Kee Myung Lee

Abdominal pain accompanied by weight loss may increase the diagnostic yield of capsule endoscopy : A Korean multicenter study

Objective. Capsule endoscopy (CE) is approved for the evaluation of obscure gastrointestinal (GI) bleeding and its use has increased in the assessment of patients with various small-bowel disorders. The yield of CE for indications of disorders other than GI bleeding is not yet well described. The aim of the present study was to determine in which subgroup of patients with unexplained abdominal pain, CE would be a helpful evaluation tool. Material and methods. The results of CE in 110 patients (70 M, 40 F, mean age 50.8±14.1 years) with unexplained abdominal pain from 12 tertiary referral centers between September 2002 and September 2004 were retrospectively analyzed. Results. The visualization of the small bowel to the cecum was successfully carried out in 69.1% of the patients. Nineteen out of the 110 cases revealed positive findings that explained the symptoms of the patient (diagnostic yield = 17.3%). Diagnosis included small-bowel stricture (5), Crohns disease (3), small-bowel tumor (2), radiation-induced enteritis (1), NSAID-induced enteropathy (1), ischemic ileitis (1), diffuse lymphangiectasia (1), and significant erosion or ulceration (5). By univariate logistic regression analysis, the positive findings of CE were significantly associated with weight loss (odds ratio (OR), 11.9; 95% CI [2.0, 70.6]), elevated erythrocyte sedimentation rate (ESR) (>20 mm/h) (OR, 11.5; 95% CI (1.9, 69.5)), elevated C-reactive protein (CRP) (≥0.4 mg/dL) (OR, 5.0; 95% CI (1.6, 15.9)), and hypoalbuminemia (albumin <3 g/dL) (OR, 23.1; 95% CI (2.4, 223.1)). Using a multivariate analysis, weight loss was found to be a significant risk factor for positive findings of CE (OR, 18.6; 95% CI (1.6, 222.4), p = 0.02). Conclusions. The results of this study suggest that CE can be helpful in patients suffering from abdominal pain that cannot be explained by established examinations, if the pain is accompanied by weight loss.

Palliative treatment of malignant gastroduodenal obstruction with metallic stent: prospective comparison of covered and uncovered stents

Background. The placement of self-expandable metallic stents (SEMS) is known to be effective palliative treatment of malignant gastroduodenal obstruction. There are two types of SEMS – covered and uncovered – each with its own advantages and disadvantages. This study was conducted to compare between the clinical outcomes of covered and uncovered stents in patients with malignant gastroduodenal obstruction. Patients and methods. The study was conducted prospectively from January 1998 to June 2007 and 154 patients were included. All had symptomatic gastroduodenal obstruction and were not candidates for curative operation. Seventy patients received covered SEMS, while the other 84 received uncovered SEMS. We compared technical and clinical success rates, tumour ingrowth rate, stent migration rate, stent patency time and patient survival in both SEMS groups. Results. The technical and clinical success rates of the covered and uncovered stent groups did not differ. Stent migration was more frequent in the covered stent group than in the uncovered group (17.1% versus 0%; p=0.0001). Tumour ingrowth was more frequent in the uncovered stent group than in the covered group (16.6% versus 2.9%; p=0.0066). Stent re-intervention rate, stent patency time and patient survival did not differ between groups. Conclusion. Covered and uncovered stent insertions are technically feasible and effective palliative treatment of malignant gastroduodenal obstruction. Covered stents can reduce the risk of tumour ingrowth, whereas uncovered stents are effective in preventing stent migration. However, covered stents did not differ from uncovered stents in regard to other clinical outcomes.

Minimally invasive treatment of gastric gastrointestinal stromal tumors: laparoscopic and endoscopic approach.

Purpose: This study aimed to verify the long-term outcome of a minimally invasive endoscopic or laparoscopic approach for the treatment of gastric gastrointestinal stromal tumor (GIST). Methods: This single-center study involved a retrospective review of gastric tumors that were pathologically confirmed as GIST. A total of 84 patients who underwent minimally invasive endoscopic or laparoscopic resection for gastric GIST were enrolled from February 2002 to June 2007. These demographics, tumor characteristics, and outcomes were analyzed for identification of outcomes and feasibility of endoscopic or laparoscopic resection. Results: Of 84 patients, 27 and 57 patients underwent endoscopic and laparoscopic resection, respectively. The average tumor size was 3.1±1.7 cm. With a mean follow-up of 40.5±20.7 months, 82 (97.7%) patients were disease free. Two patients, both of whom underwent laparoscopic resection, were alive with peritoneal recurrence. Two (7.4%) and 6 (10.5%) patients, respectively, had postoperative complications after endoscopic resection and laparoscopic resection. There was no significant difference in the operative morbidity according to tumor size. There was no postoperative mortality. Conclusions: Laparoscopic surgery for gastric GIST is safe and feasible, even in large (>5 cm) tumors. Because endoscopic resection showed good results without recurrence, this approach can be useful in selected cases with a high operative risk or a need for preservation of organ function.

Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones

BackgroundEndoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) has been proposed as an alternative to manage large bile duct stones. However, recent reports indicate that LBD without EST may be safe and effective in this setting.MethodsOne hundred thirty-one patients with large common bile duct (CBD) stones 12 mm in size or larger underwent LBD alone (n = 62) or EST plus LBD (n = 69) for lithotripsy. The therapeutic outcome and complications were reviewed and compared.ResultsThere were no differences between the two groups with regard to age, size and number of stones, or bile duct diameter. The LBD alone group (mean age, 70.4 years) and the EST plus LBD group (mean age, 68.2 years) had similar outcomes in terms of overall successful stone removal (96.8% vs. 95.7%, P = 0.738) and complete stone removal without the need for mechanical lithotripsy (80.6% vs. 73.9%, P = 0.360). Complications in the LBD alone and EST plus LBD groups were as follows: pancreatitis (6.5% vs. 4.3%, P = 0.593), impaction of basket and stone (0% vs. 1.4%, P = 0.341), and perforation (0% vs. 1.4%, P = 0.341).ConclusionsLBD alone may be a simple, safe, and effective alternative to EST plus LBD in relatively aged patients with large CBD stones, and it can simplify the procedure compared with EST plus LBD.

Association of the human leukocyte antigen class II alleles with chronic atrophic gastritis and gastric carcinoma in Koreans

OBJECTIVE:  Gastric carcinogenesis is a multi‐step process and is influenced by several etiological agents, including the hosts genetic factors. Since whether a patient remains with chronic superficial gastritis (CSG) or progresses to either chronic atrophic gastritis (CAG) or gastric carcinoma (GC) could be a genetic predisposition unique in each population, we hypothesized that host human leukocyte antigen (HLA) alleles could be discriminative in predicting the risk of CSG progression to precancerous CAG and GC in Koreans.

Efficacy of Endoscopic Ultrasonography for Prediction of Tumor Depth in Gastric Cancer

Purpose As the proportion of early gastric cancer (EGC) has recently been increased, minimally invasive treatment is currently accepted as main therapy for EGC. Accurate preoperative staging is very important in determining treatment options. To know the accuracy of endoscopic ultrasonography (EUS), we compared the depth of invasion of the tumor with preoperative EUS and postoperative pathologic findings. Materials and Methods We retrospectively analyzed 152 patients who underwent EUS before laparoscopic gastrectomy. The preoperative EUS results were compared with the pathological findings. Results The overall proportion of coincidence for depth of invasion between EUS and pathologic results was 41.4%. Univariate analysis showed that the rate of corrected prediction of EUS for tumor depth significantly decreased for the lesions more than 3cm in diameter (P=0.033), and those with a depressed morphology (P=0.035). In multivariate analysis, the depressed type (P=0.029, OR=2.873) and upper lesion (P=0.035, OR=2.151) was the significantly independent factors influencing the inaccurate prediction of EUS for tumor depth. Conclusions When we decide the treatment modality considering the clinical depth of invasion by EUS, the possibility of discordance with pathologic results should be considered for the lesions located in the upper third of the stomach and with a depressed morphology.

Late reactivation of sonic hedgehog by Helicobacter pylori results in population of gastric epithelial cells that are resistant to apoptosis: implication for gastric carcinogenesis.

As much as that a disturbance of tissue homeostasis through dysregulated apoptosis is generally associated with carcinogenesis, gastric carcinogenesis after Helicobacter pylori infection could be the accumulated consequence of imbalances between apoptosis and proliferation. Since sonic hedgehog (Shh) has been reported to play versatile roles in various tumorigenesis, we hypothesized that late reactivation of sonic hedgehog by H. pylori infection results in population of gastric epithelial cells that are resistant to apoptosis. The Resistant Clones against H. pylori-induced Apoptosis (RCHA) were established and maintained up to 19th cell passages, during which the serial changes of Shh expression were measured. Apoptosis was measured in N-Shh over-expressed stable cell lines and compared with parent cell line after either infected with H. pylori or treated with cyclopamine. For clinical relevance, the expressions of Shh were compared in tissues from gastric adenoma or adenocarcinoma according to H. pylori infection. Longer passages of RCHA after H. pylori infection, the higher expressions of Shh, suggesting RCHA was associated with the reactivation of Shh. Significant decrement in subG1 phase of cell cycle and attenuated executions of apoptosis after H. pylori infection in cells of Shh overexpression, whereas either Shh siRNA or cyclopamine increased the H. pylori-induced cytotoxicity and significantly abrogated anti-apoptotic actions imposed by Shh. Significantly higher expressions of Shh were seen in H. pylori-associated gastric cancers than H. pylori-not associated gastric cancer. Late reactivation of sonic hedgehog by H. pylori infection results in population of gastric epithelial cells that are resistant to apoptosis and imposes proliferative changes under the background of atrophic gastritis, providing the carcinogenic basis.

The relationship between the failure to eradicate Helicobacter pylori and previous antibiotics use.

BACKGROUND The previous use of antibiotics is known to correlate positively with antibiotic resistance; whether this is also the case in the eradication of Helicobacter pylori infection is unclear. AIM To investigate the relationship between the previous use of antibiotics and the failure of eradication therapy in H. pylori infection. METHODS The relationship between the clinical parameters and the failure of H. pylori eradication was analyzed in patients administered standard triple therapy and then assessed for the eradication of H. pylori based on a C13-urea breath test. RESULTS In a multivariate analysis, failure rates increased significantly in patients with a history of clarithromycin (odds ratio [OR], 4.445) or other macrolides (OR, 2.407) use, who were female (OR, 1.339), or who were older than 60 years of age (OR, 1.326). The eradication failure rate in patients with a history of macrolides use for >2 weeks was significantly higher than if the duration of use was <2 weeks (44.8% vs. 29.3%, p=0.047). CONCLUSIONS A patients history of macrolides is a useful predictor of the likelihood of standard triple therapy failure in H. pylori eradication. The alternatives such as a bismuth-based quadruple or a levofloxacin-containing therapy should be considered in patients treated with macrolides for >2 weeks.

Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage.

BACKGROUND Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration. OBJECTIVE To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy. DESIGN Prospective outcome study. SETTING A tertiary-care referral university hospital. PATIENTS This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy. INTERVENTION PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy. MAIN OUTCOME MEASUREMENTS Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate. RESULTS All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur. LIMITATIONS A small number of patients. Further prospective, randomized, controlled trials are needed. CONCLUSION PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.

High circulating microRNA-122 expression is a poor prognostic marker in patients with hepatitis B virus-related hepatocellular carcinoma who undergo radiofrequency ablation

OBJECTIVES Aim of this study was to investigate the prognostic potential of plasma microRNA-122 levels in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma after hepatic resection or radiofrequency ablation (RFA). DESIGN AND METHODS A total of 120 patients with HBV-related hepatocellular carcinoma who underwent hepatic resection (n=63) or RFA (n=57) were included. The pretreatment plasma microRNA-122 level was assessed using quantitative real time polymerase chain reaction, and the correlation between microRNA-122 expression and various clinical parameters was investigated. RESULTS Multivariate Cox regression analysis demonstrated that, in all patients, a low platelet count (<100×10(9)/L), low albumin level (≤3.5g/dL.), and advanced tumor stage (modified Union for International Cancer Control stage III/IV) were independent prognostic factors for disease-free survival, while a low albumin level and advanced tumor stage were independent prognostic factors for overall survival (OS). In a subgroup analysis of patients who underwent RFA, the patients with high miR-122 expression (>100) had significantly lower OS on Kaplan-Meier analysis (P=0.042). Furthermore, high microRNA-122 expression (hazard ratio [HR]=2.67; 95% confidence interval [CI]=1.12-6.35; P=0.026) and advanced tumor stage (HR=2.27; 95% CI=1.23-4.18; P=0.009) were independent risk factors for poor OS in patients treated with RFA. The combination of microRNA-122 and tumor stage resulted in an area under the curve of 0.818 for predicting 1-year OS in patients who underwent RFA. CONCLUSIONS High plasma microRNA-122 expression was associated with poor OS in patients with HBV-related hepatocellular carcinoma who underwent RFA.