Digestive Endoscopy最新文献

Malignant biliary obstruction (MBO) is a biliary system disease caused by various cancers, including cholangiocarcinoma [1], and endoscopic biliary drainage is the cornerstone of treatment in patients with unresectable disease. For hilar MBO, bilateral metal stenting is recommended based on reports of longer survival, better patency, and fewer reinterventions [2]. However, when biliary obstruction recurs because of tumor ingrowth, overgrowth, or debris with disease progression, endoscopic reintervention becomes difficult. Intraductal radiofrequency ablation (RFA) is a palliative endoscopic treatment for MBO [3] and may be a rescue procedure for metal stent malfunction caused by tumor ingrowth [4]. We report a case of successful recanalization using RFA in a patient with hilar cholangiocarcinoma. A 70-year-old man with bilateral self-expandable metal stent deployment for unresectable hilar MBO was admitted with severe acute cholangitis caused by stent malfunction. After nasal-biliary drainage tube placement, endoscopic retrograde cholangiography (ERC) and peroral cholangioscopy (POCS) revealed stent occlusion due to ingrowth (Figure 1a). Additional stent placement through previously inserted bilateral metal stents had a risk of side branch obstruction and was considered technically challenging. Therefore, RFA was performed with a temperature-controlled RF catheter (ELRA; STARmed Co., Goyang, Korea; Figure 2). This probe has an 18-mm exposure length and 7-Fr (2.31-mm) diameter, with a median microscopic ablation depth estimated as 2.1 mm (range 1.7–2.4) in a swine model [5]. Ablation was performed stepwise, spanning the stricture from its proximal to distal edge (Figure 1b). After completing RFA, a temporary endoscopic nasobiliary drainage tube was placed. To evaluate the therapeutic effect over time, ERC and POCS were performed 3 days after RFA, confirming a sufficient ablation effect (Figure 1c, Video S1). The patient was discharged with no procedure-related adverse events, and liver dysfunction or acute cholangitis did not recur for more than 5 months.

Kenjiro Yamamoto was involved in script preparation. Kenjiro Yamamoto and Takao Itoi were involved in endoscopic procedures. Hiroyuki Kojima was involved in data collection. Takao Itoi was involved in supervising the manuscript. All authors have read and approved the submitted version of the paper.

Takao Itoi has received consulting fees from Gadelius Medical Co. and Boston Scientific. All other authors declare no financial relationships relevant to this publication.

Inside stents [1, 2] placed above the papilla for upper bile duct strictures were useful [3] and equipped with a retrieval thread for stent removal (Figure 1). However, when the distal flap becomes lodged in a biliary branch, stent removal is challenging due to the weak grip of the forceps and slippage of the retrieval thread. We report a useful technique for easy stent retrieval by rotating an 8-wire basket catheter (RASEN2, Kaneka Medix Corporation, Osaka, Japan) and entangling the retrieval thread to the basket catheter for a firm grasp.

The patient was a 76-year-old man with intrahepatic cholangiocarcinoma who had two stents placed 4 months prior to biliary obstruction. Endoscopic retrograde cholangiopancreatography was performed for the stent exchange. The first stent was easily retrieved by grasping the retrieval thread using forceps; however, the distal flap of the second stent was caught on the biliary duct branch, making retrieval difficult. Attempts to grasp the stent using a snare and forceps were unsuccessful. An 8-wire basket catheter was then used and deployed alongside the retrieval thread. The guide wire was placed inside the catheter to prevent tangling. As the catheter was advanced, the retrieval thread was pulled into the side of the stent. While rotating the catheter, we deliberately pressed it against the bile duct to change its angle. The catheter and retrieval threads were easily tangled, allowing the stent to integrate securely and rotate. The retrieval thread was firmly grasped, the flap was released, and the stent was successfully retrieved (Figure 2).

In conclusion, rotating a basket catheter and entangling the retrieval thread make it possible to easily retrieve stents, even in challenging cases, as the retrieval thread and catheter become integrated.

Masafumi Watanabe designed the study, the main conceptual ideas, and the outline. Masafumi Watanabe edited the video and wrote the manuscript with support from Kosuke Okuwaki. Chika Kusano supervised the project. All the authors discussed the results and commented on the manuscript.

The authors have nothing to report.

The authors declare no conflicts of interest.

Endoscopic observation of lesions located at the esophagogastric junction (EGJ) is technically challenging. This difficulty primarily arises from the anatomical narrowness of the EGJ, which makes it difficult to maintain an optimal distance between the endoscope and the target lesion. While some endoscopists employ the water-flooding technique, the rapid flow of water into the stomach prevents stable observation. Moreover, excessive water use increases the risk of aspiration. Gel immersion endoscopy is a useful method for securing a clear visual field during hemostatic procedure [1, 2]. In this report, we further highlight its effectiveness in magnified endoscopic observation.

A 68-year-old man was referred to our hospital for further evaluation of suspected Barrett's esophageal cancer. Upper gastrointestinal endoscopy revealed a reddish, depressed lesion at the 2 o'clock position in the EGJ area (Figure 1a). Magnified endoscopy with narrow-band imaging was performed using the gel immersion technique (Figure 1b), with a transparent hood attached to the distal tip of the endoscope. The gel we used was “VISCOCLEAR” (Otsuka Pharmaceutical Factory, Tokushima, Japan), which was administered through the endoscope using a standard 50 mL syringe. To minimize bubble formation during observation, we slowly pushed the syringe plunger to gently introduce the gel into the esophagus. Thanks to its specific viscosity, the gel remained in the EGJ without flowing into the stomach, allowing for a stable and clear endoscopic view without the need for constant infusion. Moreover, the relatively low intraluminal pressure under the gel permitted gentle contact, minimizing the risk of tissue damage. The time required from gel infusion to the completion of magnified observation was < 2 min. The lesion was endoscopically diagnosed as benign, and a biopsy revealed only inflammatory changes (Group 1).

In conclusion, the gel immersion technique may offer a safe, stable, and effective approach for endoscopic observation of lesions in the EGJ area.

I.T.: investigation and endoscopic procedure, writing – original draft preparation. I.T., Y.N.: conceptualization and methodology. Y.N., H.I.: writing – review and editing. H.I.: supervision and project administration. All authors: approval of final manuscript.

The authors declare no conflicts of interest.