Yung-Kuan Tsou

Inflammatory pseudotumor of the liver: report of eight cases, including three unusual cases, and a literature review.

Background:u2002 Inflammatory pseudotumor (IPT) of the liver is a rare but increasingly recognized tumor‐like lesion. This condition is becoming an important differential diagnosis in patients with hepatic space‐occupying lesions. This study reports the clinical features of eight cases of IPT of the liver, including the first report of three cases with an unusual associated disease or clinical course.

Direct peroral cholangioscopy using an ultraslim endoscope and overtube balloon-assisted technique: a case series.

Overtube balloon-assisted direct peroral cholangioscopy (POC) using an ultraslim endoscope may be an effective alternative to the conventional mother-baby endoscope system. A total of 14 patients with biliary diseases underwent direct POC with an ultraslim endoscope. The endoscope was successfully advanced into the bile duct in all 14 patients (100 %). The success rate of the POC was 92.9 % (13/14) on the criterion of reaching the hilum or stricture site. Endoscopic biopsy was performed in six patients. Cystic duct or residual common bile duct stones were removed successfully under direct endoscopic visualization in three patients. A diagnosis of malignant or indeterminate bile duct stricture was changed to benign lesion or stricture or normal biliary mucosa in eight of ten patients. Procedure-related biliary tract infection occurred in one patient. This series demonstrated that direct POC using an ultraslim endoscope is useful for both diagnosis and treatment.

Predictors of Rebleeding and Mortality in Patients with High-Risk Bleeding Peptic Ulcers

Background and AimPatients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality.MethodsA prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes.ResultsBleeding recurred in 46 patients (11.8%) within 3xa0days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3xa0days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level <10xa0g/dl (OR 3.3) and ulcer ≥2xa0cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3).ConclusionThe study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Endoscopic retrograde cholangiography in the diagnosis and treatment of mucobilia.

Objective. Some biliary neoplasms secrete copious mucin into bile ducts, yet the management of mucobilia is not well known. The objective of this study was to analyze 16 patients with copious mucin in the biliary tract stressing the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography (ERC). Material and methods. Sixteen patients with mucobilia were found among 5635 cases of ERC from October 1999 to October 2006 in our institution. Diagnostic and therapeutic ERC as well as clinical features were retrospectively analyzed. Results. Mucin had a greater impact than the neoplasm itself on the cholangiogram and clinical presentation. ERC failed to show the tumors but a disproportionate or aneurysmal dilatation of the segmental or lobar duct correlated with the tumor-bearing duct was evident. Endoscopic managements included clearance of intraductal mucin and/or endoscopic nasobiliary drainage (ENBD). Three patients were excluded from outcome assessment because of non-specific symptoms or spontaneously subsiding jaundice. Among the 13 patients eligible for assessment, subjective improvement in symptoms and/or a decrease in jaundice along with subsiding cholangitis following ERC was observed in 5 of the 7 patients that underwent both clearance of intraductal mucin and ENBD (ENBD function was poor in all 7 patients), in 1 patient who underwent only clearance of intraductal mucin, and in 3 of the 5 patients who underwent only ENBD. The three patients with progressive jaundice, despite endoscopic management, had advanced disease. Conclusions. ERC revealed the tumor-bearing duct but not the extent of the disease in most of the patients with mucobilia. When mucobilia is encountered during ERC, the management should include clearance of as much intraductal mucin as possible. ENBD is frequently obstructed by mucin and may be helpful only in selected cases.

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIMnTo detect and manage residual common bile duct (CBD) stones using ultraslim endoscopic peroral cholangioscopy (POC) after a negative balloon-occluded cholangiography.nnnMETHODSnFrom March 2011 to December 2011, a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography (ERC) and direct POC were prospectively enrolled in this study. Those patients who were younger than 20 years of age, pregnant, critically ill, or unable to provide informed consent for direct POC, as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded. Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.nnnRESULTSnThe ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct (IHD) in 8 patients (36.4%), to the extrahepatic bile duct where the hilum could be visualized in 10 patients (45.5%), and to the distal CBD where the hilum could not be visualized in 4 patients (18.2%). The procedure time of the diagnostic POC was 8.2 ± 2.9 min (range, 5-18 min). Residual CBD stones were found in 5 (22.7%) of the patients. There was one residual stone each in 3 of the patients, three in 1 patient, and more than five in 1 patient. The diameter of the residual stones ranged from 2-5 mm. In 2 of the patients, the residual stones were successfully extracted using either a retrieval balloon catheter (n = 1) or a basket catheter (n = 1) under direct endoscopic control. In the remaining 3 patients, the residual stones were removed using an irrigation and suction method under direct endoscopic visualization. There were no serious procedure-related complications, such as bleeding, pancreatitis, biliary tract infection, or perforation, in this study.nnnCONCLUSIONnDirect POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

Endoscopic retrograde cholangiopancreatography (ERCP) for intradiverticular papilla: endoclip-assisted biliary cannulation.

make biliary cannulation difficult during endoscopic retrograde cholangiopancreatography (ERCP), and endoscopists sometimes need to use special techniques to achieve deep common bile duct (CBD) cannulation [1–3]. We describe two difficult IDP cases in which successful biliary cannulation was achieved after using endoclips to facilitate a temporary change in the anatomical position of the major papilla. A 56-year-old man underwent ERCP for CBD stones. On duodenoscopy, the major papilla was observed to be lying on the floppy mucosa, within the inferior rim of a diverticulum (● Fig. 1a). Although the papilla could be everted from the diverticulum using a catheter tip (● Fig. 1b), it would rotate back inside soon after the mechanical traction was withdrawn. This anatomical orientation prevented cannulation. An endoclip (Hx-600–135, Olympus Medical Systems Corp., Tokyo, Japan) was used to rotate the papilla externally and to fix it on the outside rim of the diverticulum. This procedure resulted in successful biliary cannulation (● Fig. 1c). A 77-year-old woman underwent ERCP for biliary sepsis with shock. On duodenoscopy, the small papilla could be identified on the left edge of the diverticulum onlywhen the scopewas advancedwithin the diverticulum (● Fig. 2a). Biliary cannulation was unsuccessful in this anatomical position. Therefore, two endoclips were applied to the inferior and lateral diverticular walls and the duodenal mucosa. This manipulation successfully everted and fixed the papilla on the diverticular margin (● Fig. 2b). The altered orientation allowed biliary cannulation to be carried out along the diverticular rim (● Fig. 2c). Scotiniotis and Ginsberg reported the first case of successful treatment of IDP using endoclip-assisted biliary cannulation [4]. The satisfactory results obtained in our two cases confirm that this method can be added to the inventory for difficult biliary cannulation.

Gastrointestinal: Spontaneous pancreaticoduodenal fistula associated with acute necrotizing pancreatitis

A 51-year-old man was admitted with acute pancreatitis for 2 weeks. Two weeks after hospital discharge, he presented with postprandial vomiting. Contrast-enhanced computed tomography (CT) scans revealed pancreatic necrosis, particularly in the head and in some regions of the body, suggesting the possibility of disconnected pancreatic duct syndrome. Three communicating pseudocysts were also detected; the largest one measured 10 cm in diameter and extended from the pancreatic body, causing gastroduodenal compression. A nasojejunal tube was placed for enteral feeding. One week after the CT study, the patient complained of dyspnea when lying down, upper abdominal fullness, and pain. These symptoms were attributed to the progressive enlargement of the pseudocyst owing to persistent pancreatic juice leakage. Several days later, before endoscopic drainage of the pseudocysts could be performed, the patient reported that his symptoms had subsided spontaneously. Repeat CT scans revealed air bubbles within the 3 pseudocysts and a marked reduction in the size of the largest pseudocyst. Pancreatic abscesses were the initial impression. However, a cystoduodenal fistula was subsequently visualized on careful review of the CT scans (Figure 1). Endoscopy confirmed the presence of a fistula on the lesser curvature side in the duodenal bulb, with thick, milky, and purulent discharge (Figure 2, right bottom). The scope (GF-UMQ240, Olympus) was inserted into the fistula and necrotic pancreatic tissue was revealed (Figure 2). Thereafter, the patient was treated conservatively. Follow-up CT scans 5 weeks after the second CT study demonstrated almost complete disappearance of the pseudocysts. Necrosis of the gastrointestinal tract is a rare complication of necrotizing pancreatitis. In case of the duodenum, necrosis mostly occurs on the medial aspect of the duodenal loop. The diagnosis of pancreaticoduodenal fistulae is often made on endoscopic retrograde cholangiopancreatography and sometimes on endoscopy. To the best of our knowledge, this is the first case in which pancreaticoduodenal fistula is diagnosed on CT scans. The presence of air bubbles is an important diagnostic feature of pancreatic abscesses on CT scanning; therefore, it is necessary to differentiate pseudocysts associated with pancreaticoduodenal fistulae from pancreatic abscesses. Once fistulization has occurred, as seen in the present case, patients with pancreaticoduodenal fistulae may gradually recover under conservative treatment, albeit in 30% of cases, this may be associated with massive gastrointestinal bleeding. Incorrect diagnosis of pancreaticoduodenal fistulae instead of that of pancreatic abscesses would result in unnecessary intervention such as endoscopic or surgical necrosectomy. A pancreaticoduodenal fistula that is large enough to be directly visualized on CT scans may be rare, however, in patients without clinical deterioration, a ruptured pseudocyst with air bubbles on follow-up CT scans indicates pancreaticoduodenal (or pancreaticogastrointestinal) fistula rather than pancreatic abscess.

Learning curve for endoscopic submucosal dissection of esophageal neoplasms

There is a significant learning curve for endoscopic submucosal dissection of esophageal neoplasms that has not been fully characterized. This retrospective study included 33 consecutive superficial esophageal neoplasms for analysis of the learning curve for esophageal endoscopic submucosal dissection based on a single, novice endoscopists experience. The study was divided into three periods (T1, T2, and T3) of 10 endoscopic submucosal dissection procedures in chronological order, with 13 procedures in the last period. Patient factors (age, sex, coexistent esophageal varices, or submucosal fibrosis) and tumor factors (location at upper esophagus, involving >3/4 esophageal circumference) for endoscopic submucosal dissection were not statistically different between the periods. The mean procedure time was 74.6u2009min/cm(2) , 23.4u2009min/cm(2) , and 10.5u2009min/cm(2) for T1, T2, and T3, respectively. The procedure time decreased over time (P = 0.02) and post hoc test revealed significant difference was only between T3 and T1 (P = 0.019). The en bloc resection rate was 50%, 100%, and 92.3% for T1, T2, and T3, respectively (P for trend = 0.015). R0 resection rate was 40%, 100%, and 84.6% for T1, T2, and T3, respectively (P for trend = 0.023). Two patients had complications: each one patient in T1 and T3 period experienced major bleeding during the procedure (P for trend = 0.875). None of the patients had esophageal perforation. The results of the study concluded that at least 30 cases of endoscopic submucosal dissection of esophageal neoplasms are needed for a novice endoscopist to gain early proficiency in this technique.

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis

Abstract Objective. Roux-en-Y reconstructions can be divided into intact papilla of Vater and bilioenteric anastomosis (BEA) with respect to endoscopic retrograde cholangiography (ERC). Double-balloon enteroscopy-assisted ERC (DBE-ERC) may produce different results between the two populations but lacks studies. Material and methods. Forty-seven patients with Roux-en-Y anastomosis undergoing 73 procedures of DBE-ERC were enrolled between July 2007 and August 2013. There were 14 patients with intact papilla of Vater (group A) and 33 patients with BEA (group B). The effectiveness of DBE-ERC, including data of reaching the blind end, performance of ERC, results of endoscopic therapies, and follow-up were retrospectively analyzed and compared between the two groups. Results. For reaching the blind end, the success rate was not different between the groups (85.7% vs. 81.8%, p = 0.7), but the mean procedure time was significantly shorter for group A (28 min vs. 52 min, p = 0.01). For ERC, the success rate was not different between the groups (91.7% vs. 96.3%, p = 0.53), but the mean procedure time was significantly longer for group A (28.4 min vs. 4 min, p < 0.001). All endoscopic therapies could be successfully performed in both groups. No group A patients and five (23.8%) group B patients developed recurrent biliary stricture/stones requiring interventions during a mean follow-up period of 26.1 months. Conclusions. DBE-ERC was effective for both populations with biliary disorders. Reaching the blind end was more difficult but ERC was easier for patients with BEA in terms of procedure time rather than success rates.

Histological examination of ulcer margin for diagnosing Helicobacter pylori infection in patients with gastric ulcers

Biopsy of ulcer margin is routinely performed to exclude malignancy in patients with gastric ulcers, but its utility in diagnosing Helicobacter pylori infection has not yet been fully studied. A cohort of 50 patients with gastric ulcer was prospectively examined. Three tests including histology, rapid urease test, and urea breath test were performed in all patients for diagnosing H pylori infection. Six biopsied specimens from the margin of the gastric ulcer and 1 each specimen from antrum and body of non-ulcer part were obtained for histology using hematoxylin-eosin (H&E) stain. The criterion used for defining H pylori infection was a positive result in at least 2 of the 3 tests. H pylori infection was diagnosed in 27 (54%) of the patients. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the histological examination of the ulcer margin were 92.6%, 95.7%, 96.2%, 91.7%, and 94%, respectively. The addition of 1 specimen from the antrum or body or a combination of the 2 specimens did not increase the diagnostic yields of those for histological examination of ulcer margin alone. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the rapid urease test were 96.3%, 100%, 100%, 95.8%, and 98%, respectively, and the corresponding values for the urea breath test were 88.9%, 87%, 88.9%, 87%, and 88%. We performed Giemsa stain for the 3 patients with false-negative and false-positive results of histological examination of ulcer margin using H&E stain, and all were positive for H pylori infection. In conclusion, histological examination of the ulcer margin using hematoxylin-eosin stain was quite accurate and useful for diagnosing H pylori infection in patients with gastric ulcers. A special stain is required when the diagnosis of H pylori infection is questionable on routine H&E staining.