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1.  Endoscopic Ultrasonography-Guided Ethanol Ablation for Small Pancreatic Neuroendocrine Tumors: Results of a Pilot Study 
Clinical Endoscopy  2015;48(2):158-164.
Endoscopic ultrasonography (EUS)-guided ethanol ablation is gaining popularity for the treatment of focal pancreatic lesions. The aim of this study was to evaluate the safety, feasibility, and treatment response after EUS-guided ethanol injection for small pancreatic neuroendocrine tumors (p-NETs).
This was a retrospective analysis of a prospectively collected database including 11 consecutive patients with p-NETs who underwent EUS-guided ethanol injection.
EUS-guided ethanol injection was successfully performed in 11 patients with 14 tumors. The final diagnosis was based on histology and clinical signs as follows: 10 non-functioning neuroendocrine tumors and four insulinomas. During follow-up (median, 370 days; range, 152 to 730 days), 10 patients underwent clinical follow-up after treatment, and one patient was excluded because of loss to follow-up. A single treatment session with an injection of 0.5 to 3.8 mL of ethanol resulted in complete responses (CRs) at the 3-month radiologic imaging for seven of 13 tumors (response rate, 53.8%). Multiple treatment sessions performed in three tumors with residual viable enhancing tissue increased the number of tumors with CRs to eight of 13 (response rate, 61.5%). Mild pancreatitis occurred in three of 11 patients.
EUS-guided ethanol injection appears to be a safe, feasible, and potentially effective method for treating small p-NETs in patients who are poor surgical candidates.
PMCID: PMC4381144  PMID: 25844345
Endosonography; Ethanol; Ablation; Neuroendocrine tumors
2.  Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis 
World Journal of Gastroenterology : WJG  2014;20(44):16582-16595.
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
PMCID: PMC4248201  PMID: 25469026
Endoscopic retrograde cholangiopancreatography; Prevention; Pancreatitis; Pancreas stent; Cannulation; Fistulotomy
3.  A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model 
AIM: To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for one-step endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) in a new experimental biliary dilatation porcine model.
METHODS: A novel dedicated device for one-step EUS-guided biliary drainage system (DEUS) introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation. A self-expandable metal stent, consisting of both uncovered and nitinol-covered portions, was preloaded into DEUS introducer. After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs, EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices.
RESULTS: One-step EUS-BD was technically successful in seven pigs [7/9 (77.8%) as intention to treat] without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic (n = 2) or common hepatic (n = 5) duct. Primary technical failure occurred in two cases that did not show adequate biliary dilatation. In seven pigs with a successful bile duct dilatation, the technical success rate was 100% (7/7 as per protocol). Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min (IQR; 8.9-18.1). There were no immediate procedure-related complications.
CONCLUSION: Modified tapered metal tip and low profile introducer may be technically feasible for one-step EUS-BD in experimental porcine model.
PMCID: PMC4024795  PMID: 24914346
Endoscopic ultrasound; Biliary drainage; Biliary dilation; Feasibility; Complications
4.  Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy 
AIM: To evaluate the success rates, procedural time and adverse event rates of the modified methods in endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS).
METHODS: Twenty-eight patients in a prospective case series who underwent EUS-HGS (phase I). Forty-six patients in a matched case-control study (phase II). The simplified technique for fistula dilation was the primary use of a 4 mm balloon catheter with a stainless steel stylet. The stent deployment was modified by deploying the metal stent inside a bile duct (half of the stent) under EUS and fluoroscopic guidance and gently pulling the echoendoscope after full deployment of the stent inside the echoendoscope channel (remaining portion of the stent) under fluoroscopic guidance. This cohort was compared with a matched historical cohort.
RESULTS: In phase I, the technical and clinical success with the modified method was 96% (27/28) and 89% (24/27 as per-protocol analysis). The overall adverse event rate was 7%. In phase II, there was no difference in technical and clinical success, stent patency and overall adverse events in each group. However, the procedural time (15.3 ± 5.2 min vs 22.3 ± 6.0 min, P < 0.001) and early adverse events (0% vs 26%, P = 0.02) were statistically improved in case cohort compared with control cohort.
CONCLUSION: Compared with the conventional EUS-HGS technique, the procedural time was shorter and early adverse events were less frequent with our simplified and modified technique.
PMCID: PMC4009540  PMID: 24803818
Endoscopic ultrasonography; Biliary drainage; Hepaticogastrostomy; Treatment outcome; Adverse event
5.  Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy 
Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However, up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula, which remains a serious problem and usually requires prolonged hospitalization, or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage, which were endoscopically closed with fibrin glue injection via the necrotic cavity.
PMCID: PMC2760186  PMID: 18932292
Fibrin glue; Pancreatocutaneous fistula; Infected pancreatic necrosis; Pancreatic abscess; Endoscopic necrosectomy
6.  Aortoduodenal fistula and aortic aneurysm secondary to biliary stent-induced retroperitoneal perforation 
Duodenal perforations caused by biliary prostheses are not uncommon, and they are potentially life threatening and require immediate treatment. We describe an unusual case of aortic aneurysm and rupture which occurred after retroperitoneal aortoduodenal fistula formation as a rare complication caused by biliary metallic stent-related duodenal perforation. To our knowledge, this is the first report describing a lethal complication of a bleeding, aortoduodenal fistula and caused by biliary metallic stent-induced perforation.
PMCID: PMC2712183  PMID: 18494067
Stents; Retroperitoneal perforation; Aortic aneurysm; Fistula
7.  Ampullary adenomyoma presenting as acute recurrent pancreatitis 
Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature, ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore, it is frequently treated with extensive surgery. To our knowledge, this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.
PMCID: PMC4395647  PMID: 17569131
Ampulla; Adenomyoma; Acute recurrent pancreatitis; Endoscopic resection
8.  Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation 
Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.
PMCID: PMC4146936  PMID: 17457983
Liver abscess; Gallbladder perforation; Endoscopic stent placement; Cholecystohepatic communication
9.  Forward-viewing endoscopic ultrasound-guided NOTES interventions: A study on peritoneoscopic potential 
AIM: To evaluate the feasibility of diagnostic and therapeutic transgastric (TG) peritoneoscopic interventions with a forward-viewing endoscopic ultrasound (FV-EUS).
METHODS: This prospective endoscopic experimental study used an animal model. Combined TG peritoneoscopic interventions and EUS examination of the intra-abdominal organs were performed using an FV-EUS on 10 animal models (1 porcine and 9 canine). The procedures carried out include EUS evaluation and endoscopic biopsy of intraperitoneal organs, EUS-guided fine needle aspiration (EUS-FNA), EUS-guided radiofrequency ablation (EUS-RFA), and argon plasma coagulation (APC) for hemostatic control. The animals were kept alive for 7 d, and then necropsy was performed to evaluate results and complications.
RESULTS: In all 10 animals, TG peritoneoscopy, followed by endoscopic biopsy for the liver, spleen, abdominal wall, and omentum, was performed successfully. APC helped control minor bleeding. Visualization of intra-abdominal solid organs with real-time EUS was accomplished with ease. Intraperitoneal EUS-FNA was successfully performed on the liver, spleen, and kidney. Similarly, a successful outcome was achieved with EUS-RFA of the hepatic parenchyma. No adverse events were recorded during the study.
CONCLUSION: Peritoneoscopic natural orifice transluminal endoscopic surgery (NOTES) interventions through FV-EUS were feasible in providing evaluation and performing endoscopic procedures. It promises potential as a platform for future EUS-based NOTES.
PMCID: PMC3819553  PMID: 24222961
Forward-viewing endoscopic ultrasound; Oblique-viewing endoscopic ultrasound; Endoscopic ultrasound guided intervention; Peritoneoscopy; Natural orifice transluminal endoscopic surgery
10.  Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique 
AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model.
METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope.
RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction.
CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.
PMCID: PMC3683683  PMID: 23801837
Natural orifice transluminal endoscopic surgery; Endoscopy; Pigs; Aanastomosis
11.  Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents 
AIM: To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with a fully covered self-expandable metallic stent (FCSEMS).
METHODS: From April 2009 to August 2010, 15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography (ERCP) were included. These 15 patients consisted of 8 men and 7 women and had a median age of 61 years (range: 30-91 years). The underlying causes of the distal malignant biliary obstruction were pancreatic cancer (n = 9), ampulla of Vater cancer (n = 2), renal cell carcinoma (n = 1), advanced gastric cancer (n = 1), lymphoma (n = 1), and duodenal cancer (n = 1).
RESULTS: The technical success rate of EUS-CDS with an FCSEMS was 86.7% (13/15), and functional success was achieved in 100% (13/13) of those cases. In two patients, the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct. The mean duration of stent patency was 264 d. Early adverse events developed in three patients (3/13, 23.1%), including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient. During the follow-up period (median: 186 d, range: 52-388 d), distal stent migration occurred in four patients (4/13, 30.8%). In 3 patients, the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.
CONCLUSION: EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.
PMCID: PMC3436062  PMID: 22969210
Bile duct obstruction; Drainage; Endosonography; Self-expandable metallic stent; Neoplasms
12.  Efficacy and Safety of Pancreatobiliary Endoscopic Procedures during Pregnancy 
Gut and Liver  2015;9(5):672-678.
Endoscopic therapy with endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective diagnostic and therapeutic tool for biliary and pancreatic disorders during pregnancy. In this report, we describe our experiences with pancreatobiliary endoscopic procedures during pregnancy.
We reviewed ERCP and endoscopic ultrasonography (EUS) procedures that were performed at a single tertiary care referral center between January 2002 and October 2013. Medical records were reviewed for the procedure indication, the duration of fluoroscopy, postprocedure complications, etc. Pregnancy outcomes and fetal complications were identified by chart review and phone calls to patients.
A total of 10 ER-CPs and five EUSs were performed in 13 pregnant patients: four of whom underwent the procedure in the first trimester, eight in the second trimester, and one in the third trimester. Indications for endoscopic therapy included gallstone pancreatitis, obstructive jaundice with common bile duct (CBD) stone, asymptomatic CBD stone, pancreatic cyst, choledochal cyst, and acute cholecystitis. Only one patient had a complication, which was postprocedural hyperamylasemia. Two patients underwent an artificial abortion, one according to her own decision and the other due to an adverse drug reaction.
ERCP seems to be effective and safe for pregnant women. Additionally, EUS can be an alternative to ERCP during pregnancy.
PMCID: PMC4562786  PMID: 26087783
Cholangiopancreatography; endoscopic retrograde; Endosonography; Pregnancy; Fetus
13.  Evaluation of the Feasibility and Efficacy of Forward-Viewing Endoscopic Ultrasound 
Gut and Liver  2015;9(5):679-684.
We aimed to evaluate the feasibility and efficacy of a forward-viewing linear endoscopic ultrasound (FV-EUS) in diagnostic EUS procedures compared to standard oblique-viewing EUS (OV-EUS).
This study was a prospective, randomized study that permitted crossover. Fifty-one patients with subepithelial pancreatobiliary and upper gastrointestinal lesions underwent FV-EUS and OV-EUS sequentially, in random order. The EUS visualization was performed by a novice endosonographer, and the image quality of specific lesions was scored by an expert endosonographer. If fine-needle aspiration (FNA) was indicated, it was performed using both echoendoscopes by an expert endosonographer.
Both of the EUS procedures had similar visualization times and image quality. In general, the visualization time was inversely related to the diameter of the specific lesions. In subepithelial lesions of the stomach and duodenum, the visualization time (98.8±62.2 seconds vs 139.0±66.6 seconds, p=0.008) and image quality (4.1±1.3 vs 3.3±1.7, p=0.02) of FV-EUS were significantly superior to OV-EUS. FV-EUS-guided FNA of pancreatic masses was successful in seven patients (87.5%).
FV-EUS may increase the ease of access to gastrointestinal subepithelial lesions compared to conventional OV-EUS. The performance of FV-EUS for evaluating pancreatobiliary diseases and performing interventions was comparable to conventional OV-EUS.
PMCID: PMC4562787  PMID: 26087791
Endoscopic ultrasound guided intervention; Forward-viewing endoscopic ultrasound; Oblique-viewing endoscopic ultrasound
14.  Peroral Direct Cholangioscopic-Guided Biopsy and Photodynamic Therapy Using an Ultraslim Upper Endoscope for Recurrent Hepatocellular Carcinoma with Intraductal Tiny Nodular Tumor Growth 
Gut and Liver  2010;4(3):398-401.
Bile-duct invasion is rare in patients with hepatocellular carcinoma (HCC). We report a case that received peroral direct cholangioscopy (PDCS)-guided endoscopic biopsy and photodynamic treatment (PDT) for recurrent HCC with intraductal tiny nodular tumor growth. A 64-year-old woman presented with recurrent right upper-quadrant pain. Six months previously she had been diagnosed with HCC with bile-duct invasion in the right anterior segment and had received right anterior segmentectomy. On pathological examination, the margin of resection was clear, but macroscopic bile-duct invasion was noted. On admission, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed a 0.5-cm-sized polypoid mass at the hilar portion. ERCP-guided biopsy failed, and an ampullary stricture was noted. PDCS-guided endoscopic biopsy was thus performed, and histopathology of the retrieved specimen revealed HCC. The patient submitted to PDT. There was no procedure-related complication. After 1 month of PDT the polypoid lesion and scar change at the hilar lesion had disappeared.
PMCID: PMC2956356  PMID: 20981221
Peroral direct cholangioscopy; Photodynamic treatment; Recurrent hepatocellular carcinoma; Intraductal growth
15.  EUS-Guided Multitransgastric Endoscopic Necrosectomy for Infected Pancreatic Necrosis with Noncontagious Retroperitoneal and Peritoneal Extension 
Gut and Liver  2010;4(1):140-145.
Endoscopic necrosectomy was introduced as a safe and effective treatment modality for infected pancreatic necrosis. Although there have been many reports of endoscopic drainage of retroperitoneal pancreatic necrosis, the optimal endoscopic management of pancreatic necrosis extending to the noncontagious retroperitoneal and peritoneal spaces has yet to be established. We report herein a patient with infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension who was treated successfully by endoscopic ultrasound (EUS)-guided multiple cystogastrostomy and endoscopic necrosectomy. EUS-guided multitransgastric necrosectomy may be technically feasible and effective for the management of infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension that demonstrates suitable anatomy. Further studies to assess the efficacy and safety of this technique are needed before its routine clinical use can be recommended.
PMCID: PMC2871603  PMID: 20479929
Infected pancreatic necrosis; Pancreatitis; Endoscopic necrosectomy; Endoscopic ultrasound; Transmural drainage
16.  Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy 
AIM: To compare small sphincterotomy combined with endoscopic papillary large balloon dilation (SES + ELBD) and endoscopic sphincterotomy (EST) for large bile duct stones.
METHODS: We compared prospectively SES + ELBD (group A, n = 27) with conventional EST (group B, n = 28) for the treatment of large bile duct stones (≥ 15 mm). When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy.
RESULTS: No significant differences were observed in the mean largest stone size (A: 20.8 mm, B: 21.3 mm), bile duct diameter (A: 21.4 mm, B: 20.5 mm), number of stones (A: 2.2, B: 2.3), or procedure time (A: 18 min, B: 19 min) between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B (P = 0.473). Mechanical lithotripsy was required for stone removal in nine of 27 patients (33%) in group A and nine of 28 patients (32%, P = 0.527) in group B.
CONCLUSION: SES + ELBD did not show significant benefits compared to conventional EST, especially for the removal of large (≥ 15 mm) bile duct stones.
PMCID: PMC2744186  PMID: 19750573
Sphincterotomy; Endoscopic; Balloon dilatation; Cholelithiasis; Lithotripsy
17.  Endoscopic Management of Bile Leakage after Liver Transplantation 
Gut and Liver  2015;9(3):417-423.
Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks.
Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed.
In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases.
ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.
PMCID: PMC4413977  PMID: 25717048
Cholangiopancreatography; endoscopic retrograde; Bile leakage; Liver transplantation
18.  Factors Affecting Tumor Ablation during High Intensity Focused Ultrasound Treatment 
Gut and Liver  2013;8(4):433-437.
High intensity focused ultrasound (HIFU) utilizes a targeted extracorporeal focused ultrasound beam to ablate neoplastic pancreatic tissue. We used an in vitro model to examine the effects of bone, metallic stents, plastic stents, metal plates, and cyst-like lesions on HIFU treatment.
HIFU was delivered to the phantom models implanted with foreign bodies, and the location, shape, and size of the ablated zones were evaluated.
Bone and metallic plates reflected the ultrasound beam, shifting the ablation zone from the focal zone to the prefocal area. In the phantoms containing metal stent, plastic stent, and cyst, most of the ablative energy was reflected to the prefocal area by the surface, with the remainder penetrating through the phantom. The area of the ablated margins was significantly larger in size and volume than the intended focal ablation zone.
During HIFU therapy, artificial or anatomical barriers could affect the direction of the ultrasound beams, shifting the ablation zone from the focal area to a prefocal site with a larger than expected ablation zone. These factors should be considered prior to HIFU treatment for pancreatic tumors because they could limit ablation success, in addition to causing complications.
PMCID: PMC4113055  PMID: 25071910
High-intensity focused ultrasound ablation; Cysts; Metal stent; Phantom
19.  Fiducial Placement for Stereotactic Body Radiation Therapy under Only Endoscopic Ultrasonography Guidance in Pancreatic and Hepatic Malignancy: Practical Feasibility and Safety 
Gut and Liver  2013;8(1):88-93.
Stereotactic body radiation therapy (SBRT) for gastrointestinal malignancies requires the placement of fiducials to guide treatment delivery. This study aimed to determine the safety and technical feasibility of endoscopic ultrasonography (EUS)-guided fiducial placement for SBRT.
From November 2010 to August 2012, 32 consecutive patients who were scheduled to receive SBRT for pancreatic and hepatic malignancies were referred for EUS-guided fiducial placement. Primary outcome measurements included technical success, the fiducial migration rate, and procedural complications.
All 32 patients had successful fiducial placement under EUS guidance. The mean number of fiducials placed per patient was 2.94±0.24 (range, 2 to 3 seeds). Spontaneous fiducial migration was noted in one patient (3.1%). Of the 32 patients with fiducials placed, 29 patients (90.6%) successfully underwent SBRT. One patient (3.1%) developed mild pancreatitis, requiring a 2-day prolonged hospitalization after fiducial placement. Five patients (15.6%) underwent same-session, EUS-guided fine needle aspiration for histologic confirmation at the time of fiducial placement, without any procedure-related complication.
EUS-guided fiducial placement is a safe and technically feasible technique for preparing patients with both pancreatic and hepatic malignancies for SBRT. The fiducial markers facilitate safe and accurate targeting of the tumor during SBRT.
PMCID: PMC3916693  PMID: 24516706
Fiducial markers; Endosonography; Radiosurgery; Pancreatic neoplasms; Liver neoplasms
20.  Histological Changes in the Bile Duct after Long-Term Placement of a Fully Covered Self-Expandable Metal Stent within a Common Bile Duct: A Canine Study 
Clinical Endoscopy  2014;47(1):84-93.
To date, it has been difficult to determine the optimal stenting duration of a fully covered self-expandable metal stent (FCSEMS) in a benign biliary stricture. The purpose of this study was to identify the histopathological changes in a bile duct resulting from long-term placement of a FCSEMS.
An FCSEMS was inserted into the common bile duct of 12 canines, and the animals were divided into four groups. Posteuthanasia, necropsy was performed to examine the histopathological changes in the bile ducts after 1, 3, 6, and 9 months.
The results of necropsy showed that the covered membranes of the FCSEMSs were intact and easily removed from the bile ducts in 11 of the canines. Severe epithelial hyperplasia of the stented bile duct and epithelial ingrowth into the stent occurred in one animal (from the 3-month group). On histopathological examination, mild inflammatory changes were observed in the stented bile ducts, and there was no significant difference between the four groups. Among the 12 animals, five had de novo stricture.
An FCSEMS can be inserted into the bile duct without severe histopathological changes up until 9 months. However, a de novo stricture and severe epithelial hyperplasia relating to the stent insertion might occur.
PMCID: PMC3928498  PMID: 24570888
Stents; Common bile duct; Common bile duct disease; Cholangiopancreatography, endoscopic retrograde; Dogs
21.  Comparison between Midazolam Used Alone and in Combination with Propofol for Sedation during Endoscopic Retrograde Cholangiopancreatography 
Clinical Endoscopy  2014;47(1):94-100.
Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable procedure that requires adequate sedation for its successful conduction. We investigated the efficacy and safety of the combined use of intravenous midazolam and propofol for sedation during ERCP.
A retrospective review of patient records from a single tertiary care hospital was performed. Ninety-four patients undergoing ERCP received one of the two medication regimens, which was administered by a nurse under the supervision of a gastroenterologist. Patients in the midazolam (M) group (n=44) received only intravenous midazolam, which was titrated to achieve deep sedation. Patients in the midazolam pulse propofol (MP) group (n=50) initially received an intravenous combination of midazolam and propofol, and then propofol was titrated to achieve deep sedation.
The time to the initial sedation was shorter in the MP group than in the M group (1.13 minutes vs. 1.84 minutes, respectively; p<0.001). The recovery time was faster in the MP group than in the M group (p=0.031). There were no significant differences between the two groups with respect to frequency of adverse events, pain experienced by the patient, patient discomfort, degree of amnesia, and gag reflex. Patient cooperation, rated by the endoscopist as excellent, was greater in the MP group than in the M group (p=0.046).
The combined use of intravenous midazolam and propofol for sedation during ERCP is more effective than midazolam alone. There is no difference in the safety of the procedure.
PMCID: PMC3928499  PMID: 24570889
Propofol; Midazolam; Cholangiopancreatography, endoscopic retrograde; Conscious sedation
22.  The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory? 
Gut and Liver  2012;6(4):457-463.
Although several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view.
Diagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order.
The technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases.
The use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary.
PMCID: PMC3493726  PMID: 23170150
Natural orifice endoscopic surgery; Endoscopy; Swine
23.  A Comparative Study on the Efficacy of Covered Metal Stent and Plastic Stent in Unresectable Malignant Biliary Obstruction 
Clinical Endoscopy  2012;45(1):78-83.
The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent.
We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate.
There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182).
The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.
PMCID: PMC3363115  PMID: 22741136
Malignant biliary obstruction; Self-expandable metal stent; Plastic stent
24.  Single-Step EUS-Guided Transmural Drainage of Pancreatic Pseudocysts: Analysis of Technical Feasibility, Efficacy, and Safety 
Gut and Liver  2010;4(4):524-529.
With the progress of product development, single-step endoscopic ultrasound (EUS)-guided transmural drainage can overcome some disadvantages of the blind or two-step procedures used in the treatment of pancreatic pseudocysts. We therefore evaluated the technical feasibility, efficacy, and safety of single-step EUS-guided transmural drainage of pancreatic pseudocysts.
Endoscopic drainage of pancreatic pseudocysts was performed in 47 patients (median age, 46 years; range, 38 years to 59 years; 40 men) by using interventional echoendoscopes with a single-step device suitable for ballooning, bougination, and plastic-stent insertion.
Endoscopic stent placement was successful in 42 patients (89%; transgastric approach, 34/38; transduodenal approach, 8/9) and failed in 5 patients because of acute angulation (n=4) or small cyst (n=1). The volume of the pseudocyst was reduced by more than 90% or it disappeared completely in all of 41 patients (100%), based on a mean follow-up period of 17 months (range, 11 months to 20 months). The overall recurrence rate was 12% (5/41) after improvement by the procedure. Minor complications (one case of bleeding, three cases of pneumoperitoneum, and one case of peritonitis) occurred after the procedure in five patients (11%), but there were no major complications.
Single-step EUS-guided transmural drainage can be used to treat pancreatic pseudocysts with acceptable feasibility, efficacy, and safety.
PMCID: PMC3021610  PMID: 21253303
Drainage; Endoscopic ultrasonography; Pancreatic pseudocyst
25.  Feasibility of the Mucosa-Tracking Technique in Precut Papillotomy with the Iso-Tome as an Alternative to the Needle-Knife Technique 
Gut and Liver  2010;4(1):76-83.
The aim of this study was to evaluate whether the mucosa-tracking technique is effective for improving precutting-related pancreatitis and the sustained failure of bile duct cannulation in precut papillotomy (PP) with the Iso-Tome (MTW Endoskopie).
From September 2004 to June 2006, PP was performed with the Iso-Tome if biliary cannulation failed by conventional methods for approximately 5 minutes. The pink intrapapillary mucosa (PIPM) exposed by PP was tracked and classified into four groups: fully exposed and oriented to the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), or unexposed (group D). The success rate of bile duct cannulation (SRBC), the procedure time required for successful bile duct cannulation (PTBC), and the complications in the first session were compared between the mucosa-exposed groups (MEGs; group A, B, and C) and the mucosa-unexposed group (MUEG; group D).
A total of 59 patients (25 females, 34 males) with a mean age of 65.2 years were enrolled. The MEGs and MUEG comprised 52 (88.1%) and 7 (11.9%) patients, respectively. SRBC in the first session was 86.4% (51/59) in total and 92.3% (48/52) in the MEGs, compared to only 42.9% (3/7) in the MUEG (p=0.005). The mean PTBC in the MEGs and MUEG was 8.7 minutes and 16.3 minutes, respectively (p=0.23). Complications occurred in 6.8% of the patients (4/59; all pancreatitis); there were no differences between the MEGs (5.8%, 3/52) and MUEG (14.3%, 1/7; p=0.41). All four patients with pancreatitis were managed medically.
The mucosa-tracking technique in PP with the Iso-Tome is a feasible and useful method of enhancing SRBC. PIPM is an important endoscopic landmark for successful PP.
PMCID: PMC2871611  PMID: 20479916
Precut papillotomy; Iso-Tome; Mucosatracking technique; Pink intrapapillary mucosa

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