論文

超音波内視鏡下吸引法生検で組織学的に診断された頸部扁平上皮癌の膵転移により閉塞性膵炎が発症し、迅速に治療効果を得るため姑息的放射線照射療法を施行した女性例を報告した。転移性膵癌による閉塞性膵炎に対する適切な治療法を選択するためには、適切な組織標本を採取し、病理学的診断を確定すること、および原発腫瘍の病理学的所見と比較することが重要である。

Objectives: Endoscopic papillectomy (EP) is a low-invasive treatment for duodenal tumors including papilla. The limit of lesion size and local recurrence have been issues in EP. We developed endoscopic submucosal dissection (ESD) for the duodenal tumors including papilla (ESDIP: ESD including papilla) to overcome the problems. The aim of this study was to evaluate the feasibility of ESDIP. Methods: We included the patients who underwent ESDIP from August 2010 to January 2024 in this study. We evaluated the retrospective characteristics of patients and lesions, clinical results of ESDIP and of endoscopic retrograde cholangiopancreatography (ERCP) as prevention for delayed adverse events, and pathological findings. We also calculated the cumulative recurrence rate and overall survival rate at 12 months after ESDIP. Results: Fifty-four patients were included in this study. The mean lesion size was 39 mm. The third-quarter cases revealed a less than half-circumferential lesion, and the one case with a full-circumferential lesion. Resection was accomplished in 96% (n = 52), and also the en-bloc resection rate was 96%. Of the cases in accomplished resection, 98% of patients were intubated with a pancreaticobiliary drainage tube by ERCP. Intraprocedural perforation occurred in eight cases. Delayed bleeding occurred in 10 cases. Delayed perforation was seen only in one case. The incidence of post-ERCP pancreatitis was 25%. Cumulative local recurrence rate and the overall survival rate were 15% and 96%, respectively. Conclusion: ESDIP may be feasible for duodenal tumors including papilla, and is a potential alternative option to avoid pancreaticoduodenectomy.

Background: Current guidelines recommend treating choledocholithiasis, regardless of symptoms or stone size, with endoscopic retrograde cholangiopancreatography (ERCP). However, asymptomatic choledocholithiasis, discovered incidentally on imaging, may carry a higher risk of ERCP-related adverse events, and some asymptomatic and diminutive stones may not cause biliary adverse events during extended follow-up. Therefore, we aimed to clarify the best treatment strategies for asymptomatic choledocholithiasis based on stone size. Methods: We retrospectively identified patients with incidental imaging-found asymptomatic diminutive (≤ 4 mm) or non-diminutive (> 4 mm) choledocholithiasis and divided them into two groups: those who did not undergo ERCP and were treated when complications arose (on-demand group) and those who underwent ERCP before being symptomatic (intervention group). Adverse events were defined as any biliary or pancreatic complication related to ERCP or arising during observation or after intervention. The primary outcome was the adjusted overall adverse event-free survival using the propensity score-based matching weights method comparing the two groups of stone size. Results: Among 148 patients identified (median follow-up period, 969 days), 68 had diminutive stones and 80 had non-diminutive stones. Of the 68 patients with diminutive stones, 51 were in the on-demand group and 17 in the intervention group. The overall adjusted adverse event-free survival was significantly higher in the on-demand group for diminutive stones (97.4% and 70.1%, respectively, at 3 years; p = 0.01). Discussion: Patients with incidental imaging-detected asymptomatic diminutive choledocholithiasis may benefit from clinical observation, pursuing ERCP when symptoms develop.

Background: Several studies have suggested that elderly patients, as well as younger patients, can be safely treated using endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic ultrasound-guided biliary drainage (EUS-BD) has not been clinically evaluated for very elderly patients. The present multicenter, retrospective study aimed to determine the safety of EUS-BD for advanced elderly patients. Method: Patients who underwent EUS-BD during this period were retrospectively enrolled, and they were divided into two groups based on age: group A (age < 75 years) and group B (age ⩾ 75). In this study, capnographic monitoring was used only for elderly patients (age ⩾ 75 years). Results: A total of 271 patients who underwent EUS-BD were enrolled in this study (group A = 177, group B = 94). The types of adverse events that were associated with EUS-BD was observed in 38 patients, and they did not differ significantly between two groups (p = 0.855). This result was confirmed after propensity score matching (p = 0.510). Adverse events were associated with sedation after propensity score matching; hypoxemia (p = 0.012) and severe hypoxemia (p = 0.003) were significantly higher in group A compared with group B. According to logistic regression analysis, monitoring (non-capnography) was also only risk factor (odds ratio: 0.317, 95% confidence interval: 0.143–0.705; p = 0.005) for sedation-related adverse events. Conclusion: In conclusion, EUS-BD could be safety performed in advanced elderly patients, the same as in younger patients. Also, capnographic monitoring might be helpful in case of sedation by a gastroenterologist in a non-intubated patient. Further prospective, randomized studies are needed to confirm these conclusions.

Objective: – Acute pancreatitis (AP) complicated by disseminated intravascular coagulation (DIC) is associated with high mortality. Although recombinant human soluble thrombomodulin (rTM) is commonly used in clinical practice, its association with outcomes in AP has not been established. Design: – A nationwide, propensity score-matched, retrospective cohort study. Setting: – The Japanese Diagnosis Procedure Combination national inpatient database. Patients: – Adult patients hospitalized with AP and DIC between July 2010 and March 2022, who survived at least 3 days. Patients were divided into those receiving rTM within three days of admission and those who did not. Propensity score matching compared in-hospital mortality. Interventions: – None. Measurements and Main Results: – The analysis included 10, 238 patients with AP and DIC, of whom 2, 001 (19.5%) received rTM and 8, 237 (80.5%) did not. Propensity score matching yielded 1, 868 well-balanced pairs. In-hospital mortality was lower in the rTM group (15.5% [290/1, 868]) compared with the non-rTM group (19.7% [368/1, 868]; risk difference: –4.2%, 95% CI, –6.6% to –1.7%; risk ratio: 0.79, 95% CI, 0.69 to 0.91). Conclusions: – Administration of rTM in patients with AP complicated by DIC was associated with lower in-hospital mortality.

Metastatic pancreatic cancer is a rare condition and cases of pancreatic metastasis from cervical cancer are infrequently reported. Furthermore, the incidence rates of pancreatic tumors as the cause of pancreatitis and of pancreatitis in patients with pancreatic tumors are similarly low. Pancreatitis may occur when a tumor obstructs the pancreatic duct. This condition may be difficult to manage and significantly reduces the quality of life because of severe abdominal pain. Here, we present a rare case of obstructive pancreatitis caused by pancreatic metastasis from cervical squamous-cell carcinoma, pathologically confirmed using endoscopic ultrasonography-guided fine-needle biopsy and treated with palliative irradiation to achieve rapid therapeutic relief. It is important to obtain appropriate tissue samples, confirm the pathological diagnosis, and compare the pathological findings with those of the primary tumor to select the appropriate treatment for obstructive pancreatitis caused by a metastatic pancreatic tumor.

Immune checkpoint inhibitors (ICPI) have been reported to be effective in various carcinomas. They excessively activate the immune system, resulting in frequent immune-related adverse events (irAEs). Colitis induced by ICPI is one of the most common and is known as immune-mediated colitis (IMC). Although IMC and inflammatory bowel disease (IBD) are similar in many respects, there are very few reports of IMC in patients with preexisting IBD such as ulcerative colitis (UC) and Crohn's disease (CD). Whether preexisting IBD is concerned with the development of the colitis is not well known. Here, we reported the case who developed severe ulcerative colitis which started from IMC. It is an important case to follow the time course of the colitis developed. Our conclusion indicated that frequent colonoscopy was important for the management of IMC in a patient who has suffered chronic inflammatory disease, such as UC.

Background: The relationship between primary sclerosing cholangitis (PSC) and biliary bile acids (BAs) remains unclear. Although a few studies have compared PSC biliary BAs with other diseases, they did not exclude the influence of cholestasis, which affects the composition of BAs. We compared biliary BAs and microbiota among patients with PSC, controls without cholestasis, and controls with cholestasis, based on the hypothesis that alterations in BAs underlie the pathophysiology of PSC. Methods: Bile samples were obtained using endoscopic retrograde cholangiopancreatography from patients with PSC (n = 14), non-hepato-pancreato-biliary patients without cholestasis (n = 15), and patients with cholestasis (n = 13). Results: The BA profiles showed that patients with PSC and cholestasis controls had significantly lower secondary BAs than non-cholestasis controls, as expected, whereas the ratio of cholic acid/chenodeoxycholic acid in patients with PSC was significantly lower despite cholestasis, and the ratio of (cholic acid + deoxycholic acid)/(chenodeoxycholic acid + lithocholic acid) in patients with PSC was significantly lower than that in the controls with or without cholestasis. The BA ratio in the bile of patients with PSC showed a similar trend in the serum. Moreover, there were correlations between the alteration of BAs and clinical data that differed from those of the cholestasis controls. Biliary microbiota did not differ among the groups. Conclusions: Patients with PSC showed characteristic biliary and serum BA compositions that were different from those in other groups. These findings suggest that the BA synthesis system in patients with PSC differs from that in controls and patients with other cholestatic diseases. Our approach to assessing BAs provides insights into the pathophysiology of PSC.

症例は71歳男性で、呼吸症状を主訴に近医を受診し、胸部CT検査で膵頭部嚢胞性病変を指摘され、精査目的に当院を紹介受診した。ガイドワイヤー誘導下で拡張した膵管内に新型経口膵管鏡SpyDSを挿入し観察した。膵管内は粘液で白濁していたが、SpyDSの特徴である持続的な洗浄吸引を行うと視野は良好となり、拡張した主膵管内腔やその上皮が鮮明に観察できた。膵頭部の主膵管内には異なる二つの形態の隆起性腫瘍が全周性かつ連続性に多発しており、イクラ状腫瘍の集簇領域が乳頭側中心に、結節状隆起性腫瘍の集簇領域が体部側中心に分布していた。また、膵体尾部の主膵管は拡張していたが、その膵管上皮は正常であった。病理診断は、洗浄吸引の検体では膵管内乳頭粘液性腺癌、生検検体では腺腫であった。膵頭十二指腸切除術を施行したが、術前と術後の診断に相違はなかった。