Efficacy of Niti-S ComVi Stents for Palliation of Malignant Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Niti-S ComVi stents are flexible and retain the shape-memory of the original configuration. ComVi stents are effective in preventing tumor ingrowth because polytetrafluoroethylene is inserted between two stent wires. The aim of this study was to examine the efficacy of Niti-S ComVi stents for the palliation of a malignant gastrointestinal obstruction. METHODS: Between April 2004 and April 2006, 17 patients (20 cases) underwent Niti-S ComVi stenting, using a through-the- scope method. The technical and clinical success, complication, and outcome were analyzed. RESULTS: Stent insertion was technically successful in 18 cases (90%). Malposition to the afferent loop occurred in 2 cases. Symptomatic improvement was achieved in 14 cases (70%). The mean gastric outlet obstruction score was 0.2 before stenting and 1.6 after stenting. The complications encountered were stent migration (2 cases) and obstruction (5 cases), which were treated by re-stenting and balloon dilatation. Twelve patients died with a median survival of 67 days. Five patients were still alive with a median follow up of 151 days. The overall median stent patency time was 60 days. The mean waist diameter of the stents was expanded to 57% of full expansion immediately after deployment, and 77% after 36 hours. CONCLUSIONS: Niti-S ComVi stenting is an effective palliative technique for inoperable or postoperative recurrent tumors, and significantly improves the quality of life.

Cyclo-oxygenase-2 and p53 Immunoreactivity in Superficial Early Colorectal Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: De novo colorectal carcinoma shows more aggressive behavior including submucosal invasiveness. Both p53 and cyclo-oxygenase-2 (COX-2) have been shown to be involved in colon carcinogenesis, progression from adenoma to carcinoma, and submucosal invasion by tumor. We performed this study to evaluate the expression of p53 and COX-2 protein in de novo carcinoma, compared with ex-adenoma carcinoma. METHODS: Twenty three flat adenomas, 19 ex-adenoma carcinomas, 6 de novo carcinomas were included in this study. The expression of p53, COX-2 and Ki-67 were examined immunohistochemically. RESULTS: Both ex- adenoma carcinomas and de novo carcinomas showed similar size and shape. Positive staining for p53 was detected in 3 of 23 (13%) flat adenomas, in 11 of 19 (57.8%) ex-adenoma carcinomas (p<0.05), and in 1 of 6 (16.6%) de novo carcinomas. Increased numbers of COX-2 positive tumor cells were observed in 1 of 23 (4.3%) flat adenomas, in 2 of 19 (10.5%) ex-adenoma carcinomas, and in 3 of 6 (50%) de novo carcinomas. COX-2 positive expression showed increased tendency in de novo carcinoma (p=0.073). There was no correlation between COX-2, p53, and Ki-67 expression. CONCLUSION: De novo carcinoma shows increased tendency of COX-2 expression, but decreased p53 expression when compared to ex-adenoma carcinoma. These immunohistochemical findings are in accordance with the fact that de novo carcinoma has no preceding adenoma, with more frequent submucosal invasion despite the small lesion size.

Effectiveness of Through-the-scope Self-expandable Metal Stent in Malignant Upper Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Self-expandable metal stents (SEMS) have been used in the palliation of malignant obstruction. The purpose of this study was to evaluate the effectiveness, safety, and outcome of SEMS using through-the-scope (TTS) method in the patients with malignant upper gastrointestinal obstruction including recurrent gastric cancer after gastrectomy. METHODS: Thirty one patients (36 stents) were treated with SEMS between October 2000 and June 2004; nineteen had inoperable malignant gastric outlet obstruction, ten had recurrent gastric cancer after gastrectomy, and two had metastatic duodenal cancer. We analyzed the technical and clinical success, complication, and outcome. RESULTS: The technical success rate was 88.8% (32/36 stents) in total cases; 95.0% (19/20) in malignant gastric outlet obstruction, 84.6% (11/13) in recurrent gastric cancer after gastrectomy, and 66.7% (2/3) in metastatic duodenal cancer. The success rate of dietary intake was 86.1% (31/36 stents). Complications occurred in 7 of 36 stents (19.4%), including stent migration (1 patient), aspiration pneumonia (1 patient), and recurrent obstruction (5 patients). The mean survival duration period was 118.1+/-180.2 days and mean patency period was 92.2+/-89.9 days. CONCLUSIONS: SEMS using TTS is an effective, safe, and less invasive palliative treatment in malignant upper gastrointestinal obstruction including recurrent gastric cancer after surgery.

A Case of Endoscopic Polypectomy Using a Hand-Made Detachable Snare Made of Nylon Fishing Line / 대한소화기내시경학회지

Hemorrhage is the most common complication of polypectomy. Though most bleeding stops spontaneously and can be managed with conservative therapies, some may necessitate intensive therapies. The detachable snare was firstly introduced in 1986. It has been reported that the use of detachable snare can effectively prevent both immediate and delayed bleeding. The detachable snare has been reformed, and now a commercial article is used in practice. But, it is expensive and cannot be used in larger polyps measuring over its fixed size of loop. A hand-made detachable snare made of nylon fishing line was introduced to prevent postpolypectomy bleeding in 2003. We have further improved it and experienced a case of successful removal of a large colonic polyp using our hand-made snare. The hand-made detachable snare is inexpensive and seems to be practical in ligating the polyp regardless of its size.

A Case of Spontaneous Gallbladder Perforation

Gallbladder perforation is an almost exclusive complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Whether it is of a calculous or acalculous origin, gallbladder perforation, as a complication of acute cholecystitis, has common symptoms, signs, laboratory data, radiological findings and treatment modalities. Even though many reports of gallbladder perforation have been published, there are few reports of gallbladder perforation without any clinical and radiological indications. We experienced a case of a 70-year-old woman with acute abdomen, which was found to be peritonitis caused by spontaneous gallbladder perforation that was devoid of clues suggesting this condition. Although rare and unusual, this case shows that this disorder should be considered in elderly patients presenting with peritonitis with an unknown etiology.

A Case of Sigmoid Colonic Perforation due to Migration of a Plastic Stent for Endoscopic Retrograde Biliary Drainage / 대한소화기내시경학회지

Placement of an endoprosthesis for billiary obstruction has been advocated as an effective alternative for internal-external drainage catheters or surgical procedure. Endoscopic retrograde biliary drainage (ERBD) is a method of transpapillary insertion and placement of drainage tube in the billiary tree under the direct view of endoscope. Early complications following ERBD that develop within 4 weeks include obstruction of the stent, cholangitis, hemorrhage, acute pancreatitis, and bile duct or duodenal perforation. Late complications include obstruction of the stent and cholangitis, migration of the stent, and intestinal perforation. We expierenced a case of sigmoid colonic perforation following ERBD in a patient with multiple biliary tract stone and cholangitis. Thus we report this case with a brief review of the literature.

A Case of Obstructive Jaundice after Insertion of Metallic Stent for Duodenal Obstruction by Recurrent Duodenal Ulcer / 대한소화기내시경학회지

Insertion of self-expandable metallic stent has been performed as a palliative therapeutic modality for cases with gastrointestinal obstruction caused by inoperable malignancies such as pancreatic cancer, stomach cancer, and cholangiocarcinoma. Although the clinical efficacy is not established yet, it can also be performed for benign gastroduodenal obstruction. Especially, when balloon dilatation is failed and patients are at high risk for surgery or general anesthesia, and when patients refuse operation, insertion of metallic stent can be considered. Complications of this therapeutic modality include intestinal perforation, hemorrhage, migration or malposition of metallic stent, and occlusion of stent by ingrowth and overgrowth of tumor or impaction of food. We report a rare case of obstructive jaundice developed after the insertion of gastroduodenal stent for duodenal obstruction caused by recurrent duodenal ulcer.

Acute Acalculous Cholecystitis Associated with Cholecystoduodenal Fistula and Duodenal Bleeding: A Case Report

Although acute acalculous cholecystitis (AAC) accounts for less than 10% of acute cholecystitis in the adult population, gangrene and perforation are much more frequent compared to the usual cases of acute cholecystitis (calculus cholecystitis). However, spontaneous biliary-enteric fistula is well recognized in AAC, 90% of which are cholecystoduodenal fistula (CDF) though it is an uncommon disorder. The majority of the CDF are caused by cholelithiasis. As patients are usually associated with complicated clinical illness, the diagnosis is often difficult to make and required surgery is often delayed. We have studied a rare complication of acute acalculous cholecystitis which was presented as intermittent upper gastrointestinal bleeding. Ulceration of the superficial branch of the cystic artery has been observed due to acalculous cholecystitis associated with a cholecystoduodenal fistula. We have performed a transfixing ligation of the bleeding vessel, cholecystectomy and simple closure of the CDF. We have finally made a diagnosis of early gallbladder cancer through a frozen section. There was no serious complication after the operation and the patient has achieved an uneventful recovery.

Efficacy of Triple Therapy with Rabeprazole for Helicobacter pylori Infection in relation to CYP2C19 Genotype / 대한소화기학회지

BACKGROUND/AIMS: Genetic polymorphism of cytochrome P450 CYP2C19 influences the efficacy of proton pump inhibitor (PPI) in Helicobacter pylori (H. pylori) eradication therapy. We investigated the difference in the cure rates of H. pylori infection by triple (rabeprazole plus amoxacillin and clarithromycin) therapy in relation to CYP2C19 genotype status. METHODS: One hundred and sixteen H. pylori infected patients with gastric ulcer and duodenal ulcer completed the triple therapy with 10 mg of rabeprazole b.i.d., 1,000 mg amoxacillin b.i.d. and 500 mg of clarithromycin b.i.d. for one week. The genotype of CYP2C19 was determined by a PCR-restriction fragment length polymorphism method. RESULTS: According to the univariate analysis, heterozygous extensive metabolizers (hetero EMs) and poor metabolizers (PMs) showed the highest (87.0%) and the lowest (80.0%) eradication rates, respectively. The difference in the therapeutic efficacy of rabeprazole among the different CYP2C19 genotypes was insignificant. With regard to gender, age and smoking history in relation to eradication rate, a statistical significance was noted only with age with odds ratio of 1.063 and p-value of 0.0202. CONCLUSIONS: In the eradication therapy of H. pylori, no statistically significant difference in therapeutic efficacy of rabeprazole was found among different CYP2C19 genotypes.

An Experimental Study about the Effects of TGF - 1 and Autogenous Periosteal Graft on Healing of Osteochondral Defect in Rabbit / 대한정형외과학회잡지

Articular cartilage is a highly differentiated tissue, lacking a vascular supply and having only limited regenerative capability. Cut or other mechanical damage restricted to the cartilage does not repair. Experimentally and clinically, cartilage defect that penetrate the subchondral bone undergoes repair through the formation of tissue usually characterized as fibrous, fibrocartilaginous or hyaline-like cartilaginous tissue. There is little definitive informations about local or systemic factors that control the differentiation of mesenchymal cells to osteoblast, chondroblast or fibroblast. Our study was designed to evaluate the effect of transforming growth factor-beta (TGF-pl) and autogenous periosteal graft on the healing of osteochondral defect of distal femur of rabbit and also the possibility of these method to be clinically applicable to human. The experimental model used in the present study for including cartilage in rabbit was based mainly on the model used by Frukawa et al14). in rabbit. A full thickness osteochondral defect of 80 rabbit were made with 2mm diameter of drill-bit and electrically driven drill. Experimental animals were divided into four group: 1) group I, osteochondral defect only, 2) group II, osteochondral defect with infiltration of phosphate buffer solution, 3) group III, osteochondral defect with infiltration of TGF-Bl, 4) group IV, osteochondral defect with autogenous periosteal graft. The healing of the defect was assessed at 1 week, 3 weeks, 5 weeks, 12 weeks after operation by gross and histochemical examination. At 1 week, fibrinoid material in edge to edge arcade arrangement was present in group I,II,III,IV. At 3 weeks, spindle shaped undifferentiated mesenchymal cell present in the periphery of fibrinous network, but there is no appearance of mesenchymal cell in group I,II. At 5 weeks, essentially complete repopulation of the defect with progressive differentiation of cells to chondroblast, chondrocyte, osteoblast and synthesis of cartilage and matrix in their appropriate location in group III and IV were found. At 12weeks, hyaline like cartilage formation was observed in group III and IV. but early trace of degeneration of the cartilage were seen in many defect with the prevalence and intensity of the degeneration increasing at group I and 3 . Our study demonstrated in detail the repair of full-thickness defect in rabbit articular cartilage extending into cancellous bone of the marrow cavity under influence of local growth factor (TGF-pl) and autogenous periosteal graft. Excellent reconstruction of articular cartilage was observed in TGF- Bl infiltration group and autogenous periosteal graft group as early as 5 weeks after the creation of defect. Although the further study should be carried out for their clinical application, we conclude that TGF-Bl regulates the overall mechanism of matrix constituent in connective tissue and autogenous periosteal graft have a chondrogenic potential to repair major osteochondral defect. these suggest that TGF-Bl and autogenous periosteal graft may be a important pathophysiological regulator of chondro- genesis.