Masamichi Enya

PREDICTIVE FACTORS FOR PAIN RELIEF AFTER ENDOSCOPIC ULTRASOUND-GUIDED CELIAC PLEXUS NEUROLYSIS

Background:  Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound‐guided CPN (EUS‐CPN) was introduced and has enabled the performance of CPN under real‐time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS‐CPN in order to enable rational selection of the therapeutic strategy.

Inflammatory pseudotumor of the liver with primary sclerosing cholangitis

Abstract: Inflammatory pseudotumor (IPT) of the liver is a rare benign variant of hepatic masses, and its exact etiology has not been elucidated. We report a case of IPT associated with primary sclerosing cholangitis (PSC). The patient was a 50-year-old man admitted to our hospital because of jaundice. Abdominal ultrasonography (US) and computed tomography showed multiple dilations of the intrahepatic bile ducts and multiple masses in the liver. On magnetic resonance imaging, the masses were slightly hypointense on T1-weighted images and slightly hyperintense on T2-weighted images. On T1-weighted images after the bolus infusion of Gd chelate, the masses had no contrast enhancement, and they were hypointense in the arterial phase and portal venous phase. However, they were slightly enhanced and became almost isointense relative to the surrounding normal liver parenchyma in the delayed phase. Endoscopic retrograde cholangiography demonstrated multiple irregular strictures and dilations of the intrahepatic bile ducts. Angiography demonstrated no abnormal findings, but, interestingly, subsequent dynamic CO2-enhanced US showed a strongly hyperechoic string, indicating that an artery had penetrated through the hypoechoic mass. A US-guided percutaneous needle biopsy revealed that the lesions were morphologically comparable to IPT. After cholangiography and microscopic analysis of the tumor, the final diagnosis was determined to be IPT of the liver with PSC. A number of previous reports have suggested a possible relationship between IPT and PSC, based on pathological findings. This report confirmed, based on clinical findings, that PSC is one of the causes of hepatic IPT.

Intraductal chilled saline perfusion to prevent bile duct injury during percutaneous radiofrequency ablation for hepatocellular carcinoma.

Background and Aim:  Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC.

Endoscopic papillary balloon dilatation for common bile duct stones: efficacy of combination with extracorporeal shockwave lithotripsy for large stones.

Background Endoscopic papillary balloon dilatation (EPBD) is generally considered a safe and effective technique for removal of common bile duct (CBD) stones. However, some reports have prompted concern about the risk of pancreatitis following the procedure, and it seems to be more difficult and to require adjunctive procedures more frequently in patients with large stones. Aims To analyse the factors influencing pancreatitis after the procedure, and to examine which is the more suitable adjunct for treating large stones, mechanical lithotripsy (ML) or extracorporeal Shockwave lithotripsy (ESWL). Patients and methods EPBD was performed in 92 patients, including 40 with large stones (≥ 12 mm). These 40 patients were randomly assigned to two groups receiving ML or ESWL to fragment stones (20 patients each). Results Complete ductal clearance was obtained in all 92 patients. Significant elevation of the serum amylase level compared with the prior value (> 300 IU/I) was observed in 26 (28%), and eight (8.7%) developed clinical pancreatitis. To assess the influence of various factors on the amylase level, multivariate analysis was used. The number of stones and the time required for treatment had a significant influence on the incidence of increased amylase level (P < 0.05), and ML also significantly increased it (P < 0.05). On the other hand, the amylase level remained low in the ESWL group. ML caused elevation of amylase level in 11 patients (55%), while three (15%) had elevation after ESWL. Conclusions In patients with multiple stones, elevation of the amylase level is more frequent This seems to be because repeated cannulation and much time is required for treatment. In patients with large stones, the rate was also high if ML was used, but was low when ESWL was used. ESWL may reduce the incidence of pancreatitis.

Therapeutic effect of intraarterial prednisolone injection in severe intestinal Behçet's disease.

A 64-year-old woman with severe intestinal Behçets disease who was unresponsive to conventional therapies, including intensive intravenous steroid injections, underwent intraarterial steroid injection therapy. After the infusion of prednisolone into the mesenteric arteries, her colon ulcers improved markedly, and the frequency of bloody stools decreased immediately. The present case suggests that intraarterial steroid injection therapy may be potentially useful in severe intestinal Behçets disease.

DIAGNOSTIC VALUE OF TRANSPAPILLARY BIOPSY USING DOUBLE LUMEN INTRODUCER FOR DETERMINATION OF MUCOSAL EXTENT IN EXTRAHEPATIC BILE DUCT CANCER

Diagnosis of the upstream extent of extrahepatic bile duct cancer has been difficult via the transpapillary approach, due to the difficulty of obtaining a biopsy sample above the stricture. We developed a new biopsy technique that allows a sample to be taken above the stricture, and prospectively evaluated the new techniques utility. Twenty‐four consecutive patients diagnosed as having possible extrahepatic bile duct cancer by endoscopic retrograde cholangiopancreatography and other imaging tests were included in the study. They initially underwent endoscopic placement of a nasobiliary drainage tube. After improvement of jaundice and cholangitis, the cholangiogram obtained via the tube was examined and transpapillary biopsy was performed using a double lumen catheter under fluoroscopic guidance. The biopsy sampling in the stricture was successful in all cases, and pathological diagnosis was confirmed in all cases. The success rate of the method of upstream diagnosis was also sufficient in cases in which stricture was located below the middle extrahepatic bile duct. However, it was relatively low in cases whose stricture was located in the upper extrahepatic bile duct. Biopsy sampling in the hepatic hilum was also difficult. The transpapillary biopsy technique is useful for determination of the upstream extent of extrahepatic bile duct cancer, especially in cases in which stricture is located in the lower extrahepatic bile duct. Compared to the percutaneous transhepatic approach, it is less invasive and can shorten the preoperative period. It was also seen to be relatively safe, easy and convenient.

Psychoneurological symptoms during interferon therapy in patients with chronic hepatitis: prospective study on predictive use of Cornell Medical Index and electroencephalogram

Abstract: Background/Aims: We assessed the usefulness of the Cornell Medical Index (CMI) and electroencephalogram (EEG) in the prediction and early detection of psychoneurological symptoms associated with interferon (IFN) therapy for chronic viral hepatitis.

Endoscopic treatment for benign biliary strictures: Can placement of a covered metallic stent be an option in refractory cases?

Background:  Recently, endoscopic treatment has been attempted to counter benign biliary strictures. It is expected to be an alternative to surgical operation because of its lower morbidity and its convenience, but the long‐term results have not yet been sufficiently elucidated. Here, we evaluate the short‐ and long‐term results of endoscopic stenting in patients with benign biliary strictures, and also describe a new technique using a covered metallic stent (CMS) in the refractory cases.

ENDOSCOPIC ULTRASOUND-GUIDED DRAINAGE OF PANCREATIC PSEUDOCYSTS USING A LARGE-CHANNEL ECHOENDOSCOPE AND A CONVENTIONAL POLYPECTOMY SNARE

Background:  Endoscopic drainage of pancreatic pseudocysts is becoming common. Recent techniques using endoscopic ultrasound (EUS) have made the procedure safer and easier. However, bleeding related to the procedure is sometimes still experienced and placement of the tube is also sometimes difficult in cases where the cystic wall is thick and hard. We describe a new technique of EUS‐guided drainage using a large‐channel echoendoscope, a conventional polypectomy snare and a high‐frequency current generator with automatic controls. We also evaluate this techniques utility.

ENDOSCOPIC NASOBILIARY DRAINAGE : CURRENT INDICATIONS AND EVALUATION OF THE PRODUCTS

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.