Endoscopic ultrasound-guided biliary drainage: Complications and their management

Hiroyuki Isayama,Yousuke Nakai,Natsuyo Yamamoto,Saburo Matsubara,Yukiko Ito,Hirfoumi Kogure,Tsuyoshi Hamada,Kazuhiko Koike 소화기인터벤션의학회 2017 International journal of gastrointestinal interven Vol.6 No.2

Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUS-BD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.

Endoscopic ultrasound-guided biliary drainage: Complications and their management

Hiroyuki Isayama,Yousuke Nakai,Natsuyo Yamamoto,Saburo Matsubara,Yukiko Ito,Hirfoumi Kogure,Tsuyoshi Hamada,Kazuhiko Koike 소화기인터벤션의학회 2017 Gastrointestinal Intervention Vol.6 No.2

Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUS-BD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.

Mid to Long Term Outcome after Arthroscopic Fragment Resection for Capitellar Osteochondritis Dissecans in Adolescent Athletes

Sugaya Hiroyuki,Ueda Yusuke,Takahashi Norimasa,Hoshika Shota,Hamada Hiroshige 대한견주관절의학회 2017 대한견주관절학회 학술대회논문집 Vol.2017 No.3

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

Tsuyoshi Hamada,Yousuke Nakai,Hiroyuki Isayama 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.2

Placement of a plastic or metal stent via endoscopic retrograde cholangiopancreatography (ERCP) currently serves as the first-line procedure for obstructive jaundice and acute cholangitis. Dysfunction of the biliary stent causes recurrence of symptoms and often requires reinterventions and hospitalizations. Therefore, duration of stent patency is commonly used as the primary endpoint in clinical studies of biliary stents. However, owing to considerable heterogeneity between studies in reporting of biliary stent patency, it has been difficult to compare and integrate results of independent studies. There has been between-study heterogeneity in definitions of stent patency, statistics reported for survival curves of stent patency, and methods to treat censored cases. In addition to stent occlusion, stent migration is a major cause of recurrent biliary obstruction after covered metal stent placement, which further complicates the reporting of stent patency. Reporting of functional success and adverse events has been also inconsistent between the studies. From the perspective of evidence-based medicine, the variations in the definitions of outcome variables potentially hinder robust meta-analyses. To overcome the issues due to the lack of outcome reporting guidelines on the topic, the TOKYO criteria 2014 for reporting outcomes associated with endoscopic transpapillary placement of biliary stents have been proposed. Due to their comprehensiveness, the TOKYO criteria can be readily utilized to evaluate various types of biliary stent placement using ERCP, irrespective of types of stents and location of biliary stricture. In this article, we review the TOKYO criteria as a standardized reporting system for endoscopically-placed biliary stents. We also discuss potential controversial issues in the application of the TOKYO criteria. Given that endoscopic ultrasound-guided biliary drainage is increasingly utilized for cases with failed ERCP or altered gastrointestinal anatomy, we further propose a potential application of the TOKYO criteria to reporting of outcomes of this procedure.

ORiginal Article : Severe Bleeding and Perforation Are Rare Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration for Pancreatic Masses ; An Analysis of 3,090 Patients from 212 Hospitals

( Tsuyoshi Hamada ),( Hideo Yasunaga ),( Yousuke Nakai ),( Hiroyuki Isayama ),( Hiromasa Horiguchi ),( Shinya Matsuda ),( Kiyohide Fushimi ),( Kazuhiko Koike ) The Editorial Office of Gut and Liver 2014 Gut and Liver Vol.8 No.2

Background/Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for the pathological diagnosis of pancreatic masses, but patients are susceptible to severe bleeding and perforation. Because the incidence and severity of these complications have not been fully evaluated. Methods: We aimed to evaluate severe bleeding and perforation after EUS-FNA for pancreatic masses using large-scale data derived from a Japanese nationwide admin-istrative database. Results: In total, 3,090 consecutive pa-tients from 212 low- to high-volume hospitals were analyzed. Severe bleeding requiring transfusion or endoscopic treat-ment occurred in seven patients (0.23%), and no perforation was observed. No patient mortality was recorded within 30 days of EUS-FNA. The rate of severe bleeding in low-volume hospitals was significantly higher than that in medium- and high-volume hospitals (0.48% vs 0.10%, p=0.045). Conclu-sions: Severe bleeding and perforation following EUS-FNA for pancreatic masses are rare, and the procedure is safe. (Gut Liver 2014;8:215-218)

Case Report : Percutaneous Transhepatic Biliary Drainage Using a Ligated Catheter for Recurrent Catheter Obstruction: Antireflux Technique

( Tsuyoshi Hamada ),( Takeshi Tsujino ),( Hiroyuki Isayama ),( Ryunosuke Hakuta ),( Yukiko Ito ),( Ryo Nakata ),( Kazuhiko Koike ) 대한간학회 2013 Gut and Liver Vol.7 No.2

Percutaneous transhepatic biliary drainage (PTBD) is an established procedure for biliary obstruction. However, duodenobiliary or jejunobiliary reflux of the intestinal contents through a PTBD catheter sometimes causes recurrent catheter obstruction or cholangitis. A 64-year-old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction. Emergent PTBD was performed, but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post-PTBD course. We therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux. A commercially available catheter was modified; side holes were made at 1 cm and 5 to 10 cm (1 cm apart) from the tip of the catheter, and the catheter was ligated with a nylon thread just proximal to the first side hole. Using this novel "antireflux PTBD technique," jejunobiliary reflux was prevented successfully, resulting in a longer patency of the catheter. (Gut Liver 2013;7:255-257)

Antireflux Metal Stent as a First-Line Metal Stent for Distal Malignant Biliary Obstruction: A Pilot Study

( Tsuyoshi Hamada ),( Hiroyuki Isayama ),( Yousuke Nakai ),( Osamu Togawa ),( Naminatsu Takahara ),( Rie Uchino ),( Suguru Mizuno ),( Dai Mohri ),( Hiroshi Yagioka ),( Hirofumi Kogure ),( Saburo Matsu 대한소화기학회 2017 Gut and Liver Vol.11 No.1

Background/Aims: In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. Methods: Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. Results: In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced nonocclusion cholangitis. Conclusions: The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted. (Gut Liver 2017;11:142-148)

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

Tsuyoshi Hamada,Yousuke Nakai,Hiroyuki Isayama 소화기인터벤션의학회 2018 International journal of gastrointestinal interven Vol.7 No.2

Placement of a plastic or metal stent via endoscopic retrograde cholangiopancreatography (ERCP) currently serves as the first-line procedure for obstructive jaundice and acute cholangitis. Dysfunction of the biliary stent causes recurrence of symptoms and often requires reinterventions and hospitalizations. Therefore, duration of stent patency is commonly used as the primary endpoint in clinical studies of biliary stents. However, owing to considerable heterogeneity between studies in reporting of biliary stent patency, it has been difficult to compare and integrate results of independent studies. There has been between-study heterogeneity in definitions of stent patency, statistics reported for survival curves of stent patency, and methods to treat censored cases. In addition to stent occlusion, stent migration is a major cause of recurrent biliary obstruction after covered metal stent placement, which further complicates the reporting of stent patency. Reporting of functional success and adverse events has been also inconsistent between the studies. From the perspective of evidence-based medicine, the variations in the definitions of outcome variables potentially hinder robust meta-analyses. To overcome the issues due to the lack of outcome reporting guidelines on the topic, the TOKYO criteria 2014 for reporting outcomes associated with endoscopic transpapillary placement of biliary stents have been proposed. Due to their comprehensiveness, the TOKYO criteria can be readily utilized to evaluate various types of biliary stent placement using ERCP, irrespective of types of stents and location of biliary stricture. In this article, we review the TOKYO criteria as a standardized reporting system for endoscopically-placed biliary stents. We also discuss potential controversial issues in the application of the TOKYO criteria. Given that endoscopic ultrasound-guided biliary drainage is increasingly utilized for cases with failed ERCP or altered gastrointestinal anatomy, we further propose a potential application of the TOKYO criteria to reporting of outcomes of this procedure.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

Tanyaporn Chantarojanasiri,Hiroyuki Isayama,Yousuke Nakai,Saburo Matsubara,Natsuyo Yamamoto,Naminatsu Takahara,Suguru Mizuno,Tsuyoshi Hamada,Hirofumi Kogure,Kazuhiko Koike 거트앤리버 소화기연관학회협의회 2018 Gut and Liver Vol.12 No.2

Background/Aims: Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published. Methods: Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed. Results: There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP. Conclusions: Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

Development of Cotton Candy Method for High Productivity Polypropylene Fibers Webs

Rutchaneekorn Wongpajan,Supaphorn Thumsorn,Hiroyuki Inoya,Masayuki Okoshi,Hiroyuki Hamada 한국섬유공학회 2018 Fibers and polymers Vol.19 No.1

The cotton candy method (CoCAM) is developed for high productivity of polymer micro- and nano-fibers. Polypropylene was molten in a single screw extruder of the CoCAM at air pressures of 0.2-0.5 MPa with nozzle temperatures of 280-350 ℃ and the constant air temperature of 600 ℃. The distance from the nozzle to the collector was set at 10-90 cm. Thermal images informed the accumulation of PP fibers flows at shorter collector distance. The diameters of PP micro-fibersdecreased with increasing the air pressures and the nozzle temperatures. Crystallinity of the PP micro-fibers increased when increasing the nozzle temperature due to higher occasion of molecular orientation. The degree of the fiber entanglement in the PP micro-fibers decreased when increasing the collector distance, which affected on the declination of tensile strength. Ductility of the PP micro-fibers improved at high collector distances. The optimum condition of the PP micro-fibers was found at the average diameter of 2.3 μm at 0.5 MPa with the nozzle temperature of 340 ℃ collected at 60 cm. The productivity of the PP micro-fibers webs from the CoCAM was 144 g/h.