stages were III and IV in 204 and 327 patients, respectively. The median survival time of the total cohort was 11.3 months. A nomogram was generated to predict survival probabilities at 6, 12, and 18 months and median survival time, based on the following six variables: age; sex; performance status; tumour size; regional lymph node metastasis; and distant metastasis. The concordance index of the present nomogram was higher than that of the AJCC TNM staging system at 12 months (0.686 vs 0.612). The calibration plots demonstrated good fitness of the nomogram for survival prediction.Conclusions:The present nomogram can provide valuable information for tailored decision-making early after the diagnosis of nonresectable pancreatic cancer.

Risk factors and early signs of pancreatic cancer in diabetes: screening strategy based on diabetes onset age

BackgroundDiabetes mellitus (DM) has long been recognized as a risk factor for pancreatic cancer (PaC) and recently has attracted attention as a manifestation of PaC. Diabetes is expected to be a clue for the early detection of PaC; however, no effective screening strategy has been established.MethodsForty diabetic patients with PaC were identified and compared with 120 diabetic patients without any malignancies. We analyzed risk factors for and early signs of PaC, focusing on the DM-onset age.ResultsAs there were peaks at 40–45 years and 60–65 years in the distribution of DM-onset age, we analyzed the clinical characteristics of and risk factors for PaC according to DM-onset age: i.e., early-onset (<55xa0years) and late-onset (≥55xa0years). PaC was diagnosed within 2xa0years of DM onset (new-onset) in 0xa0% of the patients with early-onset DM, and in 33xa0% of those with late-onset DM. The mean duration of DM in patients with early-onset DM with PaC was longer than that in the late-onset patients (26 vs. 9xa0years; Pxa0<xa00.01). A family history of DM (odds ratio [OR] 3.60) and use of insulin (OR 3.52) were significant risk factors in patients with early-onset DM, while the onset age of DM (OR 1.12) and multiple diabetic patients in the family (OR 6.13) were risk factors in those with late-onset DM. Body weight loss and exacerbation of DM were seen 12xa0months prior to PaC diagnosis in both groups.ConclusionsOur study revealed specific risk factors for and similar early signs of PaC in early-onset and late-onset DM. Thus, we could develop a screening strategy, combining these risk factors specific for DM-onset age with early signs of disease.