Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030,a high mortality rate considering the number of cases.Surgery and chemotherapy are the main treatment options,but they are burdensome for patients.A clear histological diagnosis is needed to determine a treatment plan,and endoscopic ultrasound(EUS)-guided tissue acquisition(TA)is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding.With the development of personalized medicine and precision treatment,there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure,leading to the development of the fine-needle biopsy(FNB)needle.EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration(FNA)as the procedure of choice for EUS-TA of pancreatic cancer.However,EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions,so it is important clinicians are familiar with both.Given these recent developments,we present an up-to-date review of the role of EUS-TA in pancreatic cancer.Particularly,technical aspects,such as needle caliber,negative pressure,and puncture methods,for obtaining an adequate specimen in EUS-TA are discussed.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Condyloma acuminatum of the anal canal,treated with endoscopic submucosal dissection

Condyloma acuminatum(CA) is a common sexually transmitted disease caused by human papilloma virus infection. Not all individuals develop persistent, progressive disease, but careful follow up is required with moderate-to-severe dysplasia to prevent progression to malignancy. Standard therapies include surgical treatments(trans-anal resection and transanal endoscopic microsurgery) and immunotherapeutic and topical methods(topical imiquimod); however, local recurrence remains a considerable problem. Here, we report a case with superficial CA of the anal canal, treated with endoscopic submucosal dissection(ESD). A 28-year-old man presented with a chief complaint of hematochezia. Digital exam did not detect a tumor. Screening colonoscopy revealed 10-mm long, whitish condyles extending from the anal canal to the lower rectum. The lesion covered almost the whole circumference, and only a small amount of normal mucosa remained. Magnifying endoscopy with narrow band imaging showed brownish hairpin-shaped, coiled capillaries. Although histopathological diagnosis by biopsy revealed CA, accurate histological differentiation between CA, papilloma, and squamous cell carcinoma can be difficult with a small specimen. Therefore, weperformed diagnostic ESD, which provides a complete specimen for precise histopathological evaluation. The pathological diagnosis was CA, with moderate dysplasia(anal intraepithelial neoplasia 2). There was no recurrence at 16 mo after the initial ESD. Compared to surgical treatment, endoscopic diagnosis and resection could be performed simultaneously and the tumor margin observed clearly with a magnifying chromocolonoscopy, resulting in less recurrence. These findings suggest that endoscopic resection may be an alternative method for CA that prevents recurrence.

Safety and efficacy of metallic stent for unresectable distal malignant biliary obstruction in elderly patients

AIM To study the safety of insertion of metallic stents in elderly patients with unresectable distal malignant biliary obstruction.METHODS Of 272 patients with unresectable distal malignant biliary obstruction, 184 patients under the age of 80 were classified into Group A, and 88 subjects aged 80 years or more were classified into Group B. The safety of metallic stent insertion, metal stent patency period, and the obstruction rate were examined in each group.RESULTS In Group B, patients had a significantly worse per-formance status, high blood pressure, heart disease, cerebrovascular disease, and dementia; besides the rate of patients orally administered antiplatelet drugs or anticoagulants tended to be higher(P < 0.05). Metallic stents were successfully inserted in all patients. The median patency period was 265.000 ± 26.779(1-965) d; 252.000 ± 35.998(1-618) d in Group A and 269.000 ± 47.885(1-965) d in Group B, with no significant difference between the two groups. Metallic stent obstruction occurred in 82 of the 272(30.15%) patients; in 53/184(28.80%) patients in Group A and in 29/88(32.95%) of those in Group B, showing no significant difference between the two groups. Procedural accidents due to metal stent insertion occurred in 24/272(8.8%) patients; in 17/184(9.2%) of patients in Group A and in 7/88(8.0%) of those in Group B, with no significant difference between the two groups, either.CONCLUSION These results suggested that metallic stents can be safely inserted to treat unresectable distal malignant biliary obstruction even in elderly patients aged 80 years or more.

Efficacy of combination therapy with natriuretic and aquaretic drugs in cirrhotic ascites patients: A randomized study

AIM To assess the effects of a combination therapy with natriuretic and aquaretic drugs in cirrhotic ascites patients.METHODS A two-center,randomized,open-label,prospective study was conducted. Japanese patients who met the criteria were randomized to trial group and the combination diuretic group(received 7.5 mg of tolvaptan) or the conventional diuretic group(received 40 mg of furosemide) for 7 d in addition to the natriuretic drug which was used prior to enrolment in this study. The primary endpoint was the change in body weight from the baseline. Vital signs,fluid intake,and laboratory and urinary data were assessed to determine the pharmacological effects after administration of aquaretic and natriuretic drugs.RESULTS A total of 56 patients were randomized to receive either tolvaptan(n = 28) or furosemide(n = 28). In the combination and conventional diuretic groups,the average decrease in body weight from the baseline was 3.21 ± 3.17 kg(P < 0.0001) and 1.75 ± 2.36 kg(P = 0.0006),respectively,when measured on the final dosing day. Following 1 wk of treatment,a significantly greater reduction in body weight was observed in the combination diuretic group compared to that in the conventional diuretic group(P = 0.0412).CONCLUSION Compared to a conventional diuretic therapy with only a natriuretic drug,a combination diuretic therapy with natriuretic and aquaretic drugs is more effective for patients with cirrhotic ascites.

Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system:Two case reports and review of literature

BACKGROUND Radiotherapy for hepatocellular carcinoma(HCC)is considered to have limited efficacy because of treatment intensity considering that the irradiated area includes the liver,which is highly radiosensitive.In this report,we present two cases in which tumor control by surgical resection,radiofrequency ablation,transcatheter arterial chemoembolization(TACE),and lenvatinib administration was difficult,but stereotactic body radiotherapy(SBRT)using the Synchrony system by Radixact?and Gold Anchor?(GA)was effective.CASE SUMMARY A 60-year-old man had a single 10-cm HCC in the right lobe.Viable lesions remained after TACE,and levels of alpha-fetoprotein and protein induced by vitamin K antagonists II(PIVKA-II)decreased and quickly re-elevated.We performed SBRT with GA.Three weeks after implantation,localized radiotherapy(SBRT;40 Gy/5 fractions)was performed using the Synchrony system by Radixact?.Four weeks later,the viable lesion had disappeared,and the PIVKA-II levels decreased.A 77-year-old man had a single 12-cm HCC in the right lobe.The patient experienced recurrence after hepatectomy.Further recurrence occurred after TACE,and we performed SBRT with GA.Because of the proximity of the HCC to the gastrointestinal tract,localized radiotherapy(SBRT;39 Gy/13 fractions)to the HCC was performed 3 wk after implantation using the Synchrony system by Radixact?.Four weeks later,the viable lesion had disappeared on computed tomography,and the PIVKA-Ⅱlevels decreased.CONCLUSION SBRT using the Synchrony system and GA can deliver a large dose accurately and safely,and could have a high therapeutic effect.

Clinical features and progress of ischemic gastritis with high fatalities: Seven case reports

BACKGROUND Ischemic gastritis is a clinically rare and highly fatal disease that occurs when the hemodynamics of a patient with vascular risk is disrupted.Early diagnosis and treatment are possible only with upper endoscopy after symptom appearance.We report seven cases of ischemic gastritis and its clinical features,prognosis,and indicators that may help in early detection.CASE SUMMARY Of the seven patients,six had vascular risk and five died within 2 wk of diagnosis.Their symptoms included hematemesis and hypotension.Although surgery is a choice for radical treatment,not all patients were tolerant.For such patients,conservative treatment was selected,but all of them died.In contrast,patients who underwent repeat endoscopy showed improved mucosal findings,suggesting that this improvement may not affect prognosis.Some ischemic changes such as wall thickening,mural emphysema,and fluid retention in the stomach were observed before diagnosis through endoscopy and computed tomography(CT).The CT scan can be effective for early detection,and improvement in circulatory failure and aggressive treatment may save the lives of patients with this disease.CONCLUSION The characteristic CT findings enable early detection of ischemic gastritis.Early diagnosis increases the chance of survival if early therapeutic intervention and improvement of circulatory dynamics can be achieved in this highly fatal disease.