Dong Ki Lee

Acute Hemodynamic Effects of Octreotide and Terlipressin in Patients with Cirrhosis: A Randomized Comparison

BACKGROUND:Octreotide and terlipressin are widely used in acute variceal hemorrhage to reduce the bleeding rate. They purportedly act by mesenteric arterial vasoconstriction, thus reducing portal venous flow (PVF) and portal pressure. Little is known about the immediate-early hemodynamic effects of these drugs.AIM:To compare the acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis.PATIENTS:Forty-two cirrhotic patients with a history of variceal bleeding were randomized to receive either octreotide 100 μg intravenous bolus followed by a continuous infusion at 250 μg/h (n = 21), or terlipressin 2 mg intravenous bolus (n = 21).METHODS:Mean arterial pressure (MAP), heart rate (HR), hepatic venous pressure gradient (HVPG), and PVF, assessed by duplex Doppler ultrasonography, were measured before and at 1, 5, 10, 15, 20, and 25 min after the start of drug administration.RESULTS:Octreotide markedly decreased HVPG (−44.5 ± 17.8%) and PVF (−30.6 ± 13.6%) compared to the baseline at 1 min (p < 0.05). Thereafter, both variables rapidly returned toward the baseline, and by 5 min, no significant differences in HVPG (−7.1 ± 28.9%) and PVF (10.2 ± 26.2%) were noted. A similar transient effect on MAP and HR was observed. Terlipressin significantly decreased HVPG (−18.3 ± 11.9%) and PVF (−32.6 ± 10.5%) at 1 min (p < 0.05) and sustained these effects at all time points. The effects on arterial pressure and HR were also sustained.CONCLUSIONS:Octreotide only transiently reduced portal pressure and flow, whereas the effects of terlipressin were sustained. These results suggest that terlipressin may have more sustained hemodynamic effects in patients with bleeding varices.

The effect on porcine bile duct of a metallic stent covered with a paclitaxel-incorporated membrane

BACKGROUNDnBiliary metallic stents are covered with a membrane to prevent tumor ingrowth and to prolong patency. The only function of these stents is to promote biliary drainage; they have no antitumor effect.nnnMETHODSnA metallic stent was developed that is covered with a paclitaxel-incorporated membrane. The metallic stents were coated with one of 3 concentrations of paclitaxel (0, 10, and 20 % wt/v) and polyurethane. A stent with each concentration was surgically inserted in the bile duct of two pigs. Four weeks after insertion, the segment of bile duct containing the stent was examined histologically. To determine the efficacy of the drug release, stents were placed in phosphate buffered saline solution for 6 weeks, and the amount of paclitaxel released was measured by high-performance liquid chromatography.nnnRESULTSnThe histologic changes in the pig biliary epithelium were acceptable with respect to safety and included inflammatory cell infiltration and fibrous reactions. The changes corresponded to the amount of paclitaxel incorporated within the stent in contact with the bile duct. Epithelial denudation, mucin hypersecretion, and epithelial metaplasia were noted in the bile ducts that were in contact with stents containing 20 % wt/v paclitaxel. Transmural necrosis and perforation were not observed in any animal. In the in vitro experiment, the amounts of paclitaxel released over 1 week and over 6 weeks were similar, regardless of the concentration of paclitaxel incorporated in the stent. The stent with 10% (wt/v) paclitaxel in the covering membrane was found to be better than that with 20 % (wt/v) with respect to histologic changes and the effectiveness of drug release.nnnCONCLUSIONSnA paclitaxel-incorporated metallic stent could serve as a basis for the development of a new and safe treatment modality for malignant biliary obstruction. Clinical trials of this stent with other adjuvant therapy are warranted.

Comparison of Doppler ultrasonography and the hepatic venous pressure gradient in assessing portal hypertension in liver cirrhosis

Background and Aim: This prospective study aimed to determine whether Doppler ultrasonography can represent the hepatic venous pressure gradient (HVPG) as an assessment of the severity of portal hypertension and the response to terlipressin, which reduces the portal pressure in liver cirrhosis.

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.

Risk factors for delayed postendoscopic mucosal resection hemorrhage in patients with gastric tumor.

Objective Although endoscopic mucosal resection has been recognized as the standard treatment for gastric mucosal neoplasm, postendoscopic mucosal resection hemorrhage remains a major complication of endoscopic mucosal resection, and this problem seems to be increasing owing to the development of invasive techniques. The aims of this study were to determine the incidence and grade of postendoscopic mucosal resection hemorrhage and to identify risk factors for delayed postendoscopic mucosal resection hemorrhage in patients with gastric neoplasm. Methods Data of endoscopic mucosal resections performed by three endoscopists were retrospectively collected over 8 years and then analyzed. Immediate postendoscopic mucosal resection hemorrhage was defined as bleeding during the procedure. Delayed postendoscopic mucosal resection hemorrhage was defined when two of the four following parameters were satisfied after the endoscopic mucosal resection period; (i) hematemesis, melena or dizziness, (ii) hemoglobin loss >2u2009g/dl, (iii) blood pressure decrease >20u2009mmHg or pulse rate increase >20/min and (iv) Forrest I or IIa–IIb on follow-up endoscopy. Results A total of 157 patients (mean age: 64 years, maleu2009:u2009female=44u2009:u2009113) were reviewed. Twenty-nine (18.5%) and 13 patients (8.3%) presented with immediate and delayed postendoscopic mucosal resection hemorrhage, respectively. Multivariate logistic regression analysis revealed that the patients age (≤65 years; odds ratio 6.11, 95% confidence interval 1.12–33.43), the size of lesion (>15u2009mm; odds ratio 5.90, 95% confidence interval 1.13–30.87) and the experience of the endoscopist (≤5 years; odds ratio 16.31, 95% confidence interval 1.46–181.97) were significantly predictive variables for the delayed postendoscopic mucosal resection hemorrhage. Conclusion Considering the higher risk of delayed postendoscopic mucosal resection hemorrhage, careful preparation and close monitoring are required for patients who are less than 65 years, have large lesions over 15u2009mm or if the procedures were performed by an inexperienced endoscopist.

Clinical Outcomes and Risk Factors of Rebleeding Following Endoscopic Therapy for Nonvariceal Upper Gastrointestinal Hemorrhage

Background/Aims Rebleeding after endoscopic therapy for non-variceal upper gastrointestinal hemorrhage (NGIH) is the most important predictive factor of mortality. We evaluated the risk factors of rebleeding in patients undergoing endoscopic therapy for the NGIH. Methods Between January 2003 and January 2007, 554 bleeding events in 487 patients who underwent endoscopic therapy for NGIH were retrospectively enrolled. We reviewed the clinicoendoscopical characteristics of patients with rebleeding and compared them with those of patients without rebleeding. Results The incidence of rebleeding was 21.7% (n=120). In the multivariate analysis, initial hemoglobin level ≤9 g/dL (p=0.002; odds ratio [OR], 2.433), inexperienced endoscopist with less than 2 years of experience in therapeutic endoscopy (p=0.001; OR, 2.418), the need for more 15 cc of epinephrine (p=0.001; OR, 2.570), injection therapy compared to thermal and injection therapy (p=0.001; OR, 2.840), and comorbidity with chronic renal disease (p=0.004; OR, 2.908) or liver cirrhosis (p=0.010; OR, 2.870) were risk factors for rebleeding following endoscopic therapy. Conclusions Together with patients with low hemoglobin level at presentation, chronic renal disease, liver cirrhosis, the need for more 15 cc of epinephrine, or therapy done by inexperienced endoscopist were risk factors for the development of rebleeding.

A Comparative Study on the Efficacy of Covered Metal Stent and Plastic Stent in Unresectable Malignant Biliary Obstruction

Background/Aims The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent. Methods We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate. Results There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182). Conclusions The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.

Deoxycholic acid-induced signal transduction in HT-29 cells: Role of NF-κB and interleukin-8

Background/Aims: Deoxycholic acid (DCA) has been appeared to be an endogenous colon tumor promoter. In this study, we investigated whether DCA induces nuclear factor-kappa B (NF-κB) activation and IL-8 expression, and tauroursodeoxycholic acid (TUDC) inhibits this signaling in HT-29 cells. Methods: After DCA treatments, time courses of NF-κB binding activity were determined by electrophoretic mobility shift assay (EMSA). Also, we performed Western blotting of IκBα to confirm NF-κB activation. Time and concentration courses of DCA-induced secretion of IL-8 were measured with ELISA in supernatants of cultured media from the cells. To evaluate the role of NF-κB, IL-8 levels were assessed after pretreatment with using phosphorothioate-modified anti-sense oligonucleotides (ODN). Moreover, DCA-induced secretions of IL-8 were measured after pretreatment with TUDC. Results: DCA dose-dependently induced prominent NF-κB binding complexes from 30 min to 8 hr and degradation of IκBα. The secretions of IL-8 were increased with DCA (50~200 μM) treatment in a time and dose-dependent manner. Pre-incubation of the cells with TUDC (0.1~10 μM) for 2 hours caused significant decreases in DCA induced IL-8 secretion. However, transient transfection using p50 or p65 AS-ODN showed no effect on IL-8 secretion. Conclusions: DCA may play as a colonic tumor promoter through anti-apoptotic effect of NF-κB activation and IL-8 expression, and DCA-induced NF-κB independent IL-8 expression is inhibited by TUDC. (Korean J Gastroenterol 2004;43:176-185)

4649 Preliminary results of new covered biliary nitinol stent in patients with malignant obstruction of extrahepatic bile duct (ehd).

Background : In malignant EHD obstruction, the endoscopic insertion of biliary stent is one of the available palliative therapies. Major problems of uncovered metal stents are tumor ingrowth, stent incorporation into the tumor, and impossibility in exchange of the stent. A newly developed covered self-expandable metal stent(SEMS) was designed to overcome such disadvantages of uncovered metal stent. However, Early serious complications such as pancreatitis or cholecystitis seems to be occurred frequently due to ductal obstruction by covering structure in covered SEMS. To compare the clinical efficacy and early complications of new nitinol SEMS covered with polyurethane(covered Niti-s biliary stent, Tae Woong Medical Inc, Seoul, Korea) with uncovered biliary metal stent(Wallstent, Schneider AG,Switzerland), we studied patients with malignant EHD obstuction. Methods : By prospective multicenter study, biliary stents were endoscopically inserted in 76 patients. Thirty five patients(M:F=20:15, mean age:68.8 years) received covered SEMS(covered stent group), and 41 patients (M:F=25:16, mean age:70.1 years) received Wallstent(Wallstent group). The causes of malignant EHD obstruction were bile duct cancer(21), pancreatic cancer(35), gallbladder cancer(12), and ampulla of Vater cancer(8). Results : 1) The success rate of endoscopic stent insertion was 100% in each groups. 2) There was no statistical difference in length of stenosis of common bile duct and stent between the two groups. 3) The mean follow-up period after placement of stent was 145.8±69.5 days in covered stent group, and 122.9±45.1 days in Wallstent group(p>0.05) 4) Early complications (within 30 days) such as stent migration into duodenum(2 cases) and mild acute pancreatitis(1 case) were developed in covered stent group(p>0.05). Acute pancreatitis was improved after removal of the covered nitinol SEMS. Late complications have not been noted in the two groups during follow-up period. 5) The 3 month patency rate was 88.0%(21/24) in covered stent group, 86.0%(18/21) in Wallstent group(p>0.05). 6) The causes of stent obstruction were bile sludge(1 case) and tumor ingrowth(2 cases) in Wallstent group(p>0.05). Conclusion : New covered biliary nitinol stent was as effective as Wallstent without early serious complications such as pancreatitis, cholecystitis and cholangitis, although long-term follow-up about its patency rate and complications are needed.

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.