Yosuke Michikawa

Enteral metallic stenting by balloon enteroscopy for obstruction of surgically reconstructed intestine.

We present three cases of self-expandable metallic stent (SEMS) placement using a balloon enteroscope (BE) and its overtube (OT) for malignant obstruction of surgically reconstructed intestine. A BE is effective for the insertion of an endoscope into the deep bowel. However, SEMS placement is impossible through the working channel, because the working channel of BE is too small and too long for the stent device. Therefore, we used a technique in which the BE is inserted as far as the stenotic area; thereafter, the BE is removed, leaving only the OT, and then the stent is placed by inserting the stent device through the OT. In the present three cases, a modification of this technique resulted in the successful placement of the SEMS for obstruction of surgically reconstructed intestine, and the procedures were performed without serious complications. We consider that the present procedure is extremely effective as a palliative treatment for distal bowel stenosis, such as in the surgically reconstructed intestine.

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation

AIM To investigate the need for pancreatic stenting after endoscopic sphincterotomy (EST) in patients with difficult biliary cannulation. METHODS Between April 2008 and August 2013, 2136 patients underwent endoscopic retrograde cholangiopancreatography (ERCP)-related procedures. Among them, 55 patients with difficult biliary cannulation who underwent EST after bile duct cannulation using the pancreatic duct guidewire placement method (P-GW) were divided into two groups: a stent group (n = 24; pancreatic stent placed) and a no-stent group (n = 31; no pancreatic stenting). We retrospectively compared the two groups to examine the need for pancreatic stenting to prevent post-ERCP pancreatitis (PEP) in patients undergoing EST after biliary cannulation by P-GW. RESULTS No differences in patient characteristics or endoscopic procedures were observed between the two groups. The incidence of PEP was 4.2% (1/24) and 29.0% (9/31) in the Stent and no-stent groups, respectively, with the no-stent group having a significantly higher incidence (P = 0.031). The PEP severity was mild for all the patients in the stent group. In contrast, 8 had mild PEP and 1 had moderate PEP in the no-stent group. The mean serum amylase levels (means ± SD) 3 h after ERCP (183.1 ± 136.7 vs 463.6 ± 510.4 IU/L, P = 0.006) and on the day after ERCP (209.5 ± 208.7 vs 684.4 ± 759.3 IU/L, P = 0.002) were significantly higher in the no-stent group. A multivariate analysis identified the absence of pancreatic stenting (P = 0.045; odds ratio, 9.7; 95%CI: 1.1-90) as a significant risk factor for PEP. CONCLUSION In patients with difficult cannulation in whom the bile duct is cannulated using P-GW, a pancreatic stent should be placed even if EST has been performed.

Use of Antithrombin and Thrombomodulin in the Management of Disseminated Intravascular Coagulation in Patients with Acute Cholangitis

Background/Aims To evaluate the usefulness and safety of treating disseminated intravascular coagulation (DIC) complicating cholangitis primarily with antithrombin (AT) and thrombomodulin (rTM). Methods A DIC treatment algorithm was determined on the basis of plasma AT III levels at the time of DIC diagnosis and DIC score changes on treatment day 3. Laboratory data and DIC scores were assessed prospectively at 2-day intervals. Results DIC reversal rates >75% were attained on day 7. In the DIC reversal group, statistically significant differences from baseline were observed in interleukin-6 and C-reactive protein levels within 5 days. Patients with no DIC score improvements after treatment with AT alone experienced slow improvement on a subsequent combination therapy with rTM. Although a subgroup with biliary drainage showed greater improvement in DIC scores than did the nondrainage subgroup, the mean DIC score showed improvement even in the nondrainage subgroup alone. Gastric cancer bleeding that was treated conservatively occurred in one patient. As for day 28 outcomes, three patients died from concurrent malignancies. Conclusions Although this algorithm was found to be useful and safe for DIC patients with cholangitis, it may be better to administer rTM and AT simultaneously from day 1 if the plasma AT III level is less than 70%.

Covered metal stenting for malignant lower biliary stricture with pancreatic duct obstruction: is endoscopic sphincterotomy needed?

Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.

A novel endoscopic papillectomy after a pancreatic stent placement above the pancreatic duct orifice: inside pancreatic stenting papillectomy.

Background: Although pancreatic stenting is recommended for the prevention of postprocedure pancreatitis during endoscopic papillectomy (EP), in some patients it is technically difficult to perform postprocedure insertion of a pancreatic stent after endoscopic resection. Goals: This study assessed the feasibility of a novel EP for the purpose of reliable post-EP pancreatic stenting. Study: We conducted a prospective pilot study involving 10 consecutive patients with tumor of the major duodenal papilla. We developed a novel pancreatic stent, which is attached to a suture, and devised a method by which the stent is first placed at an upstream migration into the major pancreatic duct above the orifice before resection and then placed at an appropriate location after endoscopic resection by pulling the suture attached to the stent [inside pancreatic stenting papillectomy (IPSP)]. Results: The pancreatic stent was successfully placed at an upstream migration into the pancreatic duct above the orifice in 9 of the 10 patients. For the 9 patients with successful pancreatic stent placement, IPSP was performed. Although the suture was cut in 1 patient, pancreatic stents could be placed appropriately across the orifice by pulling the suture in all patients. Although bleeding occurred in 3 patients, there was no pos-procedure pancreatitis. Conclusions: IPSP is a practicable method allowing reliable post-EP pancreatic stenting and can contribute to pancreatitis prevention. However, larger studies need to be performed before its use can be recommended.

Diagnostic Ability of Endoscopic Bile Cytology Using a Newly Designed Biliary Scraper for Biliary Strictures

BackgroundA new device with metallic wires for scrape cytology was developed.AimsTo compare the diagnostic performance of scrape cytology and conventional cytology during endoscopic retrograde cholangiopancreatography for biliary strictures.MethodsA total of 420 cases with biliary stricture underwent transpapillary bile cytology. Among them, there are 79 cases with scrape cytology using the new device (scrape group) and 341 cases with conventional cytology (control group). Seventy-two and 174 cases underwent biliary biopsy at the same time as bile cytology in the scrape and control group, respectively.ResultsThe sensitivity for malignancy of bile cytology in the scrape and control group was 41.2% [pancreatic cancer (PC): 23.1%, biliary cancer (BC): 52.5%] and 27.1% (PC: 16.3%, BC: 38.0%), respectively (P = 0.023). When analyzed PC and BC, respectively, there was no significant difference between the two groups. In the both groups, the sensitivity was significantly higher for BC than PC. In the scrape group, there was no difference in the sensitivity between cytology and biopsy [39.7% (PC: 17.4%, BC: 55.3%)], but in the control group, a significantly lower sensitivity was observed with cytology than biopsy (36.4% (PC: 19.7%, BC: 50.0%)) (P = 0.046). When analyzed PC and BC, respectively, there was no significant difference between cytology and biopsy. The sensitivity of combined cytology and biopsy was 55.6% (PC: 30.4%, BC: 71.1%) in the scrape group and 47.0% (PC: 24.6%, BC: 64.3%) in the control group.ConclusionScrape bile cytology for biliary strictures may be superior to conventional cytology.

COX-2 Gene Promoter Methylation in Patients Infected with Helicobacter Pylori

Cyclooxygenase (COX) plays a critical role in peptic ulcer development. COX-2 contains CpG islands in promoter area, which suggests possible epigenetic mechanisms of gene silencing. We evaluated COX-2 gene promoter methylation levels in the gastric mucosa of patients with various gastric diseases. DNA was extracted from endoscopic biopsy materials collected from the gastric mucosa. The methylation levels of the COX-2 gene promoter were measured quantitatively by using pyrosequencing. COX-2 mRNA expression in Kato III and AGS cells was measured using real-time PCR. COX-2 gene promoter methylation levels were significantly higher in Helicobacter pylori (HP)-positive cases than in HP-negative cases (27.5% vs. 8.1%, respectively, P < 0.001). COX-2 gene promoter methylation levels in patients in whom HP was successfully eradicated were significantly lower than those in HP-positive cases (18.7% vs. 27.5%, respectively, P < 0.01). We then investigated the effects of COX-2 gene promoter methylation on its mRNA expression in vitro. COX-2 mRNA expression was not observed in Kato III cells, despite the addition of the protein kinase C stimulator a-phorbol 12,13-dibutyrate (PDBu). COX-2 expression was observed after the addition of the demethylating agent 5-Aza-dC and was enhanced by PDBu. HP infection caused a significant increase in the methylation levels of the COX-2 gene promoter in the gastric mucosa. In addition to transcriptional regulation, COX-2 expression is regulated through epigenetic mechanisms.

Efficacy and Safety of Single-Session Endoscopic Stone Removal for Acute Cholangitis Associated with Choledocholithiasis

Background/Aims In early endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to choledocholithiasis, it is unclear that single-session stone removal can be safely performed. We examined the efficacy and safety of early single-session stone removal for mild-to-moderate acute cholangitis associated with choledocholithiasis. Methods Among patients with mild-to-moderate acute cholangitis associated with choledocholithiasis who underwent early ERCP (n = 167), we retrospectively compared the removal group (patients who underwent single-session stone removal; n = 78) with the drainage group (patients who underwent biliary drainage alone; n = 89) and examined the effectiveness and safety of single-session stone removal by early ERCP. Results The patients in the removal group had significantly fewer and smaller stones compared with those in the drainage group. The single-session complete stone removal rate was 85.9% in the removal group. The complication rate in early ERCP was 11.5% in the removal group and 10.1% in the drainage group, with no significant difference (P = 0.963). On comparing patients who underwent early endoscopic sphincterotomy (EST) with those who underwent elective EST after cholangitis had improved, the post-EST bleeding rates were 6.8% and 2.7%, respectively, with no significant difference (P = 0.600). The mean duration of hospitalization was 11.9 days for the removal group and 19.9 days for the drainage group, indicating a shorter stay for the removal group (P < 0.001). In multiple linear regression analysis, stone removal in early ERCP, number of stones, and C-reactive protein level were significant predictors of hospitalization period. Conclusions Single-session stone removal for mild-to-moderate acute cholangitis can be safely performed. It is useful from the perspective of shorter hospital stay.

Crowned dens syndrome developed after an endoscopic retrograde cholangiopancreatography procedure.

We present a unique case of crowned dens syndrome (CDS) that developed after endoscopic retrograde cholangiopancreatography (ERCP) in a patient who presented with fever and neck pain. Administration of non-steroidal anti-inflammatory drugs was extremely effective for relieving fever and neck pain, and in the improvement of inflammatory markers. To the best of our knowledge, this is the first case report of CDS caused by an ERCP procedure. In a patient with fever and neck pain after an ERCP procedure, CDS should be considered in the differential diagnosis.

Endoscopic Double Metallic Stenting in the Afferent and Efferent Loops for Malignant Afferent Loop Obstruction with Billroth II Anatomy

Placement of endoscopic self-expandable metallic stents (SEMSs) is widely performed for malignant gastrointestinal obstructions as an effective palliative procedure [1-3]. However, because only one report exists on SEMS placement at the bifurcation of a surgically reconstructed intestine [4], the safety and efficacy of the procedure have not been elucidated. We present a case of double SEMS placement at the bifurcation in Billroth-II gastrojejunostomy. A 75-year-old man who had undergone distal gastrectomy with Billroth-II reconstruction was admitted to our institution because of obstructive jaundice due to pancreatic head cancer. We performed percutaneous transhepatic biliary drainage (PTBD), and then a biliary metallic stent was placed percutaneously. Contrast medium injection to the afferent loop through the PTBD tube demonstrated an afferent loop stricture because of tumor invasion (Fig. 1). Therefore, we performed enteral metallic stenting with a rendezvous technique. A guidewire was passed through the stricture through the PTBD tube into the stomach. After an endoscope was inserted into the stomach, the guidewire was grasped and withdrawn through the channel, and an enteral stent (22 mm×6 cm; Niti-S, TaeWoong Medical, Gimpo, Korea) was placed in the stricture (Fig. 2A). However, the expanded stent compressed the efferent loop, causing efferent loop obstruction. Contrast radiography showed that the contrast medium flowed only into the afferent loop (Fig. 2B). Therefore, a guidewire was passed through the stented side and into the efferent loop. Then, an enteral stent (22 mm×10 cm; Niti-S) was placed from the efferent loop to the stomach (Fig. 3A). After efferent loop stenting, substantial contrast medium flow into the efferent loop was observed (Fig. 3B). Oral feeds were initiated a day after stent placement, and the patient was subsequently discharged. He died of primary cancer progression 5 months after stent placement, although there were no stent problems. Fig. 1. Contrast medium injection to the afferent loop through a percutaneous transhepatic biliary drainage tube demonstrating an afferent loop stricture (arrow). Fig. 2. (A) An enteral stent placed in the afferent loop stricture. (B) Contrast radiograph showing that contrast medium flows only into the afferent loop. Fig. 3. (A) Additional enteral stent placed extending from the efferent loop to the stomach. (B) Substantial contrast medium flow into the efferent loop after efferent loop stenting. In recent years, malignant gastrointestinal obstruction of the esophagus, stomach, duodenum, and colon has been widely managed with endoscopic SEMS placement as an effective palliative treatment. However, because there are few studies on the use of metallic stents in the obstruction of a surgically reconstructed intestine, particularly stenting at the bifurcation of the surgically reconstructed intestine, the safety and efficacy of the procedure have not been elucidated. To the best of our knowledge, only one report exists on SEMS placement at the bifurcation of a surgically reconstructed intestine [4]. Kwong et al. [4] reported a case of concurrent afferent and efferent stents after a pancreaticoduodenectomy. Although their case eventually required three efferent limb stents for recurrent malignant obstruction along with an afferent limb stent, there were no serious complications. In the present case, the expanded afferent stent compressed the efferent loop, causing efferent loop obstruction. Because an expanded stent may cause intestinal obstruction, endoscopists should be careful while performing enteral stenting at the bifurcation of a surgically reconstructed intestine. Especially, during afferent loop stenting, an additional efferent loop stent should be considered for the passage of food into the efferent loop.