Kensei Maeshiro

Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones

OBJECTIVE Endoscopic sphincterotomy (ES) is a well-established standard method for treating common bile duct stones. However, biliary sphincter function is impaired after the treatment, and this may influence the long-term outcomes. In this study, we aimed to compare the long-term outcomes after ES with those after endoscopic papillary balloon dilation (EPBD) because the latter procedure is expected to preserve biliary sphincter function better than ES. DESIGN A prospective follow-up of the original cohort in a previously randomized, controlled trial to compare the early outcomes after ES and EPBD. SETTING Eleven centers, including 6 clinical practices and 5 academic institutions. PATIENTS A total of 282 patients with common bile duct stones were randomly selected to undergo ES (n = 144) or EPBD (n = 138) in the previous study. INTERVENTIONS ES or EPBD. MAIN OUTCOME MEASUREMENTS Complications after ES or EPBD occurring during long-term follow-up. RESULTS The patients were followed up annually after the treatment. The median duration of the follow-up was 6.7 years. Morbidity was observed in 36 (25.0%) and 14 (10.1%) of the patients who underwent ES and EPBD, respectively (P = .0016). Kaplan-Meier analysis revealed a significantly higher incidence of biliary complications in the ES group than in the EPBD group (P = .0011). Multivariate analysis showed that ES, periampullary diverticulum, and in situ gallbladder stones were independent risk factors for stone recurrence. CONCLUSIONS During long-term follow-up, patients who underwent ES had significantly more biliary complications than those who underwent EPBD. The biliary sphincter dysfunction after ES results in additional late complications.

Intraductal tubular adenoma of the pancreas, pyloric gland type: a clinicopathologic and immunohistochemical study of 6 cases.

Abstract:The intraductal tubular adenoma (ITA), pyloric gland type, of the pancreas is an uncommon benign tumor, akin to the pyloric gland type adenoma of the gallbladder. We report 6 cases of ITA of the pancreas: 3 male and 3 female aged 50 to 79 years (mean, 63.5 years; median, 65 years); all were examined clinicopathologically. Four patients showed no symptoms, but appetite loss and/or general fatigue presented in two. Grossly, all tumors formed a localized polypoid mass protruding into the lumen of the dilated pancreatic duct. Five of the six tumors were found within the main duct, and the other arose within the branch duct of the pancreas. Microscopically, the tumors were composed of closely packed tubular glands resembling pyloric type glands. They were lined by columnar or cuboidal epithelial cells with foci of mild to moderate dysplastic change. In 2 cases, the adjacent pancreas showed foci of intraductal papillary-mucinous adenoma. Histochemically, the tumors largely showed neutral mucin with a lesser amount of acidic mucin made up mainly of sialomucin. Endocrine cells were found in five tumors. Immunohistochemically, all tumors were labeled with M-GGMC-1 and MUC6, whereas MUC1 and MUC2 stains were negative. Pepsinogen II was positive in 5 tumors; thus, the results displayed a pattern of differentiation similar to those of ordinary gastric pyloric or metaplastic pyloric glands. DPC4 expression was maintained in all tumors and p53-positive nuclei were hardly encountered. All patients are alive with no evidence of disease 3 to 10.5 years after surgical resection.

Diagnosis of small pancreatic cancer by endoscopic balloon-catheter spot pancreatography: an analysis of 29 patients.

Objectives: The diagnosis of small pancreatic cancer remains difficult. The present study describes the diagnostic value of endoscopic balloon-catheter spot pancreatography for small pancreatic cancer. Methods: Since April 1984, balloon spot pancreatography has been used to detect small-sized pancreatic cancer in patients having possible symptoms or findings of obstructive pancreatitis. Results: A resection was performed on 175 of 416 patients with conditions diagnosed as pancreatic cancer. Of the 175 patients, 23 (13%) had invasive carcinoma 2 cm or smaller based on histological measurements, 3 intraductal papillotubular adenocarcinoma, and 3 carcinoma in situ (CIS). Regarding invasive carcinoma, balloon pancreatography displayed duct abnormalities diagnosed as carcinoma in 20 of 22 patients, whereas carcinoma was suggested in 2. A definite diagnosis was obtained based on the findings of main duct stenosis or obstruction with marked stricture of the branch ducts (n = 18) and a filling defect in the main duct (n = 2). Moreover, this pancreatogram demonstrated an intraductal filling defect in 2 of 3 with intraductal carcinoma and dead twiglike findings in the branch ducts in 1 of 3 with CIS. Conclusions: Balloon spot pancreatography is an essential tool for the diagnosis of small ductal pancreatic cancer, and it also makes it possible to locate CIS lesions of the branch ducts.

Endoscopic Biliary Drainage for Acute Obstructive Cholangitis: Analysis of 100 Consecutive Patients

Abstract: Acute obstructive suppurative cholangitis is a life‐threatening condition and prompt biliary decompression is essential if the patient is to survive. One hundred patients with acute obstructive (suppurative) cholangitis were treated by simple endoscopic cannulation for biliary drainage. Forty‐eight patients had common duct stones alone, 33 patients had additional stones in the gallbladder, and 18 patients had stones in the intrahepatic ducts. Another patient had a confluence stone. Twenty‐six patients had undergone endoscopic sphincterotomy. Bile duct dilatation was present in only 25 of 47 patients (53%) studied by ultrasound tomography. Biliary decompression was achieved in 98 patients. One tortuous distal bile duct and one oversized stone were the causes of failure in two patients. Forty‐seven patients proved to have suppurative cholangitis. Most patients felt instant and dramatic relief of their syniptoms. Bleeding at sphinctetomy was the only complication associated with the decompression ocurring in 2 patients. Bending (2 patients) and withdrawal (2 patients) of a nasobiliary catheter, and nasal bleeding (1 patient) were the complications related to nasobiliary drainage. Two patients with suppurative cholangitis died despite successful decompression performed 3 and 5 days after the onset of cholangitis. This delay seemed responsible for their deaths. Thus the mortality rate was 2.0% for all the patients arid 4.3% for those with suppurative cholangitis. These results suggest that endoscopic cannulation, which is feasible even in the absence of bile duct dilatation, is a prompt, safe, and effective procedure for emergency biliary decompression for the treatment of acute obstructive (suppurative) cholangitis.

Knowledge discovery for pancreatic cancer using inductive logic programming.

Pancreatic cancer is a devastating disease and predicting the status of the patients becomes an important and urgent issue. The authors explore the applicability of inductive logic programming (ILP) method in the disease and show that the accumulated clinical laboratory data can be used to predict disease characteristics, and this will contribute to the selection of therapeutic modalities of pancreatic cancer. The availability of a large amount of clinical laboratory data provides clues to aid in the knowledge discovery of diseases. In predicting the differentiation of tumour and the status of lymph node metastasis in pancreatic cancer, using the ILP model, three rules are developed that are consistent with descriptions in the literature. The rules that are identified are useful to detect the differentiation of tumour and the status of lymph node metastasis in pancreatic cancer and therefore contributed significantly to the decision of therapeutic strategies. In addition, the proposed method is compared with the other typical classification techniques and the results further confirm the superiority and merit of the proposed method.

FU-MK-1 expression in human gallbladder carcinoma: an antigenic prediction marker for a better postsurgical prognosis.

Gallbladder carcinoma is an aggressive type of neoplasm difficult to cure by conventional procedures. Because of the lack of reliable markers for assessing the prognosis, this retrospective study was designed to investigate the prognostic significance of MK-1 overexpression in human carcinoma of the gallbladder. Immunohistochemical staining using monoclonal antibody FU-MK-1 (MK-1 antigen) was performed on paraffin-embedded tissues from 63 patients who had undergone surgical resection for gallbladder carcinoma. Expression of MK-1 was found in 50 (79%) of 63 tumor samples. All 21 papillary and 12 of 13 well-differentiated tubular adenocarcinomas but only 1 of 8 poorly differentiated adenocarcinomas were positive for FU-MK-1. Multivariate analysis showed that only MK-1 expression was an independent prognostic marker (P = .0473), and Kaplan-Meier curves showed that MK-1 expression was significantly related to increased overall survival (P < .0001). These results suggest that MK-1 expression is a prognostic marker in gallbladder carcinoma.

Management of giant common bile duct stones in high-risk patients using a combined transhepatic and endoscopic approach.

BACKGROUND Endoscopic sphincterotomy (EST) for removing common bile duct stones is regarded as the safest and most successful method, particularly in patients with a high surgical risk. However, giant immobile stones still continue to present a therapeutic problem. METHODS In our 12 patients, when endoscopic sphincterotomy and lithotomy proved to be unsuccessful a transhepatic choledochoscopic lithotomy was attempted. RESULTS The stones were fragmented using choledochoscopic electrohydraulic lithotripsy and then were completely removed through both the transhepatic route and an EST opening in all 12 patients. The number of sessions required for these choledochoscopic procedures combined with EST was fewer than that required for only a transhepatic approach (2.5 +/- 1.3 versus 3.2 +/- 1.2), which thus resulted in a shorter hospital stay. Minor complications occurred in three patients with bleeding (two from the bile duct, one from the EST opening) and in two with postprocedure chills and fever. CONCLUSIONS A combined lithotomy through duodenoscopic and choledochoscopic approaches is considered to be an efficient method for removing giant biliary calculi in patients who are not successfully treated by an ordinary duodenoscopic lithotomy.

Balloon-catheter endoscopic retrograde pancreatography-compression study for diagnosis of early-stage pancreatitis

Endoscopic retrograde pancreatography (ERP) is considered by many as the gold standard imaging method in the diagnosis of chronic pancreatitis (CP). However, conventional ERP usually has a limited ability to accurately diagnose early-stage CP, in which only the branch ducts are involved and the main pancreatic duct (MPD) is unaffected. To visualize precisely the branch ducts, we have developed a more sophisticated ERP method, called balloon ERP-compression study (balloon ERP-CS). In this procedure, a catheter equipped with a balloon at its tip is placed first into the MPD via the papilla with the aid of conventional ERP, followed by the removal of the endoscope, leaving the catheter behind. Then, the balloon is inflated, and the contrast medium is injected slowly. The balloon serves to block the back flow of the injected contrast medium from the MPD to the duodenum, enabling visualization of the branch ducts. The compression study affords further precise pancreatography of the corresponding area. Thus, balloon ERP-CS has now become an essential procedure for diagnosis of pancreatic lesions, including CP. So far (April 1984 to April 2005), we have performed the procedure in 1012 cases, for a total of 1562 examinations. In this study, we focus on the role of balloon ERP-CS in diagnosis of early-stage CP to elucidate its characteristic features in association with histological findings. This presentation will clarify the usefulness as well as the limitations of balloon ERP-CS for the diagnosis of CP, especially cases without the involvement of the MPD.

Relationship between the shape and the patency of Santorini's accessory pancreatic duct revealed by a balloon endoscopic retrograde pancreatography compression study

Background:  Pancreatic juice flows into the duodenum via two pancreatic ducts including Wirsungs duct (main pancreatic duct) and Santorinis duct (accessory pancreatic duct). In contrast to Wirsungs duct, the precise anatomy and functions of Santorinis duct are still obscure.

Combined Non-Surgical Treatment with Transileocolic Obliteration and Endoscopic Injection Sclerotherapy for Esophageal and Gastric Varices

Abstract: Clinical results associated with the combined treatment of endoscopic injection sclerotherapy (EIS) followed by transileocolic obliteration (TIO) for esophageal of gastric varices were evaluated in 31 patients. Twenty patients underwent emergency treatment, and 11 underwent non‐ememgency treatment. No fatal complications developed after this combined treatment.