Yoshimasa Kubota

Comparison of efficacy and toxicity of FOLFIRINOX and gemcitabine with nab-paclitaxel in unresectable pancreatic cancer

BACKGROUND Irinotecan, oxaliplatin and leucovorin-modulated fluorouracil (FOLFIRINOX) and the combination regimen of gemcitabine and nanoparticle albumin-bound paclitaxel (GnP) (nab-PTX) improve the prognosis of patients with metastatic pancreatic cancer. However, no study has compared the efficacy of the two regimens. We compared retrospectively the efficacy and safety of the two regimens in patients with unresectable pancreatic cancer. METHODS Thirty-eight patients with unresectable locally advanced or metastatic pancreatic cancer received FOLFIRINOX or GnP as first-line chemotherapy between December 2013 and September 2015. In the FOLFIRINOX group, patients received 85 mg/m2 oxaliplatin followed by 180 mg/m2 irinotecan and 200 mg/m2 L-leucovorin, and by 400 mg/m2 fluorouracil as a bolus and 2,400 mg/m2 fluorouracil as a 46-h continuous infusion every 14 days. In the GnP group, patients received 125 mg/m2 nab-PTX followed by 1 g/m2, and gemcitabine on days 1, 8 and 15, repeated every 28 days. RESULTS Response rate was 6.3% in the FOLFIRINOX group and 40.9% in the GnP group (P=0.025). Median progression-free survival (PFS) was 3.7 months [95% confidence interval (CI), 3.0-4.5] in the FOLFIRINOX group and 6.5 months (95% CI, 6.2-6.9 months) in the GnP group (P=0.031). Drug toxicity in the GnP group was less than in the FOLFIRINOX group. CONCLUSIONS Efficacy and safety of GnP compare favorably to those of FOLFIRINOX in patients with pancreatic cancer. Additional prospective trials are warranted.

Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma.

AIM To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma. METHODS In total, 118 patients with hilar cholangiocarcinoma underwent endoscopic management [endoscopic nasobiliary drainage (ENBD) or endoscopic biliary stenting] as a temporary drainage in our institution between 2009 and 2014. We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment. The risk factors for biliary reintervention, post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis, and percutaneous transhepatic biliary drainage (PTBD) were also analyzed using patient- and procedure-related characteristics. The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage. RESULTS In total, 137 complications were observed in 92 (78%) patients. Biliary reintervention was required in 83 (70%) patients. ENBD was significantly associated with a low risk of biliary reintervention [odds ratio (OR) = 0.26, 95%CI: 0.08-0.76, P = 0.012]. Post-ERCP pancreatitis was observed in 19 (16%) patients. An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis (OR = 3.46, 95%CI: 1.19-10.87, P = 0.023). PTBD was required in 16 (14%) patients, and Bismuth type III or IV cholangiocarcinoma was a significant risk factor (OR = 7.88, 95%CI: 1.33-155.0, P = 0.010). Of 102 patients with initial unilateral drainage, 49 (48%) required bilateral drainage. Endoscopic sphincterotomy (OR = 3.24, 95%CI: 1.27-8.78, P = 0.004) and Bismuth II, III, or IV cholangiocarcinoma (OR = 34.69, 95%CI: 4.88-736.7, P < 0.001) were significant risk factors for bilateral drainage. CONCLUSION The endoscopic management of hilar cholangiocarcinoma is challenging. ENBD should be selected as a temporary drainage method because of its low risk of complications.

Endoscopic ultrasonography-guided liver abscess drainage using a dedicated, wide, fully covered self-expandable metallic stent with flared-ends

Title Endoscopic ultrasonography-guided liver abscess drainage using a dedicated, wide, fully covered self-expandable metallic stent with flared-ends Author(s) Kawakami, Hiroshi; Kawakubo, Kazumichi; Kuwatani, Masaki; Kubota, Yoshimasa; Abe, Yoko; Kawahata, Shuhei; Kubo, Kimitoshi; Sakamoto, Naoya Citation Endoscopy, 46(S 01): E982-E983 Issue Date 2014-12-19 Doc URL http://hdl.handle.net/2115/60351 Rights

Recent advances in endoscopic ultrasonography-guided biliary interventions

Interventional endoscopic ultrasonography (EUS) based on EUS-guided fine-needle aspiration has rapidly spread as a minimally invasive procedure. Especially in patients with failed endoscopic retrograde cholangiopancreatography, EUS-guided biliary intervention is reported to be useful as salvage therapy. EUS-guided biliary interventions are carried out using three techniques: EUS-guided bilioenteric anastomosis, EUS-guided rendezvous procedure, and EUS-guided antegrade treatment. Although interventional EUS is not yet a standardized procedure, there have been recent advances in this field that address various biliary diseases. Here, we summarize the indications, techniques, clinical results of previous studies, and future perspectives.

Endoscopic ultrasonography-guided antegrade stenting combined with hepaticogastrostomy/hepaticojejunostomy using ultraslim instruments

Techniques for endoscopic ultrasonography (EUS)-guided biliary drainage (EUSBD) have been developed, and EUS-guided antegrade stenting (EUS-AGS) and EUS-guided hepaticogastrostomy (EUSHGS)/hepaticojejunostomy (HJS) are suitable for gastric outlet obstruction (GOO) or surgically altered anatomy. EUS-AGS alone carries the potential risk of causing bile leakage from a fistula; however, EUS-AGS in combination with EUS-HGS or EUS-HJS appears safer, as it can reduce the risk of a bile leak [1, 2]. We present two patients who underwent EUS-HGS or EUS-HJS combined with EUSAGS using ultraslim instruments. Patient #1 was a 62-year-old woman who had undergone a previous total gastrectomy for gastric cancer and later developed obstructive jaundice. First, a B3 branch was punctured using a 19G needle via a transjejunal approach, and a 0.025-inch guidewire (VisiGlide 2; Olympus, Tokyo, Japan) (▶Fig. 1) was placed. Next, a tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter (01 20 21 1; MTW Endoskopie, Düsseldorf, Germany) (▶Fig. 2) was used to dilate the fistula, following successful passage of the guidewire through the stricture. EUS-AGS was then performed using a novel ultraslim uncovered self-expandable metal stent (SEMS; BileRush Selective; 5.7 Fr, 10-mm diameter; Piolax Medical Devices, Kanagawa, Japan) (▶Fig. 2). Finally, a novel 7-Fr plastic stent (TYPE-IT stent; Gadelius Medical Co. Ltd., Tokyo, Japan) [3] (▶Fig. 3) was placed to create an EUS-HJS (▶Fig. 4; ▶Video1). Patient #2 was a 68-year-old man with GOO caused by gastric cancer who developed obstructive jaundice. EUS-AGS and EUS-HGS were performed as described

New curved linear echoendoscope for endoscopic ultrasonography-guided fine-needle aspiration in patients with Roux-en-Y reconstruction (with videos)

128 Address for correspondence Dr. Hiroshi Kawakami, Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Center for Digestive Disease, University of Miyazaki Hospital, 5200 Kihara, Kiyotake, Miyazaki, Miyazaki 889-1692, Japan. E-mail: hiropon@med.miyazaki-u.ac.jp Received: 2016-11-21; Accepted: 2016-12-26; Published online: 2017-07-06 New curved linear echoendoscope for endoscopic ultrasonography‐guided fine‐needle aspiration in patients with Roux‐en‐Y reconstruction (with videos)

Wire-Guided Cannulation

Selective bile duct cannulation (SBDC) is the most common technique for performing diagnostic and therapeutic biliary interventions. Wire-guided cannulation (WGC) is most commonly used in Western countries. A meta-analysis of randomized controlled trials (RCTs) found that WGC facilitates the primary SBDC and decreases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the RCTs involved one or at most two skilled endoscopists in a single-center setting. In more recent Japanese RCTs that were conducted at multiple centers by multiple endoscopists and using a crossover design, WGC did not improve the success rate of SBDC or the incidence of PEP compared with the conventional technique. We performed a multicenter RCT and found that WGC reduced the time required for SBDC, resulting in lower exposure to fluoroscopy. We conclude that WGC should be adopted for use in SBDC, leading to significantly less exposure to fluoroscopy. With a variety of SBDC techniques available, considerations for choice of technique should include operator, patient, and institutional factors. Endoscopists should be familiar with various techniques to allow flexibility depending upon each case. To improve the safety and efficacy of WGC, training and technique standardization are necessary. Here, we describe the novel use of WGC in SBDC, results of meta-analysis of WGC, results of the recent RCTs from Japan, and future perspectives.

Primary Hepatic Diffuse Large B-cell Lymphoma Mimicking Intrahepatic Cholangiocarcinoma

A 78-year-old man with obstructive jaundice and osteolytic left scapular tumor was referred to our hospital. Serum carcinoembryonic antigen (CEA), CA19-9, and soluble interleukin 2 receptor were 3.6 IU/L (reference range: 0-5), 128 IU/L (reference range: 0-37), and 2,940 IU/L (reference range: 145-519), respectively. Dynamic contrast-enhanced computed tomography showed a low-density mass in the right anterior segment of the liver and dilation of the left intrahepatic bile duct (Picture 1). We performed a transpapillary biliary biopsy and drainage (Picture 2). Histologically, the tumor was composed of cleaved lymphocytes. A liver needle biopsy confirmed diffuse large B-cell lymphoma (DLBCL) that was positive for CD20 (Picture 3), BCL6, MUM1, and MYC/BCL2 and negative for CD5, CD10, and

Curative distal pancreatectomy in patients with acinar cell carcinoma of pancreas diagnosed by endoscopic aspiration via esophago-jejunostomy: A successful case report

Highlights • This is a rare report of acinar cell carcinoma of pancreas diagnosed preoperatively.• Accurate histological diagnosis was performed by endoscopic FNA via jejunal loop after gastrectomy.• Accurate histological diagnosis is useful in the field of pancreatic surgery, especially in cases of rare or small malignant lesions.

Rendezvous biliary recanalization with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy

Despite advances in biliary stenting in patients with altered gastrointestinal anatomy, it is still a challenging procedure [1]. We present a case where percutaneous transhepatic cholangioscopy (PTCS) was combined with double-balloon endoscopy (DBE) for biliary stenting in a patient with complete obstruction of a choledochojejunostomy. A 71-year-old woman, who had a history of distal cholangiocarcinoma and had undergone pancreaticoduodenectomy 7 years previously, experienced recurrent cholangitis. DBE-assisted balloon dilation had been performed 7 months previously for stricture of the choledochojejunal anastomosis. However, she developed complete obstruction of the anastomosis (▶Fig. 1). A 7.2-Fr percutaneous transhepatic biliary drainage (PTBD) catheter was initially placed, and the fistula tract was dilated up to 12Fr within 4 weeks. DBE-assisted endoscopic retrograde cholangiopancreatography was then attempted. First, the double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) was advanced to the afferent limb, and a percutaneous transhepatic cholangiogram revealed complete obstruction of the anastomosis. Next, a PTCS scope (BF type P260F; Olympus, Tokyo, Japan) was inserted via the PTBD route. However, a guidewire (0.018-inch, Pathfinder Exchange; Boston Scientific Japan, Tokyo, Japan) through the PTCS scope could not pass the anastomosis (▶Video1). Therefore, we attempted direct precutting (KD-V451M; Olympus) at the anastomosis, using the double-balloon endoscope and guided by transillumination from the percutaneous transhepatic cholangioscope’ (▶Fig. 2, ▶Video1). A small incision was carefully made in order to create a fistula (▶Fig. 3). This was followed by successful passage of the guidewire (0.032-inch, Radifocus Guidewire M; Terumo, Tokyo, Japan) Video 1 Biliary recanalization, using a rendezvous technique with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy, for a completely obstructed choledochojejunostomy. ▶ Fig. 1 Percutaneous transhepatic cholangiogram showing complete obstruction of the choledochojejunal anastomosis in a patient who had undergone pancreaticoduodenectomy 7 years previously. ▶ Fig. 2 Left panel: The choledochojejunal anastomosis has an appearance similar to an ulcer scar. Right panel: Transillumination from the percutaneous transhepatic cholangioscope guides direct precutting using the double-balloon endoscope. E-Videos