Ichiro Yasuda

TOKYO criteria 2014 for transpapillary biliary stenting

It is difficult to carry out meta‐analyses or to compare the results of different studies of biliary stents because there is no uniform evaluation method. Therefore, a standardized reporting system is required. We propose a new standardized system for reporting on biliary stents, the ‘TOKYO criteria 2014’, based on a consensus among Japanese pancreatobiliary endoscopists. Instead of stent occlusion, we use recurrent biliary obstruction, which includes occlusion and migration. The time to recurrent biliary obstruction was estimated using Kaplan–Meier analysis with the log–rank test. We can evaluate both plastic and self‐expandable metallic stents (uncovered and covered). We also propose specification of the cause of recurrent biliary obstruction, identification of complications other than recurrent biliary obstruction, indication of severity, measures of technical and clinical success, and a standard for clinical care. Most importantly, the TOKYO criteria 2014 allow comparison of biliary stent quality across studies. Because blocked stents can be drained not only using transpapillary techniques but also by an endoscopic ultrasonography‐guided transmural procedure, we should devise an evaluation method that includes transmural stenting in the near future.

EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos)

BACKGROUND AND AIMS Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study. METHODS EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation. RESULTS The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20). CONCLUSIONS EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates.

International consensus recommendations for difficult biliary access

ERCP is the standard procedure for endoscopic biliary therapy. The endoscopic approach to the ampulla followed by selective deep biliary cannulation is the first step before further therapy. Difficult biliary access can occur during endoscope intubation or when attempting selective biliary cannulation in normal or surgically altered anatomy. Difficult cannulation increases the risk of post-ERCP adverse events, particularly post-ERCP pancreatitis (PEP) and perforation. In normal anatomy, about 11% of therapeutic ERCPs may be considered difficult biliary cannulation. Biliary access in patients with surgically altered anatomy, such as Billroth II or Roux-en-Y anastomosis, is considered difficult because special instruments and maneuvers are often needed. Various methods are used to overcome difficult biliary access, including advanced ERCP-based techniques using precut papillotomy or double guidewires (DGWs), specialized instruments like echoendoscopes or device-assisted enteroscopy, or percutaneous approach. These techniques and procedures are more complex and carry significant risks, requiring specific training. This consensus aims to develop an evidence-based framework for biliary endoscopists to tackle difficult biliary access.

Bench-top testing of suction forces generated through endoscopic ultrasound-guided aspiration needles

Adequate needle size and tissue acquisition techniques for endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) need further elucidation. Moreover, the actual negative pressure and suction forces of FNA needles remain unknown. We evaluated the suction forces of 19‐gauge, 22‐gauge, and 25‐gauge conventional FNA needles and side hole aspiration needles using conventional negative pressure and the slow pull technique.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment.

Walled‐off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high‐quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management.

Walled‐off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high‐quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

Current situation of endoscopic biliary cannulation and salvage techniques for difficult cases: Current strategies in Japan

In the pancreatobiliary session at Endoscopic Forum Japan (EFJ) 2015, current trends of routine biliary cannulation techniques and salvage techniques for difficult biliary cannulation cases were discussed. Endoscopists from nine Japanese high‐volume centers along with two overseas centers participated in the questionnaires and discussion. It was concluded that, currently, in Western countries, the wire‐guided cannulation (WGC) technique is favored during initial cannulation attempts. However, the conventional technique using an endoscopic retrograde cholangiopancreatography catheter with contrast medium injection is still used as first choice at most Japanese high‐volume centers. The WGC technique is used as the second choice at some institutions only. After failed biliary cannulation attempts, the initial salvage option preferred in most centers includes pancreatic guidewire placement, followed by precut techniques as the second salvage choice. Among several precut techniques, the free‐hand needle knife sphincterotomy with cutting upwards from the pancreatic duct is most popular. Endoscopic ultrasonography‐guided rendezvous technique is also carried out as a final salvage option at select institutions.

Endoscopic ultrasound-guided antegrade biliary stenting for unresectable malignant biliary obstruction in patients with surgically altered anatomy: Single-center prospective pilot study

Endoscopic retrograde cholangiography (ERCP) with biliary stenting for the treatment of unresectable malignant biliary obstruction (MBO) is challenging among patients with surgically altered anatomy. Endoscopic ultrasound‐guided antegrade biliary stenting (EUS‐ABS) was introduced as an alternative biliary drainage method, although it has not yet been well studied. In this single‐center prospective pilot study, we aimed to evaluate the feasibility and safety of EUS‐ABS for MBO in patients with surgically altered anatomy.

Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures

Abstract Benign biliary strictures (BBSs) are commonly caused by surgical injury, chronic pancreatitis, and inflammatory cholangiopathies. Although advanced imaging tests and tissue acquisition methods have been developed for evaluation of indeterminate biliary strictures, differentiation of BBSs from biliary malignancies remains a challenge to clinicians. The majority of BBSs have good response to nonsurgical treatment and surgical intervention mainly serves as a rescue when nonsurgical approaches fail. Endoscopic management is a safe, effective, and less-invasive treatment for BBSs compared with other approaches. Endoscopic biliary stricture dilation followed by placement of multiple plastic stents has been the first-line choice with good long-term ductal patency. Recently, covered self-expanding metal stents (CSEMSs) has been increasingly used in the management of BBSs with similar effectiveness but easier deployment, fewer endoscopic sessions compared with plastic stents. Moreover, other technologies are emerging in the diagnosis and management of BBSs. To assist clinicians in managing BBSs, the Asia-Pacific ERCP Club (APEC) has developed this statement through a systematic review of the literature.

Endoscopic ultrasound-guided celiac plexus block and neurolysis

Endoscopic ultrasound‐guided celiac plexus neurolysis (EUS‐CPN) is widely used for reducing pain originating from upper abdominal organs. It is mainly indicated to treat pancreatic cancer pain, but also to relieve pain as a result of chronic pancreatitis. Real‐time guidance and color Doppler imaging by EUS made the procedure easier and safer, resulting in greater pain relief. Currently, two techniques are used for EUS‐CPN. The classic approach, known as the central technique, involves injection of a neurolytic agent at the base of the celiac axis. In the bilateral technique, the neurolytic agent is injected on both sides of the celiac axis. In addition, EUS‐guided direct celiac ganglia neurolysis (EUS‐CGN) was introduced recently. Pain relief is achieved by EUS‐CPN in 70–80% of patients with pancreatic cancer and in 50–60% of those with chronic pancreatitis. The bilateral technique may be more efficient than the central technique, although the central technique is easier and possibly safer. Moreover, EUS‐CGN may provide greater pain relief than conventional EUS‐CPN. Procedure‐related complications include transient pain exacerbation, transient hypotension, transient diarrhea, and inebriation. Although most complications are not serious, major adverse events such as retroperitoneal bleeding, abscess, and ischemic complications occasionally occur.