Ryunosuke Hakuta

Covered versus uncovered metal stents for malignant gastric outlet obstruction: Systematic review and meta-analysis

Self‐expandable metal stents (SEMS) are used for non‐resectable malignant gastric outlet obstruction (GOO). Studies of covered versus uncovered SEMS have yielded inconsistent results as a result of heterogeneity in design and patient population. We carried out a meta‐analysis to compare covered and uncovered gastroduodenal SEMS.

Feasibility of conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage

Background/Aim: Percutaneous cholecystostomy [percutaneous transhepatic gallbladder drainage (PTGBD)] is the treatment of choice in surgically unfit patients with acute cholecystitis. However, PTGBD tube removal after symptoms resolution results in 41–46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy. Patients and Methods: Patients who underwent internal transmural EUS-GBD as a conversion from PTGBD were reviewed. EUS-GBD was performed after the improvement of cholecystitis due to recurrent cholecystitis and PTGBD intolerance. One or two 7-Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed. Results: Six patients (age 61–88), with three cases of acute cholecystitis after metallic biliary stenting and three cases of calculus cholecystitis, who underwent PTGBD were included. EUS-GBD was performed 10–63 days after PTGBD, using one plastic stent in five cases, two stents in one case, with temporary ENGBD in two cases. The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within 5 days after insertion. Bile leak with peritonitis was demonstrated in one case, which was treated conservatively. No recurrent cholecystitis was seen during 3–26 months of follow-up. Conclusion: The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. However, more studies are still needed to confirm the results.

Multicenter retrospective and comparative study of 5-minute versus 15-second endoscopic papillary balloon dilation for removal of bile duct stones

Background and study aims  Endoscopic papillary balloon dilation (EPBD) is a method of bile duct stone removal that has a better long-term outcome but a high risk of post-ERCP pancreatitis (PEP). Recent studies have suggested that 5-minute EPBD can reduce the incidence of PEP. This study aimed to examine the safety and effectiveness of longer duration EPBD compared with shorter duration EPBD (5 minutes vs. 15 seconds after disappearance of the waist of a dilation catheter). Patients and methods  Patients without a history of endoscopic sphincterotomy or EPBD who underwent EPBD to remove bile duct stones were selected retrospectively from five centers. The incidence of PEP, other early adverse events, and outcomes of EPBD were compared between the groups. A multivariable analysis of risk factors for PEP was performed. Results  A total of 607 patients (157 and 450 in the 5-minute and 15-second EPBD groups, respectively) were included. There were no statistically significant differences between the groups in terms of the incidence of PEP (8.3 % and 8.9 % in the 5-minute and 15-second EPBD groups, respectively; P  = 0.871) and the incidence of overall early adverse events ( P  = 0.999). Although 5-minute EPBD elongated the procedure time (45 vs. 37 minutes, P  < 0.001), it increased the rate of complete stone removal during a single session ( P  < 0.001) and decreased the use of lithotripsy ( P  < 0.001). Conclusions  Compared with 15-second EPBD, 5-minute EPBD did not reduce the incidence of PEP.

Successful guidewire placement across hilar malignant biliary stricture after deceased donor liver transplantation using new digital cholangioscopy

A 70-year-old man with metastatic rectal cancer was referred to our department for endoscopic management of obstructive jaundice due to metastatic lymph nodes. He previously received deceased donor liver transplantation with duct-toduct biliary reconstruction. Computed tomography and magnetic resonance cholangiopancreatography showed hilar biliary stricture due to metastatic lymph nodes at the duct-to-duct anastomosis (▶Fig. 1,▶Fig. 2). Endoscopic retrograde cholangiopancreatography revealed a markedly dilated recipient bile duct and a stricture of the donor hepatic duct (▶Fig. 3). Multiple attempts to pass the hilar stricture using a 0.035-inch hydrophilic guidewire and a cannula or a rotatable sphincterotome failed because a guidewire easily advanced to the remnant cystic duct just below the stricture. Hence, after endoscopic sphincterotomy, guidewire passage using SpyGlass DS Direct Visualization System (SpyDS; Boston Scientific Japan, Tokyo, Japan) was attempted. Cholangioscopy allowed direct visualization of both torturous biliary stricture with non-tumorous mucosa and the wide-opening remnant cystic duct (▶Fig. 4). A guidewire was readily passed through the stricture into the left intrahepatic duct under SpyDS and fluoroscopy guidance (▶Fig. 5). Given the presence of high-grade hilar biliary stricture, bilateral metal stent placement in a partially stent-in-stent method was successfully performed with rapid resolution of jaundice (▶Fig. 6). Selective guidewire placement across biliary stricture can be technically challenging, especially in patients after liver transplantation or with hilar biliary stricture [1, 2]. To our knowledge, this is the first report demonstrating the utility of SpyDS for guidewire placement across complex hilar malignant biliary stricture at the anastomotic site after liver transplantation. Although several studies reported the effectiveness of cholangioscopy-assisted guidewire placement [3– 5], its success rate was unsatisfactory. The SpyDS has potential advantages over the original Spyglass system: its better image quality, irrigation and 4-way steering. In summary, SpyDS-assisted guidewire passage can be an alternative technique after failed guidewire passage under fluoroscopic guidance.

Early pancreatic stent placement in wire-guided biliary cannulation: A multicenter retrospective study: Early pancreatic stent for cannulation

Guidewire insertion to a pancreatic duct under wire‐guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high incidence of post‐ERCP pancreatitis (PEP). Pancreatic stent placement followed by WGC (PS‐WGC) is considered for these cases to reduce PEP. This study was aimed to examine the effectiveness of PS‐WGC compared with repeated WGC.

Successful endoscopic lithotripsy using a new digital cholangioscope through an overtube placed by an enteroscope

A 29-year-old woman who had undergone extrahepatic bile duct resection and hepaticojejunostomy for congenital biliary dilation was admitted to our hospital with cholangitis. Magnetic resonance cholangiopancreatography revealed multiple large intrahepatic bile duct stones (▶Fig. 1). Most of the stones were fragmented and removed by extracorporeal shock wave lithotripsy and endoscopic mechanical lithotripsy (LithoCrush V; Olympus, Tokyo, Japan) during double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography (EI-580BT; Fujifilm, Tokyo, Japan). However, intrahepatic stones in the right posterior branch could not be removed owing to the acute angle of the duct (▶Fig. 2). To perform intraductal lithotripsy under direct visualization, the enteroscope was withdrawn while leaving the overtube in situ. The direct cholangioscope (SpyGlass DS Direct Visualization System; Boston Scientific Japan, Tokyo, Japan) was successfully advanced through the overtube into the right posterior branch. The intrahepatic stones were visualized (▶Fig. 3) and successfully fragmented by electrohydraulic lithotripsy using the Autolith EHL system and 1.9-Fr probe (Boston Scientific Japan). Finally, the cholangioscope was exchanged for the enteroscope, and fragmented stones were extracted using a balloon catheter (▶Fig. 4, ▶Video1). Endoscopic removal of large bile duct stones remains challenging, especially in cases with surgically altered anatomy [1, 2]. Direct insertion of an enteroscope is possible in cases with a large bile duct [3–5], though this technique cannot be utilized in cases with intrahepatic stones in small bile ducts. To our knowledge, this is the first report of successful endoscopic treatment of intrahepatic bile duct stones under direct cholangioscopy in a patient with surgically altered anatomy. Although scope exchange to a direct cholangioscope through the overtube is E-Videos

Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis

Endoscopic papillary large balloon dilation (EPLBD) without endoscopic sphincterotomy (EST) may facilitate extraction of large bile duct stones through achieving adequate dilation of the ampulla. However, contrary to favorable long‐term outcomes after endoscopic papillary balloon dilation (EPBD), that of EPLBD without EST has been little investigated. Therefore, we conducted the current study to evaluate short‐ and long‐term outcomes of EPLBD without EST and EPBD after removal of large bile duct stones (LBDS; ≥10 mm).

Lack in Standardized Reporting of Biliary Stents: A Meta-Analysis Complicated by the Inconsistency

Lack in Standardized Reporting of Biliary Stents: A Meta-Analysis Complicated by the Inconsistency