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)

Vitamin D status after colorectal cancer diagnosis and patient survival according to immune response to tumour

Hamada, Tsuyoshi,Liu, Li,Nowak, Jonathan A.,Mima, Kosuke,Cao, Yin,Ng, Kimmie,Twombly, Tyler S.,Song, Mingyang,Jung, Seungyoun,Dou, Ruoxu,Masugi, Yohei,Kosumi, Keisuke,Shi, Yan,da Silva, Annacarolina,G Elsevier 2018 European journal of cancer Vol.103 No.-

<P><B>Abstract</B></P> <P><B>Background</B></P> <P>High-level plasma 25-hydroxyvitamin D [25(OH)D] has been associated with lower colorectal cancer incidence and mortality. Considering evidence indicating immunomodulatory effects of vitamin D, we hypothesised that survival benefits from high systemic vitamin D level might be stronger for colorectal carcinoma with lower immune response to tumour.</P> <P><B>Methods</B></P> <P>Using 869 colon and rectal cancer cases within the Nurses' Health Study and Health Professionals Follow-up Study, we assessed the prognostic association of postdiagnosis 25(OH)D score [derived from diet and lifestyle variables to predict plasma 25(OH)D level] in strata of levels of histopathologic lymphocytic reaction. The Cox proportional hazards regression model was adjusted for potential confounders, including microsatellite instability, CpG island methylator phenotype, LINE-1 methylation, <I>PTGS2</I> (cyclooxygenase-2) expression and <I>KRAS</I>, <I>BRAF</I> and <I>PIK3CA</I> mutations.</P> <P><B>Results</B></P> <P>The association of postdiagnosis 25(OH)D score with colorectal cancer-specific mortality differed by levels of peritumoural lymphocytic reaction (<I>p</I> <SUB>interaction</SUB> = 0.001). Multivariable-adjusted mortality hazard ratios for a quintile-unit increase of 25(OH)D score were 0.69 [95% confidence interval (CI), 0.54–0.89] in cases with negative/low peritumoural lymphocytic reaction, 1.08 (95% CI, 0.93–1.26) in cases with intermediate peritumoural reaction and 1.25 (95% CI, 0.75–2.09) in cases with high peritumoural reaction. The survival association of the 25(OH)D score did not significantly differ by Crohn's-like lymphoid reaction, intratumoural periglandular reaction or tumour-infiltrating lymphocytes.</P> <P><B>Conclusions</B></P> <P>The association between the 25(OH)D score and colorectal cancer survival is stronger for carcinomas with lower peritumoural lymphocytic reaction. Our results suggesting interactive effects of vitamin D and immune response may contribute to personalised dietary and lifestyle intervention strategies.</P> <P><B>Highlights</B></P> <P> <UL> <LI> The survival association of vitamin D is stronger in cancer with fewer lymphocytes. </LI> <LI> Vitamin D and peritumoural lymphocytes interact to modify cancer progression. </LI> <LI> Vitamin D may exert anti-tumour immune-enhancing effects. </LI> <LI> Peritumoural lymphocytic reaction may be a biomarker for benefits from vitamin D. </LI> <LI> Our data support immunomodulatory lifestyle interventions for cancer patients. </LI> </UL> </P>

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.

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.

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)

A Meta-Analysis of Slow Pull versus Suction for Endoscopic Ultrasound-Guided Tissue Acquisition

( Yousuke Nakai ),( Tsuyoshi Hamada ),( Ryunosuke Hakuta ),( Tatsuya Sato ),( Kazunaga Ishigaki ),( Kei Saito ),( Tomotaka Saito ),( Naminatsu Takahara ),( Suguru Mizuno ),( Hirofumi Kogure ),( Kazuhi 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2021 Gut and Liver Vol.15 No.4

Background/Aims: Endoscopic ultrasound (EUS)-guided tissue acquisition is widely utilized as a diagnostic modality for intra-abdominal masses, but there remains debate regarding which suction technique, slow pull (SP) or conventional suction (CS), is better. A meta-analysis of reported studies was conducted to compare the diagnostic yields of SP and CS during EUS-guided tissue acquisition. Methods: We conducted a systematic electronic search using MEDLINE/PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify clinical studies comparing SP and CS. We meta-analyzed accuracy, sensitivity, blood contamination and cellularity using the random-effects model. Results: A total of 17 studies (seven randomized controlled trials, four prospective studies, and six retrospective studies) with 1,616 cases were included in the analysis. Compared to CS, there was a trend toward better accuracy (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.97 to 2.27; p=0.07) and sensitivity (OR, 1.67; 95% CI, 0.95 to 2.93; p=0.08) with SP and a significantly lower rate of blood contamination (OR, 0.48; 95% CI, 0.33 to 0.69; p<0.01). However, there was no significant difference in cellularity between SP and CS, with an OR of 1.28 (95% CI, 0.68 to 2.40; p=0.45). When the use of a 25-gauge needle was analyzed, the accuracy and sensitivity of SP were significantly better than those of CS, with ORs of 4.81 (95% CI, 1.99 to 11.62; p<0.01) and 4.69 (95% CI, 1.93 to 11.40; p<0.01), respectively. Conclusions: Compared to CS, SP appears to provide better accuracy and sensitivity in EUSguided tissue acquisition, especially when a 25-gauge needle is used. (Gut Liver 2021;15:625- 633)

Usefulness of stent placement above the papilla, so-called, ‘inside stent’

Tanyaporn Chantarojanasiri,Hirofumi Kogure,Tsuyoshi Hamada,Hiroyuki Isayama 소화기인터벤션의학회 2018 International journal of gastrointestinal interven Vol.7 No.2

Stent occlusion and cholangitis are common complications after endoscopic biliary stenting caused by duodenobiliary refluxes and food impaction. To prolong the stent patency, the concept of stenting above the papilla, so-called inside stent, has been developed. Various studies of the inside stent in the treatment of both benign and malignant biliary obstruction have been published, with a promising result. However, most studies were retrospective, with wide variation of stent type and the etiology of biliary obstruction. This review aims to summarize the principle, evidence, and the usefulness of inside biliary stent.

Usefulness of stent placement above the papilla, so-called, ‘inside stent’

Tanyaporn Chantarojanasiri,Hirofumi Kogure,Tsuyoshi Hamada,Hiroyuki Isayama 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.2

Stent occlusion and cholangitis are common complications after endoscopic biliary stenting caused by duodenobiliary refluxes and food impaction. To prolong the stent patency, the concept of stenting above the papilla, so-called inside stent, has been developed. Various studies of the inside stent in the treatment of both benign and malignant biliary obstruction have been published, with a promising result. However, most studies were retrospective, with wide variation of stent type and the etiology of biliary obstruction. This review aims to summarize the principle, evidence, and the usefulness of inside biliary stent.

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.