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1.  Innovations and techniques for balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy 
Endoscopic retrograde cholangiopancreatography (ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine. Recently, many studies have reported that balloon-enteroscope-assisted ERCP (BEA-ERCP) is a safe and effective procedure. However, further improvements in outcomes and the development of simplified procedures are required. Percutaneous treatment, Laparoscopy-assisted ERCP, endoscopic ultrasound-guided anterograde intervention, and open surgery are effective treatments. However, treatment should be noninvasive, effective, and safe. We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications. BEA-ERCP still requires high expertise-level techniques and is far from a routinely performed procedure. Various techniques have been proposed to facilitate scope insertion (insertion with percutaneous transhepatic biliary drainage (PTBD) rendezvous technique, Short type single-balloon enteroscopes with passive bending section, Intraluminal injection of indigo carmine, CO2 inflation guidance), cannulation (PTBD or percutaneous transgallbladder drainage rendezvous technique, Dilation using screw drill, Rendezvous technique combining DBE with a cholangioscope, endoscopic ultrasound-guided rendezvous technique), and treatment (overtube-assisted technique, Short type balloon enteroscopes) during BEA-ERCP. The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients. A standard procedure for ERCP yet to be established for patients with a reconstructed intestine. At present, BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as first-line treatment. In this article, we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.
PMCID: PMC4458757  PMID: 26074685
Balloon enteroscopy; Endoscopic retrograde cholangiopancreatography; Altered gastrointestinal anatomy; Balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography
2.  Phase I trial of combination chemotherapy with gemcitabine, cisplatin, and S-1 in patients with advanced biliary tract cancer 
AIM: To evaluate the dose-limiting toxicities (DLTs) and determine the maximum-tolerated dose (MTD) and recommended dose (RD) of combination chemotherapy with gemcitabine, cisplatin and S-1 which is an oral fluoropyrimidine pro-drug in patients with advanced biliary tract cancer.
METHODS: Patients with histologically or cytologically confirmed unresectable or recurrent biliary tract cancer were enrolled. The planned dose levels of gemcitabine (mg/m2), cisplatin (mg/m2), and S-1 (mg/m2 per day) were as follows: level -1, 800/20/60; level 0, 800/25/60; level 1, 1000/25/60; and level 2, 1000/25/80. In each cycle, gemcitabine and cisplatin were administered intravenously on days 1 and 15, and S-1 was administered orally twice daily on days 1 to 7 and days 15 to 21, every 4 wk.
RESULTS: Twelve patients were enrolled, and level 0 was chosen as the starting dose. None of the first three patients had DLTs at level 0, and the dose was escalated to level 1. One of six patients had DLTs (grade 4 febrile neutropenia, leucopenia, and neutropenia; grade 3 thrombocytopenia) at level 1. We then proceeded to level 2. None of three patients had DLTs during the first cycle. Although the MTD was not determined, level 2 was designated at the RD for a subsequent phase II study.
CONCLUSION: The RD was defined as gemcitabine 1000 mg/m2 (days 1, 15), cisplatin 25 mg/m2 (days 1, 15), and S-1 80 mg/m2 per day (days 1-7, 15-21), every 4 weeks. A phase II study is planned to evaluate the effectiveness of combination chemotherapy with gemcitabine, cisplatin, and S-1 in advanced biliary tract cancer.
PMCID: PMC4438033  PMID: 26019463
Gemcitabine; Cisplatin, S-1; Advanced biliary tract cancer
3.  Passive-bending, short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients 
AIM: To evaluate short-type-single-balloon enteroscope (SBE) with passive-bending, high-force transmission functions for endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis.
METHODS: Short-type SBE with this technology (SIF-Y0004-V01; working length, 1520 mm; channel diameter, 3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis. The rate of reaching the blind end, time required to reach the blind end, diagnostic and therapeutic success rates, and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology (SIF-Y0004; working length, 1520 mm; channel diameter, 3.2 mm) in 25 patients.
RESULTS: The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004 (P = 0.59). The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004 (16 min vs 24 min, P = 0.04). The diagnostic success rate was 93% with SIF-Y0004-V01 and 84% with SIF-Y0004 (P = 0.17). The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004 (P = 0.68). The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004 (P = 0.50). The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group (P = 0.723). The incidence of pancreatitis was 0% in the SIF-Y0004-V01 group and 5.9% in the SIF-Y0004 group (P > 0.999). The incidence of gastrointestinal perforation was 2.0% (1/50) in the SIF-Y0004-V01 group and 2.9% (1/34) in the SIF-Y0004 group (P > 0.999).
CONCLUSION: SIF-Y0004-V01 is useful for ERCP in patients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.
PMCID: PMC4316096  PMID: 25663773
Passive bending; Roux-en-Y anastomosis; Endoscopic retrograde cholangiopancreatography; Short type; Single-balloon enteroscope
4.  First case of IgG4-related sclerosing cholangitis associated with autoimmune hemolytic anemia 
To our knowledge, patients with immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) associated with autoimmune hemolytic anemia (AIHA) have not been reported previously. Many patients with IgG4-SC have autoimmune pancreatitis (AIP) and respond to steroid treatment. However, isolated cases of IgG4-SC are difficult to diagnose. We describe our experience with a patient who had IgG4-SC without AIP in whom the presence of AIHA led to diagnosis. The patient was a 73-year-old man who was being treated for dementia. Liver dysfunction was diagnosed on blood tests at another hospital. Imaging studies suggested the presence of carcinoma of the hepatic hilus and primary sclerosing cholangitis, but a rapidly progressing anemia developed simultaneously. After the diagnosis of AIHA, steroid treatment was begun, and the biliary stricture improved. IgG4-SC without AIP was thus diagnosed.
PMCID: PMC4093730  PMID: 25024635
IgG4-related sclerosing cholangitis; Immunoglobulin G4-related sclerosing cholangitis; Autoimmune hemolytic anemia; Autoimmune hemolytic anemia; Autoimmune pancreatitis
5.  Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy 
AIM: To evaluate the effectiveness of a short-type single-balloon-enteroscope (SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a reconstructed intestine.
METHODS: Short-type SBE was developed to perform ERCP in postoperative patients with a reconstructed intestine. Short-type SBE is a direct-viewing endoscope with the following specifications: working length, 1520 mm; total length, 1840 mm; channel diameter, 3.2 mm. In addition, short-type SBE has a water-jet channel. The study group comprised 22 patients who underwent 31 sessions of short-type SBE-assisted ERCP from June 2011 through May 2012. Reconstruction was performed by Billroth-II (B-II) gastrectomy in 6 patients (8 sessions), Roux-en-Y (R-Y) gastrectomy in 14 patients (21 sessions), and R-Y hepaticojejunostomy in 2 patients (2 sessions). We retrospectively studied the rate of reaching the blind end (papilla of Vater or choledochojejunal anastomosis), mean time required to reach the blind end, diagnostic success rate (defined as the rate of successfully imaging the bile and pancreatic ducts), therapeutic success rate (defined as the rate of successfully completing endoscopic treatment), mean procedure time, and complications.
RESULTS: Among the 31 sessions of ERCP, the rate of reaching the blind end was 88% in B-II gastrectomy, 91% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The mean time required to reach the papilla was 18.3 min in B-II gastrectomy, 21.1 min in R-Y gastrectomy, and 32.5 min in R-Y hepaticojejunostomy. The diagnostic success rates in all patients and those with an intact papilla were respectively 86% and 86% in B-II gastrectomy, 90% and 87% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The therapeutic success rates in all patients and those with an intact papilla were respectively 100% and 100% in B-II gastrectomy, 94% and 92% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. Because the channel diameter was 3.2 mm, stone extraction could be performed with a wire-guided basket in 12 sessions, and wire-guided intraductal ultrasonography could be performed in 8 sessions. As for complications, hyperamylasemia (defined as a rise in serum amylase levels to more than 3 times the upper limit of normal) occurred in 1 patient (7 sessions) with a B-II gastrectomy and 4 patients (19 sessions) with an R-Y gastrectomy. After ERCP in patients with an R-Y gastrectomy, 2 patients (19 sessions) had pancreatitis, 1 patient (21 sessions) had gastrointestinal perforation, and 1 patient (19 sessions) had papillary bleeding. Pancreatitis and bleeding were both mild. Gastrointestinal perforation improved after conservative treatment.
CONCLUSION: Short-type SBE is effective for ERCP in patients with a reconstructed intestine and allows most conventional ERCP devices to be used.
PMCID: PMC3607749  PMID: 23555161
Endoscopic retrograde cholangiopancreatography; Single-balloon-enteroscope; Short type; Billroth-II gastrectomy; Roux-en-Y gastrectomy
6.  Behavior and Distribution of Heavy Metals Including Rare Earth Elements, Thorium, and Uranium in Sludge from Industry Water Treatment Plant and Recovery Method of Metals by Biosurfactants Application 
In order to investigate the behavior, distribution, and characteristics of heavy metals including rare earth elements (REEs), thorium (Th), and uranium (U) in sludge, the total and fractional concentrations of these elements in sludge collected from an industry water treatment plant were determined and compared with those in natural soil. In addition, the removal/recovery process of heavy metals (Pb, Cr, and Ni) from the polluted sludge was studied with biosurfactant (saponin and sophorolipid) elution by batch and column experiments to evaluate the efficiency of biosurfactant for the removal of heavy metals. Consequently, the following matters have been largely clarified. (1) Heavy metallic elements in sludge have generally larger concentrations and exist as more unstable fraction than those in natural soil. (2) Nonionic saponin including carboxyl group is more efficient than sophorolipid for the removal of heavy metals in polluted sludge. Saponin has selectivity for the mobilization of heavy metals and mainly reacts with heavy metals in F3 (the fraction bound to carbonates) and F5 (the fraction bound to Fe-Mn oxides). (3) The recovery efficiency of heavy metals (Pb, Ni, and Cr) reached about 90–100% using a precipitation method with alkaline solution.
PMCID: PMC3368164  PMID: 22693485
7.  Recent Advances of Biliary Stent Management 
Korean Journal of Radiology  2012;13(Suppl 1):S62-S66.
Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Even we employed metallic stents which contributed to higher rates and longer durations of patency, and occlusion of covered metallic stents now occurs in about half of all patients during their survival. We investigated the complication and patency rate for the removal of covered metallic stents, and found that the durations were similar for initial stent placement and re-intervention. In order to preserve patient quality of life, we currently recommend the use of covered metallic stents for patients with malignant biliary obstruction because of their removability and longest patency duration, even though uncovered metallic stents have similar patency durations.
PMCID: PMC3341462  PMID: 22563289
Metallic stent; Stent obstruction; Re-intervention; Biliary stricture; Stent patency
9.  Comparison of diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration with 22- and 25-gauge needles in the same patients 
Various factors, such as the optimal number of passes, aspiration pressure, and the use of 19-gauge and Trucut biopsy needles, have been studied to improve the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We retrospectively compared the diagnostic accuracy of EUS-FNA between 25- and 22-gauge needles, which have been widely used recently.
Subjects and Methods
The study group comprised 47 consecutive patients who underwent EUS-FNA with both 22- and 25-gauge needles from October 2007 through March 2010. Their underlying diseases were pancreatic cancer in 24 patients, submucosal tumors in 11, other pancreatic tumors in 4, chronic pancreatitis in 4, enlarged lymph nodes in 3, and gall bladder cancer in 1. Tissue specimens, which were pushed out of the puncture needle, were placed into physiological saline solution. Gray-whitish, worm-like specimens were used for histologic diagnosis. The remaining specimen was centrifuged, and the sediment was plated on slides and examined by a cytopathologist to obtain the cytologic diagnosis.
A total of 75 punctures (mean, 1.6) were performed with 25-gauge needles, and 69 punctures (mean, 1.4) were performed with 22-gauge needles. The overall tissue-sampling rate for cytology was 100% (47/47), which was significantly (p=0.01) superior to 83% (39/47) for histology. The overall diagnostic accuracy on the cytologic and histologic examinations was 79% (37/47) and 85% (33/39) (p=0.48). According to needle type, the tissue-sampling rate for cytology and histology on each puncture was 97% (73/75) and 56% (42/75) with 25-guage needles, and was 97% (67/69) and 58% (40/69) with 22-guage needles, the accuracy of cytologic diagnosis on each puncture was 73% (53/73) with 25-gauge needles and 66% (44/67) with 22-gauge needles (p=0.37); the accuracy of histologic diagnosis on each puncture was 60% (25/42) and 75% (30/40) (p=0.14), respectively. No patient had complications.
The tissue-sampling rate and diagnostic accuracy did not differ significantly between 22- and 25-gauge needles in patients with pancreatic or gastrointestinal diseases who underwent EUS-FNA.
PMCID: PMC3234693  PMID: 22163079
EUS-FNA; 25-guage needle; 22-guage needle; diagnostic accuracy; pancreatic disease; upper gastroitestinal diseases
10.  Biosorption of Lanthanides from Aqueous Solutions Using Pretreated Buccinum tenuissimum Shell Biomass 
Biosorption experiment from aqueous solutions containing known amount of rare earth elements (REEs) using pre-treated Buccinum tenuissimum shell was explored to evaluate the efficiency of shell biomass as sorbent for REEs. In this work, four kinds of sieved shell samples: (a) “Ground original sample”, (b) “Heat-treatment (480°C, 6 hours) sample”, (c) “Heat-treatment (950°C, 6 hours) sample” and (d) “Heat-treatment (950°C, 6 hours) and water added sample” were used. Furthermore, to confirm the characteristics of the shell biomass, the crystal structure, the surface morphology, and the specific surface area of these shell samples were determined. Consequently, the following matters have been mainly clarified. (1) The crystal structure of the shell biomass was transformed from aragonite (CaCO3) into calcite (CaCO3) phase by heat-treatment (480°C, 6 hours); then mainly transformed into calcium oxide (CaO) by heat-treatment (950°C, 6 hours), and calcium hydroxide (Ca(OH)2) by heat-treatment (950°C, 6 hours) and adding water. (2) The shell biomass showed excellent sorption capacity for lanthanides. (3) Adsorption isotherms using the shell biomass can be described by Langmuir and Freundlich isotherms satisfactorily for lanthanides except “heat-treatment (950°C, 6 hours) sample”. (4) Shell biomass (usually treated as waste material) can be an efficient sorbent for lanthanides in future.
PMCID: PMC2963800  PMID: 20981250
11.  Biosorption of Uranium and Rare Earth Elements Using Biomass of Algae 
In order to investigate the behavior of rare earth elements (REEs) and uranium (U) in marine organism, the concentrations of REEs and U in some brown algae samples taken on the coast of Niigata Prefecture were determined. In addition, laboratory model experiment to uptake these elements using living and dried algae (Undaria pinnatifida and Sargassum hemiphyllum) was also carried out to survey the uptake and bioaccumulation mechanism of REEs and U in algae. Consequently, the following matters have been mainly clarified. (1) The order of the concentration of REEs for each organ in Sargassum hemiphyllum is “main branch” > “leaf” > “vesicle,” however for U, the order is “leaf” > “vesicle” > “main branch.” (2) The concentration of REEs in Sargassum hemiphyllum may be strongly affected by suspended solid in seawater. (3) The uptake and/or accumulate mechanism of REEs in brown algae may be different from that of U.
PMCID: PMC2593843  PMID: 19081786

Results 1-11 (11)