Fully covered self-expandable metallic stents (FCSEMSs) are inserted in patients with unresectable pancreatic ductal adenocarcinoma (PDAC) to resolve malignant distal bile duct obstructions. Some patients receive FCSEMSs during primary endoscopic retrograde cholangiopancreatography (ERCP), and others receive FCSEMSs during a later session, after the placement of a plastic stent. We aimed to evaluate the efficacy of FCSEMSs for primary use or following plastic stent placement. A total of 159 patients with pancreatic adenocarcinoma (m:f, 102:57) who had achieved clinical success underwent ERCP with the placement of FCSEMSs for palliation of obstructive jaundice. One-hundred and three patients had received FCSEMSs in a first ERCP, and 56 had received FCSEMSs after prior plastic stenting. Twenty-two patients in the primary metal stent group and 18 in the prior plastic stent group had recurrent biliary obstruction (RBO). The RBO rates and self-expandable metal stent patency duration did not differ between the two groups. An FCSEMS longer than 6 cm was identified as a risk factor for RBO in patients with PDAC. Thus, choosing an appropriate FCSEMS length is an important factor in preventing FCSEMS dysfunction in patients with PDAC with malignant distal bile-duct obstruction.

Background: Recurrent common bile duct stone after endoscopic retrograde cholangiopancreatography is an undesirable problem, even when a following cholecystectomy is carried out. Important factors are the composition and properties of stones; the most significant etiology among these is the lipid level. While numerous studies have established the association between serum lipid levels and gallstones, no study has previously reported on recurrent common bile duct stones after endoscopic sphincterotomy with following cholecystectomy. Materials and methods: We retrospectively collected 2016 patients underwent endoscopic sphincterotomy from 1 January 2015 to 31 December 2017 in Linkou Chang Gung Memorial Hospital. Finally, 303 patients whose serum lipid levels had been checked following a cholecystectomy after ERCP were included for analysis. We evaluated if metabolic factors including body weight, BMI, HbA1C, serum lipid profile, and lipid-lowering drugs may impact the rate of common bile duct stone recurrence. Furthermore, we tried to find if there is any factor that may impact time to recurrence. Results: A serum HDL level ≥ 40 (p = 0.000, OR = 0.207, 95% CI = 0.114–0.376) is a protective factor, and a total cholesterol level ≥ 200 (p = 0.004, OR = 4.558, 95% CI = 1.625–12.787) is a risk factor of recurrent common bile duct stones after endoscopic sphincterotomy with cholecystectomy. Lipid-lowering drugs, specifically statins, have been shown to reduce the risk of recurrence significantly (p = 0.003, OR = 0.297, 95% CI = 0.132–0.665). No factors were found to impact the time to recurrence in this study. Conclusions: The serum lipid level could influence the recurrence of common bile duct stones after endoscopic sphincterotomy followed by cholecystectomy, and it appears that statins can reduce the risk of recurrence.

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

Background and Aims: A higher incidence of extra-pancreatic malignancies (EPMs) in patients with pancreatic intraductal papillary mucinous neoplasm (IPMN) than in the general population has been shown in several studies. We suppose that EPMs also occur after IPMN has been diagnosed, but few reports have discussed the risk factors that have been identified, except for old age, which was only noted in one study. Our study aims to recognize the distribution of EPMs in Taiwanese patients with a longer duration of follow-up and investigate the risk factors to predict EPMs in IPMN patients. Methods: We retrospectively analyzed 114 patients with pancreatic IPMN from 1 January 2010 to 31 December 2014 in Chang Gung Memorial Hospital. The characteristics of the patients were all recorded. Different EPMs are demonstrated as occurring before, concurrently with, or after IPMN diagnosis. The risk factors were compared between patients with or without an EPM. Results: After an average follow-up duration of 10.45 years, 47 EPMs occurred in 42 patients (36.8%), and over half were found after IPMN was diagnosed (55.3%). The most common EPMs were colon cancer and lung cancer (21.3%). Moreover, cyst size progression was highly associated with EPM occurrence (p = 0.004) and predictive of EPM occurrence after IPMN (p = 0.002), with a cut-off value of 1 cm (accuracy: 79%; sensitivity: 88%; specificity: 58%). Conclusions: Colon cancer and lung cancer account for the majority EPMs in Taiwan. EPMs were also frequently found after IPMN diagnosis when the follow-up duration was prolonged up to 10.45 years. Cyst size progression is a risk factor of EPM after IPMN diagnosis and we suggest a cut-off value of 1 cm for clinical utility.

Background: Totally laparoscopic surgery for early gastric cancer and subepithelial tumors has been popularized worldwide, yet localization of early or small-sized tumors is a persistent challenge due to difficulty being identified with the lack of manual tactile sensation. Thus, accurate localization with tattooing before the surgery would help improve efficiency during surgery. There are multiple methods to localize tumors before laparoscopy, each with varying advantages and disadvantages. The use of endoscopic tattooing with dye has been carried out for several decades due to its safety, lower cost, and convenience. However, there is a lack of studies on endoscopic tattooing before totally laparoscopic resection. Aims: To evaluate the effect of endoscopic tattooing with dye for gastric subepithelial tumors localization before laparoscopic resection and to evaluate the tattooing effect on different locations of tumors in stomach. Method: We retrospectively collected data of patients with gastric subepithelial tumors who underwent endoscopic tattooing before totally laparoscopic resection from 2017 to 2020 in a university affiliated medical center. All patients were analyzed for preoperative characteristics and then categorized into two groups based on tumor locations concerning the difficulty of laparoscopic surgery. The independent t test and Chi-square test were performed to compare perioperative outcome and complications between these two groups. Result: A total of 19 patients were included retrospectively at our center. The individuals were 5 male and 14 female patients with a mean age of 58.2 years old. Most patients had no symptoms, and the tumors were found incidentally in 12 patients (63%). All tumors were identified clearly during laparoscopic resection. The mean tumor size was 2.3 cm. The surgeries took an average of 111 min and a mean of 7 mL blood loss was found. All tumors had negative resection margins with no recurrence during follow-up. Gastrointestinal stromal tumor was the major pathologic diagnosis, found in 12 patients (63%), followed by the leiomyoma in 5 patients (26%). Only three patients had mild adverse effects after surgery and the symptoms were self-limited. Our analysis found no significant difference in preoperative patient characteristics and perioperative outcomes between patients with differing tumor locations. Conclusion: This study is the first and largest report on endoscopic tattooing with dye before laparoscopic resection of gastric subepithelial tumor resection. Our results emphasize that endoscopic tattooing with dye is a safe and reliable method for localizing subepithelial tumors in the stomach prior to totally laparoscopic resection, with no correlation to where the tumor is located.

Background: End-stage renal disease (ESRD) is a risk factor of post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding, which may prolong hospitalization or increase the mortality rate. Hemodialysis is known to correct platelet dysfunction from ESRD but whether it can decrease post-ERCP bleeding is still uncertain. Endoscopic papillary balloon dilation (EPBD) had been reported to decrease post-ERCP bleeding but lacks evidence on whether replacing endoscopic sphincterotomy (EST). Aims: To explore the predictive factors of post-ERCP bleeding and if hemodialysis could decrease post-ERCP bleeding in ESRD patients. Furthermore, to investigate if the post ERCP bleeding rate, the severity of hemorrhage, and difficulty of treatment differ between EST and EPBD. Materials and Methods: This retrospective study acquired patient data from Chang Gung Memorial Hospitals by using Chang Gung Research Database (CGRD) from January 1, 2010, to June 30, 2020. We enrolled ESRD patients who underwent EST or EPBD on the naïve major papilla. First, we analyze the protective factors to prevent post-ERCP bleeding. And to compare the severity of post-ERCP bleeding and difficulty of hemostatic treatment between EST or EPBD with bleeding. Results: Total 580 patients enrolled, and we found hemodialysis significantly decreased post ERCP bleeding in the group of eGFR < 15 mL / min / 1.73m2 (p = 0.039, OR = 0.65, 95% CI: 0.43–0.98). Although the bleeding incidence was similar between EST and EPBD groups, there were significantly more patients in the EST bleeding group who required invasive hemostasis procedures (p = 0.001, N = 30/41, 73.17%). Patients who required two or more hemostasis procedures, such as trans-arterial embolization or endoscopic hemostasis, were exclusively in the EST bleeding group. Conclusion: Hemodialysis can decrease post ERCP bleeding rate in patients with eGFR < 15 mL / min / 1.73m². Although the bleeding incidence is similar between EST and EPBD in ESRD patients, hemostatic treatments were more complicated in EST with bleeding than in EPBD.