Underwater versus conventional cold snare polypectomy of colorectal polyps 4-9 mm in diameter: a prospective randomized controlled trial.

BACKGROUND AND AIMS: Cold snare polypectomy (CSP) has been reported as safe and effective method for the removal of small colorectal polyps. However, some studies showed low R0 resection rate. Underwater endoscopic mucosal resection is an effective technique to increase the proportions of complete resection. Therefore, the aim was to compare the rate of R0 resection of colorectal polyps 4-9 mm in diameter between conventional CSP (C-CSP) and underwater CSP (U-CSP). METHODS: This study was a prospective randomized controlled trial. A total of 198 polyps (4-9 mm) in 110 patients were enrolled between December 2019 and June 2020. The polyps were randomized to be treated with either C-CSP (100 polyps) or U-CSP (98 polyps). RESULTS: The R0 resection rate was significantly higher in U-CSP group than in C-CSP groups (84.7% vs. 59.0%; p < 0.001). The polyp retrieval rate of C-CSP and U-CSP was 94.5% and 100% (p = 0.030). The rate of polyp fragmentation of C-CSP and U-CSP group was 5.3% and 0% (p = 0.027). The resection time and retrieval time were longer in C-CSP than U-CSP (45.0 ± 37.7 s vs. 34.1 ± 21.2 s, p = 0.032 and 51.9 ± 67.7 s vs. 12.7 ± 12.4 s, p < 0.001). No clinically significant bleeding or perforation occurred in either group. CONCLUSIONS: The results of this study were excellent with U-CSP of 4-9 mm colorectal polyps in terms of R0 resection, polyp retrieval and fragmentation rate, and procedure/retrieval time. Therefore, U-CSP is a safe and effective technique for removing colorectal polyps 4-9 mm in diameter. KCT (0004530).

A novel technique using endoscopic band ligation for removal of long-stalked (>10 mm) pedunculated colon polyps: A prospective pilot study.

BACKGROUND: Endoscopic removal of large and thick-stalked pedunculated colonic polyps, often leads to massive hemorrhage. Several techniques to minimize this complication have not been widely adopted due to some caveats. In order to prevent postpolypectomy bleeding, we invented a novel technique to dissect long-stalked pedunculated colonic polyps using endoscopic band ligation (EBL) by laterally approaching the stalk. METHODS: In this prospective single-center study, 17 pedunculated polyps in 15 patients were removed between April 2012 and January 2016. We targeted pedunculated polyps with a long stalk length (>10 mm) and a large head (>10 mm) located in the distal colon. After identifying lesions with a colonoscope, we reapproached the middle part of the stalk of the targeted polyp with an EBL-equipped gastroscope to ligate it. Snare polypectomy was performed just above the ligation site of the stalk. RESULTS: EBL-assisted polypectomy removed all of the lesions successfully, which were confirmed pathologically. There was little technical difficulty associated with the endoscopic procedures, regardless of polyp size and stalk thickness, except for one case with a very large polyp that impeded the visualization of the ligation site. We observed a positive correlation between procedure time and the diameter of the head (spearman ρ = 0.52, P = 0.034). After dissection of the polyp, the EBL bands remained fastened to the dissected stalks in all cases. There was no complication associated with polypectomy for 1 month. CONCLUSION: EBL-assisted polypectomy is an easy, safe, and effective technique to remove long-stalked pedunculated colonic polyps without postpolypectomy bleeding.

Metachronous Development of Peritoneal Carcinomatosis in a Patient with Autoimmune Pancreatitis.

Autoimmune pancreatitis (AIP) is a rare and unique type of chronic pancreatitis. The prognosis of AIP, particularly when associated with pancreatic cancer or a related malignancy, is not known. Only a few cases, where metachronous pancreas-related cancer developed during follow-up, have been reported. Most of these patients either underwent surgery or steroid therapy. This paper reports a case of a 66-year-old woman with untreated type I AIP who developed peritoneal carcinomatosis more than 2 years later. Initially, the patient had a markedly elevated serum IgG4 level and a diffuse, infiltrative mass-like lesion in the pancreatic head, in which the biopsy results were consistent with type I AIP. The patient was not treated with steroids because of a cerebellar infarction. Twenty-eight months after the diagnosis of AIP, peritoneal carcinomatosis developed without noticeable changes in the pancreas from the initial findings.

Prolonged hyperamylasemia in patients with acute pancreatitis is associated with recurrence of acute pancreatitis.

Serum amylase levels in patients with acute pancreatitis often remain or fluctuate above the upper normal limit for over a week. This study investigated the clinical characteristics of patients with prolonged hyperamylasemia and their prognoses, including recurrence.We retrospectively analyzed patients with first attacks of acute pancreatitis in a single center between March 2010 and December 2016. Patients were divided into 2 groups according to normalization of the serum amylase levels within a week.A total of 313 patients were enrolled after exclusion. The serum amylase levels were normalized within a week in 205 patients (65.5%, group 1) and elevated over a week in 108 patients (34.5%, group 2). Group 2 was more related to alcohol, higher computed tomography (CT) severity index, local pancreatic complication, and moderately severe pancreatitis than group 1 (P < .05). Recurrent pancreatitis developed significantly more in group 2 (39.8%) than in group 1 (19.5%) (P < .001). The factors related to recurrent pancreatitis were amylase group, sex, alcohol, CT severity index, necrosis, and severity of pancreatitis (P < .05). Multivariate analysis showed that recurrent pancreatitis was independently associated with amylase group (odds ratio [OR] 2.123, 95% confidence interval [CI]= 1.227-3.673, P = .007) and alcohol (OR 2.023, 95% CI 1.134-3.611, P = .017).In conclusion, prolonged hyperamylasemia over a week is associated with recurrence of acute pancreatitis.

Subsets associated with developing acute pancreatitis in patients with severe hypertriglyceridemia and the severity of pancreatitis.

BACKGROUND AND OBJECTIVES: Hypertriglyceridemia (HTG) is a rare but well-recognized cause for acute pancreatitis (AP). This study aimed to determine subsets related to development of AP in patients with severe HTG and the severity of HTG-induced AP (HTG-AP). METHODS: Patients who had severe HTG (serum triglyceride level >1,000 mg/dL) more than once between Jan. 2010 and Dec. 2017 in a single institute were evaluated retrospectively. Patients were divided into two groups, with AP or without AP, and were compared. HTG-APs in patients with severe HTG were compared to APs due to other causes during the same period. RESULTS: Sixty-three patients (19.3%) presented with AP of a total 326 patients with severe HTG. The AP group displayed younger age, more alcohol consumption and diabetes mellitus, and higher initial/maximum serum levels of triglyceride, glucose, HbA1c, total cholesterol, and calculated non-high-density lipoprotein cholesterol (p < 0.05). HTG-APs were clinically more severe compared with 277 APs due to other causes in terms of CRP (p < 0.001), CT severity index (p = 0.002), revised Atlanta classification (p < 0.001), and hospital stay (p = 0.011). In logistic regression analysis, maximum serum triglyceride level (OR 2.706, p = 0.015), alcohol consumption amount (OR 5.292, p < 0.001), and age (OR 0.358, p = 0.017) were independently associated with development of AP in patients with severe HTG. CONCLUSIONS: Development of AP in patient with severe HTG was independently associated with younger age, higher serum TG level, and more alcohol consumption. HTG-APs are clinically more severe than APs due to other causes.

Online registry for nationwide database of Helicobacter pylori eradication in Korea: Correlation of antibiotic use density with eradication success.

BACKGROUND: The Helicobacter pylori eradication rate has decreased with increasing antibiotic resistance. We conducted a prospective, nationwide, multicenter registry study to monitor the real status of H. pylori eradication therapy and to investigate the association between eradication success and antibiotic use density in Korea. MATERIALS AND METHODS: We enrolled 9318 patients undergoing H. pylori eradication therapy from 37 hospitals through "on-line database registry" from October 2010 to July 2015. Demographic data, detection methods, treatment indications, regimens, durations, compliance, adverse events, and eradication results were collected. The use of all commercially available eradication antibiotics was analyzed through the Korean National Health Insurance data of the Health Insurance Review and Assessment Service. The defined daily dose of antibiotics was used to standardize drug use comparisons. RESULTS: Finally, 6738 patients were analyzed. The overall eradication rate of first-line therapy was 71.8%. The eradication success rates were 71.7%, 86.9%, and 74.0% for standard triple therapy for 7 days, quadruple therapy, and concomitant therapy, respectively. The eradication success rate in naive patients was higher than that in those who previously underwent H. pylori eradication. Eradication success was significantly associated with younger age, female sex, and high compliance. Regional differences in eradication rates were observed. The yearly use density of clarithromycin increased statistically in seven regions across the country from 2010 to 2015. The yearly use density of amoxicillin in the Gyeongsang and Chungcheong areas was significantly increased (P < .01), whereas that of other macrolides was significantly lower in the Gyeonggi area than in other areas (P = .01). The overall use of eradication antibiotics has increased while the eradication rate steadily decreased for 5 years. However, there was no significant correlation between antibiotic use density and eradication. CONCLUSION: There was no relationship between the eradication rate and antibiotic use density in Korea.

Online Registry for Nationwide Database of Current Trend of Helicobacter pylori Eradication in Korea: Interim Analysis.

Eradication of Helicobacter pylori using first-line therapy is becoming less effective. Subjects who had been treated for H. pylori infection were prospectively enrolled through an on-line database registry from October 2010 to December 2012. Demographic data, detection methods, treatment indication, regimens, durations, compliance, adverse events, and eradication results for H. pylori infection were collected. Data of 3,700 patients from 34 hospitals were analyzed. The overall eradication rate of the first-line therapy was 73.0%. Eradication failure was significantly associated with old age, concomitant medication, and comorbidity. Regional differences in eradication rates were observed. The most common first-line therapy was proton pump inhibitor-based triple therapy (standard triple therapy, STT) for 7 days (86.8%). The eradication rates varied with regimens, being 73% in STT, 81.8% in bismuth-based quadruple therapy, 100% in sequential therapy, and 90.3% in concomitant therapy. The eradication rate in treatment-naïve patients was higher than that in patients previously treated for H. pylori infection (73.8% vs. 58.5%, P < 0.001). The overall eradication rate for second-line therapy was 84.3%. There was no statistical difference in eradication rates among various regimens. H. pylori eradication rate using STT is decreasing in Korea and has become sub-optimal, suggesting the need for alternative regimens to improve the efficacy of first-line therapy for H. pylori infection.

mRNA expression of CDH3, IGF2BP3, and BIRC5 in biliary brush cytology specimens is a useful adjunctive tool of cytology for the diagnosis of malignant biliary stricture.

Although advances have been made in diagnostic tools, the distinction between malignant and benign biliary strictures still remains challenging. Intraductal brush cytology is a convenient and safe method that is used for the diagnosis of biliary stricture, but, low sensitivity limits its usefulness. This study aimed to demonstrate the usefulness of mRNA expression levels of target genes in brush cytology specimens combined with cytology for the diagnosis of malignant biliary stricture. Immunohistochemistry for cadherin 3 (CDH3), p53, insulin-like growth factor II mRNA-binding protein 3 (IGF2BP3), homeobox B7 (HOXB7), and baculoviral inhibitor of apoptosis repeat containing 5 (BIRC5) was performed in 4 benign and 4 malignant bile duct tissues. Through endoscopic or interventional radiologic procedures, brush cytology specimens were prospectively obtained in 21 and 35 paitents with biliary strictures. In the brush cytology specimens, the mRNA expressions levels of 5 genes were determined by real-time polymerase chain reaction. Immunohistochemistry for CDH3, p53, IGF2BP3, HOXB7, and BIRC5 all showed positive staining in malignant tissues in contrast to benign tissues, which were negative. In the brush cytology specimens, the mRNA expression levels of CDH3, IGF2BP3, HOXB7, and BIRC5 were significantly higher in cases of malignant biliary stricture compared with cases of benign stricture (P = 0.006, P < 0.001, P < 0.001, and P = 0.001). The receiver-operating characteristic curves of these 4 mRNAs demonstrated that mRNA expression levels are useful for the prediction of malignant biliary stricture (P = 0.006, P < 0.001, P < 0.001, and P = 0.002). The sensitivity and specificity, respectively, for malignant biliary stricture were 57.1% and 100% for cytology, 57.1% and 64.3% for CDH3, 76.2% and 100% for IGF2BP3, 71.4% and 57.1% for HOXB7, and 76.2% and 64.3% for BIRC5. When cytology was combined with the mRNA levels of CDH3, IGF2BP3, or BIRC5, the sensitivity for malignant biliary stricture improved to 90.5%. The measurement of the mRNA expression levels of CDH3, IGF2BP3, and BIRC5 by real-time polymerase chain reaction combined with cytology was useful for the differentiation of malignant and benign biliary strictures in brush cytology specimens.

Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation.

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.

Interleukin-6 is associated with obesity, central fat distribution, and disease severity in patients with acute pancreatitis.

BACKGROUND/OBJECTIVE: Acute pancreatitis (AP) is a systemic inflammatory disease, and cytokines are suggested to be related to the course of AP. Obesity and central fat distribution are considered to have been associated with severe AP. This study investigated the profile of inflammatory cytokines in AP to determine how they are related to obesity, central fat distribution, and AP severity. METHODS: Fifty-nine patients with AP were prospectively enrolled in the study. Body mass index and waist circumference were obtained at admission. Serum levels of inflammatory cytokines, IL-Iß, IL-1ra, IL-6, TNF-α, sTNFR-I, and sTNFR-II, were measured on day 1 and 2 of AP. RESULTS: Of the patients included in the study, 19 (32%) were overweight, 23 (39%) had central fat distribution, and 23 (39%) had moderate AP. IL-1ra and IL-6 were significantly higher in overweight patients compared with non-overweight patients. IL-1ra, IL-6, TNF-α, and sTNFR-I were significantly higher in patients with central fat distribution compared with patients with non-central fat distribution. IL-6, sTNFR-I, and sTNFR-II were significantly higher in patients with moderate pancreatitis compared to those with mild pancreatitis. Among the six cytokines, IL-6 was commonly elevated in patients with central fat distribution, overweight, and moderate AP. The areas under the receiver operating characteristic curves of IL-6 for predicting the association with overweight, central fat distribution, and AP severity were 0.678, 0.716, and 0.801, respectively (P < 0.05). CONCLUSIONS: IL-6 is a good marker for AP severity and is associated with obesity and central fat distribution in AP patients.

Efficacy of Lafutidine Versus Famotidine in Patients with Reflux Esophagitis: A Multi-Center, Randomized, Double-Blind, Non-inferiority Phase III Trial.

BACKGROUND: There has been no study on the efficacy of lafutidine for patients with reflux esophagitis in Korea. AIM: To evaluate the efficacy of a new-generation histamine-2 receptor antagonist, lafutidine, in comparison with famotidine in patients with reflux esophagitis. METHODS: This was a randomized, double-blind, non-inferiority trial enrolling patients with erosive esophagitis. The efficacy and safety of 20 mg lafutidine (treatment group) were compared with those of 40 mg famotidine (control group) and 20 mg omeprazole (reference group). The primary endpoint was the complete healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment. The non-inferiority margin was assumed to be -15 %. RESULTS: The healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment were 70.14 % (101/144) in the lafutidine, 63.45 % (92/145) in the famotidine, and 85.71 % (126/147) in the omeprazole group. The difference in healing rates between the lafutidine and famotidine groups was 6.69 % (95 % confidence interval = [-4.14 to 17.52]). In addition, lafutidine was superior to famotidine in clinical improvement (53.73 % vs. 39.55 %, P = 0.0200). CONCLUSIONS: Lafutidine was non-inferior to famotidine in healing of reflux esophagitis. Lafutidine, however, was superior to famotidine in terms of symptom relief of reflux esophagitis.

Size of recurrent symptomatic common bile duct stones and factors related to recurrence.

BACKGROUND/AIMS: Some common bile duct (CBD) stones recur after endoscopic stone extraction. Little information is available on the size and recurrence interval of recurrent symptomatic CBD stones or on ways to prevent recurrence. MATERIALS AND METHODS: Between January 2007 and December 2011, consecutive 481 patients undergoing endoscopic extraction of CBD stones at a single institute were enrolled. We selected 34 patients with recurrent symptomatic CBD stones and 63 patients who were followed up more than five years without recurrence. RESULTS: The sizes of the CBD stones increased during the recurrences: 10.1±5.2 mm, 13.5±7.3 mm, and 16.8±7.8 mm at the initial presentation, the first recurrence, and the second recurrence, respectively (p=0.016). Among CBD stone recurrences, 50% occurred within 2.3 years, and 80% occurred within 5.3 years. The recurrence group had a smaller proportion of patients under 50 years of age, larger CBD diameters, less histories of more than 10 mm endoscopic papillary large-balloon dilation (EPLBD), and more type I periampullary diverticula, compared with the non-recurrence group (p<0.05). Multivariate analysis revealed that EPLBD more than 10 mm and smaller CBD diameter were independently related to less recurrence of CBD stones (p=0.001 and 0.012, respectively). CONCLUSION: The sizes of CBD stones increased during recurrences. EPLBD more than 10 mm and smaller CBD diameter were related to less recurrence of CBD stones.

Undiagnosed Borrmann type II gastric cancer due to necrosis and regenerative epithelium.

Endoscopic biopsy is essential to the proper diagnosis and treatment of gastric cancer. Unfortunately, the results of endoscopic biopsy are not always the same as what is expected based on gross endoscopic findings. The results of endoscopic biopsy can be negative for malignancy in Borrmann type IV advanced gastric cancer (AGCa) or gastric lymphoma. However, in the case of type II AGCa, repeated biopsies negative for malignancy have not been reported. A 49-year-old male patient underwent esophagogastroduodenoscopy three times due to large gastric ulcer suspected to be Borrmann type II cancer. However, three repeat endoscopic biopsies with multiple specimens showed necrosis and superficial regenerative epithelium without malignant findings. The patient underwent laparoscopic distal gastrectomy with D2 lymph node dissection. The surgical specimen revealed that the mucosal layer was completely replaced with regenerative epithelium without cancer cells.

Initial large diameter of common bile duct is associated with long-term dilatation of bile duct after endoscopic extraction of stones.

OBJECTIVE: To investigate the time and extent of recovery of dilated common bile duct (CBD) after the extraction of CBD stones and to identify the factors related to the long-term dilatation of the CBD after stone removal. METHODS: Data of 329 consecutive patients undergoing endoscopic extraction of CBD stones from January 2008 to December 2012 were retrospectively reviewed. Finally, 44 patients were enrolled in the study. RESULTS: The CBD diameter significantly decreased after stone extraction (P < 0.001). However, the CBD diameter in patients who were followed up for 1 week and longer and <1 week did not differ significantly. The diameter decreased more in patients with an initial CBD diameter ≥ 15 mm than in those with an initial CBD diameter <15 mm before stone extraction (P = 0.007), but the normalization of dilated CBD was less frequent in patients with a large initial CBD diameter. The factors related to the long-term dilatation of CBD (>10 mm for >6 months) were initial CBD diameter, the largest diameter of CBD stone and endoscopic papillary large balloon dilatation. Initial CBD diameter was an independent factor with multivariate analysis (OR 1.754, P = 0.017). CONCLUSIONS: The CBD diameter recovers rapidly after the extraction of CBD stones. An initial large CBD diameter before stone extraction is associated with the long-term dilatation of CBD.

Gastroprotective Effects of Grape Seed Proanthocyanidin Extracts against Nonsteroid Anti-Inflammatory Drug-Induced Gastric Injury in Rats.

BACKGROUND/AIMS: To investigate the gastroprotective effects of grape seed proanthocyanidin extracts (GSPEs) against nonsteroid anti-inflammatory drug (NSAID)-induced gastric mucosal injury in rats. METHODS: Sprague-Dawley rats were randomly allocated to the normal control, indomethacin, low-dose GSPE, high-dose GSPE and misoprostol groups. All groups except the normal control group received pretreatment drugs for 6 consecutive days. On the 5th and 6th day, indomethacin was administered orally to all groups except for normal control group. The microscopic features of injury were analyzed. The levels of gastric mucosal glutathione, gastric mucosal prostaglandin E2 (PGE2), and proinflammatory cytokines were investigated. RESULTS: The total areas of ulceration in the GSPE and misoprostol groups were significantly decreased compared with the indomethacin group (p<0.05). However, a difference in ulcer formation among the drug treatment groups was not observed. Meanwhile, the glutathione levels in the high-dose GSPE group were higher than those of both the indomethacin and misoprostol groups (p<0.05) and were similar to those of the normal control group. Additionally, there was no difference among the groups in the levels of gastric mucosal PGE2 and proinflammatory cytokines. CONCLUSIONS: High-dose GSPE has a strong protective effect against NSAID-induced gastric mucosal injury, which may be associated with the antioxidant effects of GSPE.

Common bile duct stones on multidetector computed tomography: attenuation patterns and detectability.

AIM: To investigate the attenuation patterns and detectability of common bile duct (CBD) stones by multidetector computed tomography (MDCT). METHODS: Between March 2010 and February 2012, 191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography (ERCP) were enrolled and reviewed retrospectively. The attenuation patterns of CBD stones on MDCT were classified as heavily calcified, radiopaque, less radiopaque, or undetectable. The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol, mixed cholesterol, brown pigment, and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated. RESULTS: MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity. The attenuation patterns of CBD stones on MDCT were heavily calcified 34 (26%), radiopaque 31 (24%), less radiopaque 46 (35%), and undetectable 19 (15%). The radiopacity of CBD stones differed significantly according to stone type (P < 0.001). From the receiver operating characteristic curve, stone size was useful for the determination of CBD stone by MDCT (area under curve 0.779, P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm. The factors related to detectability of CBD stones on MDCT were age, stone type, and stone size on multivariate analysis (P < 0.05). CONCLUSION: The radiopacity of CBD stones on MDCT differed according to stone type. Stone type and stone size were related to the detectability by MDCT, and appropriate cut-off stone size was 5 mm.

Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones.

BACKGROUND AND AIM: Periampullary diverticula (PAD) are not uncommon findings during endoscopic retrograde cholangiopancreatography, but its clinical significance had not been established. To investigate the clinical characteristics associated with PAD and their relationships with the type and size of PAD in patients with common bile duct (CBD) stones was aimed. METHODS: Three hundred seventy patients undergoing endoscopic retrograde cholangiopancreatography between March 2010 and July 2012 were consecutively enrolled, and their demographics, laboratory data, and CBD stone-related characteristics according to PAD type and PAD size were analyzed. RESULTS: Mean age, mean size of CBD stones, prevalence of systemic inflammatory response syndrome, and serum C-reactive protein level differed in patients with CBD stones according to the presence or absence of PAD. The presence of PAD and positive blood culture were correlated with systemic inflammatory response syndrome (P = 0.033 and P < 0.001, respectively). The recurrence of CBD stones was more frequent, and the diameter of CBD was larger in patients with PAD type I than in those with PAD type III. Mean age and CBD diameter were lower in patients with PAD size < 15 mm than those with PAD size ≥ 15 mm. Multivariate analyses indicated that CBD diameter was related to PAD size (P = 0.002) and the recurrence of CBD stones was related to PAD type (P = 0.001). CONCLUSIONS: PAD are associated with larger CBD stones and severe cholangitis with CBD stones. CBD diameter is related to PAD size, and the recurrence of CBD stones is related to PAD type.

Comparative study of rendezvous techniques in post-liver transplant biliary stricture.

AIM: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures. METHODS: The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively. RESULTS: The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group. CONCLUSION: The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.

Newly developed autoimmune cholangitis without relapse of autoimmune pancreatitis after discontinuing prednisolone.

A 57-year-old man presented with a 2-wk history of painless jaundice and weight loss. He had a large ill-defined enhancing mass-like lesion in the uncinate process of the pancreas with stricture of the distal common bile duct. Aspiration cytology of the pancreatic mass demonstrated inflammatory cells without evidence of malignancy. Total serum immunoglobulin G level was slightly elevated, but IgG4 level was normal. After the 2-wk 40 mg prednisolone trial, the patient's symptoms and bilirubin level improved significantly. A follow-up computed tomography (CT) scan showed a dramatic resolution of the pancreatic lesion. A low dose steroid was continued. After six months he self-discontinued prednisolone for 3 wk, and was presented with jaundice again. A CT scan showed newly developed intrahepatic biliary dilatation and marked concentric wall thickening of the common hepatic duct and the proximal common bile duct without pancreatic aggravation. The patient's IgG4 level was elevated to 2.51 g/L. Prednisolone was started again, after which his serum bilirubin level became normal and the thickening of the bile duct was resolved. This case suggests that autoimmune pancreatitis can progress to other organs that are not involved at the initial diagnosis, even with sustained pancreatic remission.