ENDOSCOPIC SNARE PAPILLECTOMY FOR TUMORS OF THE MAJOR DUODENAL PAPILLA

Safer procedures for performing endoscopic papillectomy on papillary tumors should be established. Fourteen patients underwent endoscopic papillectomy between January 2000 and February 2007. Before papillectomy, tumors were slightly elevated by submucosal injection of glycerol, followed by semi‐circular mucosal incision of the anal border of the lesion in five cases. In nine cases, balloon‐catheter‐assisted endoscopic snare papillectomy was performed. All patients routinely underwent endoscopic nasobiliary drainage tube placement in the bile duct. A pancreatic stent was inserted only in patients with non‐patent minor papilla. The rate of positive margins was lower in patients who received balloon‐catheter‐assisted papillectomy than in patients who received papillectomy without a balloon catheter. Of three patients with local recurrence, only one patient required surgery. Post‐procedural complications included hemorrhage in eight patients, pancreatitis in one patient, and perforation in one patient. No perforation occurred after submucosal injection and mucosal incision. In three of four patients with early hemorrhage, bleeding was noticed as hemobilia through the nasobiliary drainage tube; this appears to be useful for early diagnosis of bleeding. No pancreatitis occurred in patients with patent minor papilla, suggesting that pancreatic stent placement is unnecessary in patients with patent minor papilla.     

BorrmannⅣ型胃癌超声内镜诊断价值的研究

目的:评价超声内镜(EUS)对 BorrmannⅣ型胃癌的诊断效果。材料与方法:138例胃癌病例术前均经内镜和病理活检检查。其中36例胃镜疑为 BorrmannⅣ型胃癌的病例术前同时做了 EUS 检查,结果与术后外科病理诊断进行对照。结果:胃镜检出的138例胃癌中,Borrmann Ⅰ型、Ⅱ型和Ⅲ型胃癌内镜活检多能明确诊断,第1次活检确诊率达88.5%以上。再次内镜活检取材,97.4%以上的病例能确诊。36例内镜可疑为 BorrmannⅥ型胃癌首次活检14例(38.9%)为粘膜炎症反应,未见癌瘤细胞。虽经再次活检,仍有12例(33.3%)未能获得明确诊断.该型胃癌在 EUS 下声像图常有特征性的变化,表现为大部分或全胃壁弥漫性全层增厚,粘膜下层尤明显,回声减弱。增厚的胃壁并无明显结构紊乱,其层次尚可辨认。根据这一特征,36例内镜疑诊为该型的胃癌病变均行 EUS 检查,均作出了正确的诊断,确诊率达100%。结论:EUS 能显示 BorrmannⅣ型胃癌特征性的变化,用于该型胃癌的诊断,优于内镜及活检检查。     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

ENDOSCOPIC DIAGNOSIS AND TREATMENT OF AMPULLARY NEOPLASM (WITH VIDEO)

Background and aim: For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP. Methods: We conducted a review of studies regarding EP for ampullary neoplasms. Results: Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post‐EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting. Conclusions: EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long‐term follow up after EP are awaited.     

EOSINOPHILIC GASTROENTERITIS WITH PREDOMINANT MUSCULAR LAYER DISEASE: FEATURE OF ENDOSCOPIC ULTRASONOGRAPHY

A 34‐year‐old man was admitted to Kansai‐Denryoku Hospital because of severe epigastric pain and vomiting. Laboratory studies revealed peripheral blood eosinophilia and elevated immunoglobulin E. Endoscopy showed narrowing of the antrum and pylorus with edematous mucosa. Endoscopic ultrasonography (EUS) demonstrated a transmural circumferential thickening of the antrum predominantly in the muscularis propria. The overall thickness of the antrum was 1.2 cm. Mucosal biopsies of the antrum showed a small number of eosinophilic infiltrations. A diagnosis of eosinophilic gastroenteritis with predominant muscular layer disease was made, and predonisone (40 mg/day) was given. Thereafter, symptoms and peripheral eosinophilia resolved rapidly. Repeated endoscopy showed improvement of the narrowing and EUS revealed that the thickness of the antrum improved to 0.7 cm and 0.5 cm at 1 and 3 months later, respectively. Thus, EUS is valuable in evaluating and diagnosing muscular involvement in eosinophilic gastroenteritis with predominant muscular layer disease.     

Interventional EUS for the treatment of pancreatic cancer

Since the curved linear array echoendoscope (linear EUS) was developed in the 1990s, EUS has evolved from EUS imaging, to EUS-guided FNA, and now to EUS-guided fine needle injection (FNI), giving EUS even wider application. This advancement has brought “interventional EUS” into the pancreato-biliary field. Interventional EUS for pancreatic cancer includes delivery of contrast agents, drainage/anastomosis, celiac neurolysis (including ganglion neorolysis), radiofrequency ablation, photodynamic therapy, brachytherapy, and delivery of a growing number of anti-tumor agents. This review will focus on interventional EUS in the treatment of pancreatic cancer.     

PANCREATIC TUBERCULOSIS AND ITS DIAGNOSIS BY ENDOSCOPIC ULTRASONOGRAPHY: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Mass lesions in the head of the pancreas are generally malignant and it is difficult to diagnose benign lesions preoperatively. We describe two patients with pancreatic tuberculosis, who presented with abdominal pain, jaundice and a pancreatic head mass, mimicking cancer. The correct diagnosis could be made by endoscopic ultrasonography (EUS) and EUS‐guided fine‐needle aspiration (FNA) cytology in both patients, precluding the need for surgery. Both patients responded well to anti‐tuberculosis treatment. We conclude that EUS with guided FNA is a useful modality to diagnose pancreatic tuberculosis.     

EDUCATION AND TRAINING FOR ENDOSCOPIC ULTRASONOGRAPHY IN JAPAN

While EUS was developed in 1980 originally for detecting small early stage biliopancreatic malignancies, it has been recently employed in Japan mostly for evaluating gastrointestinal diseases. The main reason for this seems to be the difficulty in understanding biliopancreatic anatomy compared with gastrointestinal diseases in the use of EUS; also because no standard EUS operation has been established for the examination of pancreatobiliary region, although there are several different ways to perform EUS. To promote the use of EUS, we need to establish a standard EUS scanning technique. It is fortunate that the guidebook Standard Imaging Techniques in the Pancreatobiliary Region Using Radial Scanning EUS was published in 2003 and EUS live demonstration seminars have already started at some institutions. These activities are good opportunities for doctors wishing to learn EUS examination procedures. We anticipate that it is necessary to foster a large number of EUS operators to establish effective training and education programs in Japan.     

EUS AND PANCREATIC CYST DRAINAGE: AN UPDATE

Endoscopic drainage has become the primary therapy for pancreatic pseudocysts. Diagnostic endoscopic ultrasound (EUS) has added safety to the procedure and interventional EUS has broadened the indications to non‐bulging lesions. At the same time, more aggressive endoscopic treatment has also made it possible to treat infected pseudocysts and organized pancreatic necrosis. The indications and technique are reviewed in this paper.     

ENDOSCOPIC NECROSECTOMY UNDER DIRECT VISION AFTER ENDOSCOPIC ULTRASOUND‐GUIDED CYSTGASTROSTOMY FOR ORGANIZED PANCREATIC NECROSIS

A 56‐year‐old man was referred for an enlarging pancreatic pseudocyst that developed after severe acute pancreatitis with gallstones. Abdominal ultrasound showed a huge cystic lesion with a large amount of solid high echoic components. Arterial phase contrast‐enhanced computed tomography scan revealed arteries across the cystic cavity. Stents were placed after endoscopic ultrasound‐guided cystgastrostomy; however, the stents were obstructed by necrotic debris, and secondary infection of the pseudocyst occurred. Therefore, the cystgastrostomy was dilated by a dilation balloon, and a forward‐viewing endoscope was inserted into the cystic cavity. Many vessels and a large amount of necrotic debris existed in the cavity. Under direct vision, all necrotic debris was safely removed using a retrieval net and forceps. One year after this procedure, there was no recurrence. Our case indicates that peripancreatic fat necrosis can cause exposure of vessels across/along the cystic cavity, and blind necrosectomy should be avoided.     

INTRADUCTAL ULTRASONOGRAPHY OF THE GALLBLADDER IN APPLICATION OF THE ENDOSCOPIC NASO‐GALLBLADDER DRAINAGE

Background: Although endoscopic naso‐gallbladder drainage (ENGBD) for gallbladder disease is useful, the procedure is difficult and investigations involving many cases are lacking. Furthermore, reports on transpapillary intraductal ultrasonography (IDUS) of the gallbladder using a miniature probe are rare. Methods: A total of 150 patients (119 suspected of having gallbladder carcinoma, 24 with acute cholecystitis (AC), and seven with Mirizzi’s syndrome (MS)) were the subject. (i) ENGBD: We attempted to put ENGBD tube into the GB. (ii) IDUS of the gallbladder: Using the previous ENGBD tube, we attempted to insert the miniature probe into the gallbladder and perform transpapillary IDUS of the gallbladder. In five patients, we attempted three‐dimensional intraductal ultrasonography (3D‐IDUS). Results: (i) ENGBD: Overall success rate was 74.7% (112/150); the rate for the patients suspected of having gallbladder carcinoma was 75.6% (90/119), and was 71.0% (22/31) for the AC and MS patients. Inflammation and jaundice improved in 20/22 successful patients with AC and MS. Success rate was higher when cystic duct branching was from the lower and middle parts of the common bile duct than from the upper part, and was higher when branching was upwards than downwards. (ii) IDUS of the gallbladder: Success rate for miniature probe insertion into the gallbladder was 96.4% (54/56). Lesions could be visualized in 50/54 patients (92.6%). Of these, detailed evaluation of the locus could be performed in 41. In five patients attempted 3D‐IDUS, the relationship between the lesion and its location was readily grasped. Conclusion: IDUS of the gallbladder is superior for diagnosing minute images. Improvement on the device will further increase its usefulness.     

COMPARISON OF THE HEIGHT OF PAPILLARY TUMOR IN INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS BETWEEN MEASURED PREOPERATIVE IMAGES AND RESECTED MATERIAL

The height of the mural nodules and papillary tumors in main pancreatic duct or dilated branch duct is the most important factor for diagnosis of intraductal papillary mucinous neoplasm (IPMN). In this study, the authors compared the height of the papillary lesions and mural nodules between the height of resected tissues and the height detected by the preoperative imaging tools (endoscopic ultrasonography [EUS] and intraductal ultrasonography [IDUS]) in 38 patients with IPMN. In 21 out of 23 cases of adenoma, and in cases with the non‐invasive cancer, the difference of the height of operative and preoperative analysis measured by EUS and IDUS was within 1–2 mm. EUS and IDUS are useful for diagnosis of degree of malignancy in IPMN.     

IMPACT OF ULTRASONOGRAPHY ON DIAGNOSIS OF T1 ESOPHAGEAL CANCER AS A CANDIDATE FOR ENDOSCOPIC MUCOSAL RESECTION

To get the correction information to decide whether endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) should be performed, endoscopic examinations, including multiple modalities such as chromoendoscopy, magnifying endoscopy and ultrasonography, are routinely performed in one or two sessions of endoscopic examination. Ultrasonography provides a cross sectional view of the tumor, which is useful information in the decision between EMR or surgery. The final treatment strategy should be decided according to the histological analysis of the resected specimen.     

NEW DEVICES FOR EUS STUDY

It is likely that new endoscopic ultrasound (EUS)‐guided therapies, particularly those that aim to provide local therapy to a neoplastic lesion, will require more sophisticated instrumentation than currently available. In particular, current linear array echoendoscopes are able to image only in two dimensions. New EUS‐guided interventions to ablate tumors might benefit from the development of echoendoscopes which can provide three‐dimensional (3D) images of tumors or lymph nodes. This paper describes the development of such a system.     

IDUS: DIAGNOSIS OF BILE DUCT CARCINOMA

The main IDUS indications for bile duct carcinomas are the diagnosis of a stenosis of unknown origin and the staging. We review the advantages and limitations of IDUS in these indications.     

A CASE WITH PERFORATION AFTER ENDOSCOPIC BALLOON DILATATION FOR STRICTURE OF MALIGNANT LYMPHOMA

We have experienced a case with perforation after endoscopic balloon dilatation. The patient was diagnosed as having malignant lymphoma in the terminal ileum, and treated with eradication of H. Pylori and chemotherapy. The severe stenosis appeared at the same site of the tumor after the medical treatment. The first dilatation with a 15 mm balloon was successful. The lower small bowel obstruction occurred 14 months after the first balloon dilatation. The second dilatation with an 18 mm balloon was performed. The stricture site was remarkably dilated and could be passed by the scope. Perforation was confirmed because of the complaint of severe abdominal pain. The laparotomy finding showed the hole at the stricture site and remarkable fibrosis without tumorous tissue. The fragility of the tissue, the excessive inflation of the balloon and the insertion of the scope might be causes of the perforation. The case with severe stricture having almost no flexibility should be considered carefully in the determination of treatment procedures for the balloon dilatation.     

Macrocystic serous cystadenoma of the pancreas: importance of co-existent tiny cysts depicted by EUS

The case of a 38-year-old man with an unusual type of serous cystadenoma of the pancreas is reported. A multilocular cystic tumor in the head of the pancreas was detected on abdominal ultrasonography and computed tomography. On endoscopic ultrasonography, the major cysts ranged from 2.0 to 4.5 cm in size. In addition to these large cysts, a few small cysts were detected. Based on these findings, this tumor was diagnosed as a macrocystic type serous cystadenoma. Because endoscopic retrograde pancreatogram showed a compression of the main pancreatic duct around the tumor, and because the size of the tumor had been increasing over a 3-year period, surgical intervention was performed. The resected tumor consisted of macrocysts, with a few small cysts, and was histologically diagnosed as serous cystadenoma. Endoscopic ultrasonography appears to provide an excellent inside image of this unusual tumor, and because of its ability to detect small cystic lesions clearly, it could be useful in the diagnosis of macrocystic serous cystadenoma. Received: February 5, 1999 / Accepted: October 22, 1999     

ENDOSCOPIC NASOBILIARY GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

A 77‐year‐old man was admitted for the treatment of obstructive jaundice and right hypochondralgia with high fever. An abdominal computed tomography revealed common bile duct stones and acute cholecystitis with gallstones. Magnetic resonance cholangiopancreatography revealed stones in the common bile duct. Endoscopic retrograde cholangiopancreatography also revealed stones in the common bile duct, and immediately endoscopic sphincterotomy was performed. After lithotripsy of the bile duct, continuous endoscopic nasogallbladder drainage was performed successfully. There was severe pus in the gallbladder. Next day, the patient was doing well; there was no pain and fever was down.     

RISK MANAGEMENT FOR ENDOSCOPIC TREATMENT FOR COMMON BILE DUCT STONES: ENDOSCOPIC SPHINCTEROTOMY AND ENDOSCOPIC PAPILLARY BALLOON DILATION

Currently, endoscopic treatment for common bile duct stones is widely performed all over the world. Endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) are representative treatments of this modality in Japan. Both of them are much more convenient and much less invasive than surgical operation. These two procedures are also recognized as being relatively safe, but it is also a fact that serious complications may still occur at a certain rate. Bleeding, pancreatitis and duodenal perforation can occur in association with EST, and pancreatitis is the most important issue related to EPBD. To reduce the risk, these procedures should be performed only under the appropriate indications and in an appropriate manner. In addition, several special medications and treatments before and/or after the procedure might also be useful in reducing the risks associated with it.     

Ultrasonographic evaluation in patients with autoimmune-related pancreatitis

Background The concept of autoimmune-related pancreatitis (AIP) has recently been described. It is important to exclude pancreaticobiliary malignancy in patients with AIP who develop distal bile duct strictures. The aim of this study was to evaluate distal common bile duct strictures in AIP patients by endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and contrast-enhanced EUS (ceEUS).Methods Five patients with AIP, encountered from January 2000 through December 2001, underwent EUS, IDUS, and ceEUS, using Levovist as a contrast medium. EUS and ceEUS were used to follow changes in distal bile duct strictures in three of these five patients following a trial of steroid therapy.Results Of the five patients, four had cholestatic biochemical profiles, three were positive for autoantibodies, and three had elevated serum immunoglobulin G (IgG) or IgG4. A diffusely enlarged pancreas, narrowing of the main pancreatic duct (MPD), and strictured common bile duct in the pancreatic head were features common to all patients. Pretherapy EUS or IDUS imaging showed concentric wall thickening of the distal common bile duct causing bile duct stenosis. ceEUS showed diffuse strong enhancement of the thickened bile duct wall, possibly due to inflammation. After the steroid therapy, the stenotic lesions in both the MPD and distal common bile duct were rapidly attenuated, with a decline in biochemical cholestatic enzymes and serum IgG or IgG4 levels.Conclusions On EUS and IDUS imaging, concentric bile duct wall thickening and its strong enhancement by Levovist was characteristic in AIP patients.