Efficacy and safety of intragastric balloon for obesity in Korea

Background/Aims@#Intragastric balloon (IGB) is the only available endoscopic bariatric and metabolic therapy in Korea. End-ball (Endalis) has the longest history of clinical use among the IGBs available in Korea. However, little clinical data on this system have been reported. In this study, we aimed to evaluate the efficacy and safety of End-ball in Korea. @*Methods@#We performed a retrospective cohort study of patients who underwent IGB insertion (End-ball) from 2013 to 2019. Demographic and anthropometric data were collected. The efficacy and safety of IGB treatment were analyzed. @*Results@#In total, 80 patients were included. Mean age was 33.7 years and 83.8% were female. Initial body mass index was 34.48±4.69 kg/m2. Body mass index reduction was 3.72±2.63 kg/m2 at the time of IGB removal. Percent of total body weight loss (%TBWL) was 10.76%±6.76%. Percentage excess body weight loss was 43.67%±27.59%. Most adverse events were minor, and 71.4% of participants showed nausea, vomiting, or abdominal pain. @*Conclusions@#IGB treatment showed good efficacy and safety profile in Korean patients with obesity. In terms of %TBWL and percentage excess body weight loss, the efficacy was similar to that in the Western population.

Diagnosis and Management of Biliary Tract Cancer / 대한췌담도학회지

Biliary tract cancer (BTC) are highly aggressive and fatal malignancies. As one of the leading cause of death in Republic of Korea, BTC amoung various malignancies has been one of major public health concerns in the country. Although BTCs, including intrahepatic, perihilar, and distal cholangiocarcinoma, are relatively low-incidence malignancies compared to other cancer, but they represent a major health problem in endemic areas like Korea and Asia contries; moreover, the incidence of intrahepatic cholangiocarcinoma is rising globally. Surgery is the only curative treatment. The optimal surgical approach depends on the anatomical site of the primary tumour, and the best outcomes are achieved through management by specialist multidisciplinary team. Unfortunately, most patients present with locally advanced or metastatic disease. Only up to 20% of patients are diagnosed in early-stage, suitable for the curative surgery. Despite the surgery performed with potentially-curative intent, recurrence rates are high, around 60-70% of patients expected to have disease recurrence. In this review, we present an update of the causes, diagnosis, and treatment with a focus on chemotherapy of BTC.

Prognosis and Clinical Characteristics of Patients with Pancreatic Ductal Adenocarcinoma Diagnosed by Endoscopic Ultrasonography but Indeterminate on Computed Tomography

Background/Aims@#Endoscopic ultrasonography (EUS) provides high-resolution images and is superior to computed tomography (CT) scan in diagnosing small pancreatic ductal adenocarcinoma (PDAC). As a result, the use of EUS for early detection of PDAC has attracted attention. This study aimed to identify the clinical and radiological characteristics of patients with PDAC diagnosed by EUS but not found on CT scan. @*Methods@#The medical records of patients diagnosed with PDAC at 12 tertiary referral centers in Korea from January 2003 to April 2019 were reviewed. This study included patients with pancreatic masses not clearly observed on CT scan but identified on EUS. The clinical characteristics and radiological features of the patients were analyzed, and survival analysis was performed. @*Results@#A total of 83 patients were enrolled. The most common abnormal CT findings other than a definite mass was pancreatic duct dilatation, which was identified in 61 patients (73.5%). All but four patients underwent surgery. The final pathologic stages were as follows: IA (n=31, 39.2%), IB (n=8, 10.1%), IIA (n=20, 25.3%), IIB (n=17, 21.5%), III (n=2, 2.5%), and IV (n=1, 1.4%). The 5-year survival rate of these patients was 50.6% (95% confidence interval, 38.8% to 66.7%). Elevated liver function testing and R1 resection emerged as significant predictors of mortality in the multivariable Cox regression analysis. @*Conclusions@#This multicenter study demonstrated favorable long-term prognosis in patients with PDAC diagnosed by EUS but indeterminate on CT scan. EUS should be considered for patients with suspected PDAC but indeterminate on CT scan.

The Pathologic Confirmation in Subepithelial Tumors

Background/Aims@#Subepithelial tumors (SETs) are small, mostly asymptomatic lesions with normal overlying mucosa, usually identified incidentally on endoscopy. The aim of this study was to evaluate the pathologic diagnosis of SETs, and to assess the diagnostic yield and impact of endoscopic submucosal dissection (ESD) biopsy on the management of patients with SETs. @*Materials and Methods@#We included 52 subepithelial lesions in this study during the study period. Inclusion criteria included size of the SET >2 cm, and a gastrointestinal stromal tumor (GIST) that cannot be excluded using EUS. We performed an endoscopic biopsy of each SET using the ESD technique. @*Results@#The mean diameter of the lesions was 24.15±6.0 mm. The diagnostic yield of this method was 96.15%. Among the 52 participants, 45 were located in the stomach, four in the esophagus, and three in the duodenum. The pathologic diagnoses included: 17 leiomyomas, 13 GISTs, 11 ectopic pancreases, two carcinomas, two inflammatory fibroid polyps, two Brunner’s gland hyperplasia, two lipomas, one glomus tumor, and two remained undiagnosed. The mean duration of the procedure was 13.44±2.41 minutes. Three complications were associated with the procedure. @*Conclusions@#Deep biopsy via ESD is useful in determining the histopathologic nature of SETs. This method minimizes the need for unnecessary surgery in benign SETs.

Diagnostic Performance of Serum Asialo α1 -Acid Glycoprotein Levels to Predict Liver Cirrhosis

Background/Aims@#To date, studies on various noninvasive techniques have been suggested to evaluate the degree of liver fibrosis. We aimed to investigate the diagnostic performance of se-rum asialo α1-acid glycoprotein (AsAGP) in the diagnosis of liver cirrhosis compared with chronic hepatitis for clinically useful result. @*Methods@#We conducted a case-control study of 96 patients with chronic liver disease. Chronic hepatitis was defined as the presence of chronic liver disease on ultrasonography, with a liver stiffness of less than 5.0 kPa as shown on magnetic resonance elastography (MRE). Liver cirrho-sis was defined as liver stiffness of more than 5.0 kPa on MRE. The serum AsAGP concentration was compared between the two groups. @*Results@#Serum AsAGP levels were significantly higher in patients with cirrhosis than in those with chronic hepatitis (1.83 μg/mL vs 1.42 μg/mL, p<0.001). Additionally, when comparing pa-tients in each cirrhotic group (Child-Pugh grades A, B, and C) to those with chronic hepatitis, AsAGP levels were significantly higher in all the cirrhotic groups (p<0.05, p<0.01, p<0.001, respectively). The sensitivity and specificity of AsAGP for detecting cirrhosis were 79.2% and 64.6%, respectively, and the area under the curve value was 0.733. The best diagnostic cutoff to predict cirrhosis was 1.4 μg/mL. AsAGP and bilirubin were found to be independent risk factors for the prediction of cirrhosis in the logistic regression analysis. @*Conclusions@#Serum AsAGP showed an acceptable diagnostic performance in predicting liver cirrhosis.

The Pathologic Confirmation in Subepithelial Tumors

Background/Aims@#Subepithelial tumors (SETs) are small, mostly asymptomatic lesions with normal overlying mucosa, usually identified incidentally on endoscopy. The aim of this study was to evaluate the pathologic diagnosis of SETs, and to assess the diagnostic yield and impact of endoscopic submucosal dissection (ESD) biopsy on the management of patients with SETs. @*Materials and Methods@#We included 52 subepithelial lesions in this study during the study period. Inclusion criteria included size of the SET >2 cm, and a gastrointestinal stromal tumor (GIST) that cannot be excluded using EUS. We performed an endoscopic biopsy of each SET using the ESD technique. @*Results@#The mean diameter of the lesions was 24.15±6.0 mm. The diagnostic yield of this method was 96.15%. Among the 52 participants, 45 were located in the stomach, four in the esophagus, and three in the duodenum. The pathologic diagnoses included: 17 leiomyomas, 13 GISTs, 11 ectopic pancreases, two carcinomas, two inflammatory fibroid polyps, two Brunner’s gland hyperplasia, two lipomas, one glomus tumor, and two remained undiagnosed. The mean duration of the procedure was 13.44±2.41 minutes. Three complications were associated with the procedure. @*Conclusions@#Deep biopsy via ESD is useful in determining the histopathologic nature of SETs. This method minimizes the need for unnecessary surgery in benign SETs.

Recurrent Coronary Artery Vasospasm in a Patient with Hepatocellular Carcinoma Treated with Sorafenib: a Case Report and Literature Review

Tyrosine kinase inhibitors are widely used as targeted treatments for various malignancies. Sorafenib is an orally active tyrosine kinase inhibitor that blocks the signaling pathways of several growth factors. Its use is approved for various malignancies such as unresectable hepatocellular carcinoma, renal cell carcinoma, and gastrointestinal stromal tumors. Several adverse effects have been reported in the literature; however, cardiotoxicity is rare. We present a case of recurrent coronary vasospasm caused by short-term administration (5 days) of sorafenib. Since it caused refractory ischemia after re-administration, we had no choice but to stop the treatment.

Current Status of Bariatric Endoscopy in Obesity Control / 대한내과학회지

Obesity and metabolic syndrome affect ~40% of individuals in the United States alone. They are significant conditions that can cause severe economic problems. Obesity is also a global issue, with ~400 million obese adults worldwide. Moreover, the number of overweight children is increasing. Bariatric surgery is the gold standard treatment for obesity; however, endoscopic approaches may have a significant role in improving metabolic syndrome and achieving weight loss. Many endoscopic methods have been introduced, some of which are currently available and some that are undergoing experimentation. Endoscopists have a role in the treatment of obesity because endoscopic therapies are expected to become safer and more efficacious in the coming years. Endoscopic bariatric therapies can be categorized as space occupying, malabsorption, and gastric volume reduction. In this review, we summarize the currently available endoscopic procedures.

Evaluation of Patients Suspected of Common Bile Duct Stone / 대한췌담도학회지

Common bile duct stones (CBDS) are estimated to be present in 10–20% of individuals with symptomatic gallstones. Most patients with gallstones remain asymptomatic throughout their lifetime, but 10–25% of them may develop biliary pain or complications including pain, jaundice, infection and acute pancreatitis, with an annual risk of about 2–3% for symptomatic disease and 1–2% for major complications. The primary treatment, endoscopic retrograde cholangio-pacreatography (ERCP), is minimally invasive but associated with adverse events in 6% to 15% of patients. Therefore, exact evaluation of CBDS is important in patients with gallstones. Clinicians are therefore confronted with a number of potentially valid options such as endoscopic ultrasonography versus magnetic retrograde cholangiopancreatography in order to diagnose suspected CBDS. The aim of this review for evaluation of patients suspected of common bile duct stone is to provide practical advice on how to manage patients with CBDS. It considers diagnostic strategies in patients with suspected CBDS, as well as the different therapeutic options available for CBDS.

Current Status of Bariatric Endoscopy in Obesity Control / 대한내과학회지

Obesity and metabolic syndrome affect ~40% of individuals in the United States alone. They are significant conditions that can cause severe economic problems. Obesity is also a global issue, with ~400 million obese adults worldwide. Moreover, the number of overweight children is increasing. Bariatric surgery is the gold standard treatment for obesity; however, endoscopic approaches may have a significant role in improving metabolic syndrome and achieving weight loss. Many endoscopic methods have been introduced, some of which are currently available and some that are undergoing experimentation. Endoscopists have a role in the treatment of obesity because endoscopic therapies are expected to become safer and more efficacious in the coming years. Endoscopic bariatric therapies can be categorized as space occupying, malabsorption, and gastric volume reduction. In this review, we summarize the currently available endoscopic procedures.

ERCP Educational Guidelines for Fellows / 대한췌담도학회지

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an essential endoscopic technique in diagnosis and treatment of pancreatobiliary diseases. Although its diagnostic role is decreasing because of less invasive modalities such as magnetic resonance cholangiopancreatography or endoscopic ultrasound, it is still very important in treatment of pancreatobiliary diseases. However, there is a trend of hesitation to learn ERCP by the fellows in Korea because of following reasons; concentration of ERCP in a few high volume centers, high risk of post-procedural complications, and long training courses. In this background, the education committee of Korean Pancreatobiliary Association has prepared for ERCP educational guidelines for fellows in Korea. This guideline should be helpful to fellows who are currently under the training.

ERCP Educational Guidelines for Fellows / 대한췌담도학회지

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an essential endoscopic technique in diagnosis and treatment of pancreatobiliary diseases. Although its diagnostic role is decreasing because of less invasive modalities such as magnetic resonance cholangiopancreatography or endoscopic ultrasound, it is still very important in treatment of pancreatobiliary diseases. However, there is a trend of hesitation to learn ERCP by the fellows in Korea because of following reasons; concentration of ERCP in a few high volume centers, high risk of post-procedural complications, and long training courses. In this background, the education committee of Korean Pancreatobiliary Association has prepared for ERCP educational guidelines for fellows in Korea. This guideline should be helpful to fellows who are currently under the training.

Endoscopic submucosal dissection of gastric subepithelial tumors: a systematic review and meta-analysis

BACKGROUND/AIMS: To evaluate the therapeutic outcomes of the endoscopic submucosal dissection (ESD) technique for the treatment of gastric subepithelial tumors (SETs). METHODS: A systematic literature review was conducted using the core databases. Data on the complete resection rates and the procedure-related perforation rates were extracted and analyzed. A random effects model was then applied for this meta-analysis. RESULTS: In all, 288 patients with 290 SETs were enrolled from nine studies (44 SETs originated from the submucosal layer; 246 SETs originated from the muscularis propria layer). The mean diameter of the lesions ranged from 17.99 to 38 mm. Overall, the pooled complete resection rate was estimated to be 86.2% (95% confidence interval [CI], 78.9 to 91.3). If the analysis was limited to the lesions that originated from the submucosal layer, the pooled complete resection rate was 91.4% (95% CI, 77.9 to 97). If the analysis was limited to the lesions that originated from the muscularis propria, the pooled complete resection rate was 84.4% (95% CI, 78.7 to 88.8). The pooled procedure-related gastric perforation rate was 13% (95% CI, 9.4 to 17.6). Sensitivity analyses showed consistent results. Finally, publication bias was not detected. CONCLUSIONS: ESD, including endoscopic muscularis dissection, is a technically feasible procedure for the treatment of SETs. However, selection bias is suspected from the enrolled studies. For the development of a proper indication of ESD for SETs, further studies are needed.

Intrahepatic Cholangiocarcinoma with Central Calcification / 대한췌담도학회지

A 50-year-old woman complained of jaundice and dyspepsia that started 2 weeks prior to consultation. Abdomen-pelvic computed tomography showed a 3 cm mass in the right hepatic duct with central calcification, which was spreading into the second branch. Repeated biopsies through endoscopic retrograde cholangiopancreatography were needed for pathology, which was consistent with an adenocarcinoma. Imaging studies including positron emission tomography showed no evidence of distant metastasis. The patient underwent right lobectomy with bile duct resection. The final diagnosis was intrahepatic cholangiocarcinoma with central calcification. We reported a very rare case of centrally calcified mass growing in the second branch of the right hepatic duct. The possibility of intrahepatic cholangiocarcinoma with central calcification should be considered for differential diagnosis of intrahepatic calcification.

Tuberculous Prostatic Abscess with Prostatorectal Fistula after Intravesical Bacillus Calmette-Guérin Immunotherapy

Intravesical bacillus Calmette-Guérin (BCG) immunotherapy is a common treatment modality for bladder cancer after transurethral resection of a bladder tumor. This therapy is generally safe, and development of a prostatic abscess with a prostatorectal fistula after intravesical BCG immunotherapy is a very rare complication. This finding was incidentally obtained by the authors, who examined a patient with colonoscopy for evaluation of abdominal pain. The patient was successfully treated with antitubercular drugs. To the authors’ knowledge, this is the first report of a patient with a tuberculous prostatic abscess with prostatorectal fistula after BCG immunotherapy in South Korea.

Clinical efficacy of serum lipase subtype analysis for the differential diagnosis of pancreatic and non-pancreatic lipase elevation

BACKGROUND/AIMS: Non-pancreatic elevations of serum lipase have been reported, and differential diagnosis is necessary for clinical practice. This study aimed to evaluate the clinical efficacy of serum lipase subtype analysis for the differential diagnosis of pancreatic and non-pancreatic lipase elevation. METHODS: Patients who were referred for the serum lipase elevation were prospectively enrolled. Clinical findings and serum lipase subtypes were analyzed and compared by dividing the patients into pancreatitis and non-pancreatitis groups. RESULTS: A total of 34 patients (12 pancreatitis vs. 22 non-pancreatitis cases) were enrolled. In univariate analysis, the fraction of pancreatic lipase (FPL) in the total amount of serum lipase subtypes was statistically higher in patients with pancreatitis ([median, 0.004; interquartile range [IQR], 0.003 to 0.011] vs. [median, 0.002; IQR, 0.001 to 0.004], p = 0.04). Based on receiver operating characteristic curve analysis for the prediction of acute pancreatitis, FPL was the most valuable predictor (area under the receiver-operating characteristic curve [AUROC], 0.72; 95% confidence interval [CI], 0.54 to 0.86; sensitivity, 83.3%; specificity, 63.6%; positive predictive value, 55.6%; negative predictive value, 97.5%). In multivariate analysis, a cut-off value higher than 0.0027 for the FPL was associated with acute pancreatitis (odds ratio, 8.3; 95% CI, 1.3 to 51.7; p = 0.02). CONCLUSIONS: The results did not support that serum lipase subtype analysis could replace standard lipase measurement for the diagnosis of acute pancreatitis. However, the test demonstrated adequate sensitivity for use in triage or as an add-on test for serum lipase elevation.

Functional Gastrointestinal Disorders in Young Military Men

BACKGROUND/AIMS: To estimate the prevalence and evaluate the associated psychological factors of functional gastrointestinal disorders (FGIDs) in males in their twenties who are currently enrolled in military service. METHODS: A total of 1,073 men in the Korean army were asked to complete questionnaires based on the Rome III criteria and Symptom Checklist-90-revised (SCL-90R). The prevalence of FGIDs was estimated, and the associated psychological factors were evaluated. RESULTS: A total of 967 men participated. The total prevalence of FGIDs was 18.5% (age-adjusted prevalence, 18.1%; 95% confidence interval [CI], 15.3% to 20.8%). The total SCL-90R scores were higher in men with FGIDs than men without FGIDs (24 [interquartile range, 13 to 44] vs 13 [5 to 28], p<0.001) and higher in men with overlapping syndromes than in those with single FGIDs (31 [18 to 57] vs 14 [5.75 to 29], p<0.001). Somatization (odds ratio [OR], 1.141; 95% CI, 1.09 to 1.20; p<0.001), obsessive-compulsive behaviors (OR, 1.084; 95% CI, 1.03 to 1.14; p=0.002) and depression (OR, 0.943; 95% CI, 0.90 to 0.99; p=0.020) were identified as independent predictive factors for FGIDs. CONCLUSIONS: FGIDs are common among men in their twenties who are fulfilling their military duty. Somatization and obsessive-compulsive features from the tense atmosphere are associated with the development or progression of FGIDs. Patients who exhibit overlapping syndromes require greater attention given their more severe psychopathology.

Effect of Training in Upper Endoscopic Biopsy

BACKGROUND/AIMS: The optimal number of biopsy samples and the detection rate of neoplastic lesions are not established. This study aimed to assess the current practice patterns and effects of training in upper endoscopic biopsy. MATERIALS AND METHODS: From May through July 2013, all the biopsy-proven lesions detected during diagnostic esophagogastroduodenoscopy were enrolled in a single teaching hospital of Korea. Endoscopic findings, including number of biopsied samples, discrepancy rates between endoscopic and histologic diagnosis, and endoscopists' experience, were retrospectively assessed. RESULTS: A total of 1,208 biopsy-proven lesions were enrolled. 76 (6.3%) lesions were determined to be neoplastic. The neoplasm detection rate of trainees was lower than that of faculty doctors (4.6% vs. 7.7%; OR, 0.57; P=0.024). The number of biopsied samples was not different between trainees and faculty doctors, although faculty doctors tended to identify more neoplastic lesions. The concordance rates between endoscopic and histologic diagnosis were improved with training for both total and benign lesions, but there was no changes in concordance for neoplastic lesions. CONCLUSIONS: Training should be focused on detection of neoplastic lesions so as not to overlook these diseases.

Helicobacter pylori Eradication for Prevention of Metachronous Recurrence after Endoscopic Resection of Early Gastric Cancer

Controversies persist regarding the effect of Helicobacter pylori eradication on the development of metachronous gastric cancer after endoscopic resection of early gastric cancer (EGC). The aim of this study was to assess the efficacy of Helicobacter pylori eradication after endoscopic resection of EGC for the prevention of metachronous gastric cancer. A systematic literature review and meta-analysis were conducted using the core databases PubMed, EMBASE, and the Cochrane Library. The rates of development of metachronous gastric cancer between the Helicobacter pylori eradication group vs. the non-eradication group were extracted and analyzed using risk ratios (RRs). A random effect model was applied. The methodological quality of the enrolled studies was assessed by the Risk of Bias table and by the Newcastle-Ottawa Scale. Publication bias was evaluated through the funnel plot with trim and fill method, Egger's test, and by the rank correlation test. Ten studies (2 randomized and 8 non-randomized/5,914 patients with EGC or dysplasia) were identified and analyzed. Overall, the Helicobacter pylori eradication group showed a RR of 0.467 (95% CI: 0.362-0.602, P < 0.001) for the development of metachronous gastric cancer after endoscopic resection of EGC. Subgroup analyses showed consistent results. Publication bias was not detected. Helicobacter pylori eradication after endoscopic resection of EGC reduces the occurrence of metachronous gastric cancer.

Additive Effect of Pronase on the Eradication Rate of First-Line Therapy for Helicobacter pylori Infection

BACKGROUND/AIMS: Helicobacter pylori colonizes on the apical surface of gastric surface mucosal cells and the surface mucous gel layer. Pronase is a premedication enzyme for endoscopy that can disrupt the gastric mucus layer. We evaluated the additive effects of pronase combined with standard triple therapy for H. pylori eradication. METHODS: This prospective, single-blinded, randomized, controlled study was conducted between June and October 2012. A total of 116 patients with H. pylori infection were enrolled in the study (n=112 patients, excluding four patients who failed to meet the inclusion criteria) and were assigned to receive either the standard triple therapy, which consists of a proton pump inhibitor with amoxicillin and clarithromycin twice a day for 7 days (PAC), or pronase (20,000 tyrosine units) combined with the standard triple therapy twice a day for 7 days (PACE). RESULTS: In the intention-to-treat analysis, the eradication rates of PAC versus PACE were 76.4% versus 56.1% (p=0.029). In the per-protocol analysis, the eradication rates were 87.5% versus 68.1% (p=0.027). There were no significant differences concerning adverse reactions between the two groups. CONCLUSIONS: According to the interim analysis of the trial, pronase does not have an additive effect on the eradication of H. pylori infection (ClinicalTrial.gov: NCT01645761).