Tomihiro Miura

ENDOSCOPIC DIAGNOSIS OF INTRADUCTAL PAPILLARY‐MUCINOUS NEOPLASM OF THE PANCREAS BY MEANS OF PERORAL PANCREATOSCOPY USING A SMALL‐DIAMETER VIDEOSCOPE AND NARROW‐BAND IMAGING

Background:  Intraductal papillary‐mucinous neoplasm (IPMN) is an intraductal tumor in which the mucin‐producing epithelium shows proliferated papillary and a wide variety of pathological changes ranging from hyperplasia to adenocarcinoma. Therefore, it is important to determine whether an IPMN is benign or malignant. In the present study of patients with IPMN, the protrusion was observed by a peroral pancreatoscopy (PPS) using a small‐diameter videoscope and narrow‐band imaging (NBI). We carried out the differential diagnosis of benign lesion to malignant lesion.

PERORAL CHOLANGIOSCOPY USING A NEW THINNER VIDEOSCOPE (CHF‐B260)

The CHF‐B260 videoscope has a 3.4 mm outer diameter, 1.2 mm forceps channel, and two‐way angulations function (70° up and 70° down). Peroral cholangioscopy (POCS) was performed using the CHF‐B260 in 13 patients who were admitted to our hospital between October 2002 and June 2004. The CHF‐B260 was successfully inserted into the bile duct in all cases. Clear images were obtained in 11 patients. Endoscopic images for two cases of malignant stricture due to metastasis of colon cancer and gallbladder cancer were not clear because of bleeding from the tumors. POCS was performed safely in all patients without any complications. POCS with the CHF‐B260 was very useful for the diagnosis of biliary disorders. If the outer diameter and biopsy channel of CHF‐B260 are improved, POCS will become even more effective for the diagnosis of biliary disorder.

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.

ENDOSCOPIC DIAGNOSIS OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM USING PERORAL PANCREATOSCOPY WITH NARROW BAND IMAGING

A 77‐year‐old man was diagnosed with a pancreas cyst at another hospital. Abdominal ultrasonography revealed a cyst in the head of the pancreas and a small protrusion. These findings suggested intraductal papillary mucinous neoplasm. Cytologic finding of the pancreatic juice revealed a Class III lesion, and intraductal ultrasonography and peroral pancreatoscopy (PPS) were performed. An abnormal course of main pancreatic duct (MPD) prevented the insertion of an ultrasonography probe into the MPD, and PPS was performed. The mucosal surface of the MPD near the papillary area was normal, and narrow band imaging (NBI) clearly showed the vascular structure. When the PPS was inserted more deeply, many small protrusions were observed and NBI delineated the protrusions more clearly. Papillary protrusions were observed in the cyst, but NBI did not reveal any tumor vessels. These findings led to a diagnosis of benign intraductal papillary mucinous neoplasm lesion. Since then, follow‐up examinations have been made. Changes in the cyst and protrusion have not been observed.

ENDOSCOPIC TREATMENT FOR THE BENIGN BILIARY STRICTURE IN THE PATIENT WITH CHRONIC PANCREATITIS

In some patients with chronic pancreatitis (CP), strictures are observed in the intrapancreatic bile ducts due to fibrosis and inflammation in the pancreas. Normally, even when biliary strictures exist, obstructive jaundice is rarely observed. It seemed that obstructive jaundice was brought about by temporary pancreatitis due to immoderate alcohol ingestion, followed by the aggravation of the intrapancreatic biliary stricture. When immoderate alcohol ingestion is incriminated for the pancreatic disorder, the patient should be strictly instructed to abstain from alcohol, but failure to observe this instruction seems to render endoscopic biliary stenting ineffective. When CP is complicated with pancreatolithiasis, stone fragmentation using extracorporeal shock wave lithotripsy (ESWL) is effective, and combination with endoscopic lithotomy makes it possible to remove pancreatic stones in the main pancreatic duct (MPD). To treat the beside dilating stricture of the MPD, balloon dilation and pancreatic duct stenting are performed. We obtained good results with 10 Fr pancreatic duct stents, but biliary strictures are better treated with a combination of these methods. When 10 Fr or larger straight biliary stents are used, they may be dislodged or stray if the bile duct is sharply curved. To prevent this accident we have used 10 Fr double layer stents and obtained good results. In patients with benign biliary strictures, stents are temporarily placed and should be removable. Some cases have been reported where Wallstent gave good results in a short period, but the stents were occluded due to hyperplastic proliferation of the biliary epithelium. Metal stents are not considered desirable for benign biliary strictures. Our results seem to support the assumption that benign biliary strictures are improved with 10 Fr or larger biliary stents while exercizing care to keep the patient abstinent from alcohol and performing ESWL and endoscopic treatment for CP.