When compared with bilateral biliary drainage, unilateral biliary drainage is associated with a lower incidence of liver abscess as well as a comparable outcome of stent patency time and complication-free survival. We therefore propose that hilar biliary obstruction can be treated first by unilateral drainage with a metallic stent and by bilateral drainage only in patients who develop cholangitis in the contralateral biliary tree.

Pancreatic cancer is one of the most highly fatal cancers and is generally resistant to chemotherapy. Currently, gemcitabine appears to be the only effective agent for its treatment and is the preferred first-line therapy. However, the clinical impact of gemcitabine remains modest due to a high level of inherent and acquired tumor resistance. We investigated protein expression in gemcitabine-resistant and-sensitive human pancreatic adenocarcinoma cell lines by proteomics. Tumor cell proteins were separated by two-dimensional gel electrophoresis, then the protein spots that showed increased or decreased expression in gemcitabine-sensitive cell lines were identified by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and Western blotting. Nine out of ten proteins showing differential expression in gemcitabine-resistant and-sensitive cell lines were identified, confirming an increase in heat shock protein 27 (HSP27) and a decrease in nucleophosmin (NPM) in the resistant lines. These results suggest that HSP27 and NPM may play a role in the poor response of pancreatic cancer to gemcitabine.

Endoscopic papillectomy is therefore considered to be an effective treatment for patients with a benign-malignant borderline lesion of the major duodenal papilla. This method also has an important clinical impact because it provides an accurate diagnosis, aids in the selection of an appropriate treatment strategy, and reduces unnecessary surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux-en-Y anastomosis. We herein present the results of ERCP for patients with a Roux-en-Y anastomosis using a double-balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux-en-Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle-knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N-butyl-2-cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux-en-Y anastomosis.

The development of DBEs has created the possibility of performing ERCP for patients with Roux-en-Y reconstruction in whom an endoscopic approach has conventionally been believed to be difficult.