Nobuhiro Ando

EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos)

BACKGROUND AND AIMS Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study. METHODS EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation. RESULTS The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20). CONCLUSIONS EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates.

A multicenter prospective phase II study of first-line modified FOLFIRINOX for unresectable advanced pancreatic cancer

Background FOLFIRINOX (FX) has been reported as an effective treatment for unresectable advanced pancreatic cancer. However, FX is associated with a high incidence of adverse events (AEs). A previous phase II study in Japan showed high incidences of hematological AEs, including febrile neutropenia (22.2%). A modified FX regimen (mFX) may decrease the rates of AEs and be more effective than FX by improving the treatment compliance. Aims To assess the safety and efficacy of first-line mFX for unresectable advanced pancreatic cancer. Patients and methods This was as a multicenter prospective phase II study in chemotherapy-naïve Japanese patients with pathologically confirmed unresectable advanced pancreatic adenocarcinoma or adenosquamous carcinoma. Treatment with mFX (85 mg/m2 oxaliplatin, 150 mg/m2 irinotecan, and 200 mg/m2 l-leucovorin, followed by 46-h continuous infusion of 2400 mg/m2 5-fluorouracil) was administered every 2 weeks. The primary endpoint was the response rate. The secondary endpoints were overall survival, progression-free survival, and safety. Results Thirty-one patients (18 men; median age, 64 years) were enrolled. A median of 13 treatment cycles were administered during a median follow-up period of 14.2 months. The response rate, median overall survival, and median progression-free survival were 38.7%, 14.9 months, and 7.0 months, respectively. Grade 3 or 4 AEs included neutropenia (83.9%), febrile neutropenia (16.1%), peripheral sensory neuropathy (9.7%), thrombocytopenia (6.5%), diarrhea (6.5%), anorexia (6.5%), and vomiting (3.2%). Conclusion Compared to FX, mFX may result in fewer Grade 3 or 4 non-hematological AEs, with a comparable response rate. However, further efforts might be required to reduce hematological AEs.

MAGNIFYING ENDOSCOPY FOR THE DIAGNOSIS OF EARLY GASTRIC CANCER

Magnifying endoscopy of stomach cancer requires observation of minute structure and minute vessel patterns of the mucosal surface. The small pits, various‐sized pits, irregularly branched pits and irregular vessels were found to be characteristics as the surface structure of early gastric cancer. Small pits were commonly observed on the differentiated type of early gastric cancer (88%) compared with the undifferentiated type (50%). We found it important to analyze not only the minute vessel patterns, but also the minute surface structure to ensure magnifying endoscopic observation using 0.1% indigo‐carmine and the binarized images would be effective in determining the margin of the lesion. The relationship between the findings of magnifying endoscopy in cancer and the histology should now be investigated. Applying the techniques mentioned above, more delicate observation in the regular endoscopy and prudent photographing to obtain clear images might be promoted. Thus, this would contribute to endoscopy with a concept similar to optical biopsy, and which can depend on the usual biopsy methods.

Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

Percutaneous transhepatic drainage is the most common method for non‐operative gallbladder drainage, but the technique does have several disadvantages because of its invasive nature and requirement for continuous drainage. To overcome these disadvantages, we developed a novel procedure, endoscopic gallbladder lavage followed by stent placement, carried out in a single endoscopic session. Our aim was to prospectively evaluate the efficacy and safety of this procedure in patients with acute cholecystitis.

A case of liver hilar tuberculous lymphadenitis complicated by biliary stricture diagnosed by endoscopic ultrasound-guided fine-needle aspiration

This report describes a case of liver hilar tuberculous lymphadenitis complicated by biliary stricture, diagnosed with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). A 44-year-old woman was referred to our center for further evaluation of abnormal liver function tests. Abdominal ultrasound/contrast-enhanced computed tomography (CT) revealed a 15-mm hypovascular mass with a weakly enhanced margin at the liver hilum. Magnetic resonance cholangiopancreatography revealed dilatation of the intrahepatic bile ducts in the left lobe of liver and gradual narrowing of the left hepatic duct. Biliary stricture associated with enlarged hilar lymph nodes due to metastasis or malignant lymphoma was suspected, but calcification on chest CT and a positive T-SPOT test did not rule out tuberculosis. After transpapillary brush cytology of the bile duct stricture failed to confirm the diagnosis, EUS-FNA of hilar lymph nodes was performed and showed positive for the acid-fast bacillus and polymerase chain reaction for Mycobacterium tuberculosis DNA as well as epithelioid granulomas on pathological evaluation. Those findings led to a diagnosis of hilar tuberculous lymphadenitis. The patient is under treatment with antituberculosis drugs. Abdominal tuberculous lymphadenitis is rare and some cases diagnosed as lymphadenopathy of unknown origin have required surgery. EUS-FNA is a safe and minimally invasive diagnostic method in such cases.

7232 Diagnosis of gastric submucosal tumors by endoscopic ultrasonography (eus); only image vs. eus-guided fine needle aspiration biopsy.

Introduction:Endoscopic ultrasonography-guided fine needle aspiration biopsy (EUS-FNAB) for gastric submucosal tumors (SMTs) is controversial. Although it is generally believed that the EUS diagnosis of SMTs is reliable, and the rate obtained from histological samples from SMTs by EUS-FNAB is admittedly not so high, we are sometimes at a loss whether we should recommend a patient to undergo surgical resection or merely be observed. Therefore, we compared simple EUS diagnosis by experienced EUS doctors and results of EUS-FNAB. Subjects and methods: From March 1994 to May 1999 we performed EUS-FNAB in twenty-three patients with gastric SMT. All SMTs were over 3 cm. We gave five senior EUS doctors 2 EUS images of each SMT, and had them answer questionnaires regarding the diagnosis of SMT and treatment options. These doctors have experienced EUS for over five years. They judged the diagnosis of SMT and surgical resection or follow-up. Initially, we used a radial scanner GF-UM20 (Olympus Optical Co. Ltd.) for diagnosis. EUS-FNAB was performed using Pentax FG-32UA or FG-36UX convex array endosonography. Results: 1. Twenty-three patients with SMT were average 57.7 years old, 14 men and 9 women. SMTs were 14 leiomyomas, 4 leiomyosarcomas, 4 aberrant pancreases, and 1 ectopic gastric gland (mean size 33.4mm). 2. Simple EUS diagnosis was about 50% accurate by EUS senior doctors. 3. Diagnosis in 17 out of 23 SMTs was in accordance among experienced doctors („ 80%). Six of 17 SMTs were misdiagnosed. Of these 6 SMTs we obtained 4 correct diagnoses by EUS-FNAB. The six out-of-accordance cases included 3 aberrant pancreases. 4. Even when the doctors diagnosed leiomyoma, they recommended surgical resection because of a diameter over 50 mm and rapid growth in a short time. Conclusions: 1. FNA was useful for the relatively large solid tumor with cystic structure, for example, leiomyoma, leiomyosarcoma, and aberrant pancreas. 2. However, FNA diagnosis did not influence the choice of surgery or follow-up for tumors over 50 mm in diameter.

4540 Diagnosis of gastrointestinal stromal tumor using endscopic ultrasonography-guided fine needle aspiration biopsy.

Background: In the diagnosis of submucosal tumors we have already reported the usefulness of EUS-FNAB. But there are some cases in which the differentiation of gastrointestinal mesenchymal tumors is difficult. The aim of this study was to evaluate the diagnosis of GIST using EUS-FNAB by immunohistochemical analysis. Patients and Methods: From October 1993 to September 1999, 21 patients (12 men and 9 women) with GISTs were preoperatively examined with EUS-FNAB. EUS-FNAB was performed using the Pentax FG-32UA or FG-36UX convex array endosonographer (Pentax Precision Instrument Corp., Orangeburg, NY) connected to the Hitachi ultrasound scanner EUB-525 (Hitachi Medico Corp., Tokyo, Japan) and a 22G Pentax needle. The final diagnosis of malignant GISTs are based on mitotic figures of surgically resected legions. The diagnostic accuracy of EUS-FNAB was compared to that of EUS. EUS-FNAB specimens and surgically resected legions were studied by immunohistochemical procedures with search of some markers :CD34, c-kit, vimentin, alphasmooth muscle actin, desmin, NSE and S-100. We compared immunohistochemical characteristics of EUS-FNAB specimens to that of surgically resected legions. Results: In 21 cases (benign GISTs 15, malignant GISTs 6) the final diagnosis based on surgery was obtained. In the evaluation of malignant GISTs the accuracy was 86% with EUSFNAB(sensitivity 50% and specificity 100%) and 76% with EUS (sensitivity 83% and specificity 73%). In 3 cases EUS-FNAB specimens were negative for desmin , alpha-smooth muscle actin and S-100, but they were positive for CD34 and vimentin. Their immunohistochemical characteristics were coincided with that of surgically resected legions. Conclusion: EUS-FNAB was useful in the evaluation of the preoperative diagnosis of GISTs.

7074 Does new imaging process change the detection rate of disease in upper gastrointestinal endoscopy

Aims:Adaptive structure enhancement in endoscopy is effective fordefining the microstructure of the mucosal surface and superficial blood vessels. We conducted a study to assess the utility of this approach for endoscopic investigation of the upper gastrointestinal tract. Subjects and Methods:From July 1996 until June 1997, a total of 1443 cases undergoing upper gastrointestinal endoscopy were randomly divided into imaging positive (730 cases) and negative (703 cases) groups and compared for capacity to detect and diagnose gastrointestinal diseases. The instrument used for adaptivestructure enhancement was the Olympus EVIP-230. We performed upper gastrointestinal endoscpy using Q230 (Olympus Co.Ltd.) with and without the EVIP 230. Results:With regard to endoscopic screening, the numbers of demonstrated disease cases were 318 and 298 for the positive and negative groups, respectively. Among the positive group we detected 2 early gastric cancers, 16 gastric ulcers, 15 duodenal ulcers and others. In the negative groupwe detected 2 early gastric cancers, 13 gastric ulecrs, 4 duodenal ulcers and others. Detection of cases with clear irregularitiesof the mucosal surface and erythema demonstrated tended to be slightly higher in the positive group, but the number of biopsies did not differ between the two groups. When we examined the patients with known disease, for example malignantcases, it was useful in clarifiying the border between the tumor and surrounding normal tissue in esophageal and gastric cancers, as well as determining the extent of invasion. With gastric and duodenal ulcers, erythema and the structure of regenerative epithelium could be clarifiedso that a strict classification of stages was possible. Conclusion:Adaptive structure enhancement is effective for the precise delineation of lesions by endoscopy in the upper gastrointestinal tract. However, there was no significant difference in detecting malignancy when we used the screening endoscopy with or without this enhancement system.