Eui Joo Kim

Stents for colorectal obstruction: Past, present, and future.

Since the development of uncovered self-expanding metal stents (SEMS) in the 1990s, endoscopic stents have evolved dramatically. Application of new materials and new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.

Diagnostic efficacy of quantitative endoscopic ultrasound elastography for differentiating pancreatic disease

Endoscopic ultrasound elastography (EUS‐EG) constitutes a novel imaging procedure that allows for the quantification of tissue stiffness with high degrees of accuracy in pancreatic disease. However, the optimal cut‐off and reference strain ratio (SR) value of quantitative EUS‐EG for differential diagnosis in patients with pancreatic disease remains unclear. This study aimed to clarify these values of normal pancreas, chronic pancreatitis, or pancreatic cancer in an Asian population.

Anti-inflammatory and anti-apoptotic effects of rosuvastatin by regulation of oxidative stress in a dextran sulfate sodium-induced colitis model.

AIM To evaluate the anti-inflammatory and anti-apoptotic effects of rosuvastatin by regulation of oxidative stress in a dextran sulfate sodium (DSS)-induced colitis model. METHODS An acute colitis mouse model was induced by oral administration of 5% DSS in the drinking water for 7 d. In the treated group, rosuvastatin (0.3 mg/kg per day) was administered orally before and after DSS administration for 21 d. On day 21, mice were sacrificed and the colons were removed for macroscopic examination, histology, and Western blot analysis. In the in vitro study, IEC-6 cells were stimulated with 50 ng/mL tumor necrosis factor (TNF)-α and then treated with or without rosuvastatin (2 μmol/L). The levels of reactive oxygen species (ROS), inflammatory mediators, and apoptotic markers were measured. RESULTS In DSS-induced colitis mice, rosuvastatin treatment significantly reduced the disease activity index and histological damage score compared to untreated mice (P < 0.05). Rosuvastatin also attenuated the DSS-induced increase of 8-hydroxy-2’-deoxyguanosine and NADPH oxidase-1 expression in colon tissue. Multiplex ELISA analysis revealed that rosuvastatin treatment reduced the DSS-induced increase of serum IL-2, IL-4, IL-5, IL-6, IL-12 and IL-17, and G-CSF levels. The increased levels of cleaved caspase-3, caspase-7, and poly (ADP-ribose) polymerase in the DSS group were attenuated by rosuvastatin treatment. In vitro, rosuvastatin significantly reduced the production of ROS, inflammatory mediators and apoptotic markers in TNF-α-treated IEC-6 cells (P < 0.05). CONCLUSION Rosuvastatin had the antioxidant, anti-inflammatory and anti-apoptotic effects in DSS-induced colitis model. Therefore, it might be a candidate anti-inflammatory drug in patients with inflammatory bowel disease.

The Risk Factors for Moderately Severe and Severe Post–endoscopic Retrograde Cholangiopancreatography Pancreatitis According to the Revised Atlanta Classification

Objectives The aim of this study was to confirm the value of the revised Atlanta classification for predicting the severity of post–endoscopic retrograde choloangiopancreatography pancreatitis (PEP) and to validate the risk factors for moderately severe and severe PEP. Methods Among 2672 patients, 86 with PEP and 172 randomly selected control patients were included in this study. Post–endoscopic retrograde choloangiopancreatography pancreatitis was evaluated according to Cotton criteria and the revised Atlanta classification. The agreements between the 2 sets of criteria were compared, and the risk factors for moderately severe and severe PEP were identified. Results According to the revised Atlanta classification, 72 patients (83.7%) had mild, 11 (12.8%) had moderately severe, and 3 (3.5%) had severe disease. The agreement between the revised Atlanta classification and Cotton criteria was fair (&kgr; = 0.285). Statistically significant risk factors for PEP were difficult cannulation and dye injection in the pancreatic duct, including acinarization. For moderately severe or severe PEP, obesity (hazard ratio, 3.384 [95% confidence interval, 1.023–11.191]) was the only statistically significant risk factor. Conclusions The revised Atlanta classification of acute pancreatitis is an effective and feasible classification system for predicting PEP severity. Obesity was identified as an important risk factor predicting moderately severe and severe PEP.

Korean Red Ginseng extract reduces hypoxia-induced epithelial-mesenchymal transition by repressing NF-κB and ERK1/2 pathways in colon cancer

Background The incidence of colorectal cancer (CRC) is increasing, with metastasis of newly diagnosed CRC reported in a large proportion of patients. However, the effect of Korean Red Ginseng extracts (KRGE) on epithelial to mesenchymal transition (EMT) in CRC is unknown. Therefore, we examined the mechanisms by which KRGE regulates EMT of CRC in hypoxic conditions. Methods Human CRC cell lines HT29 and HCT116 were incubated under hypoxic (1% oxygen) and normoxic (21% oxygen) conditions. Western blot analysis and real-time PCR were used to evaluate the expression of EMT markers in the presence of KRGE. Furthermore, we performed scratched wound healing, transwell migration, and invasion assays to monitor whether KRGE affects migratory and invasive abilities of CRC cells under hypoxic conditions. Results KRGE-treated HT29 and HCT116 cells displayed attenuated vascular endothelial growth factor (VEGF) mRNA levels and hypoxia-inducible factor-1α (HIF-1α) protein expression under hypoxic conditions. KRGE repressed Snail, Slug, and Twist mRNA expression and integrin αVβ6 protein levels. Furthermore, hypoxia-repressed E-cadherin was restored in KRGE-treated cells; KRGE blocked the invasion and migration of colon cancer cells by repressing NF-κB and ERK1/2 pathways in hypoxia. Conclusions KRGE inhibits hypoxia-induced EMT by repressing NF-κB and ERK1/2 pathways in colon cancer cells.

The efficacy of real-time colour Doppler flow imaging on endoscopic ultrasonography for differential diagnosis between neoplastic and non-neoplastic gallbladder polyps

ObjectivesWe evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.MethodsBetween August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.ResultsOf the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.ConclusionsThe presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.Key points• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited.• The use of real-time CDF-EUS was convenient, with high agreement between operators.• The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

Contrast-enhanced ultrasound-guided radiofrequency ablation in inconspicuous hepatocellular carcinoma on B-mode ultrasound

BACKGROUND/AIMS B-mode ultrasound (US) has difficulty targeting small hepatocellular carcinomas (HCCs) with poor conspicuity during radiofrequency ablation (RFA). Contrast-enhanced ultrasound (CEUS) can improve visualization of small or inconspicuous HCCs. This study was conducted to evaluate the effectiveness of CEUS-guided RFA electrode insertion during the arterial phase in inconspicuous HCCs. MATERIALS AND METHODS Ninety-three treatment-naïve HCCs from 80 patients treated with RFA from August 2012 to December 2014 were retrospectively reviewed. Seventy-five HCCs from 65 patients underwent B-mode US-guided RFA, and 15 HCCs from 14 patients that were inconspicuous on B-mode US underwent CEUS-guided RFA during the arterial phase after injection of sulfur hexafluoride microbubbles (SonoVue®). Technical success was assessed by contrast-enhanced computed tomography within 1 week and 3 months after the procedure. RESULTS The mean size of HCCs treated with CEUS-guided RFA was smaller than that of HCCs treated with B-mode US-guided RFA (1.17±0.36 vs. 1.63±0.55 cm, p=0.003). Technical success rates of CEUS-guided RFA within 1 week and 3 months were 100% (15/15) and 93.3% (14/15), respectively. Technical success rates of B-mode US-guided RFA were 97.3% (73/75) and 94.5% (69/73), respectively. CONCLUSION CEUS-guided RFA is highly efficacious for ablation of very small and inconspicuous HCCs.

Successful hemostasis using a covered self-expandable metallic stent for spurting hemobilia in patients with advanced pancreatic cancer-induced portal biliopathy.

A 68-year-old woman who underwent biliary plastic stent placement for pancreatic head cancer was admitted for hematochezia. Her vital signs were mostly normal; however, she had a hemoglobin level of 5.6 g/dL. Upper and lower GI endoscopy did not identify the bleeding focus, but abdominal CT showed a high-density lesion in the duodenum (Fig. 1). Because we suspected hemobilia-associated bleeding, ERCP was performed and showed that the stent was filled with blood clots. After removal of the previously placed stent, we confirmed spurting hemobilia. To overcome this potentially fatal hemobilia, we put in place a covered biliary selfexpandable metal stent (SEMS) (80-mm ComVi Biliary

Synchronous Peripancreatic Lymph Node Gastrinoma and Gastric Neuroendocrine Tumor Type 2.

A 34-year-old man was referred to our hospital with gastric polypoid lesions and biopsy-confirmed neuroendocrine tumor (NET). Computed tomography (CT) revealed a 3×3.5×8-cm retroperitoneal mass behind the pancreas, with multiple hepatic metastases. His serum gastrin level was elevated to 1,396 pg/mL. We performed a wedge resection of the stomach, a right hemi-hepatectomy, and a retroperitoneal mass excision. After careful review of the clinical, radiological, histopathological, and immunohistochemical findings, peripancreatic gastrinoma, and synchronous gastric NET were ultimately diagnosed. We reviewed a CT scan that had been performed 6 years previously after surgery for a duodenal perforation. There was no evidence of gastric or hepatic lesions, but the retroperitoneal mass was present at the same site. Had gastrinoma been detected earlier, our patient could have been cured using less invasive treatment. This case demonstrates how important it is to consider Zollinger-Ellison syndrome in patients with a recurrent or aggressive ulcer.

The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.