How often should percutaneous gastrostomy feeding tubes be replaced? A single-institute retrospective study.

OBJECTIVE: Percutaneous gastrostomy (PG) is a common procedure that enables long-term enteral nutrition. However, data on the durability of individual tube types are insufficient. We conducted this study to compare the longevities and features of different PG tube types. DESIGN: We performed a 5-year retrospective analysis of patients who underwent endoscopic and radiologic PG-related feeding tube procedures. The primary and secondary outcomes were tube exchange intervals and revenue costs, respectively. Demographic factors, underlying diseases, operator expertise, materials used, and complication profiles were assessed. RESULTS: A total of 599 PG-related procedures for inserting pull-type PG (PGP), balloon-type PG (PGB), PG jejunal MIC* (PGJM; gastrojejunostomy type), and PG jejunal Levin (PGJL) tubes were assessed. On univariate Kaplan-Meier analysis, PGP tubes showed longer median exchange intervals than PGB tubes (405 days (95% CI: 315 to 537) vs 210 days (95% CI: 188 to 238); p<0.001). Larger PGB tubes diameters were associated with longer durations than smaller counterparts (24 Fr: 262 days (95% CI: 201 to NA), 20 Fr: 216 days (95% CI: 189 to 239), and 18 Fr: 148 days (95% CI: 100 to 245)). The PGJL tubes lasted longer than PGJM counterparts (median durations: 168 days (95% CI: 72 to 372) vs 13 days (95% CI: 23 to 65); p<0.001). Multivariate Cox proportional regression analysis revealed that PGJL tubes had significantly lower failure rates than PGJM tubes (OR 2.97 (95% CI: 1.17 to 7.53); p=0.022). PGB tube insertion by general practitioners was the least costly, while PGP tube insertion by endoscopists was 2.9-fold more expensive; endoscopic PGJM tubes were the most expensive at two times the cost of PGJL tubes. CONCLUSION: PGP tubes require replacement less often than PGB tubes, but the latter are more cost-effective. Moreover, PGJL tubes last longer than PGJM counterparts and, owing to lower failure rates, may be more suitable for high-risk patients.

Survival Benefit of Intraductal Radiofrequency Ablation for Malignant Biliary Obstruction: A Systematic Review with Meta-Analysis.

BACKGROUND/AIMS: Cholangiocarcinoma (CCA) is a rare but aggressive disease with a poor survival. Recent trials have shown improved survival with intraductal radiofrequency ablation (RFA) therapy. We performed a systematic review with meta-analysis to determine the survival benefit of endoscopic RFA for unresectable extrahepatic CCA with malignant biliary obstruction (MBO). METHODS: A systematic search from 1970 to 2020 was performed in MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials. gov. We selected eligible studies reporting relative risks, hazard ratios (HRs), or odds ratios, adjusted by controlling for confounding factors of survival rate and stent patency duration, among patients with extrahepatic CCA with MBO treated with RFA with stent insertion or stent insertion only. RESULTS: A total of eight trials (three randomized and five nonrandomized) with a total of 420 patients were included in the metaanalysis. Pooled overall survival analysis favored RFA treatment with stent insertion (HR, 0.47; 95% confidence interval [CI], 0.34- 0.64; I2=47%; p=0.09); however, no significant difference was found in the duration of stent patency between the groups (HR, 0.79; 95% CI, 0.57-1.09; I2=7%; p=0.36). CONCLUSION: RFA therapy with stent insertion may confer a survival benefit compared with stent insertion only in patients with CCA and MBO.

Alcohol Consumption Can Reduce the Risk of Gallstone Disease: A Systematic Review with a Dose-Response Meta-Analysis of Case-Control and Cohort Studies.

Background/Aims: Gallstone disease (GSD) is a common gastrointestinal disorder. Clinical epidemiological studies revealed that alcohol consumption has a preventive effect on the development of GSD. This study aimed to evaluate the relative risks of drinking for GSD development and investigate the dose-response relationships. Methods: A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases for studies published up to 2018 was performed. All studies that satisfied the following eligibility criteria were included: patients with GSD with or without cholecystitis; and cohort or case-control studies investigating the association between alcohol consumption and GSD development. Results: Sixteen case-control studies including 24,401 gallstone cases and 76,185 controls, and eight cohort studies with 14,693 GSD cases among 2,432,471 person-years were enrolled. Alcohol consumption presented a decreased overall risk of GSD (pooled relative ratio [RR], 0.84; 95% confidence interval [CI], 0.79 to 0.89; p=0.02). Subgroup analyses according to drinking levels indicated a gradual risk reduction for GSD compared to nondrinkers (light: RR, 0.96; 95% CI, 0.94 to 0.99; p=0.75; moderate: RR, 0.80; 95% CI, 0.75 to 0.85; p=0.27; high: RR, 0.66; 95% CI, 0.56 to 0.79; p＜0.01). A nonlinear risk reduction was observed in a dose-response meta-analysis of all the studies (n=14, p＜0.01 for nonlinearity). Conclusions: In this systematic review with meta-analysis, alcohol consumption could decrease the risk of GSD, and the dose-response analysis revealed a dose-dependent linear risk reduction and a weakened linear trend between alcohol consumption levels less than and greater than 28 g/day.

A Study of Alcohol Consumption and Obesity as Main Risk Factor for Symptomatic Gallbladder Stone: a Case-Control Study

Background: Gallbladder stone (GBS) is a common gastrointestinal disease that can progress to severe cholecystitis and is a strong risk factor for gallbladder cancer (GBC). The present study was conducted to evaluate region-specific causes of GBS which was proved as major risk factor for GBC in Jeju Island, Korea. Methods: Age and sex match case-control study was performed among 171 pairs of case and controls. The cases were patients who were diagnosed with GBS, had definite clinical symptoms, and underwent a cholecystectomy in Cheju Halla General Hospital, Jeju, Korea during 2010-2014. The control group included 1:1 age and sex-matched participants without GBS at the Health Promotion Center in the same institute during the same period. We compared the histories of previous chronic diseases (hypertension, diabetes, hyperlipidaemia, vascular occlusive diseases, or parity), alcohol consumption (standard drinks/week [SDW]), smoking habits, body mass index (BMI), and presence of concomitant polypoid lesions of the gallbladder. Results: A dose-dependent positive relationship existed between BMI and the risk of GBS: BMI 23­27.4 kg/m2, OR=2.5, , p=0.24; 27.5­29.9 kg/m2, OR=8.9, p=0.002; ≥30 kg/m2, OR=7.2, p=0.004. A negative correlation existed between alcohol consumption and the risk of GBS: Standard drinks per week (SDW), OR=0.24, p=0.002; 15­29.9 SDW, OR=0.26, p=0.022; ≥30 SDW, OR=0.2, 95% p=0.005. Conclusion: The present results suggest that a higher BMI and less alcohol consumption are associated with a risk of symptomatic GBS.

Epidemiological Characteristics of Gallbladder Cancer in Jeju Island: A Single-Center, Clinically Based, Age-Sex-Matched, Case-Control Study.

BACKGROUND: Gallbladder cancer (GBC) is a rare but highly invasive malignancy characterized by poor survival. In a national cancer survey, the age-standardized incidence rate of GBC was highest in Jeju Island among the 15 provinces in South Korea. The aim of this descriptive epidemiological study was to suggest the modifiable risk factors for this rare malignant disease in Jeju Island by performing an age-sex-matched case- control study. MATERIALS AND METHODS: The case group included patients diagnosed with GBC at the Department of Internal Medicine of Cheju Halla General Hospital, Jeju, South Korea, within the 5-year study period. The control group consisted of age-sex-matched subjects selected from among the participants of the health promotion center at the same institute and in the same period. We compared 78 case-control pairs in terms of clinical variables such as histories of hypertension, diabetes, vascular occlusive disorders, alcohol and smoking consumption, obesity, and combined polypoid lesions of the gallbladder (PLG) or gallstone diseases (GSDs). RESULTS: Among the relevant risk factors, alcohol consumption, parity ≥ 2, PLG, and GSDs were significant risk factors in the univariate analysis. PLG (p < 0.01; OR, 51.1; 95% confidence interval [CI], 2.98-875.3) and GSD (p < 0.01; OR, 54.9; 95% CI, 3.00-1001.8) were associated risk factors of GBC in the multivariate analysis with the conditional logistic regression model. However, we failed to find any correlation between obesity and GBC. We also found a negative correlation between alcohol consumption history and GBC in the multivariate analysis (p < 0.01; OR, 0.06; 95% CI, 0.01-0.31). CONCLUSIONS: These results suggest that combined PLG and GSDs are strongly associated with the GBC in Jeju Island and mild to moderate alcohol consumption may negatively correlate with GBC risk.

Risk factors for perihilar cholangiocarcinoma: a hospital-based case-control study.

BACKGROUND & AIMS: Perihilar cholangiocarcinoma (pCCA) is the most common form of bile duct cancer, arising from cholangiocytes at the confluence of hepatic ducts. Given the diversity of cholangiocarcinoma (CCA) aetiology according to the location, and the scarcity of studies on the aetiology of pCCA, we aimed to identify the risk factors for pCCA. METHODS: A total of 81 patients diagnosed with pCCA between July 2007 and December 2013, and 162 controls matched 2:1 for age, sex and date of diagnosis were included in this hospital-based case-control study. Potential risk factors were retrospectively investigated through clinical records, and the associations with pCCA were studied by calculating the odds ratios (ORs) using conditional logistic regression analysis. RESULTS: In the univariate model, the prevalence of choledocholithiasis (OR: 14.00, P = 0.014), hepatolithiasis (OR: 12.00, P = 0.021) and diabetes mellitus (DM) (OR: 2.74, P = 0.005) was higher in pCCA patients than in controls. Heavy smoking and cirrhosis were marginally significant risk factors for pCCA (P < 0.1). Multivariate analysis revealed an association between pCCA and hepatolithiasis, choledocholithiasis, DM, and heavy smoking, each, with adjusted ORs of 16.47, 9.39, 3.36 and 2.52 respectively. DM, heavy smoking, hepatolithiasis and choledocholithiasis accounted for about 22.5%, 17.1%, 8.5% and 4.8% of pCCA risk respectively (population attributable risk percentage). CONCLUSION: Our data showed that DM, heavy smoking, choledocholithiasis and hepatolithiasis were risk factors for pCCA development, implying that pCCA may share some aetiological factors with intrahepatic CCA although it has been classified as extrahepatic CCA.

Effect of sustained use of platelet aggregation inhibitors on post-endoscopic sphincterotomy bleeding.

BACKGROUND AND AIM: The effect of platelet aggregation inhibitors (PAI) on post-endoscopic sphincterotomy (ES) bleeding in patients who cannot discontinue PAI for sufficient time in urgent conditions has not been identified. The present study analyzed the effect of sustained use of PAI on post-procedural bleeding in patients undergoing ES. METHODS: A total of 762 patients were grouped into one of the following groups: no-PAI group (n = 601), continuation group (n = 132), and withdrawal group (n = 29). The continuation group included sustained PAI therapy (sustained user, n = 49) or those in whom therapy was interrupted <7 days prior to ES (non-sustained user, n = 83). The primary outcome was defined as the incidence, type, and severity of post-ES bleeding among groups. RESULTS: There were no significant differences between incidence, type, or severity of post-ES bleeding in the three groups. Among 132 patients with continued use of PAI, there was no significant difference regarding incidence and severity of bleeding according to sustained or non-sustained use (P = 0.071 and P = 0.086, respectively). However, post-ES delayed bleeding was more frequent in sustained PAI users than in non-sustained users (7/49, 14.3% vs 2/83, 2.4%) and was significantly associated with sustained PAI therapy in the continuation group (P = 0.013). CONCLUSION: Sustained use of PAI without interruption until ES might increase the risk of delayed bleeding.

Comparison of clinical outcomes of incidental and non- incidental gallbladder cancers: a single-center cross- sectional study.

BACKGROUND: Gallbladder cancer (GBC) is a rare malignancy characterized by high invasiveness and poor survival. In a nation-wide cancer survey, the age-standardized incidence rate of GBC was the highest in Jeju Island compared to 15 other provinces in Korea. The purpose of this study was to compare the clinical outcomes of GBC according to the nature of diagnosis, that is, incidental versus non-incidental. MATERIALS AND METHODS: Consecutive patients who were newly diagnosed with GBC at the Digestive Disease Center and Department of Internal Medicine, Cheju Halla General Hospital, between November 2008 and November 2011, were enrolled and divided into 2 groups: incidental gallbladder cancer (IGBC) and non-incidental gallbladder cancer (NIGBC). Clinical outcomes were retrospectively compared between the two groups. RESULTS: Seventy-nine patients were enrolled and analyzed in our study. Thirty-three (41.8%) and 46 (58.2%) were identified as IGBC and NIGBC, respectively. The proportions of patients with gallstone disease, gallbladder polyp, and cholecystectomy were significantly different between the two groups. Additionally, the median survival rate was significantly higher for patients with IGBC than for those with NIGBC (11.4, 95% confidence interval, 5.6-13.7 vs 4.0, 95% confidence interval 3.03-5.96 months; p=0.01) during a median follow-up period of 5.7 months. CONCLUSIONS: Patients with IGBC showed better clinical prognosis than those with NIGBC. Therefore, patients with gallstone disease or gallbladder polyps, major predictive risk factors for IGBC, should undergo advanced work-up for chelecystectomy.

CD24 and S100A4 expression in resectable pancreatic cancers with earlier disease recurrence and poor survival.

OBJECTIVES: The objectives of this study were to study the expression status of markers associated with epithelial-to-mesenchymal transition (EMT) and metastasis in pancreatic ductal adenocarcinomas (PDACs) and to explore the prognostic value of these markers. METHODS: Immunohistochemical stains for CD24, CD44, E-cadherin, N-cadherin, Snail, S100A4, Vimentin, urokinase-type plasminogen activator receptor, Ezrin, and matrix metalloproteinase 2 were performed on 67 resected PDACs. RESULTS: Proteins associated with EMT and metastasis were more frequently expressed in PDACs with poor differentiation, higher tumor stage, and lymphatic and perineural invasion. CD24 expression was associated with frequent expression of EMT markers (CD44 [P = 0.004], S100A4 [P < 0.001], Vimentin [P = 0.022], urokinase-type plasminogen activator receptor [P = 0.002], and Ezrin [P = 0.010]). CD24 and S100A4 expressions in PDAC were significant prognostic factors for early tumor recurrence (hazard risk [HR], 5.185 and 2.490, P = 0.048 and 0.009, respectively) and poor survival (HR, 11.977 and 3.202, P = 0.006 and 0.004, respectively). In addition, the interaction between CD24 and S100A4 expression status was a significant prognostic factor for poor survival (HR, 18.518, P = 0.003). CONCLUSIONS: The expression of markers of EMT and metastasis in PDACs was significantly associated with pathologic features of aggressiveness. CD24 and S100A4 expressions were significant predictors of poor survival; thus, immunohistochemistry for these markers in resected specimens may help to identify PDAC patients with a poor prognosis.

Percutaneous cholecystostomy is appropriate as definitive treatment for acute cholecystitis in critically ill patients: a single center, cross-sectional study.

BACKGROUND/AIMS: Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients. METHODS: All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery. RESULTS: The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p<0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77-4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02-1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37-6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period. CONCLUSIONS: In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

Endoscopic self-expandable metallic stent placement in malignant pyloric or duodenal obstruction: does chemotherapy affect stent patency?

AIM: Self-expandable metallic stents (SEMS) have been used for palliation in patients with malignant gastroduodenal obstructions. We evaluated clinical outcomes after SEMS placement and identified prognostic factors of SEMS patency, including chemotherapy. METHODS: A review of records of 85 patients with unresectable gastric or pancreatic cancer who underwent endoscopic SEMS insertion for gastroduodenal obstructions at Seoul National University Bundang Hospital. RESULTS: From August 2003 to October 2009, 85 patients with gastroduodenal obstruction were managed with endoscopic SEMS placement. Technical success was achieved in 82 patients (96%) and clinical success in 68 patients (80%). Of 49 patients who had clinical success, 19 underwent chemotherapy (chemoTx group), and 30 patients did not (non-chemoTx group). Cumulative SEMS patency in the 49 patients who achieved clinical success were 84, 54 and 41% at 2, 3 and 6 months, respectively. By univariate and multivariate analysis, there was no statistical difference in the SEMS patency between the two groups (cumulative SEMS patency rate: 95 vs 73% at 2 months, 15 vs 63% at 3 months, 40 vs 42% at 6 months, respectively, P < 0.793). CONCLUSION: Chemotherapy does not improve SEMS patency in patients with malignant gastroduodenal obstruction caused by unresectable gastric or pancreatic cancer.

The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.

The aim of this study was to investigate the overall clinical characteristics of elderly patients with acute pancreatitis. We retrospectively evaluated 227 consecutively enrolled patients who were admitted with acute pancreatitis. The clinical features, the radiological and laboratory data and the clinical outcome were analyzed according to the age groups (≥ 65 years vs. <65 years). Among the 227 enrolled patients with acute pancreatitis, there were 85 elderly patients and 142 non-elderly. The mean age of the elderly patients was 72.3 ± 5.5 years and that of the non-elderly was 44.7 ± 11.7 (p<0.001). For the elderly patients, biliary pancreatitis was the most common cause (56.5%), but alcoholic pancreatitis was most common in the non-elderly patients (45.8%). Although the computed tomography (CT) severity index was significantly higher for the non-elderly patients (p<0.001), the acute physiology and chronic health evaluation (APACHE II) score was significantly higher for the elderly than that for the non-elderly (p<0.001). However, the duration of the hospital stay (10.3 ± 9.6 days vs. 11.9 ± 10.1 days, p=0.619) and mortality (3.5% vs. 0.7%, p=0.148) were not different between the age-groups. In our study, chronological age had no significant influence on the clinical outcome in spite of the different etiologies and severity of acute pancreatitis.

Pre-operative factors that can predict neoplastic polypoid lesions of the gallbladder.

AIM: To investigate the preoperative factors that can predict neoplastic polypoid lesions of the gallbladder (PLGs) as well as malignant PLGs. METHODS: A retrospective analysis was conducted on the 210 consecutively enrolled patients who underwent cholecystectomy due to a PLG larger than 10 mm, as was determined by preoperative trans-abdominal ultrasonography or endoscopic ultrasonography. We analyzed the medical, laboratory, radiologic data and the pathologic results. RESULTS: In 210 cases, 146 had non-neoplastic polyps (69.5%) and 64 cases were neoplastic polyps (30.5%). An older age (≥ 65 years), the presence of diabetes mellitus (DM) and the size of polyp (≥ 15 mm) were revealed to be independent predictive variables for neoplastic polyps with odd ratios (OR) of 2.27 (P = 0.044), 2.64 (P = 0.021) and 4.94 (P < 0.01), respectively. Among the neoplastic PLGs, an older age (≥ 65 years), the presence of DM and polyp size (≥ 15 mm) were associated with malignancy with ORs of 4.97 (P = 0.005), 6.13 (P = 0.001) and 20.55 (P < 0.001), respectively. CONCLUSION: Among patients with PLGs larger than 10 mm in size, higher risk groups such as elderly patients more than 65 years old, those with DM or a large polyp size (≥ 15 mm) should be managed by cholecystectomy.

[Safety and efficacy of endoscopic retrograde cholangiopancreatograpy in very elderly patients].

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. METHODS: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; <65, 65-79 and >or=80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. RESULTS: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. CONCLUSIONS: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.

[Comparison between conventional 4 L polyethylene glycol and combination of 2 L polyethylene glycol and sodium phosphate solution as colonoscopy preparation].

BACKGROUND/AIMS: Effective bowel preparation is essential for accurate diagnosis of colon disease. We investigated efficacy and safety of 2 L polyethylene glycol (PEG) solution with 90 mL sodium phosphate (NaP) solution compared with 4 L PEG method. METHODS: Between August 2009 and April 2010, 526 patients were enrolled who visited Seoul National University Bundang Hospital for colonoscopy. We allocated 249 patients to PEG 4 L group and 277 patients to PEG 2 L with NaP 90 mL group. Detailed questionnaires were performed to investigate compliance, satisfaction and preference of each method. Bowel preparation quality and segmental quality were evaluated. Success was defined as cecal intubation time less than 20 minutes without any help of supervisors. RESULTS: Both groups revealed almost the same baseline characteristics except the experience of operation. PEG 4 L group's compliance was lower than PEG 2 L with NaP 90 mL group. Success rate and cecal intubation time was not different between two groups. Overall bowel preparation quality of PEG 2 L with NaP 90 mL group was better than PEG 4 L group. Segmental bowel preparation quality of PEG 2 L with NaP 90 mL group was also better than PEG 4 L group in all segments, especially right side colon. Occurrence of hyperphosphatemia was higher in PEG 2 L with NaP 90 mL group than PEG 4 L group. However, significant adverse event was not reported. CONCLUSIONS: PEG 2 L with NaP 90 mL method seems to be more effective bowel preparation than PEG 4 L method.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads.

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.