Jimin Han

Effect of Biliary Stenting Combined With Ursodeoxycholic Acid and Terpene Treatment on Retained Common Bile Duct Stones in Elderly Patients: A Multicenter Study

OBJECTIVES:For frail, elderly patients with large impacted common bile duct (CBD) stones, long-term treatment with biliary stenting provides palliation. Biliary stenting with choleretic agents such as ursodeoxycholic acid (UDCA) and terpene preparations may promote CBD stone size reduction. We studied the effectiveness of biliary stenting combined with UDCA and a terpene preparation as a medical treatment for difficult-to-remove CBD stones in patients older than 65 years in this multicenter, prospective study.METHODS:A total of 28 elderly patients with CBD stones refractory to conventional endoscopic removal, including mechanical lithotripsy, underwent endoscopic placement of a straight 10-F plastic biliary stent. Each patient was administered 600 mg of UDCA and 300 mg of a terpene preparation daily for a mean of 6 months. After 6 months of medication following the initial endoscopic retrograde cholangiopancreatography (ERCP), a second ERCP was performed and endoscopic stone removal was again attempted. Differences in stone size and CBD diameter before and after biliary stenting and medication were compared. The complete stone removal rate after treatment was obtained.RESULTS:The mean size (transverse × longitudinal diameter) of the CBD stones was initially 21.6 × 29.5 mm, and it decreased significantly to 12.2 × 20.1 mm at the second ERCP (P<0.01). The mean CBD diameter measured initially at the cystic duct insertion level was 23.2 mm, and it decreased significantly to 19.5 mm at the second ERCP (P<0.01). After biliary stenting with medication, endoscopic stone removal was successful in 26 of 28 patients (92.8%), with a mean of 1.7 subsequent ERCP sessions.CONCLUSIONS:Endoscopic biliary stenting with a period of combined UDCA and terpene preparation administration seems to be a safe and effective method for retained CBD stones in elderly patients. A prospective study with randomization and a control group is required to confirm these results.

Comparison of histology and extracellular matrix between autoimmune and alcoholic chronic pancreatitis.

Objectives: In autoimmune chronic pancreatitis (AIP), the histology is known to be characteristic and histologic recovery including pancreatic fibrosis has been reported after steroid therapy. The aims of this study were to demonstrate whether these histologic findings were unique to AIP and evaluate any differences in the composition of extracellular matrix between AIP and ordinary chronic pancreatitis. Methods: Histologic findings and extracellular matrix proteins (collagen types I, III, and IV and fibronectin) were evaluated in 15 patients with clinically proven AIP and compared with those of 8 patients with surgically treated alcoholic chronic pancreatitis (ACP). Results: The pattern of fibrosis was mainly loose fibrosis with stromal edema in AIP, while it was dense fibrosis in ACP. Acinar atrophy was more diffuse and severe in AIP than ACP. While diffuse with same stage of inflammatory activity was observed in AIP, multifocal inflammation with different stage of inflammatory was seen in ACP. For extracellular matrix proteins, dense deposition (compared with normal controls) of collagen type III was observed more frequently in ACP than AIP (P < 0.05). ACP showed decreased deposition of collagen type IV more frequently than AIP (P = 0.001). Conclusion: Fibrosis and inflammation are common to both AIP and ACP, but the pattern is very different between the 2 groups, and the deposition of collagen types III and IV is substantially different between AIP and ACP.

Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone

Background/Aims Between endoscopic sphincterotomy (ES) alone and combined endoscopic sphincterotomy and large balloon dilation (ES-LBD) groups, efficacy and long-term complications, difference in biliary stone recurrence rate, and risk factors of stone recurrence were compared. Methods Medical records of 222 patients who underwent ERCP for biliary stone removal were retrospectively reviewed. Patients with dilated CBD ≥11 mm and follow-up longer than 6 months were included. Results There were 101 patients in ES-LBD group and 121 patients in ES group. Mean follow-up duration was 25.0 (6-48) months and 13.0 (6-43) months, respectively (p=0.001). There was no difference in number of ERCP sessions, brown pigment stones, angle between mid and distal common bile duct (CBD angle) <135°, and lithotripsy rate. Complete retrieval success rate was excellent in both groups (100% vs. 99%). Early complication rate of ES-LBD and ES alone group was 4 and 4.1%, respectively (p=1.000). One patient in ES-LBD group died from delayed bleeding. Late complication rate was 5.9 and 3.3%, respectively (p=1.000). Stone recurrence rate was 6.9% and 5.8%, respectively (p=0.984). The only Independent risk factor of stone recurrence was presence of periampullary diverticulum. Conclusions Late complication and stone recurrence rates were similar between ES-LBD and ES alone groups.

Prognostic Validity of the American Joint Committee on Cancer and the European Neuroendocrine Tumors Staging Classifications for Pancreatic Neuroendocrine Tumors: A Retrospective Nationwide Multicenter Study in South Korea.

Objectives Pancreatic neuroendocrine tumors (pNETs) are diverse diseases with different prognosis. The American Joint Committee on Cancer (AJCC) and the European Neuroendocrine Tumor Society (ENETS) introduced 2 different tumor node metastasis (TNM) stages, and the World Health Organization (WHO) proposed WHO 2010 grading system for pNETs. Therefore, we aimed to validate the prognostic relevance of these 3 systems for pNETs in South Korea. Methods The Korean Society of Gastrointestinal Cancer created a retrospective registry of pNETs in 153 patients from 15 hospitals between 2002 and 2012. Results On the basis of the WHO 2010 grade, 2-year progression-free-survival (PFS) rates for G1, G2, and G3 were 92%, 62%, and 25% (P < 0.01). According to ENETS and AJCC staging, 2-year PFS rates for stages I through IV were 94%, 87%, 49%, 20%, and 92%, 61%, 60%, 20%, respectively (P < 0.01). A Cox multivariate regression analysis revealed that the only statistically significant prognostic factor was the TNM classification of either the AJCC or the ENETS stage (P < 0.01). In addition, the &kgr; value between the AJCC and the ENETS stages was 0.46 indicating a “moderate” agreement (P < 0.01). Conclusions The AJCC and ENETS TNM classifications for pNETs are prognostic for PFS and can be adopted in clinical practice in South Korea.

Is Endoscopic Retrograde Cholangiopancreatography Safe in Patients 90 Years of Age and Older

Background/Aims This case-control study evaluated the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years of age and older. Methods From January 2005 to August 2011, 5,070 cases of ERCP were performed at our institution. Of these, 43 cases involved patients 90 years of age and older (mean age, 91.7±1.9 years). A control group of 129 cases (mean age, 65.7±14.8 years) was matched by the patient sex, sphincterotomy, and presence of choledocholithiasis using a propensity score. The patients’ medical records were retrospectively reviewed for comorbidity, periampullary diverticulum, urgent procedure, conscious sedation, technical success, procedure duration, ERCP-related complication, and death. Results Between the case and control groups, there was no significant difference with regard to comorbidity, periampullary diverticulum, and urgent procedure. Conscious sedation was performed significantly less in the patient group versus the control group (28 [65%] vs 119 [92%], respectively; p=0.000). There was no significant difference in the technical success, procedure duration, or ERCP-related complications. In both groups, there was no major bleeding or perforation related to ERCP. Post-ERCP pancreatitis occurred significantly less in the patient group compared to the control group (0 vs 13 [10%], respectively; p=0.004). One death occurred from respiratory arrest in the case group. Conclusions ERCP can be performed safely and successfully in patients aged 90 years and older without any significant increase in complications.

The Significance of p53 and K-ras Immunocytochemical Staining in the Diagnosis of Malignant Biliary Obstruction by Brush Cytology during ERCP

BACKGROUND/AIMS Brush cytology during ERCP can provide a pathologic diagnosis in malignant biliary obstruction. K-ras and p53 mutations are commonly found in biliary and pancreatic cancers. We evaluated the diagnostic yield of brush cytology and the changes obtained by adding p53 and K-ras staining. METHODS One hundred and forty patients with biliary obstruction who underwent ERCP with brush cytology during a 7-year period were included. The sensitivity and specificity of brush cytology only and with the addition of p53 and K-ras staining were obtained. RESULTS Malignant biliary obstruction was confirmed in 119 patients. The sensitivity and specificity of brush cytology were 78.2% and 90.5%, respectively. The sensitivity of cytology was 77.3% at the ampulla-distal common bile duct (CBD), 92.6% at the mid common hepatic duct (CHD), and 94.7% at the proximal CBD-CHD (p<0.05); these values did not differ with the degree or the length of the obstruction. In the 97 patients who received additional p53 and K-ras staining, the sensitivity of cytology plus p53 was 88.2%, cytology plus K-ras was 84.0%, and cytology plus p53 and K-ras was 88.2%. The sensitivity of cytology plus p53 was higher than that of brush cytology only (95% confidence interval: 83.69-92.78 vs 72.65-83.65) but not that of cytology plus K-ras. CONCLUSIONS Brush cytology for malignant biliary obstruction has a high diagnostic accuracy. Adding p53 staining can further improve the diagnostic yield, whereas K-ras staining does not.

Endoscopic Ultrasound-Guided Direct Intervention for Solid Pancreatic Tumors

Development and use of linear-array echoendoscope and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) have made endoscopic ultrasound (EUS) more of an interventional procedure than a purely diagnostic procedure. This is a literature review of previously published clinical studies on EUS-guided direct intervention for solid pancreatic tumors, including EUS-guided fine needle injection (EUS-FNI) of antitumor agents, EUS-guided fiducial marker placement, EUS-guided brachytherapy and EUS-guided tumor ablation.

Association between Smoking and the Progression of Computed Tomography Findings in Chronic Pancreatitis.

Background/Aims Smoking and alcohol intake are two well-known risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis. Methods In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking. Results The median duration of follow-up was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio [OR], 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008). Conclusions Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.

Type 1 autoimmune pancreatitis with histologically proven granulocytic epithelial lesions.

There are two distinct subtypes of autoimmune pancreatitis (AIP): type 1 and type 2. Type 1 AIP is the pancreatic manifestation of systemic fibroinflammatory disease, which is named as IgG4-related disease. On the other hand, type 2 AIP is a pancreatic disorder that is not associated with IgG4. Type 1 and type 2 AIP have different clinical profiles and histologic findings. We present a 22-year-old man who has been diagnosed as type 1 AIP with histologically proven granulocytic epithelial lesion after surgical resection for pancreatic head mass. Since the patient had no pancreatic duct narrowing, elevation of serum IgG4, and other organ involvement, it was very difficult to diagnose preoperatively. This is a rare and interesting case in which histologic features of type 1 and type 2 AIP coexist.

Sex differences in prevalence and risk factors of asymptomatic cholelithiasis in Korean health screening examinee: A retrospective analysis of a multicenter study.

Abstract The aim of this study was to evaluate sex difference in the prevalence and risk factors for asymptomatic cholelithiasis in Korean health screening examinees. Examinees who underwent examination through health promotion center at 5 hospitals of Daegu-Gyeongbuk province in 2014 were analyzed retrospectively. All examinees were checked for height, weight, waist circumference, and blood pressure, and underwent laboratory tests and abdominal ultrasound. Diagnosis of cholelithiasis was made by ultrasound. Of the total of 30,544 examinees, mean age was 47.3 ± 10.9 years and male to female ratio was 1.4:1. Asymptomatic cholelithiasis was diagnosed in 1268 examinees with overall prevalence of 4.2%. In age below 40 years, females showed higher prevalence of asymptomatic cholelithiasis than males (2.7% vs. 1.9%, P = 0.020), whereas prevalence of asymptomatic cholelithiasis was higher in males than females older than 50 years (6.2% vs. 5.1%, P = 0.012). Multiple logistic regression analysis revealed age (≥50 years), obesity, and high blood pressure as risk factors for asymptomatic cholelithiasis in males and age, obesity, hypertriglyceridemia, and chronic hepatitis B infection in females (P < 0.05). Overall prevalence of asymptomatic cholelithiasis was 4.2% in Korean health screening examinees. Females showed higher prevalence of asymptomatic cholelithiasis than males younger than 40 years, whereas it was higher in males older than 50 years. Age and obesity were risk factors for asymptomatic cholelithiasis in both sexes. Males had additional risk factors of high blood pressure and females had hypertriglyceridemia and chronic hepatitis B infection.