Sun Gyo Lim

Effect of Virological Response to Entecavir on the Development of Hepatocellular Carcinoma in Hepatitis B Viral Cirrhotic Patients: Comparison Between Compensated and Decompensated Cirrhosis

OBJECTIVES:This study aimed to evaluate the risk of development of hepatocellular carcinoma (HCC) according to underlying liver status and virological response (VR) to entecavir (ETV) in chronic hepatitis B patients with cirrhosis. Procollagen III N-terminal peptide (PIIINP) concentration during ETV treatment and its association with HCC development were also evaluated.METHODS:A total of 306 patients with clinically diagnosed liver cirrhosis were treated with ETV for ≥12 months and were subsequently followed up for the occurrence of HCC (median follow-up duration: 37.0 months). Patients who developed HCC within 12 months were excluded. VR was defined as a hepatitis B virus DNA level <20 IU/ml at 12 months after ETV treatment.RESULTS:A total of 209 patients (68.3%) had compensated cirrhosis, and the remaining patients (31.7%) had decompensated cirrhosis. The 5-year cumulative incidence of HCC was 26.8%. A multivariate Cox regression analysis identified the following independent risk factors for developing HCC in all the patients: age >50 years (hazard ratio (HR)=8.41; 95% confidence interval (CI)=3.86–18.28; P=0.000), male sex (HR=4.24; 95% CI=1.83–9.81; P=0.001), high serum PIIINP level at 12 months (HR=1.07; 95% CI=1.02–1.13; P=0.007), and no VR at 12 months (HR=2.10; 95% CI=1.02–4.33; P=0.043). The subgroup analyses showed that no VR at 12 months is a significant risk factor for developing HCC in the patients with decompensated cirrhosis (HR=7.74; 95% CI=1.34–44.78; P=0.022) but not in those with compensated cirrhosis (P=0.749).CONCLUSIONS:The antiviral treatment with ETV did not completely eliminate the risk of developing HCC in our patients with cirrhosis. However, VR to ETV was associated with a low probability that the patients with decompensated cirrhosis would develop HCC.

Y-shaped endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: prospective long-term study.

Abstract Objective. Although still controversial, bilateral stenting may be the best option for palliative drainage of malignant hilar biliary obstruction. The aim of our study was to evaluate the technical and clinical efficacies of endoscopic bilateral metal stenting using a biliary Y-stent for the management of malignant hilar obstruction. Material and methods. This prospective, uncontrolled study included 30 consecutive patients with unresectable malignant hilar strictures in whom we intended to perform endoscopic bilateral stent-in-stent deployment using a biliary Y-stent. After deployment of the Y-stent across the hilar stricture, a conventional biliary metal stent was inserted in a Y-configuration in which it traversed the wider-mesh central portion of the Y-stent to enter the opposite hepatic lobe. Results. Bilateral metal stenting using a Y-stent was successful in 26 of 30 patients (86.7%), and successful drainage was achieved in all 26 patients (100%). Early complications occurred in 3 patients (cholangitis, 1; cholecystitis, 2) without procedure-related mortality. As late complications during the follow-up period (median, 176 days; range, 70–473 days), stent occlusion occurred in 10 of 26 patients (38.5%). Four patients were managed with the insertion of a plastic stent through the occluded metal stent, and the remaining patients were treated with percutaneous biliary drainage. The median survival and stent patency were 176 days and 140 days, respectively. Conclusions. Y-shaped endoscopic bilateral stenting using a Y-stent appears to be a feasible and effective method with high technical success and low stent-related complications for palliation of unresectable malignant hilar biliary obstruction.

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.

G-Protein Beta3 Subunit C825T Polymorphism in Patients With Overlap Syndrome of Functional Dyspepsia and Irritable Bowel Syndrome.

Background/Aims Guanine nucleotide binding protein (G-protein) beta polypeptide 3 (GNB3) C825T polymorphism alters intracellular signal transduction, which may lead to motor or sensory abnormalities of the gastrointestinal tract. The aim of the present study was to evaluate the association of the GNB3 C825T polymorphism with susceptibility to overlap syndrome of functional dyspepsia (FD) and irritable bowel syndrome (IBS) in a Korean population. Methods One hundred sixty-seven patients with FD alone, 60 patients with IBS alone, 85 patients with the overlap of FD and IBS, and 434 asymptomatic healthy subjects participated in the study. Genotyping for GNB3 C825T polymorphism was performed using their blood samples. Results No association of GNB3 genotypes in patients with FD alone, IBS alone or overlap phenotype, when compared to genotypes in controls, was detected. The frequency of CT and TT genotypes relative to the CC genotype for the phenotypes of FD alone, IBS alone and the coexistence of FD and IBS did not significantly differ. Comparison of the TT genotype with the CC/CT genotype showed no significant association for each phenotype group. Conclusions There is no apparent association of the GNB3 C825T polymorphism with the susceptibility to FD, IBS or the overlap of FD and IBS. Larger-scale studies and further investigation on other candidate genes are required.

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.

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.

Fully covered, retrievable self-expanding metal stents (Niti-S) in palliation of malignant dysphagia: Long-term results of a prospective study

Abstract Background. In the palliative treatment of malignant dysphagia, fully covered, retrievable metal stents are not commonly used, mainly due to the high risk of migration. Therefore, we performed a prospective study to evaluate the clinical efficacy of a fully covered, retrievable self-expanding metal stent (Niti-S). Method. Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction treated with the fully covered Niti-S stent (Niti-S, Taewoong Medical, Seoul, South Korea) were included. Data collected contained functional outcome, feasibility of endoscopic stent retrieval, recurrent dysphagia, complications, and survival. Result. At 4 weeks after stent placement, dysphagia significantly improved in all patients (p = 0.000). Recurrent dysphagia occurred in 19 of 100 patients treated with Niti-S stents (19%) mainly due to tumor overgrowth (7/100, 7%), stent migration (6/100, 6%), and food impaction (6/100, 6%). Endoscopic stent retrieval was successful in all the attempted 17 patients (17/100, 17%) – 7 overgrowth, 6 stent migration, 2 stent degradation, and 2 severe pain. Major complications were 2 hemorrhage, 2 severe pain, and 1 tracheal compression (5/100, 5%), and minor complications were 10 retrosternal pain and 7 symptomatic gastroesophageal reflux (17/100, 17%). After a median follow-up of 142 days, 97 patients had expired. There was no stent-related mortality or 30-day mortality. Conclusion. The fully covered, retrievable Niti-S stent has proved its effectiveness for palliation of malignant dysphagia and feasibility of endoscopic retrieval. We estimate its dog-bone shaped flanges at both ends and it being completely covered provide good resistance to migration and overgrowth.

Endoscopic resection of ampullary adenoma after a new insulated plastic pancreatic stent placement: A pilot study

Background and Aim:  Although pancreatic stent insertion is recommended for the prevention of post‐procedure pancreatitis during endoscopic papillectomy, insertion of the stent after the procedure can be technically difficult. The aim of the present study was to determine the feasibility and safety of inserting a newly developed insulated pancreatic stent before endoscopic papillectomy.

Preoperative colonoscopy for detection of synchronous neoplasms after insertion of self-expandable metal stents in occlusive colorectal cancer: comparison of covered and uncovered stents.

Background/Aims In patients with occlusive colorectal cancers, a complete preoperative evaluation of the colon proximal to the obstruction is often impossible. We aimed to evaluate the feasibility of preoperative colonoscopy after stent placement and to determine whether the success rate of colonoscopy differs between covered and uncovered stents. Methods Seventy-three patients with malignant colorectal obstruction were enrolled prospectively. In patients with a resectable cancer, a preoperative colonoscopy was performed after insertion of a self-expandable metal stent (SEMS). The success rate of complete preoperative colonoscopy was compared between covered and uncovered stents. Results Forty-five of 73 patients who underwent stent placement had a resectable cancer (61.6%). A complete preoperative colonoscopy was possible in 40 of 45 patients (88.9%). The success rate of complete preoperative colonoscopy was significantly lower in the covered-stent group when the obstructing mass lesion was located in the sigmoid colon (p=0.024). Synchronous cancer was detected in one patient (2.2%). Stent migration was observed in four patients with a covered stent. Conclusions A preoperative complete colonoscopy after SEMS placement was feasible and safe in most patients with malignant colorectal obstruction. Uncovered stents seem to have more advantages than covered stents in preoperative colonoscopy proximal to the obstruction.

Partially covered versus uncovered self-expandable nitinol stents with anti-migration properties for the palliation of malignant distal biliary obstruction: A randomized controlled trial

Abstract Objective. Covered self-expandable metal stents (SEMSs) are increasingly used as alternatives to uncovered SEMSs for the palliation of inoperable malignant distal biliary obstruction to counteract tumor ingrowth. We aimed to compare the outcomes of partially covered and uncovered SEMSs with identical mesh structures and anti-migration properties, such as low axial force and flared ends. Materials and methods. One hundred and three patients who were diagnosed with inoperable malignant distal biliary obstruction between January 2006 and August 2013 were randomly assigned to either the partially covered (n = 51) or uncovered (n = 52) SEMS group. Results. There were no significant differences in the cumulative stent patency, overall patient survival, stent dysfunction-free survival and overall adverse events, including pancreatitis and cholecystitis, between the two groups. Compared to the uncovered group, stent migration (5.9% vs. 0%, p = 0.118) and tumor overgrowth (7.8% vs. 1.9%, p = 0.205) were non-significantly more frequent in the partially covered group, whereas tumor ingrowth showed a significantly higher incidence in the uncovered group (5.9% vs. 19.2%, p = 0.041). Stent migration in the partially covered group occurred only in patients with short stenosis of the utmost distal bile duct (two in ampullary cancer, one in bile duct cancer), and did not occur in any patients with pancreatic cancer. Conclusions. For the palliation of malignant distal biliary obstruction, endoscopic placement of partially covered SEMSs with anti-migration designs and identical mesh structures to uncovered SEMSs failed to prolong cumulative stent patency or reduce stent migration.