Publications by authors named "Kazunari Nakahara"

60 Publications

Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in JAPAN.

Gastrointest Endosc 2021 Sep 14. Epub 2021 Sep 14.

Department of Gastroenterology, Kitasato University of Medicine.

Background And Aims: Although single-balloon enteroscopy (SBE)-assisted or short-type SBE (short SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been reported as useful in patients with surgically altered anatomy, most of the studies had small sample sizes or single-center designs. This study aimed to evaluate the efficacy and factors affecting the procedure results of short SBE-assisted ERCP in patients with surgically altered anatomy.

Methods: This multicenter retrospective study was conducted at 8 tertiary referral care centers in Japan. The data of patients who underwent ERCP-related procedures using short SBE between September 2011 and August 2019 at each facility were analyzed.

Results: Overall, 1,318 patients were included in this analysis. The enteroscopy (reaching the target site), cannulation, and total procedural success rates were 87.9% (95% confidence interval [CI], 86.1%-89.6%), 87.0% (95% CI, 84.9%-88.8%), and 74.9% (95% CI, 72.5%-77.2%), respectively. Adverse events occurred in 7.7% (95% CI, 6.4%-9.3%). Multiple logistic regression analysis indicated that age (≥75 years), Roux-en-Y reconstruction, pancreatic indication, and malignancy were factors affecting the total procedural failure.

Conclusions: This large-scale study proved that short SBE-assisted ERCP in patients with surgically altered anatomy was effective. Moreover, it clarified factors affecting the procedure results. Proficiency with alternative treatment techniques is required in difficult cases.
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http://dx.doi.org/10.1016/j.gie.2021.09.008DOI Listing
September 2021

Clinical Outcomes of Early Endoscopic Transpapillary Biliary Drainage for Acute Cholangitis Associated with Disseminated Intravascular Coagulation.

J Clin Med 2021 Aug 16;10(16). Epub 2021 Aug 16.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan.

Acute cholangitis (AC) is often associated with disseminated intravascular coagulation (DIC), and endoscopic transpapillary biliary drainage (EBD) under endoscopic retrograde cholangiopancreatography (ERCP) is a treatment of choice. However, no evidence exists on the outcomes of EBD for AC associated with DIC. Therefore, we retrospectively evaluated the treatment outcomes of early EBD and compared endoscopic biliary stenting (EBS) and endoscopic nasobiliary drainage (ENBD). We included 62 patients who received early EBD (EBS: 30, ENBD: 32) for AC, associated with DIC. The rates of clinical success for AC and DIC resolution at 7 days after EBD were 90.3% and 88.7%, respectively. Mean hospitalization period was 31.7 days, and in-hospital mortality rate was 4.8%. ERCP-related adverse events developed in 3.2% of patients (bleeding in two patients). Comparison between EBS and ENBD groups showed that the ENBD group included patients with more severe cholangitis, and acute physiology and chronic health evaluation II score, systemic inflammatory response syndrome score, and serum bilirubin level were significantly higher in this group. However, no significant difference was observed in clinical outcomes between the two groups; both EBS and ENBD were effective. In conclusion, early EBD is effective and safe for patients with AC associated with DIC.
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http://dx.doi.org/10.3390/jcm10163606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396990PMC
August 2021

Uncovered versus covered metallic stents for the management of unresectable malignant distal biliary obstruction: a randomized multicenter trial.

Scand J Gastroenterol 2021 Oct 10;56(10):1229-1235. Epub 2021 Aug 10.

Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan.

Objective: The treatment result of the uncovered metallic stent (uncovered MS) and covered metallic stent (covered MS) for unresectable malignant distal biliary obstruction is controversial. This time, we conducted this study to compare the efficacies and complication rates of uncovered MS and covered MS in unresectable malignant distal biliary obstructions at a prospective randomized multicenter trial.

Materials And Methods: From April 2014 to September 2018, patients with unresectable malignant distal biliary obstruction were randomly assigned to 2 groups: the uncovered MS group and the covered MS group.

Results: 92 treatment results patients were discussed. 48 patients were assigned to the uncovered MS group and 44 cases were assigned to the covered MS group. Both groups showed a drainage effect. No significant difference was found in the drainage effect between the 2 groups. The number of stent occlusion was significantly greater ( = .0467) in uncovered MS (43.8%) comparing with those in covered MS (22.7%). As the cause of stent occlusion, tumor ingrowth was significantly greater ( < .001) in the uncovered MS group (35.4%) than in the covered MS group (2.3%). The median stent patency period was significantly longer ( = .0112) in the covered MS group (455 days) than that of the uncovered MS group (301 days). A significant difference in the median survival period was not found between the 2 groups.

Conclusions: Covered MS showed the possibility of extending the stent patency period by suppressing tumor ingrowth more than uncovered MS does. The UMIN Clinical Trial Registry number is UMIN000015093.
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http://dx.doi.org/10.1080/00365521.2021.1938207DOI Listing
October 2021

The Influence of Pre-Procedural Imaging and Cystic Duct Cholangiography on Endoscopic Transpapillary Gallbladder Drainage in Acute Cholecystitis.

Diagnostics (Basel) 2021 Jul 16;11(7). Epub 2021 Jul 16.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki 216-8511, Kanagawa, Japan.

Endoscopic transpapillary gallbladder drainage (ETGBD) for acute cholecystitis is challenging. We evaluated the influence of pre-procedural imaging and cystic duct cholangiography on ETGBD. Patients who underwent ETGBD for acute cholecystitis were retrospectively examined. The rate of gallbladder contrast on cholangiography, the accuracy of cystic duct direction and location by computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP), and the relationship between pre-procedural imaging and the technical success of ETGBD were investigated. A total of 145 patients were enrolled in this study. Gallbladder contrast on cholangiography was observed in 29 patients. The accuracy of cystic duct direction and location (proximal or distal, right or left, and cranial or caudal) by CT were, respectively, 79%, 60%, and 58% by CT and 68%, 55%, and 58% by MRCP. Patients showing gallbladder contrast on cholangiography underwent ETGBD with a significantly shorter procedure time and a lower rate of cystic duct injury. No other factors affecting procedure time, technical success, and cystic duct injury were identified. Pre-procedural evaluation of cystic duct direction and location by CT or MRCP was difficult in patients with acute cholecystitis. Patients who showed gallbladder contrast on cholangiography showed a shorter procedure time and a lower rate of cystic duct injury.
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http://dx.doi.org/10.3390/diagnostics11071286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307666PMC
July 2021

Efficacy of endoscopic large balloon dilation extended for 2 minutes in bile duct stone removal: A multicenter retrospective study.

J Hepatobiliary Pancreat Sci 2021 Jul 30. Epub 2021 Jul 30.

Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kawasaki, Japan.

Background/purpose: There is no evidence regarding the optimal balloon dilation time during endoscopic papillary large balloon dilation (EPLBD). The study aim was to evaluate the efficacy of 2-minute extended balloon dilation for EPLBD.

Methods: Two hundred and five patients who underwent EPLBD during endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones at three tertiary centers were included in the analysis. Clinical outcomes and the adverse events were compared between the 0-minute group (n = 94, balloon deflated immediately after waist disappearance) and the 2-minute group (n = 111, balloon dilation maintained for 2 minutes after waist disappearance). The risk factors of post-ERCP pancreatitis (PEP) after EPLBD were assessed.

Results: There were no significant differences in the stone removal rates and hospitalization periods between the two groups. However, the total ERCP procedure time was significantly shorter in the 2-minute group (40.6 vs 48.9 min, P = .03). The incidence of PEP was 7.4% in the 0-minute group and significantly lower at 0.9% in the 2-minute group (P = .04). Multivariate analysis identified without 2-minute extended EPLBD as a significant risk factor of PEP (OR: 9.9, P = .045).

Conclusions: Extension of EPLBD for 2 minutes helped prevent PEP and shortened the procedure time.
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http://dx.doi.org/10.1002/jhbp.1029DOI Listing
July 2021

A novel mask to prevent aerosolized droplet dispersion in endoscopic procedures during the coronavirus disease pandemic.

Medicine (Baltimore) 2021 Jul;100(26):e26048

Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

Abstract: Endoscopic procedures increase the risk of transmission of severe acute respiratory syndrome coronavirus 2 to medical staff, because aerosols are generated during upper gastrointestinal endoscopy. There have been several reported studies on devices for infection prevention; however, few reports have validated them. Therefore, we developed a novel mask to prevent the diffusion of aerosol droplets from patients undergoing endoscopy.We compared microdroplet dispersion during coughing episodes when using the novel mask with microdroplet dispersion when using the conventional mouthpiece alone.The mean number of microdroplets was significantly smaller in the group that used the novel mask (57.9 ± 122.91 vs 933.6 ± 119.80 droplets; P = .01).The novel mask may aid in reducing the degree of exposure of medical personnel to microdroplets and the risk of subsequent infection.
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http://dx.doi.org/10.1097/MD.0000000000026048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8257832PMC
July 2021

Clinical impact of recombinant thrombomodulin administration on disseminated intravascular coagulation due to severe acute cholangitis (Recover-AC study).

J Hepatobiliary Pancreat Sci 2021 May 22. Epub 2021 May 22.

Department of Internal Medicine, Osaka Medical College, Osaka, Japan.

Background And Aim: Recombinant thrombomodulin (rhTM) is potentially effective in the treatment of disseminated intravascular coagulation (DIC). Several studies related to drugs for the treatment of acute cholangitis have shown negative results in improvement of overall survival (OS) with rhTM. The aim of this multicenter study was to evaluate the clinical effectiveness of rhTM in patients with acute cholangitis and sepsis-induced DIC who underwent biliary drainage.

Methods: A total of 284 consecutive patients, who were complicated with sepsis-induced DIC due to severe acute cholangitis, were included (rhTM group, n = 173; non-rhTM, n = 111) in this study. The primary outcome was the DIC resolution rate at 7 days after starting treatment. The 28-day survival rate was secondarily evaluated.

Results: DIC scores in the rhTM group improved significantly compared with the non-rhTM group on day 7 (P = .020). According to multivariate analysis, etiology of cholangitis (malignant, HR 2.28), rhTM (non-administration, HR 4.13), and DIC score (≥5, HR 2.46) were significant factors associated with failed DIC resolution on day 7. Propensity score matching created 103 matched pairs. Survival rate at day 28 was significantly higher in rhTM group (94.3%) compared with non-rhTM group (82.6%; P = .048) after propensity score matching. rhTM (non-administration, HR 2.870), DIC score (≥5, HR 2.751), and APACHE II score (≥20, HR 9.310) were significant factors associated with decreasing survival rate at day 28.

Conclusion: In conclusion, rhTM seemed to improve patient survival, but future studies should only include patients with benign or malignant disease and should be performed according to APACHE II scores.
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http://dx.doi.org/10.1002/jhbp.998DOI Listing
May 2021

Incidence and management of cystic duct perforation during endoscopic transpapillary gallbladder drainage for acute cholecystitis.

Dig Endosc 2021 Feb 18. Epub 2021 Feb 18.

Departments of, Department of, Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kanagawa, Japan.

Background And Aim: Evidence regarding the incidence and clinical outcome of cystic duct perforation (CDP) during endoscopic transpapillary gallbladder drainage (ETGBD) is inadequate. The present study aimed to evaluate the incidence and management of CDP during ETGBD.

Methods: Between March 2011 and December 2019, 249 patients underwent initial ETGBD for acute cholecystitis. The incidence of CDP was retrospectively examined and the outcomes between the CDP and non-CDP groups were compared.

Results: CDP during ETGBD occurred in 23 (9.2%) of 249 patients (caused by guidewire in 15 and cannula in 8). ETGBD was successful in 10 patients following CDP. In 13 patients who failed ETGBD, 11 underwent bile duct drainage during the same session; nine patients underwent gallbladder decompression by other methods, such as percutaneous drainage. Clinical resolution for acute cholecystitis was achieved in 20 patients, and no bile peritonitis was noted. ETGBD technical success rates (45.3% vs. 91.2%, p < 0.001), ETGBD procedure times (66.5 vs. 54.8 min, p = 0.041), and hospitalization periods (24.5 vs. 18.7 days, p = 0.028) were significantly inferior in the CDP group (n = 23) compared with the non-CDP group (n = 216). There were no differences in clinical success and adverse events other than CDP between both groups.

Conclusions: Cystic duct perforation reduced the ETGBD technical success rate. However, even in patients with cystic duct perforation, an improvement of acute cholecystitis was achieved by subsequent successful ETGBD or additional procedures, such as percutaneous drainage.
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http://dx.doi.org/10.1111/den.13959DOI Listing
February 2021

Intraductal Papillary Mucinous Neoplasm with Pancreatogastric Fistula.

Intern Med 2021 Apr 23;60(8):1211-1215. Epub 2020 Nov 23.

Department of Internal Medicine, Division of Gastroenterology, Sapporo Shirakabadai Hospital, Japan.

We herein report a rare case of intraductal papillary mucinous neoplasm with a pancreatogastric fistula in an elderly Japanese man admitted to our hospital. The pancreatogastric fistula was confirmed using endoscopic retrograde pancreatography via a cannulated guidewire placed in the stomach. Six months after admission, the patient was diagnosed with intraductal papillary mucinous carcinoma. A pancreatogastric fistula is generally a rare complication of intraductal papillary mucinous neoplasm. It was caused by mechanical penetration in this case. Interestingly, we also observed endoscopic and histochemical mucosal changes in the fistula.
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http://dx.doi.org/10.2169/internalmedicine.5889-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112989PMC
April 2021

Complete Lymphadenectomy Around the Entire Superior Mesenteric Artery Improves Survival in Artery-First Approach Pancreatoduodenectomy for T3 Pancreatic Ductal Adenocarcinoma.

World J Surg 2021 Mar 10;45(3):857-864. Epub 2020 Nov 10.

Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kawasaki, Japan.

Background: Artery-first approach pancreatoduodenectomy (AFA-PD) is an important technique for treating pancreatic ductal adenocarcinoma (PDAC). However, it remains unknown whether performing complete lymphadenectomy around the entire superior mesenteric artery (SMA) is associated with better outcomes. In this retrospective study, we aimed to investigate whether this approach improved overall and recurrence-free survival in patients with PDAC.

Methods: We identified 88 patients with T3 PDAC who underwent PD at St. Marianna University School of Medicine, Kawasaki, Japan, between April 2005 and October 2017. Two groups were defined: an "AFA-PD group" (n = 45) who had undergone AFA-PD in addition to complete lymphadenectomy around the entire SMA, and a "conventional PD group" (n = 43) in whom complete lymphadenectomy had not been performed (conventional group). Univariate and multivariate survival analyses were performed to identify risk factors for overall and disease-free survival.

Results: The AFA-PD group had a longer median survival time (40.3 vs. 22.6 months; p = 0.0140) and a higher 5-year survival rate (40.3% vs. 5.9%, p = 0.005) than the conventional PD group. Multivariate analysis showed that AFA-PD with complete lymphadenectomy around the entire SMA was an independent factor for improved overall survival (p = 0.022). Recurrences around the SMA were significantly less frequent in the AFA-PD group than in the conventional group (22.2% vs. 44.2%, p = 0.041).

Conclusions: AFA-PD with complete lymphadenectomy around the entire SMA can prevent recurrences around the SMA and may prolong overall survival in patients with PDAC.
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http://dx.doi.org/10.1007/s00268-020-05856-wDOI Listing
March 2021

Exposure of coils to the pseudocystic cavity after embolization of a pseudoaneurysm caused by lumen-apposing metal stent placement.

Gastrointest Endosc 2021 02 10;93(2):521-522. Epub 2020 Sep 10.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1016/j.gie.2020.09.004DOI Listing
February 2021

Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal.

BMC Gastroenterol 2020 Aug 24;20(1):285. Epub 2020 Aug 24.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.

Background: Recent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP.

Methods: We retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP.

Results: The rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19-9.88; P = 0.02).

Conclusions: When removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.
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http://dx.doi.org/10.1186/s12876-020-01428-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446213PMC
August 2020

Endoscopic transpapillary gallbladder stent placement in the presence of uncovered biliary metal stents using a through-the-mesh technique.

VideoGIE 2020 Jul 15;5(7):296-299. Epub 2020 May 15.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1016/j.vgie.2020.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332764PMC
July 2020

Endoscopic Transpapillary Gallbladder Drainage via the Mesh of Triple Uncovered Biliary Metal Stents Using a Soehendra Stent Retriever.

J Gastrointestin Liver Dis 2020 Jun 3;29(2):143. Epub 2020 Jun 3.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.15403/jgld-1045DOI Listing
June 2020

Hoarseness After Endoscopic Retrograde Cholangiopancreatography.

Gastroenterology 2021 01 5;160(1):e15-e16. Epub 2020 Jun 5.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1053/j.gastro.2020.05.071DOI Listing
January 2021

Splenosis diagnosed by EUS-guided FNA.

Gastrointest Endosc 2020 Nov 3;92(5):1129-1130. Epub 2020 Jun 3.

Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kawasaki, Japan.

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http://dx.doi.org/10.1016/j.gie.2020.05.037DOI Listing
November 2020

Use of washing cytology from removed self-expandable metal stents for biliary strictures: a novel cytology method.

Endosc Int Open 2020 Jun 25;8(6):E748-E752. Epub 2020 May 25.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

Removability is one of the important features of biliary covered self-expandable metal stents (CSEMS). In this study, we evaluated the diagnostic ability of washing cytology of removed CSEMS. For 14 removed CSEMS that had been placed for the biliary strictures (12 malignant, 2 benign), the surface of CSEMS was washed with saline, and pathological examination of the washing liquid as cytology (CSEMS washing cytology) was performed. The specimen sampling rates and sensitivity for malignancy of CSEMS washing cytology were 92.9 % and 41.7 %, respectively. Sensitivity according to the primary disease was 60.0 % for bile duct cancer and 20 % for pancreatic cancer. Sensitivities based on the methods of stent removal were 16.7 % and 66.7 % for removal through the channel of the scope and with the scope, respectively. Therefore, it is possible that sensitivity of CSEMS washing cytology is higher in bile duct cancer and for removal with the scope. In conclusion, CSEMS washing cytology may have potential as a pathological diagnostic method.
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http://dx.doi.org/10.1055/a-1144-2668DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247891PMC
June 2020

Endoscopic ultrasound-guided bilateral biliary drainage through the mesh of the metal stents using a balloon occlusion method.

Dig Endosc 2020 Jul 28;32(5):e104-e105. Epub 2020 May 28.

Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, Kanagawa, Japan.

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http://dx.doi.org/10.1111/den.13701DOI Listing
July 2020

Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis After Biliary Self-Expandable Metal Stent Placement.

Surg Laparosc Endosc Percutan Tech 2020 Oct;30(5):416-423

Departments of Gastroenterology and Hepatology.

Background: Endoscopic transpapillary gallbladder drainage (ETGBD) for acute cholecystitis (AC) after self-expandable metal stent (SEMS) placement is technically challenging and there are no reports about its outcome in a several cases. This study aims to assess the outcomes of ETGBD for AC after SEMS placement.

Methods: Between April 2011 and April 2019, 314 patients underwent SEMS placement for biliary stricture. Among them, 12 of 21 patients who developed AC after SEMS placement underwent ETGBD. In general, ETGBD was performed after SEMS removal in cases in which a covered SEMS was previously placed or with the SEMS kept in place in cases in which an uncovered SEMS was previously placed. When the orifice of the cystic duct overlapped the uncovered SEMS, ETGBD was performed through the mesh of the SEMS.

Results: Among the 12 patients who underwent ETGBD, the previously placed SEMS was in the distal (n=8) or perihilar (n=4) bile duct. The type of SEMS placed in the distal bile duct was covered in 7 (fully covered: 6, partially covered: 1) and uncovered in 1, whereas that in the perihilar bile duct was uncovered for all. The technical success rate of ETGBD was 83.3% (10/12), and that according to the previous SEMS placement site was 75.0% (6/8) for the distal bile duct and 100% (4/4) for the perihilar bile duct. In the technically successful, the clinical success rate for AC was 90.0% (9/10). The rate of adverse event was 16.7% (2/12) (stent kink: 1, tube self-removal: 1).

Conclusions: ETGBD can have relatively good outcomes for AC after SEMS placement.
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http://dx.doi.org/10.1097/SLE.0000000000000802DOI Listing
October 2020

Endoscopic transpapillary gallbladder drainage using the balloon occlusion method to advance the guidewire into the cystic duct.

Endoscopy 2020 09 18;52(9):E339-E341. Epub 2020 Mar 18.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Japan.

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http://dx.doi.org/10.1055/a-1125-5826DOI Listing
September 2020

Washing cytology of removed self-expandable metal stent for biliary stricture: A novel cytology technique.

Diagn Cytopathol 2019 Jul 6;47(7):743-745. Epub 2019 May 6.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Miyamae-ku, Kawasaki, Japan.

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http://dx.doi.org/10.1002/dc.24206DOI Listing
July 2019

Endoscopic Sphincterotomy before Fully Covered Metal Stent Placement Is Not Required for Distal Malignant Biliary Stricture due to a Pancreatic Head Tumor.

Gastroenterol Res Pract 2019 15;2019:9675347. Epub 2019 Jan 15.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan.

Background/aims: Endoscopic sphincterotomy (EST) is often performed before fully covered self-expandable metal stent (FCSEMS) placement in order to prevent pancreatitis. However, it is not clear whether EST prevents pancreatitis or affects other adverse events (AEs). This study is conducted to evaluate the necessity of EST before FCSEMS placement for distal malignant biliary strictures due to a pancreatic head tumor.

Methods: This study included 68 patients who underwent FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor. Treatment outcomes and AEs were retrospectively compared between 32 patients with EST before FCSEMS placement (EST group) and 36 patients without EST (non-EST group).

Results: The success rates of drainage for the EST and non-EST groups were 100% and 97.2%, respectively ( = 0.95). The incidence of pancreatitis in the EST and non-EST groups was 3.1% and 0%, respectively ( = 0.95). The incidence of hyperamylasemia in the EST and non-EST groups was 12.5% and 13.9%, respectively ( = 0.85). The incidence of all AEs in the EST and non-EST groups was 15.6% (pancreatitis: 1, cholecystitis: 2, and stent migration: 2) and 13.9% (cholecystitis: 3, stent migration: 2), respectively ( = 0.89).

Conclusions: EST before FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor does not affect the successful drainage and incidence of adverse events. The necessity of EST to prevent pancreatitis before FCSEMS placement was deemed low.
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http://dx.doi.org/10.1155/2019/9675347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350600PMC
January 2019

Daclatasvir and asunaprevir improves health-related quality of life in Japanese patients infected with hepatitis C virus.

JGH Open 2018 Jun 14;2(3):87-92. Epub 2018 May 14.

Department of Internal Medicine, Division of Gastroenterology and Hepatology St. Marianna University School of Medicine Kawasaki Japan.

Aims: Interferon-free direct-acting antiviral agent (DAA) regimens for chronic hepatitis C virus (HCV) patients have improved their health-related quality of life (HRQOL). Currently, there are no published data assessing the impact of DAAs regimens without sofosbuvir on HRQOL. The aim of this study was to investigate the improvement of HRQOL in Japanese HCV patients treated with a protease inhibitor and a nonstructural protein 5A inhibitor.

Methods And Results: A total of 123 Japanese genotype 1b HCV patients receiving daclatasvir (DCV) and asunaprevir (ASV) for 24 weeks were enrolled. HRQOL was assessed using the Japanese version of the Chronic Liver Disease Questionnaire (CLDQ) at baseline; weeks 4, 12, and 24; and post-24 weeks. Changes in CLDQ scores were calculated by subtracting the CLDQ score at each time point from the baseline value. Improvement in the mean change of the Japanese version of the CLDQ score became statistically significant as early as week 4 after the initiation of treatment (+9.3%;  < 0.0001) and was sustained during and after DCV/ASV treatment. The changes of CLDQ at posttreatment week 24 in patients with sustained virological responses (SVR) were significantly higher than those in patients without SVR (0.4% and -4.1%, respectively;  < 0.05).

Conclusions: This study of DCV/ASV treatment for Japanese HCV patients in a clinical setting demonstrated that HRQOL can improve as early as at the initiation of treatment and can continue during and after treatment, regardless of the classes of DAAs regimens and race. Moreover, SVR are needed to continue HRQOL improvement.
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http://dx.doi.org/10.1002/jgh3.12052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207024PMC
June 2018

Efficacy of Combined Thrombomodulin and Antithrombin in Anticoagulant Therapy for Acute Cholangitis-induced Disseminated Intravascular Coagulation.

Intern Med 2019 Apr 19;58(7):907-914. Epub 2018 Nov 19.

Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Japan.

Objective The efficacy and safety of concomitant use of antithrombin (AT) with recombinant human soluble thrombomodulin (rTM) for acute cholangitis-induced disseminated intravascular coagulation (AC-induced DIC) remains unclear. This study was conducted to investigate the efficacy of AT combined with rTM as anticoagulant therapy for AC-induced DIC. Methods One hundred patients with AC-induced DIC received anticoagulant therapy using rTM from April 2010 to December 2017. Of the 83 patients treated with rTM immediately after the diagnosis of DIC, excluding those who had not undergone biliary drainage or who had malignancies or a serum AT III level >70%, 56 patients were studied. Outcomes and adverse events (AEs) were retrospectively compared between the 16 patients treated with rTM alone (rTM group) and the 40 patients treated with rTM and AT (rTM+AT group). Results Patients' background characteristics did not differ markedly, except for a significantly higher serum D-dimer level in the rTM group than in the rTM+AT group (p=0.038). The DIC resolution rates on day 9 were 100% and 95.1% in the rTM and rTM+AT groups, respectively (p=0.909). The mean DIC scores were significantly lower in the rTM group than in the rTM+AT group on days 3 (p=0.012), 5 (p<0.001), 7 (p=0.033), and 9 (p=0.007). The incidence of AEs was 6.3% and 10.0% (p=0.941), and the in-hospital mortality rates was 0% and 5.0% (p=0.909) in the rTM and rTM+AT groups, respectively. Conclusion The concomitant use of AT with anticoagulant therapy using rTM for AC-induced DIC may not help improve the treatment outcome.
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http://dx.doi.org/10.2169/internalmedicine.1923-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478986PMC
April 2019

Efficacy and Safety of Single-Session Endoscopic Stone Removal for Acute Cholangitis Associated with Choledocholithiasis.

Can J Gastroenterol Hepatol 2018 8;2018:3145107. Epub 2018 Aug 8.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan.

Background/aims: In early endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to choledocholithiasis, it is unclear that single-session stone removal can be safely performed. We examined the efficacy and safety of early single-session stone removal for mild-to-moderate acute cholangitis associated with choledocholithiasis.

Methods: Among patients with mild-to-moderate acute cholangitis associated with choledocholithiasis who underwent early ERCP (n = 167), we retrospectively compared the removal group (patients who underwent single-session stone removal; n = 78) with the drainage group (patients who underwent biliary drainage alone; n = 89) and examined the effectiveness and safety of single-session stone removal by early ERCP.

Results: The patients in the removal group had significantly fewer and smaller stones compared with those in the drainage group. The single-session complete stone removal rate was 85.9% in the removal group. The complication rate in early ERCP was 11.5% in the removal group and 10.1% in the drainage group, with no significant difference (P = 0.963). On comparing patients who underwent early endoscopic sphincterotomy (EST) with those who underwent elective EST after cholangitis had improved, the post-EST bleeding rates were 6.8% and 2.7%, respectively, with no significant difference (P = 0.600). The mean duration of hospitalization was 11.9 days for the removal group and 19.9 days for the drainage group, indicating a shorter stay for the removal group (P < 0.001). In multiple linear regression analysis, stone removal in early ERCP, number of stones, and C-reactive protein level were significant predictors of hospitalization period.

Conclusions: Single-session stone removal for mild-to-moderate acute cholangitis can be safely performed. It is useful from the perspective of shorter hospital stay.
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http://dx.doi.org/10.1155/2018/3145107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106953PMC
February 2019

Diagnostic Ability of Endoscopic Bile Cytology Using a Newly Designed Biliary Scraper for Biliary Strictures.

Dig Dis Sci 2019 01 23;64(1):241-248. Epub 2018 Jul 23.

Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.

Background: A new device with metallic wires for scrape cytology was developed.

Aims: To compare the diagnostic performance of scrape cytology and conventional cytology during endoscopic retrograde cholangiopancreatography for biliary strictures.

Methods: A total of 420 cases with biliary stricture underwent transpapillary bile cytology. Among them, there are 79 cases with scrape cytology using the new device (scrape group) and 341 cases with conventional cytology (control group). Seventy-two and 174 cases underwent biliary biopsy at the same time as bile cytology in the scrape and control group, respectively.

Results: The sensitivity for malignancy of bile cytology in the scrape and control group was 41.2% [pancreatic cancer (PC): 23.1%, biliary cancer (BC): 52.5%] and 27.1% (PC: 16.3%, BC: 38.0%), respectively (P = 0.023). When analyzed PC and BC, respectively, there was no significant difference between the two groups. In the both groups, the sensitivity was significantly higher for BC than PC. In the scrape group, there was no difference in the sensitivity between cytology and biopsy [39.7% (PC: 17.4%, BC: 55.3%)], but in the control group, a significantly lower sensitivity was observed with cytology than biopsy (36.4% (PC: 19.7%, BC: 50.0%)) (P = 0.046). When analyzed PC and BC, respectively, there was no significant difference between cytology and biopsy. The sensitivity of combined cytology and biopsy was 55.6% (PC: 30.4%, BC: 71.1%) in the scrape group and 47.0% (PC: 24.6%, BC: 64.3%) in the control group.

Conclusion: Scrape bile cytology for biliary strictures may be superior to conventional cytology.
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http://dx.doi.org/10.1007/s10620-018-5217-yDOI Listing
January 2019

Esophagogastric varices were diagnosed in a non-cirrhotic liver case during long-term follow-up after oxaliplatin-based chemotherapy.

Clin J Gastroenterol 2018 Dec 11;11(6):487-492. Epub 2018 Jun 11.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Oxaliplatin, a chemotherapeutic agent for colorectal cancer, has been associated with pathological evidence of sinusoidal endothelial injury in the liver. However, esophagogastric varices are a poorly recognized outcome of oxaliplatin-based chemotherapy. We report a 78-year-old man, whose past history of colon cancer was resection and treatment with mFOLFOX6 for 20 weeks, as adjuvant chemotherapy. After 3.5-year follow-up of the oxaliplatin-based chemotherapy, he was diagnosed with esophageal varices without liver dysfunction, indicating that the hepatotoxicity caused by oxaliplatin could be prolonged after its administration. Patients who have received oxaliplatin-based chemotherapy should be followed up carefully over the long term.
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http://dx.doi.org/10.1007/s12328-018-0873-1DOI Listing
December 2018

Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks.

J Hepatobiliary Pancreat Sci 2018 Apr 11;25(4):231-239. Epub 2018 Mar 11.

Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.

Background: Enhanced recovery after surgery (ERAS) protocols are beneficial for pancreatoduodenectomy (PD). Our aim was to evaluate risk factors associated with ERAS protocol failure after PD.

Methods: Clinical variables of 187 patients managed using ERAS protocols between April 2011 and April 2017, including non-early recovery (non-ER) patients, with complications or requiring a hospital stay ≥15 days, and early recovery (ER) patients, were compared. A physical aging (PA) score was devised to predict postoperative risks.

Results: Independent risk factors of complications were a pre-albumin level ≤18 mg/dl (odds ratio (OR) 2.197; 95% confidence interval (CI) 1.052-4.622), and an American Society of Anesthesiologists (ASA) score ≥II (OR 2.195; 95% CI 1.052-4.746). Independent risk factors for hospital stay ≥15 days (P < 0.001) were age ≥70 years (OR 2.438; 95% CI 1.122-5.299) and an ASA score ≥II (OR 2.348; 95% CI 1.109-4.968). The PA score included age, ASA score, and pre-albumin level. The complication rate for each PA score was as follows: score "0", 12.1%; score "1", 18.2%; score "2", 26.9%; score "3", 30.8%; and score "≥4", 47.2%.

Conclusions: Advanced age, poor nutrition, and serious illnesses can cause ERAS protocol failure. The PA score is effective for predicting postoperative progress.
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http://dx.doi.org/10.1002/jhbp.540DOI Listing
April 2018

Crowned dens syndrome developed after an endoscopic retrograde cholangiopancreatography procedure.

World J Gastroenterol 2016 Oct;22(39):8849-8852

Hiroyasu Nakano, Kazunari Nakahara, Yosuke Michikawa, Keigo Suetani, Ryo Morita, Nobuyuki Matsumoto, Fumio Itoh, Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan.

We present a unique case of crowned dens syndrome (CDS) that developed after endoscopic retrograde cholangiopancreatography (ERCP) in a patient who presented with fever and neck pain. Administration of non-steroidal anti-inflammatory drugs was extremely effective for relieving fever and neck pain, and in the improvement of inflammatory markers. To the best of our knowledge, this is the first case report of CDS caused by an ERCP procedure. In a patient with fever and neck pain after an ERCP procedure, CDS should be considered in the differential diagnosis.
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http://dx.doi.org/10.3748/wjg.v22.i39.8849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075560PMC
October 2016
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