Naoto Kanemaki

Endoscopy and intraductal ultrasonography

Because the prognosis in pancreatic carcinoma is so poor, a reliable method for early detection of tumors is needed. Endoscopic ultrasonography (EUS) is a useful method for precise diagnosis of pancreatic tumors. Recently, peroral pancreatoscopy (POPS) and intraductal ultrasonography (IDUS) have been introduced to make a more detailed diagnosis of pancreatic tumors. These three techniques were performed in 48 patients with pancreatic carcinoma. The ultrasonographic and endoscopic findings of pancreatic carcinoma were studied. EUS, IDUS, and POPS are very useful for differentiating between benign and malignant pancreatic tumors.

The Diagnosis of the Anomalous Connection of Pancreaticobiliary Ducts Without Biliary Dilatation—The Usefulness of US/EUS Serial Examination—

The anomalous connection of the pancreaticobiliary duct (ACPBD) without accompanying dilatation of the bile duct (non‐dilated type of ACPBD) has recently been found to be associated with gallbladder cancer at a rather high rate. We analyzed the diagnostic process of 5 patients with non‐dilated type of ACPBD including 3 asymptomatic cases and reviewed the literature. Symptoms and laboratory data were not useful in detecting this type of lesion. All our patients were checked by ultrasonography for gallbladder lesions which are suggested by: wall thickening, multiple polyps, intramural gall stones, cholecystolithiaisis, and debris. ACT revealed only wall thickening of the gallbladder. An EUS revealed a high rate of ACPBD in addition to the ultrasonographic findings of gallbladder lesions obtained by US. An ERCP was effective in clearly demonstrating ACPBD, but was not so useful for the diagnosis of concomitant gallbladder lesions. Therefore, an US is considered to be a useful means for screening this disease, and EUS is useful as a procedure to follow in order to select patients with or without ACPBD, because EUS can be conducted on an outpatient basis and is highly sensitive in detecting ductal anomalies in ACPBD. Therefore, the US/EUS serial examination is thought to be an effective means for diagnosing this disease.

A Case of Pancreatolithiasis Treated by a Combination of Endoscopic Extraction and Extracorporeal Shock Wave Lithotripsy

We report on the case of a 50‐year‐old woman with idiopathic chronic calcifying pancreatitis and diabetes. An endoscopic retrograde pancreatography showed a stone with a diameter of 23 mm and multiple small stones in the head of the pancreas. An endoscopic pancreatic sphincterotomy was performed. However, the stone could not be removed endoscopically. So we performed an extracorporeal shock wave lithotripsy (ESWL) using a Tripter X1. The stone was located in the shock wave focus by fluoroscopy. Under intravenous sedation, the patient received 5 ESWL sessions (a total of 11700 shock waves with an energy of 18kv). ESWL permitted stone disintegration and successful endoscopic extraction of the fragments. Complete clearance in the main pancreatic duct was achieved. No severe complications were observed. After treatment, an improvement in the PFD test was seen. ESWL is an effective method for treatment of endoscopically unextractable pancreatic ductal stones.

Application of peroral cholecystoscopy in a case of cholecystocolic fistula

A patient with a cholecystocolic fistula, complicating cholecysto‐choledocholithiasis, was treated endoscopically with gallbladder observation by peroral cholecystoscopy (POCCS). The patient was a 71‐year‐old female admitted to our hospital for investigation and treatment of biliary stones and a cholecystocolic fistula. Endoscopic lithotripsy and extracorporeal shock wave lithotripsy (ESWL) were performed after endoscopic sphincterotomy, and the gallbladder was subsequently investigated using a duodenoscope/ cholangioscope of the mother and baby type. Full distension of the gallbladder with saline solution allowed POCCS observation of the entire surface. The gallbladder mucosa was smooth, and neither stones nor tumors were observed. Though the cholecystocolic fistula itself could not be observed, we concluded that it had resulted from cholecystitis. Peroral cholecystoscopy is thus a useful method of investigating the gallbladder in such cases.

A New Peroral Cholecystoscopy Method Utilizing a Shape Memory Alloy Bending Catheter‐Report of Two Cases

For the purpose of improving the ease and reliability of catheter insertion into the cystic duct and gallbladder, we developed a new combination method utilizing an ultrathin fiberscope (miniscope, 0.8 mm), a guidewire (0.25 inches) and a shape memory alloy, bendable, catheter (SMA catheter, 2.6 mm). The main feature of the SMA catheter, which incorporates a micro‐actuator, is that its tip can be bent by remote control as desired. The SMA catheter could be inserted successfully into the cystic duct using a guide‐wire under direct miniscope vision in two patients with gallbladder lesions.