Y. Nakai

High‐rate pulmonary involvement in autoimmune pancreatitis

Autoimmune pancreatitis (AIP) has extrapancreatic complications such as Sjögrens syndrome, retroperitoneal fibrosis and sclerosing cholangitis. We studied 30 patients with AIP. Of these, we identified pulmonary involvement in four patients during follow up. Among them, two patients had respiratory failure. They showed good response to steroid therapy, but a higher dose of prednisolone was necessary to maintain remission than that required in biliary involvement. Elevation of immunoglobulin G4 and Krebs von den Lungen‐6 levels were characteristic of pulmonary involvement. They may be useful for early detection of pulmonary complication.

Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation

INTRODUCTION Selective cannulation fails in approximately 3 % of endoscopic retrograde cholangiography (ERC) procedures. An endoscopic ultrasound-guided rendezvous technique (EUS - RV) may salvage failed cannulation. The aims of the current study were to determine the safety and efficacy of EUS - RV. METHODS A total of 40 patients underwent salvage EUS - RV. EUS - RV was attempted immediately after failed biliary cannulation. A dilated intra- or extra-hepatic biliary duct (IHBD or EHBD) was punctured from the stomach or the small intestine under EUS guidance followed by cholangiography and antegrade manipulation of the guide wire into the small intestine. Finally, the echoendoscope was exchanged for an appropriate endoscope and biliary cannulation was achieved over or adjacent to the guide wire. RESULT EUS-RV appears safe and effective and may be considered as a primary salvage technique after failed cannulation. Antegrade manipulation of the guide wire into the small intestine was achieved in 29 of 40 patients (73 %; EHBD 25 /31 and IHBD 4/9). The reasons for failure were inability to advance the guide wire through an obstruction or a native ampulla. Re-attempt at ERC immediately after failed EUS - RV was made in seven of the 11 patients, and was successful in four. The remaining seven patients underwent percutaneous drainage within 3 days. Complications occurred in five patients (13 %), including pancreatitis, abdominal pain, pneumoperitoneum, and sepsis/death, which was unlikely to be related to the procedure. CONCLUSION EUS - RV is safe and effective and should be considered as a primary salvage technique after failed cannulation. Immediate re-attempt at ERC after failed EUS - RV is warranted, as EUS-guided cholangiogram can facilitate biliary cannulation in some cases. Finally, prompt alternative biliary drainage should be available.

In vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy.

Pancreatic cystic lesions (PCLs) are increasingly identified with the widespread use of imaging modalities. The precise diagnosis of PCLs remains a challenge despite the use of CT, MRI, and EUS-FNA. Confocal laser endomicroscopy (CLE) is a new endoscopic imaging modality that provides real-time, very high magnification images. A smaller CLE probe, which can be passed through a 19-gauge FNA needle, is now available. Needle-based CLE during EUS has recently been examined to evaluate PLCs, and the specific criteria of nCLE for the diagnosis of PLCs have been proposed.

Endo-hepatology: a new paradigm.

Recent advances in hepatology have included a new and effective treatment of viral hepatitis, with an increased need for the assessment of liver function and histology. At the same time, there have been a growing number of endoscopic procedures that are pertinent to patients with liver disease. It would be ideal if the assessment and treatment of liver disease and portal hypertension could be performed and assimilated by the liver/gastrointestinal specialist. The authors like to consider this area of integration or overlap of endoscopic procedures within the practice of hepatology as endo-hepatology.

Competing risk: a potential risk factor for misleading results of length of stent patency.

We read with great interest the article by Kim et al. [1] about a retrospective study evaluating the effects of chemotherapy on the patency of self-expandable metal stents (SEMS) for malignant outlet obstruction caused by gastric cancer. Kim et al.’s analysis showed that greater time-toprogression (TTP) and first-line chemotherapy were associatedwith significantly longer SEMS patency. Better local tumor control in patients with a better response to chemotherapy theoretically provides longer SEMS patency. However, these “reasonable” results regarding SEMS patency and its association with chemotherapy should be interpreted with caution due to the presence of competing risks. “Competing risks” are defined as causes other than those included in the analysis that may affect or compromise the probability of occurrence of an event of interest [2]. Kim et al. [1] calculated the cumulative incidence functions (CIFs) of SEMS dysfunction as 1–Kaplan–Meier estimate and compared these using the log rank test; however, this conventional method of calculation overestimates CIFs in the presence of competing risks. Thus, a competing risk analysis should also be considered to compare appropriately the length of patency of SEMS in two groups with a high rate of competing risk events. We propose that the deaths prior to SEMS dysfunction in Kim et al.’s study should be treated as a competing risk for SEMS dysfunction. Although Kim et al. did not provide detailed survival data, the prognosis was probably much better in patients who had had a long TTP or had undergone first-line chemotherapy. As death prior to SEMS dysfunction is a competing risk for SEMS dysfunction, it was more likely to occur in patients who had a short TTP or had undergone salvage chemotherapy, and CIFs of SEMS dysfunction were likely to be overestimated in the groups with poor prognosis. As a result, a longer survival time might have favorably affected the CIF of SEMS dysfunction as calculated by 1–Kaplan–Meier estimate in groups with a long TTP and first-line chemotherapy, leading to apparently better SEMS patency. We believe CIFs of SEMS dysfunction should be estimated and compared using competing risk analysis [2,3] instead of conventional methods, especially when comparing SEMS patency times of two groups with different prognoses, as carried out by van Hooft JE et al. [4] in their study of duodenal SEMS.Furthermore, Kim et al. [1] separately computed CIFs of SEMS migration and restenosis; however, these two causes of SEMS dysfunction are potential competing risk events for each other. The counterpart of the Cox proportional hazards model in a competing risk framework was also proposed by Fine and Gray [5]. Thus, we believe the validity of Kim et al.’s results would have been enhanced by utilizing a competing risk regression model. Finally, we wish to comment on the prognostic factors included in the multivariate analysis. Initially, only baseline characteristics should be included in the Cox proportional hazards model; particular attention is required, e.g., the landmark method [6], when factors pertaining to the follow-up period are included in the analysis, such as response to chemotherapy or TTP, as in Kim et al.’s study.

Total Cholesterol Level for Assessing Pancreatic Insufficiency Due to Chronic Pancreatitis

Background/Aims To determine the nutritional markers important for assessing the degree of pancreatic insufficiency due to chronic pancreatitis in routine clinical practice. Methods A total of 137 patients with chronic pancreatitis were followed up for more than 1 year. They were divided into two groups: a pancreatic diabetes mellitus (DM) group, consisting of 47 patients undergoing medical treatment for DM of pancreatic origin, and a nonpancreatic DM group, consisting of 90 other patients (including 86 patients without DM). Serum albumin, prealbumin, total cholesterol, cholinesterase, magnesium, and hemoglobin were compared between the two groups. Results The total cholesterol was significantly lower in the pancreatic than the nonpancreatic DM group (164 mg/dL vs 183 mg/dL, respectively; p=0.0028). Cholinesterase was significantly lower in the former group (263 U/L vs 291 U/L, respectively; p=0.016). Among the 37 patients with nonalcoholic pancreatitis, there was no difference in the cholinesterase levels between the pancreatic and nonpancreatic (296 U/L vs 304 U/L, respectively; p=0.752) DM groups, although cholesterol levels remained lower in the former (165 mg/dL vs 187 mg/dL, respectively; p=0.052). Conclusions Cholinesterase levels are possibly affected by concomitant alcoholic liver injury. The total cholesterol level should be considered when assessing pancreatic insufficiency due to chronic pancreatitis.

Self-expandable metallic stents for malignant biliary obstruction with an anomalous pancreaticobiliary junction

BackgroundAnomalous pancreaticobiliary junction (APBJ) is associated with pancreaticobiliary cancer. Limited data are available on endoscopic biliary drainage for unresectable malignant biliary obstruction with APBJ. This study evaluated the efficacy and safety of self-expandable metallic stents (EMSs) for the management of malignant biliary obstruction with APBJ.MethodsBetween 1993 and 2005, 324 patients with unresectable malignant biliary obstruction underwent insertion of an EMS. Six of these patients with concomitant APBJ constituted the subjects of this study. Early (≤30 days after EMS insertion) and late (>30 days after EMS insertion) stent-related complications and stent patency were evaluated in these six patients.ResultsThe cause of biliary obstruction was gallbladder cancer in four patients and pancreatic cancer in two patients. Uncovered EMSs were inserted across the common channel without performance of a biliary sphincterotomy. The diameter of the uncovered EMS used was based on the diameter of the common channel. For all six patients, endoscopic biliary drainage was successful, and their jaundice subsided steadily. None of the six patients experienced early complications, including acute pancreatitis. The mean stent-related complication-free period was 163 days. Stent occlusion caused by tumor ingrowth occurred in two patients. Acute cholangitis and cholecystitis were observed in one patient each.ConclusionsUncovered EMSs are effective for palliation of unresectable malignant biliary obstruction in patients who have APBJ without increasing the risk of stent-related early complications.

Outcome of intraductal papillary mucinous tumor of the pancreas: Analysis of followed patients

[Results] The n~*mber of survived PC ceils were signif*cantly smaller in I+TU M+TL compared with VTL, M-TL The PCNA-posinve ratio of adherent cells on chamber slides were sigraficantIy stnaller in I+TL, M+TL compared with I-TL, M-TL. IFN-gamma level was higher in I + TL and M + TL (I + TL > M + TL) compared with I-TL and M-TL. VEGFA level `*,as the lowest in I + TL group. [Conclusionl Our data showed that immunntherapy with DCs had anti-cancer effect in vitro. Data also indicated that the combination of tumor lysate pulsation and using immature DCs was the most dfective for human pancreatic cancer. The mechanistns of immunotherapy may not only be stimulating IFN-gamma production from T cells, but also attenuating the production of angiogenic factors.