Cholangioscopy can provide endoscopic direct visualization of the biliary system. First described in 1970s, cholangisoscopy is categorized into peroral cholangioscopy (POCS) and percutaneous cholangioscopy (PTCS). Traditional POCS using a dedicated cholangioscope that advances through the accessory channel of the duodenal scope is called the mother-baby system. This procedure requires the presence of two experienced endoscopists because baby cholangioscopes have been shown to be fragile. Recently, single-operator cholangioscopy was introduced as the SpyGlass system. SpyGlass system is semi disposable, but the optical quality is low compared with videoscopes. More recently several endoscopists have reported the usefulness of single-operator peroral direct cholangioscopy (PDCS) using a conventional ultraslim endoscope. Compared with the mother-baby system, the advantages of PDCS are the high-resolution image and large-diameter working channel. On the other hand, the disadvantage is the difficulty to insert the ultraslim scope into the biliary system. However, the success rate can be improved using assistant devices such as guidewire, anchoring balloon, overtube duodenal balloon, and prototype cholangioscopy. PTCS is used for patients who are not able to tolerate POCS, but it is time consuming. Cholangioscopy is currently employed primarily for the characterization of indeterminate strictures. Narrow-band imaging, which displays images of the superficial mucosal surface, improves biliary tract disease diagnosis. Cholangioscopy-guided target biopsy can although increase diagnostic yields. In addition, cholangioscopy can provide an accurate diagnosis of intraepithelial tumors extending into biliary cancers. The main therapeutic indication of cholangioscopy is the management of difficult stones. Intraductal electrohydraulic lithotripsy or laser lithotripsy using cholangioscopy is an effective and safe procedure for the removal of bile duct stones. Furthermore, PDCS can be used to remove stones with a basket catheter. Several studies also reported the importance of cholangioscopy in palliative therapy for malignant jaundice, because of the ability to guide across difficult biliary strictures and to place selective biliary stents. In addition, PDCS using upper gastrointestinal (GI) endoscope or single/double balloon enteroscope is directly effective for diagnostic and therapeutic biliary diseases even in patients with altered GI anatomy. Since air embolism was reported as a fatal complication of cholangioscopy, use of CO2 and minimal air insufflation are required. In the future, with the development of new devices and endoscopes, cholangioscopy will be very useful in the diagnostic and therapeutic fields. This review will highlight the historical developments, the currently available cholangioscopic equipment and techniques, the indications and future perspectives of this procedure.

View full abstract

Aim : Treatment of endoscopic submucosal dissection (ESD) ulcers with fibrin glue and a polyglycolic acid (PGA) sheet prevents procedural accidents. We investigated conditions that improved the application of PGA sheets.
Methods : Using isolated porcine stomach, we tested the maximum tensile strength of PGA sheets when pulled off ulcers. More specifically, we investigated the impact on PGA sheets of altering application procedures, application surfaces, and their exposure to solutions as may be encountered in a clinical setting.
Results : The average tensile strength of group 1, for which the PGA sheet was applied using the standard method, was 1.78 N. The tensile strengths of groups 5, 6 and 7, with PGA sheets exposed to jelly, gastric mucus and saliva, respectively, were significantly lower, with averages of 0.36 N, 0.32 N and 0.53 N, respectively (P < 0.05 for all). The tensile strength of group 8, where PGA sheets were attached to the mucosal epithelium, was also significantly lower (P < 0.01), with an average of 0.19 N.
Conclusion : We found when treating an ESD ulcer with a PGA sheet, it is important to avoid its exposure to highly viscous solutions and to apply the sheet within the ulcer area.

View full abstract

An 81-year-old woman was admitted to our hospital for detailed examination of abdominal pain and anemia. Multiple flat, elevated, red-to-reddish brown lesions were observed in almost all areas of the gastrointestinal tract including the stomach and rectum, and the diagnosis of angiosarcoma was confirmed following a biopsy of the duodenal lesions. The patient could not undergo treatment for the angiosarcoma because of her poor general condition consequent to multiple bone and lymph node metastases. Multicentric angiosarcoma of the gastrointestinal tract is very rare. Features of this case may be useful to improve the early diagnosis and treatment of angiosarcoma.

View full abstract

A previously healthy 58-year-old man experienced difficulty with swallowing during meals to the point where he became unable to eat, and therefore presented himself to our hospital. Endoscopy revealed a yellowish, submucosal, tumor-like mass, measuring approximately 3 cm in length, in the left hypopharyngeal pyriform sinus. Because the mass showed a homogeneous, high signal intensity on both T1- and T2-weighted magnetic resonance images, a lipoma was highly suspected. In cooperation with the Department of Otorhinolaryngology, an endoscopic submucosal dissection (ESD) was performed under general anesthesia after visualizing the larynx with a curved laryngoscope. The lesion measured 35 × 32 × 27 mm and the pathological diagnosis was a lipoma. The postoperative course was favorable, and his swallowing difficulty disappeared. Although pharyngeal lipomas are rare, it should be noted that these lesions could be encountered during endoscopy and that ESD is useful for their treatment.

View full abstract

A 66-year-old man was referred to our hospital after being diagnosed with early gastric cancer. Laparoscopic distal gastrectomy was performed, and the lesion was diagnosed histologically as an early gastric endocrine carcinoma with a lymphoid stroma. A review of biopsy specimens taken preoperatively revealed not only adenocarcinoma, but also alveolar endocrine carcinoma. Gastric endocrine carcinoma with lymphoid stroma has not been reported previously. Furthermore, this case offers a valuable example of the transition from adenocarcinoma to endocrine carcinoma. To diagnose endocrine tumors preoperatively, endocrine tumors must be considered in the differential diagnosis.

View full abstract

Biliary cast syndrome (BCS) is an infrequent complication of liver transplantation and few cases have been reported in the non-transplant population. A 59-year-old man, who had undergone a distal gastrectomy and cholecystectomy due to gastric cancer, presented with jaundice and fever. Magnetic resonance cholangiopancreatography demonstrated dilatation of intra- and extra-hepatic ducts. Endoscopic biliary drainage failed due to a Roux-en-Y reconstruction, and percutaneous transhepatic biliary drainage was subsequently performed. Biliary casts were histopathologically confirmed, and found to be composed of inflammatory submucosal tissue mixed with bilirubin and collagen. The pathogenesis of the biliary casts in this case is unknown; however, we speculate that cholangitis and liver ischemia associated with surgical intervention were predisposing factors. BCS after gastrectomy is a rare event, but should be considered as a possible postoperative complication in gastric cancer patients.

View full abstract

A 63-year-old woman, with a non-resectable carcinoma of the head of the pancreas and with obstructive jaundice, was admitted to another hospital and underwent the placement of a partially covered, self-expandable metallic stent (SEMS) in the lower bile duct. Approximately 170 days after stent placement, a fully covered SEMS was inserted, using a stent-in-stent technique, for the treatment of stent occlusion. After approximately 120 days, she presented to our department with acute cholangitis. An endoscopy showed that the stent-in-stent SEMS had migrated from the duodenal papilla toward the opposite side of the duodenal lumen. Due to the poor positioning of the distal side of the SEMS, stent removal was not possible. Therefore, endoscopic sectioning of the stents using argon plasma coagulation (APC) and scissor forceps was performed. After cutting halfway around the stents, the stent-in-stent SEMS was successfully removed without any complications, and bilateral biliary plastic tube stents were inserted. After the procedure, a recurrence of stent occlusion was not noted for the rest of the patient's life. We suggest that argon plasma coagulation is a safe and effective method to transect a migrated, stent-in-stent, SEMS in the distal duodenum.

View full abstract

A 63-year-old female, who at the time was being treated with salazosulfapyridine for rheumatoid arthritis, visited our hospital complaining of a loss of appetite and watery stools. An upper gastrointestinal endoscopy and colonoscopy showed granular mucosa present in the duodenum and which was also evident from the sigmoid colon to the rectum. She was diagnosed with secondary gastrointestinal amyloidosis associated with rheumatoid arthritis by the analysis of biopsy specimens from the duodenum. Although total parenteral nutrition was not effective, anti-interleukin-6 receptor antibody (tocilizumab) dramatically improved clinical symptoms, as well as endoscopic and pathological findings. These results suggest anti-interleukin-6 receptor antibody is an effective treatment for gastrointestinal amyloidosis.

View full abstract

Colonoscopy was performed on a 60-year-old Japanese woman positive for fecal occult blood. A sessile IIa-like polyp, approximately 8 mm in diameter, was found in the sigmoid colon. Its surface was smooth, without erosion or bleeding. Endoscopic mucosal resection of the polyp was carried out for diagnosis and treatment. Microscopically, the epithelial surface of the polyp was intact and without erosion or hyperplastic epithelial cells, but increased numbers of fibroblastic cells were noted in the lamina propria. Fibroblastic cells showed diffusely expressed vimentin and focally weak CD34 expression, but did not express CD117 (c-kit), CD34, α-smooth muscle actin (αSMA) or S100. These results suggested the lesion in the sigmoid colon was a benign fibroblastic polyp.

View full abstract

A 28-years-old woman presented at our hospital with repeated abdominal pain and fever. Colonoscopy revealed erosions around appendix. Though we started therapy as atypical ulcerative colitis, the symptom was not improved. As a result of genetic analysis, we diagnosed FMF. And the symptom disappeared by internal use of colchicine. FMF also complicated with area-related colitis resembling inflammatory bowel disease. This case showed the importance of genetic analysis in indeterminate colitis with repeated abdominal pain and fever.

View full abstract

Gastric cancer detected after successful Helicobacter pylori (H. pylori) eradication is characterized by the following three points. (1) It exhibits a gastritis-like mucosal pattern and is often ill-delineated. (2) Although it exhibits gastritis-like gastric mucosa, it is present with a part or an area of a different pattern from the background mucosa. It has the characteristics of cancer to exhibit an area. (3) NBI magnifying endoscopy showed a mucosal pattern area of a white zone exhibiting “morphological heterogeneity” and “direction diversity”, although such an area is hard to detect. Background mucosa tends to exhibit a pattern and arrangement with more regularity after successful H. pylori eradication. Compared with such background mucosa, an area exhibiting “morphological heterogeneity” and “direction diversity” is relatively easily diagnosed as cancer. Endoscopy with the three characteristics in mind is a key to diagnosing gastric cancer after successful H. pylori eradication, including diagnosis of its expansion.

View full abstract

Background : Intestinal metaplasia (IM) of the gastric mucosa has long attracted attention as a premalignant lesion involved in gastric carcinogenesis. However, endoscopic diagnosis of IM has remained unclear for a long time. In recent years, the methylene blue staining technique and narrow-band imaging (NBI) magnifying endoscopy have facilitated clinical diagnosis of IM, although these methods have some problems due to their complexity. Simple methods for diagnosis of IM using conventional endoscopy and the indigo carmine contrast (IC) method are necessary.
Patients and Methods : This study was a multicenter, prospective, randomized, comparative study involving 10 facilities. The appearance of IM was examined using conventional and IC methods with an electronic endoscope.
Results : Subjects included 163 patients, of whom 87 and 76 underwent conventional and IC methods, respectively. Sensitivity, specificity, and receiver operating characteristic/area under the curve (ROC/AUC) of conventional and IC methods for the detection of IM in the gastric antrum showed that diagnostic performance of the conventional method was higher, but not significantly, than that of the IC method. Sensitivity, specificity and ROC/AUC of conventional and IC methods for the detection of IM in the gastric body showed that the IC method yielded better (but not significantly better) results than the conventional method.
Conclusion : The diagnostic performance of the conventional method did not significantly differ from that of the IC method. A villous appearance, whitish mucosa, and rough mucosal surface, as observed by both methods, and areae gastricae pattern, as observed by the IC method, were useful indicators for endoscopic diagnosis of IM.

ACKNOWLEDGMENT
The study was supported by a grant from the the Japanese Foundation for Research and promotion of endoscopy.

View full abstract