Kazumu Okushima

Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): Covered Wallstent versus DoubleLayer stent.

Background:  No study has compared covered metallic stents with Tannenbaum stents. We evaluated the efficacy of the DoubleLayer stent (DLS) and Covered Wallstent (CWS) in patients with pancreatic head cancer (PHC).

ENDOLUMINAL ULTRASONOGRAPHY FOR PANCREATIC DISEASES

Endoluminal ultrasonography was performed on 146 patients with pancreatobiliary diseases by using high-frequency, thin ultrasonic probes, and the usefulness of the new technique in diagnosis of pancreatic diseases was reported. The ultrasound probe could be inserted into the main pancreatic duct in 43 of 46 patients (93.5%), and images of the lesions could be obtained in 42 patients (91.3%). Endoluminal ultrasonography revealed a hypoechoic mass with clear margins and central echogenicity in patients with pancreatic carcinoma. Endoluminal ultrasonography showed normal pancreatic parenchyma as a fine reticular pattern and did not reveal the tumors surrounding the stenosis in patients with focal pancreatitis. Endoluminal ultrasonography in patients with intraductal papillary adenocarcinoma of the pancreas revealed cystic lesions with mural nodules more than 4 mm, mucus echoes, and solid tumors with mixed echo patterns. There were no severe complications, and acute pancreatitis occurred in none of 46 patients, but high-level serum amylase after examination occurred in 5 patients (10.9%). Endoluminal ultrasonography is useful for differential diagnosis in patients with small pancreatic tumors or cystic lesions, especially intraductal papillary tumors of the pancreas. Endoluminal ultrasonography is recommended as a precise examination for the diagnosis of cystic lesions of the pancreas or stenosis of the main pancreatic duct after ERCP and EUS.

Endoscopy and intraductal ultrasonography

Because the prognosis in pancreatic carcinoma is so poor, a reliable method for early detection of tumors is needed. Endoscopic ultrasonography (EUS) is a useful method for precise diagnosis of pancreatic tumors. Recently, peroral pancreatoscopy (POPS) and intraductal ultrasonography (IDUS) have been introduced to make a more detailed diagnosis of pancreatic tumors. These three techniques were performed in 48 patients with pancreatic carcinoma. The ultrasonographic and endoscopic findings of pancreatic carcinoma were studied. EUS, IDUS, and POPS are very useful for differentiating between benign and malignant pancreatic tumors.

SHORT-TERM METAL STENTING FOR TREATMENT OF MAIN PANCREATIC DUCT STRICTURES ASSOCIATED WITH CHRONIC PANCREATITIS

Background:  Stricture of the main pancreatic duct associated with chronic pancreatitis is a cause of pain due to ductal high pressure and the formation of pancreatic stones, but there is no established non‐surgical therapeutic procedure. We attemped a new method for treating this condition, called short‐term metal stenting.

Three‐dimensional Ultrasonography Using Ultrasonic Probes by the Transpapillary Approach for Diagnosis of Pancreatobiliary Diseases

Abstract: Three‐dimensional (3D) intraductal ultrasonography (IDUS) is more useful than two‐dimensional IDUS for the diagnosis of pancreatobiliary disease. We investigated the advantages and disadvantages of the transpapillary approach for 3D‐IDUS using a newly developed system for pancreatobiliary application. In total 12 patients with a sufficiently wide orifice were examined, bile duct (BD) scanning being successful in 100% of attempted cases and main pancreatic duct (MPD) scanning in 85.7%. In all cases, acceptable radial and linear images were obtained and 3D diagnosis was accomplished. However, several primary problems were experienced; 1) The 3D probe is relatively inflexible, having a thick shaft and a long tip, such that insertion into the BD or MPD can be somewhat difficult; 2) Clear images of the BD or MPD wall were not always obtained because of artifacts produced by the 3D probe itself; 3) In some cases, linear images could not be reconstructed with BD or MPD scanning despite sufficiently clear radial scan images. In the future, development of new 3D probes with more flexible and thinner shafts, and shorter tips, should considerably enhance the diagnostic capacity of IDUS for the pancreatobiliary system.

SPECIFIC DIAGNOSIS OF BILIARY STRICTURES BY QUANTITATIVE ASSESSMENT USING A CHOLANGIOSCOPICALLY DERIVED HEMOGLOBIN INDEX

Background:  We used percutaneous transhepatic cholangioscopy for detailed assessment of biliary tumors. Among the most important endoscopic findings is greater mucosal vascularity in malignant than in benign biliary strictures. Development of digital image processing now permits measurement of mucosal hemoglobin volume as a hemoglobin index. We studied the clinical usefulness of this hemoglobin index for differentiating malignant from benign biliary strictures.

A Case of Pancreatolithiasis Treated by a Combination of Endoscopic Extraction and Extracorporeal Shock Wave Lithotripsy

We report on the case of a 50‐year‐old woman with idiopathic chronic calcifying pancreatitis and diabetes. An endoscopic retrograde pancreatography showed a stone with a diameter of 23 mm and multiple small stones in the head of the pancreas. An endoscopic pancreatic sphincterotomy was performed. However, the stone could not be removed endoscopically. So we performed an extracorporeal shock wave lithotripsy (ESWL) using a Tripter X1. The stone was located in the shock wave focus by fluoroscopy. Under intravenous sedation, the patient received 5 ESWL sessions (a total of 11700 shock waves with an energy of 18kv). ESWL permitted stone disintegration and successful endoscopic extraction of the fragments. Complete clearance in the main pancreatic duct was achieved. No severe complications were observed. After treatment, an improvement in the PFD test was seen. ESWL is an effective method for treatment of endoscopically unextractable pancreatic ductal stones.

Application of peroral cholecystoscopy in a case of cholecystocolic fistula

A patient with a cholecystocolic fistula, complicating cholecysto‐choledocholithiasis, was treated endoscopically with gallbladder observation by peroral cholecystoscopy (POCCS). The patient was a 71‐year‐old female admitted to our hospital for investigation and treatment of biliary stones and a cholecystocolic fistula. Endoscopic lithotripsy and extracorporeal shock wave lithotripsy (ESWL) were performed after endoscopic sphincterotomy, and the gallbladder was subsequently investigated using a duodenoscope/ cholangioscope of the mother and baby type. Full distension of the gallbladder with saline solution allowed POCCS observation of the entire surface. The gallbladder mucosa was smooth, and neither stones nor tumors were observed. Though the cholecystocolic fistula itself could not be observed, we concluded that it had resulted from cholecystitis. Peroral cholecystoscopy is thus a useful method of investigating the gallbladder in such cases.

MERITS and DEMERITS OF METALLIC STENT FOR TREATMENT OF PANCREATIC DUCT STRICTURES IN PATIENTS WITH CHRONIC PANCREATITIS

We inserted a metallic stent into the strictures of the main pancreatic duct in two patients with calcified chronic pancreatitis and severe abdominal pain not to be relieved using narcotics. One patient was a 39‐year‐ old male, and the other was 49‐year‐old male. Their etiology of chronic pancreatitis was alcoholism. We inserted a Strecker stent, 7 mm in diameter and 6 cm in length, for achieving long‐term patency than plastic stent. In one patient, the stent was obstructed half a year after the first treatment and pancreatic calculi recurred with abdominal pain. After endoscopic extraction of pancreatic stone and balloon dilatation of the stent was performed three times, a plastic stent was inserted in the metallic stent twice. Even if he was performed nerve block twice, he was administered narcotics for treatment of continuous abdominal pain. In the other patient, the stent was obstructed 1.5 years after insertion and pancreatic calculi recurred with abdominal pain. He was treated with extracorporeal shock‐wave lithotripsy for pancreatic stone, abdominal pain continued. He underwent pylorus preserving pancreato‐duodenectomy 6 years after the first stenting, because the obstructed metallic stent could not be removed. Metallic stent should not be chosen for treatment of pancreatic duct stricture.