Feasibility of cap-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy.

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy. METHODS: The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope. RESULTS: The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths. CONCLUSIONS: Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.

Low pepsinogen I level predicts multiple gastric epithelial neoplasias for endoscopic resection.

BACKGROUND/AIMS: Synchronous/metachronous gastric epithelial neoplasias (GENs) in the remaining lesion can develop at sites other than the site of endoscopic resection. In the present study, we aimed to investigate the predictive value of serum pepsinogen for detecting multiple GENs in patients who underwent endoscopic resection. METHODS: In total, 228 patients with GEN who underwent endoscopic resection and blood collection for pepsinogen I and II determination were evaluated retrospectively. RESULTS: The mean period of endoscopic follow-up was 748.8±34.7 days. Synchronous GENs developed in 46 of 228 (20.1%) and metachronous GENs in 27 of 228 (10.6%) patients during the follow-up period. Multiple GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). Synchronous GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). CONCLUSIONS: Low pepsinogen I levels predict multiple GENs after endoscopic resection, especially synchronous GENs. Cautious endoscopic examination prior to endoscopic resection to detect multiple GENs should be performed for these patients.

Cap-assisted ERCP in patients with difficult cannulation due to periampullary diverticulum.

Selective biliary cannulation is an essential prerequisite for therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The cap-fitted forward-viewing endoscope has been used for ERCP in patients with surgically altered anatomy. In this case series, 12 patients with periampullary diverticulum underwent ERCP using the cap-assisted forward-viewing endoscope due to failure of biliary cannulation using the standard technique. Successful ERCP was achieved in all patients with no serious complications.

Various applications of endoscopic scissors in difficult endoscopic interventions.

Endoscopic scissors offer a benefit over other devices by avoiding potential complications related to thermal and mechanical injury of surrounding structures. We describe our experience with endoscopic scissors in three difficult endoscopic interventions. A fishbone embedded in the esophageal wall penetrated very close to the pulsating aorta and the bronchus. The fishbone was cut in half by endoscopic scissors and removed without injury to adjacent organs. A gastric submucosal tumor with an insulated core that could not be resected by electrosurgical devices was cut using endoscopic scissors following endoloop placement. Extravascular coil migration after transcatheter arterial embolization resulted in a duodenal ulcer. The metallic coil on the duodenal ulcer was cut by endoscopic scissors without mechanical or thermal injury.

Cap-assisted gastroscope versus cap-assisted colonoscope for examination of difficult sigmoid colons in a nonsedated Asian population: a randomized study.

BACKGROUND: Studies have estimated that cecal intubation failure occurs with conventional colonoscopy in about 10% of cases. Various methods have been adopted to improve the cecal intubation rate, including a transparent cap and special colonoscopes. OBJECTIVE: To assess the efficacy of using a cap-assisted gastroscope (E-cap) compared with a cap-assisted colonoscope (C-cap) for the complete examination of the colon in nonsedated patients with technically difficult sigmoid colons. DESIGN: Randomized, controlled study. SETTING: Tertiary-care referral center. PATIENTS: One hundred thirty-nine patients with technically difficult sigmoid colons were studied. INTERVENTION: Colonoscopy with either an E-cap (n = 69) or a C-cap (n = 70). MAIN OUTCOME MEASUREMENTS: Cecal intubation rate, cecal intubation time, patient-assessed pain score, and endoscopist-assessed pain score. RESULTS: The cecal intubation rate was significantly higher in the E-cap (65/69, 94.2%) than in the C-cap group (50/70, 71.4%; P < .0001). Patient-assessed pain (moderate to severe) was more frequently reported in the C-cap (14/70, 20.0%) than in the E-cap group (5/69, 7.2%; P = .029). Endoscopist-assessed pain (moderate to severe) was more frequently reported in the C-cap (13/70, 18.6%) than in the E-cap group (3/69, 7.2%; P = .009). For patients with a low body mass index (≤ 22 kg/m(2)), the cecal intubation rate was significantly higher in the E-cap (37/38, 97.4%) than in the C-cap group (15/29, 51.7%; P < .0001). LIMITATIONS: Single-center experience, lack of a gastroscope control group without a cap. CONCLUSION: The cap-assisted gastroscope is more tolerable and effective than cap-assisted colonoscope for the complete examination of the colon in patients with technically difficult sigmoid colons. ( CLINICAL TRIAL REGISTRATION NUMBER: KCT0000744.).

Endoscopic treatment of duodenal neuroendocrine tumors.

Duodenal neuroendocrine tumors (NETs) are rare neoplasms. In this study, the medical records of 14 patients with duodenal NETs diagnosed at Chonnam National University Hospital from July 2001 to August 2011 were reviewed and analyzed retrospectively. Four patients were diagnosed in the first 5 years, and 10 patients were diagnosed in the latter 5 years of the study. Ten of 12 patients (83.3%) who underwent endoscopic biopsy were confirmed to have NET before resection. Endoscopic resection was performed in 12 patients, surgical resection in one patient, and regular follow-up in one patient who refused resection. None of the patients showed recurrence or distant metastasis. Duodenal NETs are increasingly observed and are mostly detected during screening upper gastrointestinal endoscopy. Careful endoscopic examination and biopsy can improve the diagnostic yield of NETs. Most well-differentiated, nonfunctional duodenal NETs that are limited to the mucosa/submucosa can be treated effectively with endoscopic resection.

Impact of serum C-reactive protein level on the prognosis of patients with hepatocellular carcinoma undergoing TACE.

BACKGROUND/AIMS: The aim of this study was to determine the relationship between serum CRP levels and the prognosis of hepatocellular carcinoma (HCC) patients. METHODS: HCC patients who underwent the first session of transcatheter arterial chemoembolization (TACE) between January 2005 and December 2009 (n=211) were analyzed retrospectively. The patients were divided into two groups: high C-reactive protein (CRP; ≥1 mg/dL, n=51) and low CRP (<1 mg/dL, n=160). They were followed for a mean of 22.44 months and their clinicoradiological variables and overall survival were compared. RESULTS: There were significant differences between the two groups in regard to tumor type, tumor-progression-free survival, 10-month mortality, white blood cell (WBC) count, tumor size, and TNM stage. Multivariate analysis revealed that a high serum CRP level was independently associated with tumor size and tumor type. Subgroup analysis of CRP groups according to tumor size demonstrated that a high serum level of CRP was significantly associated with poorly defined (diffuse) tumor type in the tumor size <5 cm group [hazard ratio (HR)=4.81, P=0.018]. A Lipiodol dose exceeding 7 mL (HR=5.55, P=0.046) and the 10-month mortality (HR=7.693, P=0.004) were significantly associated with high serum CRP level in the group of patients with a tumor size of ≥5 cm. In addition, subgroup analysis of matched CRP according to TNM stage revealed that elevated serum CRP was independently associated with tumor type, WBC count, and tumorprogression-free survival. CONCLUSIONS: A high serum CRP level is associated with large tumors and a poorly defined tumor type, and is significantly associated with 10-month mortality in patients with large HCC (size ≥5 cm) who undergo TACE.

Clinical significance and risk factors of postembolization fever in patients with hepatocellular carcinoma.

AIM: To investigate tumor response and survival in patients with postembolization fever (PEF) and to determine the risk factors for PEF. METHODS: Four hundred forty-three hepatocellular carcinoma (HCC) patients who underwent the first session of transcatheter arterial chemoembolization (TACE) between January 2005 and December 2009 were analyzed retrospectively. PEF was defined as a body temperature greater than 38.0 °C that developed within 3 d of TACE without evidence of infection. The tumor progression-free interval was defined as the interval from the first TACE to the second TACE based on mRECIST criteria. Clinical staging was based on the American Joint Committee on Cancer tumor, node, metastases (TNM) classification of malignant tumors. All patients were admitted before their 1(st) TACE treatment, and blood samples were obtained from all patients before and after treatment. Clinicoradiological variables and host-related variables were compared between two groups: patients with PEF vs patients without PEF. Additionally, variables related to 20-mo mortality and tumor progression-free survival were analyzed. RESULTS: The study population comprised 370 (85.4%) men and 73 (14.6%) women with a mean age of 62.29 ± 10.35 years. A total of 1836 TACE sessions were conducted in 443 patients, and each patient received between 1 and 27 (mean: 4.14 ± 3.57) TACE sessions. The mean follow-up duration was 22.23 ± 19.6 mo (range: 0-81 mo). PEF developed in 117 patients (26.41%) at the time of the first TACE session. PEF was not associated with 20-mo survival (P = 0.524) or computed tomography (CT) response (P = 0.413) in a univariate analysis. A univariate analysis further indicated that diffuse-type HCC (P = 0.021), large tumor size (≥ 5 cm) (P = 0.046), lipiodol dose (≥ 7 mL, P = 0.001), poor blood glucose control (P = 0.034), alanine aminotransferase (ALT) value after TACE (P = 0.004) and C-reactive protein (CRP) value after TACE (P = 0.036) served as possible risk factors correlated with PEF. The ALT value after TACE (P = 0.021) and lipiodol dose over 7 mL (P = 0.011) were independent risk factors for PEF in the multivariate analysis. For the 20-mo survival, poor blood sugar control (P < 0.001), portal vein thrombosis (P = 0.001), favorable CT response after TACE (P < 0.001), initial aspartate aminotransferase (P = 0.02), initial CRP (P = 0.042), tumor size (P < 0.001), TNM stage (P < 0.001) and lipiodol dose (P < 0.001) were possible risk factors in the univariate analysis. Tumor size (P = 0.03), poor blood sugar control (P = 0.043), and portal vein thrombosis (P = 0.031) were significant predictors of survival in the multivariate analysis. Furthermore, the tumor progression-free interval was closely associated with CRP > 1 mg/dL (P = 0.003), tumor size > 5 cm (P < 0.001), tumor type (poorly defined) (P < 0.001), and lipiodol dose (> 7 mL, P < 0.001). CONCLUSION: PEF has no impact on survival at 20 mo or radiologic response. However, the ALT level after TACE and the lipiodol dose represent significant risk factors for PEF.

Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation.

BACKGROUND AND AIM: Needle-knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle-knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle-knife fistulotomy between patients with and without PAD. METHODS: Data from December 2005 to October 2010 were reviewed. Patients who underwent needle-knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared. RESULTS: A total of 3012 ERCP cases were analyzed. Needle-knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n=33) and control group (n =121) (93.9% vs 88.4%; P=0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups. CONCLUSIONS: Needle-knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.

Knockdown of RON inhibits AP-1 activity and induces apoptosis and cell cycle arrest through the modulation of Akt/FoxO signaling in human colorectal cancer cells.

BACKGROUND/AIMS: Altered Recepteur d'Origine nantais (RON) expression transduces signals inducting invasive growth phenotype that includes cell proliferation, migration, matrix invasion, and protection of apoptosis in human cancer cells. The aims of the current study were to evaluate whether RON affects tumor cell behavior and cellular signaling pathways including activator protein-1 (AP-1) and Akt/forkhead box O (FoxO) in human colorectal cancer cells. METHODS: To study the biological role of RON on tumor cell behavior and cellular signaling pathways in human colorectal cancer, we used small interfering RNA (siRNA) to knockdown RON gene expression in human colorectal cancer cell line, DKO-1. RESULTS: Knockdown of RON diminished migration, invasion, and proliferation of human colorectal cancer cells. Knockdown of RON decreased AP-1 transcriptional activity and expression of AP-1 target genes. Knockdown of RON activated cleaved caspase-3, -7, -9, and PARP, and down-regulated the expression of Mcl-1, survivin and XIAP, leading to induction of apoptosis. Knockdown of RON induced cell cycle arrest in the G2/M phase of cancer cells by an increase of p27 and a decrease of cyclin D3. Knockdown of RON inhibited the phosphorylation of Akt/FoxO signaling proteins such as Ser473 and Thr308 of Akt and FoxO1/3a. CONCLUSIONS: These results indicate that knockdown of RON inhibits AP-1 activity and induces apoptosis and cell cycle arrest through the modulation of Akt/FoxO signaling in human colorectal cancer cells.

Black tea extract prevents lipopolysaccharide-induced NF-κB signaling and attenuates dextran sulfate sodium-induced experimental colitis.

BACKGROUND: Black tea has been shown to elicit anti-oxidant, anti-carcinogenic, anti-inflammatory and anti-mutagenic properties. In this study, we investigated the impact of black tea extract (BTE) on lipopolysaccharide (LPS)-induced NF-κB signaling in bone marrow derived-macrophages (BMM) and determined the therapeutic efficacy of this extract on colon inflammation. METHODS: The effect of BTE on LPS-induced NF-κB signaling and pro-inflammatory gene expression was evaluated by RT-PCR, Western blotting, immunofluorescence and electrophoretic mobility shift assay (EMSA). The in vivo efficacy of BTE was assessed in mice with 3% dextran sulfate sodium (DSS)-induced colitis. The severity of colitis was measured by weight loss, colon length and histologic scores. RESULTS: LPS-induced IL-12p40, IL-23p19, IL-6 and IL-1ß mRNA expressions were inhibited by BTE. LPS-induced IκBα phosphorylation/degradation and nuclear translocation of NF-κB/p65 were blocked by BTE. BTE treatment blocked LPS-induced DNA-binding activity of NF-κB. BTE-fed, DSS-exposed mice showed the less weight loss, longer colon length and lower histologic score compared to control diet-fed, DSS-exposed mice. DSS-induced IκBα phosphorylation/degradation and phosphorylation of NF-κB/p65 were blocked by BTE. An increase of cleaved caspase-3 and poly (ADP-ribose) polymerase (PARP) in DSS-exposed mice was blocked by BTE. CONCLUSIONS: These results indicate that BTE attenuates colon inflammation through the blockage of NF-κB signaling and apoptosis in DSS-induced experimental colitis model.

[A case of lower gastrointestinal bleeding caused by primary iliac arterio-colic fistula].

Arterio-enteric fistula is a very rare cause of massive lower gastrointestinal hemorrhage. We report here on a case of massive hematochezia caused by iliac arterio-colic fistula in a 60-year-old woman who had a recent history of spinal surgery for herniated nucleus pulposus. Abdomen computed tomography showed the extravasation of radiocontrast media from right iliac artery encased by an intraabdominal abscess into the adjacent dilatated colon. Also, diagnostic angiography revealed the active extravasation of radiocontrast media via a fistula between right iliac artery and colon. Although successful endovascular exclusion of the fistula with stent graft and coils was performed, disseminated intravascular coagulation and multi-organ failure were developed.

Association of CCK(1) Receptor Gene Polymorphisms and Irritable Bowel Syndrome in Korean.

INTRODUCTION: Cholecystokinin (CCK) belongs to a group of endogenous molecules known as brain-gut neuropeptides and functions as a neuropeptide as well as a gut hormone. It remains unclear whether genetic variation of the CCK receptor plays a role in irritable bowel syndrome (IBS). The aim of this study was to determine and compare the allele and genotype frequencies of the CCK(1) receptor polymorphisms between healthy controls and patients with IBS. METHODS: Genotyping of 80 patients with IBS (who met the Rome III criteria) and 76 healthy controls was performed. We performed PCR amplification for the CCK(1) receptor intron 1 779 T > C and Exon 1 G > A. We confirmed polymorphisms by direct sequencing method. RESULTS: There was a significantly different trend for genotypic distributions of the CCK(1) receptor polymorphism between patients with IBS and healthy controls (p for trend = 0.048). The CCK(1) receptor intron 1 779 T >C polymorphic type was more common in patients with 'IBS-constipation predominant (IBS-C) and IBS-mixed (IBS-M) forms' (19/31, 61.3%) than healthy controls 32/76, 42.1% adjusted odd ratio 2.43, 95% Confidence interval 1.01-5.86). The genotypic distributions of the CCK(1) receptor exon 1 polymorphism were not significantly different between the two groups (p for trend = 0.223). CONCLUSIONS: CCK(1) receptor polymorphisms were associated with IBS. In particular, the CCK(1) receptor intron 1 779 T > C polymorphic type was associated with 'IBS-C and IBS-M'. Further studies are needed in larger number of patients with an even distribution of IBS subtypes.

[The trend of eradication rate of Helicobacter pylori infection and clinical factors that affect the eradication of first-line therapy].

BACKGROUND/AIMS: Although triple combination therapy containing a proton pump inhibitor (PPI) and two antibiotics is considered as a standard regimen for the first-line anti-Helicobacter pylori treatment, the recent trend of eradication rates following this therapy has been declined in the last few years. The purpose of this study was to investigate the trend of H. pylori eradication rates over the last 9 years and to evaluate are clinical factors affecting eradication rates. METHODS: From January 2001 to June 2009, H. pylori eradication rates in 709 patients with documented H. pylori infection who received triple combination therapy for 7 days were retrospectively evaluated according to years and various clinical factors. H. pylori status was evaluated by 13C urea breath test 4-6 weeks after completion of treatment. results: The overall H. pylori eradication rate was 77.0%. The annual eradication rates from year 2001 to 2009 were 78.9%, 72.5%, 81.0%, 75.0%, 79.1%, 77.1%, 77.8%, 77.8%, and 75.0% by per-protocol analysis. There was no decreasing tendency of the eradiation rate over 9 years (p=0.974). There was no statistical difference in the eradication rates according to age, sex, smoking, alcohol, NSAIDs, underlying diseases, endoscopic diagnosis, and PPI. However, the eradication rate was lower in patients who took aspirin (OR=0.509, 95% CI=0.292-0.887, p=0.001) and antibiotics within 6 months (OR=0.347, 95% CI=0.183-0.658, p=0.001). CONCLUSIONS: The H. pylori eradication rate has not changed at Gwangju-Chonnam province in Korea for recent 9 years. Lower eradication rate in aspirin and antibiotics users warrants further attention.

[Analysis of the clinical characteristics and prognostic factors of ruptured hepatocellular carcinoma].

BACKGROUND/AIMS: Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare but life-threatening complication. Although the prevalence rate and mortality of HCC has been reportedly high in Korea, studies on ruptured HCC are limited. The aim of this study was to determine the clinical characteristics and prognostic factors of ruptured HCC. METHODS: Among 886 cases with HCC that had been diagnosed at Chonnam National University Hospital from January 2002 to December 2007, 62 cases (7.0%) with ruptured HCC were studied retrospectively regarding their clinical characteristics and prognostic factors. RESULTS: Transarterial embolization was performed in 56 cases (90.3%) to control bleeding, with a hemostasis success rate of 89.3%. The survival time after the rupture of HCC was 8.0+/-1.7 months (mean+/-SD), although it was longer in HCC cases that were first diagnosed in a ruptured state or ruptured with a small amount of bleeding than in those that ruptured during follow-up after diagnosis or with a large amount of bleeding, respectively. The 30-day mortality rate in patients with a ruptured HCC was 43.5%, and the early deaths were independently associated with the presence of hepatic encephalopathy (odds ratio, OR=44.7; 95% confidence interval, CI=1.9-1051.1; P=0.018), serum bilirubin >3.0 mg/dL (OR=36.7; 95% CI=1.3-1068.5; P=0.036), and the massive or diffuse type of tumor morphology (OR=53.5; 95% CI=3.0-964.2; P=0.007). CONCLUSIONS: The prognosis in patients with ruptured HCCs was poor with a 30-day mortality of 43.5%. The early deaths after the rupture of HCC were associated with elevated serum bilirubin levels, hepatic encephalopathy, and the massive or diffuse type of tumor morphology.