Hirotoshi Fukatsu

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct‐to‐duct (D‐D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long‐term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D‐D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first‐line therapy for patients with biliary stricture after LDLT.

Endoscopic deployment of multiple JOSTENT SelfX is effective and safe in treatment of malignant hilar biliary strictures.

BACKGROUND & AIMS For the treatment of unresectable biliary tract carcinoma with hilar biliary stricture, antitumor therapy and biliary stenting should be addressed in terms of prolonged survival with a good quality of life. However, the endoscopic management of malignant hilar biliary strictures is difficult even for an expert endoscopist. We evaluated the efficacy and safety of the endoscopic deployment of multiple JOSTENT SelfX units in patients with hilar biliary strictures treated with or without chemotherapy. METHODS Between November 2003 and December 2006, endoscopic deployment of multiple JOSTENT SelfX units in hilar biliary strictures by using a partial stent-in-stent procedure was performed on 41 consecutive patients with primary cholangiocarcinoma (n = 34) and gallbladder carcinoma (n = 7) at a gastroenterologic center of Okayama University Hospital. Thirty-three patients were treated with gemcitabine (n = 25) or S-1 (n = 8). RESULTS Metallic stent deployment was successfully accomplished in all cases via only endoscopic procedures. During the follow-up period (mean, 210 days), mean patency time was 150 days, and metallic stent obstruction occurred in 15 cases (37%). Although a repeat intervention was required in all metallic stent obstructed cases, the deployment of the second metallic or plastic stent was completed successfully. The remaining 26 cases (63%) required no interventions. The median overall survival period was only 235 days. However, that of the patients receiving chemotherapy was 392 days. CONCLUSIONS Endoscopic partial stent-in-stent deployment with multiple JOSTENT SelfX prostheses is effective and safe for the treatment of malignant hilar biliary stricture even in patients receiving chemotherapy.

Gastric adenocarcinoma of fundic gland type (chief cell predominant type) treated with endoscopic aspiration mucosectomy.

Upper endoscopy screening in an asymptomatic 56‐year‐old man showed a small, yellowish elevated lesion with a central depression on the posterior wall in the gastric cardia. Biopsy specimens from this lesion were suspicious of carcinoid tumor. We suspected this lesion to be a sporadic gastric carcinoid tumor with a diameter of 5 mm, limited to the mucosal layer. We then performed an endoscopic aspiration mucosectomy with a cap‐fitted endoscope. Microscopically, the lesion obtained from the resected specimen was minimally invasive to the submucosa and showed highly differentiated columnar cells in irregularly anastomosing glands. Immunohistology was positive for pepsinogen‐I, and MUC6, partially positive for H+/K+‐ATPase, and negative for MUC5AC. In addition, it was positive for synaptophysin and CD56, and negative for chromogranin A. We finally diagnosed the patient as having gastric adenocarcinoma of fundic gland type (chief cell predominant type) with minimal invasion (100 µm) to the submucosa. Surveillance endoscopy with biopsy specimens and abdominal computed tomography at 1 year revealed no evidence of tumor recurrence. We herein report this rare case of gastric adenocarcinoma of fundic gland type (chief cell predominant type).

Nonprevention of post-endoscopic retrograde cholangiopancreatographic pancreatitis by pancreatic stent after aspiration of pure pancreatic juice in patients with intraductal papillary mucinous neoplasms of the pancreas

Objectives: The objective of this study was to evaluate the efficacy of a pancreatic stent regarding the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis after aspiration of pure pancreatic juice in patients with intraductal papillary mucinous neoplasms. Methods: A retrospective study was made to assess the outcome in 121 consecutive patients with intraductal papillary mucinous neoplasms who underwent endoscopic aspiration of pure pancreatic juice for cytologic examination between July 2001 and October 2007. From July 2001 to March 2004, 58 patients did not undergo pancreatic stent insertion (the no-stent [nS] group). The remaining 63 patients did undergo stent insertion (stent [S] group). Results: The overall incidences of post-ERCP pancreatitis was 11 (9.1%). The incidences of post-ERCP pancreatitis in the S and nS groups were 8 (12.7%) and 3 (5.2%; P = 0.21), respectively. In the male patients and the patients with a smaller diameter of the main pancreatic ducts, post-ERCP pancreatitis was seen more frequently in those in the S group (13% and 21%, respectively) than in those in the nS group (0% and 0%, respectively; P = 0.04, 0.03). Conclusions: The pancreatic stent did not seem to decrease the incidence of post-ERCP pancreatitis in patients with intraductal papillary mucinous neoplasms. Furthermore, the pancreatic stent seems to be potentially detrimental in male patients and in patients with small-diameter main pancreatic ducts.Abbreviations: ERCP - endoscopic retrograde cholangiopancreatography, IPMNs - intraductal papillary mucinous neoplasms, ERP - endoscopic retrograde pancreatography, IDUS - intraductal ultrasonography

Perforation of jejunum induced by the deployment of a temporary prophylactic pancreatic stent in the patient with peritonitis carcinomatosa

A great deal of medical literature describes the efficacy and safety of the prophylactic pancreatic stent in reducing the incidence of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. At the moment, no serious complication due to the migration of this stent has been reported. We describe a case with perforation of jejunum induced by the migration of a temporary prophylactic pancreatic stent. This report indicates that we should pay attention to this severe complication when we place a temporary prophylactic pancreatic stent in patients who have peritonitis carcinomatosa or adherence of the intestine irrespective of oral intake.

Endoscopic Deployment of Jostent Selfx for Malignant Hilar Biliary Stricture: A Pilot Study

Endoscopic Deployment of Jostent Selfx for Malignant Hilar Biliary Stricture: A Pilot Study Hirofumi Kawamoto, Takashi Nakanishi, Osamu Mizuno, Etsuji Ishida, Tsuneyoshi Ogawa, Yuko Okamoto, Hirotoshi Fukatsu, Yasushi Shiratori Objectives: The JoStent SelfX stent (Abbott Vascular Devices, Redwood City, California, USA) is manufactured from a nickel-titanium alloy (nitinol) with a high degree of flexibility and elasticity. The JoStent SelfX also offers a wide stent mesh, thin delivery shaft, and good pushability. Therefore, the JoStent SelfX in endoscopic deployment of partial stent-in-stent procedure may be useful in case of the hilar biliary stricture. This pilot study was conducted to evaluate the procedure of stent deployment and its short-term stent efficacy. Methods: Between March 2003 and October 2004, 17 patients (male: female 9:8, mean age 67 year old, mean observation period 146 days) with malignant hilar biliary stricture admitted to our hospital were enrolled. The patients consisted of 11 patients with hilar bile duct carcinoma, 3 with gallbladder carcinoma, and one each patient with pancreas, colon, and hepatocellular carcinoma. All patients received JoStent SelfX endoscopically. The first stent was inserted into the left lateral segment as the stent mesh space was widest at the branching. After finding the right biliary branch through the stent mesh using Naviguide (Olympus, Tokyo, Japan), the second stent was inserted into this branch as a partial stent-in-stent procedure. This procedure was termed as ‘‘L-R pattern’’. When the patients had Bismuth type 4 stricture with large tumor in the left hepatic lobe or left portal vein obstruction, the first stent was inserted into the right posterior segment and the second stent was inserted into anterior branch. This procedure was termed as ‘‘Ra-p pattern’’. Results: Classifying the pattern of stenosis according to Bismuth classification, 1 patient had type 2 stenosis, 3 patients type 3 stenosis, and 13 patients type 4 stenosis. Of these, the L-R pattern deployment was performed in 11 patients and the Ra-p pattern deployment in 6 patients. On the intention-to-treat basis, the L-R pattern deployment was not achieved in 1 patient due to the failure of passing guidewire through the stenosis. Thus, the success rate of deployment was 94% (16/17). The Ra-p deployment was performed to this patient. Conclusion: The JoStent SelfX is a suitable metallic stent to deploy in the hilar biliary stricture in partial stent-in-stent procedure. T1274 Prospective Randomized Controlled Trial of Endoscopic Sphincterotomy Compared with Endoscopic Papillary Balloon Dilatation for Bile Duct Stones: Late Complications After Stone Removal Yutaka Komatsu, Naotaka Fujita, Hiroyuki Maguchi, Ichiro Yasuda, Osamu Hasebe, Yoshinori Igarashi, Akihiko Murakami, Hidekazu Mukai, Tsuneshi Fujii, Kenji Yamao, Kensei Maeshiro Aim: To compare long term complications of the two treatments, endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), for bile duct stones, including stone recurrence. Methods: From March 2000 to March 2001, a randomized controlled trial was carried out involving 11 institutions. Two hundred eighty two patients who had bile duct stones less than 14 mm in minimum diameter on X-ray images were included in this study. Patients were randomized to EST or EPBD treatment groups. Follow-up data were collected by personal interview or telephone every year. Even if biliary events had not occurred, blood examination, abdominal ultrasound, MRCP and/or ERCP were performed to assess asymptomatic stone recurrence, as available. The clinical outcome after stone removal in three years was evaluated using Kaplan-Meier analysis supplemented by the log lank test. Results: See Table. Conclusion: Overall incidence of late complications in the EST group was higher than that in the EPBD group. Stone recurrence in the EST group was also more frequent than in the EPBD group. Furthermore, a higher rate of asymptomatic stone recurrence in EST group was proved by follow-up MRCP and/or ERCP. Further long-term follow-up study will elucidate the efficacy of both procedures. Abstracts