Seul Ki Min

Anchoring of a Fully Covered Self-Expandable Metal Stent With a 5F Double-Pigtail Plastic Stent to Prevent Migration in the Management of Benign Biliary Strictures

OBJECTIVES:Fully covered self-expandable metal stents (FCSEMSs) can be effectively placed in patients with benign biliary stricture (BBS). However, stent migration is an inherent problem of FCSEMSs. We evaluated the efficacy of anchoring with a 5F double-pigtail plastic stent (anchoring stent) to prevent migration of an FCSEMS in patients with BBS.METHODS:Between January 2007 and December 2009, 33 of 37 consecutive patients with BBS who had experienced treatment failure of at least one plastic stent placement were prospectively enrolled in this study. The patients with BBS were randomly assigned to undergo FCSEMS placement with or without an anchoring stent (anchoring group: 16 patients; non-anchoring group: 17 patients). The main outcome measures were the stent migration rate and success rates.RESULTS:The technical success rate was 100% in both groups. Significantly less stent migration occurred in the anchoring group (6.3%, 1/16) than in the non-anchoring group (41.2%, 7/17; P=0.024). The median indwelling time was significantly longer in the anchoring group (154 days; range, 86–176 days) than in the non-anchoring group (114 days; range, 19–162 days; P=0.010). Improvement or resolution of the BBS was confirmed in 15 of 16 patients (93.8%) in the anchoring group, and in 12 of 17 patients (70.6%) in the non-anchoring group (P=0.101).CONCLUSIONS:The placement of an anchoring stent appears to be a simple and effective method of preventing premature migration of FCSEMSs in patients with BBS. Appropriately powered studies are needed to confirm this finding.

Clinical feasibility of direct peroral cholangioscopy–guided photodynamic therapy for inoperable cholangiocarcinoma performed by using an ultra-slim upper endoscope (with videos)

BACKGROUND Photodynamic therapy (PDT) has emerged as a promising palliative treatment for inoperable cholangiocarcinoma. Cholangioscopy-guided PDT can be useful for identification of tumor margins, determination of the appropriate location for placement of the diffuser, and evaluation of the patients response to therapy. OBJECTIVE To evaluate the feasibility of PDT under direct peroral cholangioscopy (POC) by using an ultra-slim upper endoscope in patients with inoperable cholangiocarcinoma. DESIGN Prospective, observational, pilot study. SETTING Single tertiary-care referral center. PATIENTS This study involved 9 patients with inoperable extrahepatic cholangiocarcinoma. INTERVENTION Photofrin II was administered intravenously 48 hours before PDT. Additional PDT was performed up to 48 hours after the initial application of therapy. A successful direct POC-guided PDT was defined as advancement of the endoscope into the distal margin of the tumor and maintenance of endoscope position until PDT was completed. MAIN OUTCOME MEASUREMENTS The clinical feasibility, usefulness, and complications of direct POC for PDT. RESULTS Seventeen sessions of direct POC for PDT were performed in 9 patients. PDT was performed successfully in 15 of 17 sessions (88.2%) and 7 of 9 patients (77.8%). Biliary drainage under direct POC, if necessary after PDT, was possible in 100% of patients (7/7). Follow-up direct POC confirmed significant tumor ablation after PDT in 5 patients. One patient reported mild skin redness; no major procedure-related complications were observed. LIMITATIONS Small sample size, pilot study. CONCLUSION Direct POC-guided PDT by using an ultra-slim upper endoscope seems to be both feasible and safe in select patients with inoperable extrahepatic cholangiocarcinoma.

Correlation of Narrow Band Imaging with Magnifying Colonoscopy and Histology in Colorectal Tumors

Background/Aims Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion. Methods Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features. Results Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01). Conclusions Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.

Early Bile Duct Cancer Detected by Direct Peroral Cholangioscopy with Narrow-Band Imaging after Bile Duct Stone Removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.

A Case of Enteropathy-Type T-Cell Lymphoma Diagnosed by Small Bowel Enteroscopy: A Perspective on Imaging-Enhanced Endoscopy

Enteropathy-type T-cell lymphoma (ETL) or enteropathy-associated T-cell lymphoma is a very rare malignant intestinal tumor. ETL is usually diagnosed by surgery. Endoscopic findings of ETL are not well known, and there are few reports of findings from endoscopy that has been performed only using white light. Additionally, there are no definite treatment guidelines for ETL. Therefore, we report a case of ETL diagnosed by enteroscopy with imaging-enhanced endoscopy and also review recently developed treatment options.

Wire-Guided Endoscopic Snare Retrieval of Proximally Migrated Pancreatic Stents after Endoscopic Papillectomy for Ampullary Adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.

Endoscopic hemostasis using N-butyl-2-cyanoacrylate for massive gastric bleeding during endoscopic transgastric drainage of a pancreatic pseudocyst.

Dear Editor, For the last decade, endoscopic drainage has been accepted as a first therapeutic modality for the treatment of pancreatic pseudocyst. One complication associated with endoscopic drainage is hemorrhage.We describe a case of massive bleeding that occurred during endoscopic transgastric drainage of pancreatic pseudocyst, which was successfully controlled by injection of N-butyl-2-cyanoacrylate. A 35-year-old man with pancreatic pseudocyst was transferred for endoscopic drainage after it had failed to resolve spontaneously over 6 months. The physical examination and laboratory findings were unremarkable. Abdominal computed tomography showed a 9 ¥ 11 cm cyst in the tail of the pancreas. Endoscopic ultrasonography revealed an abundant network of collateral vessels. A needle-knife (HPC-3; Cook Endoscopy,Winston Salem, NC, USA) was used to puncture the posterior wall of the stomach to access the cyst through a forward-viewing endoscope. A massive spurting hemorrhage occurred immediately after puncture of the stomach wall (Fig. 1). First, we injected epinephrine, but failed to achieve hemostasis. We next decided to inject N-butyl-2cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) as a rescue therapy. N-Butyl-2-cyanoacrylate was mixed with Lipiodol (Guerbert GmbH, Sulzbach, Germany) in a ratio of 0.5 to 0.8 mL. The Histoacryl mixture was injected under fluoroscopy using the same regimen and technique as used to control a bleeding gastric varix. Bleeding was controlled completely after Histoacryl injection (Fig. 2; Video S1). Follow-up endoscopy 3 weeks later revealed a healing ulcer without blood on the injection site. Even under endoscopic ultrasonography guidance, complete prevention of procedure-related hemorrhage is impossible during endoscopic cystoenterostomy. Endoscopic drainage-related bleeding can usually be managed with the standard endoscopic technique. However, surgical control may be needed in some cases. In our case, N-butyl-2cyanoacrylate, which is rapidly and readily available, was used to treat a severe endoscopic pseudocyst drainagerelated hemorrhage, leading to the immediate and complete cessation of bleeding. Fig. 1. Endoscopic view demonstrating spurting bleeding from the puncture site of the posterial wall of the stomach.

Mo1476 Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation

Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation Seung Hyo Han, Jong Ho Moon, Hyun Jong Choi, Hee Yong Yoo, Hyung Su Ahn, Seul Ki Min, Hyun Cheol Koo, Tae Hoon Lee, Young Koog Cheon, Young Deok Cho, Sang-Heum Park Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Republic of Korea; Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Seoul, Republic of Korea Objectives: Post-ERCP panreatitis is the most common and serious complication of ERCP. Difficult biliary cannulation can be one of procedure-related risk factors of post-ERCP pancreatitis. Recent studies have reported that prophylactic pancreatic stent reduce the frequency of post-ERCP pancreatitis. The aim of this study was to evaluate the efficacy of 3 Fr pancreatic stent to prevent post-ERCP pancreatitis in patients with difficult biliary cannulation. Methods: A total of 65 patients with difficult biliary selective cannulation were randomly divided into the stent group (S group, n 30) or the non-stent group (nS group, n 35). The stents used was 3 Fr Zimmon pancreatic stents. Difficult biliary cannulation was defined as the failure to achieve biliary access with more than 5 times of cannulation attempts or over 10 minutes of cannulation time. The incidence of post-ERCP pancreatitis was compared between S group and nS group. The diagonisis and severity assessment were according to Cotton’s criteria. Results : Pancreatic duct stenting was successful in all patients of S group. Spontaneous stent dislodgment within 7 days was recognized in 96.6% (29/30). No procedurerelated complication occurred. Mean serum amylase level after ERCP were 197.13 U/L and 420.77 U/L in S and nS group, respectively (p 0.005). The incidence rate of post-ERCP pancreatitis were 10% (3/30) and 31.4% (11/35) in S and nS group, respectively (p 0.036). The severity of pancreatitis was 1 moderate and 2 mild in in S group, whereas 1 severe, 2 moderate and 8 mild in nS group. Conclusions: Prophylactic pancreatic duct stent placement in patient with difficult cannulation during ERCP seems to be a safe and effective procedure to prevent for post-ERCP pancreatitis.