Kensuke Yoshimoto

Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum β-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Tips for Using SpyGlass Peroral Pancreatoscopy and X-Ray-Guided Electrohydraulic Lithotripsy for Refractory Pancreatic Stones

Objective: Extracorporeal shock wave lithotripsy (ESWL) and endoscopic stone lithotomy (EL) are minimally invasive procedures that are useful for treating pancreatic stones. However, large-diameter and impacted stones can be refractory to these treatments. We retrospectively evaluated the efficacy of peroral pancreatoscopy (POPS) and X-ray-guided electrohydraulic lithotripsy (EHL) in treating refractory pancreatic stones. Methods: From May 2005 to April 2014, 159 chronic pancreatitis and pancreatic lithiasis patients were treated with ESWL and EL. EHL was performed as a second attempt for unsuccessful ESWL and EL cases. For refractory cases, we used the 10 Fr SpyGlass Direct Visualization System for POPS-guided EHL. X-ray-guided EHL (using a 7 Fr biliary dilator as an outer sheath) was performed when a 10 Fr SpyGlass system was difficult to insert into the main pancreatic duct. Results: A total of 18 patients were included in this study. The mean stone diameter was 12.3 ± 4.5 mm, with 7 patients having a single stone and 11 patients having multiple stones. POPS-guided EHL was performed in nine cases and X-ray-guided EHL was performed in nine cases. Fragmentation was successful in nine (50%) patients: four treated with POPS-guided EHL and five treated with X-ray-guided EHL. Two patients developed mild post-ERCP pancreatitis following X-ray-guided EHL. Conclusions: POPS-guided and X-ray-guided EHL may be an alternative treatment for refractory stones. Because EHL can cause severe complications, adequate precautions are necessary for these treatments.

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones

Aim Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures. Methods Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis. Results Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p = 0.03). Conclusion The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.