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

Meeting Summary of T-CAP 2014

Summary of Hitachi Medical Corporation Morning seminar

Speakers and lecture title

1. Takao Itoi: How to manage difficult post-operative biliary strictures?

2. Christopher Khor: EUS-Guided Tissue Acquisition: State of the Art 2014

Coming Soon

Summary of Session 5

Speakers and lecture title

1. Reiko Ashida: Newly developed EUS guided therapy for pancreas cancer

2. Ryan Ponnudurai: Fine needle injection

3. Kazuo Hara: EUS-BD for first-line biliary drainage procedure

Coming Soon

Summary of Session 6

Speakers and lecture title

1. Sundeep Lachatakia: Recent Progress in endotherapy for pancreato-biliary diseases Covered metal stent for Benign Biliary Stricture

2. Fumihide Itokawa: Endoscopic management of acute cholecystitis

3. Hiroshi Kawakami: Management of difficult pancrato-biliary strictures

Coming Soon

Summary of Piolax Medical Devices Corporation Luncheon Seminar

Speakers and lecture title

1. Amit Maydeo: Endotherapy of Difficult Biliary and Pancreatic duct stones


2. Hiroyuki Isayama: Newly developed retrieval basket for pancreato-biliary stone

The first talk was entitled ‘Endotherapy of Difficult Biliary and Pancreatic duct stones’ by Prof. A. Maydeo. His talk elaborates stone treatment; from the classical procedures using endoscopic sphincterotomy combined with balloon and/or basket catheter, to latest treatments such as laser lithotripsy under cholangioscopic guidance and large balloon dilation of biliary and pancreatic papillary orifice. These latest methods enable endoscopists to successfully achieve less-invasive stone removal even in difficult cases. Now, endotherapy plays a more important role in treating biliary and pancreatic duct stones.

[Discussion]

Q: What types of stone would you give up?
A: We never give up.Yet, surgical opinion is in priority when patients are very young.

Q: Is it safe and cost effective to use balloon dilation and retrieval without pulverization?
A: Non-calcified stone, basket or balloon is safe, but pulverization should be inevitably performed for calcified stones; unless, the success rate will be lower down to around 20-30%.

Q: Is large balloon sphincteroplasty for pancreatic sphincter really safe? There are some mortality cases treated with large balloon dilation for common bile duct stone.
A: This technique is safe without dilation of non-dilated ductal system. Balloon diameter chosen be 12 MM or smaller.

Q: If large balloon pancreatic sphincteroplasty is safe and useful, is pulverization of pancreatic stone using ESWL unnecessary?
A: Because of the hardness and jammed adhesion state to the epithelium, pulverization is required for removal of pancreatic stones.

Q: What about ESWL interval?
A: ESWL is done every other day. ERCP can be done after all the stones pulverized.

Q: Long term prospect of these patients?
A: 70% of the clearance is done in the week one, for the remaining 30% is treated every 3 month, one year for an average duct clearing and then follow-up. 10% out of treated patients are coming back with recurrent stones,

Q: Branch duct stone treated differently from the main duct?
A: Regarding branch duct stone, the treatment is the same, but the main duct clearing first and only pulverization done for branches. The flow of the pancreatic juice eases the powder draining out from branches, hence no need to go into each branch.

Q: After endotherapy, diabetes control better?
A: Yes, after therapy, there was definite improvement in observed endocrine and exocrine insufficiency.

Q: The recurrent rate of the pancreatic stone?
A: Of 10-12%; provided by proper follow-up.

Q: Pancreatic strictures in most cases?
A: No, stricture is found in 20%.

Q: How to choose the actual size of balloon for each patient?
A: By seeing the duct and the size of ampulla; the average is 12mm for chronic pancreatitis.

The second talk was entitled “Newly developed retrieval basket for pancreato-biliary stone” by Dr. Hiroyuki Isayama. Effective basket to removal of difficult stones or fragments is limited. Dr. Isayama talk about the usefulness and effectiveness of new nitinol basket catheter having 7.4F and 5.7 F on distal tip. This new basket composed with fine reticular structures in the distal end to catch small stones and loose in the proximal part to easy release of captured stone. The effective targets for this new basket discussed. Fragmented pancreatic stones proximal to the stricture, and intrahepatic duct stones can be good candidates to apply this basket. After stone fragmentation with other methods, fragmented small stone can effectively removed with this new basket Cost of the new basket catheter also discussed. Further large scale, multicenter study is planned to confirm initial clinical effectiveness.

The second talk was entitled ‘Newly developed retrieval basket for pancreato-biliary stone’ by Prof. H. Isayama. His talk showed efficacy and safety of a novel double-lumen basket catheter composed of nitinol wires with fine reticular structures. Their in-vitro study revealed that this new basket had a great advantage enabling effective deployment even in smaller tubes as compared to conventional basket catheters. Their recent pilot study assessing performance of this basket showed usefulness for the extraction of small pancreatic stones. He also showed the efficacy of basket for treating intrahepatic stones.

Summary of Session 7

Summary writer: Shomei Ryozawa (Saitama Medical University International Medical Center)

The Session 7 had three keynote lectures of new paradigm for endotherapy for altered anatomy. First of all, Dr. Iwashita from Gifu University Hospital presented the technical feasibility and safety of EUS-guided antegrade treatments (AG) for biliary disorders in the patient with surgically altered anatomy. Secondly, Dr. Katanuma from Teine-Keijinkai Hospital reviewed current topics of ERCP with balloon-assisted enteroscopes in patients with surgically altered anatomy. He also presented the results of a questionnaire survey on endoscopic insertion for ERCP in patients with surgically altered anatomy to clarify the current status of scope insertion at 11 high volume centers in Japan. Of the 490 ERCP procedures, single balloon enteroscope (SBE) was used in 142 procedures (29.0%) and double balloon enteroscope (DBE) was used in 295 procedures (60.2%). Overall, the success rate of reaching the target site was 91.8% (450 of 490 procedures) and there was no significant difference according to the types of endoscopes. Finally, Dr. Draganov from Florida University reviewed recent progress in ERCP in patients with altered anatomy.
After these three key note lectures, we had a fruitful discussion time with Dr. Kawakami, Dr. Kitano, Dr. Maetani, Dr. Kogure, Dr. Maydeo, Dr. Lakhtakia, Dr. Kaffe, and Dr. Ratanachu-ek.

Summary writer: Dong Ki Lee (Department of Internal Medicine Gangnam Severance Hospital, Yonsei University, Seoul)

Speakers and lecture title

1. Takuji Iwashita: EUS-guided antegrade procedures

ERCP is not always the best way to solve biliary problem. Since there are the cases of no stomach, long detour, bowel obstruction which makes ERCP difficult. In this case, another route for approaching is required. PTB approach, surgical approach, EUS-guided approach could be alternative routes. But as surgical and PTB approach have risks, EUS-guided approach has emerged as good alternative since 2010. EUS can be used in patients with biliary stones, malignant biliary obstruction and benign biliary stricture.
Prof. Iwashita conducted Anterograde EUS procedure for biliary disorders in patients with surgically altered anatomy. (2013.05~2014.06) 30 patients enrolled.
15 cases of malignant biliary obstruction, 14 cases of biliary stones and 1 case of anastomosis site stricture were included.
Anterograde biliary stenting [uncovered metal stent], balloon dilatation for CBD stone removal and various procedures were done.
For malignant biliary obstruction, technical success rate was 100%. There were 3 complication cases. Mild pancreatitis was developed in 2 cases and mild transient fever was happened in 1 case.
For biliary stone removal, technical success rate was 50%. Puncture failure (6/7) was the major cause of procedure’s failure. PTBD, repeated EUS, ERCP were done after failure of anterograde EUS stone removal. Mild abdominal pain was developed in 1 case.
For anastomosis site stricture, technical success rate was 100%.
In overall, success rate of biliary puncture was 80%, technical success rate was 73% and complication rate was 17%. No obvious biliary peritonitis was observed.
EUS is safe, can be altered to fistulotomy and has no skin scars. But it has limited access routes, no dedicated devices and insufficient evidence.
In conclusion, EUS-AG has the potential to be an effective and safe alternative management to ERCP for biliary disorders in patients with surgically altered anatomies.

2. Akio Katanuma: ERCP in patients with surgically altered anatomy

ERCP is difficult in patients with surgical altered anatomy. Recently balloon assisted eneteroscope is available to use in these patients. There are single ballooned and double ballooned types.
1. Current status of surgical altered anatomy ERCP in Japan (Mainly scope insertion)
60% of patients used double ballooned type enteroscope. And short type enterosopce was used in 80% of patients. Overall success rate was 91.9%. (Especially 86% in hepaticojejunostomy received patients)
2. Utility of short type single balloon assisted enteroscope
Success rate of short type eneteroscope was 94%. On the other hand, success rate of ERCP was 77%.
Short type single balloon assisted enteroscope could be applied to bile duct stone removal, pancreatic duct stone removal and etc.
Complication rate was 1.9%. Bowel perforation was occurred in one case.
*Short single balloon enteroscope is feasible and less invasive method for ERCP patients with surgical altered anatomy. It could be used as a therapeutic intervention with variable standard accessories.

3. Peter Draganov: Recent progress in ERCP for altered anatomy patients

1. Post-surgical anatomy : Billroth type 2, PPPD, Choledocho-jejunostomy, Roux-en-Y gastric bypass operation makes ERCP difficult.
2. Avenues available for ERCP access
- Per oral : Duodenoscope, Enteroscope, Overtube assisted enteroscopy
Single balloon, double balloon, spiral enteroscopy exist. Success rates of each modality are roughly same. We can consider these three modalities equivalent and use whichever is available.
Overtube assisted ERCP approach has limitations. Reaching the papilla/choledocho-jejunostomy, cannulation with forward-viewing enteroscope is hard. Lack of elevator, unstable position and special “long” devices are also limitations.
- Percutaneous
Gastrostomy was used in small cases instead of DB enteroscopy. Compared with enteroscope, Gastrostomy consumes shorter procedure time. And success rate of reaching papilla, cannulation, therapy is much higher in patients with gastrostomy than DB enteroscopy. However, gastrostomy can be applied only in patients with remnant stomach and it’s invasive. Since making gastrostomy take few months, urgent ERCP is impossible and repeating ERCP is difficult.

- Laparoscopy-assisted ERCP
Standard duodenoscope is inserted through a trocar into the excluded stomach. Laparoscopic ERCP was superior to Enteroscopy ERCP. But Enteroscopy ERCP needs shorter procedure time.

3. How to select the best approach?
We have to know type of surgery in detail and existence of remnant stomach. Native papilla and duct-enteric anastomosis can be important factor in making decision.
It patient received Billroth type 2 or whipple, duodenoscope is recommended. For RY hepatico-Jejunostomy with short limb, colonoscope and enteroscope are recommended. For RY hepatico-Jejunostomy with long limb, enteroscope is recommended. And lap-assisted enteroscope can be helpful in patients with RYGB.
In general, for native papilla, skin-view scope is better than forward view scope. For duct-enteric anastomosis, pediatric colonoscope is better than enteroscope.

Summary of Special lecture

Speakers and lecture title

  1. Do Hyung Park: New Treatment Modalities for Unresectable Cholangiocarcinoma: Asan's Experience
  2. Dong Ki Lee: Recent Progress in Stenting for Malignant Distal Biliary Obstruction

Summary writer: Tiing Leong Ang (Chief and Senior Consultant at the Department of Gastroenterology, Changi General Hospital. The Deputy Head, Research and Director of Endoscopy Center, as well as Adjunct Associate Professor at the Yong Loo Lin School of Medicine, National University of Singapore)
Dr Do Hyun Park’s lecture was entitled “New Treatment Modalities for Unresectable Cholangiocarcinoma: Asan's Experience. There were four key areas in his lecture. The first was the initial experience with combined EUS-guided biliary drainage and transpapillary metal stenting in the same setting for patients with Bismuth III and IV hilar cholangiocarcinoma. This was for patients with obstruction of intrahepatic ducts where bilateral metal stenting by ERCP was not possible. Technical feasibility was demonstrated and this may reduce the need for repeat procedures in patients undergoing ERCP with bilateral stenting. He then introduced new devices for EUS-guided drainage. This included customized covered biliary SEMS with anti-migratory properties and a one-step drainage device. The next two areas involved the use of photodynamic therapy (PDT) as adjunctive palliative treatment for unresectable hilar cholangiocarcinoma. He presented the results of a randomized phase II trial of PDT plus oral fluoropyrimidine, S-1, versus PDT alone for unresectable hilar cholangiocarcinoma, and demonstrated that PDT plus S-1 was well tolerated and was associated with a significant improvement of overall survival and progression-free survival compared with PDT alone. Lastly he described early promising results of EUS-guided PDT.

Dr Dong Ki Lee’s lecture was entitled “Recent Progress in Stenting for Malignant Distal Biliary Obstruction”. His talk was wide-ranging. The concept of the ideal stent was discussed. The superiority of SEMS over plastic stent was mentioned. Covered SEMS were introduced to reduce the risk of stent occlusion experienced by uncovered SEMS but clear superiority in terms of prolonging stent patency has not been established and there is a higher chance of stent migration. To overcome the issue of stent migration, specific design modifications have been created for covered SEMS. There is also the issue of sludge formation, reflux, food impact with SEMS, and SEMS with anti-reflux valves have been studied but limitations remain. Another approach to avoid food reflux and impaction was to develop a biliary SEMS with long inner covered extension that reached the jejunum. This SEMS is inserted percutaneously by the interventional radiologist and preliminary data are very promising. Other investigational approaches such as the role of PDT and radiofrequency ablation to ablate surrounding tumor tissue and thus prolong stent patency, as well as drug eluting SEMS, was discussed.

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