Naoko Kurihara

A new water instillation method for colonoscopy without sedation as performed by endoscopists-in-training

BACKGROUND Colonoscopy may be associated with discomfort when performed without sedation. A study was conducted to determine whether instillation of water into the colon at the beginning of the procedure reduces intubation time as well as patient discomfort and pain. METHODS Colonoscopy was performed in 259 patients by 3 endoscopists-in-training with limited experience. Patients were randomly allocated to 2 groups. In one, a technique was used in which 500 to 1000 mL of water is instilled into the colon by enema at the beginning of the procedure (instillation group, n = 130). In the other, patients underwent a conventional colonoscopy (control group, n = 129). Intubation time was measured and compared between the groups, and subjective discomfort experienced by the patients was measured upon completion of the examination. RESULTS Success rates for insertion to the cecum were similar, (95.4%, instillation group; 96.1%, control group). Detection rates for any colorectal diseases were not different between the groups (30.0% vs. 32.6%). Mean time to cecal intubation was 10.5 minutes in the instillation group and 16.2 minutes in the control group (p < 0.0001). The proportion of patients who complained of abdominal pain during the procedure was 17.1% in the instillation group and 33.3% in the control group (p < 0.001). CONCLUSIONS When used by endoscopists-in-training, the water-instillation colonoscopy technique was associated with less discomfort and faster cecal intubation with no decrease in the rate of detection of colorectal diseases.

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct‐to‐duct (D‐D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long‐term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D‐D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first‐line therapy for patients with biliary stricture after LDLT.

Endoscopic deployment of multiple JOSTENT SelfX is effective and safe in treatment of malignant hilar biliary strictures.

BACKGROUND & AIMS For the treatment of unresectable biliary tract carcinoma with hilar biliary stricture, antitumor therapy and biliary stenting should be addressed in terms of prolonged survival with a good quality of life. However, the endoscopic management of malignant hilar biliary strictures is difficult even for an expert endoscopist. We evaluated the efficacy and safety of the endoscopic deployment of multiple JOSTENT SelfX units in patients with hilar biliary strictures treated with or without chemotherapy. METHODS Between November 2003 and December 2006, endoscopic deployment of multiple JOSTENT SelfX units in hilar biliary strictures by using a partial stent-in-stent procedure was performed on 41 consecutive patients with primary cholangiocarcinoma (n = 34) and gallbladder carcinoma (n = 7) at a gastroenterologic center of Okayama University Hospital. Thirty-three patients were treated with gemcitabine (n = 25) or S-1 (n = 8). RESULTS Metallic stent deployment was successfully accomplished in all cases via only endoscopic procedures. During the follow-up period (mean, 210 days), mean patency time was 150 days, and metallic stent obstruction occurred in 15 cases (37%). Although a repeat intervention was required in all metallic stent obstructed cases, the deployment of the second metallic or plastic stent was completed successfully. The remaining 26 cases (63%) required no interventions. The median overall survival period was only 235 days. However, that of the patients receiving chemotherapy was 392 days. CONCLUSIONS Endoscopic partial stent-in-stent deployment with multiple JOSTENT SelfX prostheses is effective and safe for the treatment of malignant hilar biliary stricture even in patients receiving chemotherapy.

Prevention of biliary complication in radiofrequency ablation for hepatocellular carcinoma—Cooling effect by endoscopic nasobiliary drainage tube

BACKGROUND AND STUDY AIMS Biliary stricture after radiofrequency ablation (RFA) for nodules of hepatocellular carcinoma (HCC) close to major bile ducts sometimes causes septic complications and liver failure. Therefore, it may require interventional drainage for decompression during the follow-up period. The purpose of this study is to clarify the feasibility and safety of bile duct cooling using an endoscopic nasobiliary drainage (ENBD) tube in RFA for HCC close to major bile ducts. PATIENTS AND METHODS Between August 2003 and July 2007, 14 consecutive patients (14 nodules) undergoing RFA with cooling by an ENBD tube for HCCs close to major bile ducts were enrolled in this study. We infused chilled saline solution via the ENBD tube at 1ml/s to prevent heat damage during RFA. As controls, 11 patients (13 nodules) undergoing RFA without cooling close to major bile ducts between April 2001 and August 2003 were reviewed. The major outcomes for evaluation were biliary complications and the secondary outcome was local tumor recurrence. RESULTS There were no significant differences in tumor recurrence between the two groups. However, the rate of biliary complications was significantly lower in the cooling group than in the non-cooling group (0% vs. 39%, P=0.02). CONCLUSIONS Cooling of bile ducts via an ENBD tube can prevent biliary complications induced by RFA of HCC close to major bile ducts without increasing local recurrence. This technique increases indication of RFA in difficult cases.

Vascular patterns in nodules of intraductal papillary mucinous neoplasms depicted under contrast-enhanced ultrasonography are helpful for evaluating malignant potential

OBJECTIVES The purpose of this study is to evaluate the feasibility of contrast-enhanced ultrasonography (CE-US) to differentiate between benign and malignant intraductal papillary mucinous neoplasms (IPMN). PATIENTS AND METHODS Contrast-enhanced ultrasonography with a contrast agent was performed on 22 consecutive patients with IPMN suspected of being malignant. This revealed 10 carcinomas, 1 borderline lesion and 11 adenomas. All patients underwent surgery, and the histological diagnosis was confirmed by examination of resected specimens. CE-US was performed using a contrast agent. The detection rates of mural nodules were compared between CE-US and contrast-enhanced computed tomography (CE-CT), and the imaging of mural nodules depicted under CE-US was analyzed. RESULTS Seventeen of 22 resected specimens (77.3%) had mural nodules. There was no significant difference in the detection rate between CE-US (n=15; 88.2%) and CE-CT (n=12; 70.6%). In 12 (80.0%) of these patients, CE-US revealed small vessels in the mural nodule. The spotty or linear-shaped pattern was detected in 4 patients and the branch-shaped pattern in 8. The branch-shaped pattern lesion was associated with carcinoma. These mural nodules were 10mm or more in height. In the perfusion image phase, cystic walls and mural nodules were also enhanced in all cases. CONCLUSION The vessel shapes of the mural nodules depicted under CE-US were associated with size and pathological findings. These results suggested that CE-US with a contrast agent is a powerful modality with which to evaluate the malignant potential of IPMN.

Single-pattern convergence of K-ras mutation correlates with surgical indication of intraductal papillary mucinous neoplasms.

Objectives: One or more patterns of 6 K-ras mutations are detected in cells from the pancreatic juice of patients with intraductal papillary mucinous neoplasms (IPMNs). We investigated whether these mutations are associated with malignant progression. Methods: Between January 2002 and December 2007, 53 patients with IPMN were subjected to collection of pure pancreatic juice to evaluate K-ras mutation. According to the histological and radiological findings, the IPMNs were classified into 4 groups: carcinoma group, adenoma group, high-risk group, and low-risk group. We retrospectively investigated the mutation with these groups. Results: In patients with a positive K-ras mutation, a single pattern of K-ras mutation was observed in 80% (8/10) of the carcinoma group, in 71% (5/7) of the adenoma group, in 40% (2/5) of the high-risk group, and in 38% (8/21) of the low-risk group. The rate of a single pattern of K-ras mutation decreased in a stepwise order (P = 0.017). The incidence of a single pattern of K-ras mutation was significantly higher in the patients who received surgical therapy (75%, 12/16) than in those who did not (38%, 10/26; P = 0.033). Conclusions: The present study suggests that the single-clonal convergence of K-ras mutation is associated with the malignant progression of IPMNs.

Nonprevention of post-endoscopic retrograde cholangiopancreatographic pancreatitis by pancreatic stent after aspiration of pure pancreatic juice in patients with intraductal papillary mucinous neoplasms of the pancreas

Objectives: The objective of this study was to evaluate the efficacy of a pancreatic stent regarding the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis after aspiration of pure pancreatic juice in patients with intraductal papillary mucinous neoplasms. Methods: A retrospective study was made to assess the outcome in 121 consecutive patients with intraductal papillary mucinous neoplasms who underwent endoscopic aspiration of pure pancreatic juice for cytologic examination between July 2001 and October 2007. From July 2001 to March 2004, 58 patients did not undergo pancreatic stent insertion (the no-stent [nS] group). The remaining 63 patients did undergo stent insertion (stent [S] group). Results: The overall incidences of post-ERCP pancreatitis was 11 (9.1%). The incidences of post-ERCP pancreatitis in the S and nS groups were 8 (12.7%) and 3 (5.2%; P = 0.21), respectively. In the male patients and the patients with a smaller diameter of the main pancreatic ducts, post-ERCP pancreatitis was seen more frequently in those in the S group (13% and 21%, respectively) than in those in the nS group (0% and 0%, respectively; P = 0.04, 0.03). Conclusions: The pancreatic stent did not seem to decrease the incidence of post-ERCP pancreatitis in patients with intraductal papillary mucinous neoplasms. Furthermore, the pancreatic stent seems to be potentially detrimental in male patients and in patients with small-diameter main pancreatic ducts.Abbreviations: ERCP - endoscopic retrograde cholangiopancreatography, IPMNs - intraductal papillary mucinous neoplasms, ERP - endoscopic retrograde pancreatography, IDUS - intraductal ultrasonography

Perforation of jejunum induced by the deployment of a temporary prophylactic pancreatic stent in the patient with peritonitis carcinomatosa

A great deal of medical literature describes the efficacy and safety of the prophylactic pancreatic stent in reducing the incidence of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. At the moment, no serious complication due to the migration of this stent has been reported. We describe a case with perforation of jejunum induced by the migration of a temporary prophylactic pancreatic stent. This report indicates that we should pay attention to this severe complication when we place a temporary prophylactic pancreatic stent in patients who have peritonitis carcinomatosa or adherence of the intestine irrespective of oral intake.

S1019 A Randomized Phase II Study Designed to Compare Toxicity and Dose Intensity Between Four-Week Versus Three-Week Schedule of Gemcitabine for Advanced Pancreatic Cancer

Purpose: The aim of this phase II study is to compare toxicity and dose intensity (DI) between four-week (4w) and three-week (3w) schedule of gemcitabine (GEM) for advanced pancreatic cancer (PC). Methods: Patients with histologically or cytologically proven locally advanced and/or metastatic PC were assigned to receive GEM in 4w schedule or 3w schedule. The protocol of GEM was as follows: 4w schedule (1,000mg/m2 on days 1, 8 and 15 of each 28-day cycle), 3w schedule (1,000mg/m2 on days 1 and 8 of each 21-day cycle). If grade 3 to 4 hematological toxicity (only a platelate count was defined = 50%, age between 20 and 80 years, and adequate organ function. Written informed consent was obtained from all patients. The primary endpoint was a compliance rate of protocol regimen within eight weeks after initiation of chemotherapy, which was defined as the proportion of patients without a dose reduction or a delay in administration of GEM. Secondary endpoints were DI, safety, response rate and overall survival. Results: A total of 90 patients (4w: 3w schedule= 45: 45) were enrolled between January 2006 and October 2008. Baseline patient and disease characteristics were similar in both schedules. Median age was 67 (range, 49-79) years in 4w schedule vs. 66 (range, 33-79) years in 3w schedule; p=0.67. KPS (70-80: 90-100%) was (4: 41) vs. (5: 40); p=0.99. Disease (locally advanced: metastatic) was (7: 38) vs. (7: 38); p=0.99. The eight week-compliance rate of protocol regimen was the same; 53.3% (24/45) in both schedules. However, median duration of accumulative rate for adverse events tended to be extended in 3w schedule; 35days (6-334) vs. 49 (6-414), p=0.20. Consequently, the mean received DI was equivalent in both schedules; 588 +/130 mg/m2/week vs. 550 +/116, p=0.14. Grade 3-4 neutropenia was a major adverse event in both schedules; 37.7% (17/ 45) vs. 35.5 (16/45); p=0.82, in contrast, thrombocytopenia was significantly increased in 4w schedule; 26.6% (12/45) vs. 4.4 (2/45); p=0.009. Tumor response rate was 14.2% (5/ 35) vs. 17.1(6/35); p=0.92, and the disease control rate (PR, SD) was 60.0% (27/45) vs. 62.2 (28/45); p=0.82. Median survival time was 206 (33-802) days vs. 250 (39-681); p= 0.84. Conclusions: These results support the efficacy and safety in 3w schedule of GEM for PC.