Koh Fukushi

Two useful rendezvous methods are used during endoscopic retrograde cholangiopancreatography (ERCP): (1) along-the-wire method and (2) over-the-wire method [1] [2] [3]. Especially, for balloon-endoscopy-assisted ERCP (BE-ERCP) in patients with altered gastrointestinal anatomy, cannulation might be difficult even with availability of the two rendezvous methods. We developed a method of rendezvous technique, a catheter assistance system (CAS), that combines over-the-wire method with a catheter. To the best of our knowledge, this is the first video case of the CAS used for BE-ERCP with altered gastrointestinal anatomy. This video presents a typical case ([Video 1]). A 79-year-old woman with obstructive jaundice associated with bile duct stricture ([Fig. 1]) had prior gastric cancer surgery. Cannulation for that BE-ERCP was difficult; bile duct drainage was unsuccessful. Therefore, PTBD was conducted. Two weeks later, the CAS was performed through the fistula-forming PTBD route. A guidewire and the ERCP standard catheter (MTW; ABIS Inc., Japan, Tokyo) were inserted and placed in the intestine through a percutaneous route ([Fig. 2]). The catheter tip was grasped with a snare and pulled into the endoscope ([Fig. 3]). When the catheter exited the endoscopic channel, the guidewire was pulled out from the percutaneous route side ([Fig. 4]). A guidewire was inserted from the catheter tip toward the bile duct. The catheter alone was removed from the percutaneous route while retaining the wire. A guidewire was detained in the bile duct, from which the usual ERCP procedure was performed ([Fig. 5]). Drainage was performed with no adverse events. The two conventional rendezvous methods, (1) along-the-wire and (2) over-the-wire, entail some difficulties caused by possible miscannulation of the pancreatic duct, dropping of the grasped guidewire, and kinking in the endoscope channel [1] [2] [3]. By contrast, the CAS entails no such difficulties. Especially, when performing BE-ERCP, the CAS can support safer and more reliable rendezvous methods. Endoscopy_UCTN_Code_CPL_1AH_2AJ Article published online: 11 December 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Background: JCOG1113 is a randomized phase III trial that showed non-inferiority of gemcitabine plus S-1 to gemcitabine plus cisplatin in patients with advanced biliary tract cancer. Assessment of inter-institutional heterogeneity in chemotherapy contributes to confirm generalizability and reliability of the study itself. However, there have been no studies conducted to assess the heterogeneity among participating centers in randomized phase III trials for biliary tract cancer. Methods: The objective of this post-hoc analysis was to assess the inter-institutional heterogeneity in the overall survival and progression-free survival of patients with advanced biliary tract cancer treated with first-line chemotherapy in the JCOG1113 trial. The heterogeneity in the overall survival and progression-free survival was assessed according to three factors: hospital volume, experience in medical oncology and experience in biliary intervention. A total of 300 advanced biliary tract cancer patients were analyzed. There were no statistically significant trends observed between hospital volume, experience in medical oncology, or experience in biliary intervention and overall survival (hospital volume: adjusted trend P value = 0.6796; experience in medical oncology: adjusted trend P value = 0.4092; experience in biliary intervention: adjusted trend P value = 0.6112). Similarly, no statistically significant trends were observed between these factors and progression-free survival (hospital volume: adjusted trend P value = 0.3000; experience in medical oncology: adjusted trend P value = 0.1108; experience in biliary intervention: adjusted trend P value = 0.2898). Conclusions: This study revealed no inter-institutional heterogeneity in the overall survival and progression-free survival in the JCOG1113 study population of advanced biliary tract cancer patients.

With the recent development of interventional endoscopic ultrasound (EUS), EUS‐guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension‐related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS‐guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS‐guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use.

[Aim and Background] People’s lifestyles changed considerably due to the coronavirus disease 2019 (COVID-19) pandemic. The number of patients with acute pancreatitis (AP) can be expected to decrease as alcohol consumption decreases. This study was conducted to assess COVID-19 pandemic effects on AP patients in a Japanese regional hospital. [Methods] Based on the first and second states of emergency declarations in Tochigi Prefecture, the survey periods were set as follows: period A, 16 April–14 May; period B, 15 May–13 January; period C, 14 January–7 February; and period D, 8 February–15 April. Using data acquired in 2017, 2018, 2019, and 2020, we retrospectively reviewed the number of patients admitted to our hospital with a diagnosis of AP, and their clinical characteristics. [Results] According to a National Tax Agency survey, the average alcohol sales per adult in Tochigi Prefecture were 71.3 L in 2017 before the pandemic, and 64.0 L in 2021 under the pandemic. The number of AP patients in 2020 was 38% lower than in 2017. Comparing 2017 with 2020, the number of alcoholic AP patients was lower in 2020 (p = 0.007). [Conclusions] The findings suggest that COVID-19-pandemic-related lifestyle changes contributed to the decrease in AP patients.

[Background and study aim] A commonly applied method for diagnosing chronic pancreatitis (CP) uses endoscopic ultrasonography (EUS), assigning weights to each EUS diagnostic finding. It is the Rosemont classification (RC). In 2019, to improve EUS diagnostic specificity, Japanese diagnostic criteria for early chronic pancreatitis (ECP) were revised. Nevertheless, the criteria use no weighting of EUS diagnostic findings, as the RC does. This study was undertaken to propose diagnostic criteria that would weight each EUS finding of ECP and that would be more specific than the RC. [Methods] By EUS of the pancreas, 773 patients underwent detailed observation from January 2018 to March 2019 at our institution. An expert finalized all cases when patients were diagnosed. Using data from the medical records, 97 consecutive patients with EUS diagnostic findings of ECP based on the Japanese diagnostic criteria of ECP2009 (JDCECP2009) were selected. The definition under the RC of “Indeterminate for CP” was equivalent to ECP. Each case was diagnosed using (1) JDCECP2009 and (2) the Japanese diagnostic criteria of ECP2019 (JDCECP2019). Moreover, the four diagnostic EUS findings in JDCECP2019 were applied to the RC, weighted (modified-JDCECP2019), and subsequently compared with the earlier diagnostic criteria. As Modified-JDCECP2019, we suggested (3) RC-A—the current four items scored related to the RC, and (4) RC-B—the five items scored by dividing lobularity with and without honeycombing. [Results] Diagnoses produced based on each criterion were normal: ECP = (1) 20:77, (2) 46:51, (3) 52:42, and (4) 60:35. [Conclusions] Modified-JDCECP2019 may provide EUS diagnoses for ECP with higher specificity.

In recent years, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BA-ERCP) has been performed for biliary pancreatic endoscopic procedures for postoperative reconstruction of the intestinal tract. In BA-ERCP, especially in cases after Roux-en-Y anastomosis, it is often difficult to identify the afferent limb. Several methods have been reported so far [1] [2] [3]. Herein we report a new method that can discriminate more objectively. We present a video of a typical case ([Video 1]). The patient was an 83-year-old man who had undergone total gastrectomy and Roux-en-Y anastomosis for gastric cancer ([Fig. 1]). Because of treatment for obstructive jaundice, he was transferred to our hospital and underwent BA-ERCP. The initial procedure, which took 2 hours, could not be completed as it was difficult to identify the afferent limb. BA-ERCP was attempted 4 days later. After crossing the anastomotic site ([Fig. 2]), a mixture of gel (VISCOCLEAR; Otsuka Pharmaceutical Factory, Tokushima, Japan) mixed with contrast medium was slowly sprayed. Outflow of mixed fluid reflecting forward peristalsis was confirmed, and it was judged to be an efferent limb ([Fig. 3]). Next, the endoscope was advanced into the other lumen and the mixed solution was sprayed in the same manner. Retention of the mixed solution reflecting reverse peristalsis was confirmed, therefore this lumen was considered an afferent limb ([Fig. 4]). After this, we were able to reach the duodenal papilla and complete endoscopic bile duct drainage ([Fig. 5]). It took 35 minutes to reach the duodenal papilla. Video 1 A case in which “retention of gel mixed with contrast medium under fluoroscopy” was useful as a new method to determine the afferent limb in balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. The use of gel in gastrointestinal endoscopy has been reported as a means to secure the visual field for endoscopic hemostasis (gel immersion method [4]). The identification of the afferent limb in the postoperative reconstructed bowel that we reported is a new method of using gel. This simple and inexpensive method is thought to greatly contribute to finding the papilla during BA-ERCP in patients with postoperative reconstruction of the intestinal tract. Endoscopy_UCTN_Code_CCL_1AZ_2AK Article published online: 02 December 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background: Endoscopic ultrasound-guided puncture aspiration biopsy (EUS-FNA) of pancreatic ductal adenocarcinoma (PDAC) is highly diagnostic, but it is difficult to distinguish from benign disease. Our objective was to determine the usefulness of maspin staining, in addition to conventional p53 staining, in the diagnosis of PDAC by EUS-FNA. Methods: Of the patients who underwent EUS-FNA and were diagnosed with PDAC, we retrospectively identified 90 cases in which both maspin and p53 staining were performed. In addition, we identified 28 cases of benign pancreatic disease diagnosed using EUS-FNA and these were selected as a control group. For analysis of EUS-FNA specimens, Cohen’s Kappa (κ) coefficient and the prevalence and bias adjusted Kappa statistic (PABAK) were applied to assess the significance of sensitivity and specificity, comparing p53, maspin, p53+maspin. Results: The sensitivity and specificity of p53 staining were 48.9% and 100%. The κ coefficient was 0.31 (95%CI 0.18–0.44) (p < 0.01) and the PABAK coefficient was 0.22 (95%CI 0.03–0.40). The results for maspin staining were 88.9% and 92.9%. The κ coefficient was 0.72 (95%CI 0.54–0.90) (p < 0.01) and the PABAK coefficient was 0.78 (95%CI 0.64–0.88). The results for the combination of maspin and p53 staining were 94.4% and 92.2%. The κ coefficient was 0.82 (95%CI 0.64–1.00) (p < 0.01) and the PABAK coefficient was 0.86 (95%CI 0.74–0.94). Conclusion: Adding maspin staining to p53 staining showed high sensitivity and specificity. Our results demonstrated the usefulness of their combined use that might contribute to the improvement of tissue diagnostic performance of PDAC by EUS-FNA.

Success rates of balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) for patients with a reconstructed intestinal tract after surgical procedures are unsatisfactory. We retrospectively investigated the factors associated with unsuccessful BE-ERCP. Ninety-one patients who had a reconstructed intestinal tract after gastrectomy or choledochojejunostomy were enrolled. Age, sex, operative method, malignancy, endoscope type, endoscopist’s skill, emergency procedure, and time required to reach the papilla/anastomosis were examined. The primary endpoints were the factors associated with unsuccessful BE-ERCP selective cannulation, while the secondary endpoints were the rate of reaching the papilla/anastomosis, causes of failure to reach the papilla/anastomosis, cannulation success rate, procedure success rate, and rate of adverse events. Younger age (odds ratio, 0.832; 95% CI, 0.706–0.982; p = 0.001) and Roux-en-Y partial gastrectomy (odds ratio, 54.9; 95% CI, 1.09–2763; p = 0.045) were associated with unsuccessful BE- ERCP. The rate of reaching the papilla/anastomosis was 92.3%, the success rate of biliary duct cannulation was 90.5%, procedure success rate was 78.0%, and the rate of adverse events was 5.6%. In conclusion, Roux-en-Y partial gastrectomy and younger age were associated with unsuccessful BE-ERCP. If BE-ERCP is extremely difficult to perform in such patients after Roux-en-Y partial gastrectomy, alternative procedures should be considered early.