Management of Pancreatolithiasis: A Nationwide Survey in Japan.

OBJECTIVES: The aim of this study was to assess prevailing treatment of pancreatolithiasis in Japan. METHODS: We surveyed clinical data from 1834 patients (1479 men and 355 women) at 125 hospitals. RESULTS: Extracorporeal shock-wave lithotripsy (ESWL) was performed alone in 103 patients (5.6%), ESWL plus an endoscopic procedure in 446 (24.3%), endoscopic treatment alone in 261 (14.2%), and surgery in 167 (9.1%). Other treatments were given to 358 (19.5%), whereas 499 (27.2%) received no treatment. Symptoms were relieved in 85.7% after ESWL, 80.8% after endoscopic treatment alone, and 92.8% after surgery. Early complication rates within 3 months after ESWL, endoscopic treatment alone, and surgery were 8%, 4.5%, and 27.1%, respectively. Late complications after ESWL, endoscopic procedures alone, and surgery were 1.7%, 2.5%, and 8.2%, respectively. Symptom relief but also early and late complications were greater after surgery than after ESWL and endoscopic treatment. Among 417 patients undergoing ESWL, 61 (14.6%) required surgery, as did 32 (16%) of 200 patients treated endoscopically. Surgery was required less frequently following initial operative treatment (11/164 patients [6.7%]). Nonsurgical initial treatments were chosen more frequently. CONCLUSIONS: First-line treatment of pancreatolithiasis should be ESWL with or without endoscopy because of minimal invasiveness and fewer complications.

Pancreatic neuroendocrine tumor with complete replacement of the pancreas by serous cystic neoplasms in a patient with von Hippel-Lindau disease: a case report.

BACKGROUND: von Hippel-Lindau disease is a dominantly inherited multi-system syndrome with neoplastic hallmarks. Pancreatic lesions associated with von Hippel-Lindau include serous cystic neoplasms, simple cysts, and neuroendocrine tumors. The combination of pancreatic neuroendocrine tumors and serous cystic neoplasms is relatively rare, and the surgical treatment of these lesions must consider both preservation of pancreatic function and oncological clearance. We report a patient with von Hippel-Lindau disease successfully treated with pancreas-sparing resection of a pancreatic neuroendocrine tumor where the pancreas had been completely replaced by serous cystic neoplasms, in which pancreatic function was preserved. CASE PRESENTATION: A 39-year-old female with von Hippel-Lindau disease was referred to our institution for treatment of a pancreatic neuroendocrine tumor. Abdominal computed tomography demonstrated a well-enhanced mass, 4 cm in diameter in the tail of the pancreas, and two multilocular tumors with several calcifications, 5 cm in diameter, in the head of the pancreas. There was complete replacement of the pancreas by multiple cystic lesions with diameters ranging from 1 to 3 cm. Magnetic resonance cholangiopancreatography showed innumerable cystic lesions on the whole pancreas and no detectable main pancreatic duct. Endoscopic ultrasound-guided fine-needle aspiration of the mass in the pancreatic tail showed characteristic features of a neuroendocrine tumor. A diagnosis of pancreatic neuroendocrine tumor in the tail of the pancreas and mixed-type serous cystic neoplasms replacing the whole pancreas was made and she underwent distal pancreatectomy while avoiding total pancreatectomy. The stump of the pancreas was sutured as firm as possible using a fish-mouth closure. The patient made a good recovery and was discharged on postoperative day 9. She is currently alive and well with no symptoms of endocrine or exocrine pancreatic insufficiency 8 months after surgery. CONCLUSIONS: A pancreas-sparing resection should be considered for patients with pancreatic neuroendocrine tumors and complete cystic replacement of the pancreas to preserve quality of life after surgery.

A case of a "wandering" mobile solitary fibrous tumor occurring in the pancreas.

A 73-year-old male with a complaint of abdominal discomfort was examined by abdominal ultrasonography and found to have a hypoechoic mass in the upper abdomen. On abdominal computed tomography (CT), there was a 5-cm, hypervascular mass between the stomach and aorta. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) showed a homogeneous mass with hypointensity on T1-weighted images, accompanied by stenosis of the main pancreatic duct of the pancreatic head. On endoscopic ultrasonography, the mass was depicted as a round homogeneous, hypervascular mass attached to the pancreatic head. Surprisingly, the mass was located on the right side of the aorta on the second CT. Histological examination of the resected specimen showed that the lesion was composed of spindle cells with cord-like arrangement, the features of which were compatible with a mobile solitary fibrous tumor.

Efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stone removal.

BACKGROUND: Endoscopic retrograde cholangiopancreatography is difficult to perform in patients with gastrointestinal tract reconstruction. AIMS: To evaluate the efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stones in patients with gastrointestinal tract reconstruction. METHODS: We conducted a retrospective case series with a comparison to historical controls. During the period 2009-2013, 11 postoperative patients underwent endoscopic papillary large-balloon dilatation (Group A). Procedure efficacy and safety were compared with patients who underwent endoscopic sphincterotomy without endoscopic papillary large-balloon dilatation, who served as historical controls (Group B). RESULTS: Group A consisted of 11 patients (63.6% males, mean age 78±10 years), and Group B consisted of 32 patients (78.1% males, mean age 75±7 years). The stone clearance rate was significantly higher in Group A than in Group B (100% vs. 65.6%, respectively; p<0.05). Median procedure time was significantly shorter in Group A than in Group B (54min vs. 102min, respectively; p<0.05), and the complication rate was not significantly different between groups (18% vs. 15.6%, respectively; p=0.586). CONCLUSION: Endoscopic papillary large-balloon dilatation may be an effective and safe treatment procedure in patients with gastrointestinal tract reconstruction.

Endoscopic papillary large balloon dilation for removal of bile duct stones.

AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study. METHODS: Lithotomy by EPLBD was conducted in 124 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. After endoscopic sphincterotomy, the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter. RESULTS: The success rate of first-time lithotomy was 86.3% (107/124) and the final lithotomy success rate was 100% (124/124). Lithotripsy was needed in 10 of the 124 (13.6%) patients. Adverse events due to the treatment procedure occurred in 6 (4.8%) patients, all of which were mild. Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy. CONCLUSION: It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.

The effect of granulocyte and monocyte adsorptive apheresis on serum cytokine levels in patients with ulcerative colitis.

BACKGROUND: Granulocyte and monocyte adsorptive apheresis (GMA) with an Adacolumn has been reported to be effective as induction therapy in ulcerative colitis (UC). However, the effects of GMA on serial changes in cytokine levels have not been well characterized. We therefore, investigated cytokine levels in UC patients before and after treatment with GMA. A total of 16 patients with active UC, 10 men, and six women, mean age, 42.6 years were included. Fourteen patients had total colitis and two patients had left-sided colitis. The study included nine patients with a chronic intermittent course, six with a chronic continuous course and one with a single episode. The duration of each GMA session was 60 min at a flow rate of 30 mL/min as per study protocol. Serum levels of 17 cytokines were determined simultaneously using a Bio-Plex suspension array system before and after treatment with GMA. Serum interleukin (IL)-10 and macrophage inflammatory protein-1ß levels were increased significantly in UC patients after GMA treatment compared to pre-treatment levels (P < 0.05). In particular, GMA treatment caused a significant increase in serum IL-10 levels compared to pre-treatment in patients with total colitis or with a chronic intermittent UC course. In conclusion, this investigation showed that GMA was associated with a marked increase in serum level of the anti-inflammatory cytokine, IL-10. The rise in circulating IL-10 is interesting, and potentially a significant factor in the efficacy of GMA in patients with inflammatory bowel diseases.

Wire-guided biliary cannulation technique does not reduce the risk of post-ERCP pancreatitis: multicenter randomized controlled trial.

AIM: To evaluate the effect of wire-guided biliary cannulation (WGC) on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS: We investigated the impact of the WGC technique on the incidence of PEP by comparing the conventional cannulation (CC) technique in selective bile duct cannulation during ERCP with a cross-over design in a prospective multicenter randomized controlled trial and the potential risk factors for PEP. This involved six tertiary referral centers and three university hospitals. A total of 322 patients with indications for ERCP requiring selective biliary cannulation were enrolled from April 2008 to March 2009. RESULTS: One hundred and sixty-three patients were assigned to the WGC group and 159 to the CC group. The incidence of PEP was the same between the groups (6.1% vs 6.3%, P = 0.95). Primary successful biliary cannulation was achieved in 136 patients (83%) in the WGC group and in 138 (87%) in the CC group (P = 0.40). The mean time required for primary successful biliary cannulation was 7.4 ± 8.3 min and 7.2 ± 7.9 min, respectively (P = 0.83). Multivariate analysis demonstrated that accidental guidewire insertions and unintended injections of contrast into the main pancreatic duct were the only independent risk factors for PEP (P = 0.001, relative risk [RR]: 8.70, 95% confidence interval [CI]: 2.46-30.81). CONCLUSION: The WGC technique does not reduce the risk of PEP and also does not improve the success rate of selective bile duct cannulation.

Colonic mucosa-associated lymphoid tissue lymphoma.

Colonic mucosa-associated lymphoid tissue (MALT) lymphomas are rare and a definitive treatment has not been established. Solitary or multiple, elevated or polypoid lesions are the usual appearances of MALT lymphoma in the colon and sometimes the surface may reveal abnormal vascularity. In this paper we report our experience with four cases of colonic MALT lymphoma and review the relevant literature. The first patient had a smooth elevated lesion in the rectum and histopathologic examination of the biopsy from the lesion showed centrocyte-like cells infiltrating the lamina propria. Endoscopic ultrasonography (EUS) revealed thickening of the submucosa and muscularis propria. The patient underwent radiation therapy, and 9 months later a repeat colonoscopy showed complete resolution of the lesion. In case 2, colonoscopy showed a polyp in the cecum; the biopsy was diagnostic of MALT lymphoma. EUS detected a hypoechoic lesion confined to the mucosal layer of the colonic wall. The patient underwent endoscopic mucosal resection of the lesion and after 6 years of follow-up there was no evidence of recurrence. The third patient had a sessile elevated lesion in the sigmoid colon for which she underwent sigmoidectomy. Pathological examination of the surgical specimen was suggestive of MALT lymphoma. The last patient had a smooth elevated lesion in the rectum and magnification endoscopy showed irregular vascular pattern. The patient underwent endoscopic submucosal dissection, and biopsy examination showed the tumor to be MALT lymphoma. Although rare, awareness of MALT lymphoma of the colon is important to evaluate the patient appropriately and to plan further management.

Unusual Manifestation of Gastric Helicobacter pylori Infection.

Infection with Helicobacter pylori (HP) is common in many parts of the world. While most patients are asymptomatic, it causes peptic ulcer disease and malignancy in some of them. Other rare conditions have occasionally been reported in association with this infection. We report a case of hypertrophic gastropathy caused by HP in a 52-year-old asymptomatic patient. He was found to have marked enlargement of the gastric mucosal folds on radiological imaging and endoscopy. A gastric mucosal biopsy showed HP colonization associated with neutrophilic inflammation. After exclusion of neoplasia, other infections and infiltrative disorders, HP was thought to be the cause of the gastric fold hypertrophy. The patient responded well to HP eradication therapy, with normalization of the gastric mucosal folds. HP infection should be considered in the differential diagnosis of hypertrophic gastropathy and treated accordingly.

Serial changes in cytokine expression in irritable bowel syndrome patients following treatment with calcium polycarbophil.

BACKGROUND/AIMS: Calcium polycarbophil improves abdominal symptoms in patients with irritable bowel syndrome (IBS). We examined cytokine expression in IBS patients before and after administration of calcium polycarbophil. METHODOLOGY: A total of 24 IBS patients (13 diarrhea type, 11 constipation type; median age, 55 years) were enrolled. Serum levels of high sensitive C-reactive protein (CRP) and 17 cytokines (interleukin [IL]-1ß, -2, -4, 5, -6, -7, -8, -10, -12, -13 and -17; tumor necrosis factor-a [TNF-a]; interferon [IFN]-?; granulocyte colony-stimulating factor [G-CSF]; granulocyte macrophage colony-stimulating factor [GM-CSF]; macrophage inflammatory protein [MIP]-1ß; and macrophage chemo-attractant protein [MCP-1]) were simultaneously determined using a Bio-Plex suspension array system before and 12 weeks after administration of calcium polycarbophil 1,500-3,000mg/day. RESULTS: Serum MCP-1 levels in diarrhea type IBS patients were significantly higher than those in constipation type patients (p<0.05). In IBS patients, no significant changes in serum cytokine levels were observed following calcium polycarbophil administration. In constipation type patients, serum high sensitive CRP levels were significantly lower after treatment than before treatment. CONCLUSIONS: Decreases in serum high sensitive CRP levels following calcium polycarbophil treatment may be involved in the relief of abdominal symptoms in IBS patients; diarrhea type IBS is characterized by increased MCP-1 expression.

Peripheral Blood CD64 Levels Decrease in Crohn's Disease following Granulocyte and Monocyte Adsorptive Apheresis.

Granulocyte and monocyte adsorptive apheresis (GMA) is reportedly useful as induction therapy for Crohn's disease (CD). However, the effects of GMA on CD64 have not been well characterized. We report here our assessment of CD64 expression on neutrophils before and after treatment with GMA in two patients with CD. The severity of CD was assessed with the CD activity index (CDAI). The duration of each GMA session was 60 min at a flow rate of 30 ml/min as per protocol. CD64 expression on neutrophils was measured by analyzing whole blood with a FACScan flow cytometer. In case 1, CD64 levels after each session of GMA tended to decrease compared to pretreatment levels, whereas in case 2, CD64 levels dropped significantly after treatment. The CDAI decreased after GMA in both cases 1 and 2. A significant correlation was noted between CDAI scores and CD64 levels in both cases. In conclusion, GMA reduced blood CD64 levels, which would be an important factor for the decrease of CDAI scores.

Characterization of follicular lymphoma in the small intestine using double-balloon endoscopy.

Follicular lymphomas occur rarely in the gastrointestinal tract, representing only 1-3% of all gastrointestinal tract B-cell non-Hodgkin lymphomas. We describe endoscopic analysis of 3 cases of follicular lymphoma in the small intestine using double-balloon endoscopy. Double-balloon endoscopy revealed multiple nodular lesions and elevated white patches, multiple polypoid lesions, and scattered white polypoid and nodular lesions in the duodenum and small intestine. Fuji Intelligent Chromo Endoscopy demonstrated small, whitish nodules, and narrow-band imaging showed a coiled, elongated vascular pattern within the elevated lesions. These cases are the first follicular lymphomas in the small intestine evaluated using narrow-band imaging or Fuji Intelligent Chromo Endoscopy to be reported.