Direct peroral cholangioscopy using an ultraslim upper endoscope for biliary lesions.

BACKGROUND: The development of direct peroral cholangioscopy (DPOC) using an ultraslim endoscope simplifies biliary cannulation. The conventional techniques are cumbersome to perform and require advanced skills. The recent introduction of the guidewires and balloons has improved the therapeutic outcomes. Here we describe an effective and easier method for performing DPOC using an ultraslim upper endoscope. METHODS: Indications for DPOC were the presence of stones on follow-up of patients who had previously undergone complete sphincteroplasty, including endoscopic sphincterotomy or endoscopic papillary large balloon dilatation. Fifteen patients underwent DPOC. An ultraslim endoscope was inserted perorally and was advanced into the major papilla. The ampulla of Vater was visualized by retroflexing the endoscope in the distal second portion of the duodenum, and then DPOC was performed using a wire-guided cannulation technique with an anchored intraductal balloon catheter. RESULTS: One patient failed in the treatment due to looping of the endoscope in the fornix of the stomach. Fourteen (93.3%) were successfully treated with our modified DPOC technique. Only one patient (6.7%) experienced an adverse event (pancreatitis) who responded well to conservative management. Residual stones of the common bile duct were completely removed in 3 patients. CONCLUSION: The modified method of DPOC is simple, safe and easy to access the bile duct.

Wire-guided selective cannulation of the bile duct with a sphincterotome: a prospective randomized comparative study with the standard method.

OBJECTIVE: Wire-guided cannulation (WGC) is expected to reduce the incidence of post-ERCP pancreatitis (PEP). Our aim was to compare the incidence of PEP and the success rate of deep biliary cannulation using WGC or the standard cannulation method with contrast injection (STD). MATERIAL AND METHODS: A total of 172 cases with an intact papilla were randomized into the STD group (n = 86) and the WGC group (n = 86). First a trainee endoscopist attempted the cannulation and if it was not successful, an expert endoscopist tried. When the cannulation was not successful within 10 min, the other method was conducted as a second attempt. The primary endpoint was the incidence of PEP and the secondary endpoint was the success rate of selective cannulation. RESULTS: In successful cases, PEP occurred in 6.5% in the STD group and 3.0% in the WGC group in the first attempt. Overall rate of PEP was 6.0% (3, mild; 1, moderate and 1, severe) in the STD group and 2.3% (2, mild) in the WGC group, which were not significantly different. Selective cannulation rate in the first attempt was 73.8% in the STD group and 77.9% in the WGC group. After a crossover, the cannulation was successful in the second attempt in 36.4% and 42.1% and finally in 95.2% and 100% by the STD and WGC method, respectively. CONCLUSIONS: The incidence of PEP tended to be lower in the WGC method compared to the STD method. In addition, all cases of pancreatitis in the WGC group were mild. The success rate of cannulation was comparable between two groups.

Treating bilio-duodenal obstruction: combining new endoscopic technique with 6 Fr stent introducer.

Periampullary cancer may cause not only biliary but also duodenal obstructions. In patients with concomitant duodenal obstructions, endoscopic biliary stenting remains technically difficult and may often require percutaneous transhepatic biliary drainage. We describe a method of metal stent placement via a thin forward-viewing endoscope in patients with simultaneous biliary and duodenal obstruction. In two consecutive patients with biliary and duodenal obstruction due to pancreatic cancer, a new biliary metal stent mounted in a slim delivery catheter was placed via a thin forward viewing endoscope after passage across the duodenal stenosis without balloon dilation. In both patients, with our new placement technique, metallic stents were successfully placed in a short time without adverse events. After biliary stenting, one patient received curative resection and the other received duodenal stenting for palliation. Metallic stent placement with a forward-viewing thin endoscope is a beneficial technique, which can avoid percutaneous drainage in patients with bilio-duodenal obstructions due to periampullary cancer.

Comparison of ultraflex and niti-s stents for palliation of unresectable malignant gastroduodenal obstruction.

AIM: Self-expandable metallic stents are widely used for palliation of malignant gastric outlet obstruction (GOO), but clinical outcomes of different stents have not been compared. Here, we compared outcomes in patients with a GOO receiving either an Ultraflex (UF) or a Niti-S (NS) stent. METHODS: Prospective outcomes in 53 patients receiving palliative placement of an NS stent for symptomatic GOO over a 3-year period were compared with those obtained retrospectively in 31 patients receiving a UF stent in a previous 5-year period. Main outcome measurement was between-group comparison of clinical outcome, complications, and reintervention. RESULTS: Baseline characteristics between the groups were comparable. No difference in technical or clinical success rate was observed. Median procedure time for NS placement was shorter than for UF (15 vs 40 min; P < 0.0001). Complications were more frequent with NS than with UF placement, albeit without statistical significance (16% vs 25%). Although two severe complications occurred in each group, neither was stent related in the NS group. Reintervention was more frequent in the NS group (3% vs 21%; P = 0.0485). Median survival time was 53 versus 88 days for UF versus NS stents, respectively. CONCLUSION: Although no significant difference was seen with regard to feasibility, reintervention was less frequent with UF stents than with NS stents. However, UF stents require much more procedure time, and a complicated and difficult placement procedure. These observations suggest that although NS stents placed using a through-the-scope technique may be more patient friendly than UF stents, further optimization of through-the-scope stents is still required. Further prospective comparison of NS and UF stents in GOO treatment is warranted.

[Successful endoscopic removal of pancreatic catheter after Whipple resection being effective for improving repeated pancreatitis-a case report].

A 54-year-old man had repeated pancreatitis since three years after pylorus-preserving pancreatoduodenectomy (PpPD) and reconstruction by the modified Child method. Since abdominal pain appeared after meals, a pancreatic duct tube was removed endoscopically, which resulted in an improvement. It has been postulated that a pancreatic duct tube, used at the anastomosis between the pancreas and gastrointestinal tract, is spontaneously dislodged or creates a spatial gap with the wall of the main pancreatic duct enough to let the pancreatic juice outflow. However, endoscopic removal of the tube remained in place was significantly effective. We here discussed this case with reference of previous published reports.

Metallic stents for gastric outlet obstruction: reintervention rate is lower with uncovered versus covered stents, despite similar outcomes.

BACKGROUND: Self-expandable metallic stents (SEMSs) are widely used for palliation of malignant gastric outlet obstruction (GOO). A common complication of their use, however, is stent obstruction caused by tumor ingrowth or hyperplasia. The covered SEMS was designed to prevent these problems. OBJECTIVE: We compared the performance of uncovered and covered SEMSs in patients with GOO. DESIGN: A retrospective study, single center. SETTING: A tertiary-referral center. PATIENTS: Sixty patients with symptomatic malignant GOO. INTERVENTIONS: All patients received an uncovered or covered knitted nitinol stent by using the over-the-wire placement procedure. MAIN OUTCOME MEASUREMENT: Comparison of the clinical outcome, complications, and the reintervention rate between uncovered and covered stents. RESULTS: Thirty-one patients (mean [+/-SEM] age 72.2 +/- 2.1 years; 16 men) received uncovered SEMSs, and 29 (mean [+/-SEM] age 70.6 +/- 1.7 years; 17 men) received covered SEMSs. The technical success rate was 100% in both groups. No difference in clinical success was seen (90.3% uncovered group vs 86.2% covered group). Regarding early complications (<1 week), one mild case of pancreatitis from the stent covering the papilla occurred in each group. Late complications included reobstruction, migration, bleeding, stent fracture, and perforation. The occurrence of reobstruction did not differ between the 2 groups (3.2% uncovered group vs 10.3% covered group). No difference in migration (0% uncovered group vs 6.9% covered group) was seen. The uncovered group required less frequent reinterventions for stent reobstruction, migration, or stent fracture (3.2% uncovered group vs 20.7% covered group, P = .0490). The uncovered group had 2 major late complications: bleeding and perforation. All 60 patients died, with a median survival time of 51 days and 62 days, respectively. LIMITATIONS: Small-sized, single-center, retrospective study. CONCLUSIONS: In palliation for malignant GOO, covered stents were associated with a more frequent need for reintervention than uncovered stents, despite similar outcomes and complications. These results require confirmation in a larger randomized comparison.

Gastric emptying in patients with palliative stenting for malignant gastric outlet obstruction.

BACKGROUND/AIMS: Palliative stenting for gastric outlet obstruction (GOO) offers a more rapid resumption of oral intake than surgical gastrojejunostomy. Clinically, delayed gastric emptying is observed less frequently in patients with enteral stenting. The aim of this study was to conduct a functional assessment of gastric emptying after stent placement for GOO using isotope scanning. METHODOLOGY: Gastric emptying was assessed in 14 patients with GOO (4 female, 10 male; mean age 67.9 years; 8 with gastric cancer; 4 with pancreatic cancer; 1 with biliary cancer; 1 with metastasis) and 10 healthy volunteers (2 female, 8 male; mean age 31.5 years). None of the patients had undergone previous stomach surgery. The patients were studied 1 week after stent placement. Scintigraphy was performed for 2 hours following the ingestion of a labeled liquid meal. Gastric retention was evaluated at 2 hours in both groups. RESULTS: All patients underwent successful placement of stents and were able to resume an oral diet. All stents were fully deployed and no migration was seen at the time of the investigation. Retained gastric activity at 120 minutes (RGA120) was significantly greater in patients than in controls (65.4% vs. 27.5%, p=0.0128). Median survival time was 179 days in patients with T1/2 of 120 min or less and 75 days in patients with T1/2 of over 120 min. CONCLUSIONS: The results of our study show that although patients with GOO have resumed oral intake 1 week after stent placement, restoration of gastric emptying is often still incomplete.

Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy.

BACKGROUND: In patients with gastric outlet obstruction (GOO), palliative enteral stenting is a less invasive procedure compared with gastroenterostomy. Most diseases analyzed in previous studies of such stenting were pancreaticobiliary malignancies. METHODS: We reviewed the medical records of patients with GOO secondary to gastric cancer who were admitted to our institution between September 1994 and September 2004. The outcome of stent placement for GOO was compared with the outcome in patients who underwent palliative open gastrojejunostomy during the same period. Enrolled patients from both groups displayed symptomatic GOO. Patients with recurrent gastric cancer were excluded from this study. RESULTS: Twenty-two patients underwent palliative enteral stenting, and 22 patients were subjected to surgical gastrojejunostomy (bypass). There were no significant differences between the two groups regarding patient baseline characteristics. Technical success and clinical success were obtained in 100% and 77.3%, respectively, of both groups. The operating time was shorter in the stent group (30 vs 118 min; P<0.0001). The time from the procedure to the resumption of food intake was shorter in the stent group than in the bypass group (2 days vs 8 days; P<0.0001). An improvement in performance score after the procedure was observed in both groups (stent group; P=0.0264; bypass group; P=0.0235). No significant differences were observed regarding the possibility of discharge. In patients discharged, the median postoperative hospital stays were 19 days and 28 days (P=0.0558). The median survival periods were 65 days and 90 days. Minor complications were observed in 1 patient in the stent group and in 4 in the bypass group. No mortality or severe complications were observed for either group. CONCLUSIONS: Self-expandable metallic stent placement is a safe and efficacious procedure for palliation, with shorter operating time and more prompt restoration of oral intake, compared to surgical alternatives in patients with GOO caused by gastric cancer.

Efficacy of an overtube for reducing the risk of peristomal infection after PEG placement: a prospective, randomized comparison study.

BACKGROUND: With the conventional pull method of PEG placement, there is a significant risk of wound infection from contamination of the gastrostomy catheter as it passes through the oral cavity. This study compared the occurrence of peristomal wound infection associated with PEG placement with and without use of an overtube. METHODS: Consecutive patients with dysphagia were randomized to undergo PEG placement with (Group I) or without (Group II) an overtube. For each patient, the peristomal area was evaluated daily for 1 week after PEG placement. The presence of erythema and of exudate were scored on a scale of 0 to 4; induration was scored on a scale of 0 to 3. Criteria for infection were a maximum combined score of 8 or higher, or the presence of microscopic and microbiologic evidence of suppurating exudate. In each group, cefazolin was administered prophylactically (2 g/d intravenously) for 3 days. For patients who had received an antibiotic(s) before PEG placement, the same antibiotic(s) was used. All procedures in both groups were performed by one of two investigators who used the pull method. RESULTS: A total of 76 patients were randomized; 3 were excluded from analysis, because death occurred within 1 week after the procedure. Two of 3 deaths were procedure-related (aspiration pneumonia in Group I, peritonitis in Group II). Data for 37 patients in Group I and 36 in Group II were analyzed. There was no significant difference between the groups with respect to baseline characteristics. The occurrence of peristomal infection within 1 week of PEG was significantly lower in Group I compared with Group II (2 vs. 12; p = 0.0029). The mean daily combined scores in Group I also were significantly lower than those in Group II ( p < 0.0001), and the median maximum parameter scores in Group I were significantly lower than those in Group II (erythema, p = 0.0062; induration, p = 0.0390; exudate, p < 0.0001), although the nominal significance for induration was removed by correction for the multiple testing of data. One patient excluded from Group II died from sepsis because of procedure-induced peritonitis. Among the 73 enrolled patients, there was no procedure-related mortality or clinically important wound infections that required surgical intervention in either group. CONCLUSIONS: Use of an overtube during PEG placement reduces the risk of peristomal wound infection.

Self-expandable metallic stent placement as palliative treatment of obstructed colorectal carcinoma.

BACKGROUND: Stent placement in palliation of unresectable colon cancer is an alternative to surgical treatment. The through-the-scope stent for the exclusive treatment of colorectal cancer is not available in Japan. This report describes the use of an esophageal stent and the technical modifications required for its success in the treatment of colorectal strictures. We describe various technical strategies for colorectal stent placement and report on the outcomes. METHODS: Medical records of patients who underwent palliative colonic stenting between June 1997 and March 2003 were reviewed retrospectively, and the clinical outcome was evaluated. RESULTS: Insertion of a metallic esophageal stent was attempted in 12 patients (mean age, 73.0 years; 5 male, 7 female). Location of the stricture was in the rectum in 4 patients and in the sigmoid, descending, or transverse segments of the colon in 5, 1, and 2 patients, respectively. Two patients had recurrent colon cancer after surgery. The remaining 10 patients did not undergo surgery. Stent placement was technically successful in 11 patients, giving a technical success rate of 92%. Following successful stent placement, all but 1 patient obtained clinical success, generating a clinical success rate of 83%. Late complications occurred in 4 patients and included 2 migrations, 2 bleeds, and 1 obstruction. The complication rate of the procedure was 33.3%. There was no mortality or severe complications. The median survival period was 120 days. CONCLUSIONS: Stent placement can be considered safe and effective palliation for unresectable colorectal cancer. With technical modification of an esophageal stent, this procedure is now feasible. Stent placement in palliation of unresectable colon cancer is an alternative to surgical treatment. The through-the-scope stent for the exclusive treatment of colorectal cancer is not available in Japan. This report describes the use of an esophageal stent and the technical modifications required for its success in the treatment of colorectal strictures. We describe various technical strategies for colorectal stent placement and report on the outcomes.

PEG with introducer or pull method: a prospective randomized comparison.

BACKGROUND: PEG by the conventional pull method has the potential drawback of being associated with a higher frequency of wound infection, presumably caused by contamination of the gastrostomy catheter as it passes through the oral cavity. This study investigated the occurrence of peristomal wound infection after PEG placement by using the pull and introducer techniques. METHODS: Between September 1999 and May 2002, consecutive patients with dysphagia for whom PEG was recommended were enrolled in the study and randomly assigned to two groups: PEG with the introducer method (Group I) or PEG with the pull method (Group II). The peristomal area of each patient was evaluated on a daily basis for one week after PEG. Erythema and exudate were scored on a scale from 0 to 4 and induration on a scale of 0 to 3. Criteria for infection were a maximum combined score of 8 or higher, or the presence of microscopic and microbiologic evidence of suppurating exudate. In each group, the endoscope was passed once during the procedure, and an antibiotic (piperacillin) was given prophylactically. All procedures were performed by one investigator with the assistance of another physician. RESULTS: Of the 60 patients enrolled, 30 were assigned to each group. PEG was successful in all patients. One patient was excluded from each group because of death (Group I, stroke; Group II, myocardial infarction) within one week of the procedure. Therefore, 58 patients, 29 in each group, were evaluated. There was no significant difference between the groups in terms of clinical parameters (age, gender, disease, performance score, mode of previous feeding, and recent antibiotic exposure). The occurrence of peristomal infection within one week of PEG was lower in Group I (introducer method) (0 vs. 9; p = 0.00094). The mean daily combined scores in Group I were significantly lower than those in Group II. Median of maximum parameter scores in Group I were significantly lower than those in Group II. There were no procedure-related mortalities or clinically significant wound infections that required surgical intervention. CONCLUSIONS: The risk of peristomal wound infection after PEG is lower with the introducer method compared with the pull method.