Toshiaki Nakatsu

Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function.

To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (<12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min,P<NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P=NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.

Utility of pancreatic duct brushing for diagnosis of pancreatic carcinoma

BackgroundThe aim of this study was to evaluate the usefulness of pancreatic duct brushing for diagnosis of pancreatic carcinoma.MethodsBrush cytology was attempted in 58 patients suspected of having pancreatic malignancy because of stricture of the main pancreatic duct, confirmed by endoscopic retrograde cholangiopancreatography. Thirty-eight patients were finally diagnosed by an operation or the clinical course as having pancreatic carcinoma, and the remaining 20 patients as having chronic pancreatitis. The usefulness of brush cytology for diagnosis of pancreatic carcinoma was estimated. We interpreted failures of pancreatic duct brushing to be false negatives when the lesion was malignant.ResultsIn 48 of 58 patients (82.8%), brushing was successfully performed and satisfactory specimens were obtained. Brush cytology was positive in 25 of 38 patients with pancreatic carcinoma (sensitivity 65.8%) and negative in all patients without malignancy (specificity 100%). Overall accuracy was 76.4%. During 2001–2005, the number of back-and-forth motions of the brush was increased to more than 30 times. The sensitivity significantly improved from 43.8% in 1997–2000 to 81.8% in 2001–2005 (P < 0.05). The increased success rate of brushing by improvement of skill in manipulating the guidewire and increased number of cells smeared on glass slides by increased back-and-forth motion of the brush may account for this improvement over time. Moreover, the sensitivity in 2001–2005 was 85.7% if failures of brushing with pancreatic carcinoma are excluded. No major complications occurred, except for two patients with a moderate grade of acute pancreatitis.ConclusionsAlthough further studies with a large number of patients are needed, our results suggest that with recent improvements of the brushing technique, pancreatic duct brushing is a useful and safe method for the differential diagnosis of malignancy from benign diseases of the pancreas.

Successful closing of duodenal ulcer after endoscopic submucosal dissection with over-the-scope clip to prevent delayed perforation.

Closure of post‐endoscopic submucosal dissection (ESD) duodenal artificial ulcer is not common in the clinical setting. We consider that post‐ESD ulcer closure by an over‐the‐scope‐clip (OTSC) method is one of the most effective ways to prevent delayed perforation. We report here two cases of mucosal duodenal cancer in a 65‐year‐old woman and in a 78‐year‐old man. Pathological examinations of the resected specimens revealed well‐differentiated adenocarcinomas. In these two clinical cases, we successfully carried out complete closures of post‐ESD duodenal ulcer using OTSC without any complications.

Usefulness of single and repetitive percutaneous transhepatic gallbladder aspiration for the treatment of acute cholecystitis

BackgroundThe aim of this study was to evaluate the safety and usefulness of single and repetitive percutaneous transhepatic gallbladder aspiration (PTGBA) for the treatment of acute cholecystitis.MethodsPTGBA was performed in patients with acute cholecystitis who showed no improvement after treatment with broad-spectrum antibiotics. PTGBA was carried out at bedside. When the bile was too thick to be aspirated through a 21-gauge needle, an 18-gauge needle was used. Aspiration of the gallbladder contents and injection of antibiotics into the gallbladder were performed without the placement of a drainage catheter. When improvement was not observed after the first attempt, PTGBA was repeated.ResultsSingle PTGBA achieved improvement in 32 of 45 patients. In 11 of the remaining 13 patients, the second PTGBA was effective. In the remaining two patients, repetitive PTGBA was not carried out because of advanced cancer. In two of 45 patients, 18-gauge needles were necessary for PTGBA because of the high viscosity of the bile. PTGBA was carried out in three patients with blockage of the cystic duct by a stent, and it was effective in all three. Two patients whose conditions improved with a single PTGBA experienced a recurrence at 4 and 31 months, respectively, after PTGBA. No other severe complications related to PTGBA were observed in any patients.ConclusionsFor the treatment of acute cholecystitis that does not react to conservative therapies, PTGBA is a safe, simple, and effective treatment modality that can be performed at bedside without any severe complications.

Estimation of the stent placement above the intact sphincter of Oddi against malignant bile duct obstruction

BackgroundIn endoscopic biliary stenting against malignant biliary obstruction, stent blockage remains as an important problem. Stent blockage occurs as a result of bacterial adherence to the inner wall of the stent. We evaluated the stent placement above the intact sphincter of Oddi to retain the function of the sphincter of Oddi as a bacteriological barrier.MethodsSixteen patients with malignant biliary obstruction were assessed as the patients with the stent above the intact sphincter of Oddi. Sixteen patients with malignant biliary obstruction were assessed as the patients with the conventional stent placement across the sphincter of Oddi. Tannenbaum 10-Fr. stents were used in both the groups.ResultsThe median patency periods of the stent were 255 days (25th to 75th percentiles, 212–454 days; range, 39–454 days) for the group of the stents placed above the sphincter of Oddi and 82 days (25th to 75th percentiles, 48–131 days; range, 22–196 days) for the group of the stents placed across the sphincter of Oddi, respectively, with significant difference (P = 0.0001). The occlusion rates of stents placed above and across the sphincter of Oddi were 37.5% and 93.8%, respectively, with significant difference (P = 0.0008). The dislocation rates of the stent were 0% and 6.3%, respectively (not significant).ConclusionsPlacement of the stent above the intact sphincter of Oddi was associated with longer stent patency and lower occlusion rate.

Endoscopic transpapillary gallbladder drainage (ETGBD) for the treatment of acute cholecystitis

We performed endoscopic transpapillary gallbladder drainage (ETGBD) in 21 patients with acute cholecystitis, utilizing a guidewire coated with a hydrophilic polymer. Endoscopic sphincterotomy was not performed. The clinical efficacy of ETGBD was evaluated in terms of reduction of white blood cell count (WBC) and C-reactive protein (CRP) level. ETGBD was successful in 17 (81%) of the 21 patients, in terms of early disappearance of clinical symptoms, and significant decrease of both WBC and CRP after ETGBD (P< 0.001). In patients with the Mirizzi syndrome (n=2), accurate diagnosis was made by endoscopic retrograde cholangiography (ERC), facilitating proper drainage (ETGBD) immediately afterward. With ETGBD, emergency operation was avoided even in critically ill patients complicated with disseminated intravascular coagulopathy (n=2). There were no significant complications. ETGBD may be an effective and safe alternative to percutaneous transhepatic gallbladder drainage in the management of acute cholecystitis, and may be more suitable for patients with a strong bleeding tendency.

Concomitant colitis associated with primary sclerosing cholangitis.

Between 1985 and 2001, seven Japanese patients (four males and three females) were diagnosed as having primary sclerosing cholangitis (PSC) in our hospital. All seven patients received total colonoscopy with distal ileoscopy. All four male patients were diagnosed as having colitis by colonoscopy, while none of the three female patients had colitis. The four patients with colitis did not have any symptoms attributable to colitis, such as diarrhea or hematochezia. In three of the four patients, unclassified colitis was the most suitable diagnosis, because there were no typical findings of ulcerative colitis or Crohns disease. The remaining patient was diagnosed as having eosinophilic colitis. By colonoscopic visualization, the right-sided colon, including the terminal ileum, was mainly involved, but the lesions were not severe. The main findings were redness, erosion, stenosis, and insufficiency of haustral formation. Histologically, these lesions were nonspecific inflammatory changes in the three patients with unclassified colitis. In the patient with eosinophilic colitis, remarkable infiltration of eosinophils was observed. Thus, unclassified colitis appeared to be the main complication in these patients with PSC. Males predominated in regard to concomitant colitis, and they had no symptoms of the colitis. Colonoscopic examination revealed that the lesions were not severe. The main lesions were found in the right-sided colon, with nonspecific inflammatory changes. These results suggest that colonoscopic surveillance of patients with PSC should be performed even if they do not have any colitis symptoms.

How many cytological examinations should be performed for the diagnosis of malignant biliary stricture via an endoscopic nasobiliary drainage tube

Background and Aim:  The sensitivity of bile cytology is recognized as being low. Repeating cytological sampling is likely to improve the sensitivity. The aim of this study is to determine the optimal number of repeated cytological sampling of bile obtained via an endoscopic nasobiliary drainage (ENBD) tube for the diagnosis of malignant biliary stricture.

Combination of assay of human telomerase reverse transcriptase mRNA and cytology using bile obtained by endoscopic transpapillary catheterization into the gallbladder for diagnosis of gallbladder carcinoma

OBJECTIVES:It is difficult to make accurate diagnoses of polypoid lesions in the gallbladder. To increase the diagnostic accuracy, we have developed an endoscopic technique to obtain gallbladder bile, termed endoscopic transpapillary catheterization into the gallbladder (ETCG). We evaluated the usefulness of a molecular biological approach to the diagnosis of gallbladder carcinoma, in which gallbladder bile obtained by the ETCG technique is used.METHODS:Twenty patients undergoing an operation because of suspicion of gallbladder carcinoma were enrolled. Twelve patients were confirmed to have gallbladder carcinoma, and four were found to have chronic cholecystitis. Two patients with polypoid lesion were diagnosed as having an inflammatory polyp and a hyperplastic polyp, respectively. The remaining two patients with polypoid lesions were diagnosed as having a cholesterol polyp. Gallbladder bile collected by the ETCG technique was evaluated cytologically and also analyzed for telomerase activity and mRNA for human telomerase reverse transcriptase (hTERT), the catalytic subunit of telomerase. In 14 patients, hTERT mRNA in resected specimens (fixed in 10% formalin and embedded in paraffin) was also examined.RESULTS:Cytology of gallbladder bile was positive in eight of 11 examined patients (72.7%) with gallbladder carcinoma. hTERT mRNA was detectable in gallbladder bile as well as in resected neoplastic tissues in four of 12 patients (33.3%) with carcinoma. Conversely, telomerase activity was negative in all eight examined patients with carcinoma. Overall, either cytology or hTERT mRNA of gallbladder bile was positive in 10 of 12 patients (83.3%) with gallbladder carcinoma. Cytology, hTERT mRNA, and telomerase activity were negative in eight patients with benign disease.CONCLUSIONS:The combination of cytology and hTERT mRNA analysis of gallbladder bile might be helpful for the preoperative diagnosis of gallbladder carcinoma.

Pre-cutting using a noseless papillotome with independent lumens for contrast material and guidewire

Background:  The technical success of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) depends on selective cannulation into the bile duct. We have developed a new type of precut papillotome for selective cannulation.