[Show abstract][Hide abstract] ABSTRACT: Agenesis of the gallbladder, a rare anomaly, is generally regarded as an organogenic failure. Several reports suggest that this congenital defect is inherited but that supposition remains controversial. We described agenesis of the gallbladder in identical twins. A 21-year-old female presented with a history of acute pain in the epigastrium and right hypochondrium. Various imaging modalities showed “gallbladder agenesis.” Moreover, her older identical twin sister had also no visualized gallbladder in imaging modalities. This case report strongly suggested that agenesis of the gallbladder would be caused by a genetic abnormality.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the feasibility of using an automated spring-loaded needle device for endoscopic ultrasound (EUS)-guided abdominal paracentesis (EUS-P) to see if this would make it easier to puncture the mobile and lax gastric wall for EUS-P.
The EUS database and electronic medical records at Fukushima Medical University Hospital were searched from January 2001 to April 2011. Patients with a history of cancer and who underwent EUS-P using an automated spring-loaded needle device with a 22-gauge puncture needle were included. The needle was passed through the instrument channel and advanced through the gastrointestinal wall under EUS guidance into the echo-free space in the abdominal cavity and ascitic fluid was collected. The confirmed diagnosis of malignant ascites included positive cytology and results from careful clinical observation for at least 6 mo in patients with negative cytology. The technical success rate, cytology results and complications were evaluated.
We found 11 patients who underwent EUS-P with an automated spring-loaded needle device. In 4 cases, ascites was revealed only with EUS but not in other imaging modalities. EUS-P was done in 7 other cases because there was minimal ascitic fluid and no safe window for percutaneous abdominal aspiration. Ascitic fluid was obtained in all cases by EUS-P. The average amount aspirated was 14.1 mL (range 0.5-38 mL) and that was sent for cytological exam. The etiology of ascitic fluid was benign in 5 patients and malignant in 6. In all cases, ascitic fluid was obtained with the first needle pass. No procedure-related adverse effects occurred.
EUS-P with an automated spring-loaded needle device is a feasible and safe method for ascites evaluation.
[Show abstract][Hide abstract] ABSTRACT: Introduction:
A prior study with 22-gauge needles recommended more than seven needle passes for endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) of solid pancreatic lesions (SPL) without onsite cytopathology for optimal acquisition of cytopathological diagnosis. The feasibility of this recommendation should be re-evaluated considering the later development and popularity of 25-gauge EUS-FNA needles. We aimed to determine the optimal number of needle passes for cytopathological specimen acquisition with 25-gauge needles for EUS-FNA of SPL.
A preliminary prospective study of 22 patients with an onsite cytopathology technician showed a sensitivity of 93.3% and a specificity of 100% with four needle passes that was not statistically different from five needle passes. Based on our preliminary study, we fixed the number of needle passes to four (Group A). As a control group, we carried out sampling in consecutive patients using 25-gauge needles with an onsite cytopathologist (Group B). Sampling rate, diagnostic value and complications were evaluated.
We enrolled 20 patients in each group. Sampling rate was higher in Group B (20/20, 100%) than in Group A (19/20, 95%), but there was no statistical difference between them (P-value = 0.31). In Group A, sensitivity, specificity and accuracy were 100% among 19. In Group B, sensitivity was 94.1%, specificity 100%, accuracy 95%. There were also no statistical differences between the groups. No complications were seen.
Our study suggests that four needle passes using a 25-gauge needle may be sufficient for EUS-FNA of SPL where onsite cytology is not available.
No preview · Article · Nov 2012 · Digestive Endoscopy
[Show abstract][Hide abstract] ABSTRACT: This study evaluates the feasibility of chemosensitivity testing by use of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) samples and determines the optimum cut-off value for gemcitabine.
Thirty-four consecutive patients with unresectable pancreatic cancer were enrolled. Chemosensitivity (treated/control ratio: T/C ratio) was calculated as the quantity of adenosine triphosphate for a tumor treated with gemcitabine as a percentage of that for the control. To identify the cut-off value sufficient to predict 180 days of progression-free survival (PFS), the receiver operating characteristic curve and the corresponding area under the curve (AUC) were calculated.
The success of this assay was 88.2% (30/34); therefore, 30 patients were assessable and included in the population of analyzable patients.. The response was 6.7%. Median PFS was 96 days and median overall survival was 241 days, respectively. The cut-off value was determined as 74% (AUC, 0.745; p = 0.053; 95% CI 0.485-1.005). According to this cut-off value, we predicted 180 days PFS with a sensitivity and specificity of 71.4 and 91.3%, respectively. When patients were divided into two groups at T/C ratio 74%, a significant difference was found in PFS (median 77 vs. 205 days, p = 0.0036). Moreover, T/C ratio < 74% and decrease of CA19-9 were significant and independent prognostic factors by multivariate analysis.
Chemosensitivity testing by use of EUS-FNA samples in patients with unresectable pancreatic cancer is feasible. This definition emphasizes the possibility of selecting patients for whom favorable results from gemcitabine treatment can be expected.
No preview · Article · Feb 2011 · International Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: We report a rare case of autoimmune neutropenia associated with autoimmune pancreatitis.
A 61-year-old man was referred to our hospital with slight epigastralgia. He had been admitted to another hospital with exacerbation of diabetes and jaundice. Blood tests showed low white blood cell and neutrophil counts (1,800 µL-1 and 3%, respectively), and elevated transaminase, biliary enzyme, amylase and lipase levels. Serum IgG and IgG4 levels were elevated to 2,693 mg/dL and 454 mg/dL, respectively. Abdominal CT showed diffuse pancreatic swelling, and MRCP revealed diffuse narrowing of the main pancreatic duct and dilation of the common bile duct. An additional EUS-FNA was performed in our hospital. Laboratory data, imaging and histopathological findings confirmed the diagnosis of autoimmune pancreatitis. However, the low white blood cell count continued. For additional investigation, a bone marrow examination was performed, indicating a granulocyte maturation disorder. Moreover, anti-neutrophil antibodies were positive. Therefore, a diagnosis of autoimmune neutropenia associated with autoimmune pancreatitis was made. After steroid therapy, the anti-neutrophil antibodies disappeared and the white blood cell count was within the reference limit. No recurrence of disease has been observed since then.
Autoimmune neutropenia, which is positive for anti-neutrophil antibodies, can be associated with autoimmune pancreatitis.
Full-text · Article · Jan 2011 · JOP: Journal of the pancreas
[Show abstract][Hide abstract] ABSTRACT: To objectively compare the electronic radial scanning echoendoscope (ER-ES) with the mechanical radial scanning echoendoscope (MR-ES) in the quality of endoscopic ultrasonography (EUS) images of gastrointestinal tract and pancreaticobiliary lesions.
Studied were 56 patients: 20 with gastric cancer, 20 with gallbladder lesions, and 16 with intraductal papillary-mucinous neoplasms of the pancreas (IPMN). They were subjected to EUS, half of them using the ER-ES, and the other half using the MR-ES. EUS images thus obtained were evaluated concerning four items in patients with gastric cancer and those with gallbladder lesions, and three items in patients with IPMN. Six endosonographers blindly assessed two EUS images per patient on a visual analogue scale. In each of the three groups of patients, the evaluators' median scores for the ER-ES and MR-ES for each item were compared.
The median scores for the ER-ES were significantly higher than those for the MR-ES in all items in patients with gastric cancer and those with IPMN, and in one item in patients with gallbladder lesions.
The ER-ES is certainly superior to the MR-ES in the quality of EUS images of gastrointestinal tract and pancreaticobiliary lesions.
Full-text · Article · Dec 2010 · Fukushima journal of medical science
[Show abstract][Hide abstract] ABSTRACT: A 58-year-old woman was admitted to our institute in June 2007 because of obstructive jaundice. A mass in the pancreatic head and multiple swollen lymph nodes surrounding the common hepatic artery were identified using computed tomography (CT). Subsequently, endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA) was done. Histopathologic results revealed anaplastic carcinoma of the pancreas. Using specimens obtained with EUS-FNA, chemosensitivity testing with adenosine triphosphate assay was performed. Testing indicated high chemosensitivity to paclitaxel (PTX). According to this result, chemotherapy using PTX was performed, and the primary lesion and lymph node metastases disappeared completely on CT. The patient has been doing well with no recurrence for 1 year and 11 months since initial chemotherapy.
No preview · Article · Mar 2010 · International Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: We report a case of a 50-year-old man with a medical history of alcoholic cirrhosis, in addition to esophagogastric and duodenal varices (DV), who was transferred to our institution because of hemorrhagic DV. Emergent esophagogastroduodenoscopy showed hemorrhagic varices in the horizontal portion of the duodenum. Abdominal contrast-enhanced CT showed hemodynamics of DV derived from anastomosis between the superior mesenteric vein and right renal vein. Cyanoacrylate was injected into the DV. Subsequently, 5% ethanolamine-oleate was injected endoscopically as a sclerosant into the DV feeding vein. Radiographic fluoroscopic findings revealed that the injected cyanoacrylate and sclerosant remained, respectively, in the varices and its feeder. Five days later, CT showed that the injected cyanoacrylate occupied the DV, and thrombus formation of the afferent vein led to bifurcation of superior mesenteric vein. This case showed the usefulness of endoscopic injection sclerotherapy using cyanoacrylate and sclerosant for the management of DV.
No preview · Article · Dec 2009 · Surgical laparoscopy, endoscopy & percutaneous techniques
[Show abstract][Hide abstract] ABSTRACT: This report describes our experience with two cases that were ultimately diagnosed as retroperitoneal liposarcoma using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Case 1 is that of a 54-year-old woman with chief complaints of nausea and abdominal distention. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large (15 cm diameter) tumor, which was significantly compressing the stomach and apparently occupied the entire left abdominal cavity. Although advanced primary gastrointestinal stromal tumor (GIST) or retroperitoneal tumor was inferred as the differential diagnosis, a definitive diagnosis was difficult using imaging alone. After EUS-FNA was done, the tumor was diagnosed histopathologically as high-grade liposarcoma. Case 2 is that of a 73-year-old man. Abdominal ultrasonography and CT showed a 6 cm diameter tumor within the pelvic cavity. The tumor had high MRI signal-intensity on both T1 and T2 images. Endorectal EUS showed a hyperechoic mass. The images suggested lipoma or liposarcoma containing lipoma-like components. Myxoid liposarcoma was revealed by subsequent EUS-FNA. Performing EUS-FNA was clinically useful for determining the subsequent therapeutic strategy in these cases where a tumor of unknown origin existed in the retroperitoneum.
Full-text · Article · Oct 2009 · Diagnostic and Therapeutic Endoscopy
[Show abstract][Hide abstract] ABSTRACT: An 81-year-old man, who experienced upper abdominal pain after shoveling snow, was admitted to a local hospital where a computed tomography (CT) showed a cystic lesion adjoining the pancreas. He was transferred to our department for detailed investigations and treatment. On ultrasonography, a tumor of the caudate lobe of the liver, with which the cystic lesion was continuous, was seen. The tumor of the caudate lobe of the liver was enhanced in the early phase of the CT but was washed out in the delayed phase. Subsequently, T(1)-weighted and T(2)-weighted magnetic resonance imaging (MRI) images showed a low intensity and a high intensity, respectively. Because the cystic lesion was continuous with the tumor of the caudate lobe of the liver, its CT value was higher than that of water, and both the T(1)-weighted and T(2)-weighted MRI images showed a high intensity, which was attributed to a hematoma. Examination of the image suggested that rupture of a hepatocellular carcinoma (HCC) might have caused intracavitary hemorrhage. After the HCC was treated by transcatheter arterial embolization therapy, the patient was discharged. Subsequently, tumor enlargement was confirmed, and surgical removal of the tumor was conducted at the hospital where the patient had originally presented. On histology, moderately differentiated HCC was diagnosed, but the cyst-like lesion was confirmed to be a hepatic subcapsular hematoma extending into the bursa omentalis. Although ruptured HCC often causes intraperitoneal bleeding, this rare case showed a cyst-like imaging finding in the form of a subcapsular hematoma within the bursa omentalis.
No preview · Article · Oct 2009 · Hepatology Research
[Show abstract][Hide abstract] ABSTRACT: The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment.
This study enrolled 115 patients who underwent endoscopic treatment for GV between October 1988 and December 2003 using cyanoacrylate and 5% ethanolamine oleate. Successful hemostasis, recurrence rates, rebleeding rates, survival rates, complications and prognostic factors after the treatment were retrospectively reviewed.
Treatment sessions for GV were performed 3.4 +/- 2.5 times. All cases, including 14 emergency cases, were treated successfully. The cumulative recurrence rates at 1, 3 and 5 years after the treatment were 7.0%, 15.6% and 20.0%, respectively, and the cumulative rebleeding rates at 1, 3 and 5 years were 3.5%, 8.7% and 14.8%, respectively. The overall survival rates were 78.3%, 63.7% and 51.5% at 1, 3 and 5 years, respectively. Grade B or C in Child-Pugh classification, emergency or elective cases, and association with hepatocellular carcinoma were identified as significant negative prognostic factors after endoscopic treatment by multivariate analysis. Although several complications were observed, there was no mortality.
Grade B or C in Child-Pugh classification, emergency or elective situation, and association with hepatocellular carcinoma are negative prognostic factors after endoscopic treatment.
No preview · Article · Oct 2009 · Digestive Endoscopy
[Show abstract][Hide abstract] ABSTRACT: The recent progression of endoscopic ultrasonography (EUS) enables EUS-guided transmural drainage based on the EUS-guided fine-needle aspiration biopsy technique. Prior to the development of EUS-guided drainage procedures, the options for treating obstruction of the pancreatobiliary system included surgical drainage, percutaneous drainage using ultrasound and radiological guidance, and endoscopic (non EUS-guidance) transmural drainage. Today, using EUS guidance and dedicated accessories, it is possible to create bilio- or pancreato-digestive anastomosis, EUS-guided biliary drainage (EUS-BD), and EUS-guided pancreatic drainage (EUS-PD). The recent literature describes that EUS-BD and EUS-PD have acceptable success and complication rates. These procedures are anticipated for use as alternatives to surgery or percutaneous drainage when endoscopic transpapillary procedures fail.
No preview · Article · Sep 2009 · Journal of Hepato-Biliary-Pancreatic Surgery
[Show abstract][Hide abstract] ABSTRACT: Advanced pancreatic cancer is a major cause of cancer-related death. However, if surgery achieves clear margins and negative lymph nodes, the prognosis for survival can be prolonged. Therefore, early diagnosis - as early as possible - is important for improving overall survival and quality of life in patients with pancreatic cancer. Because of higher imaging resolution near the pancreas through the gastroduodenal wall, endoscopic ultrasonography enables detection of subtle pancreatic abnormalities. In fact, many investigators have reported the high ability of EUS not only for detection of small lesions but also recognition of chronic pancreatitis, which is the risky status of pancreatic cancer. As a tool for early diagnosis of pancreatic cancer, EUS is a highly anticipated modality.
No preview · Article · Jul 2009 · Digestive Endoscopy
[Show abstract][Hide abstract] ABSTRACT: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE) has been reported to provide a more accurate diagnosis than EUS-FNA without such evaluation. However, even endosonographers can evaluate ROSE regarding sample adequacy. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers compared to ROSE by cytopathologists in patients with solid pancreatic masses.
Between September 2001 and October 2005, of the 73 EUS-FNA procedures with the final diagnoses, 38 procedures after the introduction of ROSE by endosonographers (September 2001-September 2003, period 1), and 35 procedures after the introduction of ROSE by cytopathologists (October 2003-October 2005, period 2) were included. The specimens were stained with Diff-Quik stain and assessed. When the on-site assessors (endosonographers or cytopathologists) indicated that the amounts of cell samples were adequate, the procedure was stopped.
Results are presented with 95% confidence limits. The average numbers of needle passes were 4.0 +/- 1.6 and 3.4 +/- 1.5 in periods 1 and 2, respectively (P = 0.06). The specimen collection rates were 97.4 and 97.1% in periods 1 and 2, respectively (P = 0.51). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy and benign were 92.9, 100, 100, 83.3, and 94.7%, respectively, in period 1, and 93.1, 100, 100, 75.0, and 94.3%, respectively, in period 2 (P = 0.97, P = 1.0, P = 1.0, P = 0.65, P = 0.93, respectively). No complications were seen.
For accurate diagnosis, ROSE should be performed during EUS-FNA by the endosonographer, if no cytopathologist is available.
No preview · Article · Apr 2009 · Journal of Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: Pancreatic mesenchymal tumors are rare, accounting for only 1-2% of pancreatic tumors. A pancreatic lipoma is an especially rare condition. This is only the second report of a pancreatic lipoma diagnosed before surgery using endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA).
A 75-year-old woman with a round low-density lesion which had been detected by CT was referred to our hospital. EUS revealed an oval 49x32 mm homogeneous and almost isoechoic mass (as compared to normal pancreatic parenchyma) in the pancreatic head. Its outer margin was not clearly differentiated from the parenchyma. Although a benign pancreatic lipomatous lesion was deemed most probable from information obtained using CT/MRI, a mass with malignancy such as a liposarcoma could not be ruled out as a differential diagnosis. Therefore, EUS-FNA was performed for a definitive diagnosis. Two passes were performed with on-site pathology. The results obtained from the sample analysis indicated a pancreatic lipoma consisting of mature fat cells with no atypia.
Although imaging modalities are useful for the diagnosis of pancreatic lipomatous lesions, it is sometimes difficult to diagnose lipomatous malignancies mimicking benign lipoma. This case demonstrates the usefulness of EUS-FNA for the differential diagnosis of pancreatic lipomatous lesions.
No preview · Article · Feb 2009 · JOP: Journal of the pancreas