Tae Jun Song

Endoscopic Ultrasound-Guided Transmural and Percutaneous Transhepatic Gallbladder Drainage Are Comparable for Acute Cholecystitis

BACKGROUND & AIMS Endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute, high-risk, or advanced-stage cholecystitis who do not respond to initial medical treatment and cannot undergo emergency cholecystectomy. However, the technical feasibility, efficacy, and safety of EUS-GBD and PTGBD have not been compared. METHODS Fifty-nine patients with acute cholecystitis, who did not respond to initial medical treatment and were unsuitable for an emergency cholecystectomy, were chosen randomly to undergo EUS-GBD (n = 30) or PTGBD (n = 29). The technical feasibility, efficacy, and safety of EUS-GBD and PTGBD were compared. RESULTS EUS-GBD and PTGBD showed similar technical (97% [29 of 30] vs 97% [28 of 29]; 95% 1-sided confidence interval lower limit, -7%; P = .001 for noninferiority margin of 15%) and clinical (100% [29 of 29] vs 96% [27 of 28]; 95% 1-sided confidence interval lower limit, -2%; P = .0001 for noninferiority margin of 15%) success rates, and similar rates of complications (7% [2 of 30] vs 3% [1 of 29]; P = .492 in the Fisher exact test) and conversions to open cholecystectomy (9% [2 of 23] vs 12% [3 of 26]; P = .999 in the Fisher exact test). The median post-procedure pain score was significantly lower after EUS-GBD than after PTGBD (1 vs 5; P < .001 in the Mann-Whitney U test). CONCLUSIONS EUS-GBD is comparable with PTGBD in terms of the technical feasibility and efficacy; there were no statistical differences in the safety. EUS-GBD is a good alternative for high-risk patients with acute cholecystitis who cannot undergo an emergency cholecystectomy.

Comparison of clinical findings between histologically confirmed type 1 and type 2 autoimmune pancreatitis.

Background and Aim:  Type 2 autoimmune pancreatitis (AIP) has been reported mainly in Western countries and is thought to be very rare in Asia. The aim of this study was to compare the prevalence, clinical profiles, detailed radiological findings, and steroid responsiveness between type 1 and type 2 AIP in Korea.

IgG4-related sclerosing esophagitis: a case report

decided to initially use an OVESCO (over-the-scope clip) with an 11-mm diameter that partially occluded the fistula and worked as an anchor point for the posterior placement of a self-expandable covered metal stent (20-mm diameter and 8-cm length) (Figs. 2-4). At the end of the procedure, there was a good flow of contrast to the stomach, with no evidence of the fistulous tract (Figs. 5 and 6). At the 48-hour evaluation, there was proper positioning of the clip and stent and no evidence Figure 5. Stent and endoclip in situ.

Xanthogranulomatous pancreatitis presents as a solid tumor mass: a case report.

Xanthogranulomatous inflammation (XGI) is a rare, idiopathic process in which lipid-laden histiocytes are deposited at various locations in the body. Although XGI has been reported to occur in various organs such as the gallbladder, kidney, bone, stomach, colon, appendix, lymph nodes, urachus, and urinary bladder and in soft tissues, xanthogranulomatous pancreatitis (XGP) is extremely rare. Herein, we report a case of XGP occurring in a 70-yr-old woman, who presented with abdominal pain for several months. On physical examination, mild epigastric tenderness was noted. Abdomen CT scan revealed a low attenuated mass in uncinate process of pancreas, suggesting malignant lesion. Whipples operation was performed and the final pathologic diagnosis was XGP. The patients post-operative course was uneventful, and no recurrence was found within 7 months of the operation. When a pancreatic mass does not show clinico-radiological features typical of common pancreatic neoplasms, XGP should be considered for a differential diagnosis.

Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial

Background/Aims Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for the treatment of common bile duct (CBD) stones. However, there is no established consensus on the optimal balloon dilation duration (BDD). We prospectively evaluated the efficacy and post-endoscopic retrograde cholangiopancreatography (ERCP) complications between the 20- and 60-second EPBD groups. Methods A total of 228 patients with small CBD stones (≤12 mm) were randomly assigned to undergo EPBD with a 20- or 60-second duration at six institutions. We evaluated baseline patient characteristics, endoscopic data, clinical outcomes, and procedure-related complications. In addition, we analyzed risk factors for postprocedural pancreatitis. Results CBD stones were removed successfully in 107 of 109 patients (98.1%) in the 20-second group and in 112 of 119 patients (94.1%) in the 60-second group (p=0.146). Post-ERCP pancreatitis developed in seven patients (6.4%) in the 20-second group and nine patients (7.5%) in the 60-second group (p=0.408). In multivariate analysis, contrast dye injection into the pancreatic duct is a significant risk factor for post-EPBD pancreatitis. Conclusions Based on the data showing that there were no significant differences in safety and efficacy between the two BDD groups, 20 seconds of BDD may be adequate for treatment of small CBD stones with EPBD.

Risk Factors of Cryptogenic Hepatocellular Carcinoma in Patients with Low Body Mass Index or without Metabolic Syndrome

Background/Aims Many patients are diagnosed with cryptogenic hepatocellular carcinoma (HCC) without metabolic syndrome (MS). We investigated the risk factors for cryptogenic HCC in patients with a low body mass index (BMI) or without MS. Methods Thirty-six patients were diagnosed with cryptogenic HCC over a 10-year period at a tertiary research hospital. Data including BMI score and risk factors for MS were analyzed retrospectively. Patients with fewer than two risk factors for MS (n = 16) were compared with those with two or more risk factors (n = 20). Patients with high BMI (≥ 23 kg/m2, n = 20) were also compared with those with lower BMI (n = 16). Results Patients with fewer than two risk factors for MS were significantly more likely to smoke and be hepatitis B surface antibodies (anti-HBs)-positive vs. patients with two or more risk factors. However, only smoking was statistically significant on multivariate analysis. Peaks of BMI were observed in two regions. Lower BMI was significantly associated with the presence of anti-HBs compared with high BMI, although this association was not statistically significant on multivariate analysis. Conclusions Smoking is a potential risk factor for cryptogenic HCC in patients without MS. Remote hepatitis B virus infection may be a risk factor for cryptogenic HCC in patients without MS or with a low BMI.

Acute pancreatitis associated with pegylated interferon-alpha-2a therapy in chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma. Combination therapy of pegylated interferon-alpha (PEG-IFN-α) and ribavirin (RBV) is a current standard treatment for chronic HCV infection in Korea, which has considerable adverse effects. Acute pancreatitis is a rare complication of PEG-IFN-α administration. We report a case of a 62-year-old female who experienced acute pancreatitis after 4 weeks of PEG-IFN-α-2a and RBV combination therapy for chronic HCV infection. The main cause of the acute pancreatitis in this case was probably PEG-IFN-α rather than RBV for several reasons. A few cases have been reported in which acute pancreatitis occurred during treatment with PEG-IFN-α-2b. This is the first report of acute pancreatitis associated with PEG-IFN-α-2a in Korea.

One-step transfistula large versus conventional balloon dilation following precut fistulotomy in difficult biliary cannulation for the removal of biliary stones: A multicenter retrospective study

After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one‐step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones.

Sa1300 Clinical Significance of Biliary Dilatation and Cholelithiasis After Subtotal Gastrectomy: Data From Swan (Sustainable Work and Announcement Network for Pancreas and Biliary Disease) Club in Korea

Background: Choledocholithiasis (CDL) is a common and potentially severe form of gallstone disease. Magnetic resonance cholangio-pancreatography (MRCP) is an increasingly used imaging modality in patients with a suspicion of CDL but limited data exist of the diagnostic accuracy in clinical practice. We aimed to assess its diagnostic performance in patients with a suspicion of CDL. Methods: A retrospective study of patients who were suspected to have CDL that had MRCP in a University Hospital in consecutive patients investigated during one year at this single Institution. Patients with other indications than gallstone disease for MRCP such as malignancy were excluded. Information was obtained on age, gender, liver tests, lipase/amylase and number of patients that underwent ERCP following the MRCP and the outcome of ERCP. Results: A total of 179 patients (females 63%, median age 56 years) had an MRCP due to suspected CDL. MRCP showed stones in the common bile duct (CBD) in 49 patients and none in 130. Overall 55 patients underwent ERCP after an abnormal MRCP (stones and/or dilated ducts) and 39 of them had documented stones (71%). Only 1/49 (2%) patient had a stone demonstrated on ERCP followed by a normal MRCP. None of the other patients with a normal MRCP had symptoms or signs of choledocholithiasis or were hospitalized for gallstone disease during at least 6 months after the normal MRCP. Patients with stones in the CBD on MRCP had higher values of bilirubin (45 μmol/L vs. 19, p=0.001), GGT (458 vs. 286, p=0.04) and AST (214 vs. 130, p=0.03) than those without stones, whereas other blood tests did not differ between the two groups. A total of 37/49 (76%) of patients with CBD stones had elevated bilirubin vs. 52/130 (40%) in those without CBD stones (p,0.05). Overall 46 patients were diagnosed with pancreatitis ( .threefold elevation of lipase) and among those only 9/49 (18%) had stones in the CBD on ERCP and/ or MRCP. The patients diagnosed with gallstones demonstrated in the CBD had a median value of lipase 4068 (981-9332) vs. 4400 (1192-11851) in those without stones (NS). Conclusion: MRCP in patients suspected to have stones in CBD has a very high negative predictive value and can prevent unnecessary ERCPs. Elevation of bilirubin, GGT and AST along with stones and dilated ducts shown on MRCP is a strong indicator of the presence of stones in the CBD. Gallstone pancreatitis is as common in those with and without stones in the CBD, suggesting that in surprisingly many patients the elevation in lipase is associated with spontaneous passage of stones through the CBD.