Seroepidemiology of Hepatitis A among Healthcare Workers and Their Response to Vaccination Recommendation at a Korean Hospital / 감염과화학요법

BACKGROUND: Recently, the incidence of hepatitis A has increased in Korea and an outbreak among healthcare workers (HCWs) has also been reported. This study was performed to evaluate the seroepidemiology of hepatitis A among HCWs and their response to vaccination recommendation at a Korean hospital. MATERIALS AND METHODS: HCWs aged 20-39 years were tested for IgG antibodies against hepatitis A virus (HAV) using ARCHITECT HAVAb-IgG (Abbott Diagnostics Division, Wiesbaden, Germany) during July, 2008. Vaccination was recommended for the seronegative HCWs. Data on age, sex, place of birth, number of siblings, number of children, travel history to endemic areas, occupations, and vaccination history were collected. Statistical analyses were conducted to identify variables related to HAV seropositivity. RESULTS: Among a total of 391 HCWs enrolled, 75 (19%) were males and 316 (81%) were females. The percentages of HCWs aged 20 to 24 years, 25 to 29 years, 30 to 34 years, and 35 to 39 years were 23%, 48%, 17%, and 12%, respectively. The study population comprised of physicians (11%), nurses (62%), nurse aides (5%), paramedical technicians (13%), and administrative staff (9%). Seropositivity for HAV significantly increased with age (P or = 3 children (P<0.05). The types of work the HCWs do at the hospital were not significantly associated with HAV seropositivity in multivariate analyses. Of a total of 322 seronegative HCWs, 121 (38%) were not vaccinated in spite of recommendation. The reasons for non-compliance were lack of understanding on the necessity of vaccination (39%), lack of time (26%), expensive costs (16%), fear of injection (15%), and some other reasons including pregnancy (4%). CONCLUSIONS: Since the seropositivity for HAV is low, vaccination against Hepatitis A should be considered for all HCWs aged 20-39 years in Korea. Education on the necessity of vaccination is warranted to increase compliance.

Seroepidemiology of Hepatitis A among Healthcare Workers and Their Response to Vaccination Recommendation at a Korean Hospital / 감염과화학요법

BACKGROUND: Recently, the incidence of hepatitis A has increased in Korea and an outbreak among healthcare workers (HCWs) has also been reported. This study was performed to evaluate the seroepidemiology of hepatitis A among HCWs and their response to vaccination recommendation at a Korean hospital. MATERIALS AND METHODS: HCWs aged 20-39 years were tested for IgG antibodies against hepatitis A virus (HAV) using ARCHITECT HAVAb-IgG (Abbott Diagnostics Division, Wiesbaden, Germany) during July, 2008. Vaccination was recommended for the seronegative HCWs. Data on age, sex, place of birth, number of siblings, number of children, travel history to endemic areas, occupations, and vaccination history were collected. Statistical analyses were conducted to identify variables related to HAV seropositivity. RESULTS: Among a total of 391 HCWs enrolled, 75 (19%) were males and 316 (81%) were females. The percentages of HCWs aged 20 to 24 years, 25 to 29 years, 30 to 34 years, and 35 to 39 years were 23%, 48%, 17%, and 12%, respectively. The study population comprised of physicians (11%), nurses (62%), nurse aides (5%), paramedical technicians (13%), and administrative staff (9%). Seropositivity for HAV significantly increased with age (P or = 3 children (P<0.05). The types of work the HCWs do at the hospital were not significantly associated with HAV seropositivity in multivariate analyses. Of a total of 322 seronegative HCWs, 121 (38%) were not vaccinated in spite of recommendation. The reasons for non-compliance were lack of understanding on the necessity of vaccination (39%), lack of time (26%), expensive costs (16%), fear of injection (15%), and some other reasons including pregnancy (4%). CONCLUSIONS: Since the seropositivity for HAV is low, vaccination against Hepatitis A should be considered for all HCWs aged 20-39 years in Korea. Education on the necessity of vaccination is warranted to increase compliance.

The Effect of Education in Reducing Catheter-related Urinary Tract Infections in Intensive Care Units at a University Hospital / 병원감염관리

BACKGROUND: Urinary tract infections (UTIs) are the most frequent nosocomial infections and are frequently associated with indwelling urinary catheters. It is known that adherence to standard infection control measures for urinary catheters can reduce UTIs in hospitals. This study was performed to evaluate the effect of education in reducing catheter-related UTIs (CR-UTIs) in intensive care units (ICUs) of a university hospital. METHODS: CR-UTIs were prospectively monitored for all patients with indwelling urinary catheters in ICUs from July 2006 through December 2007. Recommendations based on previously known guidelines for catheter insertion, catheter management, and specimen collection to prevent CR-UTIs were formulated and educated in March 2007. Knowledge and adherence level were evaluated before and after educating healthcare workers about the recommendations using questionnaire. Changes in knowledge and adherence level before and after education were compared by Chi-square test. Changes in the rate of CR-UTIs and urinary catheter utilization ratios were also analyzed by Fisher's exact test. RESULTS: After education, knowledge level of and adherence level to most of the recommendations were improved significantly. The rate of CR-UTIs significantly decreased by 48% from 7.43/1,000 catheter-days before intervention to 3.87/1,000 catheter-days after intervention (P=0.02). CONCLUSION: Surveillance for nosocomial infections and education for standard infection control measures are very important in preventing CR-UTIs in ICUs.

Multicenter Surgical Site Infections Surveillance System Report, 2007: In Total Hip and Total Knee Arthroplasties and Gastrectomies / 병원감염관리

BACKGROUND: A prospective multicenter study was performed to make a surgical site infections (SSI) surveillance system for hip (HRA) and knee (KRA) replacement arthroplasties and gastrectomies (GAST) in Korea. The rates, risk factors, and clinical characteristics of SSI were evaluated. METHODS: Demographic data, clinical and operative risk factors for SSI, and information of prophylactic antibiotic uses for the patients who took HRA/KRA and GAST in 7 and 5 hospitals, respectively were collected during July through December of 2007. SSI surveillance for HRA/KRA and GAST was done for 1 year and 1 month after operations, respectively. RESULTS: A total of 1,294 cases (HRA, 342; KRA, 453; GAST, 499) were monitored for SSI. The SSI rates of HRA, KRA, and GAST were 1.75 (6/342), 1.10 (5/453), and 4.41 (22/499) per 100 operations, respectively. Diabetes mellitus (DM) was more frequently accompanied and the dates of hospitalization before operations were longer in the infected group than the non-infected group of HRA. DM was more frequently found in the infected groups of KRA and GAST. Reoperation, emergent operation, and transfusion were more frequent in the infected group of GAST. Prophylactic antibiotics were used in 1,279 operations (99%) and started within 60 minutes before skin incision in 93% (1,190/1,279). The most frequently used antibiotics were 1st generation cephalosporins. Prophylactic antibiotics were used in combination in 33 operations (3%) and the median duration of antibiotic use was 4 days (0-89). CONCLUSION: The SSI rates of HRA, KRA, and GAST in this SSI surveillance system were 1.75, 1.10, and 4.41 per 100 operations, respectively.

The Effect of Simethicone as a Bowel Preparative: Is a Higher Dosage More Helpful? / 대한소화기내시경학회지

BACKGROUND/AIMS: Simethicone has been effectively used as a preprocedure drink during colonoscopy because it causes bubbles in the lumen to coalesce. We tried to confirm whether simethicone could effectively lessen the bubble formation and shorten the procedure time. In addition, we tried to determine the proper dose of this medication. METHODS: Patients were randomized to receive 0 mg as a control group (group I), 200 mg of simethicone at 7 PM in the evening before the procedure (group II), or 200 mg at 7 PM in the evening and 200 mg at 7 AM in the next morning (group III). The bubbles were scored as follows: 0, none or small amounts of bubbles that don't require any jet of water; 1, moderate amounts of bubbles that require two or three jets of water due to the focal distribution; And 2, large amounts of bubbles that require repeated jets (> or = 4) of water due to the extensive distribution. RESULTS: 101 patients were included in this study. The number of patients in groups I, II and III were 38, 35 and 28, respectively. The procedure time was statistically similar among the three groups. Severe bubbles (score 2) were significantly more likely to occur in group I than in groups II and III (p=0.014). On the other hand, the presence of significant bubbles (> or = 1) was not different between groups II and III. CONCLUSIONS: Simethicone significantly diminished the presence of bubbles. We recommend using 200 mg of simethicone in the evening before the colonoscopy.

A case of lymphoplasmacytic sclerosing pancreatitis presenting as an obstructive jaundice / 대한내과학회지

Lymphoplasmacytic sclerosing pancreatitis, also referred to as autoimmune pancreatitis, is a benign disease characterized by irregular narrowing of the pancreatic duct, swelling of the pancreatic parenchyma, lymphoplasmacytic infiltration and fibrosis. A few cases with locally affected lesions show features similar to cancer. Lymphoplasmacytic sclerosing pancreatitis is the most common benign disease in patients undergoing Whipple resection for a presumed pancreatic malignancy. We report a case of lymphoplasmacytic sclerosing pancreatitis diagnosed after surgery in a patient presenting with obstructive jaundice, with a review of the literature.

The Decision-making Value of Magnetic Resonance Cholangiopancreatography in Patients Suspicious for Pancreatobiliary Diseases / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is an operator-dependent procedure and has significant procedure-related morbidity and mortality. Magnetic resonance cholangiopancreatography (MRCP) is a safe noninvasive method for pancreatobiliary imaging. The aims of this study were to evaluate the potential impact of MRCP on performing ERCP and to evaluate the decision-making value of MRCP in patients suspicious for pancreatobiliary diseases. METHODS: Two hundreds twelve patients (M:F 108:104, mean age 59.3+/-13.7) who underwent MRCP due to clinical or sonographic suggesting pancreatobiliary disease were included. We divided patients into four groups according to their presumptive diagnosis: biliary stone (group 1), biliary tumor (group 2), gallstone pancreatitis (group 3) and other biliary diseases (group 4). RESULTS: Numbers of cases in group 1, 2, 3 and 4 were 145, 43, 17 and 7, respectively. In 144 cases (67.9%), ERCP was unnecessary and 76 cases (35.8%) required neither ERCP nor any other treatment. Thereafter, these cases were thought to be a patient group in whom the workload of performing ERCP could be reduced. CONCLUSIONS: MRCP can reduce the number and efforts doing ERCP and is helpful in decision-making for the treatment of pancreatobiliary disease. Therefore, MRCP could be the primary diagnostic tool before choosing ERCP.

Characteristics of Hospitals Participating in the Korean Nosocomial Infections Surveillance System 2006 / 병원감염관리

BACKGROUND: Korean Nosocomial Infections Surveillance System (KONIS) operating since July 2006 is the first nationwide monitoring system for nosocomial infections in the in the intensive care unit (lCU) with a standard protocol and web-based prompt response network in Korea. This report describes the characteristics of the KONIS hospitals compared with those of all Korean hospitals with 400 beds and over. METHODS: A survey was conducted for the 44 hospitals participating in KONIS 2006, and the data were rechecked by the KONIS hospitals through KONIS web-network. The survey form included questions about the size of the hospital, infection control personnel, nursing personnel, and the status of microbiologic laboratory. RESULTS: Compared to all Korean hospitals with 400 beds and over, the KONIS hospitals were larger in term of average number of beds (857 vs 654); the number of hospitals with 700 beds and over was over-represented in Seoul (P=0.01) and under-represented in the central/south area (P<0.001) The majority of the KONIS hospitals were major teaching university-affiliated (88,6%) and private (72.7%), but in the central/south area, public hospitals comprised up to 60%. The number of infection control professionals (ICP) averaged 1.6, hospital beds per ICP 531, and infectious disease physicians 1.3. Medical and medical combined ICUs were the major component (67,1%) of the KONIS ICUs, The lCU bed per nurse was 0.63. CONCLUSION: The KONIS 2006 hospitals were over-represented in the overall indicators in Seoul. Because no objective indicators were available regarding the patient quality, KONIS data must be interpreted in consideration of all indicators.

Korean Nosocomial Infections Surveillance System (KONIS) Report: Data Summary from July through September 2006 / 병원감염관리

BACKGROUND: THe Korean Society for Nosocomial Infection Control (KOSNIC) orfanized the Korean Nosocomial Infections Surveillance System (KONIS) to establish a nationwide database of Nosocomial infection (NI) rate in the intensive care units (ICUs) of Korean hospitals. This report is a summary of the data from July through September 2006. METHODS: The KONIS performed a prospective sruveillance for nosocomial urinary tract infections (UTI), bloodstream infections (BSI), and pneumonia (PNEU) at 76 ICUs in 44 hospitals. NI rates were calculated as the numbers of infections per 1,000 patient-days or device-days. RESULTS: A total of 846 nosocomial infections were fOlllld during the study period: 407 UTIs (397 cases were urinary catheter-associated), 204 BSIs (182 were central line-associated), and 235 PNEUs (161 were ventilator-associated). The rate of urinary catheter-associated UTIs was 4.61 cases per 1,000 device-days and urinary catheter utilization ratio was 0.83. The rate of central line-associated BSIs was 3.16 and the utilization ratio was 0.55. The rate of ventilator-associated PNEUs was 3.80 and the utilization ratio was 0.41. Although the ventilator utilization ratio was lower in the hospitals with 400-699 beds than in the hospitals with more than 900 beds, the rate of ventilator-associated pneumonia was higher in the smaller hospitals than in the larger ones. The rates of all three device-associated infections were the highest in the neurosurgical ICUs and the rates were the lowest in the surgical ICUs. CONCLUSION: This study may contribute to the development of effective strategies for NI control according to the size of hospital and the type of ICUs.

A Case of Duodenal Diverticulum Accompanied with Choledochoduodenal and Pancreaticoduodenal Fistulas / 대한소화기학회지

Choledochoduodenal fistula (CDF) occurring simultaneously with pancreaticoduodenal fistula is extremely rare. CDF has known to be a chronic sequela of cholelithiasis, but it is unknown whether pancreaticoduodenal fistula results from chronic cholelithiasis as well. We report a case of cholelithiasis accompanied with choledochoduodenal and pancreaticoduodenal fistula opening into small suprapapillary diverticulum in a 80-year-old woman.

A Case of Submucosal Tumor-like Early Gastric Adenocarcinoma Diagnosed by Endoscopic Mucosal Resection / 대한소화기내시경학회지

In rare cases, early gastric cancer resembles the endoscopic features of a submucosal tumor (SMT). A correct histological diagnosis is difficult with repeated biopsy specimens because they are covered with normal mucosa. Some features known to suggest malignant SMT include a size greater than 3 to 5 cm, a rapid growth rate, echoheterogeneity and irregular margins on endoscopic ultrasonography (EUS). Various techniques including US-guided biopsy, partial removal by an endoscopic snare excision, as well as EUS with a fine needle aspiration were used to enhance the diagnostic accuracy. We recently experienced a case of early gastric cancer, presenting as a submucosal tumor-like lesion, which was confirmed by endoscopic mucosal resection. We report this case with a review of the relevant literature.

Endoscopic Treatment of Benign Hypopharyngeal Tumors / 대한소화기내시경학회지

During endoscopy, most endoscopists insert endoscopes into the esophagus without visual aid in order to minimize the discomfort to patients. However, studies have shown that visual guided insertion imposes little discomfort, is safe and can increase the diagnostic rate of abnormal pathology of the throat. As for the treatment of hypopharyngeal lesions, cases of endoscopic treatment are rare and any guidelines have not been clearly defined yet. However, endoscopic treatment may be feasible in selected cases. Several procedures, such as endoscopic mucosal resection with cap (EMR-C) and saline injection polypectomy can be applied. We experienced seven patients who had benign hypopharyngeal masses that were removed endoscopically without serious complications. Compared to surgical treatment, endoscopic removal of the benign hypopharyngeal tumors does not require general anesthesia; it is simple, less invasive and less costly. Therefore, endoscopy should be regarded as a treatment option. However, further studies are required before widespread application of endoscopic removal for the definitive treatment of hypopharyngeal masses, including malignancies.

The changing patterns of acute hepatitis B infection in Korea in the early 2000's / 대한내과학회지

BACKGROUND: The prevalence of the hepatitis B virus (HBV) carrier state in Korean children is markedly reduced after the introduction of routine HBV vaccination program. The aims of this study were to evaluate the recent changing patterns of acute HBV infection, and to elucidate the diagnostic value of IgM anti-HBc in distinguishing acute hepatitis B from acute exacerbation in chronic HBV infection (CHB). METHODS: Fifty seven patients with acute hepatitis B and ninety nine patients with acute exacerbation in CHB were included. The titer of IgM anti-HBc was measured and the distribution of age was analyzed retrospectively. Signal to cut off ratio (S/CO ratio) of IgM anti-HBc was calculated in each IgM anti-HBc positive cases. RESULTS: The peak age of acute hepatitis B was 30~39 years old in 2000's. IgM anti-HBc was positive in 25.3% of CHB with acute exacerbation and the peak age of this group was also 30-39 years old. Mean(+/-SD) value of S/CO ratio was 8.3+/-9.1 in CHB group, while 22.9+/-18.7 in acute hepatitis group. The difference was significant between two groups (p value=0.001). However, S/CO ratio in 43.6% of CHB group was greater than 3. CONCLUSIONS: The incidence of acute hepatitis in Korea was highest in 30-39 years old recently. Therefore, catch-up vaccination is better to be recommended in adults. As the peak age of distribution of acute hepatitis B and CHB with acute exacerbation overlaps, much more caution is needed to differentiate these two conditions from each other by IgM anti-HBc only.

Spontaneous Resolution of Vanishing Bile Duct Syndrome in Hodgkin's Lymphoma / 대한간학회지

Cholestasis in a patient with Hodgkin's disease is uncommon, and the causes of cholestasis are mainly direct tumor involvement of the liver, hepatotoxic effects of drugs, viral hepatitis, sepsis and opportunistic infections. Vanishing bile duct syndrome (VBDS) represents a very rare cause for cholestasis in this disease. We report here on a case of a 45-year-old man who developed VBDS during the complete remission stage of Hodgkin's lymphoma. There was no history of hepatitis or intravenous drug abuse, and the patient had negative results for hepatitis A virus, hepatitis B virus, hepatitis C virus, cytomegalovirus, and human immunodeficiency virus. The serological studies for antinuclear antibodies, anti-mitochondrial antibodies and anti-smooth muscle antibodies were also negative. Liver biopsy disclosed the absence of interlobular bile ducts in 9 of 10 portal tracts without any active lymphocyte infiltration and there were no Reed-Sternberg cell in the liver. The patient's cholestasis was in remission and the serum bililrubin level was normalized after two months without treatment, but tumor recurrence was noted at multiple sites of the abdominal lymph nodes on follow-up abdomino-pelvic computed tomogram.

Treatment of Chronic Hepatitis C / 대한소화기학회지

Chronic infection with HCV represents second most common cause of end-stage liver diseases and hepatocellular carcinoma in Korea. The introduction of new agents and regimens for the treatment of chronic hepatitis C, such as pegylated forms of interferon-alpha (Peg-IFN) and combination with oral ribavirin has resulted in substantial improvement in sustained virologic response (SVR) rates. SVR rate of Peg-IFN and ribavirin combination therapy can be 40-46% of individuals infected with genotype 1 and approximately 75-85% with genotype 2 and 3. Peg-IFN/ribavirin combination therapy represents current standard therapy of chronic hepatitis C. This article reviews the treatment objectives, outcomes, optimal regimens, efficacy and predictors of response, monitoring during treatment, adverse events, retreatment of persons who failed to respond to previous treatments, and treatment of special patient groups in chronic hepatitis C.

Clinical Outcome in Cases of Viral Breakthrough During Lamivudine Therapy in Chronic Hepatitis B Patients / 대한간학회지

BACKGROUND/AIMS: Long-term lamivudine therapy can induce the emergence of lamivudine resistant hepatitis B virus (HBV) mutants. Clinically emergence of the mutant is expressed by the reappearance of disappeared HBV DNA in serum. Continued lamivudine treatment has been usually recommended in cases of viral breakthrough. However, the clinical outcome in patients with viral breakthrough is not clear. The aim of this study was to investigate the clinical course of chronic hepatitis B patients after viral breakthrough during lamivudine therapy. METHODS: A total of 74 patients with chronic hepatitis B who showed viral breakthrough after at least 6 months of lamivudine treatment were included in this study. They had positive HBeAg and HBV DNA before treatment. The median follow-up duration after breakthrough was 13 months. RESULTS: After viral breakthrough, only 8 patients (11%) maintained normal ALT levels and 66 patients (89%) showed elevation of ALT. 30 patients (41%) showed acute exacerbation of hepatitis (ALT increase over five-times upper normal limit). These acute exacerbations occurred within three months after breakthrough in 19 patients (63%). In the cases of acute exacerbation, 6 patients showed decompensated progression such as elevation of serum total bilirubin. One of them died of hepatic failure. A predictive factor for acute exacerbation was not found. HBeAg seroconversion occurred in 8 patients after viral breakthrough but their clinical course was highly variable. CONCLUSIONS: Chronic hepatitis B patients who had viral breakthrough during lamivudine therapy should be followed carefully and regularly in mind of potential clinical deterioration. New strategies are needed to manage the cases of acute exacerbation after viral breakthrough.

Viral Breakthrough in HBeAg-Negative Chronic Hepatitis B Patients Receiving Lamivudine Therapy / 대한간학회지

BACKGROUND/AIMS: Long-term efficacy and the rate of viral breakthrough in patients with HBeAg- negative chronic hepatitis B receiving lamivudine therapy is uncertain. This study was conducted to determine the rate of viral breakthrough according to the HBeAg status and the relation of viral breakthrough with YMDD mutants. METHODS: Two hundred and five patients with HBeAg-positive and 49 patients with HBeAg-negative chronic hepatitis B, who had received lamivudine for at least 9 months, were included. The mean durations of the lamivudine treatment were 176 months and 155 months in HBeAg-positive and negative patients, respectively. Analysis of HBV genome for YMDD mutations was performed by restriction-fragment-length polymorphism assay and direct sequencing. RESULTS: While the cumulative rates of viral breakthrough at 12th and 24th months of the lamivudine therapy were 0% and 7% in the HBeAg-negative group, they were 12% and 39% in the HBeAg-positive group. The cumulative rate of viral breakthrough in the HBeAg-negative group was significantly lower than in the HBeAg-positive group (p<0.01). In multivariate analysis, the only significant factor related to viral breakthrough was the HBeAg status (p<0.05). The YMDD mutants were detected in all patients with viral breakthrough irrespective of HBeAg status. However, in patients without viral breakthrough, the rate of YMDD mutants was significantly higher in the HBeAg-negative group than in the HBeAg-positive group (13.3% vs 5.1%; p<0.01). CONCLUSIONS: Lamivudine is expected to be more persistently effective in HBeAg-negative chronic hepatitis B because of a lower viral breakthrough rate than in HBeAg-positive chronic hepatitis B in spite of the emergence of YMDD mutants.

Endoscopically Observed Lower Esophageal Capillary Patterns

BACKGROUND: It has been reported that there are four zones of distinct venous patterns around the gastroesophageal junction (GEJ); i.e. truncal, perforating, palisade (PZ) and gastric zones. Using the distal end of PZ as a marker for GEJ, this study was done to assess the length and patterns of PZ in Koreans, and to assess the prevalence of endoscopic Barrett's esophagus (E-BE) and hiatal hernia (E-HH). METHODS: 847 consecutive patients undergoing diagnostic endoscopy were included. During endoscopy, PZ, squamocolumnar junction (SCJ) and pinchcock action (PCA) were identified. Patterns were classified according to the relationships of the distal end of PZ with SCJ and PCA; A: all three at the same level, B: SCJ proximal to the other two which are at the same level, C: PCA distal to the other two which are at the same level, D: SCJ proximal to the distal end of PZ which is proximal to PCA. Cases with patterns B and D were thought to have E-BE, and those with patterns C and D to have E-HH. RESULTS: Patterns A, B, C and D were 79.2%, 12.1%, 3.8% and 4.9%, respectively. Length of PZ was 3.0+/-0.1 cm. E-BE and E-HH were found in 17.0% and 8.7%, respectively. Both E-BE and E-HH were more frequently found in males and in cases with reflux esophagitis. CONCLUSION: E-BE and E-HH are not so infrequent in Koreans as previously thought, if we use the distal end of PZ as an endoscopic marker of GEJ.

Endoscopic Treatment of a Giant Mid-Esophageal Diverticulum / 대한소화기내시경학회지

Most patients with esophageal diverticula are asymptomatic and treatment should be reserved only for the symptomatic patients. The mainstay of treatment is surgery. Recently, in cases of Zenker's diverticula, endoscopic diverticulotomy has become increasingly popular. In lower esophageal diverticula, minimally invasive surgery (i.e. laparoscopic approach) has been successful. However, treatment with flexible endoscope has not been reported yet in mid- esophageal diverticulum. We present a case with a giant symptomatic mid-esophageal diverticulum, which was successfully treated by clip and cut technique through a flexible endoscope without general anesthesia.