Current situation of endoscopic treatment for common bile duct stones

BACKGROUND/AIMS

The progression of endoscopy and devices as well as newly developed treatment methods have enabled endoscopic lithotomy. In this study, we examined to what degree is it possible to endoscopically treat patients who are diagnosed as having common bile duct stones.

METHODOLOGY

Lithotomy was conducted using a backward side-viewing endoscope for patients without surgical history of upper gastrointestinal tract and patients with stomach reconstructed with Billroth-I method, using an ordinary endoscope for patients with stomach reconstructed with Billroth-II method (Bil-II) and using a double balloon endoscope for patients with difficulty in reaching the papilla or patients of Roux-en-Y anastomosis (R-Y). As for treatment methods, we selected endoscopic sphincterotomy as the first choice for papilla treatment and selected endoscopic papillary balloon dilation for patients with bleeding tendency or patients of Bil-II or R-Y. For patients with multiple stones or giant stones, lithotripsy was selected depending on judgment of the endoscopist.

RESULTS

Endoscopic complete lithotomy was successful in 97.7% (168/172). An accidental disease was observed in 2.9% (5/172). In one patient with the perforated gastrointestinal tract, a surgery was performed but others were mild.

CONCLUSIONS

Common bile duct stones can be endoscopically treated safely with high rate.

Transpancreatic precut papillotomy in patients with difficulty in selective biliary cannulation

BACKGROUND/AIMS

Transpancreatic precut papillotomy (TPPP) is considered as an effective method in patients with difficulty in selective biliary cannulation. However, the use of placing a pancreatic duct stent as a measure against post-ERCP pancreatitis has not been clarified. Here we examine the methods of implementing TPPP safely.

METHODOLOGY

TPPP was conducted on patients with difficulty in selective biliary cannulation. The incidence of pancreatitis was compared between group P(+) in which a spontaneous dislodgement type pancreatic duct stent was placed and group P(-) without a duct stent.

RESULTS

The success rate of biliary cannulation was 83.3% at the first ERCP and finally 93.9%. Post-ERCP pancreatitis was observed in 9.09% of patients. The success rate of placement of pancreatic duct stent in the P(+) group was 100%. The incidence of pancreatitis in the P(+) group was 4.1% and the mean post-ERCP amylase level was 340.071 ±420.035IU/L. The incidence of pancreatitis in the P(-) group was 23.5% and the mean post-ERCP amylase level was 661.250±772.285IU/L. The incidence of pancreatitis and the mean post-ERCP amylase level were significantly lower in the P(+) group (p<0.05).

CONCLUSIONS

In the patients with difficulty in selective biliary cannulation, TPPP is a useful technique for biliary cannulation. The placement of a spontaneous dislodgement type pancreatic duct stent after TPPP may be useful for prevention of post-ERCP pancreatitis.

New cannulation method for pancreatic duct cannulation-bile duct guidewire-indwelling method

The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis. Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice, endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus. Pancreatogram was slightly and insufficiently obtained by injecting the contrast media via the common channel of the duodenal main papilla. We tried to cannulate selectively into the pancreatic duct for a clear image. However, the selective cannulation of the pancreatic duct was difficult because of instability of the papilla. On the other hand, selective cannulation of the bile duct was relatively easily achieved. Therefore, after the imaging of the bile duct, a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted. As a result, selective pancreatic duct cannulation became possible. It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is difficult (“selective pancreatic duct difficult cannulation case”).

Utility of placement of pancreatic duct spontaneous dislodgement stent for prevention of post-ERCP pancreatitis in patients with difficulty in selective biliary cannulation

BACKGROUND/AIMS

To examine the utility of placement of pancreatic duct spontaneous dislodgement stents for prevention of post-ERCP pancreatitis in patients with difficulty in selective biliary cannulation.

METHODOLOGY

The incidence of pancreatitis was compared between the group with P(+) pancreatic duct spontaneous dislodgement stent placed for prevention of post-ERCP pancreatitis and the group without P(-) in patients with difficulty in selective biliary cannulation.

RESULTS

The final success rate of selective biliary cannulation was 94.45%. Post-ERCP pancreatitis was observed at 7.07%. The success rate of placement of pancreatic duct stent in the P(+) group was 99.0%. The incidence of pancreatitis in 99 patients in the P(+) group was 3.0%, that of abdominal pain was 3.0%, that of hyperamylasemia was 16.2%, and the mean post-ERCP amylase level was 353.031 +/- 520.792 IU/L. The incidence of pancreatitis in the P(-) group was 11.1%, that of abdominal pain was 20.2%, that of hyperamylasemia was 33.3%, and the mean post-ERCP amylase level was 541.204 +/- 771.843 IU/L. Comparing between the P(+) group and P(-) group, the incidence of pancreatitis, that of abdominal pain, that of hyperamylasemia and the mean post-ERCP amylase level were significantly decreased in the P(+) group (p<0.05).

CONCLUSION

Placement of pancreatic duct spontaneous dislodgement stent in patients with difficulty in selective biliary cannulation could be useful for prevention of post-ERCP pancreatitis.

Oculocutaneous albinism in the i6 mutant of the medaka fish is associated with a deletion in the tyrosinase gene

Three mutant alleles (i1, i4, and i5) of the tyrosinase gene in the i locus of the medaka fish Oryzias latipes have hitherto been described, all being associated with transposable element insertion. We have recently identified another allele causing a complete albino phenotype in homozygous carriers and named it i6. Sequence comparison between the tyrosinase gene for the i6 allele (Tyr-i6) and the wild-type gene previously obtained (Tyr-i+) revealed three deletions of 8, 44, and 245 bp. The first two deletions reside in an intron and are differences in the number of tandem tetranucleotide repeats that are polymorphic even among wild-type genes, and, thus, not likely to be responsible for the i6 albino phenotype. The largest deletion spans over the last 180 bp of the second intron and the first 65 bp of the third exon. Because of this deletion, the Tyr-i6 gene lacks the branch point sequence and the acceptor site for the second intron, both being considered to be necessary for normal RNA splicing. Therefore, the 245-bp deletion is likely to be responsible for the albino phenotype. With a mutant gene of this type, unlike ones bearing transposable element insertions, the possibility of reversion mutations to the wild-type would be negligible. Therefore, fish having the i6/i6 genotype should serve as superior recipients for the tyrosinase gene in rescue experiments.