Digestive Endoscopy最新文献

A 73-year-old woman underwent pyloric resection and B-1 reconstruction for gastric cancer followed by duodenal bile duct anastomosis to treat common bile duct stones. The patient was later referred for bile duct dilation examination. Magnetic resonance imaging revealed intrahepatic gallstones in the posterior intrahepatic bile duct. Consequently, endoscopic retrograde cholangiopancreatography was performed.

Initially, direct peroral cholangioscopy (POCS) with an endoscope equipped with water-jet functionality was used to attempt stone fragmentation via electrohydraulic lithotripsy (EHL). However, this approach failed due to challenging angulation of the bile duct, which obstructed access to the posterior biliary duct. Subsequently, the mother–baby technique was employed using a duodenoscope and cholangioscope (SpyScope; Boston Scientific, Marlborough, MA, USA). However, advancing the SpyScope into the posterior biliary duct was unsuccessful due to the instability of the duodenoscope, which impeded the effective transmission of force and passage beyond the bend.

To address the need for greater scope stability and rigidity, a colonoscope (CF HQ290ZI, channel diameter 3.7 mm; Olympus Medical Systems, Tokyo, Japan) was introduced through the choledochoduodenal anastomosis, effectively serving as the mother endoscope. This combination of direct POCS and the mother–baby system, referred to as combined-POCS, significantly improved scope stability and enhanced the insertability of the choledochoscope. This rigidity of the colonoscope helped facilitate successful access to the posterior biliary branch (Figs 1,2). Complete stone removal was achieved using stone fragmentation with EHL (Video S1).

Generally, EHL is effective in treating intrahepatic stones,^{1, 2} but its success is often limited by the devices used in the postoperative intestinal tract.³ In this case, the sequential application of various treatment methods led to effective resolution. The therapeutic intervention proceeded without adverse events, demonstrating the efficacy of combined-POCS in the management of postoperative intrahepatic stones.

Authors declare no conflict of interest for this article.

Endoscopic procedures for large common bile duct stones in patients with altered anatomy remain challenging, despite reports on direct peroral cholangioscopy (POCS).^1-4 Recently, a novel slim cholangioscope (9F eyeMAX; Micro-Tech, Nanjing, China) facilitated balloon enteroscopy-assisted POCS (BE-POCS).⁵

An 83-year-old man, after Billroth II gastrectomy, was admitted with a large common bile duct stone. BE-POCS using a Holmium YAG (Ho:YAG) laser was employed for stone removal (Video S1). A balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan) was inserted into the afferent loop, and cholangiography revealed a large stone (15 mm) in the dilated common bile duct (20 mm). After papillary balloon dilation (15 mm), 9F eyeMAX was smoothly inserted via enteroscopy. A large stone was located in the hepatic hilum. Ho:YAG laser (LithoEVO; EDAP TMS, Lyon, France) lithotripsy effectively crushed the stone core under cholangioscope guidance (Fig. 1). The irrigation ability was sufficient to maintain a clear view because of a separate irrigation channel. A basket catheter (LithoCrush V; Olympus) was used to remove the fragments; however, the largest piece could not be extracted, and mechanical lithotripsy failed. A plastic stent was placed until the second session because of the procedure length (100 min). One month later, the largest fragment was completely crushed using the Ho: YAG laser to prevent basket impaction (Fig. 2). The green color of the laser helped detect the probe tip during the procedure. The fragmented stones were removed using a spiral basket catheter (KANEKA Medics, Tokyo, Japan). Cholangioscopy confirmed no residual stones in the intrahepatic bile ducts. Finally, small fragments were extracted using a microbasket catheter (ABIS, Hyogo, Japan) (60 min).

This is the first report of laser lithotripsy with BE-POCS for a patient with Billroth II gastrectomy. Ho:YAG laser lithotripsy using a slim cholangioscope is useful for treating difficult stones in patients with altered anatomy.

Authors declare no conflict of interest for this article.

When performing endoscopic procedures for bile duct stones, confirming the absence of residual stones is crucial. However, during postprocedural cholangiography, the presence of air or debris can pose challenges in assessing residual stones.¹ Especially in cases of altered anatomy, pursuing reintervention may not be feasible, even if residual stones are present.^{2, 3} Although peroral cholangioscopes can confirm stone absence,⁴ their routine use is impractical because of high costs. Therefore, we developed a novel method using the complementary metal oxide semiconductor (CMOS) camera unit of a new ultrathin cholangioscope (DRES Slim Scope; Japan Lifeline, Tokyo, Japan), allowing for the reliable confirmation of the absence of residual stones at a low cost (Video S1). The CMOS camera unit, with a 1 mm diameter, is priced at 300,000 Japanese yen and can be reused 10 times with proper washing and sterilization (30,000 yen/use).⁵ It can be passed through the lumen after removing the brush from the double-lumen biliary cytology brush (CytoMaxII; Cook Japan Inc., Tokyo, Japan) (Fig. 1). Substituting the CytoMaxII sheath priced at 12,000 yen for the original sheath priced at 39,000 yen enables biliary duct observation at 42,000 yen.

We present an actual case utilizing this method. A 71-year-old woman with a history of pancreaticoduodenectomy developed cholangitis resulting from hepaticojejunostomy anastomotic stricture and bile duct stones. The stricture was dilated with a balloon, and stone removal was performed using a basket and balloon. However, the cholangiography indicated the possible presence of residual stones, although definitive confirmation remained elusive. By using the aforementioned method while irrigating saline solution through the Y-shaped connector, we visualized the bile duct and confirmed the absence of stones (Fig. 2). Given the reduced effort and cost associated with endoscopic nasobiliary drainage tube placement or reintervention, this method proves beneficial for both altered and normal anatomy cases.

Authors declare no conflict of interest for this article.

Fully covered self-expandable metal stents (SEMS) are an alternative treatment option for persistent benign main pancreatic duct stricture (BPS), but their removal can be hampered by fibrosis formation and tissue overgrowth if the indwelling duration exceeds 3 months.¹ We present a case in which a fully covered SEMS, which initially could not be removed from the pancreatic duct, was retrieved using a “SEMS-in-SEMS” technique.

A 69-year-old male patient with a history of symptomatic chronic pancreatitis treated by multiple exchanges of plastic stents presented with abdominal pain. Computed tomography identified refractory BPS at the pancreatic head, and a fully covered SEMS (Bonastent M-intraductal; Standard Sci Tech, Seoul, South Korea) with a diameter of 8 mm and a length of 5 cm was inserted across the stricture. Although stent removal and a follow-up pancreatogram were scheduled at 3 months, the patient arbitrarily delayed visiting the hospital until 7 months after SEMS insertion. During the delayed follow-up endoscopic retrograde cholangiopancreatography, the inserted SEMS could not be removed, likely because it had become embedded in the pancreatic duct wall. Subsequent pancreatogram suggested tissue hyperplasia and overgrowth into the stent. The SEMS-in-SEMS technique was performed by placing a second fully covered SEMS with a diameter of 10 mm and a length of 7 cm, extended by 1 cm at both ends, inside the existing SEMS to compress the hyperplastic tissue and induce its ischemia and necrosis (Fig. 1, Video S1). One month later, an attempt to remove both stents using a rat-tooth forceps succeeded (Fig. 2).

The placement of a SEMS inside another SEMS can induce pressure necrosis of bile duct hyperplasia, enabling subsequent removal of the embedded biliary stent.^2-4 The SEMS-in-SEMS technique, which was documented only in the bile duct interventions, can also be safe and effective for the extraction of embedded SEMS in patients with BPS.

Authors declare no conflict of interest for this article.

This work was partly supported by the SoonChunHyang University Research Fund.

WEO Newsletter Editor: Nalini M Guda MD, MASGE, AGAF, FACG, FJGES

Luciano Lenz and Fauze Maluf-Filho

“Water is the principle of all things”.

Thales of Miletus (c. 620 B.C.E. – c. 546 B.C.E.)

Thales investigated almost all areas of knowledge. Aristotle defined him as the first philosopher. Today, he is also considered by many to be the pioneer of scientific thought.

Colorectal cancer is the third most common malignancy and the second most common cause of death. In the attempt to change this scenario, colonoscopy is the best tool for the diagnosis and prevention of colorectal cancer. Endoscopic removal of polyps reduces the incidence of colorectal cancer by up to 90%.1 Most polyps are small and can be easily treated with conventional polypectomy. However, larger nonpedunculated lesions present a technical challenge.

Conventional endoscopic mucosal resection (CEMR) is the currently accepted standard of care. CEMR uses submucosal injection of a solution to separate the superficial layers from the deep submucosa and the muscularis propria. In theory, this reduces the risk of thermal injury to the deeper tissue layers and iatrogenic perforation. Conversely, submucosal injection may paradoxically make snare capture of a flat polyp more difficult. Another major concern after CEMR is the risk of recurrence detected on follow-up colonoscopy. Rates of 15% to 50% of recurrent lesions have been reported in several CEMR series.

To overcome these limitations, Binmoeller et al. conceived an alternative way to remove the lesion without submucosal injection. Since their first description of underwater EMR (UEMR) in 2012, many articles have been published indicating acceptable rates of technical success and a low incidence of adverse events (AE) with UEMR and even a lower recurrence rate than CEMR.

Even with such compelling evidence, many endoscopists are reluctant to perform underwater polyp resection. This article highlights the useful clinical tips for successful underwater resection of colon polyps.

Finally start soon, don't be outdated. Don't be the last to dive into the aquatic world of endoscopy.

Pancreatic duct stenting is often performed to prevent postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis,^{1, 2} but adverse events (AEs), including stent migration, can occur. Although endoscopic pancreatic stent (EPS) sometimes migrates into the pancreatic duct,^3-5 there is no report about the migration of EPS into the endoscopic biliary stent (EBS). Herein, this is a first case in which EPS had migrated into the EBS.

A 76-year-old woman with obstructive jaundice due to a pancreatic head mass was referred to our hospital. An EBS (7F 7 cm, Flexima; Boston Scientific Japan, Tokyo, Japan) was placed to treat the obstructive jaundice, while an EPS (5F 3 cm, Geenen; Cook Medical, Bloomington, IN, USA) was placed to prevent post-ERCP pancreatitis (Fig. 1). Seven days later, an endoscopic ultrasound to exam the pancreatic head mass indicated that the EPS had migrated into the EBS. ERCP was immediately performed, confirming the EPS migration (Fig. 2a,b). We grabbed the EPS and EBS tips with a snare and removed them in one batch. No AEs occurred when we removed the EPS and EBS. After snare removal of both the EPS and EBS (Fig. 2c), a covered biliary metal stent (10 mm × 7 cm, BONASTENT Biliary; Medico's Hirata Inc., Osaka, Japan) was placed, and the obstructive jaundice subsequently improved (Video S1). In this case, the EPS had migrated through a side hole of the EBS and was emerging from the tip of the EBS. Fortunately, even with the EPS migrating into the EBS, improvement of obstructive jaundice was not delayed. And obstructive pancreatitis did not occur. Probably, bile and pancreatic juice were draining through the common ducts of the EBS and EPS. Although a pigtail stent can prevent the stent migration, it is difficult to predict this AE when using a straight-type stent. Endoscopists should be aware of this rare AE of EPS.

Authors declare no conflict of interest for this article.

Water pressure method (WPM) is useful for colorectal endoscopic submucosal dissection (ESD), characterized not only by underwater conditions but also by active water pressure via the waterjet function. However, the extension of the colorectum by injecting excess water and contaminating the operative field by stool and bleeding have been issues. This study aimed to evaluate the feasibility of a novel perfusion system using a continuous liquid-suction catheter attachment (CLCA) in colorectal ESD with WPM. We retrospectively reviewed cases in which the perfusion system was used in colorectal ESD with WPM between August 2022 and September 2023. We evaluated clinical characteristics, treatment outcomes, volume of injection by the waterjet function, volume of suction by the endoscope and CLCA, and concentration of floating matter in the operative field over time. Thirty-one cases were enrolled. The median lesion size was 30 (range, 15–100) mm. In all cases, en bloc resection was achieved without perforation. The median injection volume was 2312 (range, 1234–13,866) g. The median suction volumes by the endoscope and CLCA were 918 (range, 141–3162) and 1147 (range, 254–11,222) g, respectively. The median concentration of floating matter in the operative field (measured in 15 cases) was 15.3 (range, 7.3–112) mg/mL when the endoscope arrived at the lesion and 8.0 (range, 3.2–16) mg/mL after endoscopically washing at the beginning of the ESD. It ranged from 7.6 to 13.4 mg/dL every 20 min during ESD. This perfusion system could prevent the extension of the lumen and maintain a good field of view in colorectal ESD with WPM.