Cholangioscopy-guided lithotripsy for difficult bile duct stone clearance in a single session of ERCP: results from a large multinational registry demonstrate high success rates

BACKGROUND

Peroral cholangioscopy (POCS) can be useful for difficult bile duct stone clearance. Large prospective multinational data on POCS-guided lithotripsy for clearing difficult bile duct stones in a single session of endoscopic retrograde cholangiopancreatography (ERCP) are missing.

METHODS

Patients with difficult bile duct stones (defined as one or more of: largest stone diameter ≥ 15 mm, failed prior attempt at stone clearance, impacted, multiple, hepatic duct location, or located above a stricture) were enrolled at 17 centers in 10 countries. The principal endpoint was stone clearance in a single ERCP procedure using POCS. RESULTS : 156 patients underwent 174 sessions of POCS-guided electrohydraulic or laser lithotripsy. Stone clearance had failed in a previous ERCP using traditional techniques in 124/156 patients (80 %), while 32 /156 patients (21 %) were referred directly to POCS-guided therapy based on preprocedural assessment of the difficulty of stone clearance. In 101/156 patients (65 %), there were impacted stones. POCS-guided stone clearance was achieved in a single POCS procedure in 125 /156 patients (80 %, 95 % confidence interval [CI] 73 % - 86 %), and was significantly more likely for stones ≤ 30 mm compared with > 30 mm (odds ratio 7.9, 95 %CI 2.4 - 26.2; P = 0.002). Serious adverse events occurred in 3/156 patients (1.9 %, 95 %CI 0.4 % - 5.5 %), and included pancreatitis, perforation due to laser lithotripsy, and cholangitis (n = 1 each), all resolved within 1 week.

CONCLUSION

POCS-guided lithotripsy is highly effective for clearance of difficult bile duct stones in a single procedure and successfully salvages most prior treatment failures. It may also be considered first-line therapy for patients with difficult choledocholithiasis to avoid serial procedures.

Life-threatening upper gastrointestinal bleeding due to gastric Dieulafoy's lesion: Successful minimally-invasive management

Dieulafoy's lesion (DL) is a relatively rare, but potentially life-threatening condition. It accounts for 1-2% of acute gastrointestinal bleedings. Its serious nature makes it necessary for early diagnosis and treatment. This is a case report of a patient who presented with life-threatening haematemesis due to gastric Dieulafoy's that was successfully treated laparoscopically after failed endotherapy.

Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center

BACKGROUND AND AIMS

ERCP is an established technique for the management of bile duct stones. Large bile duct stones (>1.2 cm) require additional techniques such as mechanical lithotripsy and balloon sphincteroplasty for ductal clearance. The literature on endoscopic management of cystic duct stones (CDSs) and Mirizzi syndrome (MS) is limited. We report our experience with cholangioscopy-assisted extraction of CDSs and MS in patients in whom conventional endoscopic and surgical techniques failed.

METHODS

Between August 2011 and August 2014, 50 patients (15 males) diagnosed with MS (n = 40) and CDSs (n = 10) were recruited for the study. MRCP was the preferred diagnostic modality to outline the biliary anatomy. ERCP was performed by using an Olympus TJF 160/180 duodenoscope (Olympus, Tokyo, Japan). Cholangioscopy was performed by using the Spyglass system (Boston Scientific, Marlborough, Mass). Holmium laser lithotripsy (LL) was performed when conventional stone extraction techniques failed.

RESULTS

Cholangioscopy-guided LL was required in 34 of 50 patients (68%) with MS and CDSs. Stone extractions using conventional endoscopy techniques were successful in 8 patients and with surgery in another 8 patients, and these patients were excluded from the final statistical analysis. The mean stone size for MS was 21 mm (range 15-41 mm), and the CDS size was 8 mm (range 6-12 mm). Single-session ductal clearance could be achieved in 32 patients (94%). Adverse events were mild and included fever (2 patients), transient abdominal pain (2 patients), and self-limited pancreatitis (2 patients).

CONCLUSIONS

Cholangioscopy-guided LL is a useful technique for extraction of CDSs and in MS with high single-session success rates. It is also a rescue technique in patients in whom surgical stone extraction failed.

Percutaneous endoscopic management of intrahepatic stones in patients with altered biliary anatomy: A case series

Incidence of primary intrahepatic stones (IHS) in India is very less as compared to the Far East. However patients with altered biliary anatomy are prone for IHS formation secondary to anastomotic stricture formation. Indian data on percutaneous endoscopic management of IHS is scare. Five patients with IHS were managed percutaneously. All patients had undergone Roux-en-Y hepaticojejunostomy and were not suitable for direct endoscopic intervention. All patients underwent percutaneous biliary drainage followed by cholangioscopy-guided laser lithotripsy. Crushed stones were pushed across the anastomotic site using basket/balloon and ductal clearance was achieved. Good stone pulverization could be achieved in five patients (100 %). Complete ductal clearance could be achieved in all patients (100 %). Cholangioscopy-guided treatment of IHS can be valuable alternative to surgery in select group of patients especially those having dilated biliary tree with absence of intrahepatic strictures. However long-term follow up studies are required to see for recurrence of stone formation.

Endoscopic management of internally migrated pancreatic duct stents (with video)

BACKGROUND AND AIMS

Spontaneous intestinal migration of pancreatic stents is a known phenomenon. However, retrieval of a proximally migrated pancreatic stent (PMPS) poses a therapeutic challenge. The primary aim of this study was to evaluate technical success of endoscopic retrograde of cholangiopancreatography (ERCP) for extraction of PMPS, including number of sessions, need of surgery for failures and intervention-induced adverse events. The secondary outcome was to evaluate long-term effects of PMPS on the ductal morphology.

METHODS

Data of patients undergoing pancreatic stenting since January 2007 was reviewed. Fourteen patients were found to have PMPS. The level of stent migration was divided into two categories: level 1: retropapillary migration of the stent, the distal end seen till the genu (n = 6). Level II: PMPS with distal end seen beyond genu (n = 8). The stents were placed due to following reasons, prophylactic pancreatic stenting after common bile duct stone extraction (n = 6), pancreatic endotherapy for chronic pancreatitis (n = 7), and recurrent acute pancreatitis with incomplete pancreas divisum (n = 1). ERCP was done using Olympus TJF 160/180 duodenoscope. Stent extraction was initially attempted using rat tooth forceps, snare with or without wire, wire-guided basket, and in case of failures, pancreatoscope was used (Boston Scientific, USA).

RESULTS

PMPS could successfully be retrieved in 13 out of 14 patients (92.8 %). Stents were retrieved using stone extraction balloon in two (14.2 %), modified angiography balloon in one (7 %), rat tooth in three patients (21.4 %), over-the-wire snare in three patients (21.4 %), lasso technique in one (7 %), and under pancreatoscope guidance in three patients (21.4 %). Adverse events encountered were mild pancreatitis (n = 2, 14 %) and self-limited bleeding (n = 2, 14 %).

CONCLUSIONS

Endotherapy of PMPS could be complex and associated with adverse events. Level II-migrated stents may require specialized methods like pancreatoscopy for stent retrieval.

Endoscopic management of radio-opaque bile duct stones

BACKGROUND

Majority of the bile duct stones (BDS) are radiolucent (RL) and are amenable to conventional endoscopic extraction techniques. There is no publication that specifically discusses the optimal management of radio-opaque (RO) BDS and makes a distinction from the strategy followed for RL BDS.

METHODS

Data of patients with BDS managed endoscopically from January 2009 till June 2015 were retrospectively reviewed. Diagnosis of RO stone was established during initial fluoroscopy, just prior to obtaining a cholangiogram. Endoscopic retrograde cholangiopancreatography (ERCP) was done using therapeutic duodenoscope. Stone extraction was attempted initially using conventional techniques. Balloon sphincteroplasty or mechanical lithotripsy (ML) or both were done if conventional techniques failed. Cholangioscopy-guided intracorporeal holmium laser lithotripsy (LL) was done when all the above techniques failed.

RESULTS

Fifteen patients were found to have RO stones in the bile duct during the study period. ERCP was successful in all patients. Discrepancy of the stone size in relation to the lower CBD diameter was seen in eight patients (53.34 %). Stone extraction with conventional techniques was successful in 2/15 patients (13 %). Successful controlled radial expansion (CRE) balloon sphincteroplasty/ML was possible in 5/15 patients (33 %). Cholangioscopy guided LL was done in eight patients (53.34 %) with successful pulverization of RO BDS (100 %).

CONCLUSIONS

RO bile duct stones provide unique challenges for endoscopic management with success of conventional techniques in only about half of them (46 %). RO stones detected on fluoroscopy are extremely hard and difficult to crush with lithotripsy basket probably due to high calcium content. Cholangioscopy guided LL provides an excellent alternative management strategy.

EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients

BACKGROUND

EUS-guided pseudocyst drainage with fully covered self-expandable metal stents (FCSEMSs) was recently described. The appropriate period for stent removal is not known.

OBJECTIVE

To assess the safety and efficacy of EUS-guided FCSEMS placement for 3 weeks, along with pancreatic ductal stenting in selected patients.

STUDY DESIGN

Prospective, single-center evaluation.

SETTING

Tertiary referral center.

PATIENTS

Symptomatic pseudocysts in the body and tail region of the pancreas.

INTERVENTIONS

EUS-guided transgastric placement of FCSEMS. MRCP was performed after 3 weeks. Patients with a suspected pancreatic duct leak underwent ERCP and plastic stent placement. The FCSEMSs were removed at 3 weeks.

MAIN OUTCOME MEASUREMENTS

Success of FCSEMS placement, adverse events, and recurrence rate.

RESULTS

Forty-seven patients met the eligibility criteria. Technical and functional success was achieved in 43 patients (intention to treat, 91.48% and 95.34% patients [per protocol, 41/43, respectively]). Adverse events occurred in 2 patients (cyst infections, 4.6%). Follow-up of 42 patients at 3 weeks was performed. MRCP detected a ductal leak in 3 patients (7.1%) and a disconnected duct in 2 patients (4.7%). ERCP and stenting were successful in all 3 patients with a ductal leak. During a median follow-up of 306 days in 42 patients, 2 recurrences (4.7%) were detected, both in patients with disconnected duct. Multivariate analysis showed that pancreatic ductal leak or disconnection was an independent factor affecting pseudocyst resolution at 3 weeks (P = .0001).

LIMITATIONS

Single-center study.

CONCLUSION

Short-term placement of FCSEMSs with pancreatic ductal stenting in selected patients appears safe and effective for the treatment of pseudocysts.

Comparison of transhepatic and extrahepatic routes for EUS-guided rendezvous procedure for distal CBD obstruction

BACKGROUND

EUS-guided rendezvous procedure (EUS-RV) can be done by the transhepatic (TH) or the extrahepatic (EH) route. There is no data on the preferred access route when both routes are available.

STUDY AIM

To compare the success, complications, and duration of hospitalization for patients undergoing EUS-RV by the TH or the EH route.

PATIENTS AND METHODS

Patients with distal common bile duct (CBD) obstruction, who failed selective cannulation, underwent EUS-RV by the TH route through the stomach or the EH route through the duodenum.

RESULTS

A total of 35 patients were analysed (17 TH, 18 EH). The mean procedure time was significantly longer for the TH group (34.4 vs. 25.7 min; p = 0.0004). There was no difference in the technical success (94.1 vs. 100%). However, the TH group had a higher incidence of post-procedure pain (44.1 vs. 5.5%; p = 0.017), bile leak (11.7 vs. 0; p = 0.228), and air under diaphragm (11.7 vs. 0; p = 0.228). All bile leaks were small and managed conservatively. Duration of hospitalization was significantly higher for the TH group (2.52 vs. 0.17 days; p = 0.015).

CONCLUSIONS

EUS-RV has similar success rate by the TH or the EH route. However, the TH route has higher post-procedure pain, longer procedure time, and longer duration of hospitalization. The EH route should be preferred for EUS-RV in patients with distal CBD obstruction when both access routes are technically feasible.

Recurrent acute pancreatitis in a patient with wirsungocele and neuroendocrine tumor of ampulla of Vater

CONTEXT

Wirsungocele has recently been shown to be associated with acute recurrent, severe necrotizing pancreatitis and chronic pancreatitis or chronic pain in abdomen. Till to date there is no report on association of wirsungocele with an ampullary neuroendocrine tumor, and recurrent pancreatitis.

CASE REPORT

We report a first ever case of wirsungocele diagnosed on EUS, its association with neuroendocrine tumor of ampulla and recurrent acute pancreatitis.

CONCLUSION

This case report highlights the diagnostic utility of EUS in diagnosing small ampullary pathology like wirsungocele and neuroendocrine tumor.

Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos)

BACKGROUND

Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy.

OBJECTIVE

To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy.

DESIGN

Retrospective study.

SETTING

Tertiary care referral center.

PATIENTS

Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy.

INTERVENTIONS

Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy.

MAIN OUTCOME MEASURES

Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session.

RESULTS

Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27).

LIMITATIONS

Retrospective nonrandomized study design; highly selective patient cohort.

CONCLUSIONS

In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings.

Endosonography-guided fine needle aspiration cytology of intra-abdominal lymph nodes with unknown primary in a tuberculosis endemic region

BACKGROUND AND AIM

Intra-abdominal lymphadenopathy poses a diagnostic and management challenge in highly endemic regions for tuberculosis. Opting for empirical anti-tuberculosis treatment raises the risk of wrong or delayed treatment. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the procedure of choice for tissue acquisition from peri-luminal lymph nodes. We studied the utility of EUS-FNA in evaluating intra-abdominal lymph nodes of unknown etiology, in the setting of high endemicity of tuberculosis.

METHODS

Consecutive patients with intra-abdominal lymph nodes of unknown etiology underwent EUS-FNA using a 22-gauge needle. Final diagnosis was made on surgical histology or on 6-months follow-up. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic yield were calculated.

RESULTS

Sixty-six patients were included. Final diagnoses were tuberculosis, 35 (53%); metastatic adenocarcinoma, 11 (16.7%); lymphoma, three (4.5%); carcinoid, one (1.5%) and reactive nodes, 16 (24.2%). EUS-FNA provided a diagnosis in 61 patients (92.4%). Sensitivity, specificity, PPV and NPV for diagnosing tuberculosis via EUS-FNA were 97.1%, 100%, 100% and 96.9%, respectively. In 10 (15.2%) patients receiving empirical anti-tuberculosis treatment, the final diagnoses were metastatic adenocarcinoma (5), lymphoma (2), carcinoid (1) and reactive adenopathy (2).

CONCLUSION

Despite being in a highly endemic area, almost half of the patients studied have a non-tuberculosis etiology. EUS-FNA is a safe and accurate procedure for establishing the diagnosis of unexplained intra-abdominal lymphadenopathy.

Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos)

BACKGROUND

Scant data exist on the utility of the holmium:yttrium-aluminum-garnet laser for the treatment of biliary or pancreatic duct stones.

OBJECTIVE

To evaluate the efficacy and safety of fiberoptic probe and catheter system-guided holmium laser lithotripsy of difficult biliary and pancreatic duct stones.

DESIGN

Prospective study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 64 patients who underwent holmium laser stone fragmentation.

INTERVENTION

A total of 64 patients (60 bile duct stones, 4 pancreatic duct stones) underwent endoscopic retrograde stone fragmentation with a holmium laser and a fiberoptic probe and catheter system. The inclusion criterion for bile duct stones was stones not amenable to retrieval by mechanical lithotripsy and/or balloon sphincteroplasty or standard techniques. Pancreatic duct stones included in this study were not amenable to removal by stone retrieval basket or balloon.

MAIN OUTCOME MEASUREMENTS

Rates of ductal clearance and procedural complications.

RESULTS

All 64 patients had successful fragmentation of biliary and pancreatic duct stones with the holmium laser. Fifty of 60 patients (83.3%) had complete biliary duct clearance after a single session; 10 patients required an additional session. All pancreatic duct stones were fragmented in a single session. Mean duration of ERCP sessions was 45.9 minutes (range 30-90 minutes). Complications were mild and were encountered in 13.5% of patients; fever (n = 3), transient abdominal pain (n = 4), and biliary stricture (n = 1).

LIMITATIONS

No comparative treatment group.

CONCLUSION

The fiberoptic probe and catheter system facilitates transpapillary access for holmium laser fragmentation of difficult biliary and pancreatic duct stones. The technique is safe and highly effective for single-setting duct clearance. Complications are minimal and transient.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

Endoscopic balloon sphincteroplasty for extraction of large radiolucent pancreatic duct stones (with videos)

BACKGROUND

Although radiopaque pancreatic duct stones can be targeted by extracorporeal shock wave lithotripsy (ESWL) and extracted by ERCP, large and radiolucent stones remain a therapeutic challenge.

OBJECTIVE

To evaluate the technical success and safety of endoscopic balloon sphincter dilation technique (sphincteroplasty) for extraction of large radiolucent pancreatic duct stones.

DESIGN

Case series.

SETTING

Tertiary referral center.

PATIENTS

Four symptomatic patients with large (> or =1 cm) radiolucent stones occluding the main pancreatic duct that could not be retrieved by standard endoscopic maneuvers.

INTERVENTIONS

Pancreatic sphincterotomy followed by balloon dilation of the pancreatic orifice to aid retrieval of large radiolucent stones occluding the main pancreatic duct.

MAIN OUTCOME MEASUREMENTS

Technical success and safety of the balloon dilation (sphincteroplasty) technique. Technical success was defined as the ability to achieve pancreatic duct clearance in 1 endoscopic encounter. Complications were assessed according to consensus criteria.

RESULTS

The procedure was technically successful in all 4 patients. Pancreatic duct clearance was achieved in all 4 patients in 1 endoscopy session with complete symptom relief at 12-month follow-up. Mild post-ERCP pancreatitis developed in 1 patient, and minor bleeding developed in another patient; both were managed conservatively.

LIMITATION

Small number of patients.

CONCLUSIONS

Endoscopic balloon dilation of the pancreatic orifice after sphincterotomy is a safe technique that facilitates the removal of large radiolucent stones from the main pancreatic duct in 1 endoscopic session. More studies with larger numbers of patients are required before this technique can be adopted routinely as a treatment alternative for patients with large radiolucent pancreatic duct stones.

Balloon sphincteroplasty for removing difficult bile duct stones

BACKGROUND AND STUDY AIMS

Extraction of common bile duct stones at endoscopic retrograde cholangiopancreatography can be technically challenging when the size of the stone exceeds that of an endoscopic sphincterotomy. The aim of this study was to evaluate the efficacy and safety of papillary balloon dilation after sphincterotomy for extraction of these difficult-to-remove bile duct stones.

PATIENTS AND METHODS

This was a prospective study of all patients with large common bile duct stones that could not be extracted using a stone retrieval balloon and basket after endoscopic sphincterotomy. These patients underwent papillary dilation using a radial expansion balloon after maximum sphincterotomy. Biliary ductal clearance was then reattempted using a stone retrieval balloon and/or basket. The success rate and the complication rate for the papillary balloon dilation technique were assessed.

RESULTS

A total of 60 patients (16 men, 44 women; mean age 58, range 28 - 73) were enrolled in this study. The mean stone size was 16 mm (range 12 - 20 mm). After maximum sphincterotomy and papillary balloon dilation, ductal clearance was achieved in 57/60 patients (95 %); three patients required adjunctive mechanical lithotripsy for stone extraction. Bleeding occurred in five patients (8.3 %) and was managed conservatively in all cases.

CONCLUSIONS

Papillary balloon dilation after endoscopic sphincterotomy is an effective and safe technique for retrieval of difficult common bile duct stones. The procedure is technically safe and obviates the need for mechanical lithotripsy in a majority of patients.

Endotherapy for chronic pancreatitis with intracanalar stones

Endotherapy for pancreatic stone is an emerging specialty. The judicious application of extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) in selected groups of patients has increased the success rates of endotherapy, with excellent long-term results. In this review the authors share their vast experience of treating patients with pancreatic stones. The article will focus on the basic principles of pancreatic endotherapy, the instrumentation required, details of the ESWL technique and its applications, as well as the limitations, success rate, and complications of endotherapy in selected patients.

Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment

BACKGROUND AND STUDY AIMS

We evaluated the therapeutic effects of percutaneous transhepatic photodynamic therapy (PDT) in patients with advanced bile duct cancer. The utility of intraductal ultrasonography (IDUS) for the assessment of responses and for regular follow up after PDT was also examined.

METHODS

Percutaneous transhepatic biliary drainage (PTBD) was initiated before PDT. Following dilation and maturation of the PTBD tract, percutaneous PDT was performed. Intraluminal photoactivation was carried out using percutaneous cholangioscopy 2 days after intravenous application of a hematoporphyrin derivative. All patients were additionally provided with percutaneous bile duct drainage catheters after PDT. IDUS was conducted monthly to measure the thickness of the tumor mass before and after PDT.

RESULTS

24 patients with advanced cholangiocarcinomas (Bismuth IIIa, n = 4; IIIb, n = 10; IV, n = 10) were treated with PDT. At 3 months after PDT, the mean thickness of the tumor mass had decreased from 8.7 +/- 3.7 mm to 5.8 +/- 2.0 mm (P < 0.01). At 4 months after PDT, the thickness of the mass had increased to 7.0 +/- 3.7 mm. Quality of life indices improved dramatically and remained stable 1 month after PDT; the Karnofsky index increased from 39.1 +/- 11.36 to 58.2 +/- 22.72 points (P = 0.003). The 30-day mortality rate was 0 %, and the median survival time was 558 +/- 178.8 days (current range 62 - 810 days).

CONCLUSIONS

PDT using percutaneous cholangioscopy is safe and effective for advanced hilar cholangiocarcinoma, and seems to prolong survival. IDUS is useful for evaluating changes in the thickness of the tumor mass after PDT.

Management of malignant strictures of the cervical esophagus with a newly-designed self-expanding metal stent

Recently, the use of self-expanding metal stents has become a well-established method of palliative treatment for stenotic malignant diseases in the middle and distal esophagus. However, published results on the use of self-expanding metal stents in cervical esophageal cancer are somewhat limited by a paucity of clinical details and experience. A new self-expanding esophageal metal stent with a short upper flange 0.7 cm in length was studied prospectively in order to assess its efficacy for palliative treatment. This report presents experience in three patients in whom this new stent was used in the treatment of cervical esophageal cancers. Stent placement was successful in all three patients, with no serious complications such as esophageal perforation, hemorrhage, or foreign-body sensation. All of the patients experienced rapid improvement in dysphagia and clinical symptoms. The newly designed self-expanding stent can be of value in the treatment of stenotic cervical esophageal cancer.

Usefulness of three-dimensional, multidetector row CT (virtual gastroscopy and multiplanar reconstruction) in the evaluation of gastric cancer: a comparison with conventional endoscopy, EUS, and histopathology

BACKGROUND

The aim of this study was to assess the role of three-dimensional multidetector row CT for detection, precise localization, and staging of gastric cancer by comparison with conventional endoscopy, EUS, and histopathology.

METHODS

Sixty-three patients with gastric cancer (31 early stage, 32 advanced) were evaluated by EGD with biopsies, EUS, and three-dimensional multidetector row CT between January 2003 to August 2003. Three-dimensional multidetector row CT findings were analyzed by a single radiologist blinded to the endoscopic findings. Among 63 patients, the findings were confirmed in 48 at surgery or by EMR. In the remaining cases, the findings were confirmed by EGD and biopsy specimen. The accuracy of three-dimensional multidetector row CT for detection, localization, and staging of gastric cancer was determined, compared with endoscopy, EUS, and histopathology.

RESULTS

Among the 63 patients, there were 67 gastric cancers. The overall accuracy of three-dimensional multidetector row CT for detection of gastric lesions was 94% (63/67), with accuracies of 96.7% (30/31) and 100% (32/32) for detection of, respectively, early and advanced stage gastric cancer. The overall accuracy, sensitivity, and specificity for EUS and three-dimensional multidetector row CT in the pre-operative determination of depth of invasion (T stage) were, respectively, 87.5%, 82.4%, and 96%; and 83.3%, 69.1%, and 94.4%. The accuracy, sensitivity, and specificity of EUS and three-dimensional multidetector row CT for lymph node staging was, respectively, 79.1%, 57%, and 89.5%; and 75%, 57.4%, and 89.3%.

CONCLUSIONS

Three-dimensional multidetector row CT, along with virtual gastroscopy is a promising method for pre-operative evaluation of gastric cancer.

Invasive intraductal papillary mucinous tumor of the pancreas with simultaneous invasion of the stomach and duodenum

An 81-year-old woman was admitted with epigastric pain and weight loss. She had been diagnosed with an intraductal papillary mucosal tumor (IPMT) 7 years previously, but had refused surgery for religious reasons. Esophagogastroduodenoscopy revealed a nodular, elevated lesion that was discharging mucin into the duodenal bulb and posterior wall of the upper body of the stomach. Endoscopic ultrasonography, abdominal computed tomography, and endoscopic retrograde cholangiography were carried out, and a highly invasive IPMT with simultaneous invasion of the stomach and duodenum was diagnosed.