Successful treatment for infected biloma after endoscopic ultrasound-guided hepaticogastrostomy using double stent placement technique

This case report describes a treatment of an elderly man who had undergone pancreaticoduodenectomy (Whipple Procedure) due to bile duct cancer. Herein, we describe technical tips of endoscopic ultrasound (EUS)-guided hepaticojejunostomy EUS-HJS combined with EUS-guided antegrade stenting (EUS-AS) using novel plastic stent. First, intrahepatic bile duct was punctured using 19G fine needle aspiration needle. Next, the 0.025-inch guidewire was inserted into the biliary tract. After the guidewire was advanced into the intestine, the bile duct and the intestine wall were dilated using by balloon catheter. The covered metal stent delivery system was antegradely inserted across the stricture site, and stent placement was performed from the intestine to the bile duct. Finally, stent placement from the intrahepatic bile duct to the intestine using novel plastic stent was successfully performed without any adverse events

Increased serum IgG4 levels and intimal IgG4-positive cell infiltration in rapidly growing aortic aneurysm

A 67-year-old Japanese man had been complaining of discomfort in the chest and back and feeling febrile for 2 weeks. Chest computed tomography indicated a thoracic aortic aneurysm. He occasionally showed a high fever (up to 38.0°C), even after hospital admission, irrespective of antibiotic therapy. The patient was found to have elevated serum IgG4 levels (366 mg/dL). The aneurysm demonstrated rapid growth; therefore, rifampicin-soaked woven Dacron synthetic graft replacement was performed 22 days after admission. Immunohistostatining of the resected aorta segment showed an IgG4-positive plasma cell infiltrate within the intimal layer neighboring the cholesterol-rich atheromatous plaque. After surgery, the patient’s serum IgG4 level dropped acutely; however, it did not reach the normal range. The possible role of IgG4 in the development or suppression of aortic remodeling, as well as in atherogenesis, among patients with rapidly growing aortic aneurysm requires further investigation

Can Lemborexant for Insomnia Prevent Delirium in High-Risk Patients with Pancreato-Biliary Disease after Endoscopic Procedures under Deep Sedation?

Background and aim: Pancreato-biliary patients who undergo endoscopic procedures have high potential risk of delirium. Although benzodiazepine has traditionally been used to treat insomnia, this drug might increase delirium. Lemborexant may be useful for patients with insomnia, without worsening delirium, although there is no evidence for high-risk patients with pancreato-biliary disease. The aim of this pilot study was to evaluate the safety and efficacy of lemborexant for insomnia and the frequency of delirium after endoscopic procedures under deep sedation in patients with pancreato-biliary disease. Method: This retrospective study included consecutive patients who were administered lemborexant after endoscopic procedures for pancreato-biliary disease between September 2020 and June 2022. The primary outcome of this study was evaluation of the safety and efficacy of lemborexant for insomnia. Frequency of delirium was the secondary outcome. Result: In total, 64 patients who had the complication of insomnia after an endoscopic procedure were included in the study. Risk factors for delirium were advanced age (n = 36, 56.3%), dementia (n = 10, 15.6%), and regular alcohol use (n = 13, 20.3%), as well as the sedatives midazolam and pentazocine that were administered to all patients at the time of the endoscopic procedure. Successful asleep was achieved by 61/64 patients (95.3%). No fall event was observed during the night following the procedure in any patient. However, mild consciousness transformation was observed in one patient. Conclusions: In conclusion, lemborexant use may be effective and safe for use after endoscopic procedures in pancreato-biliary patients, without increasing the risk of delirium

Comparison of Endoscopic Hemostasis for Endoscopic Sphincterotomy Bleeding between a Novel Self-Assembling Peptide and Conventional Technique

Introduction: Recently, a novel self-assembling peptide hemostatic gel has become available in Japan. However, the safety and efficacy of this novel self-assembling peptide hemostatic gel remain unclear for bleeding after EST. The aim of this study was to evaluate the safety and efficacy of a novel self-assembling peptide hemostatic gel for bleeding after EST, and to perform a comparison to a conventional endoscopic hemostasis technique. Method: This retrospective study was carried out between January 2019 and October 2022. Patients who developed bleeding associated with EST were enrolled. The patients were divided into two groups based on the hemostasis technique used: a conventional hemostasis technique (Group A) or a novel self-assembling peptide hemostatic gel hemostasis technique (Group B). Result: A total of 62 patients (Group A, n = 36; Group B, n = 26) were included. Endoscopic hemostasis was initially obtained in 72.2% (26/32) of patients in Group A and in 88.4% (23/26) of patients in Group B, which was not significantly different (p = 0.1320). However, the procedure time was significantly shorter in Group B (mean, 9.38 min) compared with Group A (mean, 15.4 min) (p = 0.0103). There were no significant differences in the severity of bleeding between the two groups (p = 0.4530). Post-EST bleeding was observed in six patients (Group A, n = 4; Group B, n = 2). Adverse events were more frequently observed in Group A (n = 12) than in Group B (n = 1) (p = 0.0457). Conclusions: PuraStat application for EST bleeding might be safe and effective, and is comparable to the conventional endoscopic hemostasis technique, although further prospective randomized trials are needed