Akihisa Ohno

Takehiko Koga, Yusuke Ishida, Akihisa Ohno, Ryota Sagami, Yoshitaka Nakamura, Makoto Hinokuchi, Kosuke Takahashi, Hidefumi Nishikori, Nao Fujimori, Yasuhisa Hiroshima, Hiroki Taguchi, Shinichi Hashimoto, Eisuke Ozawa, Hiroaki Tsuji, Naoaki Tsuchiya, Takanori Kitaguchi, Keisuke Matsumoto, Makoto Fukuyama, Tatsuro Nii, Fumihito Hirai. Gut and Liver -0001;0:. https://doi.org/10.5009/gnl260042

Objectives: Enteroscopy‐assisted endoscopic retrograde pancreatography‐guided pancreatic duct drainage (eERP‐PDD) and endoscopic ultrasound‐guided pancreatic duct drainage (EUS‐PDD) are minimally invasive alternatives to surgery for pancreaticojejunostomy stricture (PJS); however, comparative data remain limited. We compared the effectiveness and safety of these approaches and identified factors associated with technical failure. Methods: This multicenter retrospective study included 88 patients (111 procedures) who underwent endoscopic intervention for PJS at 13 Japanese tertiary centers. We compared clinical outcomes between eERP‐PDD and EUS‐PDD. The primary outcome was technical success; secondary outcomes included clinical success, procedure time, and adverse events (AEs). Propensity‐score overlap weighting was used to adjust for baseline differences. Results: As initial treatment, 77 patients underwent eERP‐PDD and 11 underwent EUS‐PDD. After adjustment, EUS‐PDD achieved higher technical success (eERP‐PDD, 28% vs. EUS‐PDD, 71%; p = 0.012) and clinical success (22% vs. 71%; p = 0.003), with shorter procedure time (76 min vs. 41 min; p = 0.001). AE incidence was higher with EUS‐PDD before adjustment (5% vs. 27%; p = 0.039) but comparable after adjustment (7% vs. 29%; p = 0.15); all AEs resolved with conservative management. Age < 75 years, male sex, and main pancreatic duct (MPD) diameter ≥ 5 mm were independently associated with eERP‐PDD failure. Conclusions: EUS‐PDD demonstrated higher technical and clinical success than eERP‐PDD for PJS, with comparable safety after adjustment. An MPD diameter ≥ 5 mm was associated with eERP‐PDD failure. An MPD‐based algorithm is proposed: eERP‐PDD for MPD < 5 mm with EUS‐PDD as salvage, and EUS‐PDD for MPD ≥ 5 mm. This algorithm is hypothesis‐generating and requires prospective validation.

Pancreatic ductal adenocarcinoma (PDAC) has two subtypes: the “classical/progenitor” type and “basal-like/squamous” type, the latter of which has poor clinical outcomes with no effective treatment strategies. We aimed to elucidate the role of epithelial membrane protein 1 (EMP1) in PDAC and its potential as a therapeutic target, particularly in aggressive disease such as “basal-like/squamous” type of PDAC. We examined the association of EMP1 expression using patient-derived organoids (PDOs) of human PDAC, K-RAS^LSL-G12D, Trp 53^LSL-R172H, and Pdx1-Cre recombinase mice, human PDAC cell lines, and publicly available clinical datasets. The functional roles of EMP1 were evaluated in vitro and in vivo through its knockout and stable overexpression. EMP1 knockout reduced proliferation, metastasis, and drug resistance, whereas overexpression enhanced malignant features. Transcriptomic analysis revealed that EMP1 promotes epithelial-mesenchymal transition (EMT), extracellular matrix remodeling, and the K-RAS signaling pathway. EMP1 expression is inversely implicated in the oxidative phosphorylation pathway, which is characteristic of the “classical/progenitor” type. Furthermore, integrated analysis revealed an association between EMP1 expression and ERK phosphorylation. EMP1 plays a crucial role in the pathogenesis of PDAC, as it contributes to the proliferative and metastatic characteristics of PDAC. This study suggests that EMP1 may be a potential therapeutic target gene for aggressive disease.

Yasuhiro Komori, Akihisa Ohno, Nao Fujimori, Kazuhide Matsumoto, Keijiro Ueda, Kazuki Takeishi, Tomoharu Yoshizumi, and Yoshihiro Ogawa. Int J Gastrointest Interv 2025;14:35-8. https://doi.org/10.18528/ijgii240060

A guidewire fracture in the main pancreatic duct (MPD) is uncommon during endoscopic retrograde cholangiopancreatography (ERCP). The number of reported cases of fractured guidewires in the MPD is limited, and most retrieval attempts present significant technical challenges [1] [2]. We used a novel endoscopic sheath (EndoSheather; Piolax Medical Devices, Kanagawa, Japan) with a tapered inner sheath to facilitate passage through strictures as a rescue technique. Instruments with lengths of up to 1.9 mm could be easily inserted after removal of the inner sheath. Several reports have described the use of this device to retrieve migrated stents [3] [4] [5], but no previous publication has documented the retrieval of a fractured guidewire in the MPD ([Fig. 1]). A 46-year-old man with a history of jaundice and abdominal pain initially underwent ERCP at a different institution for the removal of common bile duct stones. The catheter and guidewire were inadvertently advanced into the MPD during stone extraction, resulting in a guidewire tip fracture inside the MPD ([Fig. 2] a). The fragment remained lodged in the MPD after multiple retrieval attempts, leading to acute pancreatitis ([Fig. 2] b). A rescue ERCP was subsequently performed at our institution. Pancreatography revealed a focal stricture extending from the pancreatic head to the body, with mild upstream dilation in the tail ([Fig. 3]). A novel device (EndoSheater) was inserted proximal to the retained guidewire. Biopsy forceps (Radial Jaw 4 Standard Capacity, Boston Scientific, Marlborough, MA, USA) were inserted through the outer sheath after the inner sheath was removed to grasp the guidewire. The fractured guidewire was successfully removed through the device without any complications ([Fig. 4] and [Video 1]). This case demonstrates the safe and effective retrieval of a fractured guidewire from the MPD using the novel endoscopic sheath. Endoscopy_UCTN_Code_CPL_1AK_2AD Article published online: 29 October 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/Aims: Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed globally, the procedure remains challenging. Guidewire manipulation is the most difficult step, and there are few reports on the factors associated with unsuccessful guidewire manipulation. This study aimed to assess the significance of the puncture angle on EUS images and identify the most effective guidewire rescue method for patients with unsuccessful guidewire manipulation.Methods: We retrospectively enrolled 115 patients who underwent EUS-HGS between May 2016 and April 2022 at two centers. The puncture angle between the needle and the intrahepatic bile duct was measured through EUS movie records.Results: Guidewire manipulation was unsuccessful in 28 patients. Receiver operating characteristic (ROC) curves identified an optimal puncture angle cutoff value of 85° (cutoff value, 85°; area under the ROC curve, 0.826; sensitivity, 85.7%; specificity, 81.6%). Multivariate analysis demonstrated that a puncture angle <85° was a significant risk factor for unsuccessful guidewire manipulation (odds ratio, 19.8; 95% confidence interval, 6.42–61.5; p<0.001). Among the 28 unsuccessful cases, 24 patients (85.7%) achieved successful guidewire manipulation using various rescue methods.Conclusions: The puncture angle observed on EUS is crucial for guidewire manipulation. A puncture angle of <85° was associated with unsuccessful guidewire manipulation.

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A 72-year-old man with autoimmune pancreatitis type 2 presented with acute pancreatitis due to an impacted pancreatic stone ([Fig. 1]). Immediate transpapillary drainage was unsuccessful, leading us to attempt drainage via endoscopic ultrasonography-guided pancreaticogastrostomy (EUS-PGS) ([Video 1]). A linear echoendoscope (EG-740UT; Fujifilm, Tokyo, Japan) was used to puncture the pancreatic duct with a 19-G fine-needle aspiration needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan). The guidewire was successfully advanced into the duodenum using a 3-Fr microcatheter (Daimon ERCP catheter; Hanaco Medical, Saitama, Japan), which improved guidewire control. After the punctured tract over the stones had been dilated with a drill dilator (Tornus ES; Asahi Intecc, Aichi, Japan), a plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed ([Fig. 2] a). One month later, a 9-Fr peroral pancreatoscope (POPS) (eyeMAX; Micro-Tech, Nanjing, China) was inserted via the EUS-PGS, and the stones were fragmented using electrohydraulic lithotripsy (EHL; Nortech AUTOLITH lithotripter with a 1.9-Fr probe; Northgate Technologies, Illinois, USA). Following endoscopic pancreatic sphincterotomy using a rendezvous technique, the fragmented stones were completely crushed transgastrically and removed by pushing the POPS through the papilla ([Fig. 2] b, c). Due to obstruction of the papilla by the fragmented stones, stent placement via the EUS-PGS was not possible. The stones were therefore removed endoscopically using grasping forceps, and the stent was pulled out from the papilla under fluoroscopic guidance to secure the EUS-PGS route. The patient remained asymptomatic 2 months after the intervention. Recently, numerous procedures have been conducted via EUS-PGS [1], and the efficacy of transgastric POPS with EHL has been documented [2] [3] [4]. In the current case, the stones were successfully removed by propelling the POPS through the papilla into the duodenum, in conjunction with conventional endoscopic retrograde cholangiopancreatography techniques. Stone removal using POPS via EUS-PGS could potentially be a valuable treatment option for challenging stones. Endoscopy_UCTN_Code_TTT_1AR_2AI Article published online: 13 November 2024 © 2024. 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

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a procedure to access the pancreatic duct in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) [1] [2]. In patients with surgically altered anatomy, transmural drainage is the preferred technique [3]. A single-pigtail plastic stent designed for EUS-PDD has been developed with favorable outcomes [4] ([Fig. 1]). A 58-year-old man with a history of pancreatic cancer who underwent pylorus-preserving pancreaticoduodenectomy 14 years previously was admitted to our institution for recurrent acute pancreatitis. Computed tomography revealed no recurrence of malignancy, pancreatic duct dilatation, or obstruction. To assess the pancreatic duct-jejunal anastomotic site, balloon ERCP was performed. The anastomotic site could not be identified, hence we performed EUS-PDD and inserted a single-pigtail stent (7 Fr, 14 cm, Type IT; Gadelius, Tokyo, Japan). Post-procedure he developed severe abdominal pain with elevated pancreatic enzymes, leading to a diagnosis of acute pancreatitis. Evaluation presumed pancreatic duct occlusion from the stent location. A rescue procedure was performed via balloon ERCP, identifying the pancreatic duct from the distal end of the stent followed by dilatation using a balloon dilation device (4mm, REN; Kaneka, Tokyo, Japan). Finally, a single-pigtail stent was inserted (4 Fr, 5 cm; Gadelius) ([Fig. 2] a–f, [Video 1]). The procedure was successful, and he was discharged with no further recurrence of pancreatitis. We determined three contributing factors that caused ductal occlusion: the pancreatic duct was not dilated, the puncture site was near the anastomotic site, and hence the stent drainage holes were located outside the pancreatic duct ([Fig. 3] a–d). To our knowledge, this is the first report of duct occlusion occurring after EUS-PDD. In conclusion, careful consideration of the puncture site and awareness of the side hole location are key for prevention. Additionally, a rescue procedure is feasible with insertion of an additional stent for optimal drainage. Endoscopy_UCTN_Code_CPL_1AL_2AD Article published online: 01 July 2024 © 2024. 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 Rüdigerstraße 14, 70469 Stuttgart, Germany