Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation(EPLBD)with endoscopic sphincterotomy(EST)has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy(EML)for the removal of large or difficult bile duct stones.Furthermore,EPLBD without EST was recently introduced as its simplified alternative technique.Thus,we systematically searched PubMed,Medline,the Cochrane Library and EMBASE,and analyzed all gathered data of EPLBD with and without EST,respectively,by using a single standardized definition,reviewing relevant literatures,published between 2003and June 2013,where it was performed with largediameter balloons(12-20 mm).The outcomes,including the initial success rate,the rate of needs for EML,and the overall success rate,and adverse events were assessed in each and compared between both of two procedures:"EPLBD with EST"and"EPLBD without EST".A total of 2511 procedures from 30 published articles were included in EPLBD with EST,while a total of413 procedures from 3 published articles were included in EPLBD without EST.In the results of outcomes,the overall success rate was 96.5%in EPLBD with EST and97.2%in EPLBD without EST,showing no significant difference between both of them.The initial success rate(84.0%vs 76.2%,P<0.001)and the success rate of EPLBD without EML(83.2%vs 76.7%,P=0.001)was significantly higher,while the rate of use of EML was significantly lower(14.1%vs 21.6%,P<0.001),in EPLBD with EST.The rate of overall adverse events,pancreatitis,bleeding,perforation,other adverse events,surgery for adverse events,and fatal adverse events were 8.3%,2.4%,3.6%,0.6%,1.7%,0.2%and 0.2%in EPLBD with EST and 7.0%,3.9%,1.9%,0.5%,0.7%,0%and 0%in EPLBD without EST,respectively,showing no significant difference between both of them.In conclusion,recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events,when performed under appropriate guidelines.

Long-type double-balloon enteroscopy-assisted ERCP using hand-made accessories in Roux-en-Y hepaticojejunostomy(with video)

To the Editor:Short-type balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography(BE-ERCP)is becoming the procedure of choice for biliopancreatic disease treatment in patients with postoperative anatomy^([1,2]).However,it has not yet been available in many countries.Although a long-type balloon enteroscope with a200-cm working length has been widely used for small bowel endoscopy,its use for ERCP was limited by the lack of commercially available extra-long accessories^([3]).

Robotic cholecystectomy with new port sites

AIM:To introduce robotic cholecystectomy(RC) using new port sites on the low abdominal area.METHODS:From June 2010 to June 2011,a total of 178 RCs were performed at Ajou University Medical Center.We prospectively collected the set-up time(working time and docking time) and console time in all robotic procedures.RESULTS:Eighty-three patients were male and 95 female;the age ranged from 18 to 72 years of age(mean 54.6 ± 15.0 years).All robotic procedures were successfully completed.The mean operation time was 52.4 ± 17.1 min.The set-up time and console time were 11.9 ± 5.4 min(5-43 min) and 15.1 ± 8.0 min(4-50 min),respectively.The conversion rate to laparoscopic or open procedures was zero.The complication rate was 0.6%(n = 1,bleeding).There was no bile duct injury or mortality.The mean hospital stay was 1.4 ± 1.1 d.There was a significant correlation between the console time and white blood cell count(r = 0.033,P = 0.015).In addition,the higher the white blood cell count(more than 10000),the longer the console time.CONCLUSION:Robotic cholecystectomy using new port sites on the low abdominal area can be safely and efficiently performed,with sufficient patient satisfaction.

Clinicopathological features of patients with middle third gastric carcinoma

AIM: To compared the prognosis of middle third gastric carcinoma(MGC) patients with those of patients with proximal/distal gastric carcinoma(PGC/DGC).METHODS: Of 3299 patients diagnosed with gastric carcinoma who underwent surgery at our hospital over a 15-year period, 919(27.9%) were diagnosed with MGC. For each patient, the following information was obtained from hospital records: Age, sex, tumor size, depth of invasion, histologic type, nodal involvement, extent of lymph node dissection, hepatic metastasis, peritoneal dissemination, stage at initial diagnosis, operative type, curability, and survival rate.RESULTS: T1 category tumors were more common in patients with MGC than in patients with PGC(P < 0.001). Tumor stage(stage Ⅰ), N category(N0), and T category(T1) significantly influenced the 5-year survival rates for patients with curatively resected tumors. A multivariate analysis showed that age, tumor size, serosal invasion, lymph node metastasis, and curability were significant predictors of survival in patients with MGC. The survival rate for MGC patients was similar to that for PGC/DGC patients(52.8% vs 44.4%/51.4%, P = 0.1138). The 5-year survival rate for MGC patients with curative resection was higher than that for MGC patients with non-curative resection(62.9% vs 8.7%, P < 0.001).CONCLUSION: These results indicate that tumor location did not affect the prognosis. Curative resection is important for improving the prognosis of patients with MGC.

On the Classification of Positive Quaternionic Khler Manifolds with b_4=1

Let M be a positive quaternionic Kahler manifold of dimension 4m. We already showed that if the symmetry rank is greater than or equal to [m/2] ＋ 2 and the fourth Betti number b4 is equal to one, then M is isometric to HPm. The goal of this paper is to report that we can improve the lower bound of the symmetry rank by one for higher even-dimensional positive quaternionic Kahler manifolds. Namely, it is shown in this paper that if the symmetry rank of M with b4（M） = 1 is greater than or equal to m/2 ＋ 1 for m ≥ 10, then M is isometric to HPm. One of the main strategies of this paper is to apply a more delicate argument of Frankel type to positive quaternionic Kahler manifolds with certain symmetry rank.