Takahiko Mimura

EFFECTIVENESS OF PERORAL CHOLANGIOSCOPY AND NARROW BAND IMAGING FOR ENDOSCOPICALLY DIAGNOSING THE BILE DUCT CANCER

CHF‐B260 has thinner diameters, and the quality of the endoscopic images has improved. Recently, narrow band imaging (NBI) system has been developed for high‐contrast observation of mucosal structures and vascular patterns. It is available to diagnose for the bile duct cancer endoscopically and it is useful for desciding of surgical margin before operation.

Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum β-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Drinking status of heavy drinkers detected by arrival time parametric imaging using sonazoid-enhanced ultrasonography: study of two cases.

Chronic heavy consumption of alcohol is associated with increased risks of developing liver cirrhosis, hepatocellular carcinoma, and esophageal varices. Cessation of alcohol consumption is the most important requirement in treating these diseases. However, judging whether patients have actually maintained abstinence from alcohol requires reliance on their reports, which vary substantially across individuals using the test methods currently available. Arrival time parametric imaging (At-PI) using Sonazoid-enhanced ultrasonography is regarded as a useful approach for assessing the progression of lesions that have developed in liver parenchyma. In this study, we report two cases for whom this approach was successfully applied to indicate the drinking status of a heavy drinker. At-PI enables approximate and objective assessment of the drinking status of patients, independent of their reports; therefore, it is a promising method for providing information about drinking status.

Efficacy of Combined Endoscopic Lithotomy and Extracorporeal Shock Wave Lithotripsy, and Additional Electrohydraulic Lithotripsy Using the SpyGlass Direct Visualization System or X-Ray Guided EHL as Needed, for Pancreatic Lithiasis

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

ENDOSCOPIC OBSERVATION OF MUCOSAL SPREAD LESION OF CHOLANGIOCARCINOMA USING PERORAL CHOLANGIOSCOPY WITH NARROW BAND IMAGING

A 69‐year‐old man was admitted to Toho University Omori Medical Center complaining of icterus. Abdominal computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were suspicious of cholangioma of inferior bile duct. Peroral cholangioscopy using narrow band imaging (NBI) was performed and it was possible to diagnose the mucosal spread lesions of cholangioma. Histological findings reflected the endoscopic findings. Mucosal spread lesions of cholangiocarcinoma were successfully diagnosed using the CHF‐B260 for NBI.

Endosonographic Preoperative Evaluation for Tumors of the Ampulla of Vater Using Endoscopic Ultrasonography and Intraductal Ultrasonography

Background/Aims In recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy. Methods The subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors. Results The diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging. Conclusions EUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer.

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Endoscopic snare excision for a major papilla tumor

Tumors of the duodenal papilla include hyperplasia, adenoma, carcinoma in adenoma and carcinoma. As the duodenal papilla has special anatomical characteristics and treatment involves major intervention and correct preoperative diagnosis. In patients with adenoma, or early carcinoma of the papilla, various endoscopic snare excision techniques are indicated for complete removal the tumor. Pancreatitis and cholangitis are major complications caused by endoscopic techniques. In the present study, endoscopic snare excision of the tumor located at the major papilla was carried out in two cases with early carcinoma or adenoma patients using a therapeutic duodenoscope, a spiral snare for the colon, and pure cutting current. The patients who underwent insertion of a 5‐Fr pancreatic stent and a 7‐Fr biliary stent inserted immediately after endoscopic tumor resection did not develop either pancreatitis nor cholangitis. This seems to be a safe technical method to prevent complications of endoscopic snare excision of the major papilla tumor.

Necessity for endoscopic sphincterotomy for biliary stenting in cases of malignant biliary obstruction

Endoscopic biliary stenting is a useful way to treat distal malignant biliary strictures that are not eligible for surgery. A 10‐Fr plastic or metal stent is used for stenting. Typically, endoscopic sphincterotomy (EST) has often been carried out as a way to prevent pancreatitis after stent placement given the ease of stent insertion, but EST has flaws such as bleeding and stent migration.The present study describes the need for EST prior to stent placement.

Efficacy of the new double-layer stent for unresectable distal malignant biliary obstruction: a single-center retrospective study.

Background and Aims. For distal malignant biliary obstruction in cases with short life expectancy, occlusion of plastic stents (PSs) does not usually occur before death, and the application of such a procedure is considered adequate from the viewpoint of cost-effectiveness. Methods and Setting. A new commercially available DLS with side holes, a conventional DLS, and, uncovered self-expanding metal stents (SEMSs) were retrospectively evaluated in patients with jaundice due to unresectable distal malignant biliary obstruction. Results. A total of 64 patients received endoscopic biliary stenting (23 patients with the new DLS, 24 patients with conventional DLS, and 17 patients with uncovered SEMS) from December 2002 to August 2009. Median patency time was found to be 198 days for the new DLS group and 99 days for the conventional DLS group, revealing a significant difference between devices. There was, however, no significant difference in median patency time between the new DLS and the uncovered SEMS (198 days versus 344 days). Conclusion. The new DLS is efficient and safe and may be considered the first choice for unresectable distal malignant obstruction in cases with short life expectancy.