Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series

BACKGROUND

Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones.

AIMS

We sought to identify factors predictive of adverse events (AEs) following EPLBD.

METHODS

This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12-20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan.

RESULTS

Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015).

CONCLUSIONS

EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia-Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia-Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Direct biliary drainage using transnasal endoscopy for patients with severe-to-moderate acute cholangitis

BACKGROUND AND AIM

Endoscopic biliary drainage (BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy (TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy (ES) previously.

METHODS

Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5-Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated.

RESULTS

A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred.

CONCLUSION

Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously.

Endoscopic ultrasound elastography for the pancreas in Korea: a preliminary single center study

BACKGROUND/AIMS

Endoscopic ultrasound elastography (EUS-EG) has been widely used for the evaluation of pancreatic cancer in the Western world. To date, there is very little experience with EUS-EG in Korea. We described the results of comparison between normal pancreas and pancreatic cancer in Korea.

METHODS

The present study was performed at a tertiary hospital on 35 subjects comprising 20 with normal pancreas (control group) and 15 with pancreatic cancer (disease group). We compared the EUS-EG performance of the two groups.

RESULTS

The pancreas in the control group showed a mean elasticity value of 0.53% (95% confidence interval [CI], 0.45 to 0.61). The elasticity value was higher than that previously reported from Western country (0.47%; 95% CI, 0.38 to 0.57). In the disease group, the mean elasticity value of pancreatic lesions was 0.02% (95% CI, 0.01 to 0.02). The mean elasticity value of the disease group was significantly lower than that of the control group (p<0.0001).

CONCLUSIONS

EUS-EG could be a highly sensitive diagnostic modality for pancreatic cancer in Korea with little EUS-EG experience. We also provided the reference range of elasticity value of normal pancreas, which might be valuable in the interpretation of pancreatic elasticity data for Korean adults.

Technical feasibility and revision efficacy of the sequential deployment of endoscopic bilateral side-by-side metal stents for malignant hilar biliary strictures: a multicenter prospective study

BACKGROUND

Theoretically, the side-by-side bilateral placement of metal stents may be technically easier than stent-in-stent bilateral placement in stent revision. However, side-by-side placement can be technically challenging, as the deployment of the first stent can preclude the passage of the second stent.

AIM

We explored the technical feasibility and revision efficacy of endoscopic bilateral side-by-side stent placement for malignant hilar biliary strictures.

METHODS

Forty-four patients with Bismuth type II or higher malignant hilar biliary strictures were enrolled in seven academic tertiary referral centers. Endoscopic placement of side-by-side bilateral metal stents with 7F thin delivery shaft was performed. The outcome measurements were the technical and functional success, adverse events, endoscopic revision success rate, and stent patency.

RESULTS

Overall, the technical and functional success rates were 91 % (40/44), and 98 % (39/40), respectively. Two of the failed patients were converted successfully with subsequent contralateral stent-in-stent placement, and the other patients underwent percutaneous intervention. Early stent-related adverse events occurred in 10 %. The endoscopic revision rate due to stent malfunction during follow-up (median: 180 days) was 45 % (18/40; tumor ingrowth in 4 and in-stent sludge impaction/stone formation in 14 patients). The endoscopic revision success rate was 92 % (12/13). Five patients with comorbidity underwent initial percutaneous intervention. The median survival and stent patency periods were 180 and 157 days, respectively.

CONCLUSIONS

The sequential placement of a metal stent with a 7F thin delivery shaft in bilateral side-by-side procedures may be feasible and effective for malignant hilar biliary strictures and for endoscopic stent revision.

Aortoenteric fistula diagnosed by double balloon enteroscopy: a case report

A secondary aortoenteric fistula (AEF) is a direct communication between the gastrointestinal tract and the aorta in a patient who has undergone major surgery on the aorta, often an aorta graft operation. We experienced a patient who had undergone graft interposition for abdominal aortic aneurysm and was admitted due to three episodes of hematemesis and following hamatochezia. Gastroscopy, colonoscopy, and radioactive iodine scan failed to identify the bleeding site in the patient. He was diagnosed with AEF by double balloon enteroscopy and recovered after surgical intervention.

Uncovered self-expandable metallic stent placement as a first-line palliative therapy in unresectable malignant duodenal obstruction

OBJECTIVE

To report treatment outcomes and complications of uncovered self-expandable metallic stents (SEMS) as a first-line therapy for inoperable malignant duodenal obstructions in our hospital.

METHODS

A retrospective analysis was performed in patients who had undergone placement of uncovered SEMS as a first-line therapy for inoperable malignant duodenal obstruction from August 2001 to July 2011. Treatment outcomes and complications of the procedures were investigated.

RESULTS

In total, 47 patients (25 men; mean age 65 years) underwent the procedure. The technical and clinical success rates were 93.6% and 83.0%, respectively. Early complications occurred in 8 patients, including two guidewire-induced micro-perforations and six pancreatitis. All these 8 patients recovered with conservative treatment. Six late complications requiring additional procedures consisted of five stent occlusions due to tumor ingrowth and one stent migration. Four stent occlusions and one migration were treated by the placement of an additional covered stent and the remaining case was treated by balloon dilatation. The median primary stent patency period and median survival period after primary stent placement were 103 days and 131 days, respectively.

CONCLUSIONS

Uncovered SEMS placement is effective as a first-line palliative therapy for inoperable malignant duodenal obstruction. Complications such as stent occlusion or migration can be easily managed with additional covered SEMS.

Esophageal submucosal dissection under steady pressure automatically controlled endoscopy (SPACE): a randomized preclinical trial

BACKGROUND AND STUDY AIMS

A new overtube system has been developed for steady pressure automatically controlled endoscopy (SPACE) in the gastrointestinal tract. The objectives of this study were to validate the feasibility and safety of SPACE in the esophagus, and to evaluate its potential advantages over conventional (manually insufflating) endoscopy in endoscopic submucosal dissection (ESD).

METHODS

This was a multicenter preclinical trial using acute porcine models (n = 20). In Experiment 1 (feasibility/safety study), SPACE was attempted in the esophagus with continuous monitoring of cardiopulmonary parameters and intraluminal pressures in the downstream bowel. Different insufflation pressures were tested to optimize the insufflation condition. Each session was video-recorded and scored by blinded reviewers. In Experiment 2 (randomized trial), esophageal ESD was attempted using either SPACE or conventional endoscopy, and results were compared.

RESULTS

In Experiment 1, SPACE was performed safely without intraluminal pressure elevation in the downstream bowel. According to video review, SPACE provided more stable, reproducible, and rapid visualization than conventional endoscopy. The insufflation pressure was optimized at 14 mmHg for esophageal SPACE. In Experiment 2, ESD was completed in all animals. The ESD time was significantly shorter with SPACE compared with conventional endoscopy (1326 vs. 1616 seconds; P = 0.009). Responses to questionnaires showed that 94 % - 100 % of participants considered SPACE to provide improved exposure and more uniform tissue tension than conventional endoscopy. Other data were comparable.

CONCLUSIONS

SPACE is feasible, safe, and potentially effective for complicated endoscopic procedures, such as ESD. SPACE improves and standardizes endoscopic exposure and tissue tension. A clinical study is required to further confirm its safety and clinical effectiveness.

A Survey of the Radiation Exposure Protection of Health Care Providers during Endoscopic Retrograde Cholangiopancreatography in Korea

Background/Aims

During endoscopic retrograde cholangiopancreatography (ERCP), all efforts should be made to be aware of radiation hazards and to reduce radiation exposure. The aim of this study was to investigate the status of radiation protective equipment and the awareness of radiation exposure in health care providers performing ERCP in Korean hospitals.

Methods

A survey with a total of 42 questions was sent to each respondent via mail or e-mail between October 2010 and March 2011. The survey targeted nurses and radiation technicians who participated in ERCP in secondary or tertiary referral centers.

Results

A total of 78 providers from 38 hospitals responded to the surveys (response rate, 52%). The preparation and actual utilization rates of protective equipment were 55.3% and 61.9% for lead shields, 100% and 98.7% for lead aprons, 47.4% and 37.8% for lead glasses, 97.4% and 94.7% for thyroid shields, and 57.7% and 68.9% for radiation dosimeters, respectively. The common reason for not wearing protective equipment was that the equipment was bothersome, according to 45.7% of the respondents.

Conclusions

More protective equipment, such as lead shields and lead glasses, should be provided to health care providers involved in ERCP. In particular, the actual utilization rate for lead glasses was very low.

Influenza A (H1N1) 2009 pandemic calm down the prevalence of acute hepatitis A in the latter half of 2009: Korean population study

BACKGROUND/AIMS

There was a spiking incidence of acute hepatitis A (AHA) in 2009 summer, but it went down drastically after an outbreak of influenza A (H1N1). We assessed the relationship between 2009 H1N1 pandemic and AHA prevalence from August to December 2009.

METHODS

We compared AHA cases nationwide and in our hospital for the period from the latter half of 2008 to the end of 2010. H1N1 cases in our hospital from August 2009 to December 2009 were included in the study and the correlation between 2009 H1N1 pandemic and AHA prevalence was assessed.

RESULTS

The national surveillance system reported 2,233, 7,895, 15,231 and 7,660 AHA cases from 2007 to 2010, respectively. A similar trend was noted in our hospital in the same periods. Although the national total incidence was increased in 2009, it showed steep decreasing trend line in the final 21 weeks of 2009 (weeks 32-52), as compared with 2008 and 2010. The mean weekly incidence percentage (AHA cases in a week/total in a year) in weeks 32-52 of 2009 was 1.17±0.55%, significantly lower than that in 2008 and 2010 (1.61±0.43% and 1.56±0.51%; p<0.001). Furthermore, we found a significant negative correlation between 2009 H1N1 pandemic and AHA in our hospital for weeks 32-52 of 2009 (r=-0.597; p<0.001).

CONCLUSIONS

The widespread occurrence of 2009 H1N1 pandemic highlighted the benefits of health care and good hygiene, such as effective hand washing and wearing of masks, which may have also interrupted hepatitis A virus transmission.

Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones

BACKGROUND AND STUDY AIMS

The incidence of residual stones after mechanical lithotripsy for retained common bile duct (CBD) stones is relatively high. Peroral cholangioscopy using a mother-baby system may be useful for confirming complete extraction of stones, but has several limitations regarding routine use. We evaluated the role of direct peroral cholangioscopy (DPOC) using an ultraslim upper endoscope for the evaluation and removal of residual CBD stones after mechanical lithotripsy.

PATIENTS AND METHODS

From August 2006 to November 2010, 48 patients who had undergone mechanical lithotripsy for retained CBD stones with no evidence of filling defects in balloon cholangiography were recruited. The bile duct was inspected by DPOC after balloon cholangiography. Detected residual CBD stones were directly retrieved with a basket or balloon catheter under DPOC. The incidence of residual stones detected by DPOC, and the success rate of residual stone retrieval under DPOC were investigated.

RESULTS

DPOC was successfully performed in 46 of the 48 patients (95.8%). Of these, 13 patients (28.3%) had residual CBD stones (mean number 1.4, range 1-3; mean diameter 4.5 mm, range 2.3-9.6). The residual stones were removed directly under DPOC in 11 of these patients (84.6%). There were no complications associated with DPOC or stone removal.

CONCLUSION

DPOC using an ultraslim upper endoscope is a useful endoscopic procedure for the evaluation and extraction of residual stones after mechanical lithotripsy for retained CBD stones.

The role of endoscopic retrograde cholangiopancreatography at an academic medical center in the era of less-invasive diagnostic tools

Evaluation of: Coté GA, Singh S, Bucksot LG et al. Association between volume of endoscopic retrograde cholangiopancreatography at an academic medical center and use of pancreatobiliarytherapy. Clin. Gastroenterol. Hepatol. 10(8), 920-924 (2012). Many patients have pancreatobiliary diseases involving complications and comorbidities. This study shows the trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) at an academic medical center from 1994 to 2009. During that time, the use of ERCPs for the treatment of bile duct stones reached a plateau and those for the treatment of pancreas divisum showed a decline. However, endoscopic therapy for benign biliary stricture and management for obstructive chronic pancreatitis increased during this period. There was a trend toward greater use of therapeutic ERCP for bile duct stenting involving metal stents and for pancreatic therapeutics. In that same period, there was an increase in the proportion of patients who had undergone unsuccessful ERCP at various other centers. Consequently, at academic medical centers, ERCP has become an increasingly complex intervention. Increasing numbers of patients with comorbidities, complications and history of failed ERCPs are being referred to academic centers to receive endotherapy.

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

BACKGROUND

Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy.

OBJECTIVE

To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures.

DESIGN

Prospective observational clinical feasibility study.

SETTING

Tertiary-care academic center.

PATIENTS

This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed.

INTERVENTION

Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months.

MAIN OUTCOME MEASUREMENTS

Success, complications, removability, midterm outcome.

RESULTS

FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture.

LIMITATIONS

The small number and lack of comparison with other types of FCSEMSs.

CONCLUSION

Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/Aims

Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.

Methods

Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.

Results

Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.

Conclusions

Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.

Endoscopic double-metallic stenting for malignant biliary and duodenal obstructions

BACKGROUND

Endoscopic metallic stenting is a safe, effective treatment for malignant biliary obstructions, but can be technically difficult when combined malignant biliary and duodenal obstructions exist. Available duodenal metallic stents feature a tight mesh unsuitable for transpapillary biliary stenting. We evaluated the feasibility and usefulness of new endoscopic procedures for endoscopic double-stent placement in managing such obstructions.

METHODS

The through-the-scope duodenal metallic stent has a central cross-wired, unfixed structure that allows insertion of the biliary stent through the mesh wall of a duodenal stent. Transpapillary endoscopic placement of a biliary stent was performed through the lumen of this duodenal stent. Endoscopic ultrasound (EUS)-guided biliary drainage was performed successfully through the duodenal bulb after puncturing with a 19G needle. Biliary metallic stenting through the choledochoduodenal tract and effective drainage were achieved.

CONCLUSIONS

Use of a combined endoscopic biliary and duodenal stent inserted through the mesh of the new duodenal metallic stent is feasible and effective in managing the aforementioned obstructions. EUS-guided biliary metal stenting is a therapeutic option for endoscopic management when a failed transpapillary approach through the lumen of the duodenal stent occurs. The continued development of endoscopic procedures and devices should resolve issues associated with complicated strictures.

Benefit of pronase in image quality during EUS

BACKGROUND

EUS is useful for diagnosis of GI disease. However, artifacts caused by gastric mucus may worsen visibility during EUS.

OBJECTIVE

To investigate the efficacy of premedication with pronase, the proteolytic enzyme, for improving imaging during EUS.

DESIGN

Blinded, randomized, prospective study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 183 patients scheduled for EUS.

INTERVENTION

Patients were assigned to oral premedication with saline solution (group A), pronase and bicarbonate (group B), or pronase, bicarbonate, and simethicone (group C). Either conventional EUS or high-frequency catheter EUS (HFUS) was selected. Gastric cavity and gastric mucosal surface obscurity grades were assessed by using visibility scores from ultrasonographic images of each patient.

MAIN OUTCOME MEASUREMENTS

Means of visibility scores and proportion of images with better visibility scores of the gastric cavity and gastric mucosal surface. Lower scores indicate better visibility of the gastric mucosal surface and fewer artifacts within the gastric cavity on conventional EUS and HFUS.

RESULTS

Group B had significantly lower mean gastric cavity and gastric mucosal surface visibility scores than did groups A and C in both conventional EUS and HFUS. Group B also had a high proportion of images that had better gastric cavity and gastric mucosal surface visibility scores than did the other two groups in conventional EUS and HFUS.

LIMITATIONS

Small number of patients and no assessment of the amount of mucus before oral premedication.

CONCLUSION

Premedication for conventional EUS and HFUS by using a mixture of pronase and bicarbonate seems to decrease the number of gastric wall and lumen hyperechoic artifacts observed in patients given either saline solution or pronase/bicarbonate/simethicone.

[An experience of cyberknife treatment in patients with advanced pancreaticobilliary malignancy]

BACKGROUND/AIMS

CyberKnifeTM stereotactic body radiotherapy (SBRT) has been thought as a promising treatment modality for inoperable or recurred pancreaticobiliary malignancies. But, clinical course of CyberKnifeTM treatment have not been established yet, so we report the experience of CyberKnifeTM treatment in 19 patients with recurred or advanced pancreaticobilliary malignancies.

METHODS

Between July 2008 and May 2009, 19 patients (gallbladder cancer 4, common bile duct cancer 5, and pancreatic cancer 10) with recurred (12) and advanced pancreaticobiliary cancer (7) underwent CyberKnifeTM treatment in Soonchunhyang University Hospital. Tumor size was evaluated at 1, 3, 6, 8 and every 3 months after SBRT.

RESULTS

The mean age was 60.2 years, and the mean size of target lesions was 28.1±1.30 mm. After CyberKnifeTM treatment, the average size of target lesions was decreased; 2.53±4.18 mm from months 0-1 in 19 patients, 2.47±4.7 mm from months 1-3 in 15 patients, 0.08±5.11 mm from months 3-6 in 12 patients. However, the average size of target lesions was increased 3.67±8.98 mm from months 6-8 in 6 patients. There were 2 cases of massive duodenal ulcer bleeding after CyberKnifeTM treatment, one of them expired due to ulcer bleeding. Also, other minor complications appeared such as 1 case of abdominal pain and 1 case of diarrhea.

CONCLUSIONS

CyberKnifeTM treatment seems to be effective in local control of pancreaticobiliary cancer, but we experienced serious complications. Further prospective studies will be needed for the proper evaluation of role of CyberknifeTM treatment in patients with advanced pancreaticobiliary malignancies.

Wire-guided endoscopic snare retrieval of proximally migrated pancreatic stents after endoscopic papillectomy for ampullary adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.

Anchoring of a fully covered self-expandable metal stent with a 5F double-pigtail plastic stent to prevent migration in the management of benign biliary strictures

OBJECTIVES

Fully covered self-expandable metal stents (FCSEMSs) can be effectively placed in patients with benign biliary stricture (BBS). However, stent migration is an inherent problem of FCSEMSs. We evaluated the efficacy of anchoring with a 5F double-pigtail plastic stent (anchoring stent) to prevent migration of an FCSEMS in patients with BBS.

METHODS

Between January 2007 and December 2009, 33 of 37 consecutive patients with BBS who had experienced treatment failure of at least one plastic stent placement were prospectively enrolled in this study. The patients with BBS were randomly assigned to undergo FCSEMS placement with or without an anchoring stent (anchoring group: 16 patients; non-anchoring group: 17 patients). The main outcome measures were the stent migration rate and success rates.

RESULTS

The technical success rate was 100% in both groups. Significantly less stent migration occurred in the anchoring group (6.3%, 1/16) than in the non-anchoring group (41.2%, 7/17; P=0.024). The median indwelling time was significantly longer in the anchoring group (154 days; range, 86-176 days) than in the non-anchoring group (114 days; range, 19-162 days; P=0.010). Improvement or resolution of the BBS was confirmed in 15 of 16 patients (93.8%) in the anchoring group, and in 12 of 17 patients (70.6%) in the non-anchoring group (P=0.101).

CONCLUSIONS

The placement of an anchoring stent appears to be a simple and effective method of preventing premature migration of FCSEMSs in patients with BBS. Appropriately powered studies are needed to confirm this finding.

Early bile duct cancer detected by direct peroral cholangioscopy with narrow-band imaging after bile duct stone removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.

HBV DNA loss within 24 weeks predicts late viral breakthrough in chronic hepatitis B

BACKGROUND/AIMS

Sustained HBV DNA reduction is necessary for biochemical remission, histological improvement, and prevention of complications. We analyzed the time taken from HBV DNA loss to viral breakthrough after antiviral treatment in patients with chronic hepatitis B (CHB). The early fall of the HBV DNA level to undetectable levels assessed really whether it is related to late breakthrough.

METHODS

A total of 91 patients whose HBV DNA levels dropped below undetectable levels were chosen from lamivudine-treated 306 patients and were analyzed retrospectively. The patients were divided into 4 groups (A≤12, 12<B≤24, 24<C≤48, D>48 wk) according to the time taken for the HBV DNA to decrease below undetectable levels. HBV DNA level was determined every 3 months.

RESULTS

The mean time taken for loss of HBV DNA was 34±28 wk. The baseline ALT differed significantly among groups (A: 382±274, B: 340±30, C: 166±92, D: 54±100 IU/L) (p=0.007). Fifty nine of the 91 patients (64.8%) experienced viral breakthrough. The mean interval between HBV DNA loss and viral breakthrough was 65±40 wk and differed significantly between group A, B (82±43 wk) and group C, D (56±28 wk) (p=0.015). In multivariate analysis, only HBV DNA loss within 24 wk, was found to be independently associated with late viral breakthrough (p=0.035). Undetectable HBV DNA after 24 wk was associated with high odd ratio of 3.24 (95% CI, 1.09-9.67).

CONCLUSIONS

HBV DNA loss within 24 wk after antiviral treatment could predict the late breakthrough.

Detection of distant metastasis to skeletal muscle by 18F-FDG-PET in a case of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is a rare malignancy that originates from the epithelial cells of the intrahepatic bile ducts. Intrahepatic cholangiocarcinoma can metastasize in lymphatic chains, including the hepatoduodenal ligament, and it often invades adjacent organs or metastasizes to other visceral organs such as the lungs, bones, adrenal glands, and brain. However, distant skeletal muscle metastasis is very rare. Moreover, a metastatic skeletal muscle tumor rarely shows specific symptoms, making it difficult to identify in a routine examination. A 45-year-old man with a chief complaint of right upper quadrant abdominal pain was admitted to our hospital. Abdominal ultrasound and computed tomography with contrast enhancement showed a malignant mass in the right hepatic lobe, and 2-[¹⁸F] fluoro-2-deoxy-D-glucose positron-emission tomography revealed distant skeletal muscle metastases in the thorax and buttock. The patient underwent an ultrasound-guided percutaneous needle biopsy for the metastatic low-echo masses in the skeletal muscle.