Intraductal Radiofrequency Ablation as a Palliative Treatment for Advanced Malignant Hilar Biliary Obstruction / 대한내과학회지

Malignant hilar biliary obstruction (MHBO) frequently accompanies cholestasis and cholangitis, and requires biliary stent placement. To prevent stent occlusion and prolong survival, local ablation therapy can be considered adjunctive to stent placement. Intraductal radiofrequency ablation (ID-RFA) is a recently developed local therapy for malignant biliary obstruction that can be easily performed employing endoscopic retrograde cholangiography. The use of ID-RFA to treat MHBO (as distinct from distal biliary obstruction) was suggested to be associated with severe adverse events. However, recent comparative studies have shown that ID-RFA is feasible and safe, and acceptably efficacious, in patients with advanced MHBO; newer temperature-controlled ID-RFA devices may enhance safety further. Regularly repeated ID-RFA with stent exchange affords better survival than stenting alone. However, the optimal ID-RFA strategy for MHBO remains inconclusive given the lack of data. Further large-scale clinical trials are needed.

Long-term Outcomes of Direct Endoscopic Necrosectomy for Complicated or Symptomatic Walled-Off Necrosis: A Korean Multicenter Study

Background/Aims@#The endoscopic step-up approach is accepted as the preferred treatment for complicated or symptomatic walled-off necrosis (WON). Direct endoscopic necrosectomy (DEN) is an effective therapeutic option, but few reports describe long-term follow-up in this patient population. Thus, we aim to assess the long-term outcomes of DEN following severe necrotizing pancreatitis. @*Methods@#The data of all acute pancreatitis patients who underwent DEN following endoscopic transmural drainage from six referral centers between 2007 and 2017 were retrospectively collected. @*Results@#Sixty patients (76.7% male, mean age 48.3 years) underwent a median of 4 sessions of DEN starting at a median of 45.5 days after the onset of acute pancreatitis. Clinical success was achieved in 51 patients (85%), with a 35% complication rate and a 5% mortality rate. Using multivariate analysis, the risk factor associated with DEN failure or major DEN complications requiring intervention or surgery was an identified bacterial/fungal WON infection (odds ratio, 19.3; 95% confidence interval, 1.5 to 261.7). During the median follow-up period of 27 months, complicated WON recurrence was observed in 5.3% of patients, and long-term complications occurred in 24.6% of patients (four exocrine insufficiency, nine newly developed diabetes mellitus, one recurrent small bowel obstruction, one chylous ascites). @*Conclusions@#Considering that long-term complications are similar to those observed after pancreatectomy, DEN should be performed meticulously while minimizing damage to the viable pancreatic parenchyma with adequate antibiotic escalation.

Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis

BACKGROUND/AIMS: Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). METHODS: Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. RESULTS: Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. CONCLUSIONS: The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Endoscopic Management of Pancreatobiliary Stricture in Chronic Pancreatitis / 대한췌담도학회지

Chronic pancreatitis is a debilitating disease with complications such as pancreatobiliary ductal stricture, leakage or fistulae contributing to significant morbidity and mortality. Treatment aims to relieve symptoms of pancreatobiliary ductal obstruction, maintain long-term drainage, and preserve pancreatic endocrine/exocrine functions. Endoscopic therapy, including stricture dilatation and stenting, is thought to be effective and the first-line treatment of these complications, and surgical therapies are reserved for patients with chronic pancreatitis who are refractory to endoscopic treatments. In this review, we discuss the role of endoscopic intervention for chronic pancreatitis related pancreatobiliary ductal problems.

Utility of Early CT in Patients with Suspected Acute Biliary Pancreatitis

PURPOSE@#The purpose of this study was to investigate whether early CT scans are useful for improving the clinical management of acute biliary pancreatitis.@*MATERIALS AND METHODS@#We retrospectively reviewed 56 consecutive patients who experienced first attack of acute pancreatitis and underwent CT scans within 48 hours of symptom onset in the emergency department, between March 2015 and March 2016. CT images were retrospectively evaluated for absence or presence, and etiology of acute pancreatitis, and probability of biliary pancreatitis. Urgent procedures for acute pancreatitis were analyzed.@*RESULTS@#Of 56 patients, 54 (96.4%) showed acute pancreatitis and 23 (41.1%) had biliary pancreatitis on CT. The diagnostic accuracy, sensitivity, and specificity of CT-diagnosed biliary pancreatitis were 94.6% (53/56), 91.7% (22/24), and 96.9% (31/32), respectively. Of the 56 patients, 17 (30.4%) patients with biliary pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours (mean time interval between CT and ERCP: 25.5 ± 19.8 hours; range: 2–67 hours). There was a significant difference in the urgent procedures between non-biliary and biliary pancreatitis groups (0 of 32 vs. 17 of 24, p < 0.001).@*CONCLUSION@#Early CT may be used in patients visiting hospital with suspected acute biliary pancreatitis to facilitate urgent treatment.

Intramural Gastric Hematoma after Acute Necrotizing Pancreatitis: A Case Report and Review of Imaging Findings

Intramural hematoma of the gastrointestinal tract is a rare disease entity. Pancreatitis-induced intramural gastric hematoma (IGH) is far more seldom reported. Here, we report a rare case of a giant IGH occurring as a delayed complication of pancreatitis in a 51-year-old man. The diagnosis was made using computed tomography (CT) and endoscopic ultrasonography. The patient was conservatively managed, and follow-up abdominal CT showed marked decreases in the size of the IGH.

Therapeutic Approaches to Atrophic Vaginitis in Postmenopausal Women: A Systematic Review with a Network Meta-analysis of Randomized Controlled Trials

OBJECTIVES: Atrophic vaginitis (AV), which is common in postmenopausal women, is characterized by vaginal dryness, dyspareunia, and discomfort. There are a variety of therapeutic agents for the treatment of AV, besides hormone replacement therapy. We performed this systematic review to compare the effectiveness of various therapies for symptom improvement in AV patients. METHODS: We searched the Cochrane Library, EMBASE, MEDLINE, and other literature (Google Scholar, Web of Science, and hand search) for studies published between January 2010 and March 2015. AV was evaluated by the following outcomes: vaginal pH, dyspareunia, vaginal dryness, or cytological change (endometrial thickness, percentages of superficial cells and parabasal cells). They measured treatment efficacy with various outcomes pertaining to AV symptoms. RESULTS: Meta-analysis suggested that ospemifene was effective against dyspareunia, vaginal dryness, endometrial thickness, and percentage changes in superficial and parabasal cells. Vaginal pH was most affected by soy isoflavone vaginal gel. Ospemifene was effective for AV symptoms. CONCLUSIONS: This systematic review compared the effects of several therapeutic agents on symptoms of AV through a network meta-analysis. This study provides objective evidence for clinical treatment and efficacy management in AV.

Epidemiology and Risk Factors of Gallbladder Cancer / 대한췌담도학회지

Gallbladder cancer (GBC)t is highly fatal. Despite recent advances in diagnostic and therapeutic modalities, 5-year survival rate of patients with GBC is less than 5%. Most cases are diagnosed in advanced stage and the efficacy of treatment has been disappointing. In this review, an overview of epidemiology and risk factors of GBC with the focus on the recent researches of the predisposing factors is provided. Women are more frequently afflicted than men with female to male ratio of 3 to 1. Incidence of GBC varies widely depending on geography and ethnicity. The highest incidence in the world is seen in women from Chile, Poland, and northern part of India. High rate of GBC is reported in Korea. The most important risk factor for the development of GBC is cholelithiasis. The association between cholelithiasis and GBC is confirmed by many case control studies. Up to 95% of GBC are associated with gallstones. Other predisposing factors include gallbladder polyp, gallbladder wall thickening, chronic cholecystitis, porcelain gallbladder and primary sclerosing cholangitis. Dietary and environmental factors are also supposed to play various roles in the pathogenesis of GBC. However, most gallbladder cancers are diagnosed after a cholecystectomy and only a third of cases are recognized preoperatively. Therefore, early detection and referral for cholecystectomy are essential for the improvement of overall survival of patients with GBC.

The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum / 대한소화기학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.

Drug Induced Acute Pancreatitis / 대한췌담도학회지

Drug induced acute pancreatitis (AP) is considered a relative rare disease. It has no distinguishing clinical features and physician may ignore the possibility of that due to lack of clinical recognition. Although estimates of the relative frequency with which drugs causes AP vary widely, there is a difficulty in proving the causal relationship between drug and pancreatitis. Therefore, a careful history taking and high index of suspicion is required for making a correct diagnosis. Drug induced AP is classified (class I-IV) based on previous literatures demonstrating the latent period and rechallenge reaction. Generally, class I and II drugs have the greatest potential for causing AP. In conclusion, physicians should be more aware of the possibility of drug induced AP in patients with unexplained AP and treat appropriately by discontinuation of the offending drugs. Besides, well designed epidemiological studies are needed to better define the frequency and specific risk of pancreatitis associated with any individual drug in Korea.

Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan

BACKGROUND/AIMS: When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings. METHODS: Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group. RESULTS: EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis. CONCLUSIONS: An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.

Incomplete Pancreas Divisum Presented with Acute Exacerbation of Chronic Pancreatitis in a Young Female / 대한소화기학회지

No abstract available.

Uterine cancer and ezrin expression / 고신대학교의과대학학술지

Today, almost 20% of female cancers are gynecological in nature. In particular, uterine cervical cancer and endometrial cancer (which have been intensively studied) seriously compromise female health. One of the ezrin-radixin-moesin (ERM) proteins, ezrin, has been associated with cancer in prior studies, including the two cancers mentioned above. Ezrin expression increases, as does the expression of other factors, in uterine cervical cancer; ezrin may promote cancer development by influencing the actions of the other factors. Also, an increase in ezrin level contributes to the development of diseases such as endometrial cancer.

Optimal Treatment of Advanced Pancreatic Neuroendocrine Tumor / 대한췌담도학회지

Pancreatic neuroendocrine tumors (pNETs) are diverse diseases with different prognosis. Among available various therapeutic options, curative resection should be considered for localized tumors and in some selected cases of metastatic disease. Somatostatin analogs are used to control hormonal symptoms and also effective to inhibit the tumor progression in specific settings. The molecular targeted agents such as sunitinib and everolimus are efficacious treatments for metastatic WHO grade 1/2 pNETs. Chemotherapy is generally used in highly symptomatic and rapidly growing pNETs such as WHO grade 3. In addition, local ablative therapy should be considered in patients with hepatic predominant unresectable metastatic pNETs, and peptide receptor radionucleotide therapy, which is unavailable in Korea, could be considered after failure of initial medical therapy. The most important of all is a multidisciplinary approach to pNETs. This is essential to optimal management of pNETs regarding the diverse disease nature

Xanthogranulomatous Pancreatitis Mimicking Pancreatic Cancer / 대한췌담도학회지

Xanthogranulomatous inflammation (XGI) is characterized histologically by the deposition of foamy macrophages and infiltration of inflammatory cells. While XGI is extremely rare, it has been reported in the gallbladder, kidney, stomach, and lymph nodes. A 61-year-old woman presented with epigastric pain for 2 weeks. Abdominal computed tomography and magnetic resonance imaging showed a pancreatic head mass with distal common bile duct wall thickening. Endoscopic ultrasonography followed by fine needle aspiration was performed, and subsequent pathology report revealed a benign disease. Because uncontrolled abdominal pain persisted and possibility of malignancy could not be excluded, Whipple's operation was eventually performed, and pathology report showed xanthogranulomatous pancreatitis (XGP). Herein, we report a case of symptomatic XGP mimicking of pancreas cancer. Although XGP is extremely rare, it should be considered as a differential diagnosis of neoplastic lesions of the pancreas.

Expression of Vitamin D Receptor in Seminal Vesicles of Cholesterol Formula Mice

OBJECTIVES: Genomic function of vitamin D receptor (VDR) indicates spermatogenesis that is important for in male reproductive organ authors evaluated the VDR expression in seminal vesicles with high cholesterol (HC) formula diet rat, because there is no report about relationship or difference in VDR in seminal vesicles between HC and control. METHODS: Male C57BL/6 mice aged 5 weeks were raised for 13 weeks. After one week of adaptation-period, they were fed different diet on normal AIN-93G diet, or HC diet containing 2% cholesterol for 12 weeks. The antibodies used were rabbit anti-VDR primary polyclonal. RESULTS: There was no significant difference in VDR reactivity in seminal vesicles, body weight of rat and weight of seminal vesicles between HC group and normal control group. CONCLUSION: Our data give the no difference in expression of VDR of seminal vesicles rat between HC formula diet and normal AIN-93G diet. But we confirmed the VDR expression in seminal vesicles.

A Pilot Study of the Impacts of Menopause on the Anogenital Distance

OBJECTIVES: It has been known that there is a difference in anogenital distance (AGD) in the animals and newborn depending on the exposure of androgenic hormones. The anatomical changes occur in the female genitalia in women after menopause. This was pilot study to find out whether the menopause affects AGD. METHODS: We evaluated a total of 50 women targeted for premenopausal and postmenopausal group in each 25 people. AGD was defined as a length between the posterior commissure of labia and anal center. AGD was measured in lithotomy position using sterile paper ruler. In order to control bias of the height and weight, which could influence the AGD, anogenital index (AGI) is defined as the weight divided by the AGD value. We used a Mann-Whitney U test to analyze the relationship between AGD and menopause for statistical analysis. RESULTS: AGD was significantly longer in premenopausal women compared to postmenopausal women (34.8 +/- 6.4 vs. 30.3 +/- 6.6, P = 0.019). AGI was significantly higher in premenopausal women than postmenopausal women (1.7 +/- 0.4 vs. 1.3 +/- 0.3, P < or = 0.000). CONCLUSION: The changes of AGD and AGI in postmenopausal women demonstrated to have potential to be used as on scale predicting the physical changes that may occur after menopause. This study could be used as the cornerstone of a large-scale studies in the future.

Mucinous Borderline Ovarian Tumor in Very Old Aged Postmenopausal Woman

Mucinous borderline ovarian tumors (BOTs) occur most often in women between the ages of 20 and 30. Early-stage detection of the condition has a more favorable prognosis. In this case report, the authors present an elderly 93-year old woman who visited our hospital due to severe abdominal pain after being diagnosed with a pelvic mass 2 years ago and not undergoing any treatment since the diagnosis was made. She underwent emergency left salpingo-oophorectomy and was diagnosed with mucinous BOT according to biopsy results.

Rare Nonneoplastic Cysts of Pancreas

Pancreatic cysts represent a small proportion of pancreatic diseases, but their incidence has been recently increasing. Most pancreatic cysts are identified incidentally, causing a dilemma for both clinicians and patients. In contrast to ductal adenocarcinoma, neoplastic pancreatic cysts may be cured by resection. In general, pancreatic cysts are classified as neoplastic or non-neoplastic cysts. The predominant types of neoplastic cysts include intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystic neoplasms, and solid pseudopapillary neoplasms. With the exception of serous type, neoplastic cysts, have malignant potential, and in most cases requires resection. Non-neoplastic cysts include pseudocyst, retention cyst, benign epithelial cysts, lymphoepithelial cysts, squamous lined cysts (dermoid cyst and epidermal cyst in intrapancreatic accessory spleen), mucinous nonneoplastic cysts, and lymphangiomas. The incidence of nonneoplastic, noninflammatory cysts is about 6.3% of all pancreatic cysts. Despite the use of high-resolution imaging technologies and cytologic tissue acquisition with endosonography, distinguishing nonneoplastic from neoplastic cysts remains difficult with most differentiations made postoperatively. Nonetheless, the definitive distinction between non-neoplastic and neoplastic cysts is crucial as unnecessary surgery could be avoided with proper diagnosis. Therefore, consideration of these rare disease entities should be entertained before deciding on surgery.

A Case of Epidermoid Cyst in the Intrapancreatic Accessory Spleen Mimicking Pancreas Mucinous Cystic Neoplasm / 대한췌담도학회지

An epidermoid cyst arising from intrapancreatic accessory spleen (ECIPAS) is a rare disease. Most patients with an ECIPAS are detected incidentally and could be misdiagnosed as a pancreatic cystic neoplasm such as mucinous cystic neoplasm (MCN) or intraductal p ancreatic mucinous neoplasm (IPMN). We described an ECIPAS with high cystic fluid carcinoembryonic antigen (CEA), which was misdiagnosed as a MCN of pancreas. Fifty one-year-old female was presented with a 2 cm sized non-enhancing pancreas cystic mass on the outside CT scan. Endoscpic ultrasonography (EUS) guided aspiration was performed. It showed a 2.3 x 1.9 cm unilocular cyst nearby 1.6 x 1.1 cm homogenous hypoechoic mass in pancreas tail, and cystic fluid CEA was 1564.18 ng/mL. On the basis of EUS results with elevated fluid CEA level, the presumptive diagnosis is likely to MCN of pancreas, and she underwent a laparoscopic distal pancreatectomy. The final pathology was the epidermal cyst in the intrapancreatic accessory spleen.