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Toshio Tsuyuguchi,
Takao Itoi,
Tadahiro Takada,
Steven M Strasberg,
Henry A Pitt,
Myung-Hwan Kim,
Avinash N Supe,
Toshihiko Mayumi,
Masahiro Yoshida,
Fumihiko Miura,
Harumi Gomi,
Yasutoshi Kimura,
Ryota Higuchi,
Kohji Okamoto,
Yuichi Yamashita,
Toshifumi Gabata,
Jiro Hata,
Shinya Kusachi
Journal of hepato-biliary-pancreatic sciences. 04/2013;
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Yuji Sakai, Toshio Tsuyuguchi,
Nobuto Hirata,
So Nakaji,
Kenji Shimura,
Tatsuya Fujimoto,
Shin Tsuchiya,
Takayoshi Nishino,
Takao Nishikawa,
Harutoshi Sugiyama,
Osamu Yokosuka
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ABSTRACT: Background/Aims: The purpose of this study was to investigate whether endoscopic sphincterotomy (EST) can be usefully and safely performed in elderly patients aged 80 years or older. Methodology: The eligible patients with pancreatic and biliary diseases who required EST were divided into two groups depending on their age: under 80 (group A) and 80 or older (group B). Patient characteristics, EST success rate and incidence of the related complications were evaluated. Results: Of the 720 patients who required EST, 522 patients were in group A and 198 in group B. Group B incidences of patient characteristics at baseline disease and anticoagulant/antiplatelet therapy were significantly higher than in group A (p<0.05). The EST success rates were 97.1% (507/522) in group A and 96.5% (191/198) in group B. The incidences of the related complications were 8.8% (46/522) in group A and 4% (8/198) in group B, respectively, again without significant difference. Conclusions: The EST success rate and the incidence of related complications were comparable between patients in groups A and B, indicating that EST can be safely performed even in the elderly aged 80 years or older.
Hepato-gastroenterology 01/2013; 60(127). · 0.66 Impact Factor
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Toshio Tsuyuguchi,
Takao Itoi,
Tadahiro Takada,
Steven M Strasberg,
Henry A Pitt,
Myung-Hwan Kim,
Avinash N Supe,
Toshihiko Mayumi,
Masahiro Yoshida,
Fumihiko Miura,
Harumi Gomi,
Yasutoshi Kimura,
Ryota Higuchi,
Kohji Okamoto,
Yuichi Yamashita,
Toshifumi Gabata,
Jiro Hata,
Shinya Kusachi
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ABSTRACT: Percutaneous transhepatic gallbladder drainage (PTGBD) is considered a safe alternative to early cholecystectomy, especially in surgically high-risk patients with acute cholecystitis. Although randomized prospective controlled trials are lacking, data from most retrospective studies demonstrate that PTGBD is the most common gallbladder drainage method. There are several alternatives to PTGBD. Percutaneous transhepatic gallbladder aspiration is a simple alternative drainage method with fewer complications; however, its clinical usefulness has been shown only by case-series studies. Endoscopic naso-gallbladder drainage and gallbladder stenting via a transpapillary endoscopic approach are also alternative methods in acute cholecystitis, but both of them have technical difficulties resulting in lower success rates than that of PTGBD. Recently, endoscopic ultrasonography-guided transmural gallbladder drainage has been reported as a special technique for gallbladder drainage. However, it is not yet an established technique. Therefore, it should be performed in high-volume institutes by skilled endoscopists. Further prospective evaluations of the feasibility, safety, and efficacy of these various approaches are needed. This article describes indications and techniques of drainage for acute cholecystitis.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Henry A Pitt,
Harumi Gomi,
Masahiro Yoshida,
Toshihiko Mayumi,
Fumihiko Miura,
Dirk J Gouma,
O James Garden, [......],
Atsuhiko Murata,
Shinya Kusachi,
John A Windsor,
Avinash N Supe,
Sunggyu Lee,
Xiao-Ping Chen,
Yuichi Yamashita,
Koichi Hirata,
Kazuo Inui,
Yoshinobu Sumiyama
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ABSTRACT: In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. The fundamental policy of TG07 was to achieve the objectives of TG07 through the development of consensus among specialists in this field throughout the world. Considering such a situation, validation and feedback from the clinicians' viewpoints were indispensable. What had been pointed out from clinical practice was the low diagnostic sensitivity of TG07 for acute cholangitis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. In June 2010, we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of non-inflammatory biliary disease, collected from multiple institutions. TGRC held meetings a total of 35 times as well as international email exchanges with co-authors abroad. On June 9 and September 6, 2011, and on April 11, 2012, we held three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines. Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of the evidence from retrospective multi-center analyses. To be specific, discussion took place involving the revised new diagnostic criteria, and the new severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination with the level of evidence and the grade of recommendations. GRADE systems were utilized to provide the level of evidence and the grade of recommendations. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The bundles for the management of acute cholangitis and cholecystitis are presented in a separate section in TG13.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Fumihiko Miura,
Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Henry A Pitt,
Dirk J Gouma,
O James Garden,
Markus W Büchler,
Masahiro Yoshida,
Toshihiko Mayumi, [......],
Masamichi Yokoe,
Yasutoshi Kimura,
Ryota Higuchi,
Yuichi Yamashita,
John A Windsor, Toshio Tsuyuguchi,
Toshifumi Gabata,
Takao Itoi,
Jiro Hata,
Kui-Hin Liau
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ABSTRACT: We propose a management strategy for acute cholangitis and cholecystitis according to the severity assessment. For Grade I (mild) acute cholangitis, initial medical treatment including the use of antimicrobial agents may be sufficient for most cases. For non-responders to initial medical treatment, biliary drainage should be considered. For Grade II (moderate) acute cholangitis, early biliary drainage should be performed along with the administration of antibiotics. For Grade III (severe) acute cholangitis, appropriate organ support is required. After hemodynamic stabilization has been achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. In patients with Grade II (moderate) and Grade III (severe) acute cholangitis, treatment for the underlying etiology including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has been improved. In patients with Grade I (mild) acute cholangitis, treatment for etiology such as endoscopic sphincterotomy for choledocholithiasis might be performed simultaneously, if possible, with biliary drainage. Early laparoscopic cholecystectomy is the first-line treatment in patients with Grade I (mild) acute cholecystitis while in patients with Grade II (moderate) acute cholecystitis, delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobial agent is the first-line treatment. In non-responders to initial medical treatment, gallbladder drainage should be considered. In patients with Grade III (severe) acute cholecystitis, appropriate organ support in addition to initial medical treatment is necessary. Urgent or early gallbladder drainage is recommended. Elective cholecystectomy can be performed after the improvement of the acute inflammatory process.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Yuichi Yamashita,
Tadahiro Takada,
Steven M Strasberg,
Henry A Pitt,
Dirk J Gouma,
O James Garden,
Markus W Büchler,
Harumi Gomi,
Christos Dervenis,
John A Windsor, [......],
Xiao-Ping Chen,
Angus C W Chan,
Sheung-Tat Fan,
Palepu Jagannath,
Toshihiko Mayumi,
Masahiro Yoshida,
Fumihiko Miura, Toshio Tsuyuguchi,
Takao Itoi,
Avinash N Supe
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ABSTRACT: BACKGROUND: Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. METHODS AND MATERIALS: Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. RESULTS: There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. CONCLUSION: Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Takao Itoi, Toshio Tsuyuguchi,
Tadahiro Takada,
Steven M Strasberg,
Henry A Pitt,
Myung-Hwan Kim,
Giulio Belli,
Toshihiko Mayumi,
Masahiro Yoshida,
Fumihiko Miura,
Markus W Büchler,
Dirk J Gouma,
O James Garden,
Palepu Jagannath,
Harumi Gomi,
Yasuyuki Kimura,
Ryota Higuchi
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ABSTRACT: The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Seiki Kiriyama,
Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Toshihiko Mayumi,
Henry A Pitt,
Dirk J Gouma,
O James Garden,
Markus W Büchler,
Masamichi Yokoe, [......],
Palepu Jagannath,
Sunggyu Lee,
Robert Padbury,
Miin-Fu Chen,
Christos Dervenis,
Angus C W Chan,
Avinash N Supe,
Kui-Hin Liau,
Myung-Hwan Kim,
Sun-Whe Kim
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ABSTRACT: Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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Masamichi Yokoe,
Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Toshihiko Mayumi,
Harumi Gomi,
Henry A Pitt,
O James Garden,
Seiki Kiriyama,
Jiro Hata, [......],
Christos Dervenis,
Angus C W Chan,
Wan-Yee Lau,
Avinash N Supe,
Giulio Belli,
Serafin C Hilvano,
Kui-Hin Liau,
Myung-Hwan Kim,
Sun-Whe Kim,
Chen-Guo Ker
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ABSTRACT: Since its publication in 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) have been widely adopted. The validation of TG07 conducted in terms of clinical practice has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria. As for the severity assessment criteria in TG07, there is evidence that TG07 resulted in clarification of the concept of severe acute cholecystitis. Furthermore, there is evidence that severity assessment in TG07 has led to a reduction in the mean duration of hospital stay. As for the factors used to establish a moderate grade of acute cholecystitis, such as leukocytosis, ALP, old age, diabetes, being male, and delay in admission, no new strong evidence has been detected indicating that a change in the criteria used in TG07 is needed. Therefore, it was judged that the severity assessment criteria of TG07 could be applied in the updated Tokyo Guidelines (TG13) with minor changes. TG13 presents new standards for the diagnosis, severity grading and management of acute cholecystitis.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Journal of hepato-biliary-pancreatic sciences. 01/2013;
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ABSTRACT: BACKGROUND: The diagnostic accuracy of peroral video-cholangioscopy for indeterminate biliary lesions has not been determined in a prospective study. OBJECTIVE: To evaluate and compare the diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions with that of the cholangioscopy-guided forceps biopsy findings. DESIGN: Prospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: Patients who showed indeterminate biliary lesions on endoscopic retrograde cholangiography underwent peroral video-cholangioscopy for diagnosis. INTERVENTION: Each patient underwent peroral video-cholangioscopy with cholangioscopy-guided forceps biopsy. MAIN OUTCOME MEASUREMENTS: The accuracy of diagnosis by the peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings compared with that of the final diagnosis by other methods (malignant or benign). RESULTS: Thirty-three patients were enrolled, and the final diagnoses revealed that the lesions were malignant in 21 patients. All procedures were technically successful, and fine views were obtained in all patients. Procedure-related complications occurred in 2 patients (6.1%), but these complications were mild. The sensitivity, specificity, and accuracy were 100%, 91.7%, and 97.0%, respectively, for the peroral video-cholangioscopic visual findings and 38.1%, 100%, and 60.6%, respectively, for the cholangioscopy-guided forceps biopsy findings, and a significant difference was observed in the accuracy (P = .0018). LIMITATIONS: This was not a blinded study. No comparison was made with other diagnostic modalities involving tissue sampling. CONCLUSION: The diagnostic accuracy of the peroral video-cholangioscopic visual findings for indeterminate biliary lesions was excellent and significantly higher than that of the cholangioscopy-guided forceps biopsy findings. The accuracy of the cholangioscopy-guided forceps biopsy was insufficient, but the technique had an excellent specificity.
Gastrointestinal endoscopy 12/2012; · 6.71 Impact Factor
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ABSTRACT: : We evaluated the utility of peroral cholangioscopy (POCS) for preoperative diagnosis of cholangiocarcinoma.
: POCS was performed to assess the horizontal extension of the carcinoma. We compared the results of assessment with those of histologic analysis of 44 surgically resected specimens.
: Cholangiocarcinoma types were described as filling defects and strictures in 16 and 28 patients, respectively, using cholangiography. Endoscopic retrograde cholangiography (ERC) identified tumor extension in 5 and 15 patients with filling defects (31.25%) and strictures (53.57%), respectively. ERC+POCS identified tumor extension in 15 and 16 patients with filling defects (93.75%) and strictures (60.71%), respectively. ERC+POCS was significantly useful for patients with filling defects compared with ERC alone (P=0.002). ERC+POCS was not significantly useful for patients with strictures compared with ERC alone.
: POCS is a useful preoperative examination modality for assessing tumor extension in cholangiocarcinoma patients, especially in those with filling defects.
Surgical laparoscopy, endoscopy & percutaneous techniques 12/2012; 22(6):532-6. · 1.23 Impact Factor
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Masayoshi Saito,
Takeshi Ishihara,
Motohisa Tada, Toshio Tsuyuguchi,
Rintaro Mikata,
Yuji Sakai,
Katsunobu Tawada,
Harutoshi Sugiyama,
Jo Kurosawa,
Masayuki Otsuka,
Yoshitaka Uchida,
Katsuhiro Uchiyama,
Masaru Miyazaki,
Osamu Yokosuka
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ABSTRACT: BACKGROUND & AIMS: We investigated the usefulness of dual-phase, F-18 fluorodeoxyglucose positron emission tomography with computed tomography (FDGPET/CT) to differentiate benign from malignant intraductal papillary mucinous neoplasms (IPMNs) and evaluate branch-duct IPMNs. METHODS: We used FDG-PET/CT to evaluate IPMNs in 48 consecutive patients, from May 2004 to March 2012, who underwent surgical resection. IPMNs were classified as benign (n=16) or malignant (n=32) based on histology analysis. The ability of FDG-PET/CT to identify branch-duct IPMNs was compared with that of the International Consensus Guidelines. RESULTS: The maximum standardized uptake value (SUV(max)) was higher for early-phase malignant IPMNs than that for benign IPMNs (3.5±2.2 vs 1.5±0.4;P <.001). When the SUV(max) cut-off value was set at 2.0, early-phase malignant IPMNs were identified with 88% sensitivity, specificity, and accuracy. The retention index (RI) values for malignant and benign IPMNs were 19.6±17.8 and -2.6±12.9, respectively. When the SUV(max) cut-off was set to 2.0 and the RI value to -10.0, early-phase malignant IPMNs were identified with 88% sensitivity, 94% specificity, and 90%, accuracy. In identification of branch-duct IPMNs, when the SUV(max) cut-off was set to 2.0, the sensitivity, specificity, and accuracy values were 79%, 92%, and 84%, respectively. Using a maximum main pancreatic duct diameter =7 mm, the Guidelines identified branch-duct IPMNs with greater specificity than FDG-PET/CT. The Guideline criteria of maximum cyst size =30 mm and the presence of intramural nodules identified branch-duct IPMNs with almost equal sensitivity to FDGPET/CT. CONCLUSIONS: Dual-phase FDG-PET/CT is useful for preoperative identification of malignant IPMN and for evaluating branch-duct IPMN.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 11/2012; · 5.64 Impact Factor
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ABSTRACT: Aim: We investigated the usefulness of doripenem (DRPM), a carbapenem antimicrobial drug, for the treatment of acute cholangitis. Methods: 28 patients who received a diagnosis of moderate or severe cholangitis were included in this investigation. 23 patients had moderate cholangitis; 5 patients had severe cholangitis. When moderate or severe cholangitis was diagnosed, administration of DRPM and endoscopic drainage were performed. The dose of DRPM was fixed at 0.5 g, 3 times daily. Evaluation of clinical findings (abdominal pain and body temperature) and blood test findings (WBC, CRP, ALT, ALP, and T-Bil) was performed before and on Day 5 after administration. Results: Endoscopic drainage was successful in all patients. After administration of DRPM, a significant improvement was observed in all endpoints of both clinical findings and blood test findings (p < 0.05). No adverse events due to administration of DRPM were observed. Conclusion: It was suggested that administration of DRPM may be clinically useful for the treatment of moderate and severe cholangitis.
International journal of clinical pharmacology and therapeutics 10/2012; · 1.18 Impact Factor
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Rintaro Mikata,
Takeshi Ishihara,
Motohisa Tada,
Katsunobu Tawada,
Masayoshi Saito,
Joe Kurosawa,
Harutoshi Sugiyama,
Yuji Sakai, Toshio Tsuyuguchi,
Masaru Miyazaki,
Osamu Yokosuka
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ABSTRACT: BACKGROUND: Cytological examination of pancreatic juice obtained during endoscopic retrograde cholangiopancreatography (ERCP) is well established, but its sensitivity for pancreatic cancer has not been satisfactory. The aim of this study was to evaluate the usefulness of repeated pancreatic juice cytology (PJC) via the endoscopic naso-pancreatic drainage (ENPD) tube in patients with pancreatic cancer compared with conventional PJC. METHODS: We retrospectively investigated 139 patients with pancreatic disease. Between April 2004 and November 2007, conventional PJC was performed in 56 patients with pancreatic cancer and 23 with benign pancreatic stricture. Between January 2008 and November 2010, ENPD was used in 40 patients with pancreatic cancer and 20 with benign pancreatic stricture. The ENPD tube was placed into the main pancreatic duct for up to 3 days, and cytological samples of pancreatic juice were collected up to 6 times in total. RESULTS: Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the ENPD method for pancreatic cancer were 80, 100, 100, 71, and 87 %, respectively, revealing significantly higher sensitivity than the conventional method (p = 0.0001). Sensitivities according to tumor location and size were 90 % (19/21), 69 % (9/13), and 67 % (4/6) in the head, body, and tail of the pancreas, 88 % (7/8), 79 % (19/24), and 75 % (6/8) in tumors with a diameter less than 20 mm including carcinoma in situ, 21-40, and greater than 41 mm, respectively. CONCLUSIONS: The ENPD method was found to have high diagnostic yield, especially for tumors less than 20 mm or located in the pancreatic head, and might be useful for the diagnosis of early-stage pancreatic cancer.
Journal of Gastroenterology 10/2012; · 4.16 Impact Factor
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ABSTRACT: Background/Aims: Few studies have compared endoscopic biliary stenting and endoscopic nasobiliary drainage for preoperative biliary drainage in patients with malignant distal biliary obstruction. We aimed to evaluate their safety and efficacy in such patients awaiting pancreaticoduodenectomy. Methodology: Seventy-six of 80 patients (40 with pancreatic cancer, 26 with distal bile duct cancer, and 14 with ampullary cancer) who underwent endoscopic preoperative biliary drainage were included, and we evaluated whether endoscopic biliary stenting or endoscopic nasobiliary drainage provided a safer and more effective drainage for patients awaiting pancreaticoduodenectomy. We also determined whether the type of cancer influenced tube dysfunction. Results: No significant differences in the overall rate of catheter-related complications, the rate of tube dysfunction, or the median interval from preoperative biliary drainage to the time of tube dysfunction were observed between the two groups. Tube dysfunction was observed significantly more frequently in patients with pancreatic cancer than in those with distal bile duct or ampullary cancer. Conclusions: Both endoscopic biliary stenting and endoscopic nasobiliary drainage provided safe and effective drainage for patients awaiting pancreaticoduodenectomy. Tube dysfunction was associated with preoperative biliary drainage significantly earlier in patients with pancreatic cancer than in those with distal bile duct cancer or ampullary cancer.
Hepato-gastroenterology 09/2012; 60(122). · 0.66 Impact Factor
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Masamichi Yokoe,
Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Toshihiko Mayumi,
Harumi Gomi,
Henry A Pitt,
Dirk J Gouma,
O James Garden,
Markus W Büchler, [......],
Sheung-Tat Fan,
Harijt Singh,
Eduardo de Santibanes,
Shinya Kusachi,
Atsuhiko Murata,
Xiao-Ping Chen,
Palepu Jagannath,
Sunggyu Lee,
Robert Padbury,
Miin-Fu Chen
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ABSTRACT: The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world's first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13).
We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The "gold standard" for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis.
Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III).
The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.
Journal of hepato-biliary-pancreatic sciences. 08/2012; 19(5):578-85.
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ABSTRACT: In 2007, the Tokyo Guidelines (TG07) working group established diagnostic criteria for assessment of the severity of acute cholangitis. This study aimed to analyze outcomes and identify predictors of mortality in patients with acute cholangitis managed according to the TG07.
In this study, 215 consecutive cases of acute cholangitis were reviewed. Risk factors associated with mortality or refractory cholangitis, which is defined on the basis of prolonged hospitalization (>28 days) or disease resulting in fatality, were examined using multivariate logistic regression analysis.
There were 52, 133, and 30 cases of mild, moderate, and severe cholangitis, respectively. The overall mortality rate was 4.2 % (9/215). Mortality rates in patients with mild, moderate, and severe cholangitis were 0, 2.3, and 20.0 %, respectively (moderate vs. severe, p = 0.001). Multivariate analysis showed that serum albumin levels ≤2.8 g/dl and PT-INR >1.5 were significant predictors of mortality. There were 57 patients (26.5 %) with refractory cholangitis. Multivariate analysis showed that serum albumin level ≤2.8 g/dl, PT-INR >1.5, etiology and inpatient status were significant predictors of refractory cholangitis.
The TG07 severity assessment criteria for acute cholangitis were significantly predictive of mortality. Hypoalbuminemia is an important risk factor in addition to organ dysfunction.
Journal of hepato-biliary-pancreatic sciences. 07/2012; 19(5):557-65.
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Seiki Kiriyama,
Tadahiro Takada,
Steven M Strasberg,
Joseph S Solomkin,
Toshihiko Mayumi,
Henry A Pitt,
Dirk J Gouma,
O James Garden,
Markus W Büchler,
Masamichi Yokoe, [......],
Harijt Singh,
Eduardo de Santibanes,
Harumi Gomi,
Shinya Kusachi,
Atsuhiko Murata,
Xiao-Ping Chen,
Palepu Jagannath,
Sunggyu Lee,
Robert Padbury,
Miin-Fu Chen
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ABSTRACT: The Tokyo Guidelines for the management of acute cholangitis and cholecystitis were published in 2007 (TG07) and have been widely cited in the world literature. Because of new information that has been published since 2007, we organized the Tokyo Guidelines Revision Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines (TG13). METHODS/MATERIALS : We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was suspected. The cases were collected from multiple tertiary care centers in Japan. The 'gold standard' for acute cholangitis in this study was that one of the three following conditions was present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or (3) remission was achieved by antibacterial therapy alone, in patients in whom the only site of infection was the biliary tree. Comparisons were made for the validity of each diagnostic criterion among TG13, TG07 and Charcot's triad.
The major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from 82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of Charcot's triad was only 26.4 % but the specificity was 95.6 %. However, the false positive rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading, Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors which were derived from evidence presented recently in the literature. The factors chosen allow severity assessment to be performed soon after diagnosis of acute cholangitis.
TG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.
Journal of hepato-biliary-pancreatic sciences. 07/2012; 19(5):548-56.
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Yuji Sakai, Toshio Tsuyuguchi,
Harutoshi Sugiyama,
Takao Nishikawa,
Jo Kurosawa,
Masayoshi Saito,
Katsunobu Tawada,
Rintaro Mikata,
Motohisa Tada,
Takeshi Ishihara,
Osamu Yokosuka
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ABSTRACT: Background/Aims: Recently, there have been sporadic reports of lithotomy using endoscopic sphincterotomy combined with large balloon dilation (EPLBD) against large or multiple bile duct stones. However, there are not many reports so far concerning this procedure. Therefore, we decided to discuss the results of EPLBD against large or multiple bile duct stones. Methodology: Stone retrieval using EPLBD was performed with 59 patients of choledocholithiasis, A) with 13mm or more in shortest dimension, or B) multiple (=3) bile duct stones, with the smallest more than 10mm in shortest dimension. The papilla treated with endoscopic sphincterotomy (EST) was dilated using a 12-20mm balloon suitable for the biliary ductal size. Results: The success rate for the first lithotomy for choledocholithiasis was 83.1% (49/59). The final lithotomy rate was 100% (59/59). The time required for lithotomy was 43.7 (12-125) minutes and the number of treatment was 1.3 (1-4) on average. Lithotripsy was needed in 13.6% (8/59). The incidence of coincidental events associated with the procedure was 6.8% (4/59). No pancreatitis was noted. Conclusions: An endoscopic treatment using EST plus large balloon dilation against large or multiple bile duct stones was suggested to be safe and effective.
Hepato-gastroenterology 05/2012; 60(121). · 0.66 Impact Factor
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Yuji Sakai, Toshio Tsuyuguchi,
Harutoshi Sugiyama,
Takao Nishikawa,
Katsunobu Tawada,
Masayoshi Saito,
Jo Kurosawa,
Rintaro Mikata,
Motohisa Tada,
Takeshi Ishihara,
Osamu Yokosuka
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ABSTRACT: Background/Aims: The progression of endoscopy and devices as well as newly developed treatment methods have enabled endoscopic lithotomy. In this study, we examined to what degree is it possible to endoscopically treat patients who are diagnosed as having common bile duct stones. Methodology: Lithotomy was conducted using a backward side-viewing endoscope for patients without surgical history of upper gastrointestinal tract and patients with stomach reconstructed with Billroth-I method, using an ordinary endoscope for patients with stomach reconstructed with Billroth-II method (Bil-II) and using a double balloon endoscope for patients with difficulty in reaching the papilla or patients of Roux-en-Y anastomosis (R-Y). As for treatment methods, we selected endoscopic sphincterotomy as the first choice for papilla treatment and selected endoscopic papillary balloon dilation for patients with bleeding tendency or patients of Bil-II or R-Y. For patients with multiple stones or giant stones, lithotripsy was selected depending on judgment of the endoscopist. Results: Endoscopic complete lithotomy was successful in 97.7% (168/172). An accidental disease was observed in 2.9% (5/172). In one patient with the perforated gastrointestinal tract, a surgery was performed but others were mild. Conclusions: Common bile duct stones can be endoscopically treated safely with high rate.
Hepato-gastroenterology 03/2012; 59(118):1712-6. · 0.66 Impact Factor
