Acute Cholangitis with Common Bile Duct Stone Caused by Lactococcus garvieae: A Case Report / 대한췌담도학회지

Lactococcus garvieae is a Gram-positive cocci that has been known to be a fish pathogen, and considered as a low virulence organism rarely associated with human infection. We report a case of acute cholangitis with common bile duct (CBD) stone and bacteremia by L. garvieae bacteremia in a 70-year-old male. The patient presented with epigastric pain and was diagnosed with two CBD stones. Blood culture obtained prior to empiric antimicrobial therapy with ceftizoxime sodium showed growth with Escherichia coli and L. garvieae. The bacteria were confirmed by matrix-assisted desorption/ionization time-of-flight mass spectrometry. Initial attempt at endoscopic biliary drainage failed, and the patient underwent percutaneous transhepatic biliary drainage and subsequent stone removal. He occasionally ingested raw fish and had a history of gastric ulcer with acid suppression therapy, which could be possible risk factors for L. garvieae infection. This is the first case of L. garvieae bacteremia in acute cholangitis.

Venous Thromboembolism in Patients with Advanced Pancreatic Cancer Receiving Palliative Chemotherapy: Incidence and Effect on Prognosis / 대한소화기학회지

Background/Aims@#This study evaluated the incidence of venous thromboembolism (VTE) in patients with advanced pancreatic ductal adenocarcinoma (PDAC) at the authors’ institution and analyzed the risk factors associated with VTE and the overall survival (OS). @*Methods@#One hundred and seventy patients with locally advanced or metastatic PDAC who received palliative chemotherapy at Daegu Catholic University Medical Center from January 2011 to December 2020 were included. @*Results@#During a median follow-up period of 341 days, 24 patients (14.1%) developed VTE. Cumulative incidence values of VTE were 4.7% (95% confidence interval [CI], 2.39-9.22) at 90 days, 9.9% (95% CI, 6.14-15.59) at 180 days, and 16.9% (95% CI, 11.50-24.36) at 360 days. Multivariate analysis showed that a carbohydrate antigen 19-9 (CA 19-9) level over 1,000 U/mL (hazard ratio [HR], 2.666; 95% CI, 1.112-6.389; p=0.028) and a history of alcohol consumption (HR, 0.327; 95% CI, 0.109-0.981; p=0.046) were significant factors associated with VTE. Patients with VTE showed a shorter median survival (347 days vs. 556 days; p=0.041) than those without VTE. Multivariate analysis revealed VTE (HR, 1.850; 95% CI, 1.049-3.263; p=0.033) and CA 19-9 level over 1,000 U/mL (HR, 1.843;95% CI, 1.113-3.052; p=0.017) to be significant risk factors associated with OS. @*Conclusions@#The cumulative incidence of VTE in patients with advanced PDAC was 16.9% at 360 days. While a history of alcohol consumption was a protective factor, a high CA19-9 level was a risk factor for VTE. In addition, the occurrence of VTE was associated with poor prognosis.

Differences in Clinical Features between Hypertriglyceridemia-Induced Acute Pancreatitis and Other Etiologies of Acute Pancreatitis / 대한췌담도학회지

Background@#/Aim: The aim of this study was to compare clinical features of hypertriglyceridemia-induced acute pancreatitis (HTGAP) with those of biliary acute pancreatitis (BAP) and alcoholic acute pancreatitis (AAP), respectively. @*Methods@#Medical records of patients with acute pancreatitis (AP) who were admitted to our institution from January 2014 to December 2018 were retrospectively reviewed. Disease severity and local complications were evaluated according to the 2012 Revised Atlanta Classification. Systemic complications were evaluated according to the Modified Marshall Scoring System. @*Results@#Of the total 610 patients with AP, those with BAP, AAP, and HTGAP were 310 (50.8%), 144 (23.6%), and 17 (2.8%), respectively. Compared with BAP, HTGAP showed higher proportion of moderately severe acute pancreatitis (MSAP) (64.7% vs. 28.1%, p<0.001) and severe acute pancreatitis (SAP) (17.6% vs. 5.5%, p <0.001). And HTGAP showed more local complications (76.5% vs. 26.8%, p<0.001) and higher recurrence rate (52.9% vs. 6.5%, p <0.001), but there was no significant difference in systemic complications (23.5% vs. 11.6%, p =0.140). Contrarily, there was no significant difference between HTGAP and AAP with respect to disease severity (64.7% vs. 63.9% in MSAP and 17.6% vs. 6.9% in SAP, p =0.181), local complications (76.5% vs. 67.4%, p =0.445), recurrence rate (52.9% vs. 32.6%, p =0.096), and systemic complications (23.5% vs. 11.5%, p =0.233). @*Conclusions@#HTGAP showed higher disease severity, more local complications, and higher recurrence rate than BAP. However, there was no significant difference in clinical features between HTGAP and BAP.

Difficult Biliary Cannulation from the Perspective of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis:Identifying the Optimal Timing for the Rescue Cannulation Technique

Background/Aims@#Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP). @*Methods@#An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis. @*Results@#We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2 =49.857, p5 minutes, and >5 minutes with inadvertent PD manipulation, respectively. @*Conclusions@#Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.

Difficult Biliary Cannulation from the Perspective of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis:Identifying the Optimal Timing for the Rescue Cannulation Technique

Background/Aims@#Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP). @*Methods@#An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis. @*Results@#We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2 =49.857, p5 minutes, and >5 minutes with inadvertent PD manipulation, respectively. @*Conclusions@#Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.

Endoscopic management of anastomotic stricture after living-donor liver transplantation

The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.

Recent Advances and Future Directions in Immunotherapeutics for Hepatocellular Carcinoma

Systemic target therapeutic drugs, such as sorafenib, lenvatinib, or regorafenib are the only drugs that are known to be effective against advanced hepatocellular carcinoma (HCC). However, these agents show a limited efficacy in killing residual tumors. Immunotherapy is an alternative approach to this treatment and has been used to successfully treat different cancers, including HCC. HCC is an inflammation-induced cancer and represents a very interesting target for immunotherapeutics. Immunotherapies aim to reverse the immune tolerance and suppression found in tumor microenvironments and include approaches, such as adoptive cell therapy, immune checkpoint inhibition, and cancer vaccination. Adoptive cell therapy uses autologous natural killer or cytokine-induced killer cells by cultivating them ex vivo and subsequently reinfusing them into the patient. Immune checkpoint inhibitors reactivate tumor-specific T cells by suppressing checkpoint-mediated inhibitory signaling. Cancer vaccination induces a tumor-specific immune response by activating effector T lymphocytes. A wide range of potential immunotherapy-related adverse events occur; therefore, a multidisciplinary collaborative management is required across the clinical spectrum. This review summarizes the current status of immunotherapy for HCC and provides a perspective on its future applications.

Efficient lung cancer-targeted drug delivery a nanoparticle/MSC system

Low targeting efficiency limits the applications of nanoparticles in cancer therapy. The fact that mesenchymal stem cells (MSC) trapped in the lung after systemic infusion is a disadvantage for cell therapy purposes. Here, we utilized MSC as lung cancer-targeted drug delivery vehicles by loading nanoparticles (NP) with anti-cancer drug. MSC showed a higher drug intake capacity than fibroblasts. In addition, MSC showed predominant lung trapping in both rabbit and monkey. IR-780 dye, a fluorescent probe used to represent docetaxel (DTX) in NP, delivered MSC accumulated in the lung. Both MSC/A549 cell experiments and MSC/lung cancer experiments validated the intercellular transportation of NP between MSC and cancer cells. assays showed that the MSC/NP/DTX drug delivery system exerted primary tumor inhibition efficiency similar to that of a NP/DTX drug system. Collectively, the MSC/NP drug delivery system is promising for lung-targeted drug delivery for the treatment of lung cancer and other lung-related diseases.

Increased Risk of Pancreatic Cancer Following a First-time Diagnosis of Acute Pancreatitis / 대한소화기학회지

No abstract available.

Evaluation of Recurrent or Idiopathic Pancreatitis / 대한췌담도학회지

Recurrent acute pancreatitis (RAP) is defined as two or more true episodes of acute pancreatitis and about 20% of patients with acute pancreatitis experience at least one episode of recurrence. In about 10% of RAP, no definite etiology is found despite extensive evaluation. This entity is called idiopathic acute pancreatitis (IAP). Toxic-metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, obstructive (TIGAR-O) classification is commonly used to identify risk factors for RAP. Modalities employed to find causes of RAP and IAP include meticulous history taking, blood tests, diagnostic imaging, genetic testing, bile crystal analysis, endoscopic ultrasonography, and endoscopic retrograde cholangiopancreatography with/without sphincter of Oddi manometry. Each modality is briefly reviewed in this review.

Lung Cancer Recurrence with Solitary Pancreatic Metastasis Mimicking Primary Pancreatic Cancer / 대한췌담도학회지

Pancreas metastasis of primary lung cancer is known to be very rare and if it occurs, most cases are disseminated malignant status and do not affect therapeutic plan. We experienced a case of lung cancer recurrence with solitary pancreas metastasis and mimicks primary pancreatic cancer. A 54-year old man was admitted to the hospital for further evaluation of pancreatic solitary mass. He underwent left pneumonectomy and adjuvant chemotherapy for treatment of lung adenocarcinoma 3 years ago. After surgical treatment, the lesion was confirmed metastatic adenocarcinoma of lung cancer origin. He was discharged and followed up for 24 months without recurrence.

Prognostic implications of trunk muscle mass in liver cirrhosis

No abstract available.

Treatment of Autoimmune Pancreatitis / 대한췌담도학회지

Autoimmune pancreatitis is a rare type of chronic pancreatitis. Unlike chronic pancreatitis caused by other causes, autoimmune pancreatitis is characterized by a dramatic response to corticosteroid and immunomodulator therapy. Two most widely used drugs for treatment of autoimmune pancreatitis are corticosteroid and immunomodulators. Corticosteroid is the first line drug for autoimmune pancreatitis and used for remission induction. Remission induction rate of corticosteroid therapy is more than 90%, but relapse rate is approximately 30%. Centers in Japan and Republic of Korea prefer low-dose corticosteroid for maintenance. On the other hand, centers in North America and Europe prefer immunomodulators for maintenance. In the future, well-designed studies on methods to decrease relapse rate of autoimmune pancreatitis and effective use of immunomodulators are needed.

Endoscopic Ultrasound-Guided Direct Intervention for Solid Pancreatic Tumors

Development and use of linear-array echoendoscope and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) have made endoscopic ultrasound (EUS) more of an interventional procedure than a purely diagnostic procedure. This is a literature review of previously published clinical studies on EUS-guided direct intervention for solid pancreatic tumors, including EUS-guided fine needle injection (EUS-FNI) of antitumor agents, EUS-guided fiducial marker placement, EUS-guided brachytherapy and EUS-guided tumor ablation.

A Case of Pneumatosis Cystoides Intestinalis after Erlotinib-containing Chemotherapy for Pancreatic Cancer / 대한췌담도학회지

Pneumatosis cystoides intestinalis (PCI) is an uncommon condition that is characterized by the presence of gas within the bowel wall. We experienced a case of PCI after erlotinib-containing chemotherapy for advanced pancreatic cancer. A 66-year-old woman was admitted to the hospital with intermittent epigastric pain, and she diagnosed with advanced pancreatic cancer accompanied by hepatic metastasis. Combination chemotherapy of gemcitabine and erlotinib was started. PCI occurred about 14 months after start of the chemotherapy but she did not complain of abdominal pain and physical examination showed no evidence of peritoneal irritation sign. Laboratory findings showed no abnormalities. Following conservative treatment for 3 days, no specific symptoms were observed, and abdominal X-ray examination showed reduced abnormal air deposition. Erlotinib-containing chemotherapy was continued and PCI had not recurred.

Durable Response to Pazopanib in a Patient with Metastatic Alveolar Soft Part Sarcoma / 이화의대지

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma, and frequently, metastases are found at diagnosis. In patients with metastatic or unresected ASPS, systemic treatment is extremely limited, because conventional chemotherapeutic agents have not been effective in most cases. A novel agent inhibiting angiogenesis, pazopanib, has been proven to be effective for metastatic soft tissue sarcoma in a second-line setting. However, the efficacy of pazopanib in ASPS has not yet been reported. A 22-year-old man presented with right calf ASPS and multiple lung metastases. Pazopanib as a second-line treatment showed significant tumor response. To the best of our knowledge, this is the first report of the effectiveness of pazopanib in ASPS.

Association between Smoking and the Progression of Computed Tomography Findings in Chronic Pancreatitis

BACKGROUND/AIMS: Smoking and alcohol intake are two well-known risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis. METHODS: In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking. RESULTS: The median duration of follow-up was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio [OR], 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008). CONCLUSIONS: Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.

Recent Advances in Endoscopic Papillectomy for Ampulla of Vater Tumors: Endoscopic Ultrasonography, Intraductal Ultrasonography, and Pancreatic Stent Placement

Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.

Revised Atlanta Classification of Acute Pancreatitis Can Predict Clinical Outcome Better: a Retrospective, Multicenter Study / 대한췌담도학회지

BACKGROUND/AIMS: The 2012 revision of the Atlanta classification of acute pancreatitis (AP) by international consensus has been published and in use. This study investigated and compared clinical outcome of patients with AP stratified according to the 1992 Atlanta classification and revised classification. METHODS: A total of 574 AP patients from six referral hospitals between January 2012 and July 2013 were included. Medical records were reviewed retrospectively. Severity assessment according to both classifications was done. Demographics, organ failure, local complications, length of stay, and clinical outcome were recorded. RESULTS: There were 377 males (65.7%). Median age was 55.4 years. Two most common causes of AP were alcohol (n=238, 41.5%) and gallstone (n=193, 33.6%). According to revised classification, there were mild (n=356, 62%), moderately severe (n=197, 34.3%), and severe AP (n=21, 3.7%). Length of stay showed gradual increment with increase in degrees of severity according to the revised classification (5.9 days in mild AP, 8.3 days in moderately severe AP, and 13 days in severe AP, p<0.001). All the patients with mild and moderately severe AP improved, but all the 11 cases without improvement belonged to severe AP. CONCLUSIONS: The revised classification seems to be a good predictor for clinical outcome of AP.

Is Endoscopic Retrograde Cholangiopancreatography Safe in Patients 90 Years of Age and Older?

BACKGROUND/AIMS: This case-control study evaluated the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years of age and older. METHODS: From January 2005 to August 2011, 5,070 cases of ERCP were performed at our institution. Of these, 43 cases involved patients 90 years of age and older (mean age, 91.7+/-1.9 years). A control group of 129 cases (mean age, 65.7+/-14.8 years) was matched by the patient sex, sphincterotomy, and presence of choledocholithiasis using a propensity score. The patients' medical records were retrospectively reviewed for comorbidity, periampullary diverticulum, urgent procedure, conscious sedation, technical success, procedure duration, ERCP-related complication, and death. RESULTS: Between the case and control groups, there was no significant difference with regard to comorbidity, periampullary diverticulum, and urgent procedure. Conscious sedation was performed significantly less in the patient group versus the control group (28 [65%] vs 119 [92%], respectively; p=0.000). There was no significant difference in the technical success, procedure duration, or ERCP-related complications. In both groups, there was no major bleeding or perforation related to ERCP. Post-ERCP pancreatitis occurred significantly less in the patient group compared to the control group (0 vs 13 [10%], respectively; p=0.004). One death occurred from respiratory arrest in the case group. CONCLUSIONS: ERCP can be performed safely and successfully in patients aged 90 years and older without any significant increase in complications.