Itsuki Sano

Resected tumor seeding in stomach wall due to endoscopic ultrasonography-guided fine needle aspiration of pancreatic adenocarcinoma.

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is a useful and relatively safe tool for the diagnosis and staging of pancreatic cancer. However, there have recently been several reports of tumor seeding after EUS-FNA of adenocarcinomas. A 78-year-old man was admitted to our hospital due to upper gastric pain. Examinations revealed a 20 mm mass in the pancreatic body, for which EUS-FNA was performed. The cytology of the lesion was adenocarcinoma, and the stage of the cancer was T3N0M0. The patient underwent surgery with curative intent, followed by adjuvant chemotherapy with S-1. An enlarging gastric submucosal tumor was found on gastroscopy at 28 mo after surgery accompanied by a rising level of CA19-9. Biopsy result was adenocarcinoma, consistent with a pancreatic primary tumor. Tumor seeding after EUS-FNA was strongly suspected. The patient underwent surgical resection of the gastric tumor with curative intent. The pathological result of the resected gastric specimen was adenocarcinoma with a perfectly matched mucin special stain result with the previously resected pancreatic cancer. This is the first case report of tumor seeding after EUS-FNA which was surgically resected and inspected pathologically.

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.

Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure

Background and study aims Short-type single-balloon enteroscope (short SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is a promising alternative treatment in postsurgical altered anatomy. However, it is technically demanding, and factors affecting its technical difficulty have not yet been clarified. This study aimed to examine the procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure. Patients and methods A total of 117 consecutive patients (203 procedures) with surgically altered anatomy underwent ERCP using prototype short SBEs. The procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure were examined retrospectively. Results The enteroscopy success rate and procedural success rate were 92.6 % (95 % confidence interval [CI] 88.1 % - 95.8 %) and 81.8 % (95 %CI 75.8 % - 86.8 %), respectively. Multivariate analyses indicated that pancreatic indication (odds ratio [OR] 4.35, 95 %CI 1.67 - 11.4), first ERCP attempt (OR 6.03, 95 %CI 2.17 - 16.8), and no transparent hood (OR 4.61, 95 %CI 1.48 - 14.3) were potential risk factors for procedural failure. Conclusions Short SBE-assisted ERCP was effective in postsurgical altered anatomy. This large case series suggested the potential factors affecting procedural failure.

Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique

Title Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique Author(s) Kawakubo, Kazumichi; Kuwatani, Masaki; Kato, Shin; Sugiura, Ryo; Sano, Itsuki; Sakamoto, Naoya Citation Endoscopic Ultrasound, 7(2), 133-134 https://doi.org/10.4103/eus.eus_31_17 Issue Date 2018-03 Doc URL http://hdl.handle.net/2115/71166 Rights(URL) http://creativecommons.org/licenses/by-nc-sa/3.0/ Type article File Information EndoscUltrasound72133-2596543_071245.pdf

Pancreatic Metastasis from Rectal Cancer that was Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Aspiration (EUS-FNA)

Pancreatic metastasis from colorectal cancer is rare, and there have been only a few reports of its preoperative diagnosis by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with immunohistochemical staining. We herein describe the case of a 77-year-old woman in whom a solitary mass in the pancreatic tail was detected 11 years after rectal cancer resection. The patient also had a history of pulmonary tumor resection. We performed EUS-FNA and a histopathological examination showed adenocarcinoma with CD20+, CD7-, and CDX2+ (similar to her rectal cancer). EUS-FNA enabled a histopathological examination, including immunohistochemical staining, which helped to confirm the diagnosis of pancreatic and pulmonary metastasis from rectal cancer.

Successful re-intervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy

Recently, endoscopic ultrasound (EUS)guided biliary drainage has been introduced as an alternative method after failed endoscopic biliary drainage, particularly in patients with a pre-existing duodenal obstruction [1–3]. A longer self-expandable metal stent (SEMS) is usually used for EUS-guided hepaticogastrostomy (EUS-HGS) to prevent stent migration. However, re-intervention after EUS-HGS is challenging because of the protrusion of the SEMS into the stomach. Metal stent trimming using argon plasma coagulation (APC) has been reported to be a useful option for stent-related complications such as dislocation [4,5]. We report a case in which successful re-intervention after EUS-HGS was made possible by metal stent trimming using APC. A nonagenarian woman with advanced ampullary cancer was admitted to our center. She had a history of endoscopic transpapillary bile duct stenting and duodenal stenting covering the papilla, followed by EUS-HGS with an 8-mm diameter, 12-cm long, silicone-covered nitinol braided stent, with a 1-cm uncovered portion at the proximal end (Niti-S biliary S-type; Taewoong Medical, Seoul, South Korea). The patient developed recurrent cholangitis caused by sludge formation 3 months after HGS. As she showed a good performance status, we attempted therapeutic endoscopic intervention via the HGS site; however, intervention was difficult beFig.1 Protrusion into the stomach of the long self-expandable metal stent (SEMS) used for endoscopic ultrasoundguided hepaticogastrostomy (EUS-HGS): a on computed tomography (CT) scan; b on endoscopy.

A Case of IgG4-related Lung Pseudotumor and Pleural Inflammation with Autoimmune Hepatitis.

A 63-year-old man was admitted to our department following a secondary medical examination. Blood tests showed high levels of liver enzymes, IgG, IgG4, and antinuclear antibody. Computed tomography showed tumors in the bilateral lower lobes of the lungs and pleural thickening. After pleural and liver biopsy procedures, he was conclusively diagnosed with IgG4-related lung pseudotumor and pleural inflammation with autoimmune hepatitis. We started treatment with prednisolone 40 mg/day, and chest radiograph and blood tests showed signs of improvement. This was a rare case that suggested an association between IgG4-related disease and autoimmune hepatitis.

Successful endoscopic sphincterotomy for choledocholithiasis in a patient with severe hemophilia A and inhibitors

Endoscopic sphincterotomy (ES) is a standard procedure for bile duct stone removal. However, the safety of ES in patients with hemophilia remains unknown. We treated a 46-year-old man who had choledocholithiasis and severe hemophilia A with high-responding inhibitors during immune tolerance induction therapy. Since coagulation factor VIII inhibitors neutralize and inactivate endogenous and exogenous factor VIII, bleeding risk is higher in hemophilia A patients with inhibitors than in those without inhibitors. With adequate pre- and post-procedure monitoring of the clotting factor and supplemented clotting factor, the patient could safely undergo ES without bleeding complications. ES can be also an effective and safe first-line therapy for choledocholithiasis in patients with hemophilia and inhibitors under the condition of appropriate management.

Effect of endoscopic transpapillary biliary drainage with/without endoscopic sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with biliary stricture (E-BEST): a protocol for a multicentre randomised controlled trial

Introduction The effect of endoscopic sphincterotomy prior to endoscopic biliary stenting to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis remains to be fully elucidated. The aim of this study is to prospectively evaluate the non-inferiority of non-endoscopic sphincterotomy prior to stenting for naïve major duodenal papilla compared with endoscopic sphincterotomy prior to stenting in patients with biliary stricture. Methods and analysis We designed a multicentre randomised controlled trial, for which we will recruit 370 patients with biliary stricture requiring endoscopic biliary stenting from 26 high-volume institutions in Japan. Patients will be randomly allocated to the endoscopic sphincterotomy group or the non-endoscopic sphincterotomy group. The main outcome measure is the incidence of pancreatitis within 2 days of initial transpapillary biliary drainage. Data will be analysed on completion of the study. We will calculate the 95% confidence intervals (CIs) of the incidence of pancreatitis in each group and analyse weather the difference in both groups with 95% CIs is within the non-inferiority margin (6%) using the Wald method. Ethics and dissemination This study has been approved by the institutional review board of Hokkaido University Hospital (IRB: 016–0181). Results will be submitted for presentation at an international medical conference and published in a peer-reviewed journal. Trial registration number The University Hospital Medical Information Network ID: UMIN000025727 Pre-results.

Su1471 Clinical Observation Is Possible for Branch Duct Type Intraductal Papillary Mucinous Neoplasms With Mural Nodules ≤6mm

Introduction: The presence of mural nodule (MN) is an important factor for the management of branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). International consensus guidelines 2012 recommend clinical follow-up to BD-IPMN without MNs. However, it is not clear whether BD-IPMNs with MNs need surgical treatment regardless of the height of MNs. Aim: To compare the pathological and follow-up outcomes between BDIPMNs with MNs ≤6mm in height (MN+) and those without MNs (MN-). Methods: The patients who were diagnosed as BD-IPMNs with MNs ≤6mm or without MNs since April 2004 to December 2013 were retrospectively analyzed. Inclusion criteria were the obtaining of contrast enhanced CT and EUS at initial diagnosis, and surgical resection in our center or follow-up with annual/semi-annual CT/MRCP. The cyst size and main pancreatic duct (MPD) diameter were measured by CT/MRCP, while MN height was measured by EUS. Tumor progression during follow-up was defined as follows; increased cyst size ≥10mm; increased MPD diameter ≥10mm; new development of MN or increased MN height ≥2mm. Evaluation points: 1) pathological diagnosis of resected BD-IPMN, 2) follow-up outcomes Results: Among 656 patients of BD-IPMNs diagnosed in our center, MN height was evaluated as less than or equal to 6mm in 511(78%; MN+ 50, MN352). After initial diagnosis, 17(3%; MN+ 8, MN9) of them underwent immediate resection and 385(75%; MN+ 42, MN343) of them received regular follow-up, who were eligible for this analysis. The median cyst size and MPD diameter were 20(10-70) mm and 3(2-12) mm, respectively. The median height of MNs in MN+ were 3(1-6) mm. 1) The pathological diagnosis of the patients with MNwere all low/intermediate-grade dysplasia (LID), while those of the patients with MN+ were LID in 5, high-grade dysplasia (HD) in 2, and invasive carcinoma (IC) in 1. There were no significant differences in pathological diagnosis between MN+ and MN(p=0.17, chi-square test). 2) During a median follow-up period of 3.4(0.5-10.6) years, 49(13%; MN+ 9, MN40) patients exhibited tumor progression. The 5-years cumulative tumor progression rate was higher in MN+ than those in MN(MN+ 19% vs MN9%; p<0.01, Log-rank test). Among 49 patients with tumor progression, 11(22%; MN+ 4, MN7) patients underwent surgical resection, whose pathological diagnosis were LID in 6(MN+ 2, MN4), HD in 3(MN+ 1, MN2), and IC with minimal invasion in 2(MN+ 1, MN1). The other 38 patients continued to be followed during a median period of 0.6(0.0-4.2) years. Meanwhile, concomitant pancreatic ductal adenocarcinoma (PDAC) was appeared in 9(2%; MN+ 1, MN8) patients. Conclusion: Although tumor progression rate was higher, BD-IPMN with MNs ≤6mm in height on EUS could be managed conservatively. However, careful attention should be paid to the development of PDAC during follow-up.