Yui Kishimoto

Predicting the success of endoscopic transpapillary gallbladder drainage for patients with acute cholecystitis during pretreatment evaluation

INTRODUCTION Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported to be an effective treatment for acute cholecystitis, technical difficulties have precluded more widespread use of this technique. Case evaluations that can predict the occurrence of such difficulties should increase the acceptance of ETGBD for acute cholecystitis treatment. OBJECTIVE To establish a pretreatment evaluation protocol for patients with acute cholecystitis. METHODS Eleven patients with acute cholecystitis who received ETGBD in 2003 or 2004 were enrolled in the present retrospective study. The frequency of success, complications and overall effectiveness of ETGBD for treatment of cholecystitis were measured. Factors that could affect ETGBD success, including clinical and laboratory parameters, and gallbladder ultrasonograms, were also evaluated. RESULTS ETGBD was successful in seven of 11 patients (success rate 63.6%). All seven patients who underwent ETGBD successfully were afebrile and asymptomatic within a few days. No clinical or laboratory variables were significantly associated with the success of ETGBD. In contrast, ultrasonographic measures of gallbladder minor-axis length and wall thickness in successful cases were significantly shorter (27.4 mm versus 38.0 mm; P=0.008) and thinner (4.2 mm versus 9.0 mm; P=0.041) relative to unsuccessful cases. CONCLUSIONS Ultrasonographic measures of gallbladder minor-axis length and wall thickness can serve as important predictors of ETGBD technical difficulties during pretreatment evaluation of patients with acute cholecystitis.

Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum β-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Comparison of percutaneous radiofrequency ablation and CyberKnife® for initial solitary hepatocellular carcinoma: A pilot study

AIM To compare therapeutic outcomes and adverse events in initial solitary hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) and CyberKnife(®). METHODS Seventy three consecutive patients with initial solitary HCC treated with RFA (38 patients; RFA group) and CyberKnife(®) (35 patients; CK group) were enrolled in this study. Background factors were compared between the two groups. Local and intrahepatic distant recurrence control, and cumulative survival rates were compared between the two groups. These were determined using the Kaplan-Meier method, and the significance of differences was analyzed by log-rank test. The presence of more grade 3 on CTCAE ver. 4.0 early and late adverse events was investigated. RESULTS In background factors, age was significantly higher (P = 0.005) and the tumor diameter was significantly larger (P = 0.001) in the CK group. The 1-year local recurrence control rates were 97.4% and 97.1% in the RFA and CK groups, respectively (P = 0.71); the 1-year intrahepatic distant recurrence control rates were 85.6% and 86.1%, respectively (P = 0.91); and the 1-year cumulative survival rates were 100% and 95.2%, respectively (P = 0.075), showing no significant difference in any rate between the two groups. There were no late adverse event in the RFA group, but 11.4% in the CK group had late adverse events. In the CK group, the Child-Pugh score at 12 mo after treatment was significantly higher than that in the RFA group (P = 0.003) and significantly higher than the score before treatment (P = 0.034). CONCLUSION The occurrence of adverse events is a concern, but CyberKnife(®) treatment is likely to become an important option for local treatment of early HCC.

Efficacy of Combined Endoscopic Lithotomy and Extracorporeal Shock Wave Lithotripsy, and Additional Electrohydraulic Lithotripsy Using the SpyGlass Direct Visualization System or X-Ray Guided EHL as Needed, for Pancreatic Lithiasis

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

CASE OF IMMUNOGLOBULIN G4-RELATED CHOLANGITIS ACCOMPANYING AUTOIMMUNE PANCREATITIS: DIAGNOSIS BY PERORAL CHOLANGIOSCOPY AND TREATMENT BY ENDOSCOPIC BILIARY STENTING

Recently, the progress of endoscopy has made it possible to evaluate bile duct mucosa by peroral cholangioscopy. Herein, we report a case of immunoglobulin G4‐related sclerosing cholangitis accompanying autoimmune pancreatitis in a patient who improved with treatment by steroid therapy and endoscopic biliary stenting, and observed the bile duct mucosa by peroral cholangioscopy before and after treatment.

Endosonographic Preoperative Evaluation for Tumors of the Ampulla of Vater Using Endoscopic Ultrasonography and Intraductal Ultrasonography

Background/Aims In recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy. Methods The subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors. Results The diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging. Conclusions EUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer.

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Heterotopic Pancreas of the Jejunum Incidentally Detected by Preoperative Abdominal CT: Report of Two Cases and Review of the Literature

Heterotopic pancreas (HP) is typically an asymptomatic malformation that can present anywhere along the gastrointestinal tract. It is often detected incidentally on surgery for other diseases or autopsy. We encountered 2 patients with jejunal HP incidentally detected by computed tomography (CT) performed for close evaluation of other diseases. In a 57-year-old woman diagnosed with reactive lymphoid hyperplasia on the dorsal portion of the pancreas head, CT detected a 15 mm oval-shaped submucosal lesion at the jejunum. In an 87-year-old woman diagnosed with type 2 adenocarcinoma occupying the sigmoid colon, CT detected a round-shaped submucosal tumor 15 mm in diameter in the jejunum. Both cases were histologically diagnosed as type 1 HP according to the classification by Heinrich. Contrast-enhanced CT revealed that the CT analyses of HP and pancreatic parenchyma were nearly identical in the arterial phase, but in the equilibrium phase, contrast enhancement persisted longer in HP than in the pancreatic parenchyma. There has been no report of asymptomatic jejunal HP preoperatively diagnosed by CT. These cases are presented with a review of the literature, particularly focusing on CT findings.

Efficacy of the new double-layer stent for unresectable distal malignant biliary obstruction: a single-center retrospective study.

Background and Aims. For distal malignant biliary obstruction in cases with short life expectancy, occlusion of plastic stents (PSs) does not usually occur before death, and the application of such a procedure is considered adequate from the viewpoint of cost-effectiveness. Methods and Setting. A new commercially available DLS with side holes, a conventional DLS, and, uncovered self-expanding metal stents (SEMSs) were retrospectively evaluated in patients with jaundice due to unresectable distal malignant biliary obstruction. Results. A total of 64 patients received endoscopic biliary stenting (23 patients with the new DLS, 24 patients with conventional DLS, and 17 patients with uncovered SEMS) from December 2002 to August 2009. Median patency time was found to be 198 days for the new DLS group and 99 days for the conventional DLS group, revealing a significant difference between devices. There was, however, no significant difference in median patency time between the new DLS and the uncovered SEMS (198 days versus 344 days). Conclusion. The new DLS is efficient and safe and may be considered the first choice for unresectable distal malignant obstruction in cases with short life expectancy.

Right Hepatic Artery Pseudoaneurysm Complicating Acute Pancreatitis: A Case Report

Objective: To report a rare case of right hepatic artery pseudoaneurysm complicating acute pancreatitis based upon imaging findings obtained before and after the development of pseudoaneurysm. Clinical Presentation and Intervention: A 32-year-old male with a history of acute pancreatitis 1 year prior was readmitted for acute pancreatitis. Computed tomography (CT) and angiography after admission revealed pseudoaneurysm of the right hepatic artery. Transcatheter arterial embolization with coils was used to successfully treat the pseudoaneurysm. A CT and angiography 1 year earlier did not reveal any pseudoaneurysm. Conclusion: This patient with a rare right hepatic artery pseudoaneurysm complicating acute pancreatitis was successfully treated with coil embolization.