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Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO). Biliary drainage using electrocautery lumen apposing metal stent (EC‐LAMS) is currently a well‐established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) could represent an easy and valid option. We performed a prospective study with a new EC‐LAMS with the primary aim to assess the clinical success rate of EUS‐GBD as a first‐line approach to the palliation of DMBO. Methods: In all, 37 consecutive patients undergoing EUS‐GBD with a new EC‐LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 h and >50% within 14 days after EC‐LAMS placement. Results: The mean age was 73.5 ± 10.8 years; there were 17 male patients (45.9%). EC‐LAMS placement was technically feasible in all patients (100%) and the clinical success rate was 100%. Four patients (10.8%) experienced adverse events, one bleeding, one food impaction, and two cystic duct obstructions because of disease progression. No stent‐related deaths were observed. The mean hospitalization was 7.7 ± 3.4 days. Median overall survival was 4 months (95% confidence interval 1–8). Conclusion: Endoscopic ultrasound‐guided gallbladder drainage with the new EC‐LAMS is a valid option in palliative endoscopic biliary drainage as a first‐step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC‐LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potential food impaction, which could result in stent dysfunction. [ABSTRACT FROM AUTHOR]

Background: An electrocautery‐enhanced delivery system with a lumen‐apposing metal stent (LAMS) is available for one‐step endoscopic ultrasound‐guided transmural drainage (EUS‐TD). Bipolar electrosurgery has several potential clinical advantages, including reduced collateral thermal damage, enhanced hemostasis, and no requirement for a return electrode plate. In this study, we compared the technical feasibility and safety of a newly developed bipolar electrocautery‐enhanced delivery system with a conventional delivery system for EUS‐TD using a LAMS in a porcine model. Method: Ten days before the study, 12 mini pigs underwent common bile duct ligation for EUS‐guided gallbladder drainage. Transenteric puncture was performed, followed by placement of a guidewire. In six pigs, a bipolar electrocautery‐enhanced delivery system with LAMS (Hot SPAXUS) was inserted over the guidewire and advanced into the gallbladder, without prior dilation of the tract, by applying a bipolar cut current. In the remaining six pigs, a conventional delivery system with LAMS (Cold SPAXUS) was inserted after tract dilatation using a cystotome. The stent was removed after 4 weeks. Results: In all pigs, the stent was successfully inserted and deployed in the gallbladder without adverse events. The mean procedure time of EUS‐TD was significantly lower in the Hot SPAXUS group than that of the Cold SPAXUS group (mean ± standard deviation: 188.7 ± 5.2 vs 449.5 ± 97.5 s, P =.0019). Stent migration was not observed, and all stents were removed successfully. Conclusions: Endoscopic ultrasound‐guided transmural drainage using a bipolar electrocautery‐enhanced LAMS is feasible for reducing the procedure time while maintaining the high success rate and safety of conventional LAMS. [ABSTRACT FROM AUTHOR]

This article discusses a technique called "SEMS-in-SEMS" for the removal of fully covered self-expandable metal stents (SEMS) in cases of benign pancreatic duct stricture. The article presents a case study of a patient with chronic pancreatitis who had a fully covered SEMS inserted to treat a pancreatic stricture. However, the stent became embedded in the pancreatic duct wall and could not be removed. The SEMS-in-SEMS technique was then used, which involved placing a second fully covered SEMS inside the existing one to compress the hyperplastic tissue and induce its ischemia and necrosis. After one month, both stents were successfully removed. The article suggests that this technique can be safe and effective for the extraction of embedded SEMS in patients with benign pancreatic duct strictures. [Extracted from the article]

Background/Purpose: Compared with currently available duodenoscopy‐assisted systems, direct peroral cholangioscopy (DPOC) using an ultra‐slim endoscope is limited by technical difficulties. The multibending (MB) ultra‐slim endoscope was introduced as a dedicated cholangioscope for DPOC to challenge the technical problem. We retrospectively analyzed the clinical utility of DPOC using an MB endoscope with free‐hand insertion into the bile duct in patients with biliary diseases. Methods: A total of 145 patients who underwent DPOC using an MB endoscope were analyzed. The primary outcome was the technical success rate of DPOC using the free‐hand insertion of the MB endoscope. The secondary outcomes were the technical success rates of DPOC‐guided diagnostic and therapeutic interventions, the diagnostic accuracy of DPOC‐guided target biopsy, and adverse events related to DPOC. Results: Free‐hand biliary insertion of a MB endoscope for DPOC was technically successful in 133 patients (91.7%). DPOC‐guided target biopsy was successful in 36 of 38 patients (94.7%) and had a diagnostic accuracy of 91.7% (95% confidence interval, 82.6‐100). Sixty‐nine therapeutic interventions were performed; technical success was achieved in 65 (94.2%). No severe adverse events were observed. Conclusions: The MB ultra‐slim endoscope was technically effective to perform a DPOC including various diagnosis and therapeutic interventions without device assistance. MB endoscope is considered to contribute to expanding a role of DPOC in diagnosis and treatment of diverse biliary tract diseases. [ABSTRACT FROM AUTHOR]

Background and Aim: Durable biliary drainage is essential in patients with pancreatic cancer in the era of effective neoadjuvant chemotherapy (NACT). Plastic stent (PS) tends to occlude easily, and current metal stents are designed for nonresectable cancer. We evaluated the efficacy of a modified non‐flared fully covered self‐expandable metal stent (M‐FCSEMS) during the perioperative period in patients with resectable or borderline resectable pancreatic cancer. Methods: Consecutive patients with resectable or borderline resectable pancreatic ductal adenocarcinoma had a 12‐mm M‐FCSEMS (M‐FCSEMS group) or 7‐Fr PS (PS group) placed for biliary decompression before NACT or curative‐intent surgery. The primary outcome was the re‐intervention rate, and secondary outcomes were technical success, stent patency, and adverse events (AEs). Results: Endoscopic stent placement was technically successful in all 60 patients. Twenty‐three patients underwent surgery and 37 NACT before surgery. Re‐intervention was performed in 10.0% (3/30) of patients in the M‐FCSEMS group and 36.7% (11/30) of patients in the PS group (P = 0.030). The stent patency at 180 days was 89.8% (95% confidence interval, 77.3–100.0%) in the M‐FCSEMS group and 30.2% (95% confidence interval, 11.4–80.0%) in the PS group (P < 0.0001). Stent‐related AEs occurred in 10.0% (3/30) in the M‐FCSEMS group and 40.0% (12/30) in the PS group (P = 0.015). Surgery‐related AEs occurred in 10.5% (2/19) and 14.3% (3/21) in the M‐FCSEMS and PS groups (P = 0.549). Conclusions: Modified non‐flared fully covered self‐expandable metal stents are effective and safe for durable biliary drainage in patients with resectable or borderline resectable pancreatic cancer during the perioperative period. [ABSTRACT FROM AUTHOR]

Background: Long‐term placement of lumen apposing metal stents (LAMS) with high lumen apposing force may result in adverse events. The aim of the current study was to assess the long‐term efficacy and safety of a self‐approximating LAMS with lower lumen apposing force for endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) and ‐gallbladder drainage (EUS‐GBD). Methods: Five Asian institutions participated in this study. Consecutive patients suffering from obstructive jaundice with failed ERCP or acute cholecystitis that were at high risk for cholecystectomy were recruited. We evaluated the technical and clinical success rates, adverse events rates, types of interventions through the stent and the patency profile. Results: From June 2017 to Oct 2018, a total of 53 patients received EUS‐CDS (26) and EUS‐GBD (27). The technical and clinical success rates were similar between the two groups (88.5% vs 88.9%, P = 1 and 88.5% vs 88.9%, P = 1 respectively). The differences in 30‐day mortality rates [2 (7.7%) vs 2 (7.7%), P = 1] and adverse events [3 (11.5%) vs 3 (11.5%), P = 1] did not reach significance. Regarding long‐term outcomes, two patients in each group suffered from adverse events (P = 1). One patient in the EUS‐GBD group who was on direct oral anticoagulant suffered from stent induced bleeding. Conclusion: The self‐approximating LAMS with lower lumen apposing force was effective and safe with a low risk of buried stent syndrome and bleeding in the longer term. The ClinicalTrials.gov Identifier was NCT03002051. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self‐expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent‐induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. Methods: Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5–6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow‐up period were measured. Results: Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138–196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow‐up period (median 635 days) after stent removal, only one recurrence developed. Conclusions: Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic post‐papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post‐papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. Methods: In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow‐up duodenoscopy to identify post‐papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post‐papillectomy bleeding rate and the tumor persistence rate. Results: The delayed post‐papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non‐APC group (P = 0.434). The post‐procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure‐related mortalities or serious complications. Conclusion: Prophylactic APC may not be effective in reducing delayed post‐papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration—cris.nih.go.kr; KCT0001955). [ABSTRACT FROM AUTHOR]

Backgrounds and Aim: Multiple insertions of self‐expandable metal stents (SEMS) for advanced malignant hilar obstruction (MHO) are now considered to be an effective palliative method for adequate drainage of liver volume. However, the efficacy of endoscopic reintervention in technically and clinically successful bilateral SEMS is limited. This study investigated the endoscopic revision efficacy in patients who underwent bilateral SEMS in MHO. Methods: Primary endoscopic revision using plastic or metal stents or an alternative percutaneous approach followed by secondary endoscopic revision was performed in patients who underwent clinically successful deployment of bilateral SEMS. The primary outcome was a technical success. Secondary outcomes were clinical success, adverse events, and patency duration after reintervention. Results: A total of 55 patients (83.3%) out of 66 enrolled patients underwent reintervention: primary endoscopic reintervention (n = 47) and secondary endoscopic revision following percutaneous drainage (n = 8). Intended technical success rates of primary and secondary endoscopic reintervention were 93.6% (44/47) and 87.5% (7/8), respectively (P = 0.47). Clinical success rates were 72.3% and 50%, respectively (P = 0.23). Stent malfunction rate after reintervention was 48.9% (23/47) and 37.5% (3/8) (P = 0.70) during follow up, and median cumulative stent patency duration was 119 and 55 days, respectively (log–rank P = 0.68). Stent patent rate after reintervention was not different according to the time interval. In univariate and multivariate analysis for stent patency duration‐related factors after reintervention, there were no meaningful factors. Conclusion: Primary endoscopic reintervention for bilateral SEMS in MHO was feasible technically and clinically. However, there were no statistically meaningful factors for stent patency duration after reintervention. [ABSTRACT FROM AUTHOR]

Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico‐biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato‐biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS. [ABSTRACT FROM AUTHOR]

Background and Aim: Fully covered self‐expandable metallic stent (FCSEMS) may be an effective modality for managing anastomotic biliary stricture (ABS) after liver transplantation. However, stent migration and stent‐induced ductal injury are the main limitations. The objective of this study was to evaluate the usefulness of an unflared, intraductal FCSEMS that was designed to minimize migration and ductal injury for refractory ABS after living donor liver transplantation (LDLT). Methods: A total of 32 consecutive patients with symptomatic ABS after LDLT unresolved by plastic stents with or without balloon dilation at four tertiary medical centers were prospectively enrolled. A short (3 or 5 cm) FCSEMS having long lasso (10 cm) used in this study had unflared convex ends to minimize tissue hyperplasia and smaller center portion to prevent migration. The FCSEMS was placed above the papilla and removed at 3–4 months after stenting. Results: Technical and clinical success rates of intraductal placement with FCSEMS were 100% (32/32) and 81.2% (26/32), respectively. Early stent migration was observed in five (15.6%) patients. However, three patients with early stent migration had stricture resolution without needing additional intervention. Intended stent removal was successful in 27 (100%) patients (median, 101 days; range, 23–118 days). No stent‐induced ductal change was observed in all patients. Stricture recurrence was observed in 11.5% (3/26) of patients during 639 days of median duration of follow‐up (range, 366–2079 days). Conclusions: Intraductal placement of an unflared short FCSEMS may be a promising option for refractory ABS after LDLT with minimal stent‐induced ductal injury and stent migration. [ABSTRACT FROM AUTHOR]

Background: A novel self‐approximating lumen‐apposing metallic stent (LAMS; Niti‐S Spaxus, Taewoong Medical, Gyeonggi‐do, Korea) has recently become available. The aim of the present study was to evaluate the outcomes for drainage of pancreatic fluid collections (PFC). Methods: This was a prospective international multicentered study conducted in six high‐volume institutions across Asia. Consecutive patients suffering from pancreatic pseudocyst or walled‐off pancreatic necrosis (WOPN) requiring endoscopic ultrasonography‐guided drainage were recruited. Outcomes included technical and clinical success, adverse events, procedural events, interventions through the stent and recurrence rates. Results: Between August 2016 and November 2017, 59 patients were recruited to this study. Thirty‐nine patients (66.1%) had WOPN and mean (SD) size of PFC was 11.5 (5.1) cm. Technical and clinical success rates were 100%. Mean (SD) procedural time was 35.0 (17.2) minutes. Sixteen‐millimeter stents were used in 66.1% of the patients. Fifty‐four sessions of necrosectomy were carried out with the stent in situ in 17 patients. Stent‐related adverse event (AE) rate was 6.8%. Three patients (5.1%) suffered from bleeding after stenting and one required angiographic embolization. Two patients (3.4%) suffered from recurrence during a mean (SD) follow‐up time of 325.6 (355.5) days. There were no differences in outcomes between those with pseudocysts or WOPN except for the duration of hospital stay (P = 0.012). Conclusion: Use of a self‐approximating LAMS for drainage of PFC was safe and effective. Endoscopic necrosectomy could be carried out through the stent with ease. The device was associated with a low rate of stent‐related AE. [ABSTRACT FROM AUTHOR]

Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high‐grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent‐in‐stent vs stent‐by‐stent). [ABSTRACT FROM AUTHOR]

Background and Aim: Fully covered self‐expandable metal stents (FCSEMS) may be better than plastic stents (PS) for preoperative biliary drainage (PBD) to relieve cholangitis or jaundice for resectable malignant biliary obstruction (MBO). However, modification of current FCSEMS designed originally for nonresectable MBO is needed to be a proper stent for PBD. The aim of this study was to evaluate the possible superiority of non‐flared modified FCSEMS (M‐FCSEMS) with 12‐mm diameter and waist of central portion over PS in patients with resectable MBO. Methods: Eighty‐five consecutive patients underwent PBD followed by operation from August 2015 to December 2017. In each M‐FCSEMS and PS group, 29 patients were matched for age, sex, body mass index, and preoperative albumin and bilirubin levels. Results: The overall technical success rates of PBD using M‐FCSEMS and PS were 100%. The time to operation was similar between groups (18.6 ± 10.8 vs 19.3 ± 11.6 days, respectively; P = 0.843). The prevalence of PBD‐related adverse events (AEs) was 6.9% (2/29) in the M‐FCSEMS group versus 27.6% (8/29) in the PS group (P = 0.037). Re‐intervention before operation was required in 20.7% (6/29) of patients in the PS group but no patients in the M‐FCSEMS group (P = 0.023). No differences were found between perioperative AEs in the M‐FCSEMS and PS groups (27.5% vs 31.0%, respectively; P = 0.773). Conclusion: Modified FCSEMS led to lower PBD‐related AEs, re‐intervention rate, and comparable perioperative AEs compared with PS. M‐FCSEMS may be a potential novel stent for PBD in patients with resectable MBO. [ABSTRACT FROM AUTHOR]

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single‐operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single‐operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single‐operator cholangioscopy techniques in the diagnosis and management of biliary disorders. [ABSTRACT FROM AUTHOR]

Background and Aims: Catheter‐based endobiliary radiofrequency ablation (RFA) is an endoscopic local treatment for patients with malignant biliary stricture (MBS). However, excessive heating of the bile duct by the current RFA system can induce serious complications. Recently, a new RFA system with automatic temperature control was developed. In the present study, we examined the safety of the new RFA system in patients undergoing endobiliary RFA for extrahepatic MBS. Methods: This prospective, multicenter study enrolled patients with unresectable or inoperable extrahepatic (> 2 cm from the hilum) MBS. Endobiliary RFA was performed using a newly developed RFA catheter (ELRA™, STARmed, Goyang, Korea) at a setting of 7 or 10 W for 120 s and with a target temperature of 80°C. A self‐expandable metallic stent was inserted after endobiliary RFA. The rate of procedure‐related adverse events was assessed. Results: The 30 patients were enrolled in this study. Cholangiocarcinoma was diagnosed in 19 patients, pancreatic cancer was found in 9, and gallbladder cancers were recorded in 2. The mean stricture length was 22.1 ± 6.6 mm. Post‐procedural adverse events occurred in three patients (10.0%; 2 mild pancreatitis and 1 cholangitis) without hemobilia and bile duct perforation. The pancreatitis and cholangitis resolved with conservative treatment. The cumulative duration of stent patency and survival were 236 and 383 days, respectively. Conclusions: Automatic temperature‐controlled endobiliary RFA using a newly developed catheter was safely applied in patents with extrahepatic MBS. Further prospective studies are needed to confirm the efficacy of endobiliary RFA for MBS. [ABSTRACT FROM AUTHOR]

Backgrounds: Fully covered self‐expandable metal stent (FCSEMS) are preferred for distal malignant biliary stricture (MBS). However, stent migration is a major adverse event of FCSEMS, especially for far distal MBS. We evaluated the usefulness of newly modified FCSEMS (M‐FCSEMS) having 12 mm in diameter and anti‐migration feature to minimize stent migration compared with the conventional FCSEMS (C‐FCSEMS). Methods: Total 102 patients were enrolled between January 2015 and September 2017 in this prospective comparative study; 50 were allocated to the M‐FCSEMS group and 52 to the C‐FCSEMS group. The primary outcome was stent migration, and the secondary outcomes were other adverse events, stent occlusion rate, and stent patency during the follow‐up period. Results: The baseline characteristics of the two groups did not significantly differ. Endoscopic stent placement was technically successful in all patients. Stent migration occurred in 8.0% (4/50) of the patients in the M‐FCSEMS group and 23.1% (12/52) of those in the C‐FCSEMS group (P = 0.036). The other adverse events, including stent‐related pancreatitis and cholecystitis did not significantly differ between the two groups (P = 0.415). Stent occlusion occurred in 23.9% (11/46) of the patients in the M‐FCSEMS group and 37.5% (15/40) in the C‐FCSEMS group (P = 0.171). Stent patency was significantly longer in the M‐FCSEMS group than in the C‐FCSEMS group (228 vs 157 days, P = 0.048). Conclusions: Modified FCSEMS with 12‐mm diameter and anti‐migration feature significantly decreased the risk of stent migration and had longer patency compared with C‐FCSEMS in patients with periampullary MBS. [ABSTRACT FROM AUTHOR]

Abstract: Defect‐free mixed‐matrix membranes (MMMs) were prepared by incorporating hydrophilic metal‐organic polyhedra (MOPs) into cross‐linked polyethylene oxide (XLPEO) for efficient CO2 separation. Hydrophilic MOPs with triethylene glycol pendant groups, which were assembled by 5‐tri(ethylene glycol) monomethyl ether isophthalic acid and CuII ions, were uniformly dispersed in XLPEO without particle agglomeration. Compared to conventional neat XLPEO, the homogenous dispersion of EG3‐MOPs in XLPEO enhanced CO2 permeability of MMMs. Upon increasing the amount of EG3‐MOPs, the membrane performance such as CO2/N2 selectivity was steadily improved because of unsaturated CuII sites at paddle‐wheel units, which was confirmed by Cu K‐edge XANES and TPD analysis. Therefore, such defect‐free MMMs with unsaturated metal sites would contribute to enhance CO2 separation performance. [ABSTRACT FROM AUTHOR]

Background and Aim As society ages, the need for endoscopic retrograde cholangiopancreatography ( ERCP) is increasing. This prospective comparative study evaluated the safety and efficacy of midazolam- versus propofol-based sedations by non-anesthesiologists during therapeutic ERCP in patients over 80 years of age. Methods A total of 100 patients over 80 years of age who required therapeutic ERCP were enrolled and randomly received midazolam + fentanyl ( MF group) or propofol + fentanyl ( PF group) sedation. Endoscopic sedation was titrated to a moderate level and carried out by trained registered nurses. Main outcome measurements were sedation safety in terms of cardiopulmonary components and efficacy measured on a 10-point visual analogue scale ( VAS). Results Regarding safety, hypoxia occurred in seven (14%) in the MF group and in eight patients (16%) in the PF group ( P = 0.779). Increased O2 supply was more frequent in the PF group (32% vs 42%), albeit not significantly so. There were no differences in the frequency of hypotension, bradycardia or tachycardia between the two groups. Mean VAS score for overall satisfaction with sedation by patients, endoscopists, and nurses and the scores for pain during the procedures were not different between the two groups. There was no significant difference in the procedure outcomes or rate of ERCP-related complications. Conclusions There were no significant differences of safety and efficacy between midazolam- and propofol-based sedation in patients over 80 years of age. Increased O2 supply was more frequent in the propofol group, but the prevalence of hypoxia did not differ significantly. [ABSTRACT FROM AUTHOR]

In malignant biliary stricture ( MBS), the diagnostic accuracy of ERCP-based tissue sampling is insufficient. EUS-guided fine needle aspiration biopsy ( EUS- FNAB) is emerging as a reliable diagnostic procedure. This study aimed to evaluate the usefulness of a diagnostic approach using ERCP-guided transpapillary forceps biopsy ( TPB) or EUS- FNAB according to the characteristics of suspected MBS. Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with intraductal ultrasonography ( IDUS) and TPB were performed as initial diagnostic procedures. Based on the results of imaging studies and IDUS, all MBS were classified as extrinsic or intrinsic type. If the malignancy was not confirmed by TPB, EUS- FNAB for extrinsic type or second TPB for intrinsic type was performed. Among a total of 178 patients, intrinsic and extrinsic types were detected in 88 and 90 patients, respectively. The diagnostic accuracy of first TPB was significantly higher in the intrinsic than in the extrinsic type (81.8% vs. 67.8, P = 0.023). In 33 patients with extrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of EUS- FNAB was 90.9%. In 19 patients with intrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of second TPB was 84.2%. The diagnostic accuracies of the combination of initial TPB with EUS- FNAB and second TPB were 96.7% and 96.6%, respectively. A diagnostic approach using EUS- FNAB or TPB according to the origin of MBS is considered effective to improve the diagnostic accuracy of MBS with negative for malignancy on first TPB. (Clinical trial registration number: UMIN000016886). [ABSTRACT FROM AUTHOR]

Objective: To evaluate the usefulness of maternal serum c-reactive protein (CRP), lipid peroxide, and oxygen radical absorbance capacity (ORAC), to predict the interval between membrane rupture and delivery in patients with preterm premature rupture of membranes (PPROM).Methods: The present prospective study included patients with singleton pregnancies experiencing PPROM at earlier than 34 weeks of pregnancy who underwent spontaneous vaginal delivery between August 1, 2010 and July 31, 2013 at Chonnam National University Hospital, Republic of Korea. Patients were categorized based on whether delivery occurred within 3 days of PPROM or after. CRP levels, lipid peroxide (using malondialdehyde levels), ORAC, protein carbonyl, and other potential risk factors were compared between the groups.Results: There were 72 patients included. Maternal serum CRP levels, malondialdehyde levels, and Bishop Score were higher in patients who underwent delivery within 3 days (all P<0.05); ORAC levels were lower among these patients (P=0.002). A receiver operating characteristic curve analysis showed that CRP, malondialdehyde, and ORAC levels were predictive of delivery within 3 days after PPROM.Conclusion: Maternal serum CRP, malondialdehyde, and ORAC levels at admission were useful in predicting the latent period in patients with PPROM. [ABSTRACT FROM AUTHOR]

Background and Aim KRAS mutation analysis may provide ancillary diagnostic yield in an endoscopic ultrasound (EUS)-guided histopathological evaluation. We evaluated the clinical impact of KRAS mutation analysis with cytological and histological evaluations in EUS-guided tissue sampling, using a core biopsy needle for solid liver masses. Methods EUS-guided fine needle biopsy (EUS-FNB) using a core biopsy needle was performed in patients with primary or metastatic liver masses that were suspected malignancies. KRAS mutations were analyzed in all specimens obtained. The peptide nucleic acid (PNA)-mediated polymerase chain reaction (PCR) clamping method was compared with a next-generation sequencing (NGS) method for detecting KRAS mutations. Results EUS-FNB with a core biopsy needle was performed in 28 patients with solid liver masses located in the liver's left lobe. The diagnostic accuracies for malignancy of on-site cytology, cytology using Papanicolaou staining, and histology including immunohistochemical stains were 82.1%, 85.7%, and 89.3%, respectively. KRAS gene mutations were observed in 14.3% of patients by the PNA-PCR clamping method. The NGS method detected more KRAS mutations than the PNA-PCR clamping method: in 25% of patients. Adding the results of KRAS mutation analysis to the cytohistopathological evaluation, the overall diagnostic accuracy of EUS-guided tissue sampling was 96.4%. Conclusions EUS-guided tissue sampling for solid liver masses in the left lobe provided high diagnostic accuracy from cytological and histological evaluations. KRAS mutation analysis provided additional diagnostic yield in patients with inconclusive cytohistopathological results from EUS-guided tissue sampling. The NGS method detected additional KRAS mutations in patients with negative PNA-mediated PCR clamping test results. [ABSTRACT FROM AUTHOR]

Background and Aim It can be difficult to identify the cause of an enlarged ampulla of Vater (AOV). This study evaluated the accuracy of wire-guided intraduodenal ultrasonography (US) for the differential diagnosis of an enlarged AOV during endoscopic retrograde cholangiopancreatography (ERCP). Patients and Methods Thirty-four patients with enlarged AOVs of unknown cause identified on imaging studies or endoscopic observations underwent wire-guided intraduodenal US using a catheter probe. Results The final diagnoses were malignant or premalignant tumors in 10 patients (29.4%), stones in nine patients (26.5%), inflammation in 14 patients (41.2%), and cyst in one patient (2.9%). The overall diagnostic accuracy of intraduodenal US for enlarged AOVs was 91.2%. The diagnostic accuracies of stones, inflammation, and AOV tumors were 100.0%, 94.1%, and 91.1%, respectively. Conclusions Wire-guided intraduodenal US using a catheter probe is readily applicable during ERCP and may be useful in the differential diagnosis of enlarged ampullary lesions. [ABSTRACT FROM AUTHOR]

Background and Aim A reproducible in vivo swine model of bile duct dilation (BDD) was recently established and reported for preclinical testing of newly developed biliary devices or endoscopic techniques. The aim of the present study was to develop a more advanced large animal model in which it is possible to direct examination of the biliary tree. Methods Six mini pigs were prepared for the study. BDD models were first made by closure of the Vater's ampulla in all swine. Then endoscopic papillary balloon dilation (EPBD) was done in the animals. Feasibility of single-operator peroral cholangioscopy without assistance of accessories was evaluated using an ultra-slim upper endoscope in the animals. Results EPBD could be implemented using a dilation balloon catheter (10~13.5 mm) in all BDD models (6/6, 100%). Success rate of freehand direct insertion of an ultra-slim endoscope into the common bile duct was 100% (6/6), and access to the common hepatic duct with examination was possible using direct peroral cholangioscopy in five animals (5/6, 83.3%). None of the animals died. In the cholangioscopic examination, a bile duct polyp and a benign biliary stricture occurred naturally, respectively, in two of the six swine. Conclusion An in vivo swine model of biliary dilatation-based direct peroral cholangioscopy was established. This novel animal model may be useful for preclinical research of new materials or devices because direct visualization of the biliary tree is feasible. [ABSTRACT FROM AUTHOR]

Background and Aim: A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures. Methods: This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group ( n = 22) or a CP group ( n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice. Results: Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group ( P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group ( P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups ( P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents ( P = 0.032). Conclusions: The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods. [ABSTRACT FROM AUTHOR]

Direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope is one modality of POC for intraductal endoscopic evaluation and treatment of the bile duct. Choledochoduodenostomy (CDS) is one modality of biliary bypass surgery that provides a new route to the bile duct. We carried out direct POC using an ultra-slim upper endoscope without the use of accessories in 10 patients (four sump syndromes, three bile duct strictures and three intrahepatic duct stones) previously undergoing surgical CDS. Direct POC was successful in all patients. The use of an intraductal balloon catheter was required in one patient for advancement of the endoscope into the bile duct. Distal bile ducts with sump syndromes were cleared using baskets and water irrigation under direct POC. Cholangiocarcinoma was diagnosed in one patient with hilar bile duct stricture after cholangioscopic evaluation and a targeting forceps biopsy under direct POC. Intrahepatic duct stones were successfully extracted after intraductal fragmentation under direct POC. Oozing bleeding occurred during intraductal lithotripsy but stopped spontaneously. Direct POC using an ultra-slim upper endoscope without the assistance of accessories can easily be carried out in patients undergoing CDS. [ABSTRACT FROM AUTHOR]

Endoscopic management of unresectable hilar malignant biliary stricture (MBS) is currently challenging, and the best approach is still controversial. Liver volume is the key to adequate biliary drainage in hilar MBS and multiple stenting is mandatory to drain over 50% of liver volume in most cases. The self‐expandable metallic stent (SEMS) has shown superior patency to plastic stents in recent reports. There are two methods of multiple stenting for hilar MBS: stent‐in‐stent (SIS) and side‐by‐side (SBS). Advantages of SIS include multiple SEMS placement in one stent caliber at the common bile duct (CBD), which is considered physiologically ideal. The through‐the‐mesh (TTM) technique with guidewires and the SEMS delivery system can be technically difficult in SIS, although the recent development of dedicated SEMSs having a loose portion facilitating the TTM technique makes SIS technically feasible both at stent deployment and re‐interventions. Conversely, the SBS technique, if placed across the papilla, is technically simple at initial placement and re‐intervention at stent occlusion. However, SBS has potential disadvantages of overexpansion of the CBD because of parallel placement of multiple SEMS, which can lead to portal vein thrombosis. Given the limited evidence available, a well‐designed randomized controlled trial comparing these two techniques is warranted. [ABSTRACT FROM AUTHOR]

Background and Study Aims Endoscopic ultrasound ( EUS)-guided fine needle aspiration ( EUS-FNA) is one of the alternative methods for tissue sampling of liver solid mass. However, the diagnostic efficacy using cytology alone was limited. In this study, we evaluate the diagnostic accuracy of EUS-guided fine needle biopsy ( EUS-FNB) as a percutaneous biopsy rescue for liver solid mass. Patients and Methods The EUS-FNB using core biopsy needle for liver solid mass was performed prospectively for patients who were failure to acquire a tissue or achieve a diagnosis using percutaneous liver biopsy. The primary outcome was the diagnostic accuracy of EUS-FNB for malignancy and specific tumor type. The secondary outcomes were the median numbers of passes required to establish a diagnosis, the proportions of patients in whom immunohistochemical ( IHC) stain was possible and obtained adequate specimen, and safety of EUS-FNB. Results Twenty-one patients (12 women; mean age, 63 years [range, 37-81]) underwent EUS-FNB for solid liver masses. The median number of needle passes was 2.0 (range, 1-5). On-site cytology and cytology with Papanicolaou stain showed malignancy in 16 patients (76.2%) and 17 patients (81.0%), respectively. In histology with HE stain, 19 patients (90.5%) were diagnosed malignancy and optimal to IHC stain. The overall diagnostic accuracy for malignancy and specific tumor type were 90.5% and 85.7%, respectively. No complications were seen. Conclusions EUS-FNB with core biopsy needle for solid liver mass may be helpful in the management of patients who are unable to diagnose using percutaneous liver biopsy. [ABSTRACT FROM AUTHOR]

Background and Aim Identifying a bile duct ( BD) stone in patients with acute biliary pancreatitis ( ABP) is important for the management and prevention of recurrent attack of pancreatitis. However, small BD stones may not be detected on endoscopic retrograde cholangiopancreatography ( ERCP). The aim of this study was to prospectively evaluate the usefulness of intraductal ultrasonography ( IDUS) in patients suspected to have ABP but with no evidence of choledocholithiasis on ERCP. Methods A total 92 patients suspected with ABP without evidence of BD stones on imaging studies including ERCP were enrolled. Wire-guided IDUS was performed during ERCP in all patients. Stones or sludge detected by IDUS were confirmed after endoscopic sphincterotomy ( EST) and extraction. If IDUS finding was negative, then we swept the BD with a balloon catheter and/or basket without EST. After endoscopic management, comparison between IDUS and endoscopic finding was carried out to determine the diagnostic accuracy of IDUS. Results Among the 92 patients, IDUS revealed BD stones in 33 (35.9%). All 33 patients' stones were confirmed by endoscopic visualization after EST and BD exploration. During the mean follow up of 24 months, recurrent pancreatitis did not occur in 90 of 92 patients (97.9%) with ABP after endoscopic treatment according to the IDUS findings. Conclusions IDUS improves diagnostic accuracy for the detection of clinically occult BD stones in patients suspicious ABP. IDUS-guided endoscopic management for patients with ABP can avoid unnecessary EST and help prevent recurrent pancreatitis. [ABSTRACT FROM AUTHOR]

Background and Aim Therapeutic endoscopic retrograde cholangiopancreatography ( ERCP) tends to require considerable air insufflation, which results in abdominal pain or distension. We investigated the efficacy of carbon dioxide ( CO2) compared with air insufflation when using two different sedation protocols in therapeutic ERCP. Methods Patients who required therapeutic ERCP were randomly assigned to four groups based on preliminary data: air insufflation with balanced propofol sedation ( BPS), air with propofol + opioid sedation ( PS), CO2 with BPS, and CO2 with PS. Post- ERCP abdominal pain, distension and nausea by the 10-point visual analogue scale ( VAS), and gas volume score ( GVS) by the four-point ordinal scale were measured according to the time interval. Overall satisfaction with sedation, sedation efficacy, and complications were also measured. Results The CO2 with BPS group showed lowest mean VAS score for abdominal pain (immediately after recovery, P = 0.002; and 3 h post- ERCP, P = 0.047) and distension (immediately after recovery, P = 0.018; 3 h post- ERCP, P < 0.01; and 24 h post- ERCP, P = 0.042). Overall satisfaction with sedation was greater in the CO2 with BPS group ( P = 0.005). Mean GVS at 2 h and 12 h post- ERCP was significantly lower in the CO2 with BPS group ( P < 0.05). There were no significant differences in procedure or sedation-related complications. Conclusion CO2 with BPS showed the lowest VAS score for early abdominal pain, distension and GVS, and had a higher score for overall satisfaction for sedation. [ABSTRACT FROM AUTHOR]

Background and Aim After selective biliary access following precut fistulotomy in difficult biliary cannulations ( DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones. Methods This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications. Results A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation ( P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation ( P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively ( P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307). Conclusions One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation. [ABSTRACT FROM AUTHOR]

Background Endoscopic management of recurrent bile duct stones after endoscopic sphincterotomy ( EST) is effective and safe. However, repeat EST for extension of a previous EST for recurrent bile duct stones may involve substantial risk. The aim of the present study was to evaluate the safety and efficacy of endoscopic papillary large balloon dilation ( EPLBD) without repeat EST for recurrent difficult bile duct stones after previous EST. Patients and Methods From January 2006 to October 2010, a total of 52 patients were enrolled; all had undergone EPLBD (balloon diameter: 12-20 mm) to remove recurrent difficult bile duct stones after previous EST. In all patients, stone removal had failed with conventional methods using a basket and/or balloon. The size of the balloon for EPLBD was selected to fit the diameter of the common bile duct or the largest stone. Results The median interval between initial EST and stone recurrence was 2.2 years (range 1-10). Median diameters of thelargest stone and balloon were 20.1 mm (range 12-40) and 14.7 mm (range 12-20), respectively. Complete stone removal was achieved in all patients (100%). The median number of endoscopic retrograde cholangiopancreatography sessions needed for complete stone removal was 1.6 (range 1-3). Additional lithotripsy was required in 16 patients (30.7%). No procedure-related complications were documented, with the exception of four cases of asymptomatic hyperamylasemia. The recurrence rate of CBD stones after bile duct clearance was 17.3% (9/52) during the follow-up period (mean 27.0 ± 14.1 months). Conclusions EPLBD without repeat EST is effective and relatively safe for the extraction of recurrent difficult bile duct stones after previous EST. [ABSTRACT FROM AUTHOR]

Background Although peroral direct cholangioscopy ( PDCS) is emerging as an alternative to traditional mother-daughter cholangioscopy, it is associated with high failure rates. The aim of the present study was to evaluate the ability to insert and carry out interventions using a prototype multi-bending PDCS. Patients and Methods Prospective, observational clinical feasibility study was done in 41 patients with a variety of biliary diseases. A multi-bending PDCS prototype was inserted using a free-hand technique, a guidewire alone, or with a 5- Fr diameter anchoring balloon. Diagnostic and therapeutic procedures were carried out. Results The free-hand direct insertion technique failed in all attempted cases ( n = 7). Of the remaining 34 cases, successful rate of PDCS insertion into the distal bile duct was achieved by passing the PDCS over a guidewire alone ( n = 6) and/or with a guidewire plus anchoring balloon ( n = 28) for an overall successrate of 88.2% (30/34). In 13 (92.9%) patients without an underlying biliary stricture, PDCS insertion proximal to the bifurcation was possible. In 25 cases, biliary interventions were attempted including biopsy ( n = 13), stone removal ( n = 6), stent removal ( n = 1), and intraductal electrohydraulic lithotripsy ( n = 2) and were successful in 22 (88%). Other than two patients with procedure-related cholangitis with a mild grade of severity, no complications were observed. Conclusions Using a novel multi-bending prototype peroral direct cholangioscope, cholangioscopy had a high diagnostic and therapeutic success rate only when passed over a guidewire and anchoring balloon but not with the free-hand insertion technique. Comparative studies of direct cholangioscopy are warranted. [ABSTRACT FROM AUTHOR]

Objectives The mechanism of pancreatitis development following endoscopic papillary balloon dilation ( EPBD) remains unknown. Antegrade dilation with percutaneous transhepatic papillary balloon dilation ( PTPBD) allows the removal of bile duct stones or fragments during percutaneous choledochoscopic lithotomy, with less mechanical trauma to the papilla than with EPBD-mediated stone removal. Methods A total of 56 patients with bile duct stones underwent antegrade dilation with PTPBD from March 2006 to February 2011. A total of 208 patients with common bile duct stones underwent retrograde dilation with EPBD during the same period. The conditions of papillary balloon dilation were identical in both groups. The frequencies of pancreatitis and hyperamylasemia were compared in both groups. Results Pancreatitis occurred in 14 (6.7%) of 208 patients in the EPBD group (mild, nine; moderate, four; severe, one). There was no case of pancreatitis among 56 patients in the PTPBD group ( P < 0.05). Hyperamylasemia developed in significantly more patients treated in the EPBD group (62, 29.8%) compared with the PTPBD group (4, 7.1%; P < 0.05). Complete bile duct clearance was achieved in 98.2% of PTPBD group and 97.1% of EPBD group. Conclusions The rates of post-procedural pancreatitis and hyperamylasemia were significantly higher after retrograde dilation with EPBD than after antegrade dilation with PTPBD for the removal of bile duct stones. Although the mechanism of pancreatitis following papillary balloon dilation remains unclear, post- EPBD pancreatitis may be associated with procedures before and after balloon dilation similar to mechanical lithotripsy rather than balloon dilation itself. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic biliary drainage ( BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy ( TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy ( ES) previously. Methods Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5- Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated. Results A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred. Conclusion Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously. [ABSTRACT FROM AUTHOR]

Hilar cholangiocarcinoma ( HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia- Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia- Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation. [ABSTRACT FROM AUTHOR]

Objective To report treatment outcomes and complications of uncovered self-expandable metallic stents ( SEMS) as a first-line therapy for inoperable malignant duodenal obstructions in our hospital. Methods A retrospective analysis was performed in patients who had undergone placement of uncovered SEMS as a first-line therapy for inoperable malignant duodenal obstruction from August 2001 to July 2011. Treatment outcomes and complications of the procedures were investigated. Results In total, 47 patients (25 men; mean age 65 years) underwent the procedure. The technical and clinical success rates were 93.6% and 83.0%, respectively. Early complications occurred in 8 patients, including two guidewire-induced micro-perforations and six pancreatitis. All these 8 patients recovered with conservative treatment. Six late complications requiring additional procedures consisted of five stent occlusions due to tumor ingrowth and one stent migration. Four stent occlusions and one migration were treated by the placement of an additional covered stent and the remaining case was treated by balloon dilatation. The median primary stent patency period and median survival period after primary stent placement were 103 days and 131 days, respectively. Conclusions Uncovered SEMS placement is effective as a first-line palliative therapy for inoperable malignant duodenal obstruction. Complications such as stent occlusion or migration can be easily managed with additional covered SEMS. [ABSTRACT FROM AUTHOR]

Recently, several endoscopists have reported the usefulness of direct peroral video cholangioscopy for the diagnosis and therapy of bile duct lesions. Although ultra-slim pediatric or Tran nasal video endoscopes are usually used for the direct peroral video cholangioscopy, direct scope insertion without pretreatment and any assistant is considerably difficult. Based on the previous literatures, intraductal balloon catheter-assisted scope insertion might be relatively reliable method. To overcome the issue on the scope insertion, recently prototype cholangioscope that has short bending section and anchoring balloon catheter for scope replacement and insertion has been developed. In the near future, we could establish the direct peroral cholangioscopy using new developed technology. [ABSTRACT FROM AUTHOR]

Background: Palliative treatment including stenting is limited in patients with Klatskin tumor. Argon plasma coagulation (APC) is a new local treatment modality for the devitalization and debulking of tumors. Argon plasma coagulation could be a candidate method for relief of biliary strictures in patients with non-resectable Klatskin tumor in whom biliary stenting has failed. This study provides an evaluation of the technical feasibility, safety, and effect of APC as a palliative strategy in patients with non-resectable Klatskin tumor. Methods: In vitro studies were performed in order to investigate the dimension of coagulation necrosis in 11 human gallbladders. The currents were applied in normal air conditions and a bowl filled with normal saline in five and six specimens, respectively. Argon plasma coagulation was also performed on three patients with Klatskin tumor who showed no effective drainage via percutaneous transhepatic approach with a cholangioscope. Results: A coagulation current was delivered to the specimen even if in normal saline. The maximum depth and diameter of necrosis was 3 and 6.5 mm under normal air conditions, compared with 2 and 5 mm in water conditions. No perforation of the gallbladder wall occurred in any of the lesions. The dimension of the necrosis increased with increasing impact time and energy settings. Argon plasma coagulation application was possible on tumors of patients without severe complication. Conclusion: Argon plasma coagulation seems to be applicable, effective and relatively safe in palliative treatment for advanced non-resectable Klatskin tumor via cholangioscopy. Longer follow ups and comparative trials with other treatment modalities are, however, required. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discusses the use of N-butyl-2-cyanoacrylate in achieving endoscopic hemostasis as a way to control massive gastric bleeding during endoscopic transgastric drainage of pancreatic pseudocyst in 35-year-old man.