Kye Sook Kwon

Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study.

BACKGROUND Endoscopic sphincterotomy (EST) has usually been performed before large-balloon sphincteroplasty (LBS) to retrieve large bile duct stones because of the high risk of pancreatitis and some advantages of EST. However, there are no available data on the preceding EST to confirm these assertions. OBJECTIVE We investigated the safety and efficacy of LBS without a preceding EST for the management of large bile duct stones. DESIGN Single-institution retrospective study. SETTING Tertiary referral center. PATIENTS Thirty-eight patients with large bile duct stones. INTERVENTIONS Endoscopic LBS without preceding EST. MAIN OUTCOME MEASUREMENTS Efficacy of stone removal and complications related to the procedure. RESULTS The overall success rate irrespective of whether mechanical lithotripsy (ML) was used was 97.4% (37/38). Complete duct clearance by LBS alone without ML was achieved in 29 (76.3%) patients. Complete stone retrieval was achieved by LBS alone in the first session in 25 (65.8%) patients. ML was required in 8 (21.1%) patients. Failure to extract a stone occurred in 1 (2.6%) patient. There was a mild degree of postprocedure pancreatitis in only 1 (2.6%) patient and asymptomatic hyperamylasemia in 3 (7.9%) patients. The maximum diameters of the stones and the balloon/stone diameter ratio had a tendency to affect complete stone retrieval in the success and failure groups: 16.7 +/- 3.9 mm vs 20.8 +/- 6.5 mm and 0.96 +/- 0.19 mm vs 0.80 +/- 0.23 mm, respectively (results are presented as mean +/- standard deviation). LIMITATIONS Small-scale, single-arm study. CONCLUSIONS Our data suggest that LBS without EST is safe and effective in patients with large bile duct stones.

Efficacy and safety ofdigoxin alone and in combination with low-dosediltiazem orbetaxolol to control ventricular rate in chronic atrial fibrillation

C hronic atria1 fibrillation (AF) is characterized by a rapid increase in the ventricular rate during exercise. Digoxin alone, acting primarily by causing an increase in vagal tone, often fails to control exercise-induced tachycardia in patients with AF.’ Beta-adrenergic blockade and calcium antagonists tend to act preferentially on exercise heart rate,2,3 but both can induce adverse effects2,4-7 that detract from their beneficial effects on control of heart rate, and are known to be dose-dependent.@ Few studies on the combination of digitalis and P-adrenergic blockade or calcium antagonists in chronic AF have taken into account the adequacy of digitalization as judged from serum leve1.2,6,9 Such determination seems mandatory in order to prove the true contribution of the added P-adrenergic blockade or calcium antagonist. The purpose of this study was therefore threefold: (1) to reevaluate the role of digitalis in maintaining adequate heart rates in patients with chronic AF, (2) to compare the effects and safety of digoxin in combination with low-dose diltiazem and betaxolol on ventricular rate response, blood pressure, rate-pressure products, and maximal exercise tolerance during exercise in patients with chronic AF; and (3) to study the frequency of adverse effects when using low-dose diltiazem and betaxolol. . . . Forty-five patients (22 men and 23 women, mean age 59 f 2 years, range 29 to 82) with AF for >I month (defined in this study as chronic AF) were included after providing informed consent. Three patients (2 in group III and 1 in group IV) did not complete the study protocol; thus, the results are obtained from 42 patients. On

Comparative study of efficacy and safety of low-dose diltiazem or betaxolol in combination with digoxin to control ventricular rate in chronic atrial fibrillation: randomized crossover study

BACKGROUND The combination therapy of low-dose diltiazem or bexatolol with digoxin can be a useful adjunct for achieving heart rate control with minimal side effects. But there has not been a study including patients with impaired left ventricular function and evaluating whether the beneficial effects of medication will be maintained during a follow-up period. OBJECTIVES The purpose of this study was three-fold: (1) to compare the efficacy of digoxin with low-dose diltiazem and digoxin with low-dose betaxolol on randomized crossover study; (2) to evaluate whether the beneficial effects of medication will be maintained after 7 months; (3) to evaluate the safety of the combination therapy in patients with impaired left ventricular function. METHODS We did a prospective randomized crossover study in 35 patients with chronic atrial fibrillation (AF) including 15 patients with left ventricular dysfunction. After enrollment, each patient was evaluated for heart rate, blood pressure, rate-pressure products, maximal exercise tolerance at rest and during symptom-limited treadmill test before medication, at 4 weeks after medication of digoxin (0.125-0.5 mg daily) with diltiazem (90 mg twice daily), and at 4 weeks after digoxin with betaxolol (20 mg once daily). We performed 24-h ambulatory electrocardiogram (ECG) in 15 patients at the end of each phase of treatment. We repeated symptom-limited treadmill test like above method in 15 patients at 7 months of medication. RESULTS (1) Ventricular rates were significantly reduced in digoxin with low-dose betaxolol therapy at rest and during exercise (67 +/- 3, 135 +/- 5 (mean +/- S.E.M.) beats/min, respectively) in comparison to digoxin with low-dose diltiazem therapy (80 +/- 7, 154 +/- 5) (P < 0.05). (2) Rate-pressure products were significantly less in digoxin with low-dose betaxolol at rest and during exercise (85 +/- 4, 213 +/- 12 x 10(2) mmHg/min) than in digoxin with low-dose diltiazem therapy (105 +/- 6, 269 +/- 12) (P < 0.05). (3) Exercise capacity was significantly improved in digoxin with low-dose betaxolol (9.3 +/- 0.5 METS) or digoxin with low-dose diltiazem (9.7 +/- 0.5) in comparison to control state (8.3 +/- 0.5) (P < 0.05). (4) At 7 months evaluation, there was no significant difference between at 4 weeks and at 7 months. (5) Results on 24-h ambulatory ECG showed the same findings as on treadmill test. (6) Although side effects occurred more frequently in digoxin with low-dose betaxolol therapy, they were minimal and no patient had to withdraw medication. Worsening of left ventricular dysfunction was not observed. CONCLUSION Our study suggested that (1) combination therapy of low-dose betaxolol with digoxin was more superior to low-dose diltiazem with digoxin in controlling ventricular rate and reducing rate-pressure products; (2) the effects controlling ventricular rate, reducing rate-pressure products and improving exercise capacity have been well maintained even after 7 months of medication with each combination therapy.

Identification of Helicobacter pylori in gallstone, bile, and other hepatobiliary tissues of patients with cholecystitis

BACKGROUND/AIMS Bacterial infection is accepted as a precipitating factor in cholesterol gallstone formation, and recent studies have revealed the presence of Helicobacter species in the hepatobiliary system. We utilized the polymerase chain reaction (PCR) to establish the presence of bacterial DNA, including from Helicobacter species, in gallstones, bile juice, and gallbladder mucosa from patients with gallstones. METHODS At cholecystectomy, 58 gallstones, 48 bile samples, and 46 gallbladder mucosa specimens were obtained and subjected to nested PCR using specific 16S rRNA primers of H. pylori and other bacteria. Bacterial species were identified by DNA sequencing analysis. Bacterial 16S rRNA was detected in 25 out of 36 mixed-cholesterol gallstones, 1 out of 10 pure-cholesterol gallstones, and 9 out of 12 pigmented stones. Furthermore, 16S rDNA sequencing identified Escherichia coli, Pseudomonas, Citrobacter, Klebsiella, and Helicobacter species. RESULTS Helicobacter DNA was detected in 4 out of 58 gallstones, 6 out of 48 bile samples, and 5 out of 46 gallbladder specimens. Direct sequencing of Helicobacter amplicons confirmed strains of H. pylori in all four gallstones, five out of six bile samples, and three out of five gallbladder specimens. Almost all mixed-cholesterol gallstones appear to harbor bacterial DNA, predominantly E. coli. CONCLUSIONS H. pylori was also found in the biliary system, suggesting that these bacteria are of etiological importance in gallstone formation.

Risk Factors for Long-term Outcomes after Initial Treatment in Hepatolithiasis

Hepatobiliary complications, such as stone recurrence, recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma may occur after treatment for hepatolithiasis. However, few previous studies have addressed the risk factors and long-term outcomes after initial treatment. Eighty-five patients with newly diagnosed hepatolithiasis, actively treated for hepatolithiasis, constituted the cohort of this retrospective study. Patients were treated by hepatectomy or nonoperative percutaneous transhepatic cholangioscopic lithotomy. Long-term complications, such as recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma, and their relationships with clinical parameters were analyzed. The mean follow-up period was 57.4 months. The overall hepatobiliary complication rate after the treatment was 17.6%. Multivariate analysis of suspected risk factors showed that complications were associated with age (HR, 1.046; CI, 1.006-1.089), bile duct stricture (HR, 4.894; CI, 1.295-18.495), and residual stones (HR, 3.482; CI, 1.214-9.981). In conclusion, several long-term hepatobiliary complications occur after hepatolithiasis treatment, and regular observation is necessary in patients with concomitant biliary stricture or residual stones.

A peroxisome-proliferator activated receptor-γ ligand could regulate the expression of leptin receptor on human hepatic stellate cells

Leptin is a peptide known to play a profibrogenic role in hepatic stellate cells (HSCs). Peroxisome-proliferator activated receptor (PPAR)-γ ligands are suggested to have an anti-fibrogenic effect on HSCs. Since the association of these two factors in HSC activation has not been demonstrated, we hypothesized that PPAR-γ ligands would suppress leptin-induced HSC activation and regulate leptin receptor expression. Immortalized human HSCs were activated by either leptin or platelet-derived growth factor (PDGF) in one group. In another group, ciglitazone, a PPAR-γ ligand, was treated before the leptin or PDGF stimulation. Proliferation of human HSCs was achieved by both PDGF and leptin, and this could be suppressed by ciglitazone. PPAR-γ mRNA expression was diminished in activated HSCs either by PDGF or leptin, and this was reversed by ciglitazone in both cases. Leptin receptor (OB-R) mRNA expression increased in activated HSCs either by PDGF or leptin, and the expression was inhibited by ciglitazone. Another adipogenic transcription factor, sterol regulatory element-binding protein-1c (SREBP-1c) mRNA expression was decreased either by PDGF or leptin. However, this effect was not reversed by ciglitazone pre-treatment. The inhibitory effect of ciglitazone on leptin-induced HSC proliferation was associated with the reversion of extracellular factor-regulated kinases (ERKs) activation. HSCs were OB-R expressing cells, and ciglitazone could regulate the expression of OB-R mRNA.

Does prevalence of migraine and Raynaud's phenomenon also increase in Korean patients with proven variant angina?

BACKGROUND The incidence of coronary artery spasm in oriental patients is higher than that in western patients. Oriental patients with variant angina (VA) frequently show normal or insignificant coronary artery stenosis by angiogram, compared with western patients. The prevalence of migraine and Raynauds phenomenon in oriental patients with VA has not yet reported. OBJECTIVE We did a prospective study on the prevalence of migraine and Raynauds phenomenon in patients with proven VA compared with those in two control groups using a radioisotope technique following ice water exposure. Simultaneously, we studied lipid profiles of each group. METHODS AND RESULTS migraine was diagnosed if the score in part A totalled 7 or more of 26, and Raynauds phenomenon was diagnosed if the score in part B totalled 4 or more of 11 by Miller et al. Technetium-99m-labeled red blood cells (99mTc-RBC) radionuclide angiography was performed in all patients. Patients were included in a prospective protocol. Patients were grouped as follows: Group I: 20 patients with proven VA; Group II: 30 patients with coronary artery disease; Group III: 31 patients without heart disease. Age and sex of patients were not statistically different among the three groups. Migraine was diagnosed in 8 patients (40.0%) of group I and in 6 patients (20.0%) of group II and in 12 patients (38.7%) of group III. Raynauds phenomenon was reported in 2 (10.0%) of the patients in group I and in 5 (16.1%) of the patients of group III. The mean index ratio of the digital blood flow of right over left hand on static image was 0.85 +/- 0.07 (mean +/- S.E.M.) of the patients of group I, 0.73 +/- 0.03 of the patients of group II and 0.74 +/- 0.04 of the patients of group III. The mean flow index ratio of right over left hand of the digital blood flow on dynamic study was 0.51 of the patients of group I, 0.43 of the patients of group II and 0.43 of the patients of group III. The score of migraine did not differ significantly among the three groups. The score of Raynauds phenomenon of patients with variant angina did not differ significantly from that of patients in the non-coronary control group, although it differed significantly from that of patients in the coronary control group. But, the prevalence of migraine and Raynauds phenomenon (questionnaire and radionuclide angiography) in patients of group I did not differ significantly from that in groups II and III. In the end, more patients with variant angina than coronary or non-coronary control group did not reach the predetermined point level for the diagnosis of migraine and Raynauds phenomenon. Lipid profiles were not significantly different among three groups. CONCLUSIONS This result suggests that variant angina may not be a manifestation of a generalized vasospastic disorder in Korean patients.

Peroral Endoscopic Myotomy for Treating Achalasia in an Animal Model: A Feasibility Study

Background/Aims Laparoscopic Heller myotomy with antireflux procedure is considered to be a standard treatment for achalasia. Recently, peroral endoscopic myotomy (POEM) was developed and performed on patients with achalasia. However, there is no report on POEM use in South Korea. The aim of this study was to evaluate the technical feasibility of POEM in a porcine model. Methods POEM was performed on two mini pigs. We performed upper endoscopy under general anesthesia. A submucosal tunnel was created and the circular muscle layer was incised using several knives. The mucosal entry was closed using resolution clips. We performed a follow-up endoscopy and sacrificed the pigs 2 weeks after the POEM. The myotomy site was evaluated grossly and histologically. Results POEM was successfully performed on the two mini pigs. No injuries to any abdominal or mediastinal structures occurred. Two weeks after the POEM, the esophageal mucosa healed without any endoscopic evidence of complications. Necropsy revealed that the circular muscle layer was completely lost and replaced with fibrotic tissue. Conclusions We found that POEM is a technically feasible method which can be performed on an animal model. However, to ensure safe use on patients with achalasia, further studies on technical methods and long-term follow-up examinations are required.

Accuracy of endoscopic ultrasonography for diagnosing ulcerative early gastric cancers.

AbstractAlthough endoscopic ultrasonography (EUS) is the first-choice imaging modality for predicting the invasion depth of early gastric cancer (EGC), the prediction accuracy of EUS is significantly decreased when EGC is combined with ulceration.The aim of present study was to compare the accuracy of EUS and conventional endoscopy (CE) for determining the depth of EGC. In addition, the various clinic-pathologic factors affecting the diagnostic accuracy of EUS, with a particular focus on endoscopic ulcer shapes, were evaluated.We retrospectively reviewed data from 236 consecutive patients with ulcerative EGC. All patients underwent EUS for estimating tumor invasion depth, followed by either curative surgery or endoscopic treatment. The diagnostic accuracy of EUS and CE was evaluated by comparing the final histologic result of resected specimen. The correlation between accuracy of EUS and characteristics of EGC (tumor size, histology, location in stomach, tumor invasion depth, and endoscopic ulcer shapes) was analyzed. Endoscopic ulcer shapes were classified into 3 groups: definite ulcer, superficial ulcer, and ill-defined ulcer.The overall accuracy of EUS and CE for predicting the invasion depth in ulcerative EGC was 68.6% and 55.5%, respectively. Of the 236 patients, 36 patients were classified as definite ulcers, 98 were superficial ulcers, and 102 were ill-defined ulcers, In univariate analysis, EUS accuracy was associated with invasion depth (P = 0.023), tumor size (P = 0.034), and endoscopic ulcer shapes (P = 0.001). In multivariate analysis, there is a significant association between superficial ulcer in CE and EUS accuracy (odds ratio: 2.977; 95% confidence interval: 1.255–7.064; P = 0.013).The accuracy of EUS for determining tumor invasion depth in ulcerative EGC was superior to that of CE. In addition, ulcer shape was an important factor that affected EUS accuracy.

A Case of Esophageal Fibrovascular Polyp That Induced Asphyxia during Sleep

Esophageal fibrovascular polyps are rare, benign, submucosal tumors of the upper digestive tract that usually have an indolent course until the lesion attains a very large size. The most frequent complaints associated with these tumors include dysphagia and foreign body sensation. However, a long pedunculated polyp can regurgitate into the pharynx or oral cavity and cause asphyxia and sudden death if the larynx is occluded. We describe the case of a 51-year-old man who experienced snoring and occasional asphyxia during sleep. Upper endoscopy was performed, which indicated the presence of a pedunculated esophageal polyp that regurgitated into the vocal cords. The polyp was removed using a polypectomy snare and was confirmed to be a fibrovascular polyp based on pathologic examination findings. Three months after the excision of the polyp, the patient was found to be doing well without any further occurrence of asphyxia or sleep disturbances.