Pancreatic ductal adenocarcinoma (PDAC) is the most lethal type of gastrointestinal cancer, with a 5-year survival rate of 5%; it remains a significant, unresolved therapeutic challenge. Its aggressive features include insidious presentation, unresectability due to early involvement of major vessels, debilitating symptoms at the late stage and de novo chemoresistance. However, according to the Japan Pancreatic Cancer Registry, the 5-year survival of UICC Stages 0 and 1a are 85.8% and 68.7%, respectively. Early diagnosis plays an important role in improving the overall survival of patients with PDAC; therefore, efforts should focus on early diagnosis and the reliable identification of patients who will most likely benefit from major surgical intervention. Patients with risk factors, including family history, accompanying disease, diabetes mellitus, chronic pancreatitis and intraductal papillary mucinous neoplasms (IPMN), should be followed up for early detection of PDAC. In Japan, a national team has undertaken such surveillance of patients with IPMN. The protocol comprises a semi-annual follow up using various modalities to detect not only IPMN carcinoma, but also PDAC concomitant with IPMN. I will address this protocol in detail. The most accurate imaging technique for PDAC diagnosis and staging is considered to be contrast-enhanced computed tomography (CECT). Whereas CT should be the first choice in patients with suspected PDAC, endoscopic ultrasound (EUS) is the most accurate, particularly for detecting small lesions (< 10 mm). EUS combines the potential of endoscopy, which enables visualization of the mucosal surface of the gastrointestinal (GI) tract, with ultrasonography. Thus, EUS is able to provide detailed, high-resolution images of the pancreas. However, whether a lesion is malignant or benign is unable to be discriminated solely from EUS imaging features. Obtaining samples from suspicious lesions or lymph nodes using EUS-guided fine-needle aspiration (FNA), offers the potential for cytological or histological diagnoses of pancreatic lesions with high sensitivity and specificity. Since accurate preoperative evaluation is essential to select the appropriate management strategy, the roles of EUS and EUS-FNA are crucial. Stage 0 PDAC (carcinoma in situ) has recently been discovered. This stage of PDAC is unable to be diagnosed using EUS-FNA, because EUS-FNA is only applicable after PDAC forms a cancerous mass (worse than stage1). Thus, diagnostic methods other than imaging require development. Presently, endoscopic retrograde pancreatography (ERP) combined with cytology is able to detect Stage 0 PDAC, and in Japan, nasopancreatic drainage tubes have recently been used to collect pancreatic juice for cytodiagnosis. I would also like to introduce this method.

Pancreatic ductal adenocarcinoma (PDAC) is the most lethal type of gastrointestinalcancer, with a 5-year survival rate of 5%; it remains a significant, unresolvedtherapeutic challenge. Its aggressive features include insidious presentation,unresectability due to early involvement of major vessels, debilitating symptomsat the late stage and de novo chemoresistance.However, according to the Japan Pancreatic Cancer Registry, the 5-year survivalof UICC Stages 0 and 1a are 85.8% and 68.7%, respectively.Early diagnosis plays an important role in improving the overall survival ofpatients with PDAC; therefore, efforts should focus on early diagnosis and thereliable identification of patients who will most likely benefit from major surgicalintervention.Patients with risk factors, including family history, accompanying disease,diabetes mellitus, chronic pancreatitis and intraductal papillary mucinousneoplasms (IPMN), should be followed up for early detection of PDAC. In Japan,a national team has undertaken such surveillance of patients with IPMN. Theprotocol comprises a semi-annual follow up using various modalities to detectnot only IPMN carcinoma, but also PDAC concomitant with IPMN. I will addressthis protocol in detail.The most accurate imaging technique for PDAC diagnosis and staging isconsidered to be contrast-enhanced computed tomography (CECT). WhereasCT should be the first choice in patients with suspected PDAC, endoscopicultrasound (EUS) is the most accurate, particularly for detecting small lesions (<10 mm). EUS combines the potential of endoscopy, which enables visualizationof the mucosal surface of the gastrointestinal (GI) tract, with ultrasonography.Thus, EUS is able to provide detailed, high-resolution images of the pancreas.However, whether a lesion is malignant or benign is unable to be discriminatedsolely from EUS imaging features. Obtaining samples from suspicious lesions orlymph nodes using EUS-guided fine-needle aspiration (FNA), offers the potentialfor cytological or histological diagnoses of pancreatic lesions with high sensitivityand specificity. Since accurate preoperative evaluation is essential to select theappropriate management strategy, the roles of EUS and EUS-FNA are crucial.Stage 0 PDAC (carcinoma in situ) has recently been discovered. This stage of PDACis unable to be diagnosed using EUS-FNA, because EUS-FNA is only applicableafter PDAC forms a cancerous mass (worse than stage1). Thus, diagnostic methodsother than imaging require development. Presently, endoscopic retrogradepancreatography (ERP) combined with cytology is able to detect Stage 0 PDAC,and in Japan, nasopancreatic drainage tubes have recently been used to collectpancreatic juice for cytodiagnosis. I would also like to introduce this method.

Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography, and allows imaging with a high-frequency transducer over a short distance to generate high-resolution ultrasonographic images. EUS is now a widely accepted modality for diagnosing pancreatobiliary diseases. EUS-guided fine-needle aspiration (EUS-FNA) using a curved linear-array echoendoscope was initially described more than 20 years ago, and since then many researchers have expanded its indications to sample diverse lesions and have also used it for various therapeutic purposes. EUS-guided biliary drainage (EUS-BD) is one of the therapeutic procedures that has been developed using a curved linear-array echoendoscope. Technically, EUS-BD includes rendezvous techniques via transesophageal, transgastric, and transduodenal routes, EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS). Published data have demonstrated a high success rate, albeit with a comparatively high rate of nonfatal complications for EUS-CDS and EUS-HGS, and a comparatively low success rate with a low complication rate for the rendezvous technique. At present, these procedures represent an alternative to surgery or percutaneous transhepatic biliary drainage (PTBD) for patients with obstructive jaundice when endoscopic biliary drainage (EBD) has failed. However, these procedures should be performed in centers with extensive experience in linear EUS and therapeutic biliary ERCP. Large prospective studies are needed in the near future to establish standardized EUS-BD procedures as well as to perform controlled comparative trials between EUS-BD and PTBD, between rendezvous techniques and direct-access techniques (EUS-CDS and EUS-HGS), and between EBD and EUS-BD.
Biopsy, Fine-Needle ; Cholangiopancreatography, Endoscopic Retrograde ; Choledochostomy ; Dioxolanes ; Drainage ; Endoscopy ; Endosonography ; Fluorocarbons ; Humans ; Jaundice, Obstructive ; Transducers

SUMMARY OF EVENT: Pneumoderma, mediastinal emphysema, and bilateral pneumothorax were developed in the patient who had undergone transesophageal endoscopic ultrasonography-guided rendezvous technique. Chest drainage was performed immediately. TEACHING POINT: Transesophageal approach carries the potential risks of severe complications such as mediastinal emphysema, mediastinitis, and pneumothorax. To prevent puncturing through the esophagus, clipping the esophagogastric junction using a forward-viewing scope before procedure is very useful. In cases of inadvertent transesophageal puncture, devices other than the needle should not be passed through the site.
Drainage* ; Endosonography ; Esophagogastric Junction ; Esophagus ; Humans ; Mediastinal Emphysema ; Mediastinitis ; Needles ; Pneumothorax ; Punctures ; Thorax

BACKGROUND: Both endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) and tumor ablation using ethanol are very common procedures, and the utility of these therapies has already been reported in prominent journals. However, their effectiveness appears temporary and insufficient, especially EUS-CPN. We therefore have to consider new reagents for improving the results. The present study examined the best concentration of ethanol and povidone iodine mixed with atelocollagen for more effective therapies. METHODS: The effects of the new reagents were confirmed in three live pigs. At first, we injected three kinds of reagents (including indigo carmine) in three separate areas of para-aortic tissue under EUS guidance in one pig. At more than 4 hours after injection, we checked ethanol injection sites after dissection. In next study, we performed EUS-guided injection of a total of six kinds of reagents (two kinds of ethanol, three kinds of povidone iodine, and control atelocollagen) into the livers of two living pigs. After 2 weeks, we examined tissue damage to the liver in the two pigs. RESULTS: The 75% ethanol (absolute ethanol 3.75 mL + 1% atelocollagen 1.25 mL + a very small amount of indigo carmine) was seen like blue gel, and still remained in the para-aortic tissue. Brownish areas of povidone iodine mixed with 3% atelocollagen exhibited clear, regular borders with greatly reduced infiltration into surrounding tissue compared to others. CONCLUSION: We concluded that 75% ethanol mixed with 1% atelocollagen appears optimal for EUS-CPN. Povidone iodine mixed with 3% atelocollagen may be suitable for small tumor ablation therapy.
Celiac Plexus* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Ethanol ; Indicators and Reagents ; Indigo Carmine ; Liver ; Povidone-Iodine ; Swine

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS. Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed. Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027). Conclusions For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS. Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed. Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027). Conclusions For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.