Shinya Uemura

Endoscopic Ultrasound-Guided Antegrade Treatments for Biliary Disorders in Patients with Surgically Altered Anatomy

IntroductionEndoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well.AimsTo evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies.MethodsWe retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures.ResultsEUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients.ConclusionsEUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.

Preoperative routine evaluation of bilateral adrenal glands by endoscopic ultrasound and fine-needle aspiration in patients with potentially resectable lung cancer.

BACKGROUND AND STUDY AIMS The aim of the current study was to assess the detection rate of the right adrenal gland and the diagnostic ability of endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) for the diagnosis of adrenal metastasis in potentially resectable lung cancer. PATIENTS AND METHODS This retrospective cohort study included a consecutive series of 150 patients undergoing EUS/EUS - FNA for staging of lung cancer. The detection rate of the right adrenal gland by EUS and the diagnostic accuracies of computed tomography (CT), positron emission tomography-CT (PET-CT), and EUS/EUS - FNA for the diagnosis of adrenal metastasis were evaluated. RESULTS The right adrenal gland was visualized by EUS in 131 patients (87.3 %); the left adrenal gland was visualized in all patients. Findings suggestive of metastasis in either one of the adrenal glands or in both were observed in 6 patients (4.0 %) by CT, in 5 patients (3.3 %) by PET-CT, and in 11 patients (7.3 %) by EUS. EUS - FNA was performed simultaneously in the 11 patients, and in 4 patients the diagnosis of metastasis was established. The accuracy for the diagnosis of adrenal metastasis was 100 % for EUS/EUS - FNA, 96.0 % for CT, and 97.0 % for PET-CT (P = 0.1146). CONCLUSIONS As well as the left adrenal gland, the right adrenal gland was also usually visible by EUS. EUS/EUS - FNA provided an accurate diagnosis of adrenal metastasis, although the prevalence of adrenal metastasis was relatively low in these patients with potentially resectable lung cancer.

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.

Endoscopic ultrasound-guided antegrade biliary stenting for unresectable malignant biliary obstruction in patients with surgically altered anatomy: Single-center prospective pilot study

Endoscopic retrograde cholangiography (ERCP) with biliary stenting for the treatment of unresectable malignant biliary obstruction (MBO) is challenging among patients with surgically altered anatomy. Endoscopic ultrasound‐guided antegrade biliary stenting (EUS‐ABS) was introduced as an alternative biliary drainage method, although it has not yet been well studied. In this single‐center prospective pilot study, we aimed to evaluate the feasibility and safety of EUS‐ABS for MBO in patients with surgically altered anatomy.

Endoscopic ultrasound-guided antegrade papillary balloon dilation for treating a common bile duct stone

1. Kaiser HE, Bodey B Jr, Siegel SE, Gröger AM, Bodey B. Spontaneous neoplastic regression: The significance of apoptosis. In Vivo 2000; 14: 773–88. 2. Challis GB, Stam HJ. The spontaneous regression of cancer. A review of cases from 1900 to 1987. Acta Oncol. 1990; 29: 545–50. 3. Abdelrazeq AS. Spontaneous regression of colorectal cancer: A review of cases from 1900 to 2005. Int. J. Colorectal Dis. 2007; 22: 727–36.

Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy

Abstract Introduction. Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy (SAA) is generally challenging despite the use of enteroscopy. After failed biliary cannulation, rendezvous technique (RV) can be an option to assist the biliary access. However, proper needle puncture of biliary ducts, which is critical in the RV procedure, can be difficult because of insufficient biliary dilation. By contrast, the gallbladder can be punctured as a possible access route for RV. Aim. To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA. Patients and methods. Six patients who underwent PTGB-RV were included. PTGB drainage was performed in cases without sufficient biliary duct dilation. A guidewire was inserted through the PTGB route with antegrade passage through the cystic duct, common bile duct and duodenal papilla. An enteroscope was inserted up to the papilla, at the guidewire exit site. The guidewire was pulled out through the accessory channel followed by biliary cannulation over the guidewire and endoscopic papillary balloon dilation (EPBD) for stone removal. Results. Six patients with SAA (Roux-en-Y in 4 and Billroth-II in 2) underwent PTGB-RV for removal of bile duct stones. In all patients, a guidewire was successfully inserted into the duodenum followed by insertion of the enteroscope and biliary cannulation. EPBD was then performed, but subsequent stone removal failed in 1 patient. Stone removal was successful in 5 patients without complication, except 1 case of mild pancreatitis. Conclusion. PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.

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.

Endoscopic Papillary Large Balloon Dilation as a Salvage Procedure for Basket Impaction During Retrieval of Common Bile Duct Stones

Endoscopic management of common bile duct stones (CBDSs) is an effective and minimally invasive procedure. CBDSs are retrieved using either a balloon or basket catheter after managing the major papilla with endoscopic sphincterotomy (ES) or endoscopic papillary balloon dilation (EPBD). However, this procedure is associated with complications such as pancreatitis, hemorrhage, perforation, and cholangitis [1, 2]. Although basket impaction at the papilla during stone retrieval is a rare complication with a reported incidence rate of 0.8 % [3], it can cause serious complications such as biliary obstruction and secondary cholangitis. Furthermore, attempts to release the basket impaction by forceful manipulation can lead to perforation of the duodenum or CBD that will eventually require surgery to resolve the complication. Generally, mechanical lithotripsy is initially attempted to release the impaction but may occasionally fail because of fracture of the basket wire at the cranking handle. Recently, endoscopic papillary large balloon dilation (EPLBD) has been reported as an effective papillary intervention for managing large or multiple CBDSs [4–7]. In this study, we evaluated the efficacy and safety of EPLBD as a salvage procedure for basket impaction at the ampulla.

Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer

BACKGROUND Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment. AIMS To compare the efficacy and safety of GJJ and DS for GOO with APC. METHODS Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis. RESULTS GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS. CONCLUSIONS There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.

Infected mediastinal cyst following endoscopic ultrasonography-guided fine-needle aspiration with rupture into the esophagus

A 37-year-old woman with a mediastinal mass detected by afollow-up chest computer tomography (CT) after gastrec-tomy for gastric cancer was referred to us for endoscopicultrasonography-guided fine-needle aspiration (EUS-FNA).EUSshowedawell-demarcatedhypoechoiclesion,measuring25 ¥ 13 mm,in the upper mediastinum.A single pass of FNAwith a 19 gauge needle yielded a clear jelly-like specimen.Cytologicalexaminationshowedmucusandbenignsquamousepithelium.The lesion was diagnosed as a bronchogenic cystfrom these findings.An oral prophylactic antibiotic was initi-ated because of the FNA for the cystic lesion.Six days after FNA, the patient presented at our hospitalwith fever, chest pain and dysphasia; chest CT showed asignificantly enlarged mediastinal cyst (Fig. 1).These findingswere consistent with infected mediastinal cyst. Broad spec-trum intravenous antibiotics were initiated with completeimprovementofsymptomsinacoupledays.Afollow-upchestCT showed the shrunken cyst, which was filled with air(Fig. 2a);esophagogastroduodenoscopyshowedafistulawithulceration in the esophagus (Fig. 2b). The patient was dis-charged without deterioration of her symptoms. Repeat CTand esophagogastroduodenoscopy confirmed the resolutionof a fistula and cyst.EUS-FNA for mediastinal lesions is a well-establishedtechnique to obtain pathological specimens.