Shin Kato

Efficacy, Safety, and Long-Term Follow-Up Results of EUS-Guided Transmural Drainage for Pancreatic Pseudocyst

Background and Aim. EUS-guided transmural drainage (EUS-GTD) is now considered a minimally invasive and effective alternative to surgery for drainage of symptomatic pancreatic pseudocysts. However, the technique is rather difficult, and sometimes serious complications occur to patients undergoing this procedure. We retrospectively evaluated efficacy, safety, and long-term follow-up results of EUS-GTD for pancreatic pseudocyst. Methods. Sixty-seven patients with pancreatic pseudocyst who underwent EUS-GTD from April 2000 to March 2011 were enrolled. We retrospectively evaluated (1) technical success, (2) clinical success, (3) adverse event of procedure, and (4) long-term follow-up results. Results. Total technical success rate was 88%. Ninety-one percent of external drainage, 79% of internal drainage, and 66% of puncture and aspiration only achieved clinical success. There was only one case with an adverse event, perforation (1.5%). The case required emergency operation. Total recurrence rate was 23.9%. Median follow-up period was 33.9 months. The recurrence rates in the cases of stent remaining, spontaneously dislodged, removed on schedule, external tube removal, and aspiration only were 10.0%, 12.5%, 42.9%, 50%, and 0%, respectively. Conclusion. EUS-GTD is a relatively safe and effective therapeutic method. However, further analysis should be done by larger series to determine the method of EUS-GTD for pancreatic pseudocyst.

Diagnostic utility of endoscopic ultrasound-guided fine-needle aspiration biopsy for glomus tumor of the stomach

A 52-year-old man was referred for further investigation of a gastric submucosal tumor on the greater curvature of the antrum. Endoscopic ultrasonography demonstrated a hypoechoic solid mass, which was primarily connected to the muscular layer of the stomach. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy. The pathological examination showed proliferation of oval-shaped cells with nest formation, which stained strongly positive for muscle actin, and negative for c-kit, CD34, CD56, desmin, S-100, chromogranin, and neuron-specific enolase. Therefore, we performed laparoscopy and endoscopy cooperative surgery based on the preoperative diagnosis of glomus tumor of the stomach. The final histological diagnosis confirmed the preoperative diagnosis. Although preoperative diagnosis of glomus tumor of the stomach is difficult with conventional images and endoscopic biopsy, endoscopic ultrasound-guided fine-needle aspiration biopsy is an essential tool to gain histological evidence of glomus tumor of the stomach for early diagnosis.

Prospective, randomized, comparative study of delineation capability of radial scanning and curved linear array endoscopic ultrasound for the pancreaticobiliary region.

Background and study aims: There are two types of endoscopic ultrasound (EUS) endoscope, the radial scanning (RS) and the curved linear array (CL). The type of EUS endoscope used at a first intent depends on local expertise, local habits and sometimes on how the examination is reimbursed. In Japan, RS is mainly used for observation, whereas CL is primarily used for histopathological diagnosis and treatment. We compared the imaging capabilities of RS and CL in evaluating the pancreaticobiliary region, a study which has not been performed previously. Patients and methods: This prospective and randomized trial included 200 patients undergoing endoscopic ultrasonography of the pancreaticobiliary region by RS (n = 99) or CL (n = 101). The primary end point was the basal imaging capability of each technique. Eleven pancreaticobiliary areas were assessed and scored (range, 0 – 2). Endoscopists evaluated each criterion, and a transcriber recorded the decisions in real time. Results: The mean imaging scores in the RS and CL groups were 18.39 and 19.62, respectively (significantly higher in CL, 95 %CI: 0.82 – 1.64). Although no significant difference in imaging capability for the pancreatic head, body, or tail was observed between CL and RS, the imaging capability of CL for the pancreatic head – body transition region was superior to that of RS. Although no significant difference in imaging capability for the middle and inferior bile duct or the cystic duct was observed between CL and RS, the imaging capability of RS for the major duodenal papilla and gallbladder was superior to that of CL. For the area from the hepatic portal region to the superior bile duct, the imaging capability of CL was superior. In the delineation of the branch area of the celiac and superior mesenteric arteries, CL was also superior to RS. Conclusions: The non-inferiority of the overall imaging capability of CL to that of RS was demonstrated. CL was superior in the delineation of the pancreatic head – body transition region, the area from the hepatic portal region to the superior bile duct, and the vascular bifurcation, whereas RS was superior in the delineation of the major duodenal papilla and gallbladder. Thus, for detailed evaluations of specific areas, the choice of scope should probably be considered.

Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique

Title Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique Author(s) Kawakubo, Kazumichi; Kuwatani, Masaki; Kato, Shin; Sugiura, Ryo; Sano, Itsuki; Sakamoto, Naoya Citation Endoscopic Ultrasound, 7(2), 133-134 https://doi.org/10.4103/eus.eus_31_17 Issue Date 2018-03 Doc URL http://hdl.handle.net/2115/71166 Rights(URL) http://creativecommons.org/licenses/by-nc-sa/3.0/ Type article File Information EndoscUltrasound72133-2596543_071245.pdf

Hepatobiliary and Pancreatic: Pancreatic cancer with elevated serum IgG4 level due to multiple myeloma mimicking localized autoimmune pancreatitis: Hepatobiliary and Pancreatic: Pancreatic cancer with elevated serum IgG4 level due to multiple myeloma mimicking localized autoimmune pancreatitis

An 80-year-old Japanese woman was referred for examination of a pancreas head mass lesion. She was diagnosed with multiple myeloma (MM) at another hospital 2 years before referral. Laboratory tests revealed abnormal liver function test and elevated serum IgG, IgG4, (1560 mg/dL) and CA19-9 levels (154.2 U/mL). Initial computed tomography (CT) (Fig. 1a, arrow) and endoscopic ultrasonography (EUS) (Fig. 1b, arrowheads) showed a mass in the pancreas head that involved the distal bile duct (BD). EUS guided fine-needle aspiration of the mass found no evidence of malignancy or autoimmune pancreatitis (AIP). The biopsy specimen from the distal BD showed infiltration of few plasma cells without IgG4 staining. Based on the diagnosis of localized type 1 AIP by international consensus diagnostic criteria (indeterminate imaging, level 1S and level OOI), we started to administrate prednisolone at a dose of 30 mg/day. Eight weeks after prednisolone start, the serum CA19-9 level was sharply elevated (465 U/mL), whereas serum IgG and IgG4 levels had not decreased. Follow-up CT showed expansion of the pancreas head mass. Repeated biopsy of the distal BD stricture was performed and revealed adenocarcinoma (Fig. 2a, hematoxiline and eosin stain). According to the report from the previous hospital, this patient was diagnosed with IgG-type MM (Durie-salmon staging system; clinical stage II) from laboratory test results (IgG, 2752 mg/dL; IgA, 46 mg/dL; IgM, 30 mg/dL; κ/λ ratio, 8.28; Hb, 9.0 g/dL), bone marrow findings (Fig. 2b, hematoxiline and eosin stain; Fig. 2c,d, CD138), and serum immunoelectrophoresis, which showed a clear M peak on IgG. The previous and current serum laboratory findings (IgG, 2192 mg/dL; IgG4, 1560 mg/dL; κ/λ ratio, 8.97) indicated an increase in serum monoclonal IgG4. The final diagnosis was pancreatic ductal adenocarcinoma (PDAC) complicated by MM with increased monoclonal IgG4. The patient underwent best supportive care because of her poor performance status. In the two previous studies analyzing IgG subclass distribution in patients with MM, the proportion of patients with IgG4 M-protein was extremely low (6.5% and 8%, respectively). There has been no previous report of a case of PDAC complicated by MM with IgG4 M-protein. We described an extraordinary case of PDAC that was initially misdiagnosed as localized AIP because of a markedly elevated serum IgG4 level affected by MM. Physicians should consider that the presence of MM with IgG4 M-protein could hinder a correct diagnosis of a pancreatic mass lesion.

Mixed ductal-neuroendocrine carcinoma with unique intraductal growth in the main pancreatic duct

A 64-year-old man was referred to our hospital for workup of a pancreatic mass. Ultrasonography revealed dilatation of the main pancreatic duct (MPD) in the body and tail of the pancreas [Figure 1a]. Abdominal computed tomography demonstrated a mass in the head of the pancreas with gradual enhancement [Figure 1b]. EUS showed a hypoechoic mass in MPD, measuring about 16 mm × 14 mm, with dilatation of MPD in the pancreatic body and tail [Figure 1c]. Endoscopic retrograde pancreatography showed obstruction of MPD in the head of the pancreas [Figure 1d], and we performed biopsy of the lesion. Histological examination of the biopsy specimen suggested combined carcinoma with both ductal and neuroendocrine features.

Direct recanalization of the pancreaticogastrostomy obstruction with a forward-viewing echoendoscope

Anastomotic stricture can occasionally cause repeated acute pancreatitis after partial resection of the pancreas such as pancreaticoduodenectomy or duodenum-preserving pancreatic head resection (DPPHR). Endoscopic ultrasonography-guided pancreatic duct drainage with an oblique-viewing echoendoscope has revealed feasibility and availability [1, 2], while that with a forward-viewing echoendoscope (FV-ES) has extremely been limited [3-5]. We herein describe the first case with pancreaticogastrostomy obstruction treated by direct recanalization with FV-ES. This article is protected by copyright. All rights reserved.

Successful endoscopic sphincterotomy for choledocholithiasis in a patient with severe hemophilia A and inhibitors

Endoscopic sphincterotomy (ES) is a standard procedure for bile duct stone removal. However, the safety of ES in patients with hemophilia remains unknown. We treated a 46-year-old man who had choledocholithiasis and severe hemophilia A with high-responding inhibitors during immune tolerance induction therapy. Since coagulation factor VIII inhibitors neutralize and inactivate endogenous and exogenous factor VIII, bleeding risk is higher in hemophilia A patients with inhibitors than in those without inhibitors. With adequate pre- and post-procedure monitoring of the clotting factor and supplemented clotting factor, the patient could safely undergo ES without bleeding complications. ES can be also an effective and safe first-line therapy for choledocholithiasis in patients with hemophilia and inhibitors under the condition of appropriate management.

Pancreatic Duct Stricture That Rapidly Progressed to Pancreatic Ductal Adenocarcinoma and Formed a Mass within 3 Months: A Case Report

The natural growth rate of pancreatic carcinoma in situ with pancreatic duct stricture remains unclear. Herein, we present a case with pancreatic duct stricture that rapidly grew to form a mass lesion within 3 months. A 74-year-old woman was referred to us for the investigation of a pancreatic duct dilatation. Initial images did not reveal any clear mass lesions near the pancreatic duct stricture. Pancreatic juice cytology showed suspicious findings. Distal pancreatectomy was recommended; however, the patient refused to undergo surgical treatment at that time. Images taken 3 months later demonstrated a nodular pancreatic body mass which was identified as a moderately to poorly differentiated tubular adenocarcinoma. Previous reports have suggested that pancreatic carcinoma in situ and small pancreatic ductal adenocarcinoma require at least 1–2 years to progress to an advanced mass. This case suggests that pancreatic carcinoma in situ may grow rapidly and indicates a need for close follow-up in patients with pancreatic duct strictures, even if the pathological evidence is not confirmed.

Predictors for bile duct stone recurrence after endoscopic extraction for naïve major duodenal papilla: A cohort study

Background Predictors for bile duct stone recurrence after endoscopic stone extraction have not yet been clearly defined and a study investigating naïve major duodenal papilla is warranted because studies focusing only on naïve major duodenal papilla are rare. The aim of this study was to observe the long-term outcomes of endoscopic bile duct stone extraction for naïve major duodenal papilla and to assess the predictors for recurrence. Methods This was a retrospective cohort study that consisted of 384 patients with naïve papilla who underwent initial endoscopic bile duct stone extraction. Patients were followed up in outpatient department subsequent to complete stone clearance. Recurrence was defined as symptomatic repeated stone formation observed at least three months after the procedure. Stone recurrence, predictors of recurrence, and the recurrence rate, depending on each endoscopic treatment for major duodenal papilla, were examined. Results In this study, 34 patients (8.9%) developed stone recurrence. The median time to recurrence was 439 days. Periampullary diverticulum and multiple stones were strong predictors of bile duct stone recurrence (RR, 5.065; 95% CI, 2.435–10.539 and RR: 2.4401; 95% CI: 1.0946–5.4396, respectively). The above two factors were independent predictors of stone recurrence as per logistic regression analysis adjusted for confounders (Periampullary diverticulum: OR, 7.768; 95% CI, 3.27–18.471; multiple stones: OR, 4.144; 95% CI, 1.33–12.915). No recurrence was observed after endoscopic papillary large balloon dilatation (0/20), whereas recurrence was observed in 7 patients after endoscopic papillary balloon dilatation (7/45) and in 27 patients after endoscopic sphincterotomy (27/319). However, these differences were not statistically significant (p = 0.105). Conclusions We determined that the presence of periampullary diverticulum and multiple stones are strong predictors for recurrence after endoscopic stone extraction. Moreover, endoscopic papillary large balloon dilatation tended to be correlated with non-recurrence of bile duct stone.