Byung Moo Yoo

Review of 67 patients with autoimmune pancreatitis in korea: A multicenter nationwide study

Objectives: The ideal diagnostic criteria of autoimmune pancreatitis (AIP) are still challenging. Therefore, we investigated the clinical features of AIP in Korea and assessed the clinical use of new Korean diagnostic criteria. Methods: We reviewed 67 patients with AIP enrolled in 16 hospitals via a multicenter study. The diagnosis was confirmed according to the Korean diagnostic criteria that included pancreatic imaging, laboratory findings, histopathology, and response to steroid. Results: Mean age of the patients was 56 years, and 73% were men. Obstructive jaundice (52%) was the most common symptom, and 14 patients (21%) had other organ involvement. Fifty-four patients (81%) revealed diffuse swelling of the pancreas. Either immunoglobulin (Ig)G or IgG4 was elevated in 76%. According to the Korean criteria, 65 patients had definite diagnostic criteria, and 2 patients had probable criteria. Fifteen patients were fulfilled with image, serological, and histopathologic criteria, and 4 patients could be diagnosed with image and steroid responsiveness. Ten patients experienced recurrent attacks of AIP during the mean 20-month follow-up. Conclusions: Among 67 cases of AIP, either IgG or IgG4 was elevated in 76% of patients, and 14 patients (21%) had other organ involvement. New Korean diagnostic criteria are useful for diagnosis of AIP.

Clinical Features of Chronic Pancreatitis in Korea: A Multicenter Nationwide Study

Background/Aims: No reliable nationwide clinical data about chronic pancreatitis (CP) was available in Korea. The etiology and clinical features of CP were investigated using a multicenter nationwide study. Methods: 814 cases of CP were enrolled retrospectively over the past 4 years at 13 hospitals. The following data were obtained from all patients: etiology, symptoms, complications, and surgery. Result: Alcohol (64.3%) was the major cause of CP and idiopathic CP (20.8%) was the second most common form. Mean patient age was 50.6 years and the male:female ratio was 6:1 (24:1 for alcoholic CP vs. 2:1 in idiopathic CP, p < 0.001). Diabetes (31.6%), pseudocysts (28.4%), biliary stricture (13.9%), and pancreatic ascites (6.6%) were the main complications. Of these, diabetes (35 vs. 26%) and pseudocyst (33.7 vs. 21.9%) were more frequent in alcoholic than in idiopathic CP. Pancreatic cancer developed in 25 patients (3.1%) during follow-up and their mean age was 59.1 years. Conclusions: In Korea, alcohol is the most common etiology of CP. Moreover, diabetes and pseudocysts are frequent complications, especially in alcoholic CP, and pancreatic cancer development is not infrequent.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy.

Background/Aims Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy. Methods Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications. Results Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred. Conclusions Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.

Management of Patients Who Return to the Hospital with a Bile Leak After Laparoscopic Cholecystectomy

INTRODUCTIONnBile leaks after laparoscopic cholecystectomy (LC) can be difficult to diagnose early. The aim of this study was to investigate the clinical features of minor bile leaks and to discuss how to manage patients who revisit the hospital with minor bile leaks after LC.nnnPATIENTS AND METHODSnFrom January 2001 to September 2007, 2219 LCs were performed at the Ajou University Medical Center. Twenty-four patients (1.0%) who presented with a bile leak or bile duct injury after a cholecystectomy were identified. The patients with minor bile duct injury were divided into two groups, depending on whether they revisited the hospital (group 2) or not (group 1) after LC.nnnRESULTSnSeventeen of 24 patients had minor bile leaks. The characteristics of patients in group 2 were long hospital stay, short operation time, and low frequency of indwelling surgical drains. Ten of 17 patients (58.8%) revisited the hospital at a mean of 7.0 +/- 2.7 days after the LC. However, 3 of 10 patients (30%) were discharged from the ER with atypical abdominal pain and returned to the hospital again within 5 days due to recurrent abdominal pain. There was a significant correlation between hospital stay and time to endoscopic retrograde cholangiopancreatography (ERCP) (P = 0.008) and between hospital stay and PCD (P = 0.028).nnnCONCLUSIONSnMost minor bile leaks were managed by ERCP and/or percutaneous drainage. However, early diagnosis was difficult when patients revisited the hospital within 7 days after the LC. Therefore, early ERCP should be considered in these patients to diagnose the bile leak early and limit needed hospital stay.

Temporary Placement of a Newly Designed, Fully Covered, Self-Expandable Metal Stent for Refractory Bile Leaks

Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.

Robotic cholecystectomy with new port sites.

AIMnTo introduce robotic cholecystectomy (RC) using new port sites on the low abdominal area.nnnMETHODSnFrom June 2010 to June 2011, a total of 178 RCs were performed at Ajou University Medical Center. We prospectively collected the set-up time (working time and docking time) and console time in all robotic procedures.nnnRESULTSnEighty-three patients were male and 95 female; the age ranged from 18 to 72 years of age (mean 54.6 ± 15.0 years). All robotic procedures were successfully completed. The mean operation time was 52.4 ± 17.1 min. The set-up time and console time were 11.9 ± 5.4 min (5-43 min) and 15.1 ± 8.0 min (4-50 min), respectively. The conversion rate to laparoscopic or open procedures was zero. The complication rate was 0.6% (n = 1, bleeding). There was no bile duct injury or mortality. The mean hospital stay was 1.4 ± 1.1 d. There was a significant correlation between the console time and white blood cell count (r = 0.033, P = 0.015). In addition, the higher the white blood cell count (more than 10000), the longer the console time.nnnCONCLUSIONnRobotic cholecystectomy using new port sites on the low abdominal area can be safely and efficiently performed, with sufficient patient satisfaction.

Endoscopic treatment of a large gastric duplication cyst with hook-knife and snare (with video)

Commentary The transected banded vertical gastric bypass is one of the modifications of gastric bypass in which a Silastic ring is placed around the pouch to form the stoma. Intragastric band migration or erosion is an uncommon complication of both vertical banded gastroplasty and laparoscopic adjustable gastric banding, with a reported frequency for the former of 0.5% to 3.8% and a frequency of up to 11% for the latter. Suspect this occurrence when weight regain, abdominal pain, GI bleeding, or gastric obstruction develops postoperatively. Diagnosis usually is made by endoscopy, but upper GI series can show the pathognomonic appearance of contrast material flowing around the part of the band that has eroded into the stomach. Obviously, CT scanning is best if symptoms suggest intraabdominal abscess or perforation. The appropriate treatment of intragastric band erosion is still controversial, but usually involves a decision between endoscopic and laparoscopic band removal. Recently, self-expanding plastic stents have been used to facilitate removal of partially migrated bands or in cases of refractory outlet stenosis; the therapeutic principle is that by causing ischemic damage to the gastric wall between the band and the stent, the band will gain free access to the gastric lumen. Silastic is a trademark registered to the Dow Corning Corporation and is portmanteau word resulting from the combination of silicon and plastic. It describes a widely used, flexible but nert material also referred to by another portmanteau word, elastomer (from elastic and polymer). Portemanteau riginally referred to a large traveling bag with two compartments, but in its modern meaning, the word, along with ts new spelling, was first used in 1871 by Lewis Carroll in Through the Looking Glass and What Alice Found There, n which Humpty Dumpty explains words from Jabberwocky to Alice: “Well, slithy means lithe and slimy . . . it’s like portmanteau . . .” Well, intragastric band migration is not a portmanteau, although the band may simultaneously eside in two compartments that are best separated from one another. Lawrence J. Brandt, MD Associate Editor for Focal Points

Analysis of endoscopic features for histologic discrepancies between biopsy and endoscopic submucosal dissection in gastric neoplasms: 10-year results

BACKGROUND AND AIMnThe histologic discrepancies between preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) specimens sometimes confuse the endoscope operator. This study aimed to analyze the limitation of the biopsy-based diagnosis before ESD and to evaluate which factors affect the discordant pathologic results between EFB and ESD.nnnMETHODSnA total of 1427 patients, who were diagnosed with gastric adenoma by EFB, were enrolled. Cancer confirmed on EFB was excluded (nu202f=u202f513). We retrospectively reviewed cases and compared histologic diagnoses in the biopsy sample with the final diagnosis in the endoscopically resected specimen.nnnRESULTSnThe diagnosis was upgraded (from low-grade dysplasia to high-grade dysplasia or adenocarcinoma, or from high-grade dysplasia to adenocarcinoma) in 328 cases (23.0%), concordant in 944 (66.1%), and downgraded (from high-grade dysplasia to low-grade dysplasia or non-neoplasia, or from low-grade dysplasia to non-neoplasia) in 155 (10.9%). Multivariate logistic regression analysis showed that surface ulceration and depressed lesions were associated with significant risk factors for upgrading. Age younger than 60 years and size <1u202fcm were associated with significant factors for downgrading.nnnCONCLUSIONSnCareful endoscopic observation should consider size, ulceration, and depression to ensure accurate diagnosis when a gastric neoplasm is suspected.

Cyclic Change of Sphincter of Oddi Motility and Its Relationship with Small Bowel Migrating Motor Complex in Humans

BackgroundSeveral animal and human studies have reported that sphincter of Oddi (SO) motility shows cyclical changes during the fasting state. However, to date, the relationship between the SO motility and the migrating motor complex (MMC) of the small bowel (SB) remains unclear in humans.AimsWe observed SO motility over a long study period and evaluated its relationship with the MMC of the SB in humans using percutaneous long-term manometry.MethodsOur study included patients with hepatolithiasis who required percutaneous transhepatic catheter placement and subsequently underwent choledochoscopy and stone removal. Long-term percutaneous transhepatic SO manometry was performed after complete stone removal. SO and SB motility were simultaneously recorded.ResultsSO motility showed cyclical phasic changes with periodic high-frequency contractions similar to the MMC contractions of the SB. All high-frequency contractions of the SO coincided with phase III contractions of the MMC of the SB. The proportions of phase III contractions of SO and SB were similar, but the proportions of phase I (Pu2009=u20090.001) and phase II (Pu2009=u20090.002) contractions were significantly different. The mean basal SO pressure was observed to significantly increase in phase III compared to phase I (Pu2009=u20090.001) and phase II (Pu2009=u20090.001) contractions.ConclusionsSO motility in humans showed cyclical phasic changes closely coordinated with the MMC of the SB in a fasting state; however, the proportion of phases differed between the SO and the SB. The basal pressure significantly increased during physiological high-frequency phase III contractions of the SO.

Endoscopic Treatment for Pain Relief in Chronic Pancreatitis: A Cross-Sectional Analysis by Korean Multicenter Study Group on Chronic Pancreatitis

Endoscopic Treatment for Pain Relief in Chronic Pancreatitis: A Cross-Sectional Analysis by Korean Multicenter Study Group on Chronic Pancreatitis Dong Wan Seo, Ho-Soon Choi, Dong Ki Lee, Jin Lee, Kyu Taek Lee, Woo Jin Lee, Jong Ho Moon, Young-Soo Moon, Ho Gak Kim, Jae Seon Kim, Tae Nyeun Kim, Myung Hwan Roh, Ji Kon Ryu, Byung Moo Yoo Background: Endoscopic treatment has become one of the treatment options for chronic pancreatitis. However, there are some groups of patients who are refractory to this treatment. It is not clear which subgroup could be benefited by pancreatic endotherapy. The purpose of this study is to analyze the result of endoscopic treatment of chronic pancreatitis in Korea and to identify a subgroup in which pancreatic endotherapy is helpful for the relief of pain. Method: From 14 different academic centers, 432 patients with chronic pancreatitis were screened and 137 patients who received endoscopic treatment were enrolled in this study. Using structured questionnaires, following data were collected: demographic data, response to pain medication, type of endoscopic treatment, and response to endoscopic treatment. Results: The patients were categorized into 3 different groups depending on their ductal pathology: ductal stones (23.4%), dominant strictures (46.8%), stones with strictures (29.8%). The types of endoscopic treatment were endoscopic pancreatic sphincterotomy(EPST) alone (10.5%), EPSTCstent placement(68.6%), or EPSTCstent placementCextracorporeal shock wave lithotripsy (ESWL)(20.9%). There was no significant difference in pain response rate according to the type of treatment. The diameter of stents, duration of pancreatic stenting and etiology of pancreatitis did not affect the response rate. However, the response rate was significantly lower in the patients with predominant ductal strictures (70.5%) than those in patients with stones (81.8%) or stones and stricures (85.7%) (p!0.05). Conclusions: Endoscopic treatment can be offered as a reasonable alternative to surgery for pain relief in chronic pancreatitis. However, careful patient selection seems to be important to improve the response rate, especially in patients with predominant strictures.