Duct Stricture Research Articles

Laparoscopic repair of left hepatic duct stenosis using the pedicled umbilical vein patch for hepatolithiasis (with videos).

In recent years, with the improvement in surgeons' understanding of the anatomical characteristics of biliary structures, the application of pedicled umbilical vein patch (PUVP) repair under laparotomy has become increasingly common[1-3]. Our center began performing this procedure in 1986 to improve efficacy[4,5]. Compared with that under laparotomy, suturing under laparoscopy may be challenging due to vision and movement restrictions, especially for end-to-end anastomosis, which has not been reported in previous series. More than 4000 laparoscopic operations have been carried out in our center since its establishment. This study aimed to demonstrate the laparoscopic repair of left hepatic duct stenosis with the PUVP for hepatolithiasis (Video S1, Video S2, Video S3).

S1483 A 20-Year-OId Female With Obstructive Jaundice and a Pancreatic Head Mass: A Case Report of Type 2 Autoimmune Pancreatitis

Introduction: Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that may be associated with IgG4 laden lymphoplasmacytic infiltration and fibrosis in multiple organs. It accounts for only a small percentage of all patients with chronic pancreatitis. It can present with abdominal pain, jaundice, recurrent acute pancreatitis, or clinical findings similar to pancreatic cancer. Radiologic findings can also be similar to the above. Therefore, it is important to fully understand the radiologic and histologic nuances of AIP. We review a case of a 20-year-old female who presented with abdominal pain and jaundice who was subsequently diagnosed with Type 2 AIP. Case Description/Methods: A patient with no known past medical history presented with one week of abdominal pain. Imaging demonstrated a normal appearing pancreas with a nodular area of soft tissue fullness at the junction of the pancreatic head and body. Patient returned a few weeks later with jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a significant biliary stricture which was stented. EUS with biopsies demonstrated mild acute on chronic inflammation of the ampulla and mild acute inflammation of the pancreatic head as well as benign pancreatic parenchyma with edema, very focal fibrosis, and focal neutrophilic infiltrate in acini and intralobular small ducts. Steroids were prescribed leading to resolution of signs and symptoms. Discussion: Initial presentation of AIP can mimic that of other pancreatic pathology so further imaging with biopsy is necessary to make a final diagnosis. Type 1 and Type 2 AIP both have histologic findings of periductal infiltration of plasma cells and lymphocytes, peculiar storiform fibrosis, and venulitis. Type 1 typically has a high number of IgG4 positive plasma cells and can be associated with various systemic lesions related to IgG4 positive cell infiltrates. Type 2 is known for intraluminal and intraepithelial neutrophils in small to medium ducts and acini causing destruction of the duct lumen and is considered a pancreatic specific disease. In both types imaging tends to show diffuse parenchymal enlargement with delayed enhancement and ductal strictures without significant upstream dilatation. Treatment of AIP consists of steroids with Type 1 known to have relapses requiring re-treatment. Based on the histologic and radiologic findings a presumptive diagnosis of Type 2 AIP was made. Response to steroid treatment and no evidence of relapse confirmed the diagnosis.Figure 1.: A single severe stenosis seen in the lower third of the common bile duct.

S3483 Recurrent Pyogenic Cholangitis

Introduction: Recurrent pyogenic cholangitis is a chronic infective process characterized by recurrent attacks of acute bacterial cholangitis, in the setting of intrahepatic biliary ductal dilation and strictures, traditionally seen in South East Asia. Case Description/Methods: We present a 39 year old female who immigrated to the United States from Burma referred to gastroenterology clinic for abnormal liver tests and computed topography (CT) scan. Patient also reported intermittent right upper quadrant abdominal pain, fatigue and decreased appetite. Labs were significant for mildly elevated aspartame transferase (AST), alanine transferase (ALT) and alkaline phosphatase (AP). CT and magnetic resonance cholangiopancreatography (MRCP) were notable for intrahepatic biliary ductal dilation with multiple non-enhancing filling defects suggestive of stones or sludge, most pronounced in the left lobe of the liver and left hepatic lobe atrophy. Common bile duct was non-dilated without stones, sludge, wall thickening or abnormal enhancement. Liver elastography was performed which revealed cirrhosis. Patient did not have evidence of acute infection at this time but overall clinical presentation was consistent with recurrent pyogenic cholangitis. Discussion: Treatment options for recurrent pyogenic cholangitis include antibiotic therapy with signs of sepsis, removal of extrahepatic biliary stones via endoscopic retrograde cholangiopancreatography, decompression of intrahepatic biliary system via percutaneous biliary drainage and less likely surgical removal of diseased liver segment and potential liver transplantation. After discussion between an advanced endoscopist, general gastroenterologists, interventional radiologists and surgeons, she was started on ursodeoxycholic acid with plan for antibiotic therapy if evidence of acute infection. She will continue surveillance MRCP every 6 months for evaluation of hepatocellular carcinoma and cholangiocarcinoma.Figure 1.: Patient's CT image demonstrating intrahepatic biliary ductal dilation with hyperdense material concerning for biliary sludge, chronic obstruction of the left intrahepatic biliary tree and left hepatic lobe atrophy.

Conservative or surgical treatment of chronic pancreatitis?

The cardinal symptom of chronic pancreatitis is severe belt-like upper abdominal pain, which requires immediate and adequate treatment. Furthermore, advanced stage chronic pancreatitis is often associated with complications, such as pancreatic pseudocysts, pancreatic duct stones and stenosis as well as biliary stenosis. The various endoscopic and surgical treatment options for chronic pancreatitis patients have been controversially discussed for decades. The new German S3guidelines on pancreatitis now clearly define the best treatment options depending on the indications for treatment. For the treatment of pain in chronic pancreatitis it has been known for a long time that a surgical intervention is superior to endoscopic intervention concerning long-term pain relief. The recently published ESCAPE study has further underlined this by showing that early surgical intervention was superior to astep-up approach with initial endoscopic treatment. For the treatment of pancreatic pain, an initial endoscopic treatment attempt is therefore justified for short-term pain relief but in the midterm and long term, surgical intervention is the treatment of choice. In contrast, pancreatic pseudocysts, solitary proximally situated pancreatic duct stones and benign biliary strictures (except in calcifying pancreatitis) can nowadays generally be managed endoscopically. For distal pancreatic duct stones and symptomatic pancreatic duct stenosis surgical treatment is again the method of choice. This review article discusses these indication-related procedures in detail and explains them in relation to the recently published S3guidelines on pancreatitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS).

Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in a General Hospital for Patients with Endoscopic Retrograde Cholangiopancreatography-Difficult Transpapillary Biliary Drainage.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative treatment for percutaneous transhepatic biliary drainage for patients with bile duct stenosis. At specialized hospitals, the high success rate and effectiveness of EUS-BD as primary drainage has been reported. However, the procedure is highly technical and difficult, and it has not been generally performed. In this study, we retrospectively examined the effectiveness of EUS-BD in ERCP-difficult patients with distal bile duct stenosis. We retrospectively examined 24 consecutive cases in which EUS-BD was performed at our hospital for distal bile duct stenosis from October 2018 to December 2020. EUS-guided choledochoduodenostomy (EUS-CDS) was selected for cases that could be approached from the duodenal bulb, and EUS-HGS was selected for other cases. In the EUS-CDS and EUS-HGS groups, the technical success rates were 83.3% (10/12] and 91.7% (11/12], respectively. An adverse event occurred in one case in the EUS-CDS group, which developed severe biliary peritonitis. The stent patency period was 91 and 101 days in the EUS-CDS and EUS-HGS groups, respectively. EUS-BD for ERCP-difficult patients with distal bile duct stenosis is considered to be an effective alternative for biliary drainage that can be performed not only in specialized hospitals but also in general hospitals.

Efficacy of Biodegradable Polydioxanone and Polylactic Acid Braided Biodegradable Biliary Stents for the Management of Benign Biliary Strictures.

Benign biliary strictures (BBS) are widely treated by endoscopic procedures involving temporary stent placement. Occasionally, stents are required to be removed, making the treatment process very painful as well as expensive. Until now, no effective biodegradable biliary stents are available for clinical applications. This study aims to investigate the safety and efficacy of biodegradable polydioxanone (PDO) and polylactic acid (PLA) braided biodegradable biliary stents (BDBS) both in vitro and in vivo. Three different diameter monofilaments of PDO (0.30, 0.35, and 0.40 mm) and PLA (0.10, 0.15, and 0.20 mm) were braided to biliary stents and their mechanical properties were studied. The stents were placed in an ex vivo bile duct model perfused with porcine bile, taken out, and observed every week until these were completely degraded. After the bile duct stenosis model was established successfully in piglet, stents with appropriate mechanical properties were further examined under endoscopy; haematology, patency time of stents, and pathological changes were observed for eight months. A total of 10 pigs were included (two groups; 5 PDO, 5 PLA) in the study. The patency time of the PLA group was significantly longer than that of the PDO stent group (25.7 ± 5.6w vs 11.3 ± 3.4w, respectively) in pigs. Our results prospect biodegradable PLA and PDO braided biliary stents could be a better choice to treat benign biliary strictures while degrading at different rates.

Gallbladder wall thickening in patients with IgG4-related diseases, with special emphasis on IgG4-related cholecystitis

Objectives Gallbladder (GB) wall thickening sometimes occurs in patients with autoimmune pancreatitis (AIP), a condition for which the name, IgG4-related cholecystitis, was proposed. We examined the radiological findings of the GB in patients with IgG4-related diseases and clinical features of patients with GB wall thickening and presented a hypothesis of its pathogenesis. Materials and methods GB wall thickening was defined by thickness ≥ 4 mm. GB wall thickness was examined in 258 patients with IgG4-related disease. Clinical and imaging findings of 200 patients with AIP with and without GB wall thickening were then compared. Results GB wall thickening was detected in 58 patients (29%) with AIP and two patients with isolated IgG4-related sclerosing cholangitis. In the 60 GBs examined, wall thickening was diffuse, with the walls possessing a smooth inner surface. No GB wall thickening was detected among the 56 patients with IgG4-related disease without AIP or IgG4-related sclerosing cholangitis. Bile duct stenosis was detected in 56 patients (97%) with AIP with GB wall thickening. Intraductal ultrasonography indicated cystic duct wall thickening connected to bile duct wall thickening in 11 of 14 (79%) patients with AIP or IgG4-related sclerosing cholangitis with GB wall thickening. Forty-eight patients in whom IgG4-related cholecystitis was diagnosed experienced resolution of the GB wall thickening after receiving steroid therapy. Conclusions Most cases of GB wall thickening in IgG4-related diseases are closely associated with IgG4-related sclerosing cholangitis and may be a manifestation of IgG4-related disease throughout the biliary tract, including the bile duct, cystic duct, and GB.

Immune-related cholangitis induced by immune checkpoint inhibitors: a systematic review of clinical features and management.

Background & AimsImmune checkpoint inhibitors (ICIs) improve the survival of patients with advanced tumors. However, immune-related adverse events limit the use of ICIs. Although liver toxicity has been concerned gradually, little is known about bile duct injury associated with ICIs. Hence, this review aims to describe clinicopathological features, imaging, and management of immune-mediated cholangitis (IMC) induced by ICIs.MethodsWe retrieved the literature from the PubMed database for case reports and series of IMC induced by ICIs. IMC was then classified as small-ducts type, large-ducts type and mixed type. Biochemical parameters, pathological characteristics, imaging features, treatment and response were evaluated and compared among three patterns.ResultsFifty-three cases of IMC were enrolled. The median values of alkaline phosphatase and alanine transaminase of IMC were 1328 and 156 IU/L. The ALP level of the large-ducts type was higher than that of the small-ducts type (P = 0.021). The main pathological characteristics of small-ducts cholangitis were portal inflammation, bile duct injury and ductular reaction. The imaging features of large-duct cholangitis were bile duct dilatation, stenosis and bile duct wall thickening and irregularity. Forty-eight (90%) cases received immunosuppression therapy. Biliary enzymes reduced in 79% of cases receiving immunosuppression therapy, but only 8.5% of cases returned to normal. It took a long time for biliary enzymes to recover.ConclusionsThe clinicians should be aware of the possibility of IMC if the biliary enzymes increase significantly after the use of ICIs. The liver function can be improved partially by immunosuppressive therapy in the majority of IMC.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series.

Purpose To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). Methods Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4–14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. Results Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. Conclusion Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Trans-oral robotic surgery for Hilo-parenchymal submandibular stones

Sialolithiasis represents a common benign disease of the major salivary glands. Conventional therapeutic approaches include trans-oral sialendoscopy removal of the stones, duct incision and marsupialization, and trans-cervical sialadenectomy. However, the recent technological innovations of endoscopic and robot-assisted surgery provide unique opportunities to treat submandibular salivary gland stones. During the last decade, surgical robots have been utilized to remove submandibular glands in patients with sialolithiasis. In addition, they have used surgical access methods such as trans-hairline and facelift incisions for superior cosmesis. Most salivary stones involve the submandibular gland (80%–90%), and the most frequent locations are the distal tract of the duct, the hilum, and the hilo-parenchymal area. Trans-oral robotic surgery (TORS) has been proposed for the removal of hilo-parenchymal submandibular stones. TORS appears to be a viable option specifically in cases of deep and nonpalpable stones, multiple and recurrent intraparenchymal stones as well as iatrogenic duct stenoses. In this article, we review and discuss The role of TORS in the treatment of hilo-parenchymal submandibular stones.

EUS-guided biliary interventions for benign diseases and unsuccessful ERCP - a prospective unicenter feasibility study on a large consecutive patient cohort.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of biliary obstruction of any etiology. However, cannulation failure of the common bile duct (CBD) by ERCP occurs in 5-10%. Alternatives after a failed ERCP are re-ERCP by an expert endoscopist, percutaneous transhepatic cholangio drainage (PTCD), (balloon) enteroscopy-assisted ERCP, or surgery. Endoscopic ultrasonography-guided drainage of the bile ducts (EUS-BD) is becoming the standard of care in tertiary referral centers for cases of failed ERCP in patients with malignant obstruction of the CBD. In expert hands, EUS-guided biliary drainage has excellent technical/clinical success rates and lower complication rates compared to PTCD. Despite the successful performance of EUS-BD in malignant cases, its use in benign cases is limited. The aim of this study (design, systematic prospective clinical observational study on quality assurance in daily clinical practice) was to evaluate the efficacy and safety of EUS-BD in benign indications. Patients with cholestasis and failed ERCP were recruited from a prospective EUS-BD registry (2004-2020). One hundred and three patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal = 474). Indications of EUS-BDs included surgically altered anatomy (n = 65), atypical bile duct percutaneous transhepatic cholangio orifice at the duodenal junction from the longitudinal to the horizontal segment (n = 1), papilla of Vater not reached due to the gastric outlet/duodenal stenoses (n = 6), papilla that cannot be catheterized (n = 24), and proximal bile duct stenosis (n = 7). The primary endpoint was technical and clinical success. Secondary endpoints were procedure-related complications during the hospital stay. 103 patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal=474). Different transluminal access routes were used to reach the bile ducts: transgastric (n = 72/103); -duodenal (n = 16/103); -jejunal (n = 14/103); combined -duodenal and -gastric (n = 1/103). The technical success rate was 96 % (n = 99) for cholangiography. Drainage was not required in 2 patients; balloon dilatation including stone extraction was sufficient in 17 cases (16.5 %; no additional or prophylactic insertion of a drain). Transluminal drainage was achieved in n = 68/103 (66 %; even higher in patients with drain indication only) by placement of a plastic stent (n = 29), conventional biliary metal stents (n = 24), HotAXIOS stents (n = 5; Boston Scientific, Ratingen, Germany), Hanaro stents (n = 6; Olympus, Hamburg, Germany), HotAXIOS stents and plastic stents (n = 1), HotAXIOS stents and metal stents (n = 1) and metal stents and plastic stents (n = 2). Techniques for stone extraction alone (nSuccessful=17) or stent insertion (nTotal = 85; nSuccessful=85 - rate, 100 %) and final EUS-BD access pathway included: Rendezvous technique (n = 14/85; 16.5 %), antegrade internal drainage (n = 20/85; 23.5 %), choledochointestinostomy (n = 7/85; 8.2 %), antegrade internal and hepaticointestinostomy (n = 22/85; 25.9 %), hepaticointestinostomy (n = 21/85; 24.7 %), choledochointestinostomy and hepaticointestinostomy (n = 1/85; 1.2 %).The complication rate was 25 % (n = 26) - the spectrum comprised stent dislocation (n = 11), perforation (n = 1), pain (n = 2), hemorrhage (n = 6), biliary ascites/leakage (n = 3) and bilioma/liver abscess (n = 3; major complication rate, n = 12/68 - 17.6 %). Re-interventions were required in 19 patients (24 interventions in total). EUS-BD can be considered an elegant and safe alternative to PTCD or reoperation for failed ERCP to achieve the necessary drainage of the biliary system even in underlying benign diseases. An interventional EUS-based internal procedure can resolve cholestasis, avoid PTCD or reoperation, and thus improve quality of life. Due to the often complex (pathological and/or postoperative) anatomy, EUS-BD should only be performed in centers with interventional endoscopy/EUS experience including adequate abdominal surgery and interventional radiology expertise in the background. This enables adequately adapted therapeutic management in the event of challenging complications. It seems appropriate to conduct further studies with larger numbers of cases to systematize the approach and peri-interventional management and to successively develop specific equipment.

Approach to management of pancreatic strictures: the gastroenterologist's perspective.

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.

Migration of non-absorbable polymer clips in hepato-biliary-pancreatic surgery: a report of four cases

BackgroundLigation clips are used for vessel or tissue ligation in surgery. Although previous reports have described the migration of metallic clips after hepato-biliary-pancreatic surgery, very few reports have described the migration of non-absorbable polymer clips (NAPCs: Hem-o-Lok).Case presentationWe present 4 cases of NAPC migration that occurred after laparoscopic surgery. Case 1 was an 81-year-old woman that had undergone a laparoscopic right hemihepatectomy for an intrahepatic bile duct cyst adenocarcinoma at the age of 79 years. Two years after the operation, she underwent an upper gastrointestinal endoscopy to investigate epigastric pain. The endoscopy showed NAPCs lodged at the anterior side of the duodenal bulb. Case 2 was an 80-year-old man that had undergone a laparoscopic cholecystectomy for choledocholithiasis at the age of 77 years. Three years after the operation, follow-up computed tomography and magnetic resonance cholangiopancreatography (MRCP) imaging indicated a mass in the upper bile duct. After a laparoscopic bile duct resection and reconstruction, an NAPC was found inside the inflammatory pseudotumor. Case 3 was a 63-year-old man that had undergone laparoscopic liver S4b and S5 resections and lymph node dissection for gallbladder cancer. Three months after the operation, follow-up MRCP imaging suggested a bile duct stenosis. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, and an NAPC was found inside the bile duct. Case 4 was a 74-year-old man that had undergone a laparoscopic S5 segmentectomy, S7 partial liver resection, and cholecystectomy for liver metastasis of lung cancer and cholelithiasis. A trans-cystic drainage tube was inserted, and it was ligated and fixed with NAPCs. Three months after the operation, follow-up MRCP imaging showed common bile duct stones (CBDS). An ERCP was performed, and two NAPCs were found with the CBDS.ConclusionsFew previous reports have described complications due to NAPC migration after hepato-biliary-pancreatic surgery. However, with the widespread use of NAPC, postoperative complications due to NAPC migration are expected to increase in the near future. The differential diagnosis of complications should include potential NAPC migration in patients that have undergone laparoscopic surgery.

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Long-term outcomes of fully covered self-expandable metal stents versus plastic stents in chronic pancreatitis

Chronic pancreatitis (CP) related main pancreatic duct (MPD) stricture has been a challenge for endoscopists. Fully covered self-expandable metal stents (FC-SEMS) has been tried in CP patients, but the efficacy and safety are still controversial. Thus, we aim to compare the long-term clinical efficacy of FC-SEMS vs. plastic stent placement in persistent MPD strictures secondary to CP. Between 2007 and 2018, 80 chronic pancreatitis patients (58 males, median age 49 years), who underwent endoscopic placement of FC-SEMS (n = 26) and plastic stent (n = 54) for persistent MPD strictures after at least 3 months of initial single plastic stenting, were retrospectively analyzed during a median follow-up duration of 33.7 months. As a result, MPD stricture resolution rate was statistically higher in FC-SEMS group (87.0% vs. 42.0%, p < 0.001). Although immediate complications occurred similarly (38.5% vs. 37.0%, p = 0.902), spontaneous migration (26.9%) and de novo strictures (23.1%) were pronounced delayed complications in FC-SEMS group. Pain relief during follow-up was significantly higher in FC-SEMS group (76.9% vs. 53.7%, p = 0.046). The total procedure cost was similar in both groups ($1,455.6 vs. $1,596.9, p = 0.486). In comparison with plastic stent, FC-SEMS placement for persistent MPD strictures had favorable long-term clinical efficacy, with its typical complications like spontaneous migration and de novo strictures.

Surgical treatment of distal cholangiocarcinoma

Distal cholangiocarcinoma accounts for about 20% of bile duct cancers, representing the third most common tumor entity among periampullary cancers, along with adenocarcinoma of the pancreas and carcinomas of the papilla of Vater. Precise diagnostics of tumor localization and exact knowledge of tumor-specific growth patterns are crucial for successful surgery. When planning the surgical procedure, the differential diagnosis of central bile duct cancer (Bismuth typeI) or middle bile duct carcinoma must be considered. Although benign periampullary bile duct stenosis occurs in only 5% of cases, the presence of immunoglobulin G4-associated cholangitis (IAC) should be excluded in doubtful cases. Basically, in the presence of adistal cholangiocarcinoma, partial pancreatoduodenectomy is indicated analogous to the procedure for ductal adenocarcinoma of the pancreatic head. The 5‑year survival after resection is 20-25% and therefore comparable to adenocarcinoma of the pancreas. Local resection of middle bile duct carcinoma is no longer recommended due to inadequate surgical radicality. To date, perioperative treatment for downsizing does not play arelevant role for surgical treatment of distal cholangiocarcinoma. In the presence of adistal cholangiocarcinoma primary surgery with the aim of aR0 resection is the standard treatment of choice.

High signal intensity on diffusion-weighted magnetic resonance images is a useful finding for detecting early-stage pancreatic cancer

PurposeEarly detection of pancreatic ductal adenocarcinoma (PDAC) may improve the prognosis. We evaluated novel imaging findings that may contribute to early detection.MethodsThis single-center, retrospective study enrolled 37 patients with a localized main pancreatic duct (MPD) stricture and no obvious pancreatic mass. All patients underwent endoscopic retrograde cholangiopancreatography and brush sampling with cytology and serial pancreatic juice aspiration cytologic examination via endoscopic naso-pancreatic drainage. Patients with cytology-confirmed malignancy underwent surgical resection. The remaining patients were followed by contrast-enhanced computed tomography (CECT), magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography.ResultsTwenty patients had confirmed malignancy (cancer group) and 17 did not (non-cancer group). Age, MPD stricture location, and PDAC risk factors were similar, but the sex predominance and symptom rate differed between the two groups. In the cancer group, 17 patients were diagnosed by cytology and three by clinical symptoms. CECT, MRI, and endoscopic ultrasonography (EUS) revealed no solid tumors in either group. CECT revealed no significant differences between groups. Diffusion-weighted MRI revealed significant differences in the signal intensity between groups. EUS detected indistinct and small hypoechoic areas in 70% and 41.2% of patients in the cancer and non-cancer groups, respectively. In the cancer group, 11 were diagnosed with cancer at the first indication, and nine were diagnosed at follow-up; the prognosis did not differ between these two subgroups.ssConclusionsHigh signal intensity in diffusion-weighted MRI may be useful for detecting early-stage PDAC and may be an indication for surgical resection even without pathologic confirmation.Clinical trial registrationThe study was a registered at the University Hospital Medical Information Network (UMIN000039623).Graphic abstract

A Case of Multiple Pancreatic Serous Cystic Neoplasm Accompanied by Main Pancreatic Duct Stenosis

A Case of Multiple Pancreatic Serous Cystic Neoplasm Accompanied by Main Pancreatic Duct Stenosis

Usefulness of the Novel Snare-over-the-Guidewire Method for Transpapillary Plastic Stent Replacement (with Video).

Unsuccessful stent replacement in transpapillary biliary drainage with plastic stents (PSs) has a significant impact on patient prognosis; thus, a safe and reliable replacement method is required. We aimed to compare the snare-over-the-guidewire (SOG) method, wherein the PS lumen is used as an access route to the biliary tract and the PS is removed with a snare inserted via the inserted guidewire, with the conventional side-of-stent (SOS) method, wherein the biliary approach is performed from the side of the PS. This retrospective single-center study included 244 consecutive patients who underwent biliary PS replacement between January 2018 and July 2020. The procedural success rates were compared between the two methods. A predictive analysis of unsuccessful PS replacement was also performed. The procedural success rate in the SOG group was significantly higher than that in the SOS group (p = 0.026). In the proximal biliary stenosis lesion, the same trend was observed (p = 0.025). Multivariate analysis also showed that the SOS method (p = 0.0038), the presence of proximal biliary stenosis (p < 0.0001), and parapapillary diverticulum (p = 0.0007) were predictors of unsuccessful PS replacement. The SOG method may be useful for biliary PS replacement, especially in cases of proximal hilar bile duct stenosis.

Factores implicados en el éxito y fracaso de la dacriocistorrinostomía endoscópica desde nuestra experiencia

IntroductionChronic dacryocystitis is the condition secondary to permanent lacrimonasal duct stenosis (LNDS) that generates epiphora and recurrent conjunctivitis. Endoscopic dacryocystorhinostomy (EDCR) is a more natural route than the external route and offers higher success rates than the laser technique. We value this centre's experience in this procedure. Patients and methodsA retrospective review was carried out in our centre of the medical records of adult patients undergoing EDCR due to LNDS between 1995 and 2019. The minimum follow-up period required after surgery was 6 months. ResultsOver 297 months, 167 EDCR procedures were performed on 156 patients, with an average age of 65.7±11.6 years and a male/female ratio of 1/1.98. The functional improvement was 86%, with an anatomical success rate of 87%. Lack of clinical improvement statistically significantly correlated with the age of the patient and the time since onset of the LNDS, the presence of concomitant systemic (especially diabetes mellitus) or ophthalmological disease, the intraoperative finding of a thickened tear sac and absence of drainage of the tear sac when marsupialised. Longer-term stent carriers in the rhinostomy had poorer outcomes. There were no postoperative complications of interest. ConclusionsEDCR is an effective and safe technique, based on stable anatomical references. Failure rate seems to be multifactorial and should be considered in older, multipathological patients, with a long duration of the condition.