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Background Although pancreatic duct guidewire placement (P-GW) for achieving selective biliary cannulation is reported to be effective in patients in whom endoscopic retrograde cholangiopancreatography (ERCP) is difficult, this technique entails a possible increased risk of post-ERCP pancreatitis. We conducted a prospective randomized controlled trial to evaluate the prophylactic effect of pancreatic duct stenting on the frequency of post-ERCP pancreatitis in patients who underwent P-GW. Methods Seventy patients who underwent P-GW for achieving selective biliary cannulation were included in this study. Patients were randomly assigned to either the stent group (n = 35) or the no-stent group (n = 35). The pancreatic duct stent used was a 5-Fr, 4-cm-long stent with a single pigtail at the duodenal end (Pit-stent™). The primary endpoint was the frequency of post-ERCP pancreatitis. Results Selective biliary cannulation was achieved in 80% of the stent group and in 94% of the no-stent group (P = 0.15). Post-ERCP pancreatitis occurred in 13% (9 patients; mild). Pancreatic duct stenting was successful in 91% of the stent group. One patient in the stent group developed migration of the stent during the procedure, followed by mild pancreatitis. The frequency of post-ERCP pancreatitis in the stent group was significantly lower than that in the no-stent group (2.9 vs. 23%, relative risk 0.13, confidence interval 0.016, 0.95). Conclusion Pancreatic duct stenting after P-GW for achieving selective biliary cannulation is recommended to reduce the incidence of post-ERCP pancreatitis.

BackgroundTo evaluate the lateral extent of extrahepatic cholangiocarcinoma, the value of cholangioscopy-guided mapping biopsy (CMB) compared with that of fluoroscopy-guided mapping biopsy (FMB) remains unknown. The aim of this study was to compare these two techniques.MethodsIn this prospective, randomized, crossover study, both CMB and FMB techniques were performed for all patients in a randomized order. Target sites for the mapping biopsy were determined based on resection lines of possible surgical procedures. At least two biopsy strokes were attempted at each target site. The primary outcome was the rate of site-based successful biopsies, which was defined as acquisition of epithelium-containing material appropriate for diagnosing benignancy/malignancy from each site, regardless of amount of materials obtained from the same site.ResultsBetween September 2016 and October 2018, 28 patients (16 distal bile duct cancer and 12 perihilar bile duct cancer) were enrolled and divided into two groups of 14 patients: CMB first and FMB first. Although all 118 target sites could be approached using CMB, FMB forceps reached only 71% of them with significantly poor accessibility to the B2/3 confluence. Since several materials were too small and did not contain epithelium, the overall rates of site-based successful biopsies were 78% (92/118) using CMB and 64% (76/118) using FMB (P = 0.031).ConclusionsThe rate of site-based successful biopsies using CMB was significantly higher than that using FMB when evaluated using specimens obtained from several biopsy strokes.

Researchers have examined the possibility of studying pancreatic and biliary flow and using to aid the pathological evaluation of pancreaticobiliary diseases. Recently, a new method using MR imaging (MRI) has been developed for the direct visualization of pancreatic juice flow, based on a spin labeling technique. This technique enables direct visualization of pancreatic or bile duct juice flow and has various clinical applications relating to pancreaticobiliary disease. This review discusses the principle of pancreatic and biliary flow MRI with spin labeling and typical application examples such as the evaluation of the exocrine function of the pancreas in cases of chronic pancreatitis and the visualization of pancreatic juice reflux into the bile duct. Moreover other application is also discussed.

Background Recently, the clinical application of diffusion-weighted magnetic resonance imaging (DWI) has been expanding to abdominal organs. However, only a few studies on gallbladder diseases have been published. The aim of this study was to evaluate the usefulness and limitations of high b-value DWI for gallbladder diseases. Methods A total of 153 patients (mean age 60 ± 15 years, 78 males) who had undergone DWI for evaluating gallbladder wall thickening or polypoid lesions were included in this study. Of these 153 patients, 36 had gallbladder cancer and 117 had benign gallbladder diseases (67 chronic cholecystitis, 44 adenomyomatosis, four cholesterol polyp, one gallbladder adenoma, and one xanthogranulomatous cholecystitis). We evaluated the positive signal rate with DWI and the apparent diffusion coefficient (ADC) value of each disease. Results The positive signal rate with DWI was significantly higher in gallbladder cancer (78 %) than in benign gallbladder diseases (22 %) ( p  < 0.001). The mean ADC value of gallbladder cancer was (1.83 ± 0.69) × 10 −3  mm 2 /s and that of benign gallbladder diseases was (2.60 ± 0.54) × 10 −3  mm 2 /s ( p  < 0.001). Benign gallbladder diseases with acute cholecystitis or a history of that had a higher positive signal rate with DWI ( p  < 0.001) and a lower ADC value ( p  = 0.018) than those without such conditions. Conclusion DWI can contribute to the improvement of the diagnostic capability for gallbladder wall thickening or polypoid lesions by compensating for weaknesses of other modalities by its many advantages, although cases with acute cholecystitis or such history sometimes show false-positive on DWI.

Background The diagnostic efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology may vary greatly depending on the treatment of the samples obtained and the level of proficiency of the cytopathologist or cytoscreener. Methods We prospectively evaluated the diagnostic efficacy of the cell block (CB) method and that of smear cytology using tissue samples obtained in the same needle pass at EUS-FNA in 33 patients with pancreatic tumors, abdominal tumors or swollen lymph nodes. An average of 3.1 passes were applied during the procedure without affirmation by rapid cytology. About half of the material obtained by each single pass was subjected to smear cytology, while the other half was evaluated by the CB method. Four to 12 glass slides were prepared for both Papanicolaou stain and Giemsa stain. The CB sections were prepared using the sodium alginate method and subjected to HE, PAS-AB and immunohistochemical stains. Two pathologists independently made cytological and histological diagnoses. The final diagnosis was based on integration of cytohistological findings, diagnostic imaging, and clinical course. Results The diagnostic accuracy of the CB method and that of smear cytology were 93.9 and 60.6%, respectively (p = 0.003), and their respective sensitivities were 92.0 and 60.0% (p = 0.02). It was easier to make a definite diagnosis of not only malignancies but also benign conditions by the CB method than by the smear method. Conclusion The CB method with immunostaining showed a higher diagnostic yield than smear cytology in patients who had undergone EUS-FNA without rapid on-site cytology.

Objectives Cholangioscopy‐guided mapping biopsy (CMB) is performed for preoperative evaluation of extrahepatic cholangiocarcinoma. The aim of this study was to evaluate the usefulness of CMB using a SpyBite Max and to determine the effectiveness of multiple biopsy strokes from the same site. Methods Between August 2020 and October 2022, 21 patients with extrahepatic cholangiocarcinoma were enrolled in this prospective observational study. The primary outcome was the rate of site‐based successful biopsies, which was defined as the acquisition of epithelium‐containing material appropriate for diagnosing benignity/malignancy from each site. The cumulative success rate of obtaining appropriate materials increased by increasing biopsy strokes from 1 to 4. Results The cholangioscope could be advanced to all 80 target sites. The overall adequate specimen rate was 67% (142/212). The overall rate of site‐based successful biopsies was 83% (66/80). The cumulative success rate of obtaining appropriate materials did not significantly improve by increasing the number of biopsy strokes from 1 (81%) to 4 (86%). Conclusions The biopsy material was obtained for 83% of the required sites. However, repetitive biopsy strokes for the same site did not improve the rate of site‐based successful biopsy. This study was registered in UMIN (UMIN000041530).

We investigated the mode of progression of intraductal papillary-mucinous neoplasm of the pancreas (IPMN) in patients who underwent follow-up in order to elucidate the characteristics of malignancy and to establish an effective treatment strategy. Fifty-one patients with IPMN (branch-duct type, 47; main-duct type, 4) who had undergone follow-up study by endoscopic ultrasonography (EUS) were included (mean follow-up duration, 41.0+/-32.3 months; average number of EUS examinations performed during follow-up, 4.4). Chronological changes in EUS findings and histological findings of resected specimens were evaluated. Of the patients with the branch-duct type, only 2% showed enlargement of the dilated branches. In the main-duct-type group, an increase in size of the main pancreatic duct (MPD) was observed in 75% of the patients. In 14 patients with papillary protrusions, an increase in size and lateral spread was observed in 71% and 43%, respectively. No patients developed invasive cancer. In 15 patients who had thick septum-like structures (TSS), the development of papillary protrusions and that of invasive cancer were observed in 53% and 13%, respectively. Twenty-nine patients who had thin septum-like structures showed no change. Two patients with dense multilocular large cysts and TSS developed invasive cancer without change in the cystic lesions. One patient developed carcinoma with multifocal stromal invasion. Patients with branch-duct type IPMNs without papillary protrusions or TSS are not immediate candidates for surgery. Those who have small papillary protrusions have a benign course. It is recommended that patients with the large branch-duct type with TSS should undergo surgery. Attention should be paid to the entire pancreas when performing follow-up examinations in patients with branch-duct type IPMN, as invasive ductal adenocarcinoma can develop at a site in the pancreas different from that of the IPMN.

Background This study assessed the mechanism of fistula formation in intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Methods A total of 274 patients with IPMN who had been diagnosed by endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography (EUS) at our center were enrolled. The patients with IPMN which had fistula formation into other organs were investigated retrospectively as to (1) clinical prevalence and the organs penetrated by IPMN, (2) analysis of the mechanism of fistula formation by immunohistopathological study, (3) efficacy of EUS in progression assessment, and (4) prognosis. Results Among the subjects, fistula formation into other organs was observed in 18 patients (6.6%) and into 28 organs. There were 7 patients (39%) in whom multiple organs were penetrated. Of 16 patients who had undergone investigation of the expression of mucin markers, 94% had an intestinal-type tumor. Of 9 patients who had undergone surgery or autopsy, 67% showed mechanical penetration without invasion around the fistula. Only papillary protrusions were seen by EUS in 4 of these patients with noninvasive papillary adenocarcinoma showing mechanical penetration. All 5 patients who had pancreatic parenchymal invasion showed a mass with a mixed-echo pattern in addition to papillary protrusions shown by EUS, corresponding to colloid carcinoma. Conclusions There were 2 processes in the development of fistulas in IPMN. Of those patients showing fistula formation, 94% had intestinal-type IPMN, and 67% showed mechanical penetration. Delineation of a mass with the mixed-echo pattern suggested an invasive penetration due to colloid carcinoma.

Endosonography-guided biliary drainage (ESBD) is now gaining acceptance as a useful alternative for the management of obstructive jaundice. 1 At present, ESBD is used mainly to establish an anastomosis between the biliary tree and the duodenum, stomach, jejunum, or esophagus by placing a stent so as to bridge the bile duct and alimentary tract. We herein report a new application of ESBD, that is, its temporary use for gaining access to the bile duct in order to deploy a self-expandable metallic stent (SEMS) via the transhepatic route. In a patient with pylorus stenosis due to advanced gastric cancer with extrahepatic bile duct obstruction caused by nodal metastasis, a plastic stent was placed temporarily by ESBD to bridge the esophagus and the left hepatic duct. Ten days later, the stent was retrieved, leaving a guidewire in the bile duct, and a delivery unit of a SEMS was introduced into the bile duct over the guidewire via the sinus tract. The SEMS was then successfully deployed through the stenosis. No stent was left in the sinus tract. This procedure yields a mature fistula through which a delivery unit can be safely introduced into the bile duct followed by uneventful deployment of a SEMS.

Background Prior Billroth II gastrectomy is an important factor presenting difficulties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. Methods Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls. Results The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no significant differences compared with the control group. Conclusions Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.