Masafumi Mizuide

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.

AIM To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction. METHODS Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis. RESULTS In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC). CONCLUSION PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.

Small cell carcinoma of the parotid gland.

A58-year-old female was referred for evaluation of a painless mass in the right parotid region. The tumor, which had been present for 2 to 3 months, had been previously examined by fine needle aspiration biopsy, and yielded no malignancy. The patient’s medical history was negative for prior malignancy and smoking. Apart from a firm parotid mass that measured 30 mm in diameter, she was asymptomatic and had no other clinical signs. A magnetic resonance imaging of the neck revealed a ring-enhanced parotid mass (Fig 1). She underwent total right parotidectomy and upper neck lymph node dissection. Pathologic evaluation revealed an undifferentiated small cell carcinoma (Fig 2). Immunohistochemical staining demonstrated the expression of cytokeratin, synaptophysin, and neuron-specific antigen consistent with the diagnosis. No pulmonary pathosis was detected. After she recovered from surgery, a computed tomographic (CT) scanning revealed multiple liver metastases. The multiple bone metastases were also confirmed on positron emission tomography with fluorine-18-labeled fluorodeoxyglucose scanning. However, because of mild liver dysfunction as a result of a marked tumor growth in the liver, she had general fatigue and appetite loss. Chemotherapy was initiated with carboplatin (area under the curve 4.5) given on day 1, and etoposide 80 mg/m2 from days 1 to 3, with cycles repeated every 3 weeks. After two cycles of chemotherapy, the patient felt symptomatically better, and a repeat CT revealed marked tumor reduction in the liver. However, her general condition rapidly deteriorated after three cycles of chemotherapy, and she died 3 months after surgery. An autopsy was performed, and the postmortem findings revealed extensive recurrence of small cell carcinoma. There were no suggestive sites of origin outside of the parotid region.

Hereditary hemorrhagic telangiectasia with multiple hepatic and pulmonary nodular lesions

A 50-year-old female visited the hospital for further evaluation of multiple pulmonary and hepatic nodules. First, she visited her primary physician for general fatigue due to anemia. She had recurrent epistaxis, and her mother had suffered from hereditary hemorrhagic telangiectasia (HHT). Telangiectasias were present in the stomach. This patient was diagnosed with HHT. Computed tomography (CT) revealed multiple pulmonary and hepatic nodules. The pulmonary nodules were due to bleeding from arteriovenous malformations of the lung. Abdominal CT and angiography showed a dilated and meandering hepatic artery, arteriovenous shunts and multiple hepatic nodules. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) showed enhancement in the early dynamic phase and in the liver-specific phase. A liver tumor biopsy of a hepatic nodule showed nodular regenerative hyperplasia (NRH). This report presents a case of HHT with multiple pulmonary and hepatic nodular lesions. Gd-EOB-DTPA-enhanced MRI was useful for making a diagnosis of NRH.

Multicenter study of endoscopic preoperative biliary drainage for malignant hilar biliary obstruction: E-POD hilar study: Preoperative hilar biliary drainage

Endoscopic nasobiliary drainage (ENBD) is often recommended in preoperative biliary drainage (PBD) for hilar malignant biliary obstruction (MBO), but endoscopic biliary stent (EBS) is also used in the clinical practice. We conducted this large‐scale multicenter study to compare ENBD and EBS in this setting.

Photodynamic therapy for local recurrence of esophageal cancer in the esophagus after resection and free jejunal loop interposition for pharyngeal cancer

a Department of Gastroenterology, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan b Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Address: 3-39-15 Showamachi, Maebashi, Gunma 371-8511, Japan c Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Address: 3-39-22 Showamachi, Maebashi, Gunma 371-8511, Japan Available online 2 June 2014

Gastric Ulcer Revealed by Computed Tomography in a Patient with Tongue Cancer after Percutaneous Gastrostomy

With the advances in computed tomography (CT) imaging, CT can result in precise imaging, even of the gastrointestinal tract. However, the diagnostic quality of endoscopy is superior to CT because of precise mucosal observations or biopsy procedure. In the present case, CT was useful in the diagnosis of a gastric ulcer because endoscopy was deemed too difficult to perform due to tongue cancer occupying the oral space. Three-dimensional reconstruction of the CT images revealed an ulcerous lesion at the upper posterior wall of the stomach. CT may therefore be helpful for the diagnosis of gastric lesions when usual endoscopy is difficult to perform, as observed in the present patient.