EFFICACY OF LAPAROSCOPIC RADIOFREQUENCY ABLATION FOR HEPATOCELLULAR CARCINOMA COMPARED TO PERCUTANEOUS RADIOFREQUENCY ABLATION WITH ARTIFICIAL ASCITES

Aim: Hepatocellular carcinoma (HCC) nodules close to the liver surface exhibit high recurrence compared to those in distal parts of the liver. Moreover, when nodules remain adjacent to the gastrointestinal tract or gallbladder, severe complications such as perforation of those organs may occur due to invasive therapy. Percutaneous radiofrequency ablation (PRFA) with artificial ascites or laparoscopic radiofrequency ablation (LRFA) are used to treat these patients to avoid complications. The purpose of the present study was to assess the efficacy and safety of these two methods. Methods: Subjects comprised 74 patients (48 men, 26 women; mean age, 68.5 ± 8.0 years; range, 46–89 years) with 86 HCC nodules. PRFA with artificial ascites was carried out for 37 patients (44 nodules) and LRFA was used for 37 patients (42 nodules). Clinical profiles were compared between groups. Results: No significant differences in clinical profiles were found between patients treated by PRFA or LRFA. Mean number of treatments was significantly lower for LRFA (1.0 ± 0.0) than for PRFA (2.1 ± 1.0, P < 0.001). Mean number of PRFA treatments was 2.2 ± 1.0 in patients with HCC nodules >2 cm in diameter, whereas all tumors were completely ablated with only one session of LRFA. The safety margin was significantly wider for LRFA than for PRFA. Conclusion: LRFA is a better treatment option for ablation of HCC nodules >2.0 cm in diameter.     

LAPAROSCOPIC RADIOFREQUENCY ABLATION FOR HEPATOCELLULAR CARCINOMA

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Although the percutaneous approach is less invasive and is considered the first choice, RFA with laparoscopic guidance is highly recommended for patients with a relative contraindication for percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct and heart. Recent advances in laparoscopic ultrasound have widened the indication for laparoscopic ablation. In the present paper, we review the indications, advantages, prognosis and safety of laparoscopic RFA for hepatocellular carcinoma.     

LAPAROSCOPIC ABLATION THERAPY FOR HEPATOCELLULAR CARCINOMA

Laparoscopic ablation therapy is an attractive modality for localized hepatocellular carcinoma. It is an optimal treatment in patients with superficial tumors, tumors adjacent to other vital organs, or tumors difficult to access by percutaneous procedure. Laparoscopic access allows for easier detection and more accurate targeting of the tumor compared with percutaneous access and can minimize complications. In addition, this novel technique is favorable in terms of the length of hospital stay and cost‐effectiveness because it is completed in a single session. Characteristics and therapeutic potential of laparoscopic ablation therapy are summarized and compared with other therapeutic modalities in this review.     

IMPORTANCE OF THE FISTULA TRACT ANGLE IN FISTULA TRACT DISRUPTION IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background : The fistula tract angle formed by percutaneous endoscopic gastrostomy (PEG) was examined. Also, the previous literature on fistula tract disruption is reviewed and the possible influence of the fistula tract angle on fistula tract disruption by non‐endoscopic catheter change is discussed. Methods : A total of 15 patients aged 24–80 years were examined.The fistula tract angle was measured as the angle of elevation between the tangent line at the orifice of the PEG stoma and the longitudinal axis of the catheter. Results : Values of the angle ranged from 56 to 90° (mean 77.6°), with four cases (27%) having angles below 70°.With one case of pan‐peritonitis after catheter insertion at 90°, laparotomy revealed that the angle of the fistula tract was low at 62° and that the catheter had broken through the tract just below the abdominal wall. Conclusion : This study suggests that the fistula tract angle might be a potential risk factor for fistula tract disruption by non‐endoscopic catheter change.     

ENDOSCOPIC IMAGE OF SECONDARY AORTOENTERIC FISTULA

Surgical treatment of abdominal aortic aneurysms by resection of the aneurysm and graft replacement is now an accepted procedure, but this has led to various postoperative complications. One example of this is secondary aortoenteric fistula. The diagnosis of aortoenteric fistula is often difficult to establish. We report a case of aortoenteric fistula that occurred 1 year after resection of the aneurysm and graft replacement. A 69‐year‐old man was admitted to our hospital following a sudden episode of melena. He had undergone aorto‐bifemoral bypass surgery with a prosthetic graft 1 year previously for abdominal aortic aneurysm. Upper gastrointestinal endoscopy and computed tomography scan were performed and aortoenteric fistula as a result of aortic anastomotic pseudoaneurysm, was diagnosed. In the first stage operation, an extra‐anatomic bypass was implanted from the right axillary artery to both femoral arteries. Removal of the graft and aortic stump closure were carried out in the second stage. The patient recovered uneventfully. This case shows the use of endoscopy for early diagnosis of secondary aortoenteric fistula.     

MANAGEMENT AND PROBLEM OF ENDOSCOPIC BILIARY DRAINAGE

Transpapillary biliary drainage has developed as an applied technique of endoscopic retrograde cholangiopancreatography and spread as a routine procedure. Particularly, endoscopic biliary drainage (EBD), which is characterized by physiologic nature, mild invasiveness, and no restriction of life, is a reasonable and efficient method for temporary or permanent biliary drainage. Also, improvements in the stent material, increases in the stent diameter, and advent of metallic stents have solved many problems with EBD. However, despite the improvements in various imaging techniques and development of surgical procedures and multidisciplinary treatment, many old as well as new problems such as the selection of the drainage method, stenting method, stent patency rate, stent material, and concomitant treatments still remain. For a more effective clinical use of EBD, the selection of the optimal drainage method and stent for individual patients and the development of stents and basic clinical research from the viewpoints of concomitant treatments are necessary.     

CURRENT STATUS AND FUTURE EXPECTATIONS FOR ENDOSCOPIC BILIARY DRAINAGE IN 16 HOSPITALS

The authors examined the performance of endoscopic biliary drainage (EBD) in 16 hospitals. The examination was in the form of a questionnaire given between 1 June and 20 July 2005 to clarify the status of 369 patients who had undergone EBD. A total of 124 patients underwent endoscopic nasobiliary drainage (ENBD), 224 patients underwent endoscopic biliary drainage (EBS), and one patient underwent simultaneous ENBD and EBS. With regard to the underlying diseases, 227 patients had malignant disease and 142 had benign disease. A total of 244 patients underwent EBS. Plastic stent (PS) was used in 200 cases, and metal stent (MS) in 44 cases. One stent was used in 89% of cases, two stents in 10%, three or more stents in 1%. Metal stent was used in 44 patients (23 were covered and 21 uncovered) with unresectable biliary stenosis. One stent was used in 33 patients, two stents in 10 patients, and three stents in one patient. For treating middle and inferior common bile duct stenosis, PS having a caliber of 10 Fr is too soft; newer tubes should be developed utilizing materials that provide longer stent patency. Longer patency can be achieved now by applying EBS using a covered MS. Improving the materials will also improve stent flexibility and the smoothness of the coating film. When treating superior common bile duct and porta hepatic bile duct stenosis, the stent is placed in both lobes of the liver.     

ROLE OF ENDOSCOPIC NASOBILIARY DRAINAGE INDICATION AND BASIC TECHNIQUE

Endoscopic nasobiliary drainage (ENBD) plays an important role in the treatment of patients with obstructive jaundice. Nowadays, ENBD is widely performed for not only biliary drainage, but also for gallbladder, pancreatic duct, and pancreatic cyst drainage. Herein is presented the indications for ENBD and its technique.     

ENDOSCOPIC MANAGEMENT OF BILIARY and PANCREATIC DUCTS STRICTURES

Endoscopic treatment is applied to a relatively large number of biliary and pancreatic duct strictures, and is a practical matter. It is essential to select the most appropriate treatment for each lesion. For instance, when treating malignant biliary stricture, accurate diagnosis of whether surgical treatment is required or not is vital; and in choosing a stent for an inoperable case, location of the stricture, with or without anticancer treatment, prognosis, and management of possible post‐stenting re‐stricture must be taken into consideration. For benign strictures, not only short‐term results in mobility and motality, but also decades of long‐term results must be cautiously questioned. Bearing these in mind, we need to accumulate the worldwide data of the treatments and establish a proper treatment guideline.     

MANAGEMENT OF ANTIPLATELET THERAPY FOR ENDOSCOPIC PROCEDURES: OPTIMAL CESSATION PERIOD OF ANTIPLATELET THERAPY FOR JAPANESE

Although antiplatelet agents are widely used for the treatment and prevention of thrombotic diseases, only a few studies have reported the validity of the cessation period prior to endoscopic procedures. In 2002, the American Society for Gastrointestinal Endoscopy (ASGE) published a reference on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, but it should be confirmed as appropriate for use in Asian patients. To evaluate the optimal cessation period of antiplatelet agents prior to endoscopic procedures for Japanese, we have studied: (i) the current clinically adopted cessation period of antiplatelet agents prior to invasive endoscopic procedures in Japan; (ii) the relationship between the cessation period of antiplatelet agents and complications around the invasive endoscopic procedures; (iii) colonic mucosal bleeding time after aspirin ingestion; and (iv) the time course of primary hemostasis after cessation of antiplatelet agents. We conclude that 3 days cessation period for aspirin, 5 days cessation for ticlopidine and 7 days cessation for aspirin + ticlopidine administration should be sufficient for Japanese.     

经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

ENDOSCOPIC STENT DRAINAGE FOR MALIGNANT BILIARY OBSTRUCTION: THE KOREAN EXPERIENCE

Endoscopic biliary drainage (EBD) is the treatment of choice for biliary obstruction caused by unresectable pancreaticobiliary malignancies. Clogging is an unsolved problem of the plastic stent. A self‐expanding metal stent (SEMS) was developed to overcome this limitation. Total resource utilization was reported to be lower with SEMS compared with plastic stents in the West. However, in Korea, the average total cost is estimated to be higher in the metal stent group. The use of SEMS should be indicated if the survival is expected to be more than 3 months. Covered SEMS was introduced to overcome the problem of tumor ingrowth into the uncovered stent. Patency rates for covered SEMS tended to be greater than uncovered SEMS, but the complication rate in covered SEMS was higher than uncovered SEMS due to migration, occlusion of the cystic duct, of a contralateral hepatic duct, or of pancreatic duct. Stents without clogging or migration, with antitumor or biodegradable properties are being investigated. For unresectable hilar cholangiocarcinoma (HC) of Bismuth type III or IV, unilateral percutaneous transhepatic biliary drainage (PTBD) and subsequent internal stent causes less cholangitis and longer patency than EBD or PTBD alone. However, the result with EBD is good if the Bismuth type of biliary obstruction is I or II. Photodynamic therapy may improve survival of patients with unresectable cholangiocarcinoma. Preoperative biliary drainage is not usually necessary except for HC. Procedure‐related complication and inflammation of the operative field resulting from endoscopic nasobiliary drainage or endoscopic retrograde biliary drainage are expected to cause surgical difficulties and to affect postoperative complications.     

ENDOSCOPIC NASOBILIARY DRAINAGE: CURRENT INDICATIONS AND EVALUATION OF THE PRODUCTS

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.     

经内镜胆管内引流治疗恶性胆道梗阻的探讨

为缓解胆道梗阻，对２８例恶性胆道梗阻（ＭＢＯ）患者行经内镜胆管内引流术（ＥＢＤ）。结果２５例（８９％）插管成功，共插管４４次，７Ｆ管３次，１０Ｆ２５次，１２Ｆ１６次。２３例（９２％）减黄有效，ＥＢＤ后第３天胆红素平均下降４６．３％，肝外胆管径平均回缩５８．６％，减黄有效者腹胀迅速消失或减轻。首次插管维持有效引流时间１４１．５±１５１．２天，早、中期并发胆管炎４０％，１年以上生存１７％。结果表明ＥＢＤ减黄效果和症状改善是显著的，胆红素下降与胆管径回缩相平行。认为胆管是否屈曲及乳头括约肌切开术的好坏是ＥＢＤ成败的关键；腹胀再现，有胆道感染症状及Ｂ超见肝外胆管扩张为通管的指征。ＥＢＤ适合高龄或高危人群的ＭＢＯ患者，对延长生存期有重要的价值。     

阵发性室上性心动过速射频消融术前后心率变异性的比较

目的探讨射频消融术(RFCA)后心率变异性(HRV)的改变.方法选择阵发性室上性心动过速患者51例,男27例,女24例,年龄25～48岁,平均(39.5±4.7)岁,其中左侧房室折返性心动过速23例,右侧房室折返性心动过速16例,房室结折返性心动过速12例.应用24h动态心电图观察心率变异性各时域指标(SDNN、SDANN、SDANN Index、RMSSD、PNN50)、频域指标(LFnu、HFnu).结果RFCA术前各指标值比对照组低,术后3d所有HRV的各项频域及时域指标均较RFCA前显著降低,而术后2个月各项指标虽仍较RFCA前降低,但差异无统计学意义.结论射频电流对心脏自主神经有一定的损伤,在术后2个月可基本恢复.     

CLINICAL INVESTIGATION OF UPPER GASTROINTESTINAL HEMORRHAGE AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background: Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG. Patients and Methods: We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement. Results: Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement‐related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement‐related hemorrhage and one patient each with reflux esophagitis and gastric ulcer. Conclusions: Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.     

射频消融左侧旁道有效消融点标准探讨

报道３０例预激综合征左侧旁道射频消融（ＲＦＣＡ）有效和无效消融点放电前的电生理特点。结果表明：①显性旁道有效消融点特征为房室传导时间极短（≤３０ｍｓ），房波和室波间无等电位线，室波等于或超前标测电极室波；②隐匿旁道有效消融点特征为逆传房波紧随室波后，室波和房波间无等电位线，逆传房波等于或超前标测电极房波。认为ＲＦＣＡ中正确识别上述特征有助于提高消融疗效和减少放电次数。     

恶性胆道梗阻的内镜治疗（附93例报告）

７８０例逆行胰胆管造影（ＥＲＣＰ）检查中，发现恶性胆道梗阻１２１例。９３例经内镜胆管引流术，其中经内镜鼻胆管引流术（ＥＮＢＤ）６０例，胆管内引流术（ＥＲＢＤ）３３例（２２例为塑料内置管，１１例为金属支架）。术后临床症状明显改善，无严重并发症     

IMPACT OF ENDOSCOPIC TRANSPAPILLARY NASO‐GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

Aim: To evaluate prospectively the efficacy of endoscopic transpapillary naso‐gallbladder drainage (ETGBD) after endoscopic sphincterotomy (ES) in patients with acute cholecystitis with choledocholithiasis. Patients: Twenty‐six patients with acute cholecystitis and choledocholithiasis, but without pericholecystic liver abscess, were evaluated. After ES and extraction of stones, ETGBD was performed immediately. Results: In 24 of the 26 patients with ES, complete bile duct clearance was achieved. In the other two cases treated with ES, stones could be completely removed in an additional session after ETGBD. ETGBD was successfully performed in 23 patients (88%). In three patients with unsuccessful ETGBD, a percutaneous cholecystostomy (PC) was performed. Of the 23 patients that underwent ETGBD, a positive clinical response at 72 h was seen in 22 (96%) patients. In one patient who did not show a clinical response at 72 h, catheter drainage was continued and a positive clinical response was seen 5 days after the procedure. In three patients treated with PC, a clinical response at 72 h was seen in all cases (100%). No major procedure‐related complications occurred. Conclusions: ETGBD after ES proved useful in the management of acute cholecystitis and choledocholithiasis.