T-CAP Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopist

Meeting Summary of T-CAP 2013

Summary of Session 1

Coming Soon

Summary of Session 2

Speakers and lecture title

  1. Tsuyoshi Mukai：Large diameter covered metallic stent
  2. Dong Ki Lee：Drug eluting stent
  3. Tsuyoshi Hamada：Anti-reflux stent
  4. Sundeep Lakhtakia：Benign biliary stricture

The Session 2 had four keynote lectures of new paradigm for distal stenting. First of all, Dr. Mukai from Gifu Municipal Hospital presented the data of large diameter covered metallic stent (Niti-S SUPREMO-12) in patients with malignant distal biliary obstruction. This study demonstrated high successful rate, and favorite stent patency (mean stent patency: 269days). However, slightly high stent dysfunction such as food impact, and tumor ingrowth were appeared. Furthermore, randomized controlled trials would be needed to evaluate the usefulness of this stent. Secondly, Dr. Lee from Yonsei University reviewed the current topics of drug eluting stents (DES) in malignant biliary obstruction. Non-vascular DES is expected to play vital roles in prolonging stent patency and the survival of patients with malignant biliary obstruction. Though the use of nonvasucular DES for malignant biliary obstruction may be currently insufficient, trias have led to advances in DES and have demonstrated their safety and clinical efficacy. Thirdly, Dr. Hamada from Tokyo University presented the data of the antireflux stent (ARMS). He has already reported that the enhanced duodenobiliary reflux is a key contributor for early dysfunction of SEMS for distal malignant biliary obstruction. 17 patients from two Japanese tertiary care centers were enrolled this study. He demonstrated that ARMS provided a feasible safe, and effective reintervention for SEMS occlusion due to sludge or food impact. Finally, Dr. Sundeep from Asian Institute of Gastroenterology reviewed the data of benign distal biliary stricture (BBS). He demonstrated the endoscopic management of distal benign biliary stricture using multiple plastic stents, uncovered SEMS, partially covered SEMS, and fully covered SEMS (FCSEMS). Especially, treatment of BBS with FCSEMS would have favorable successful rate (80-90%), however, studies of FCSEMS have been limited by short follow up. After these four key note lectures, we had a fruitful discussion time with Dr. Itokawa, Dr.Kitano, Dr. Isayama, Dr.Tanaka, Dr.Wang and Dr. Moon.

Summary of Session 3

Speakers and lecture title

  1. Kazuo Hara: Techniques for EUS-BD
  2. Yousuke Nakai: Stent selection for EUS-BD
  3. Mark Giovannini: Trouble Shooting for EUS-BD

Dr. Hara presented about the techniques and usefulness of EUS-BD, focusing on choledocho-duodenostomy; EUS-CDS. From his lecture, forward viewing EUS scope is suitable for EUS-CDS, and can avoid following complication. He experienced perforation due to double skewer of duodenal wall. Puncturing of folded duodenal wall by tip of scope may cause this type of complication. He uses 19G puncture needle, 0.025 inch Guidewire and cautery dilator, and places covered metallic stent. Covered SEMS can avoid bile leakage rather than plastic stent. The end of his lecture, he said,”CDS is better than HGS”, and “we need special devices for these technique”. Dr. Giovannini agreed with him to use cautery dilator, and said that needle knife is risky for dilation of anastomosis. Dr. Giovannini did not agree with “CDS is safer than HGS”. He thinks that it is safe procedure especially using special partially covered SEMS. Dr. Itoi said that he do not think that pneumoperitoneum is a kind of complication. It spontaneously improves without causing any symptoms. Dr. Hara and everybody agreed with him.
Second speaker is Dr. Nakai, and presented about the stent selection for EUS-BD. Firstly, he mentioned about the safety of covered SEMS in this technique rather than plastic stent. For CDS procedure, he pointed out the problems of current commercially available SEMSs and said that lumen apposing stent may be suitable. For HGS procedure, lumen apposing stent could not be used for this procedure, and mentioned about the GIOBOR stent developed by Dr. Giovannini. He thought this is suitable for HGS, to avoid some complications. The hepatic side of GIOBOR is uncovered to avoid the migration, and gastric side is covered to prevent the bile leakage. Flare at gastric side is also useful to prevent the stent dislocation into abdominal cavity. Now he use similar SEMS in Japan, and show the short results of this stent. He showed VTR of 2 type of SEMS; braided type like Wallflex and knitted type. He thinks that the SEMS for EUS-BD may provide the function of lumen apposing by shortening force. Braided type can be shortened the length of abdominal cavity and is considered as better than knitted type. Dr. Kei Ito asked to him the impression of laser cut type covered SEMS, but he did not use it. Dr. Itoi thinks that the length of abdominal cavity may depend on the deployment technique and we cannot reach the agreement.
Third speaker is Dr. Marc Giovannini, and present his experience of EUS-BD. He is a pioneer of this field. He raised the indications of EUS-BD; 1. Altered PTCD, 2. Conversion from　PTCD to internal drainage, 3. Klatskin tumor. In his lecture, he introduced GIOBOR stent developed by him and sold by TaeWoong Medical Company. Details of this stent were mentioned at previous sessions and the results he showed in the lecture was very good. He emphasized the usefulness of EUS-BD for the difficult management cases of biliary strictures. For management of hilar stricture, he placed uncovered metallic stent for right hepatic duct via papilla and placed HGS for left hepatic duct. The advantage of this technique is non-complex stenting at hilar lesion. Dr. Kitano asked to him to performance of antegrade stenting. Dr. Giovannini thinks that the manipulation of guidewire is difficult for antegrade procedure, then he selected HGS. Dr. Hara asked the complication of HGS; especially biloma. ENBD placement 3days after HGS was effective to prevent the cholangitis and migration of stent, and he did not experience any of these complications. Dr. Itoi asked the treatment for HGS occlusion due to food impaction and tumor ingrowth. Dr. Giovannini remove the food scraps using forward viewing endoscope or oblique view, and for ingrowth placement of covered SEMS as stent-in-stent fashion. Dr. Itoi thought that CDS is safer than HGS, but Dr. Giovannini did not agree. We could not reach to the agreement for this issue.
In this session, there were many hot discussions about the indication, technique, devices and trouble shooting. There was no strong evidence in this technique, but was some agreement. We should discuss more and make consensus in the near future.

Summary of Session 4

Coming Soon

Summary of Session 5

Coming Soon

Summary of Session 6

Speakers and lecture title

  1. Tsuyoshi Hayashi：Pancreatic cystic lesion containing microcystic component can be diagnosed correctly by endoscopic ultrasound-guided fine needle aspiration
  2. Chai Soon Ngiu：Performance of Procore Needle (19 Gauge and 22 Gauge) for Endoscopic Ultrasound Fine Needle Biopsy
  3. Naoki Sasahira：Can Early Double Guidewire Technique Facilitate Common Bile Duct Cannulation and Reduce Post ERCP Pancreatitis? -Results of a Multicenter Prospective Randomized Controlled Trial: EDUCATION Trial-
  4. Hyun Jong Choi：Comparison of the safety profiles of endoscopic papillary balloon dilation and sphincterotomy in young patients with CBD stones and gallstones
  5. Cheuk-Kay Sun：Non-fluoroscopic common bile duct stenting for prompt symptomatic relief for choledocholithiasis during pregnancy
  6. Hiroyuki Inoue：A Comparison Of Biliary Stent In Pancreatic Cancer Patients With Malignant Biliary Obstruction During Neoadjuvant Chemoradiotherapy : Plastic VS Metallic stent.

The session consisted of six high quality original research papers. The Hokkaido ESSENCE study addressed the need for endoscopic sphincterotomy (EST) before insertion of a partially covered self-expandable metal stent (SEMS) in patients with unresectable pancreatic head cancers. The group hypothesized EST prior to metallic stenting was unnecessarily and the trial was of an inferiority design with the primary outcome endpoint being rate of complications within 30 days of randomization. Of 194 patients analyzed (non-ES group 98, ES group 96), rate of complications was 15.3 and 15% respectively. Pancreatitis occurred in 8.2 and 9.4% in either group. The authors also measured serum amylase before and after procedures and found no difference between groups. No difference was observed in other endpoints including late complications, time to and causes of SEMS dysfunction, and survival. A retrospective study on the use of Procore® needle was reported by a Singaporean group. The review consisted of 24 lesions (mostly pancreatic lesions) from 19 patients. There were 3 technical failures in obtaining samples leaving 21 lesions from 17 patients to be analyzed. The authors concluded that EUS sampling via a trans-duodenal route had the highest yield. Sampling using a 19G needle was adequate in all cases while in 3 of 12 cases using a 22G needle, obtained tissue was inadequate for histologic diagnosis. Cyto-pathologists were not available on site. Dr. Sasahira then presented a randomized trial to assess the role of double guidewire technique in bile duct cannulation. The study included patients who had unintentional pancreatic duct cannulation at first pass. They were randomized to undergo either further wire guide cannulation (WGC) or the use of double wire technique (DW) with a wire left in the main pancreatic duct. Successful bile duct cannulation within 10 minutes of randomization was achieved in 96/137 (70%) and 103/137 (75%) patients in WGC and DW group respectively (P=.42). The final successful bile duct cannulation rate in either group was 97 and 98% respectively. The rate of pancreatitis was high in either group (17 and 20%) despite of use of pancreatic duct stents (16 vs. 18%). The authors concluded that a guidewire inserted in the pancreatic duct increases the risk of pancreatitis. The use of double wire technique does not appear to facilitate bile duct cannulation. A study from Korea compared endoscopic sphincterotomy (EST) to balloon dilation (EPBD) in young patients (<40 years of age) with bile duct stones ≤12 mm in size and bile duct size not less than 6 mm. The rate of pancreatitis was similar in either group (5/62, 8.1% vs. 5/70, 7.1%). There were two cases of bleeding and one case of perforation in EST group and none in the EPBD group. The study suggests that EPBD is similar to EST in safety in young patients with small bile duct stones. A Taiwan group reported endoscopic bile duct stenting without fluoroscopy in 5 pregnant women with symptomatic bile duct stones. The last presentation was a retrospective comparison between the use of plastic and metal stents in patients with pancreatic head cancers undergoing neoadjuvant chemo-irradiation. Stent occlusion occurred more frequency with plastic stents (12 /34, 35.3% vs. 2/23, 8.7%, P=0.029) and led to more interruption of treatment. Cholecystitis however was more frequent with the use of metal stents (5/23, 21.7% vs. 1 of 34, 2.9%, P=0.034).

Summary of TaeWoong &CMI Satellite symposium

Speakers and lecture title

  1. Nageshwar Reddy: Progress on pancreatic endotherapy
  2. Marc Giovannini: Place of hepaticogastrostomy guided by EUS for biliary drainage

Summary writer: Dong-Wan Seo
Role of EUS-guided confocal microscopy in solid and cystic pancreatic tumors

Lecturer: Marc Giovannini

In clinical field of pancreatology, the differential diagnosis of pancreatic cystic tumors or solid tumors is quite difficult in some cases. In some cases of pancreatic cystic tumors, unnecessary pancreatic resection is carried out under the suspicion of mucinous neoplasm but final pathology often comes out as serous cystadenoma, pseudocyst or sometimes retention cyst. For solid pancreatic lesion, the differential diagnosis of pancreatic cancer from other types of tumor is very important since pancreatic cancer show very poor prognosis and early radical resection give the only hope of cure. Conventional method for differential diagnosis is imaging studies including CT scan, MRI and EUS followed by EUS-guided FNA of solid mass or cystic fluid. But histologic analysis takes time and cannot give the answer at the examination table. Confocal endomicroscopy can give the answer right at the examination site although it may not be confirmatory.

Dr. Marc Giovannini delivered a lecture about the usefulness of EUS-guided confocal microscopy in solid and cystic pancreatic tumors. During his lecture, he highlighted the potential application of this new technology for the differential diagnosis of pancreatic lesions and shared his experience with audience.

Method of EUS-guided confocal microscopy

He used 19G needle and cellvisio probe for this evaluation. After removal of stylet, cellvisio probe was inserted into the 19G needle and tip of cellvisio probe was located near the tip area of 19G needle. Then he delineated cyst or solid lesion in the pancreas and punctured the lesion. For cystic lesions, he tried to touch the cyst wall or papillary projections and imaged the detailed wall structure. For solid lesion, needle tip was inserted inside the solid mass and tried to see the cells and vasculature around cells.

Findings of pancreatic cystic or solid tumors under confocal endomicroscopy

For the evaluation of cystic lesions, it seems to be important to touch the wall of cyst and try to visualize the delicate vascular structures and cells. Upon endomicroscopy, serous cystadenoma showed thin thread-like fine network of vessel and it was possible to image red blood cells flowing through the vessel. For IPMN, finger-like projections of lining mucosa were characteristic findings. Neo-vessel formation and irregular tumor vessel were observed in the malignant form of IPMN. Normal pancreatic duct showed coffee-bean like dark structures in the whitish background. Pseudocyst or abscess showed debris inside and no visible vessel in the wall.

Normal pancreatic tissue shows coffee-bean like clumps in the bright background. On the other hand, pancreatic cancer showed irregular big clumps suggesting tumor cells, irregular crowding of vessel and irregular uptake of fluorescein. Chronic pancreatitis showed large space between acinar and fibrotic tissue in the background. Neuroendocrine tumor showed dark small cells which are different from adenocarcinoma and network of vessel with small black areas were observed.

French group of endosconographers conducted multicenter study (CONTACT study) and they enrolled 31 cases of solid pancreatic mass. In all cases, confocal endomicroscopy of solid pancreatic mass was possible without any complication. Although it was a pilot study, the conclusion was that probe based confocal endomicroscopy can be a useful modality for the differentiation of pancreatic mass lesions.

Questions and Answers

  1. Is there any size limitation in case of pancreatic cystic tumor ?
    - Targetted cysts were unilocular cyst with a size > 2cm.
  2. Is there any technical difficulties in imaging of solid mass because of the position of needle, target movement ?
    - Confocal image is good enough even though there was movement.
  3. In case of IPMN, there can be diverse histologies in one lesion ranging from adenoma to adenocarcinoma. Cellvisio probing is just one point examination. Is it enough to tell the whole histology by one point examination ?
    - We can try to check several areas and patient position can be changed. But main target was most suspicious area such as prominent papillary changes and mural nodules suggesting malignancy.
  4. Is the any possibility that sticky mucin can be problematic for this exam ?
    - We are not imaging mucin or fluid. We just touch the wall and see the wall structure. Therefore sticky mucin is not an obstacle.

Summary writer: Iruru Maetani

First lecture by Dr. Nageshwer Reddy entitled ‘Progress on pancreatic endotherapy’ was a topic focusing on therapeutic endoscopy for pancreatolithiasis and strictures due to chronic pancreatitis.

Endotherapy (ESWL, ERCP) plays a significant role on treatment of pancreatolithiasis. Subsequently to crushes of pancreatic stones by ESWL, endoscopic removal is conducted.

He showed the result could vary by the types of ESWL machines or operator’s skills despite its significant effect, which correlates stone size and the presence of calcification.

With ERCP followed by ESWL, removal of stone fragment or pancreatic sphincterotomy is employed. 65% of patients with successful removal can anticipate pain relief of about 5 years.

ERCP is also manipulated for stent placement to treat pancreatic duct stenosis. With　showing historical transition of stents, and traditional use of single plastic stent, he indicated some reports on ability of multiple stent, concluding with transition from current self-expandable metallic to SEMS as promising alternatives which are not yet generally promoted and requires more evidencing reports.

This talk including Dr. Reddy’s ample experience and literature review was very significant and informative to attendees.

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