Purpose: We report two patients receiving high doses of systemic opioids in whom gradual switching of the opioid administration route from systemic to intrathecal provided satisfactory pain relief without excessive sedation or withdrawal symptoms. Case reports: In one of the patients, who was already receiving 500mg morphine intravenously but still suffered from right upper quadrant pain, it was difficult to increase the opioid dosage according to the WHO guidelines because of intolerable side effects. The other patient, in spite of taking a combination of systemic opioids equivalent to 760mg oral morphine, had inadequate pain relief and could not continue receiving home medical care. In both cases we could successfully change from systemic to intrathecal opioid administration in a step-wise manner without deterioration of pain control, adverse effects due to over dosage, or withdrawal symptoms. Intrathecal opioid administration also reduced drowsiness and improved daily activity. Conclusion: Currently, there are no guidelines for change of route of opioid administration from systemic to intrathecal administration and few published reports have concretely documented opioid route switching in Japan. A carefully planned, step-wise switching of opioid administration route from systemic to intrathecal should be considered in patients who are already taking high doses of systemic opioids. Palliat Care Res 2009; 4(1): 317-320

Background/Aims: The use of endoscopic intervention (EI) for acute biliary pancreatitis (ABP) remains controversial because the severity of biliary obstruction/cholangitis/pancreatitis is not reflected in the indications for early EI (EEI). Methods: A total of 148 patients with ABP were included to investigate 1) the differences in the rate of worsening cholangitis/pancreatitis between the EEI group and the early conservative management (ECM) group, especially for each severity of cholangitis/pancreatitis, and 2) the diagnostic ability of imaging studies, including endoscopic ultrasound (EUS), to detect common bile duct stones (CBDSs) in the ECM group. Results: No differences were observed in the rate of worsening cholangitis between the EEI and ECM groups, regardless of the severity of cholangitis and/or the existence of impacted CBDSs. Among patients without impacted CBDSs and moderate/severe cholangitis, worsening pancreatitis was significantly more frequent in the EEI group (18% vs. 4%, p=0.048). In patients in the ECM group, the sensitivity and specificity for detecting CBDSs were 73% and 98%, respectively, for EUS, whereas the values were 13% and 92%, respectively, for magnetic resonance cholangiopancreatography. Conclusions EEI should be avoided in the absence of moderate/severe cholangitis and/or impacted CBDSs because of the high rate of worsening pancreatitis. EUS can contribute to the accurate detection of residual CBDSs, for the determination of the need for elective EI.

BACKGROUND/AIMS: Although both radial- and convex-arrayed endoscopic ultrasonography (EUS) scopes are widely used for observational EUS examinations, there have been few comparative studies on their power of visualization. The aim of this study was to evaluate the capability of these EUS scopes for observation of the pancreatobiliary junction. METHODS: The rate of successful visualization of the pancreatobiliary junction was retrospectively compared between a radial-arrayed and a convex-arrayed echoendoscope, from a prospectively maintained database. Study periods were defined as January 2010 to December 2012 for the radial group, and February 2015 to October 2016 for the convex group because the respective scope was mainly used during those periods. RESULTS: During the study period, 1,660 cases with radial EUS and 1,984 cases with convex EUS were recruited. The success rates of observation of the pancreatobiliary junction were 80.0% and 89.5%, respectively (p < 0.0001). CONCLUSIONS: The capability of visualization of the pancreatobiliary junction in observational EUS was found to be better with a convex-arrayed than with a radial-arrayed echoendoscope.
Endosonography ; Prospective Studies ; Retrospective Studies

BACKGROUND/AIMS: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis. METHODS: The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference. RESULTS: The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively. CONCLUSIONS: EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.
Bile ; Cholecystitis, Acute ; Constriction, Pathologic ; Dislocations ; Drainage ; Gallbladder ; Humans ; Retrospective Studies ; Stents ; Treatment Outcome

Background/Aims: We aimed to investigate (1) promising clinical findings for the recognition of focal type autoimmune pancreatitis (FAIP) and (2) the impact of endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA) on the diagnosis of FAIP. Methods: Twenty-three patients with FAIP were involved in this study, and 44 patients with resected pancreatic ductal adenocarcinoma (PDAC) were included in the control group. Results: (1) Multivariate analysis revealed that homogeneous delayed enhancement on contrast-enhanced computed tomography was a significant factor indicative of FAIP compared to PDAC (90% vs. 7%, p=0.015). (2) For 13 of 17 FAIP patients (76.5%) who underwent EUS-TA, EUS-TA aided the diagnostic confirmation of AIPs, and only one patient (5.9%) was found to have AIP after surgery. On the other hand, of the six patients who did not undergo EUS-TA, three (50.0%) underwent surgery for pancreatic lesions. Conclusions Homogeneous delayed enhancement on contrast-enhanced computed tomography was the most useful clinical factor for discriminating FAIPs from PDACs. EUS-TA is mandatory for diagnostic confirmation of FAIP lesions and can contribute to a reduction in the rate of unnecessary surgery for patients with FAIP.

Background/Aims: This study aimed to clarify the efficacy and safety of pancreatic duct lavage cytology combined with a cell-block method (PLC-CB) for possible pancreatic ductal adenocarcinomas (PDACs). Methods: This study included 41 patients with suspected PDACs who underwent PLC-CB mainly because they were unfit for undergoing endoscopic ultrasonography-guided fine needle aspiration. A 6-Fr double lumen catheter was mainly used to perform PLC-CB. Final diagnoses were obtained from the findings of resected specimens or clinical outcomes during surveillance after PLC-CB. Results: Histocytological evaluations using PLC-CB were performed in 87.8% (36/41) of the patients. For 31 of the 36 patients, final diagnoses (invasive PDAC, 12; pancreatic carcinoma in situ, 5; benignancy, 14) were made, and the remaining five patients were excluded due to lack of surveillance periods after PLC-CB. For 31 patients, the sensitivity, specificity, and accuracy of PLC-CB for detecting malignancy were 94.1%, 100%, and 96.8%, respectively. In addition, they were 87.5%, 100%, and 94.1%, respectively, in 17 patients without pancreatic masses detectable using endoscopic ultrasonography. Four patients developed postprocedural pancreatitis, which improved with conservative therapy. Conclusions PLC-CB has an excellent ability to detect malignancies in patients with possible PDACs, including pancreatic carcinoma in situ.

Background/Aims: The aim of this study was to evaluate outcomes of inside plastic stents (iPSs) versus those of metal stents (MSs) for treating unresectable perihilar malignant obstructions. Methods: For all patients who underwent endoscopic suprapapillary placement of iPS(s) or MS(s) as the first permanent biliary drainage for unresectable malignant perihilar obstructions between January 2014 and August 2019, clinical outcomes using iPSs (n=20) and MSs (n=85), including clinical efficacy, adverse events, and time to recurrence of biliary obstruction (RBO), were retrospectively evaluated. Results: There were no differences in clinical effectiveness (95% for the iPS group vs. 92% for the MS group, p=1.00). Procedure-related adverse events, including pancreatitis, acute cholangitis, acute cholecystitis, and death, were observed for 8% of the MS group, although no patient in the iPS group developed such adverse events. The median time to RBO was 561 days (95% confidence interval, 0–1,186 days) for iPSs and 209 days (127–291 days) for MSs, showing a significant difference (p=0.008). Conclusions Time to RBO after iPS placement was significantly longer than that after MS placement. IPSs, which are removable, unlike MSs, were an acceptable option.

Background/Aims: The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy. Methods: In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated. Results: Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations. Conclusions Propofol sedation was found to be safe—without severe adverse events or accidents—for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

BACKGROUND/AIMS: This study aimed to identify the predictive factors for inaccurate endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnosis of swollen lymph nodes without rapid on-site cytopathological evaluation. METHODS: Eighty-three consecutive patients who underwent EUS-FNA for abdominal or mediastinal lymph nodes from January 2008 to June 2017 were included from a prospectively maintained EUS-FNA database and retrospectively reviewed. The sensitivity, specificity, and accuracy of EUS-FNA for the detection of neoplastic diseases were calculated. Candidate factors for inaccurate diagnosis (lymph node size and location, needle type, puncture route, number of passes, and causative disease) were evaluated by comparison between accurately diagnosed cases and others. RESULTS: The final diagnosis of the punctured lymph node was classified as neoplastic (65 cases: a metastatic lymph node, malignant lymphoma, or Crow-Fukase syndrome) or non-neoplastic (18 cases: a reactive node or amyloidosis). The sensitivity, specificity, and accuracy were 83%, 94%, and 86%, respectively. On multivariate analyses, small size of the lymph node was the sole predictive factor for inaccurate EUS-FNA diagnosis with a significant difference (odds ratios, 19.8; 95% confidence intervals, 3.15–124; p=0.0015). CONCLUSIONS: The lymph node size of <16 mm was the only independent factor associated with inaccurate EUS-FNA diagnosis of swollen lymph nodes.
Diagnosis ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Humans ; Lymph Nodes ; Lymphatic Diseases ; Lymphoma ; Multivariate Analysis ; Needles ; Prospective Studies ; Punctures ; Retrospective Studies ; Risk Factors ; Sensitivity and Specificity

BACKGROUND/AIMS: In this study, we aimed to evaluate the predictive value of localized stenosis of the main pancreatic duct (MPD) for early detection of pancreatic cancer.METHODS: Among 689 patients who underwent endoscopic retrograde pancreatography from January 2008 to September 2018, 19 patients with MPD findings were enrolled. These patients showed findings for indicating suspicious pancreatic cancer at an early stage (FiCE); FiCE was defined as a single, localized stenosis in the MPD without a detectable mass (using any other imaging methods) and without other pancreatic diseases, such as definite chronic pancreatitis, intraductal papillary mucinous neoplasm, and autoimmune pancreatitis. Final diagnoses were established by examining resected specimens or through follow-up examinations after an interval of >5 years.RESULTS: Among 19 patients with FiCE, 11 underwent surgical resection and 8 were evaluated after a >5-year observation period. The final diagnosis of the MPD stenosis was judged to be pancreatic cancer in 9 patients (47%), including 3 with intraepithelial cancer, and to be a non-neoplastic change in 10. The sensitivity, specificity, and accuracy of preoperative pancreatic juice cytology were 75%, 100%, and 88%, respectively.CONCLUSIONS: The predictive value of FiCE for pancreatic cancer prevalence was 47%. Histological confirmation with pancreatic juice cytology is necessary before surgical resection.
Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Diagnosis ; Follow-Up Studies ; Humans ; Mucins ; Pancreatic Diseases ; Pancreatic Ducts ; Pancreatic Juice ; Pancreatic Neoplasms ; Pancreatitis ; Pancreatitis, Chronic ; Prevalence ; Sensitivity and Specificity