BACKGROUND Elobixibat reportedly improves bowel movements in patients with chronic constipation.However,its effect on bowel movements in elderly patients with chronic constipation in clinical settings has not been exa...BACKGROUND Elobixibat reportedly improves bowel movements in patients with chronic constipation.However,its effect on bowel movements in elderly patients with chronic constipation in clinical settings has not been examined.AIM To examine bowel movement frequency and stool form before and after elobixibat administration in elderly patients with chronic constipation at our clinic.METHODS A total of 10 mg elobixibat was administered to 35(<65 years old)patients and 45(≥65 years old)patients with chronic constipation.The frequency of bowel movements and stool forms,assessed using the Bristol Stool Form Scale(BSFS),were compared between the two groups 1 week before and after elobixibat administration.RESULTS In patients aged<65 years with chronic constipation,the pre-elobixibat frequency of bowel movements and BSFS scores were 2.167±0.732 and 2.286±0.742,respectively.After elobixibat administration,the frequency of bowel movements and BSFS scores improved to 2.389±0.502 and 3.995±0.566,respectively,showing a significant improvement in bowel movement status.In patients aged≥65 years with chronic constipation,the pre-elobixibat frequency of bowel movements and BSFS scores were 2.003±0.733 and 2.217±0.758,respectively.After elobixibat administration,the frequency of bowel movements and BSFS scores improved to 4.402±1.346 and 3.800±0.704,respectively,indicating an improvement in bowel movement status(P<0.001).No significant differences were observed in the frequency and improvement status of bowel movements or BSFS scores between patients with chronic constipation aged≥65 years and<65 years.Adverse events due to the administration of elobixibat occurred in 16 cases(20%).No significant differences were found in the incidence of adverse events between patients with chronic constipation aged<65 years(8 cases,22.9%)and those aged≥65 years(8 cases,17.8%).CONCLUSION Elobixibat is effective in improving bowel movement status in patients with chronic constipation.No significant differences were found in the improvement of bowel movement status or the incidence of adverse events between patients with chronic constipation aged<65 years and≥65 years,suggesting that the drug may be safely used in elderly patients.展开更多
AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent ...AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.展开更多
Endoscopic retrograde cholangiopancreatography(ERCP) is an endoscopic procedure with high frequency of accidental symptoms, and particularly some patients who develop and aggravate pancreatitis due to the procedure ma...Endoscopic retrograde cholangiopancreatography(ERCP) is an endoscopic procedure with high frequency of accidental symptoms, and particularly some patients who develop and aggravate pancreatitis due to the procedure may need treatment of surgery or die. Various attempts were performed so far to prevent post-ERCP pancreatitis, however, it is impossible to completely prevent pancreatitis at this time because there are various factors for occurrence of post-ERCP pancreatitis.One of the most frequent causes of post-ERCP pancreatitis is considered to be congestion of pancreatic juice associated with duodenal papilledema after examination or treatment. Recently it is often reported that use of a pancreatic duct stent may prevent occurrence of pancreatitis which occurs because of an increased inner pressure of the pancreatic duct caused by congestion of pancreatic juice associated with duodenal papilledema. However, there are some patients who develop pancreatitis even if treated with the pancreatic duct stent, thus further clarification of the pathology and advancement of the prophylactic method will be needed.展开更多
Bile duct epithelial tumours showing papillary neoplasm in the bile duct lumen are present in the intrahepatic and extrahepatic bile ducts.Clinicopathological images of these tumours are distinctive and diverse,includ...Bile duct epithelial tumours showing papillary neoplasm in the bile duct lumen are present in the intrahepatic and extrahepatic bile ducts.Clinicopathological images of these tumours are distinctive and diverse,including histological images with a low to high grade dysplasia,infiltrating and noninfiltrating characteristics,excessive mucus production,and similarity to intraductal papillary mucinous neoplasm(IPMN)of the pancreas.The World Health Organization Classification of Tumours of the Digestive System in 2010 named these features,intraductal papillary neoplasm of the bile duct(IPNB),as precancerous lesion of biliary carcinoma.IPNB is currently classified into type 1 that is similar to IPMN,and type 2 that is not similar to IPMN.Many of IPNB spreads superficially,and diagnosis with cholangioscopy is considered mandatory to identify accurate localization and progression.Prognosis of IPNB is said to be better than normal bile duct cancer.展开更多
Preoperative biliary drainage(PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will u...Preoperative biliary drainage(PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and Pub Med using the keywords "PBD", "pancreaticoduodenectomy", and "obstructive jaundice". Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.展开更多
AIM To evaluate the short-and long-term results of endoscopic ultrasound-guided transmural drainage(EUS-GTD) for pancreatic fluid collection(PFC) and identify the predictive factors of treatment outcome for walled-off...AIM To evaluate the short-and long-term results of endoscopic ultrasound-guided transmural drainage(EUS-GTD) for pancreatic fluid collection(PFC) and identify the predictive factors of treatment outcome for walled-off necrosis(WON) managed by EUS-GTD alone.METHODS We investigated 103 consecutive patients with PFC who underwent EUS-GTD between September 1999 and August 2015. Patients were divided into four groups as follows: WON(n = 40), pancreatic pseudocyst(PPC; n = 11), chronic pseudocyst(n = 33), and others(n = 19). We evaluated the short-and long-term outcomes of the treatment. In cases of WON, multiple logistic regression analyses were performed to identify the predictor variables associated with the treatment success. In addition, PFC recurrence was examined in patients followed up for more than 6 mo and internal stent removal after successful EUS-GTD was confirmed.RESULTS In this study, the total technical success rate was 96.1%. The treatment success rate of WON, PPC, chronic pseudocyst, and others was 57.5%, 90.9%, 91.0%, and 89.5%, respectively. Contrast-enhanced computed tomography using the multivariate logistic regression analysis revealed that the treatment success rate of WON was significantly lower in patients with more than 50% pancreatic parenchymal necrosis(OR = 17.0; 95%CI: 1.9-150.7; P = 0.011) and in patients with more than 150 mm of PFC(OR = 27.9; 95%CI: 3.4-227.7; P = 0.002).The recurrence of PFC in the long term was 13.3%(median observation time, 38.8 mo). Mean amylase level in the cavity was significantly higher in the recurrence group than in the no recurrence group(P = 0.02).CONCLUSION The reduction of WON by EUS-GTD alone was associated with the proportion of necrotic tissue and extent of the cavity. The amylase level in the cavity may be a predictive factor for recurrence of PFC.展开更多
BACKGROUND:Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting.Although there are some procedures to retrieve the migrated stent,inc...BACKGROUND:Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting.Although there are some procedures to retrieve the migrated stent,including surgical,percutaneous,and endoscopic approaches,endoscopy should be attempted first because it is least invasive.This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.METHODS:Plastic stents that migrated in the bile duct(35 patients)or pancreatic duct(2)were retrieved with endoscopic retrograde cholangiopancreatography.Devices used were snare forceps,a basket catheter,grasping forceps,biopsy forceps,a balloon catheter,and the Soehendra stent retriever.RESULTS:Endoscopic retrieval of migrated stents was performed successfully in 36(97.0%)of the 37 patients.The devices utilized for successful treatment were basket catheter(13 patients),grasping forceps(10),snare forceps(8),balloon catheter(3),biopsy forceps(1),and the Soehendra stent retriever(1).The unsuccessfully treated patient with chronic pancreatitis underwent surgery since the guide wire did not move forward due to bile duct stenosis,and there was also duodenal stenosis.One patient developed mild pancreatitis after withdrawal of the stent;the pancreatitis was relieved with conservative treatment.CONCLUSIONS:Endoscopic retrieval of migrated biliary and pancreatic stents appears to be useful because of its safety and low invasiveness.However,various forceps should be prepared for the retrieval of a migrated stent.展开更多
AIM:To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into t...AIM:To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into the common bile duct.METHODS:Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever,and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes.These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP.All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.RESULTS:No stones were detected by ERCP in any patient,confi rming the results of MRCP.CONCLUSION:When clinical symptoms improve,blood biochemical parameters have normalized,and MRCP shows there are no stones in the common bile duct,it can be considered the stone has spontaneously passed and thus ERCP is not necessary.展开更多
AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study.
Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used...Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy(EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.展开更多
AIM To examine the utility of endoscopic retrograde cholangiopancreatography(ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach.METHODS For 26 cases of biliopancreatic diseases in...AIM To examine the utility of endoscopic retrograde cholangiopancreatography(ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach.METHODS For 26 cases of biliopancreatic diseases in patients with Billroth Ⅱ-reconstructed stomach,ERCP was conducted using a straight-view scope or a retrograde obliqueviewing endoscope.All the cases were patients aiming at selective insertion into the bile duct.One patient aimed at diagnosis,and 25 patients aimed at treatment.The cases in which the endoscope reached the duodenal papilla and anastomosis,and insertion into the bile duct became possible,were considered successful.RESULTS The rate of reaching the duodenal papilla and anastomosis was 84.7%(22/26 patients).Among the cases without reaching the duodenal papilla and anastomosis,there were 2 in which the endoscope did not pass due to tumor-induced duodenal infiltration.In 1 case,the fiber did not reach the duodenal papilla due to long afferent loop.The success rate of insertion into the bile duct in patients in which the endoscope reached the duodenal papilla and anastomosis was 90.9%(20/22 patients),and the success rate of procedures including treatment was 86.3%(19/22 patients).After treatment,mild cholangitis was observed in 1 patient(4.5%,1/22 patients) but relieved conservatively.No other accidental symptom was observed.CONCLUSION It was considered that the ERCP for biliopancreatic diseases in patients with Billroth II-reconstructed stomach will become a less invasive,safe and useful examination and treatment approach.展开更多
AIMTo investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors. METHODSTen consecutive patients with stones in the pancreatic head an...AIMTo investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors. METHODSTen consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents (7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct (CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared. RESULTSEndoscopic therapy was completed in 8 (80%) patients, whereas 2 (20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two (20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six (60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group (6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation (complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo. CONCLUSIONSequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.展开更多
AIM: To investigate whether endoscopic papillary large balloon dilation(EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile ...AIM: To investigate whether endoscopic papillary large balloon dilation(EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A(< 80 years) and group B(≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies(ERCP), and incidence of complications were examined in both groups.RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent(P < 0.05). The success rate of the initial lithotomy was 88.7(94/106)%. The final lithotomy rate was 100(106/106)%. Complications due to treatment procedure occurred in 4.72(5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.展开更多
AIM: To examine whether it is possible to prevent the occurrence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis in patients experiencing difficulties with selective biliary duct cannulation ...AIM: To examine whether it is possible to prevent the occurrence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis in patients experiencing difficulties with selective biliary duct cannulation by pancreatic duct stenting using a looptipped guidewire.METHODS: Procedure success rate, frequency of unintended insertion of the guidewire into side branches of the pancreatic duct, and incidence of procedural accidents were examined using a loop-tipped guidewire(Group A, 20 patients), and a conventional straighttype guidewire(Group B, 20 patients).RESULTS: The success rate of the procedure was 100% in both groups. Unintended insertion of the guidewire into a side branch of the pancreatic duct occurred 0.056 ± 0.23(0-1) times in Group A and 2.3 ±1.84(0-5) times in Group B; thus, unintended insertion of the guidewire into a side branch of the pancreatic duct was seen significantly less frequently in Group A. There were no procedural accidents in Group A, whereas pancreatitis occurred in one Group B patient; however, the difference between the two groups was not statistically significant. The serum amylase level after ERCP was 257.15 ± 136.4(88-628) IU/L in Group A, and 552.05 ± 534.57(101-2389) IU/L in Group B, showing a significantly lower value in Group A. Hyperamylasemia was found in two patients(10%) in Group A, and nine(45%) in Group B, showing a significantly lower value in Group A.CONCLUSION: The results suggest that in patients who experience difficulties with biliary cannulation, the use of a loop-tipped guidewire for pancreatic duct stenting may assist with the prevention of post-ERCP pancreatitis, and thereby to a reduction of the risk of post-ERCP pancreatitis or hyperamylasemia.展开更多
AIM To study the safety of insertion of metallic stents in elderly patients with unresectable distal malignant biliary obstruction.METHODS Of 272 patients with unresectable distal malignant biliary obstruction,184 pat...AIM To study the safety of insertion of metallic stents in elderly patients with unresectable distal malignant biliary obstruction.METHODS Of 272 patients with unresectable distal malignant biliary obstruction,184 patients under the age of 80 were classified into Group A,and 88 subjects aged 80 years or more were classified into Group B.The safety of metallic stent insertion,metal stent patency period,and the obstruction rate were examined in each group.RESULTS In Group B,patients had a significantly worse per-formance status,high blood pressure,heart disease,cerebrovascular disease,and dementia;besides the rate of patients orally administered antiplatelet drugs or anticoagulants tended to be higher(P<0.05).Metallic stents were successfully inserted in all patients.The median patency period was 265.000±26.779(1-965)d;252.000±35.998(1-618)d in Group A and 269.000±47.885(1-965)d in Group B,with no significant difference between the two groups.Metallic stent obstruction occurred in 82 of the 272(30.15%)patients;in 53/184(28.80%)patients in Group A and in 29/88(32.95%)of those in Group B,showing no significant difference between the two groups.Procedural accidents due to metal stent insertion occurred in 24/272(8.8%)patients;in 17/184(9.2%)of patients in Group A and in 7/88(8.0%)of those in Group B,with no significant difference between the two groups,either.CONCLUSION These results suggested that metallic stents can be safely inserted to treat unresectable distal malignant biliary obstruction even in elderly patients aged 80 years or more.展开更多
AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction.METHODS: This prospective, observational, multicenter study included 39 consecutiv...AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction.METHODS: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, selfexpandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline.RESULTS: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients(10.3%) in the form of mild pneumonitis. No other morbidities or mortalitieswere observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients(7.7%) on account of tumor growth.CONCLUSION: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients' quality of life.展开更多
BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cas...BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.展开更多
The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis.Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice,endoscopi...The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis.Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice,endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus.Pancreatogram was slightly and insuff iciently obtained by injecting the contrast media via the common channel of the duodenal main papilla.We tried to cannulate selectively into the pancreatic duct for a clear image.However,the selective cannulation of the pancreatic duct was difficult because of instability of the papilla.On the other hand,selective cannulation of the bile duct was relatively easily achieved.Therefore,after the imaging of the bile duct,a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted.As a result,selective pancreatic duct cannulation became possible.It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is diff icult("selective pancreatic duct diff icult cannulation case").展开更多
AIM: To examine the usefulness of a new tapered metallic stent(MS) in patients with unresectable malignant hilar bile duct obstruction.METHODS: This new tapered MS was placed in 11 patients with Bismuth Ⅱ or severer ...AIM: To examine the usefulness of a new tapered metallic stent(MS) in patients with unresectable malignant hilar bile duct obstruction.METHODS: This new tapered MS was placed in 11 patients with Bismuth Ⅱ or severer unresectable malignant hilar bile duct obstruction, as a prospective study. The subjects were six patients with bile duct carcinoma, three with gallbladder cancer, and two with metastatic bile duct obstruction. Stenosis morphology was Bismuth Ⅱ: 7, Ⅲa: 3, and Ⅳ: 1. UMIN Clinical Trial Registry(UMIN000004758).RESULTS: MS placement was 100%(11/11) successful. There were no procedural accidents. The mean patency period was 208.401 d, the median survival period was 142.000 d, and the mean survival period was 193.273 d. Occlusion rate was 36.4%(4/11); the causes of occlusion were ingrowth and overgrowth in 2 patients each, 18.2%, respectively. Patients with occlusion underwent endoscopic treatment one more time and all were treatable. CONCLUSION: The tapered MS proved useful in patients with unresectable malignant hilar bile duct obstruction because it provided a long patency period, enabled re-treatment by re-intervention, and no procedural accidents occurred.展开更多
文摘BACKGROUND Elobixibat reportedly improves bowel movements in patients with chronic constipation.However,its effect on bowel movements in elderly patients with chronic constipation in clinical settings has not been examined.AIM To examine bowel movement frequency and stool form before and after elobixibat administration in elderly patients with chronic constipation at our clinic.METHODS A total of 10 mg elobixibat was administered to 35(<65 years old)patients and 45(≥65 years old)patients with chronic constipation.The frequency of bowel movements and stool forms,assessed using the Bristol Stool Form Scale(BSFS),were compared between the two groups 1 week before and after elobixibat administration.RESULTS In patients aged<65 years with chronic constipation,the pre-elobixibat frequency of bowel movements and BSFS scores were 2.167±0.732 and 2.286±0.742,respectively.After elobixibat administration,the frequency of bowel movements and BSFS scores improved to 2.389±0.502 and 3.995±0.566,respectively,showing a significant improvement in bowel movement status.In patients aged≥65 years with chronic constipation,the pre-elobixibat frequency of bowel movements and BSFS scores were 2.003±0.733 and 2.217±0.758,respectively.After elobixibat administration,the frequency of bowel movements and BSFS scores improved to 4.402±1.346 and 3.800±0.704,respectively,indicating an improvement in bowel movement status(P<0.001).No significant differences were observed in the frequency and improvement status of bowel movements or BSFS scores between patients with chronic constipation aged≥65 years and<65 years.Adverse events due to the administration of elobixibat occurred in 16 cases(20%).No significant differences were found in the incidence of adverse events between patients with chronic constipation aged<65 years(8 cases,22.9%)and those aged≥65 years(8 cases,17.8%).CONCLUSION Elobixibat is effective in improving bowel movement status in patients with chronic constipation.No significant differences were found in the improvement of bowel movement status or the incidence of adverse events between patients with chronic constipation aged<65 years and≥65 years,suggesting that the drug may be safely used in elderly patients.
基金Supported by The grant from the Japanese Foundation for Research and Promotion of Endoscopy,No.12-042
文摘AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.
文摘Endoscopic retrograde cholangiopancreatography(ERCP) is an endoscopic procedure with high frequency of accidental symptoms, and particularly some patients who develop and aggravate pancreatitis due to the procedure may need treatment of surgery or die. Various attempts were performed so far to prevent post-ERCP pancreatitis, however, it is impossible to completely prevent pancreatitis at this time because there are various factors for occurrence of post-ERCP pancreatitis.One of the most frequent causes of post-ERCP pancreatitis is considered to be congestion of pancreatic juice associated with duodenal papilledema after examination or treatment. Recently it is often reported that use of a pancreatic duct stent may prevent occurrence of pancreatitis which occurs because of an increased inner pressure of the pancreatic duct caused by congestion of pancreatic juice associated with duodenal papilledema. However, there are some patients who develop pancreatitis even if treated with the pancreatic duct stent, thus further clarification of the pathology and advancement of the prophylactic method will be needed.
文摘Bile duct epithelial tumours showing papillary neoplasm in the bile duct lumen are present in the intrahepatic and extrahepatic bile ducts.Clinicopathological images of these tumours are distinctive and diverse,including histological images with a low to high grade dysplasia,infiltrating and noninfiltrating characteristics,excessive mucus production,and similarity to intraductal papillary mucinous neoplasm(IPMN)of the pancreas.The World Health Organization Classification of Tumours of the Digestive System in 2010 named these features,intraductal papillary neoplasm of the bile duct(IPNB),as precancerous lesion of biliary carcinoma.IPNB is currently classified into type 1 that is similar to IPMN,and type 2 that is not similar to IPMN.Many of IPNB spreads superficially,and diagnosis with cholangioscopy is considered mandatory to identify accurate localization and progression.Prognosis of IPNB is said to be better than normal bile duct cancer.
文摘Preoperative biliary drainage(PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and Pub Med using the keywords "PBD", "pancreaticoduodenectomy", and "obstructive jaundice". Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.
文摘AIM To evaluate the short-and long-term results of endoscopic ultrasound-guided transmural drainage(EUS-GTD) for pancreatic fluid collection(PFC) and identify the predictive factors of treatment outcome for walled-off necrosis(WON) managed by EUS-GTD alone.METHODS We investigated 103 consecutive patients with PFC who underwent EUS-GTD between September 1999 and August 2015. Patients were divided into four groups as follows: WON(n = 40), pancreatic pseudocyst(PPC; n = 11), chronic pseudocyst(n = 33), and others(n = 19). We evaluated the short-and long-term outcomes of the treatment. In cases of WON, multiple logistic regression analyses were performed to identify the predictor variables associated with the treatment success. In addition, PFC recurrence was examined in patients followed up for more than 6 mo and internal stent removal after successful EUS-GTD was confirmed.RESULTS In this study, the total technical success rate was 96.1%. The treatment success rate of WON, PPC, chronic pseudocyst, and others was 57.5%, 90.9%, 91.0%, and 89.5%, respectively. Contrast-enhanced computed tomography using the multivariate logistic regression analysis revealed that the treatment success rate of WON was significantly lower in patients with more than 50% pancreatic parenchymal necrosis(OR = 17.0; 95%CI: 1.9-150.7; P = 0.011) and in patients with more than 150 mm of PFC(OR = 27.9; 95%CI: 3.4-227.7; P = 0.002).The recurrence of PFC in the long term was 13.3%(median observation time, 38.8 mo). Mean amylase level in the cavity was significantly higher in the recurrence group than in the no recurrence group(P = 0.02).CONCLUSION The reduction of WON by EUS-GTD alone was associated with the proportion of necrotic tissue and extent of the cavity. The amylase level in the cavity may be a predictive factor for recurrence of PFC.
文摘BACKGROUND:Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting.Although there are some procedures to retrieve the migrated stent,including surgical,percutaneous,and endoscopic approaches,endoscopy should be attempted first because it is least invasive.This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.METHODS:Plastic stents that migrated in the bile duct(35 patients)or pancreatic duct(2)were retrieved with endoscopic retrograde cholangiopancreatography.Devices used were snare forceps,a basket catheter,grasping forceps,biopsy forceps,a balloon catheter,and the Soehendra stent retriever.RESULTS:Endoscopic retrieval of migrated stents was performed successfully in 36(97.0%)of the 37 patients.The devices utilized for successful treatment were basket catheter(13 patients),grasping forceps(10),snare forceps(8),balloon catheter(3),biopsy forceps(1),and the Soehendra stent retriever(1).The unsuccessfully treated patient with chronic pancreatitis underwent surgery since the guide wire did not move forward due to bile duct stenosis,and there was also duodenal stenosis.One patient developed mild pancreatitis after withdrawal of the stent;the pancreatitis was relieved with conservative treatment.CONCLUSIONS:Endoscopic retrieval of migrated biliary and pancreatic stents appears to be useful because of its safety and low invasiveness.However,various forceps should be prepared for the retrieval of a migrated stent.
文摘AIM:To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into the common bile duct.METHODS:Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever,and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes.These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP.All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.RESULTS:No stones were detected by ERCP in any patient,confi rming the results of MRCP.CONCLUSION:When clinical symptoms improve,blood biochemical parameters have normalized,and MRCP shows there are no stones in the common bile duct,it can be considered the stone has spontaneously passed and thus ERCP is not necessary.
文摘AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study.
文摘Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy(EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.
文摘AIM To examine the utility of endoscopic retrograde cholangiopancreatography(ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach.METHODS For 26 cases of biliopancreatic diseases in patients with Billroth Ⅱ-reconstructed stomach,ERCP was conducted using a straight-view scope or a retrograde obliqueviewing endoscope.All the cases were patients aiming at selective insertion into the bile duct.One patient aimed at diagnosis,and 25 patients aimed at treatment.The cases in which the endoscope reached the duodenal papilla and anastomosis,and insertion into the bile duct became possible,were considered successful.RESULTS The rate of reaching the duodenal papilla and anastomosis was 84.7%(22/26 patients).Among the cases without reaching the duodenal papilla and anastomosis,there were 2 in which the endoscope did not pass due to tumor-induced duodenal infiltration.In 1 case,the fiber did not reach the duodenal papilla due to long afferent loop.The success rate of insertion into the bile duct in patients in which the endoscope reached the duodenal papilla and anastomosis was 90.9%(20/22 patients),and the success rate of procedures including treatment was 86.3%(19/22 patients).After treatment,mild cholangitis was observed in 1 patient(4.5%,1/22 patients) but relieved conservatively.No other accidental symptom was observed.CONCLUSION It was considered that the ERCP for biliopancreatic diseases in patients with Billroth II-reconstructed stomach will become a less invasive,safe and useful examination and treatment approach.
文摘AIMTo investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors. METHODSTen consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents (7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct (CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared. RESULTSEndoscopic therapy was completed in 8 (80%) patients, whereas 2 (20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two (20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six (60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group (6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation (complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo. CONCLUSIONSequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.
文摘AIM: To investigate whether endoscopic papillary large balloon dilation(EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A(< 80 years) and group B(≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies(ERCP), and incidence of complications were examined in both groups.RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent(P < 0.05). The success rate of the initial lithotomy was 88.7(94/106)%. The final lithotomy rate was 100(106/106)%. Complications due to treatment procedure occurred in 4.72(5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.
文摘AIM: To examine whether it is possible to prevent the occurrence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis in patients experiencing difficulties with selective biliary duct cannulation by pancreatic duct stenting using a looptipped guidewire.METHODS: Procedure success rate, frequency of unintended insertion of the guidewire into side branches of the pancreatic duct, and incidence of procedural accidents were examined using a loop-tipped guidewire(Group A, 20 patients), and a conventional straighttype guidewire(Group B, 20 patients).RESULTS: The success rate of the procedure was 100% in both groups. Unintended insertion of the guidewire into a side branch of the pancreatic duct occurred 0.056 ± 0.23(0-1) times in Group A and 2.3 ±1.84(0-5) times in Group B; thus, unintended insertion of the guidewire into a side branch of the pancreatic duct was seen significantly less frequently in Group A. There were no procedural accidents in Group A, whereas pancreatitis occurred in one Group B patient; however, the difference between the two groups was not statistically significant. The serum amylase level after ERCP was 257.15 ± 136.4(88-628) IU/L in Group A, and 552.05 ± 534.57(101-2389) IU/L in Group B, showing a significantly lower value in Group A. Hyperamylasemia was found in two patients(10%) in Group A, and nine(45%) in Group B, showing a significantly lower value in Group A.CONCLUSION: The results suggest that in patients who experience difficulties with biliary cannulation, the use of a loop-tipped guidewire for pancreatic duct stenting may assist with the prevention of post-ERCP pancreatitis, and thereby to a reduction of the risk of post-ERCP pancreatitis or hyperamylasemia.
文摘AIM To study the safety of insertion of metallic stents in elderly patients with unresectable distal malignant biliary obstruction.METHODS Of 272 patients with unresectable distal malignant biliary obstruction,184 patients under the age of 80 were classified into Group A,and 88 subjects aged 80 years or more were classified into Group B.The safety of metallic stent insertion,metal stent patency period,and the obstruction rate were examined in each group.RESULTS In Group B,patients had a significantly worse per-formance status,high blood pressure,heart disease,cerebrovascular disease,and dementia;besides the rate of patients orally administered antiplatelet drugs or anticoagulants tended to be higher(P<0.05).Metallic stents were successfully inserted in all patients.The median patency period was 265.000±26.779(1-965)d;252.000±35.998(1-618)d in Group A and 269.000±47.885(1-965)d in Group B,with no significant difference between the two groups.Metallic stent obstruction occurred in 82 of the 272(30.15%)patients;in 53/184(28.80%)patients in Group A and in 29/88(32.95%)of those in Group B,showing no significant difference between the two groups.Procedural accidents due to metal stent insertion occurred in 24/272(8.8%)patients;in 17/184(9.2%)of patients in Group A and in 7/88(8.0%)of those in Group B,with no significant difference between the two groups,either.CONCLUSION These results suggested that metallic stents can be safely inserted to treat unresectable distal malignant biliary obstruction even in elderly patients aged 80 years or more.
文摘AIM: To determine the safety and efficacy of endoscopic duodenal stent placement in patients with malignant gastric outlet obstruction.METHODS: This prospective, observational, multicenter study included 39 consecutive patients with malignant gastric outlet obstruction. All patients underwent endoscopic placement of a nitinol, uncovered, selfexpandable metal stent. The primary outcome was clinical success at 2 wk after stent placement that was defined as improvement in the Gastric Outlet Obstruction Scoring System score relative to the baseline.RESULTS: Technical success was achieved in all duodenal stent procedures. Procedure-related complications occurred in 4 patients(10.3%) in the form of mild pneumonitis. No other morbidities or mortalitieswere observed. The clinical success rate was 92.3%. The mean survival period after stent placement was 103 d. The mean period of stent patency was 149 d and the patency remained acceptable for the survival period. Stent dysfunction occurred in 3 patients(7.7%) on account of tumor growth.CONCLUSION: Endoscopic management using duodenal stents for patients with incurable malignant gastric outlet obstruction is safe and improved patients' quality of life.
文摘BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.
文摘The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis.Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice,endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus.Pancreatogram was slightly and insuff iciently obtained by injecting the contrast media via the common channel of the duodenal main papilla.We tried to cannulate selectively into the pancreatic duct for a clear image.However,the selective cannulation of the pancreatic duct was difficult because of instability of the papilla.On the other hand,selective cannulation of the bile duct was relatively easily achieved.Therefore,after the imaging of the bile duct,a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted.As a result,selective pancreatic duct cannulation became possible.It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is diff icult("selective pancreatic duct diff icult cannulation case").
文摘AIM: To examine the usefulness of a new tapered metallic stent(MS) in patients with unresectable malignant hilar bile duct obstruction.METHODS: This new tapered MS was placed in 11 patients with Bismuth Ⅱ or severer unresectable malignant hilar bile duct obstruction, as a prospective study. The subjects were six patients with bile duct carcinoma, three with gallbladder cancer, and two with metastatic bile duct obstruction. Stenosis morphology was Bismuth Ⅱ: 7, Ⅲa: 3, and Ⅳ: 1. UMIN Clinical Trial Registry(UMIN000004758).RESULTS: MS placement was 100%(11/11) successful. There were no procedural accidents. The mean patency period was 208.401 d, the median survival period was 142.000 d, and the mean survival period was 193.273 d. Occlusion rate was 36.4%(4/11); the causes of occlusion were ingrowth and overgrowth in 2 patients each, 18.2%, respectively. Patients with occlusion underwent endoscopic treatment one more time and all were treatable. CONCLUSION: The tapered MS proved useful in patients with unresectable malignant hilar bile duct obstruction because it provided a long patency period, enabled re-treatment by re-intervention, and no procedural accidents occurred.
