High-Resolution Probe-Based Confocal Laser Endomicroscopy for Diagnosing Biliary Diseases

Hiroki Koda,Kazuo Hara,Okuno Nozomi,Takamichi Kuwahara,Mizuno Nobumasa,Shin Haba,Miyano Akira,Isomoto Hajime 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.6

Probe-based confocal laser endomicroscopy is an endoscopic technique that enables in vivo histological evaluation using fluorescentpigment. The ability to diagnostically differentiate between benign and malignant biliary disease using the “CholangioFlexTM”, adedicated biliary device, has been reported. However, the Miami and Paris classifications, used as diagnostic criteria, mainly evaluatefindings in the submucosa, and visualizing the epithelium as the main site of lesions remains difficult. To address this problem, weverified the imaging findings and diagnostic ability of three types of probes: CholangioFlexTM, GastroFlexTM, and AlveoFlexTM. WithGastroFlexTM, the clear mucosal epithelium was observed, and differential diagnoses as benign/malignant could be made based onepithelial findings. GastroFlexTM may be a good first-choice probe for probe-based confocal laser endomicroscopy of biliary diseases,and a new diagnostic classification based on bile duct epithelial findings may provide useful criteria independent of the Miami orParis classifications.

Endoscopic ultrasound-guided portal vein coiling: troubleshooting interventional endoscopic ultrasonography

Shin Haba,Kazuo Hara,Nobumasa Mizuno,Takamichi Kuwahara,Nozomi Okuno,Akira Miyano,Daiki Fumihara,Moaz Elshair 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.3

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) is widely performed not only as an alternative to transpapillary biliarydrainage, but also as primary drainage for malignant biliary obstruction. For anatomical reasons, this technique carries an unavoidablerisk of mispuncturing intrahepatic vessels. We report a technique for troubleshooting EUS-guided portal vein coiling to preventbleeding from the intrahepatic portal vein after mispuncture during interventional EUS. EUS-HGS was planned for a 59-year-old malepatient with unresectable pancreatic cancer. The dilated bile duct (lumen diameter, 2.8 mm) was punctured with a 19-gauge needle,and a guidewire was inserted. After bougie dilation, the guidewire was found to be inside the intrahepatic portal vein. Embolizing coilswere placed to prevent bleeding. Embolization coils were successfully inserted under stabilization of the catheter using a double-lumencannula with a guidewire. Following these procedures, the patient was asymptomatic. Computed tomography performed the next dayrevealed no complications.

Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography

Yasuhiro Kuraishi,Kazuo Hara,Shin Haba,Takamichi Kuwahara,Nozomi Okuno,Takafumi Yanaidani,Sho Ishikawa,Tsukasa Yasuda,Masanori Yamada,Nobumasa Mizuno 대한소화기내시경학회 2023 Clinical Endoscopy Vol.56 No.4

Background/Aims: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique. Methods: One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated. Results: The median size of the papillary roof was 6 mm (range, 3–20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3–15 minutes). Conclusions: Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.

Infectious peritonitis after endoscopic ultrasound-guided biliary drainage in a patient with ascites

Nozomi Okuno,Kazuo Hara,Nobumasa Mizuno,Takamichi Kuwahara,Hiromichi Iwaya,Masahiro Tajika,Tsutomu Tanaka,Makoto Ishihara,Yutaka Hirayama,Sachiyo Onishi,Kazuhiro Toriyama,Ayako Ito,Naosuke Kuraoka,Shi 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.1

Summary of Event Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient’s general condition gradually deteriorated due to aggravation of the primary cancer and he died. Teaching Point This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.

Utility of Forward-View Echoendoscopy for Transcolonic Fine-Needle Aspiration of Extracolonic Lesions: An Institutional Experience

Nithi Thinrungro,Kazuo Hara,Nobumasa Mizuno,Takamichi Kuwahara,Nozomi Okuno 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.1

Background/Aims: Non-invasive tissue sampling from the lower intra-abdominal and pelvic cavity is challenging. The role ofendoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this situation is not well-established because of the limitations ofthe curved linear-array echoendoscopy-EUS for colonic insertion. The aim of this study was to report our institutional experience oftranscolonic EUS-FNA using forward-viewing therapeutic linear echoendoscopy-EUS (FV-EUS) in combination with fluoroscopicguidance. Methods: Medical records of 13 patients who underwent transcolonic EUS-FNA of extracolonic lesions using FV-EUS in combinationwith fluoroscopic guidance at Aichi Cancer Center Hospital, Nagoya, Japan from June 2015 to November 2018 were retrospectivelyreviewed. Results: Using FV-EUS under fluoroscopic guidance, the FNA procedure could be performed successfully in all patients (100%technical success), with a median procedure time of 31 minutes. The sensitivity, specificity, and accuracy of EUS-FNA for detectingmalignant lesions in this study were 91%, 100%, and 92%, respectively. There were no adverse events associated with the EUS-FNAprocedure. Conclusions: FV-EUS in combination with fluoroscopic guidance is an easy, safe, and effective technique for FNA of extracoloniclesions in the lower abdomen.

Forward viewing liner echoendoscopy for therapeutic interventions

Kazuo Hara,Nozomi Okuno,Shin Haba,Takamichi Kuwahara 대한소화기내시경학회 2024 Clinical Endoscopy Vol.57 No.2

Therapeutic endoscopic ultrasonography (EUS) procedures using the forward-viewing convex EUS (FV-EUS) have been reviewed based on the articles reported to date. The earliest reported procedure is the drainage of pancreatic pseudocysts using FV-EUS. However, the study on drainage of pancreatic pseudocysts focused on showing that drainage is possible with FV-EUS rather than leveraging its features. Subsequently, studies describing the characteristics of FV-EUS have been reported. By using FV-EUS in EUS-guided choledochoduodenostomy, double punctures in the gastrointestinal tract can be avoided. In postoperative modified anatomical cases, using the endoscopic function of FV-EUS, procedures such as bile duct drainage from anastomosis, pancreatic duct drainage from the afferent limb, and abscess drainage from the digestive tract have been reported. When a perpendicular puncture to the gastrointestinal tract is required or when there is a need to insert the endoscope deep into the gastrointestinal tract, FV-EUS is considered among the options.

Infectious peritonitis after endoscopic ultrasound-guided biliary drainage in a patient with ascites

Nozomi Okuno,Kazuo Hara,Nobumasa Mizuno,Takamichi Kuwahara,Hiromichi Iwaya,Masahiro Tajika,Tsutomu Tanaka,Makoto Ishihara,Yutaka Hirayama,Sachiyo Onishi,Kazuhiro Toriyama,Ayako Ito,Naosuke Kuraoka,Shi 소화기인터벤션의학회 2018 International journal of gastrointestinal interven Vol.7 No.1

Summary of Event Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient’s general condition gradually deteriorated due to aggravation of the primary cancer and he died. Teaching Point This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection. Summary of Event Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient’s general condition gradually deteriorated due to aggravation of the primary cancer and he died. Teaching Point This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.

Clinical utility of endoscopic ultrasound-guided tissue acquisition for comprehensive genomic profiling of pancreatic cancer

Nozomi Okuno,Kazuo Hara,Nobumasa Mizuno,Shin Haba,Takamichi Kuwahara,Yasuhiro Kuraishi,Daiki Fumihara,Takafumi Yanaidani 대한소화기내시경학회 2023 Clinical Endoscopy Vol.56 No.2

Background/Aims: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is essential for the diagnosis of pancreatic cancer. The feasibility of comprehensive genomic profiling (CGP) using samples obtained by EUS-TA has been under recent discussion. This study aimed to evaluate the utility of EUS-TA for CGP in a clinical setting. Methods: CGP was attempted in 178 samples obtained from 151 consecutive patients with pancreatic cancer at the Aichi Cancer Center between October 2019 and September 2021. We evaluated the adequacy of the samples for CGP and determined the factors associated with the adequacy of the samples obtained by EUS-TA retrospectively. Results: The overall adequacy for CGP was 65.2% (116/178), which was significantly different among the four sampling methods (EUS-TA vs. surgical specimen vs. percutaneous biopsy vs. duodenal biopsy, 56.0% [61/109] vs. 80.4% [41/51] vs. 76.5% [13/17] vs. 100.0% [1/1], respectively; p=0.022). In a univariate analysis, needle gauge/type was associated with adequacy (22 G fine-needle aspiration vs. 22 G fine-needle biopsy [FNB] vs. 19 G-FNB, 33.3% (5/15) vs. 53.5% (23/43) vs. 72.5% (29/40); p=0.022). The sample adequacy of 19 G-FNB for CGP was 72.5% (29/40), and there was no significant difference between 19 G-FNB and surgical specimens (p=0.375). Conclusions: To obtain adequate samples for CGP with EUS-TA, 19 G-FNB was shown to be the best in clinical practice. However, 19 G-FNB was not still sufficient, so further efforts are required to improve adequacy for CGP.

Endoscopic ultrasound-guided drainage for an abscess cavity

Nozomi Okuno,Kazuo Hara,Nobumasa Mizuno,Shin Haba,Takamichi Kuwahara,Yasuhiro Kuraishi,Takafumi Yanaidani,Sho Ishikawa,Tsukasa Yasuda,Masanori Yamada,Toshitaka Fukui 소화기인터벤션의학회 2022 International journal of gastrointestinal interven Vol.11 No.4

Endoscopic ultrasound (EUS)-guided interventions, including EUS-guided biliary drainage and EUS-guided cystic drainage, are now well developed and in widespread use. Intraperitoneal abscess requires drainage because mortality associated with an undrained abscess is high. Percutaneous or surgical drainage has traditionally been performed, but there have been numerous reports of EUS-guided drainage for intraperitoneal abscesses in recent years. EUS-guided abscess drainage has the advantage of being less invasive and enabling direct access to the cavity via the trans-luminal route as well as clear visualization of interposed vessels using color Doppler ultrasonography. It is necessary to consider the advantages and disadvantages when selecting a drainage method. This article reviews the current status of EUS-guided abscess drainage at three sites: the liver, pelvis, and mediastinum.

Refractory benign biliary stricture due to chronic pancreatitis in two patients treated using endoscopic ultrasound-guided choledochoduodenostomy fistula creation: case reports

Sho Ishikawa,Nozomi Okuno,Kazuo Hara,Nobumasa Mizuno,Shin Haba,Takamichi Kuwahara,Yasuhiro Kuraishi,Takafumi Yanaidani 대한소화기내시경학회 2024 Clinical Endoscopy Vol.57 No.1

Benign biliary stricture (BBS) is a complication of chronic pancreatitis (CP). Despite endoscopic biliary stenting, some patients do not respond to treatment, and they experience recurrent cholangitis. We report two cases of CP with refractory BBS treated using endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) fistula creation. A 50-year-old woman and a 60-year-old man both presented with obstructive jaundice secondary to BBS due to alcoholic CP. They underwent repeated placement of a fully covered self-expandable metal stent for biliary strictures. However, the strictures persisted, causing repeated episodes of cholangitis. Therefore, an EUS-CDS was performed. The stents were eventually removed and the patients became stent-free. These fistulas have remained patent without cholangitis for more than 2.5 years. Fistula creation using EUS-CDS is an effective treatment option for BBS.