Naruomi Jinno

Predictors of stent dysfunction after self-expandable metal stent placement for malignant gastric outlet obstruction: tumor ingrowth in uncovered stents and migration of covered stents

BackgroundEndoscopic metallic stenting is widely accepted as a palliation therapy for malignant gastric outlet obstruction (GOO). However, the predictors of stent dysfunction have not been clarified. We aimed to evaluate the predictors, especially tumor ingrowth in uncovered self-expandable metallic stents (U-SEMS) and migration of covered self-expandable metallic stents (C-SEMS), which are the main causes related to the stent characteristics.MethodsIn this multicenter retrospective study, we compared patients with U-SEMS and C-SEMS in terms of clinical outcomes, and predictors of stent dysfunction.ResultsIn total, 252 patients (126 with U-SEMS and 126 with C-SEMS) were enrolled. There were no significant differences in technical success, clinical success, GOO score, or time to stent dysfunction. Tumor ingrowth was significantly more frequent in U-SEMS (U-SEMS, 11.90% vs. C-SEMS, 0.79%; p = 0.002), and stent migration was significantly more frequent for C-SEMS (C-SEMS, 8.73% vs. U-SEMS, 0.79%; p = 0.005). Karnofsky performance status (p = 0.04), no presence of ascites (p = 0.02), and insufficient (<30%) stent expansion (p = 0.003) were significantly associated with tumor ingrowth in U-SEMS. Meanwhile, a shorter stent length (p = 0.05) and chemotherapy (p = 0.03) were predictors of C-SEMS migration.ConclusionsBoth U-SEMS and C-SEMS are effective with comparable patencies. Tumor ingrowth and stent migration are the main causes of stent dysfunction for U-SEMS and C-SEMS, respectively. With regard to stent dysfunction, U-SEMS might be a good option for patients receiving chemotherapy, while C-SEMS with longer stents for patients in good condition. (Clinical trial registration number: UMIN000024059).

Case of pancreatic metastasis from colon cancer in which cell block using the Trefle® endoscopic scraper enables differential diagnosis from pancreatic cancer

Endoscopic transpapillary brush cytology and forceps biopsy during endoscopic retrograde cholangiopancreatology are generally used to obtain pathological evidence of biliary strictures. Recently, the new endoscopic scraper Trefle® has been reported and demonstrated high cancer detectability in malignant biliary strictures. This device is used to scrape the stricture over the guidewire, and, in the original method, the tissue and/or cell samples obtained are subjected to histological and/or cytological analysis separately. However, discrimination of chunks of tissue is hampered by the opacity of the surrounding fluid. We have developed a cell block technique for the Trefle® device without dividing obtained specimens into tissue and cellular components, which is the simplest method and enables immunohistochemical analysis. We present a case of obstructive jaundice diagnosed immunohistochemically as pancreatic metastasis from colon cancer using cell block sections obtained with the Trefle® device, which procedure is as easy as conventional brush cytology.

Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: the largest series of bilioduodenal obstruction

Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS.

Percutaneous Transhepatic Self-expanding Metallic Stent Placement for the Treatment of Malignant Afferent Loop Obstruction

We report the case of a 71-year-old man with afferent loop obstruction (ALO) after Roux-en-Y reconstruction due to gastric cancer. Computed tomography showed a distended afferent loop and a dilatated bile duct. We could not reach the stricture site in the afferent loop using a gastroscope. We performed percutaneous transhepatic biliary drainage (PTBD) and placed a self-expanding metallic stent (SEMS) in the duodenal stricture through the PTBD route. Although an endoscopic approach is preferable, when PTBD can be performed, percutaneous transhepatic SEMS placement might be an alternative option for treating ALO in cases in which it is not possible to reach the site of stenosis with an endoscope.

Autoimmune Hemolytic Anemia Obscured by the Obstructive Jaundice Associated with IgG4-related Sclerosing Cholangitis in a Patient with Type 1 Autoimmune Pancreatitis: A Case Report and Review of the Literature

Type 1 autoimmune pancreatitis (AIP) is a pancreatic manifestation of IgG4-retated disease that is often associated with IgG4-related sclerosing cholangitis (IgG4-SC). Autoimmune hemolytic anemia (AIHA) is an immune-related disease that causes hemolytic anemia. Although type 1 AIP/IgG4-SC and AIHA have a shared etiology as a presumed autoimmune disease, they rarely overlap, and their association has not been clarified. Secondary AIHA might not be diagnosed appropriately because the obstructive jaundice observed in type 1 AIP/IgG4-SC can obscure the presence of hemolytic jaundice. We herein report a case of type 1 AIP/IgG4-SC overlapping with secondary AIHA along with a review of the literature.

Simultaneous side-by-side bilateral metal stent placement using a colonoscope in a patient with Billroth II reconstruction

Bilateral metal stent placement for malignant hilar biliary obstruction (MHBO) can be technically challenging, despite the frequent use of self-expandable metal stents (SEMSs) for palliative therapy [1, 2]. Simultaneous side-by-side (SBS) stent placement using a thin delivery system is straightforward and has a high success rate [3]. However, simultaneous SBS placement is considered to be technically difficult in patients with surgically altered anatomy because few suitable devices are available. This is the first report of simultaneous SBS stent placement for MHBO using a novel SEMS with a thin delivery system (Zeo Stent V; Zeon Medical, Tokyo, Japan) (▶Fig. 1) and a colonoscope in a patient with surgically altered anatomy. An 86-year-old man with Billroth II reconstruction was diagnosed with MHBO caused by unresectable cholangiocarcinoma (▶Fig. 2 a). A CF-260AI colonoscope (Olympus, Tokyo, Japan), which has a 3.7-mm working channel, was used for biliary drainage. Two 0.025inch guidewires (VisiGlide 2; Olympus) were inserted into the intrahepatic bile ducts, and two SEMS delivery systems were simultaneously inserted over the guidewires (▶Fig. 2b). We used two novel SEMSs (8×80mm) with a 5.4-Fr delivery system (Zeo Stent V). The two SEMSs were deployed successfully without interfering with each other and were placed in the optimal positions using the SBS technique (▶Fig. 2 c, d; ▶Video1). No adverse events were observed and the total procedure time was 9 minutes. Endoscopic bilateral metal stenting is technically challenging [4, 5] because of the complexity of the second SEMS insertion. Simultaneous SBS placement avoids the risk of placement failure with the second SEMS.However, few devices are suitable for simultaneous SBS placement in patients with surgically altered anatomy. This combination of a novel SEMS with a 5.4-Fr delivery system and a colonoscope offers the potential for bilateral stenting to treat MHBOs in patients with surgically altered anatomy.