Hyun Cheol Koo

Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope for the Treatment of Retained Bile Duct Stones

OBJECTIVES:Intracorporeal lithotripsy must be used under direct visual control with an additional endoscope in order to ensure safety and precise targeting during the removal of difficult-to-extract bile duct stones using conventional methods. The currently available “mother–baby” scope system has several disadvantages. We evaluated the feasibility and efficacy of direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope for electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) for the treatment of difficult-to-extract bile duct stones.METHODS:A total of 18 patients who were unsuccessfully treated for common bile duct (CBD) stones using conventional endoscopy, including mechanical lithotripsy (ML), underwent EHL or LL under intraductal balloon-guided direct POC using an ultra-slim upper endoscope. The balloon catheter was used to maintain access while an ultra-slim upper endoscope was advanced directly into the bile duct. EHL or LL was performed until it became possible to capture the fragmented stones in a basket. Endoscopic removal of stone fragments by duodenoscopy was attempted in the same session.RESULTS:The overall success rate of bile duct clearance by lithotripsy under direct POC by a single endoscopist was 88.9% (16 of 18). Stone fragmentation under direct POC was successfully performed in nine patients using EHL and in seven patients using LL. The average number of treatment sessions required to complete stone removal was 1.6. ML was performed to complete stone removal in 5 of 18 (27.8%) patients. Procedure-related complications were not observed.CONCLUSIONS:Lithotripsy with EHL or LL under direct POC involving the use of an ultra-slim endoscope by a single endoscopist seems to be an effective and safe treatment for select patients with difficult-to-extract CBD stones.

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

BACKGROUND Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. OBJECTIVE To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. DESIGN Prospective observational clinical feasibility study. SETTING Tertiary-care academic center. PATIENTS This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. INTERVENTION Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. MAIN OUTCOME MEASUREMENTS Success, complications, removability, midterm outcome. RESULTS FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. LIMITATIONS The small number and lack of comparison with other types of FCSEMSs. CONCLUSION Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

Combined endoscopic stent-in-stent placement for malignant biliary and duodenal obstruction by using a new duodenal metal stent (with videos)

BACKGROUND Self-expandable metal stents (SEMSs) are an effective palliative treatment for malignant biliary or duodenal strictures, but endoscopic stenting for combined malignant biliary and duodenal obstruction remains technically difficult. OBJECTIVE To evaluate the feasibility and clinical success rate of endoscopic double stent-in-stent placement by using a new duodenal metallic stent for the management of malignant biliary and duodenal obstructions. DESIGN Prospective, observational clinical feasibility study. SETTING Tertiary referral center. MAIN OUTCOME MEASUREMENT Technical and clinical success, complications, midterm outcome. PATIENTS AND METHODS Eight patients with inoperable malignant biliary and duodenal strictures were enrolled. Endoscopic placement of a biliary SEMS was performed through the mesh of the duodenal stent. RESULTS The duodenal strictures were in the first part of the duodenum in 3 patients (type 1) and in the second part in 5 patients (type 2). Duodenal stents were successfully deployed in all patients. Endoscopic placement of a biliary SEMS through the mesh of the duodenal stent was successful in 7 (87.5%) of 8 patients. In 2 of 3 patients with type 2 duodenal strictures with failed bile duct cannulation, biliary stenting was successful by using the rendezvous procedure. Early complications occurred in 1 patient. The overall median survival after combined stenting was 91 days (range 36-314 days). LIMITATIONS Small number of patients and no comparison with other enteral stents. CONCLUSIONS Biliary stenting through the new duodenal metallic stent is technically feasible and has a high success rate. Combined endoscopic biliary and duodenal stent-in-stent placement is a promising solution for the palliation of malignant biliary and duodenal obstruction.

The utility of a multibending endoscope for selective cannulation during ERCP in patients with a Billroth II gastrectomy (with video).

BACKGROUND Selective cannulation in patients with a Billroth II gastrectomy is still challenging. OBJECTIVE To evaluate the usefulness of a multibending, forward-viewing endoscope (M-scope) for selective cannulation during diagnostic or therapeutic ERCP in patients with a Billroth II gastrectomy. DESIGN Case series. SETTING Tertiary center. PATIENTS Fourteen patients having biliary disease with a Billroth II gastrectomy in whom selective cannulation failed when using a conventional forward-viewing endoscope. INTERVENTIONS In all cases, we attempted selective biliary cannulation for ERCP with a single-bending, forward-viewing endoscope for 10 minutes. After failure with the conventional endoscope, we retried selective cannulation with the M-scope for 10 minutes. After cannulation, the diagnostic or therapeutic endoscopic procedures were performed. MAIN OUTCOME MEASUREMENTS We assessed the success rate of selective cannulation, the possibility of therapeutic approaches, and procedure-related complications. RESULTS In all cases, we successfully reached the ampulla of Vater with the M-scope. The overall success rate of selective cannulation with the M-scope was 92.9% (13/14). One patient developed mild pancreatitis. Therapeutic procedures such as sphincterotomy, balloon dilatation, stone removal, and biliary drainage were all possible. LIMITATIONS Small number of patients; uncontrolled, single-center study. CONCLUSIONS The M-scope seems to be helpful for selective cannulation during ERCP in patients with a Billroth II gastrectomy. All diagnostic and therapeutic procedures were possible through the M-scope.

Should colonoscopy be performed in patients with cryptogenic liver abscess

BACKGROUND/AIM The interruption of a mucosal barrier by colon cancer or a polyp can lead to the development of a liver abscess. This study aimed to evaluate the possible contribution of colon cancer to the development of liver abscess and the necessity of colonoscopy in patients presenting with cryptogenic liver abscess. METHODS We reviewed the medical records of 268 patients diagnosed with liver abscess between January 2001 and April 2010. Among cases with no definite cause of liver abscess, differences between patients with and without colon cancer were evaluated in terms of clinical, laboratory, imaging, and microbiological findings. RESULTS Pyogenic liver abscess with no apparent etiology was encountered 163 patients; colonoscopy was performed in 121 of these 163 patients. The tumor diagnosis was confirmed by total colonoscopy in 12/163 (7.4%) patients with adenocarcinoma and 8/163 (4.9%) patients with high-grade dysplasia. Nine patients were diagnosed with stage I, two patients with stage II, and one with stage III disease according to the tumor, nodes, and metastases (TNM) staging system for colorectal cancer. The prevalence of incidental colon cancer in patients with pyogenic liver abscess was significantly higher than that of normal individuals who underwent colonoscopy (0.8%, 90/11,272) at our health care center. CONCLUSIONS Colon cancer may be one etiology of liver abscess. Colonoscopy should be considered in patients with pyogenic liver abscess with not an apparent primary source of infection.

ENDOSCOPIC REMOVAL OF AN ENTEROLITH CAUSING AFFERENT LOOP SYNDROME USING ELECTROHYDRAULIC LITHOTRIPSY

Electrohydraulic lithotripsy is a very useful method for fragmenting biliary stones and it can be used for endoscopic removal of difficult biliary stones. Acute afferent loop syndrome induced by enterolith is very rare, and surgical treatment is the usual choice for this condition. We describe a patient with acute afferent loop syndrome, which was induced by an enterolith after a Billroth II gastrectomy. We used electrohydraulic lithotripsy to endoscopically remove the enterolith.

Effect of Transdermal Fentanyl Patches on the Motility of the Sphincter of Oddi

BACKGROUND/AIMS Pain is one of the most troublesome symptoms of pancreatitis. Transdermal fentanyl patches (TFPs) are long-acting analgesics with a reduced risk of dependency. This prospective study evaluated the effect of TFPs on sphincter of Oddi (SO) motility for the management of pain in pancreatitis. METHODS SO manometry (SOM) was performed using triple-lumen catheters anterogradely inserted through the percutaneous transhepatic route during cholangioscopy in 16 patients. The basal pressure, amplitude, and frequency of the SO were assessed before and after applying a TFP at 24 hour at doses of 25 and 12.5µg/hr, respectively. RESULTS Two of 16 patients receiving a 25µg/hr. TFP were excluded because of adverse side effects (headache and/or nausea). The mean basal pressure, amplitude, and frequency of SOM did not change significantly in the 25µg/hr TFP group (n=4 patients). Parameters of SO function also did not significantly change in the 12.5µg/hr TFP group (n=11 patients). CONCLUSIONS TFPs below a dose of 25µg/hr may not affect the motility of the SO. Administration of TFPs at lower dosages seems to be a safe analgesic treatment for the pain control of patients with pancreatitis without affecting the function of the SO.

Mo1476 Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation

Prophylactic 3F Pancreatic Duct Stent to Prevent Post-ERCP Pancreatitis in Patients With Difficult Biliary Cannulation Seung Hyo Han, Jong Ho Moon, Hyun Jong Choi, Hee Yong Yoo, Hyung Su Ahn, Seul Ki Min, Hyun Cheol Koo, Tae Hoon Lee, Young Koog Cheon, Young Deok Cho, Sang-Heum Park Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Republic of Korea; Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Seoul, Republic of Korea Objectives: Post-ERCP panreatitis is the most common and serious complication of ERCP. Difficult biliary cannulation can be one of procedure-related risk factors of post-ERCP pancreatitis. Recent studies have reported that prophylactic pancreatic stent reduce the frequency of post-ERCP pancreatitis. The aim of this study was to evaluate the efficacy of 3 Fr pancreatic stent to prevent post-ERCP pancreatitis in patients with difficult biliary cannulation. Methods: A total of 65 patients with difficult biliary selective cannulation were randomly divided into the stent group (S group, n 30) or the non-stent group (nS group, n 35). The stents used was 3 Fr Zimmon pancreatic stents. Difficult biliary cannulation was defined as the failure to achieve biliary access with more than 5 times of cannulation attempts or over 10 minutes of cannulation time. The incidence of post-ERCP pancreatitis was compared between S group and nS group. The diagonisis and severity assessment were according to Cotton’s criteria. Results : Pancreatic duct stenting was successful in all patients of S group. Spontaneous stent dislodgment within 7 days was recognized in 96.6% (29/30). No procedurerelated complication occurred. Mean serum amylase level after ERCP were 197.13 U/L and 420.77 U/L in S and nS group, respectively (p 0.005). The incidence rate of post-ERCP pancreatitis were 10% (3/30) and 31.4% (11/35) in S and nS group, respectively (p 0.036). The severity of pancreatitis was 1 moderate and 2 mild in in S group, whereas 1 severe, 2 moderate and 8 mild in nS group. Conclusions: Prophylactic pancreatic duct stent placement in patient with difficult cannulation during ERCP seems to be a safe and effective procedure to prevent for post-ERCP pancreatitis.