Sho Ishikawa

An unusual pancreatic tumor with prominent calcification in a middle-aged man: what is the diagnosis?

Protein kinase R (PKR) functions both as a promoter and inhibitor in various cancers; however, its role in pancreatic ductal adenocarcinoma (PDAC) remains unclear. We investigated the role of PKR in PDAC. PKR expression in PDAC cell lines was assessed using real-time reverse transcriptase polymerase chain reaction and western blotting. The effect of PKR on cell proliferation was examined using MTS assay. To determine the mechanisms of PKR’s action on PDAC, RNA-sequencing analysis was performed, and the effects of PKR knockdown on cell cycle progression and apoptosis in PDAC cells were examined using flow cytometry. PDAC cell lines transfected with PKR-targeting short interfering RNAs or treated with PKR inhibitors exhibited significantly reduced proliferation. RNA-sequencing analysis revealed substantial upregulation of GADD45A expression upon inhibition of PKR expression. Following PKR silencing, cell cycle analysis showed marked accumulation of cells in G1 phase, consistent with the role of GADD45A as a cell cycle regulator. Proliferation inhibition caused by PKR knockdown was reversed by downregulation of GADD45A, suggesting that PKR and GADD45A interact to regulate PDAC cell growth. PKR promotes PDAC cell proliferation by modulating the cell cycle via regulation of GADD45A expression, demonstrating its potential as a therapeutic target for PDAC.

Background/Aims: Hepatobiliary scintigraphy (HBS) is used to evaluate bile excretion. This study aimed to evaluate biliary excretion during endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using HBS.Methods: We retrospectively evaluated 78 consecutive patients with malignant extrahepatic biliary obstruction, who underwent HBS after EUS-HGS between April 2015 and July 2022. The peak time and decay rate were scored with 0, 1, or 2 points based on thresholds of 20 and 35 minutes, and 10% and 50%, respectively. A total score of 4 or 3 was considered indicative of good bile excretion, whereas scores of 2, 1, or 0 indicated poor bile excretion.Results: The good and poor bile excretion groups included 40 and 38 cases, respectively. The group with good bile excretion had a significantly longer time to recurrent biliary obstruction compared to the poor bile excretion group (not reached vs. 124 days, p=0.026). Multivariate analysis identified the site of obstruction as a significant factor influencing good bile excretion (odds ratio, 3.39; 95% confidence interval, 1.01–11.4, p=0.049), with superior bile excretion observed in cases involving upper biliary obstruction compared to middle or lower biliary obstruction.Conclusions: In patients with malignant biliary obstruction who underwent HGS, the site of obstruction is significantly associated with stent patency.

Background/Aims: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) performed at the intrahepatic bile duct segment 3 (B3) is widely used for biliary drainage. Although performing post-puncture procedures is easier in the intrahepatic bile duct segment 2 (B2) when using a conventional oblique-viewing (OV) EUS scope, this method may cause transesophageal puncture and severe adverse events. We evaluated the safety and efficacy of B2 puncture using a novel OV-EUS scope.Methods: In this single-center retrospective study, we prospectively enrolled and collected data from 45 patients who consecutively underwent EUS-HGS procedures with a novel OV-EUS scope between September 2021 and December 2022 at our cancer center.Results: The technical success rates of B2-EUS-HGS and EUS-HGS were 93.3% (42/45) and 97.8% (44/45), respectively. The early adverse event rate was 8.9% (4/45) with no cases of scope changes or transesophageal punctures. The median procedure time was 13 minutes (range, 5–30).Conclusions: B2-EUS-HGS can be performed safely with the novel EG-740UT (Fujifilm) OV-scope without transesophageal puncture and with a high success rate. B2-EUS-HGS using this novel OV scope may be the preferred strategy for EUS-HGS.

Background/Aims: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is a standard diagnostic method for biliary tract cancer (BTC), and samples obtained in this manner may be used for comprehensive genomic profiling (CGP). This study evaluated the utility of EUS-TA for CGP in a clinical setting and determined the factors associated with the adequacy of CGP in patients with BTC.Methods: CGP was attempted for 105 samples from 94 patients with BTC at the Aichi Cancer Center, Japan, from October 2019 to April 2022.Results: Overall, 77.1% (81/105) of the samples were adequate for CGP. For 22-G or 19-G fine-needle biopsy (FNB), the sample adequacy was 85.7% (36/42), which was similar to that of surgical specimens (94%, p=0.45). Univariate analysis revealed that 22-G or larger FNB needle usage (86%, p=0.003), the target primary lesions (88%, p=0.015), a target size ≥30 mm (100%, p=0.0013), and number of punctures (90%, p=0.016) were significantly positively associated with CGP sample adequacy.Conclusions: EUS-TA is useful for CGP tissue sampling in patients with BTC. In particular, the use of 22-G or larger FNB needles may allow for specimen adequacy comparable to that of surgical specimens.

Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method for diagnosing pancreatic neuroendocrine tumors (PNETs); however, some PNETs are difficult to diagnose. Recently, the efficacy of needle-based confocal laser endomicroscopy (nCLE) in diagnosing solid pancreatic masses has been reported. However, the efficacy of nCLE in the diagnosis of PNETs remains unknown and only a small number of cases have been reported. Hence, this study aimed to evaluate the efficacy of nCLE in the diagnosis of PNETs.Methods: This single-center retrospective study evaluated 30 consecutive patients with suspected PNETs on contrast-enhanced computed tomography, who consented to nCLE combined with EUS-FNA and were diagnosed using EUS-FNA or surgical resection. The diagnostic criteria for PNETs using nCLE were based on the nesting and trabecular and glandular arrangement of tumor cell clusters surrounded by capillary vessels and fibrosis, as reported in previous studies.Results: The diagnosis using nCLE was classified into three categories: misdiagnosis in three cases (10%), non-diagnostic in six cases (20%), and diagnostic in 21 cases (70%). nCLE was able to diagnose PNET in one of the two cases with inconclusive EUS-FNA.Conclusions: Although further development of the resolution and optimization of the diagnostic criteria are required, nCLE may constitute a useful diagnostic option in cases of inconclusive EUS-FNA for PNETs.

Background/Aims: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) is useful for patients with biliary cannulation failure or inaccessible papillae. However, it can lead to serious complications such as bile peritonitis in patients with ascites; therefore, development of a safe method to perform EUS-HGS is important. Herein, we evaluated the safety of EUS-HGS with continuous ascitic fluid drainage in patients with ascites.Methods: Patients with moderate or severe ascites who underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after the procedure at our institution between April 2015 and December 2022, were included in the study. We evaluated the technical and clinical success rates, EUS-HGS-related complications, and feasibility of re-intervention.Results: Ten patients underwent continuous ascites drainage, which was initiated before EUS-HGS and terminated after completion of the procedure. Median duration of ascites drainage before and after EUS-HGS was 2 and 4 days, respectively. Technical success with EUS-HGS was achieved in all 10 patients (100%). Clinical success with EUS-HGS was achieved in 9 of the 10 patients (90 %). No endoscopic complications such as bile peritonitis were observed.Conclusions: In patients with ascites, continuous ascites drainage, which is initiated before EUS-HGS and terminated after completion of the procedure, may prevent complications and allow safe performance of EUS-HGS.

Benign biliary stricture (BBS) is a complication of chronic pancreatitis (CP). Despite endoscopic biliary stenting, some patients do not respond to treatment, and they experience recurrent cholangitis. We report two cases of CP with refractory BBS treated using endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) fistula creation. A 50-year-old woman and a 60-year-old man both presented with obstructive jaundice secondary to BBS due to alcoholic CP. They underwent repeated placement of a fully covered self-expandable metal stent for biliary strictures. However, the strictures persisted, causing repeated episodes of cholangitis. Therefore, an EUS-CDS was performed. The stents were eventually removed and the patients became stent-free. These fistulas have remained patent without cholangitis for more than 2.5 years. Fistula creation using EUS-CDS is an effective treatment option for BBS.

Endoscopic transpapillary gallbladder drainage (ETGBD) is one of the most difficult endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to perform, as it often causes adverse events in the gallbladder duct [1]. Retrieval is technically difficult if a sheared guidewire remnant remains in the gallbladder duct. Herein, we present a case in which a sheared guidewire remnant was successfully retrieved from the gallbladder duct using a novel basket catheter. A 78-year-old man was admitted to our hospital with acute cholecystitis ([Fig. 1]). He was promptly treated using antibiotics and ETGBD. While manipulating the guidewire in the gallbladder duct, the guidewire became kinked, broke off, and remained in the duct ([Fig. 2] a, b). We attempted to retrieve the sheared guidewire using a RASEN 2 basket catheter (Kaneka Medical, Osaka, Japan) that was inserted along the guidewire, deployed into the gallbladder duct, and rotated clockwise to confirm that the guidewire remnant was inside ([Fig. 2] c). Once we closed the basket, we were able to firmly grip the guidewire and pull it out of the patient through the channel of the endoscope ([Fig. 2] d, [Fig. 3]). There have been few reports in the literature concerning techniques for retrieving residual guidewires, mostly using biopsy forceps during endoscopic ultrasound or ERCP [2] [3]. To our knowledge, no studies have yet described remnant guidewire retrieval in the gallbladder duct using a basket catheter. This new type of basket catheter has a unique shape and rotational mechanism that may be useful not only for removing bile duct stones but also for retrieving foreign bodies in narrow areas such as the gallbladder duct ([Video 1]). Endoscopy_UCTN_Code_TTT_1AR_2AG Article published online: 08 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

Background/Aims: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique.Methods: One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated.Results: The median size of the papillary roof was 6 mm (range, 3–20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3–15 minutes).Conclusions: Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.