Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Genetic susceptibility to post-endoscopic retrograde cholangiopancreatography pancreatitis identified in propensity score-matched analysis

Background/Aims@#A previous history of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a risk factor for PEP, suggesting that there may be a genetic predisposition to PEP. However, nothing is known about this yet. The aim of this study was to identify genetic variations associated with PEP. @*Methods@#A cohort of high-risk PEP patients was queried from December 2016 to January 2019. For each PEP case, two propensity score-matched controls were selected. Whole exome sequencing was performed using blood samples. Genetic variants reported to be related to pancreatitis were identified. To discover genetic variants that predispose to PEP, a logistic regression analysis with clinical adjustment was performed. Gene-wise analyses were also conducted. @*Results@#Totals of 25 PEP patients and 50 matched controls were enrolled. Among the genetic variants reported to be associated with pancreatitis, only CASR rs1042636 was identified, and it showed no significant difference between the case and control groups. A total of 54,269 non-synonymous variants from 14,313 genes was identified. Logistic regression analysis of these variants showed that the IRF2BP1 rs60158447 GC genotype was significantly associated with the occurrence of PEP (odds ratio 2.248, FDR q value = 0.005). Gene-wise analyses did not show any significant results. @*Conclusions@#This study found that the IRF2BP1 gene variant was significantly associated with PEP. This genetic variant is a highly targeted PEP risk factor candidate and can be used for screening high-risk PEP groups before ERCP through future validation. (ClinicalTrials.gov no. NCT02928718)

Endoscopic and Percutaneous Biliary Interventions after Liver Transplantation: Nationwide Data in Korea

Background/Aims@#Biliary complications including biliary strictures and bile leaks are the most common complications that occur after liver transplantation (LT). Endoscopic treatment with endoscopic retrograde cholangiography (ERC) is considered the first-line treatment, and percutaneous transhepatic cholangiography (PTC) can serve as an alternative or rescue therapy.However, nationwide clinical data on the frequency of ERC and PTC following LT have not yet been investigated. @*Methods@#Using the nationwide claims database, we investigated patients who underwent LT between 2012 and 2014 in Korea and followed them until 2015. We analyzed the prevalence and characteristics of patients and biliary procedures, including ERC and PTC implemented after LT. @*Results@#A total of 3,481 patients underwent LT during the 3-year study period. Among them, 3.0% of patients underwent biliary intervention postoperatively during the same hospitalization period, and 21.4% of patients received biliary intervention later on after initially being discharged from the hospital following LT. A total of 16.9% and 12.1% of patients underwent ERC and PTC after LT, respectively. The median period from LT to the first biliary intervention was 7.8 months (interquartile range, 3.5 to 14.6 months), and these patients underwent an average of 3.2±2.8 biliary procedures during the follow-up period. Patients undergoing living donor LT were more than twice as likely to undergo biliary procedures as those undergoing deceased donor LT (25.5% vs 12.1%). @*Conclusions@#Approximately one-fourth of patients in Korea who underwent LT subsequently underwent ERC or PTC. Compared with deceased donor LT patients, those undergoing living donor LT underwent more biliary interventions and were more difficult to treat.

Osteoporosis Is Associated with an Increased Risk of Colorectal Adenoma and High-Risk Adenoma: A Retrospective, Multicenter, Cross-Sectional, Case-Control Study

Background/Aims@#The protective effects of vitamin D and calcium on colorectal neoplasms are known. Bone mineral density (BMD) may be a reliable biomarker that reflects the long-term anticancer effect of vitamin D and calcium. This study aimed to evaluate the association between BMD and colorectal adenomas including high-risk adenoma. @*Methods@#A multicenter, cross-sectional, case-control study was conducted among participants with average risk of colorectal cancer who underwent BMD and screening colonoscopy between 2015 and 2019. The main outcome was the detection of colorectal neoplasms. The variable under consideration was low BMD (osteopenia/osteoporosis). The logistic regression model included baseline demographics, components of metabolic syndrome, fatty liver disease status, and aspirin and multivitamin use. @*Results@#A total of 2,109 subjects were enrolled. The mean age was 52.1±10.8 years and 42.6% were male. The adenoma detection rate was 43%. Colorectal adenoma and high-risk adenoma were both more prevalent in subjects with low BMD than those with normal BMD (48.2% vs 38.8% and 12.1% vs 9.1%). In the univariate analysis, old age, male sex, smoking, metabolic components, fatty liver, and osteoporosis were significantly associated with the risk of adenoma and high-risk adenoma. In the multivariate analysis, osteoporosis was independently associated with risk of colorectal adenoma (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.11 to 2.46; p=0.014) and high-risk adenoma (OR, 1.94; 95% CI, 1.14 to 3.29; p=0.014). @*Conclusions@#Osteoporosis is an independent risk factor of colorectal adenoma and high-risk adenoma

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Acute Pancreatitis: Severity Assessment / 대한췌담도학회지

The severity of acute pancreatitis (AP) is classified into mild, moderately severe, and severe, considering the presence and duration of organ failure and local complications. Since patients with AP show a large difference in mortality and morbidity according to AP severity, evaluation of the severity of patients with AP in the early stage is important for predicting the prognosis and determining treatment plans including transfer to the intensive care unit or advanced facilities. In order to evaluate the initial severity of AP, it is necessary to confirm the presence of organ failure and objective evaluation using imaging or clinical examinations. In this guideline, it is recommended that evaluation using various severity indices such as bedside index for severity in acute pancreatitis (BISAP), systemic inflammatory response syndrome (SIRS), and acute physiology and chronic health evaluation (APACHE)-II scores be considered.

Complete Endoscopic Clearance of Common Bile Duct Stones / 대한소화기학회지

Common bile duct stones (CBDS) are the most common cause of acute cholangitis. Removal by endoscopic retrograde cholangiopancreatography became the standard of care after endoscopic sphincterotomy was introduced. On the other hand, it is still difficult to remove 10-15% of CBDS completely in the first attempt for various reasons. This review describes the methods for the complete endoscopic clearance of CBDS, including difficult cases, reflecting the latest knowledge and techniques.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections / 대한췌담도학회지

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on indication for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam

Background/Aims@#The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions. @*Methods@#This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction. @*Results@#A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups. @*Conclusions@#Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

Trends and Characteristics of Endoscopic Retrograde Cholangiopancreatography: A Nationwide Database Study in Korea / 대한췌담도학회지

Background@#/Aim: Endoscopic retrograde choangiopancreatography (ERCP) has been established as an effective tool for the diagnosis and treatment of pancreatobiliary diseases. However, after the evolution for more than 4 decades, nationwide data on current trends and characteristic is not well known. Therefore, we conducted an analysis of nationwide database to determine the number and status of ERCP performed in Korea. @*Methods@#We used the nationwide claims database, Korean Health Insurance Review and Assessment between 2012 and 2015. We investigated the frequencies and characteristics of ERCP procedure performed as well as demographics of the patients. @*Results@#A total of 158,038 ERCP procedures were performed in 114,757 patients during study period. The number of total ERCPs increased every year, and especially the rate of therapeutic ERCPs is on the increased trend. About two-thirds of ERCPs (63.3%) were performed in high-scaled hospitals. In 2015, the proportion of elderly patients over 80 years old increased compared to that in 2011, from 14.3% to 17.2%. @*Conclusions@#The annual number of ERCPs performed is increasing in Korea. With increasing ERCP for therapeutic purposes or for older patients, more attention should be paid to safety for patients.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Trends and Characteristics of Endoscopic Retrograde Cholangiopancreatography: A Nationwide Database Study in Korea / 대한췌담도학회지

Background@#/Aim: Endoscopic retrograde choangiopancreatography (ERCP) has been established as an effective tool for the diagnosis and treatment of pancreatobiliary diseases. However, after the evolution for more than 4 decades, nationwide data on current trends and characteristic is not well known. Therefore, we conducted an analysis of nationwide database to determine the number and status of ERCP performed in Korea. @*Methods@#We used the nationwide claims database, Korean Health Insurance Review and Assessment between 2012 and 2015. We investigated the frequencies and characteristics of ERCP procedure performed as well as demographics of the patients. @*Results@#A total of 158,038 ERCP procedures were performed in 114,757 patients during study period. The number of total ERCPs increased every year, and especially the rate of therapeutic ERCPs is on the increased trend. About two-thirds of ERCPs (63.3%) were performed in high-scaled hospitals. In 2015, the proportion of elderly patients over 80 years old increased compared to that in 2011, from 14.3% to 17.2%. @*Conclusions@#The annual number of ERCPs performed is increasing in Korea. With increasing ERCP for therapeutic purposes or for older patients, more attention should be paid to safety for patients.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Vegetarianism as a protective factor for asymptomatic colonic diverticulosis in Asians: a retrospective cross-sectional and case-control study

Background/Aims@#Dietary fiber intake is considered a protective factor for diverticular disease such as diverticulitis. However, evidence for an inverse connection between dietary fiber consumption and asymptomatic colonic diverticulosis is lacking. Specifically, few studies have investigated this subject in Asians with different presentations of diverticulosis. Therefore, we assessed the protective effects of a vegetarian diet for asymptomatic colonic diverticulosis in Buddhist monks who are obligatory vegetarians for spiritual reasons compared with the general population. @*Methods@#A retrospective, cross-sectional, case-control study was conducted in age- and sex-matched Buddhist monks and the general population who underwent colonoscopy for screening at a Korean health promotion center from August 2005 to June 2018. We compared the prevalence of asymptomatic diverticulosis between the 2 groups using a self-administered questionnaire. @*Results@#In this study, a total of 1,316 individuals were included (Buddhist monks of 658 and general population of 658) with a mean age of 52.6±9.5 years. The prevalence of asymptomatic diverticulosis in Buddhist monks was lower compared with the general population (6.7% [44/658] vs. 10.8% [71/658], P=0.008). Buddhist monks had a higher rate of high body mass index (BMI) and metabolic syndrome. By a multivariate regression analysis model, a nonvegetarian diet (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.21–2.72, P=0.004), old age (OR, 4.53; 95% CI, 1.36–15.12; P=0.014), male sex (OR, 1.91; 95% CI, 1.28–2.85; P=0.002), and a high BMI (OR, 1.50; 95% CI, 1.01–2.23; P=0.047) were independent predictors of asymptomatic diverticulosis. Moreover, a nonvegetarian diet was associated with both right-sided and left-sided diverticulosis. @*Conclusions@#A nonvegetarian diet may increase a risk of asymptomatic colonic diverticulosis in Asians.

Pancreatic Hemangioma Suspected of Neuroendocrine Tumor / 대한소화기학회지

Adult pancreatic hemangioma is an extremely rare disease, with only 22 cases reported since 1939. Pancreatic hemangioma has no specific symptoms, diagnostic imaging, or laboratory findings, making it difficult to be clinically suspected and diagnosed. The majority are confirmed after surgery. In this report, a 61-year-old woman presented with melena and showed multiple small hyper- vascular lesions in the pancreas. A pancreatic neuroendocrine tumor was suspected, and the patient underwent a distal pancreatectomy. The pathology examination and immunohistochemical study revealed a pancreatic hemangioma.

Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea

Background/Aims@#Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy. @*Methods@#A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes. @*Results@#A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups. @*Conclusions@#The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.

Cholelithiasis as a Risk Factor for Gallbladder Cancer / 대한소화기암학회지

Although the incidence of gallbladder cancer is relatively low, Korea is one of the countries with the highest incidences of gallbladder cancer in the world. Gallbladder cancer is also often diagnosed in an advanced state, and has poor prognosis. A gallstone is one of the major risk factors for gallbladder cancer and a majority of epidemiological studies support correlation between cholelithiasis and gallbladder cancer. Clear mechanism, however, regarding how gallstones cause gallbladder cancer is not known. In this article, results of studies about the relationship between gallstone and gallbladder cancer were thoroughly reviewed. Also, it was discussed whether prophylactic cholecystectomy is necessary to prevent gallbladder cancer in asymptomatic gallstone patients without other risk factors such as a gallbladder polyp or porcelain gallbladder.

Natural Course and Risk of Cholangiocarcinoma in Patients with Recurrent Pyogenic Cholangitis: A Retrospective Cohort Study

BACKGROUND/AIMS: Recurrent pyogenic cholangitis (RPC) is a chronic progressive disease frequently accompanied by cholangiocarcinoma (CCA). This study aimed to investigate the natural course of RPC and identify factors associated with CCA. METHODS: From January 2005 to December 2016, 310 patients diagnosed with RPC at Seoul National University Hospital were included. Complications and management during follow-up were recorded. CCA-free probability was estimated by Kaplan-Meier method, and risk factors associated with CCA were analyzed using log-rank test and Cox’s proportional hazard regression model. RESULTS: Mean age at diagnosis was 59.1±10.9 years and mean follow-up duration was 84.0±64.1 months. An intrahepatic duct stone was found in 253 patients (81.6%). Liver atrophy was identified in 185 patients (59.7%) and most commonly located at the left lobe (65.4%). Acute cholangitis, liver abscesses, cirrhotic complications, and CCA developed in 41.3%, 19.4%, 9.7%, and 7.4%, respectively. During follow-up, complete resolution rate after hepatectomy, biliary bypass surgery, and choledocholithotomy with T-tube insertion reached 82.3%, 55.2%, and 42.1%, respectively. None of the patients who maintained complete resolution by the last follow-up day developed CCA. In univariate analysis, female, both-sided intrahepatic duct stones, and liver atrophy at any location were associated with increased risk of CCA. Multivariate analysis revealed that both-sided atrophy significantly increased risk of CCA (hazard ratio, 4.56; 95% confidence interval, 1.48 to 14.09; p=0.008). In 21 patients who developed intrahepatic CCA, tumor was located mostly in the atrophied lobe (p=0.023). CONCLUSIONS: In RPC patients, acute cholangitis, liver abscess, cirrhotic complications, and CCA frequently developed. Both-sided liver atrophy was a significant risk factor for developing CCA.

Management Algorithm of Pancreatic Calculi / 대한췌담도학회지

Pancreatic calculi associated with chronic pancreatitis lead to severe abdominal pain, which significantly reduces the quality of life of patients. Pancreatic calculi, especially those that obstruct the main pancreatic duct and cause abdominal pain, are considered to be treated. First, if pancreatic calculi are located in the head or body and the size is less than 5 mm, endoscopic removal can be attempted. If the size is greater than 5 mm, extracorporeal shockwave lithotripsy may be performed first, and subsequent endoscopic removal may be considered depending on the results. If such treatment fails, pancreatoscopic lithotripsy or surgery should be considered. Pancreatic duct stenting may be used as a bridge therapy during this process.