Koichi Fujita

Deep learning models detected direct and indirect imaging findings associated with pancreatic cancer (PC) on abdominal CT scans and diagnosed PC with performance comparable to or better than that of physicians, particularly for small PCs.

Objectives: Post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is an adverse event of ERCP‐related procedures. The present study aimed to evaluate the incidence of PEP in patients with an intact papilla who underwent ERCP for common bile duct stones and identify risk factors and preventive measures for PEP. Methods: Between April 2017 and March 2018, ERCP‐related procedures were performed in 16,032 patients with an intact papilla at 36 institutions affiliated with the Bilio‐pancreatic Study Group of West Japan. Of these, 3739 were prospectively enrolled to investigate adverse events of ERCP‐related procedures targeting the biliary tract; the present study included 2106 patients with common bile duct stones. Results: PEP occurred in 132 patients (6.3%), and its severity was graded as mild ( n = 104), moderate ( n = 17), and severe ( n = 11). Multivariable analysis identified the followin significant risk factors for PEP: age <50 years, female sex, wire‐guided biliary cannulation, pancreatic guidewire‐assisted biliary cannulation, biliary cannulation attempt duration ≥10 min, and total procedure time ≥60 min. Only pancreatic stenting was a preventive factor for PEP. Conclusions: To prevent PEP, it is necessary to avoid guidewire insertion into the pancreatic duct, prolonged biliary cannulation attempts, and long ERCP procedure time, regardless of biliary cannulation with or without guidewire assistance. When a guidewire is inserted into the pancreatic duct in patients at high risk of PEP, pancreatic stenting should be considered.

Objectives: The risk of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) needs to be predicted in order to take adequate preventive measures in individual cases. The aim of this study was to develop a clinical prediction rule for PEP in biliary ERCP for patients with intact papilla. Methods: We conducted a multicenter prospective cohort study to investigate the adverse events of biliary ERCP in patients with intact papilla. A total of 3739 patients were prospectively enrolled at 36 hospitals in western Japan between April 2017 and March 2018. Data on patient‐related factors, operator‐related factors, procedure‐related factors, and preventative measures were collected. A multivariable logistic regression was used to identify predictors for PEP, and a scoring model was developed. Results: The scoring model included 11 factors: age younger than 50 years (2 points), female sex (1 point), ASA 3 (‐2 points), cholangitis (‐1 point), hypoamylasemia (‐1 point), obstruction of the main pancreatic duct at the pancreatic head (‐2 points), cannulation time >20 min (1 point), guidewire insertion into the pancreatic duct (3 points), intraductal ultrasonography (1 point), biopsy (1 point), and total procedure time >60 min (2 points). The area under the receiver operating characteristic curve of this model was 0.729. All cases were stratified into three groups according to the total score: low‐risk, intermediate‐risk, and high‐risk groups, with an incidence of PEP of 1.6%, 6.0%, and 17.7%, respectively. Conclusions: This scoring model stratified the risk of PEP in individual ERCP cases with intact papilla fairly well.

Background: Focal parenchymal atrophy and main pancreatic duct (MPD) dilatation have been identified as early signs of pancreatic ductal adenocarcinoma. However, limited evidence exists regarding their temporal progression due to previous study limitations with restricted case numbers.Objective: To ascertain a more precise frequency assessment of suspicious pancreatic ductal adenocarcinoma findings as well as delineate the temporal progression of them.Methods: A multicenter retrospective study was conducted on patients diagnosed with pancreatic ductal adenocarcinoma between 2015 and 2021. We included patients who had undergone at least one computed tomography (CT) scan ≥6 months before diagnosing pancreatic ductal adenocarcinoma. The temporal progression of suspicious pancreatic ductal adenocarcinoma findings on CT was investigated.Results: Out of 1832 patients diagnosed with pancreatic ductal adenocarcinoma, 320 had a previous CT before their diagnosis. Suspicious pancreatic ductal adenocarcinoma findings were detected in 153 cases (47.8%), with focal parenchymal atrophy (26.6%) being the most common followed by MPD dilatation (11.3%). Focal parenchymal atrophy was the earliest detectable sign among all suspicious findings and became visible on average 2.7 years before diagnosis, and the next most common, MPD dilatation, 1.1 years before diagnosis. Other findings, such as retention cysts, were less frequent and appeared around 1 year before diagnosis. Focal parenchymal atrophy followed by MPD dilatation was observed in 10 patients but not in reverse order. Focal parenchymal atrophy was more frequently detected in the pancreatic body/tail. No significant relationship was found between the pathological pancreatic ductal adenocarcinoma differentiation or tumor stage and the time course of the CT findings. All cases of focal parenchymal atrophy progressed just prior to diagnosis, and the atrophic area was occupied by tumor at diagnosis. Main pancreatic duct dilatation continued to progress until diagnosis.Conclusion: This large‐scale study revealed that the temporal progression of focal parenchymal atrophy is the earliest detectable sign indicating pancreatic ductal adenocarcinoma. These results provide crucial insights for early pancreatic ductal adenocarcinoma detection.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21–43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83–34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45–33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11–0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01–0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.

Objectives: Endoscopic ultrasound‐guided tissue acquisition (EUS‐TA) plays a crucial role in the diagnosis of pancreatic tumors. The present study aimed to investigate the current status of needle tract seeding (NTS) after EUS‐TA of pancreatic tumors based on a nationwide survey in Japan.Methods: Patients who underwent surgical resection of primary pancreatic tumors after EUS‐TA performed between April 2010 and March 2018 were surveyed. The incidence rates of NTS were determined, and compared in patients with pancreatic ductal adenocarcinomas (PDACs) and other tumors, and in patients who underwent transgastric and transduodenal EUS‐TA of PDACs. The detailed features and prognosis of patients with NTS were also assessed.Results: A total of 12,109 patients underwent surgical resection of primary pancreatic tumors after EUS‐TA. The overall incidence rate of NTS was 0.330%, and the NTS rate was significantly higher in patients with PDAC than in those with other tumors (0.409% vs. 0.071%, P = 0.004). NTS was observed in 0.857% of patients who underwent transgastric EUS‐TA, but in none of those who underwent transduodenal EUS‐TA. Of the patients with NTS of PDACs, the median time from EUS‐TA to occurrence of NTS and median patient survival were 19.3 and 44.7 months, respectively, with 97.4% of NTS located in the gastric wall and 65.8% of NTS resected. The patient survival was significantly longer in patients who underwent NTS resection than in those without NTS resection (P = 0.037).Conclusions: Needle tract seeding appeared only after transgastric not after transduodenal EUS‐TA. Careful follow‐up provides an opportunity to remove localized NTS lesions by gastrectomy.

Objectives: The reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post‐ERCP pancreatitis (PEP).Methods: Patients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs.Results: A total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP‐related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire‐assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post‐ERCP administration of non‐steroidal anti‐inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla.Conclusions: In patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP.Registration: This study was registered in the University Hospital Medical Information Network (UMIN000024820).

A 60-year-old male with cStage IVB lung cancer was treated with pembrolizumab. However, after five courses of pembrolizumab, he developed pembrolizumab-related cholangitis. Imaging studies showed enlargement and diffuse wall thickening of the gallbladder and mild dilation of the bile ducts without any obvious obstruction. As the patient experienced severe abdominal pain, we suspected bile stasis and performed biliary drainage. However, his condition did not improve, and he developed multiple liver abscesses and died during immunosuppressive therapy. Our case suggests that in ir-cholangitis, the indication and method of endoscopic retrograde cholangiopancreatography should be carefully judged.