The Efficacy of Percutaneous Transhepatic Choledochoscopic Removal of Intrahepatic Stones / 대한내과학회지

OBJECTIVE: Intrahepatic stones provide a quite different spectrum of problems faced by surgeons in the Eastern hemisphere. Although unilateral left intrahepatic stones have been treated by left hepatic lobectomy, bilateral or right intrahepatic stones can be even more troublesome because they frequently cannot be completely removed by conventional surgical stone extraction procedure. Recently, the use of a flexible fiberoptic choledochoscope, electrohydraulic lithotriptor(EHL) and dilators make it possible to completely remove intrahepatic stones by nonsurgical procedures in the majority of cases. METHODS: During the last 5 years, we treated intrahepatic stones in 114 patients with a fiberoptic choledochoscope, EHL and dilators via percutaneous transhepatic route. For construction of percutaneous transhepatic routes, we punctured intrahepatic ducts by ultrasonographic guidance and then dilated the tracts by PTBD set(Nipro Co., Japan) under fluoroscopic guidance. Choledochoscopy were performed at 4-6 weeks later, and Dormina basket, EHL, balloon or bougie dilators were used for removal of stones. RESULTS: Success rates according to the locations of stones were 87.5%(14/16) in unilateral right intrahepatic stones, 92.9%(39/42) in unilateral left intrahepatic stones, and 89.3%(50/56) bilateral intrahepatic stones. Overall success rate was 90.4%(103/114). Causes of incomplete removal of the stones in our patients included the failure of construction or maintenance of percutaneous transhepatic routes in 4 cases, intrahepatic bile duct stricture proximal to impacted stones in 3, acute ductal angulation in 2, and stones located at the very distal branches of intrahepatic ducts in 2 cases. Complications associated with the procedure were transient fever in 8 cases, severe hemobila in 2 cases and biliary perforation in 3 cases. CONCLUSON: These results suggest that percutaneous transhepatic choledochoscopic approach is a relatively safe and effective method for treatment of intrahepatic stones.

Comparative Evaluation of Various Biliary Stents in the Palliative Treatment of Malignant Biliary Obstruction / 대한내과학회지

OBJECTIVES: Endoscopic biliary drainage has been established as the palliative treatment of choice for malignant obstructive jaundice. At present, the major drawback of endoscopic biliary stenting is occlusion of the endoprosthesis with sludge, resulting in recurrence of jaundice or cholangitis. Recently, there are variable stents that have different materials, sizes, and designs have been used in efforts to overcome this problem. To determine the success rate of stent insertion, successful drainage rate, duration of patency, complications related to stent insertion, and cause of stent malfunction, plastic endoprosthesis compared to metal stents in palliative treatment of malignant biliary obstruction. METHOD: We retrospectively evaluated 157 patients (total number of stent insertion: 308 cases) with unresec table malignant biliary obstruction to receive either a plastic stent(group I, 261 cases) or metal stent(group II, 47 cases). The patients who were recieved plastic stent were subdivided to general plastic stents(group Ia, polyethylene, polyurethane, polyvinylchloride, 225 cases) and Tannenbaum stent(group Ib, Teflon, 36 times) group. And the patients who were received metal stent were subdivided to uncovered metal stents(group IIa, Gianturco R sch, Wall, Strecker, EndoCoil stent, 26 times) and membrane covered self-expandable metal stent(group IIb, 21 cases) group. RESULTS: 1) There were no statistical difference in successful rate of stent insertion and drainage effect of stent accord ing to the types of stent(p>0.05). 2) Median patency of the stent was significantly prolonged in patients with a metal stent(group II) com pared with those with a plastic stent(group I) (249 vs 123 days; p 0.05). 3) The rate of early complication related to stent insertion showed no significant difference in plastic and metal stent groups(P > 0.05). 4) Major causes of stent malfunction in plastic and metal stent were sludge(90% vs 21.4%), tumor ingrowth (4.4% vs 71.4%), and dislocation(5.6% vs 7.2%), respec tively. CONCLUSION: Metal stents have a longer patency than plastic stent in patients with malignant biliary obstruc tion. In plastic stents, Tannenbaum stents have a slighlty longer patency than other plastic stents, but there were no differences in the success rates, drainage effect and complication rates according to types of stents.

Endoscopic Ultrasonographic Features of a Gastric Aberrant Pancreas without Central Dimpling / 대한소화기내시경학회지

BACKGROUND/AIMS: A gastric aberrant pancreas can be easily diagnosed through con- ventional endoscopy and radiologic modalities due to its characteristic features such as central dimpling. However, in cases involving an aberrant pancreas without the central dimpling, the differential diagnosis has been some troublesome. As for differential diag- nosis of gastric submucosal tumors, endoscopic ultrasonography (EUS) allows us to visu- alize the structures underlying the gastrointestinal wall in a non-invasive manner, and has a great advantage over conventional modalities such as conventional endoscopy or the UGI series. METHODS: We studied the EUS findings of a gastric aberrant pancreas without the central dimpling. We compared EUS features in 10 cases involving a gastric aberrant pancreas without the central dimpling to those in 16 cases with the central dimpling.

Three Cases of Esophageal Granular Cell Tumor / 대한소화기내시경학회지

Granular cell tumors (GCT), previously termed granular cell myoblastorna, was first described as a myoblastic myoma of the tongue in 1926 by Abrikossoff and has been reported in many different locations throughout the body. In 1931, Abrikossaff described the first granular cell tumor of the esophagus. The gastrointestinal tract is one of the more uncommon locations for granular cell tumors. Until recently, granular cell tumors had been considered rare but, the incidence of granular cell tumors has been slowly raising since endoscopy has been used more commonly as a diagnostic tool. In this study, we report three cases of esophageal granular cell tumors which were successfully diaganosed by an esophagoscopy and an endoscopic ultrasonography and confirmed using an endoscopic esophageal mucosal resection (EEMR).

The Usefulness of Pit Patterns of Colorectal Tumors and Magnifying Colonoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: To investigate the usefulness of pit patterns of colorectal tumors and magnifying colonoscopy. METHODS: The surface mucosal pits of seventy five colorectal lesions were observed using a magnifying colonoscopy with a zoom 1 to 100 magnification after indigo carmine or methylene blue spray. The lesions were removed by hot biopsy, palypectomy, or endoscopic mucosal resection. Histologic diagnoses were determined by light microscopy.

Clinicopathoalogic Features of Colonic Flat Adenoma / 대한내과학회지

OBJECTIVES: To determine accurate diagnosis and proper treatment, we reviewed colonoscopic and histologic findings of flat adenoma of colon, METHODS: We studied retrospectively 2148 cases of colonoscopic findings performed in our hospital from March of 1993 to September of 1995. RESULTS: 1) The incidence of adenoma is 9.5%(203 cases), and that of flat adenoma is 1.6%(34 cases). 2) The location of flat adenoma is 3 cases in rectum(8.8%), 15 cases in sigmoid colon(44.1%), 9 cases in descending colon(26.5%), 3 cases in transverse colon(8.8%) and 4 cases in ascending colon and cecum(11.8%). 3) The diameter of flat adenoma was smaller than 5mm in 17 cases(50.0%), between 5-10mm in 8 cases(23.5%) and larger than 10mm in 9 cases (26.5%). Mean size was 9.2mm. 4) In colonoscopic features, type IIa was 25 cases (73.5%), type IIa + IIc was 5 cases(14.7%) and lateral spreading tumor was 4 cases(11.8%). 5) In histologic findings, tubular adenoma was 26 cases(76.5%), tubulovillous adenoma was 6 cases (17.6%) and serrated adenoma was 2 cases(5.9%). 6) The incidence of severe dysplasia or carcinoma was zero in smaller than 5mm, 25.0%(2 case) in 5-10mm and 55.6%(5 cases) in larger than 10mm. 7) The incidence of severe dysplasia or carcinoma was 11.5%(3 cases) in tubular adenoma and 66.7%(6 cases) in tubulovillous adenoma. 8) It was confirmed by abdominal CT scan or operation that lesions were limited to intraepithelium in 4 cases, mucosa in 2 cases submucosa in 1 case and no lymph node metastasis in any case. CONCLUSION: Even though flat adenoma of colon was smaller than polypoid adenoma, the incidence of malignant change was higher. When it was smaller than 10mm, the incidence of submucosal invasion or lymph node invasion was rare. Therefore endoscopic mucosal resection(EMR) can be the treatment of choice in flat adenoma smaller than 10mm, and after EMR, it is desirable to decide the treatment modality depending on the histologic findings.

Clinical Significance of Multi - Band Ligation for Esophageal Variceal Bleeding / 대한소화기내시경학회지

Endoscopic esophageal variceal ligation(EVL) was first introduced by Stiegmann and colleagues in 1986, and it has since grown to he became an extremely popular modality throughout the world as well as Korea. Endoseopic variceal ligation(EVL), which consists of mechanical ligation and thrombosis of varices using elastic O-rings, has been recently developed as a non-operative alternative to endapic injection sclerotherapy(EIS). EVL is minimally operator-dependent and is also associated with fewer local and systemic complications than sclerotherapy. However, the conventional device has only one O ring, and thus the inner cylinder has to be exchanged after each ligation, So, it is a time-consurning procedure that requires the use of an overtube which has somtimes caused tearing of the esophageal mucosa. To save time and control variceal bleeding, multi-band ligation(MBL) was developed. These ligators have five or six O rings, and serial ligation is now possible without exchanging the cylinder or withdrawing the endoscope.(continue...)

The Usefulness of Endoscopic Hemoclipping in the Management of Mallory - Weiss syndrome / 대한소화기내시경학회지

Mallory-Weiss syndrome is a laceration in the region of the gastroesophageal junction due to vomiting, retching, coughing preceding hematemesis in alcoholic patient. Bleeding from Mallory-Weiss tears stop spontaneously without specific therapy in 80-90 percent of patient, but rebleeding is uncommonly occurring in 2 to 5 percent of patients. Thus most patients require only supportive care. Rarely endoscopic therapy or operative therapy may be required. We conducted an uncontrolled study to evaluate an improved metallic clip(Olympus hemoclip) for the endoscopic treatment of Mallory-Weiss syndrome. Initial hemostasis was achieved in all patients with active bleeding. No complications resulted from this treatment. Clips did not impair healing of teared mucosa. We conclude that endoscopic hemoclip placement is a highly effective and safe method for treating uncontrolled Mallory-Weis syndrome.

The Usefulness of Endoscopic O-ring Band Ligation in the Management of Mallory - Weiss Syndrome / 대한소화기내시경학회지

Mallory-Weiss syndrome is a laceration in the region of the gastroesophageal junction due to vomiting, retching, coughing preceding hematemesis in alcoholic patient. Bleeding from Malloly-Weise tears stop spontaneously without specific therapy in 80-90% of patient, but rebleeding occurs in 2 to 5% of patients. Thus most patients require only supportive care. Rarely endoscopic therapy or operative therapy may be required. We performed endoscopic mucosal ligation using intraluminal negative pressure with band ligation for uncontrolled Mallory-Weiss syndrome. In conclusion, Endoscopic O-ring band ligation in uncontrolled intractable Mallory-Weiss syndrome is safe and effective method, but its important that accurate endoscopic O-ring band ligation an bleeding site in laceration area. We experienced endoscopic O-ring band ligation in 6 cases of Mallory-Weiss syndrome.

Cholecysto - Duodeno - Colic Fistula : Report of One Case / 대한소화기내시경학회지

Biliary-enteric fistula is in 0.5% to 5% of patients undergoing biliary tract surgery. The most common cause of biliary-enteric fistula is gallstones and their complications, Much less common causes are complieation of peptic ulcer, malignancy, trauma, and rarely, Crohns, disease. The most common type of biliary-enteric fistula is cholecysto-duadenal. Cholecysto-colic, cholecysto-gastric, and choledocho-duodenal fistula are reported much less frequently. The combination of cholecysto-duodenal fistula with cholecysto-colic fistula is a very rare. Symptoms are generally nonspecific, so diagnosis has depended on plain film of abdomen and barium studies. Recently, endoscopic examination and cannulation of the fistula for precise radiographic delineation will help to make a diagnosis. A 78-year-old man was admitted our hospital because of epigastric discomfort, indigestion, nausea and vomiting for 10 days. He was confirmed as cholecysto-duodeno-colic fistula by gastroduodenoscopy, colonoscopy, and endoscopic cholangio-graphic techniques. So, we report a case of cholecysto-duodeno-colic fistula of the patient with a review of relevant literatures.

Clinical Usefulness of Ultrathin - caliber Pancreatoscopy on Diagnosis of Various Pancreatic Diaeases / 대한소화기내시경학회지

Although ERCP has been widely used to diagnose and occasionally treat chronic pancreatitis, it is not always easy to differentiate between malignancy and benign disease by ERCP alone. So peroral pancreatoscopy(PPS) using mother and baby type scopes was developed and several types of peroral pancreatoscopes with various diameters have been used at several institutes. To assess the clinical usefulness of ultrathin-caliber pancreatoscopy on diagnosis of various pancreatic diseases, we performed peroral pancreatoscopy with PF 8P (Olympus, external diameter: 0.8 mm) in 12 cases(6 cases of chronic pancreatitis, 5 cases of pancreatic tumor, and 1 case of mucinous ductal ectasia) of pancreatic diseases. The pancreatoscope was successfully inserted into main pancreatic duct in 11 cases and permitted satisfactory endoscopic observation. The endoscopic findings of chronic pancreatitis were smooth stenosis, protein plug, and stones in pancreatic duct. Peroral pancreatoscopic findings of pancreatic cancer were characteristically seen as stenosis with irregular mucosal protrusion. In the mucin-producing tumor cases, the lesions were generally not clearly visualized due to the presence of copious amount of mucin. We conclude that pancreatoscopy is a valuable alternative or supplementary procedure to diagnostic imaging method of arriving at a more definite diagnosis in difficult cases. But several limitations, such as poor visual field, absence of biopsy channel and controllable tip, and poor durability of endoscope will be overcomed to serve as essential diagnosic tool for pancratic diseases.

A Case of Polypoid Gastric Metaplasia in Duodenal Bulb / 대한소화기내시경학회지

Gastric metaplasia of the duodenum, defined as the presence of groups of gastric mucosal cell within normal duodenal epithelium, is an almost constant feature of duodenal ulcer. The pathogenesis of gastric metaplasia is unclear, but acid and Helicobacter pylori infection are contributory factors to the development of gastric metaplasia. Generally, endoscopic finding of gastric metaplasia in duodenum is typically patchy distribution in duodenal bulb, but polypoid gastric metaplasia in duodenum is very rare. We report that the patient who complaints of abdominal pain has a villous, polypoid gastric metaplasia in duodenal bulb without duodenal ulcer.

Clinical Significance of Esophageal Glycogenic Acanthosis / 대한소화기내시경학회지

Glycogenic acanthosis(GA) of the esophagus,is often found in routine endoscopic examination of the upper GI tract but has not drawn much attention. However, there is controversy concerning the nature, clinical significance and prevalence of this candition. An endoscopic study, performed in 1041 patients, showed that the incidence of GA was 32,9%. Its incidence was found to be significantly higher in male than in female(40.0% vs. 22.1%; p<0.0001) and frequency of high grade(II+III) GA was higher in male than in female(58.1% vs. 45.3~%; p<0.0D01). An increasing tendency was observed with respect to age(X 36~343, p~<0,0001). The frequency of GA was higher in smoker than in non-smoker(49.2% vs. 20.8%; p<0.0001). GA did not have a clear relationship with alcohol intake, dietary habit, condiments, and diet temperature. The frequency of GA was higher in the patient with reflux esophagitis than without reflux esophagitis(3.8% vs. 1.7%; p~<0.05). Therefore, age, sex and smoking appear to be risk factors of GA, as in esophageal carcinoma.

Endoscopic Characteristics of Lymphangioma of Colon / 대한소화기내시경학회지

Lymphangioma of the large bowel is a rare benign tumor which is composed of numerous small or large thin-walled lymphatie spaces contained fibrous tissue, smooth muscle and aggregates of lymphoid tissue. Lymphangioma never demonstrated any potential for malignant degeneration. There are three types; l. simple capillary lymphangioma, 2 cavernous lymphangioma and 3 cystic lymphangioma. Endoscopically, lymphangioma appears as a compressible smooth, round, or oval submucosal tumor covered with pale intact mucosa. The surfaces is smooth and the superficial color is the same as the surrouding mucosa or slightly more yellowish. There are change of dimension and shape during propagation of the peristaltic wave and on compression. Recently, authors experienced 4 cases of lymphangioma of large intestine which has been revealed by typical colonoscopic findings and/or endoscopic ultrasound, and confirmed by surgical resection and colonscopic snare polypectomy. 3 of 4 cases show cystic lymphangioma and one case shows carvenous lymphangio~rna. We report these cases with review of literatures.

Endoscopic Ligation of Large Gastric Varices Using a Detachable Snares and Rubber Bands / 대한소화기내시경학회지

Bleeding from gastric varices greater than 2cm in diameter represents a major limitation for endoscopic hemostasis. The endoscopic injection sclerotherapy (EIS) using conventional sclerosing agents is not satisfactory for the control of acute bleeding from gastric varices which have large diameter, fast blood flow and abundant collateral circulations. Endoscopic ligation using small rubber bands, known to be alternative to EIS, never obliterate large gastric varices greater than 2 cm in diameter. Obliteration therapy using Histoacryl (n-buty1-2-cyanoacrylate), known to be more satisfactory, has some drawback such as embolization. We per formed endoscopic ligation using detachable snares and rubber bands in 22 patients who had recently bleeding from gastric varices larger than 2 cm in diameter. For ligation of gastric varices larger than 2 cm in diameter, the detachable snares were used, and then for ligation of adjacent small gastric varices, rubber bands were used. In seven patients active bleedings were noted at initial endoscopy; 6 of them were successfully controlled by endoscopic ligation using detachable snares and rubber bands, but one patient who was uncontrolled by it died from bleeding and multiple organ failure. In remaining 15 patients, there were no active bleeding but red color signs on large gastric varices; all of them were successfully controlled by endoscopic ligation using detachable snares and rubber bands. Early rebleeding, fol lowing initial treatment, occurred in two patients (9.5%). So overall hemostatic rate of endoscopic ligation using the detachable snares and the rubber bands was 86.4% (19/22). Varices were nearly eradicated in 18 (85.7%) of the 21 survivors by ligation of 1-3 detachable snares (mean, l.3 snares) and 4-30 rubber bands (mean, 16,2 bands) in 2-6 sessions (mean, 3.2 sessions). During or after ligation, there were no serious complications, except transient epigastric pain or discomfort in 14.7% and fever in 1.3%. These results suggest that endoscopic ligation therapy with detachable snares and rubber bands is a safe and effective method for treatment of acute bleeding of gastric varices, especially gastric varices larger than 2 cm in diameter, which can not he controlled by conventional scleratherapy or variceal band ligation.

A Case of Early Esophageal Cancer Treated by Endoscopic Mucosal Resection Using a EEMR Tube / 대한소화기내시경학회지

Although esophageal cancer has been recognized as difficult to treat, its long-term survival statistics are significant lower than those of other gastrointestinal cancers, Postoperative 5-year survival of the early esophageal cancer which invasion is limited to the mucosa is close to 100%. So, early detection of esophageal cancer has been extremely significant. Progress in the endoscopic technique has enabled to make not only early detection but also curative endoscopic resection of the early esophageal cancers. The indication for curative endoscopic resection of esophageal cancer are as follows: mucosal cancer apart from gross invasion to the muscularis mucosae without nodal involvement and less than 2 cm * 2 cm in size of lesion. EEMR tube(endoscopic esophageal mucoaal resection tube), which was designed by Makuuchi in 1991, is widely used for resection of early esophageal cancers. We report a case of patient with early esophageal cancer, who was admitted due to complation of postprandial epigastric pain, diageosed by endoscopy, endoscopic ultra sonography and chest computerized tomography, and successfully resected by using EEMR tube.