Aim To analyze factors involved in procedural failure and to discuss responses to procedural failure by using the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) carried out using a short‐type single‐balloon enteroscope (short SBE) in patients with surgically altered gastrointestinal anatomy. Methods The study sample included patients who underwent ERCP‐related procedures using a short SBE between September 2011 and September 2018 at our hospital. Outcomes, including procedural success rate, were studied retrospectively to analyze the factors involved in procedural failure. Results Analysis included 191 procedures carried out in 121 patients. Procedural success rate was 85.9% with an adverse event rate of 8.4%. Causes of procedural failure included malignant biliary obstruction (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.19–7.25, P = 0.02), first ERCP attempt (OR: 5.32, 95% CI: 1.30–36.30, P = 0.02), and Roux‐en‐Y reconstruction (OR: 0.08, 95% CI: 0.004–0.39, P < 0.001). With regard to the response to failure, in cases of malignant biliary obstruction, reattempted short SBE‐assisted ERCP was difficult because of invasion of the small intestine or papilla. A large number of these cases required alternative treatment (10 of 15 cases, 66.7%) using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound‐guided biliary drainage (EUS‐BD). Conclusion Endoscopic retrograde cholangiopancreatography using a short SBE is safe and effective, with malignant biliary obstruction being a specific cause of failure. Technical proficiency with different modalities, such as PTBD and EUS‐BD, is necessary to respond to failure in these cases.
Objectives We investigated the results of biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and analyzed the factors associated with successful cannulation. Methods The study subjects consisted of patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and endoscopic retrograde cholangiopancreatography using a short-type singleballoon enteroscope at our institution between September 2011 and July 2019. We carried out a retrospective investigation of the outcomes, including assessing the success rate of biliary cannulation, and analyzed the factors associated with successful cannulation. Results In total, 78 patients underwent biliary cannulation of a native papilla. The success rate of biliary cannulation was 80.8% (88.5% when including success on repeated attempts). The success rate of the standard cannulation technique was 60.3%, with the use of advanced cannulation techniques to secure the pancreatic duct providing the same additional effect as a normal anatomy. Adverse events occurred in 9.0% of cases. A multivariate analysis of the Roux-en-Y gastrectomy patients found that cannulation was more likely to be successful in patients in whom the scope could be placed in the retroflex position (odds ratio: 7.88, 95% confidence interval: 2.19-37.77, P<0.001). Conclusions Selective biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had undergone Roux-en-Y gastrectomy was effective and safe. The retroflex position provided a good papilla field of view and improved the success rate of biliary cannulation.
Abstract. Esophageal squamous cell carcinoma (ESCC) is one of the most common types of cancer, and its progression is strongly influenced by the presence of inflammation. Recently, there has been growing interest in the host inflammatory response, and increasing evidence has indicated that the neutrophil-to-lymphocyte ratio (NLR), a useful marker of systemic inflammation, may be an effective prognostic indicator in various types of malignant diseases. In the present study, 260 patients with ESCC were enrolled, including 110 who received chemoradiation therapy (CRT) involving irradiation and chemotherapy of 5-fluorouracil and cisplatin, and 150 received chemotherapy using 5-fluorouracil and cisplatin (FP). The patients of each group were both divided into two groups according to their NLR: High NLR (NLR>3.0) and low NLR (NLR≤3.0). Serum levels of prealbumin and retinol binding protein, which are nutritional parameters, were both significantly inversely correlated with NLR in patients treated with CRT, and patients treated with FP. Levels of CRP, a marker of inflammation, were significantly correlated with NLR, and stimulation indices, markers of immune reactions, were inversely correlated with NLR in both of CRT patients and FP patients. In patients treated with CRT, a partial response was significantly higher in patients with a low NLR and with progressive disease compared to those with a high NLR. In patients treated with FP, a partial response was also significantly higher in patients with a low NLR and with progressive disease compared to those with a high NLR. The overall survival of patients with CRT and FP were both significantly worse in patients with a high NLR than in those with a low NLR. NLR may serve as a useful marker of the tumor response, immune suppression, malnutrition and prognosis upon CRT or FP in patients with locally advanced or metastatic ESCC.
Background and study aims This study aimed to investigate the diagnostic accuracy and utility of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) performed using a Franseen needle on solid pancreatic lesions. Patients and methods This study included 132 consecutive lesions sampled by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) using a 22-G conventional needle and 95 consecutive lesions evaluated by EUS-FNB using a 22-G Franseen needle to evaluate solid pancreatic lesions at our medical center between July 2013 and November 2018. We used propensity-matched analysis with adjustment for confounders. Patient data were analyzed retrospectively. Results Diagnostic accuracy was higher in the Franseen needle group (Group F; 91.6 %, 87 /95) than in the conventional needle group (Group C; 86.3 %, 82 /95), showing no significant difference (P = 0.36). In Group F, diagnostic accuracies for pancreatic head lesions and lesions sampled by transduodenal puncture were 98.0 % (48/49) and 97.9 % (46/47), respectively. These values were significantly higher than values in Group C (P = 0.013, 0.01). Group F displayed a significantly lower number of punctures. In terms of differentiating benign from malignant lesions, Group C showed 85.1 % sensitivity (74/87), 100 % specificity (8/8), 100 % positive predictive value (74/74), and 38.1 % negative predictive value (8/21), compared to values of 90.1 % (73/81), 100 % (14/14), 100 % (73/73), and 63.6 % (14/22), respectively, in Group F. Sensitivity and negative predictive value were better in Group F. Conclusions Franseen needles for EUS-FNB of solid pancreatic lesions offer similar puncture performance at different lesion sites while requiring fewer punctures than conventional needles.
Covered self-expandable metallic stents (CSEMS) may provide palliative drainage for unresectable distal malignant biliary strictures. Laser-cut CSEMS allows easy positioning due to its characteristic of minimal stent shortening. Endoscopic stent removal is sometimes recommended for recurrent biliary obstruction (RBO). However, there are no previous reports of endoscopic removal of laser-cut CSEMS. The current study presents data from 6 patients who were placed a laser-cut CSEMS for unresectable distal malignant biliary strictures, and later endoscopic stent removal was attempted for RBO at the present institute. The duration of stent placement, the procedural success rate, the procedural duration, and accidental complications were evaluated. The mean duration of stent placement was 156±37.9 days (range, 117–205). The procedural success rate was 100%. The mean procedural duration was 11.8±7.5 min (range, 5–24). No complications were reported. Laser-cut CSEMS were safely removed from all patients. The present case report is the first to demonstrate that Endoscopic stent removal of laser-cut CSEMS was safely performed.
Lymphadenopathy may be difficult to diagnose using imaging results alone. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) may help to diagnose and determine the appropriate management of lymphadenopathy. EUS-FNA has been used as a safe and less invasive method for obtaining pathologic specimens from extraluminal lesions using endoscopic ultrasound. The present study evaluated the usefulness of EUS-FNA for lymphadenopathy. Between July 2013 and December 2016, 72 patients undergoing EUS-FNA for lymphadenopathy that could not be diagnosed solely using imaging were included. The present study evaluated the sensitivity, specificity, positive and negative predictive value, overall accuracy, helpfulness in determining the management of lymphadenopathy and EUS-FNA-associated complications. Of the 72 included patients, 8 were diagnosed with benign (inflammatory or reactive) lymphadenopathy. The diagnostic sensitivity, specificity, positive and negative predictive value, and overall accuracy were 95.3, 100, 100, 72.7 and 95.8%, respectively. While EUS-FNA of metastatic nodes identified the origin in the majority of cases, the procedure resulted in a different histopathological diagnosis from the previous image-based diagnosis in 9 patients. Consequently, 2 patients with testicular cancer were administered bleomycin, etoposide, and cisplatin. An individual with GIST was administered imatinib, and a patient with prostate cancer was administered degarelix (antihormon drug). A total of 5 other patients received palliative medicine due to the change in diagnosis. EUS-FNA also helped determine the appropriate cancer management plan in other patients; specifically, based on the cytology of the metastatic lymph node, EUS-FNA helped determine the cancer stage, and to identify recurrence or the primary cancer from which tissue could not be collected. No EUS-FNA-associated symptoms were reported. To conclude, the present study suggested that EUS-FNA of suspected metastatic lymph nodes appears safe and useful for cancer staging and diagnosing recurrence. It may also useful for diagnosing patients whose collection of samples from the original cancer appeared impractical. EUS-FNA for lymphadenopathy that may not be diagnosed with imaging alone may assist in diagnosis and help to determine the appropriate management strategy.
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered gastrointestinal anatomy has been reported to be useful. However, selective biliary cannulation through the papilla is difficult in cases with surgically altered gastrointestinal anatomy. Herein, we report a successful biliary cannulation using a pancreatic duct (PD) stent in patients with Roux‐en‐Y anatomy. A 70‐year‐old man who underwent total gastrectomy with Roux‐en‐Y anatomy was admitted to our hospital with jaundice due to recurrence of gastric cancer. ERCP was performed for biliary drainage. We approached the papilla using a short‐type single‐balloon enteroscope (SIF‐H290; Olympus Medical Systems). Because the papilla was positioned tangentially, it was difficult to adjust the catheter in the direction of the bile duct. As only a PD could be cannulated, we placed a guidewire in the PD. Although we attempted the double‐guidewire technique using a guidewire placed in PD, selective biliary cannulation was difficult. Therefore, we placed a PD stent 5Fr‐5cm (Geenen, Pancreatic Stent Sets, Cook Medical, Bloomington, IN, USA) to assist biliary cannulation. We inserted a catheter crossing the PD stent. With this, selective biliary cannulation was successful. We successfully performed selective biliary cannulation using the PD stent as we were able to fix the papilla, straighten the common channel and the axis of the bile duct, and not restrict scope movement by not using the PD guidewire placement method. This novel technique using a PD stent appears to be useful in patients with surgically altered gastrointestinal anatomy.
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