Publications by authors named "Keigo Suetani"

28 Publications

  • Page 1 of 1

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

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

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

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

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 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

A rare case of Epstein-Barr virus-positive mucocutaneous ulcer that developed into an intestinal obstruction: a case report.

BMC Gastroenterol 2020 Jan 13;20(1). Epub 2020 Jan 13.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, 1-30-37, Shukugawara, Tama-Ku, Kawasaki, Japan.

Background: Epstein-Barr virus-positive mucocutaneous ulcer (EBV-MCU) is a new category of mature B-cell neoplasms. Ulcers occur in the oropharyngeal mucosa, skin, and gastrointestinal tract. The onset of EBV-MCU is suggested to be related to the decreased immunity of the patient, the causes of which include the use of immunosuppressive agents and aging. EBV-MCU may regress spontaneously and it often has a benign course after the dose reduction or discontinuation of immunosuppressive agents or during follow-up. Here, we report the case of a patient who required surgical resection for the intestinal obstruction arising from EBV-MCU.

Case Presentation: A Japanese elderly male visited our hospital with chief complaints of a palpable mass and dull pain in the left upper quadrant, loss of appetite, and weight loss. Although abdominal computed tomography and total colonoscopy (TCS) revealed a tumor with circumferential ulcer in the transverse colon, histopathological analysis of a biopsy specimen of this lesion showed only nonspecific inflammation. Because the tumor spontaneously regressed during the time he underwent tests to obtain a second opinion from another hospital, TCS was reperformed on the patient. TCS revealed that the tumor decreased in size and the inflammatory changes in the surrounding mucosa tended to improve; however, tightening of the surrounding mucosa due to scarring was observed. Another histopathological analysis of a biopsy specimen showed widespread erosion of the mucosa and the formation of granulation tissue with marked infiltration of various inflammatory cells into the mucosal tissue of the large intestine. Moreover, some of the B-lymphocyte antigen CD20-positive B cells were also positive for EBV-encoded small RNA-1, suggesting the possibility of EBV-MCU. Later, the tumor developed into an intestinal obstruction; thus, the transverse colon was resected. Histopathological analysis of the resected specimen demonstrated scattered Hodgkin and Reed-Sternberg-like multinucleated large B cells in addition to EBER-1-positive cells. The patient was finally diagnosed as having EBV-MCU.

Conclusions: This is the first report of a case of EBV-MCU that developed into an intestinal obstruction requiring surgical resection. It is necessary to consider the possibility of EBV-MCU when examining an ulcerative or tumorous lesion in the gastrointestinal tract.
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http://dx.doi.org/10.1186/s12876-020-1162-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958744PMC
January 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

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

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

A case of Ménétrier's disease seemingly caused by hilar cholangiocarcinoma.

Nihon Shokakibyo Gakkai Zasshi 2016 ;113(6):975-82

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

A 54-year-old man presented to our department with abdominal discomfort and anorexia and was diagnosed as having Ménétrier's disease (MD) with hilar cholangiocarcinoma. Based on his clinical examination, there was no evidence of Helicobacter pylori or cytomegalovirus (CMV) infection. Although we administered proton pump inhibitor and high-calorie enteral nutrition, hypoproteinemia did not improve, and the refractory protein-losing enteropathy persisted. However, interestingly, MD improved immediately after resection of the hilar cholangiocarcinoma. Generally, the etiology of MD is unknown, but H. pylori and CMV infections have been implicated. To our knowledge, there has been no previous report indicating that a malignant tumor could be involved in the etiology of MD. Thus, we report an extremely rare case of MD which is seemingly caused by malignancy.
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http://dx.doi.org/10.11405/nisshoshi.113.975DOI Listing
February 2017

A Novel Approach for Endoscopic Papillary Balloon Dilation with the Guidewire Left in the Pancreatic Duct to Ensure Pancreatic Stenting.

Hepatogastroenterology 2015 Jun;62(140):1027-31

Background/aims: Endoscopic papillary balloon dilation (EPBD) was reported to be superior for preserving the function of the sphincter of Oddi and to cause fewer late complications than endoscopic sphincterotomy. If the early complication of post-EPBD pancreatitis can be prevented, EPBD might be useful as long-term outcomes. This study assessed the feasibility of a novel EPBD for the purpose of reliable post-EPBD pancreatic stenting.

Methodology: Among 1814 ER-CPs, in 17 patients undergoing biliary cannulation with pancreatic duct guidewire placement method, we performed EPBD with the guidewire left in the pancreatic duct by the two-devices-in-one-channel method. This approach employed in order to ensure pancreatic stenting.

Results: Procedures were successfully performed without the guidewire displacement, and pancreatic stents were easily placed in all patients. Post-EPBD pancreatitis occurred in only 1 patient (5.9%), and the severity was mild. Asymptomatic hyperamylasemia occurred in 3 patients (17.6%). There were no other early complications. The mean serum amylase levels (mean ± SD) before, 1 day, and 2 days after procedure were 81.4 ± 61.9, 301.2 ± 273.0, and 220.0 ± 177.6 IU/L.

Conclusions: EPBD with a guidewire left in the pancreatic duct is useful method allowing reliable pancreatic stenting and may contribute to the prevention of pancreatitis.
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June 2015

Enteral metallic stenting by balloon enteroscopy for obstruction of surgically reconstructed intestine.

World J Gastroenterol 2015 Jun;21(24):7589-93

Kazunari Nakahara, Chiaki Okuse, Nobuyuki Matsumoto, Keigo Suetani, Ryo Morita, Yosuke Michikawa, Shun-ichiro Ozawa, Kosuke Hosoya, Fumio Itoh, Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki 216-8511, Japan.

We present three cases of self-expandable metallic stent (SEMS) placement using a balloon enteroscope (BE) and its overtube (OT) for malignant obstruction of surgically reconstructed intestine. A BE is effective for the insertion of an endoscope into the deep bowel. However, SEMS placement is impossible through the working channel, because the working channel of BE is too small and too long for the stent device. Therefore, we used a technique in which the BE is inserted as far as the stenotic area; thereafter, the BE is removed, leaving only the OT, and then the stent is placed by inserting the stent device through the OT. In the present three cases, a modification of this technique resulted in the successful placement of the SEMS for obstruction of surgically reconstructed intestine, and the procedures were performed without serious complications. We consider that the present procedure is extremely effective as a palliative treatment for distal bowel stenosis, such as in the surgically reconstructed intestine.
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http://dx.doi.org/10.3748/wjg.v21.i24.7589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4481457PMC
June 2015

Thrombomodulin in the management of acute cholangitis-induced disseminated intravascular coagulation.

World J Gastroenterol 2015 Jan;21(2):533-40

Keigo Suetani, Chiaki Okuse, Kazunari Nakahara, Yosuke Michikawa, Yohei Noguchi, Midori Suzuki, Ryo Morita, Nozomi Sato, Masaki Kato, Fumio Itoh, Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki 216-8511, Japan.

Aim: To evaluate the need for thrombomodulin (rTM) therapy for disseminated intravascular coagulation (DIC) in patients with acute cholangitis (AC)-induced DIC.

Methods: Sixty-six patients who were diagnosed with AC-induced DIC and who were treated at our hospital were enrolled in this study. The diagnoses of AC and DIC were made based on the 2013 Tokyo Guidelines and the DIC diagnostic criteria as defined by the Japanese Association for Acute Medicine, respectively. Thirty consecutive patients who were treated with rTM between April 2010 and September 2013 (rTM group) were compared to 36 patients who were treated without rTM (before the introduction of rTM therapy at our hospital) between January 2005 and January 2010 (control group). The two groups were compared in terms of patient characteristics at the time of DIC diagnosis (including age, sex, primary disease, severity of cholangitis, DIC score, biliary drainage, and anti-DIC drugs), the DIC resolution rate, DIC score, the systemic inflammatory response syndrome (SIRS) score, hematological values, and outcomes. Using logistic regression analysis based on multivariate analyses, we also examined factors that contributed to persistent DIC.

Results: There were no differences between the rTM group and the control group in terms of the patients' backgrounds other than administration. DIC resolution rates on day 9 were higher in the rTM group than in the control group (83.3% vs 52.8%, P < 0.01). The mean DIC scores on day 7 were lower in the rTM group than in the control group (2.1 ± 2.1 vs 3.5 ± 2.3, P = 0.02). The mean SIRS scores on day 3 were significantly lower in the rTM group than in the control group (1.1 ± 1.1 vs 1.8 ± 1.1, P = 0.03). Mortality on day 28 was 13.3% in the rTM group and 27.8% in the control group; these rates were not significantly different (P = 0.26). Multivariate analysis identified only the absence of biliary drainage as significantly associated with persistent DIC (P < 0.01, OR = 12, 95%CI: 2.3-60). Although the difference did not reach statistical significance, primary diseases (malignancies) (P = 0.055, OR = 3.9, 95%CI: 0.97-16) and the non-use of rTM had a tendency to be associated with persistent DIC (P = 0.08, OR = 4.3, 95%CI: 0.84-22).

Conclusion: The add-on effects of rTM are anticipated in the treatment of AC-induced DIC, although biliary drainage for AC remains crucial.
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http://dx.doi.org/10.3748/wjg.v21.i2.533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292285PMC
January 2015

Endoscopic retrograde cholangiography using an anterior oblique-viewing endoscope in patients with altered gastrointestinal anatomy.

Dig Dis Sci 2015 Apr 18;60(4):944-50. Epub 2014 Oct 18.

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

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients who have undergone gastrointestinal (GI) reconstruction.

Aims: The aim of this study was to evaluate the utility of the anterior oblique-viewing endoscope (AOE) for ERCP in patients with a retained major duodenal papilla after GI reconstruction.

Methods: This was a retrospective study involving 40 patients (50 procedures) with a retained papilla after GI reconstruction who underwent ERCP using AOE. Reconstruction consisted of Billroth II gastrectomy (BII) in 25 patients (30 procedures) and Roux-en-Y anastomosis (RY) in 15 patients (20 procedures). In RY cases, the long single-balloon enteroscope (LSBE) was exchanged with AOE after reaching the papilla.

Results: The overall rate of reaching the papilla using AOE was 90.0 % (45/50) [BII; 86.7 % (26/30), RY; 95.0 % (19/20)]. The overall rate of biliary cannulation was 97.8 % (44/45) [BII; 100 % (26/26), RY; 94.7 % (18/19)], and the rate of biliary cannulation for intact papilla was 96.6 % (28/29) [BII; 100 % (14/14), RY; 93.3 % (14/15)]. Treatment success rate in cases of successful biliary cannulation was 97.7 % (43/44) [BII; 100 % (26/26), RY; 94.4 % (17/18)]. The rate of adverse events was 6.0 % (3/50) [BII; 3.3 % (1/30), RY; 10.0 % (2/20)], with mild pancreatitis occurring in 3 cases.

Conclusions: High biliary cannulation and treatment rates can be achieved during ERCP using AOE in altered GI anatomy cases with a retained papilla, as long as the papilla can be reached. In RY cases, exchanging AOE with LSBE is useful after reaching the papilla.
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http://dx.doi.org/10.1007/s10620-014-3386-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408371PMC
April 2015

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation.

World J Gastroenterol 2014 Jul;20(26):8617-23

Kazunari Nakahara, Chiaki Okuse, Keigo Suetani, Yosuke Michikawa, Fumio Itoh, Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan.

Aim: To investigate the need for pancreatic stenting after endoscopic sphincterotomy (EST) in patients with difficult biliary cannulation.

Methods: Between April 2008 and August 2013, 2136 patients underwent endoscopic retrograde cholangiopancreatography (ERCP)-related procedures. Among them, 55 patients with difficult biliary cannulation who underwent EST after bile duct cannulation using the pancreatic duct guidewire placement method (P-GW) were divided into two groups: a stent group (n = 24; pancreatic stent placed) and a no-stent group (n = 31; no pancreatic stenting). We retrospectively compared the two groups to examine the need for pancreatic stenting to prevent post-ERCP pancreatitis (PEP) in patients undergoing EST after biliary cannulation by P-GW.

Results: No differences in patient characteristics or endoscopic procedures were observed between the two groups. The incidence of PEP was 4.2% (1/24) and 29.0% (9/31) in the Stent and no-stent groups, respectively, with the no-stent group having a significantly higher incidence (P = 0.031). The PEP severity was mild for all the patients in the stent group. In contrast, 8 had mild PEP and 1 had moderate PEP in the no-stent group. The mean serum amylase levels (means ± SD) 3 h after ERCP (183.1 ± 136.7 vs 463.6 ± 510.4 IU/L, P = 0.006) and on the day after ERCP (209.5 ± 208.7 vs 684.4 ± 759.3 IU/L, P = 0.002) were significantly higher in the no-stent group. A multivariate analysis identified the absence of pancreatic stenting (P = 0.045; odds ratio, 9.7; 95%CI: 1.1-90) as a significant risk factor for PEP.

Conclusion: In patients with difficult cannulation in whom the bile duct is cannulated using P-GW, a pancreatic stent should be placed even if EST has been performed.
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http://dx.doi.org/10.3748/wjg.v20.i26.8617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093712PMC
July 2014

Evaluation of hepatic tissue blood flow using xenon computed tomography with fibrosis progression in nonalcoholic fatty liver disease: comparison with chronic hepatitis C.

Int J Mol Sci 2014 Jan 14;15(1):1026-39. Epub 2014 Jan 14.

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

Aims: The present study evaluated the utility of xenon computed tomography (Xe-CT) as a noninvasive diagnostic procedure for the measurement of hepatic tissue blood flow (TBF) in patients with nonalcoholic fatty liver disease (NAFLD) or chronic hepatitis C (CH-C).

Methods: Xe-CT was performed in 93 patients with NAFLD and in 109 patients with CH-C. Subjects were classified into one of three groups, based on fibrosis stage: group 1, no bridging fibrosis; group 2, bridging fibrosis; and group 3, liver cirrhosis. Correlations between hepatic TBFs in each fibrosis stage were examined.

Results: In group 1, portal venous TBF (PVTBF), hepatic arterial (HATBF), and total hepatic TBF (THTBF) were significantly lower in patients with in nonalcoholic steatohepatitis (NASH) than in those with CH-C (p < 0.001, p < 0.05, p < 0.001, respectively). In group 2, PVTBF and THTBF were significantly lower in patients with in NASH than in those with CH-C (p < 0.001, p < 0.05, respectively). In group 3, hepatic TBFs were not significantly different when comparing patients with NASH and those with CH-C.

Conclusions: PVTBF decreased due to fat infiltration. Therefore, hemodynamic changes occur relatively earlier in NAFLD than in CH-C. Patients with NASH should be monitored carefully for portal hypertensive complications in the early fibrosis stage.
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http://dx.doi.org/10.3390/ijms15011026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3907854PMC
January 2014

Covered metal stenting for malignant lower biliary stricture with pancreatic duct obstruction: is endoscopic sphincterotomy needed?

Gastroenterol Res Pract 2013 12;2013:375613. Epub 2013 Nov 12.

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

Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.
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http://dx.doi.org/10.1155/2013/375613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845734PMC
December 2013

A novel endoscopic papillectomy after a pancreatic stent placement above the pancreatic duct orifice: inside pancreatic stenting papillectomy.

J Clin Gastroenterol 2014 Oct;48(9):796-800

*Department of Gastroenterology and Hepatology †Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kawasaki, Japan.

Background: Although pancreatic stenting is recommended for the prevention of postprocedure pancreatitis during endoscopic papillectomy (EP), in some patients it is technically difficult to perform postprocedure insertion of a pancreatic stent after endoscopic resection.

Goals: This study assessed the feasibility of a novel EP for the purpose of reliable post-EP pancreatic stenting.

Study: We conducted a prospective pilot study involving 10 consecutive patients with tumor of the major duodenal papilla. We developed a novel pancreatic stent, which is attached to a suture, and devised a method by which the stent is first placed at an upstream migration into the major pancreatic duct above the orifice before resection and then placed at an appropriate location after endoscopic resection by pulling the suture attached to the stent [inside pancreatic stenting papillectomy (IPSP)].

Results: The pancreatic stent was successfully placed at an upstream migration into the pancreatic duct above the orifice in 9 of the 10 patients. For the 9 patients with successful pancreatic stent placement, IPSP was performed. Although the suture was cut in 1 patient, pancreatic stents could be placed appropriately across the orifice by pulling the suture in all patients. Although bleeding occurred in 3 patients, there was no pos-procedure pancreatitis.

Conclusions: IPSP is a practicable method allowing reliable post-EP pancreatic stenting and can contribute to pancreatitis prevention. However, larger studies need to be performed before its use can be recommended.
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http://dx.doi.org/10.1097/MCG.0000000000000019DOI Listing
October 2014

Use of antithrombin and thrombomodulin in the management of disseminated intravascular coagulation in patients with acute cholangitis.

Gut Liver 2013 May 25;7(3):363-70. Epub 2013 Apr 25.

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

Background/aims: To evaluate the usefulness and safety of treating disseminated intravascular coagulation (DIC) complicating cholangitis primarily with antithrombin (AT) and thrombomodulin (rTM).

Methods: A DIC treatment algorithm was determined on the basis of plasma AT III levels at the time of DIC diagnosis and DIC score changes on treatment day 3. Laboratory data and DIC scores were assessed prospectively at 2-day intervals.

Results: DIC reversal rates >75% were attained on day 7. In the DIC reversal group, statistically significant differences from baseline were observed in interleukin-6 and C-reactive protein levels within 5 days. Patients with no DIC score improvements after treatment with AT alone experienced slow improvement on a subsequent combination therapy with rTM. Although a subgroup with biliary drainage showed greater improvement in DIC scores than did the nondrainage subgroup, the mean DIC score showed improvement even in the nondrainage subgroup alone. Gastric cancer bleeding that was treated conservatively occurred in one patient. As for day 28 outcomes, three patients died from concurrent malignancies.

Conclusions: Although this algorithm was found to be useful and safe for DIC patients with cholangitis, it may be better to administer rTM and AT simultaneously from day 1 if the plasma AT III level is less than 70%.
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http://dx.doi.org/10.5009/gnl.2013.7.3.363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3661971PMC
May 2013
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