Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients

BACKGROUND： Acute cholangitis in old people is a cause of mortality and prolonged hospital stay. We evaluated the effects of methods and timing of biliary drainage on the outcomes of acute cholangitis in elderly and very elderly patients. METHODS： We analyzed 331 patients who were older than 75 years and were diagnosed with acute calculous cholangitis. They were admitted to our hospital from 2009 to 2014. Patients＇ demographics, severity grading, methods and timing of biliary drainage, mortality, and hospital stay were retrospectively obtained from medical records. Clinical parameters and outcomes were compared between elderly （75-80 years, n= 156） and very elderly （≥81 years, n=175） patients. We analyzed the effects of methods [none, endoscopic retrograde cholangio- pancreatography （ERCP）, percutaneous transhepatic biliary drainage, or failure] and timing （urgent or early） of biliary drainage on mortality and hospital stay in these patients. RESULTS： Acute cholangitis in older patients manifested as atypical symptoms characterized as infrequent Charcot＇s triad （4.2%） and comorbidity in one-third of the patients. Patients were graded as mild, moderate, and severe cholangitis in 104 （31.4%）, 175 （52.9%）, and 52 （15.7%）, respectively. Urgent bili-ary drainage （≤24 hours） was performed for 80.5% （247/307） of patients. Very elderly patients tended to have more severe grades and were treated with sequential procedures of transient hiliary drainage and stone removal at different sessions. Hospital stay was related to methods and timing of biliary drainage. Mortality was very low （1.5%） and not related to patient age but rather to the success or failure of biliary drainage and severity grading of the acute cholangitis. CONCLUSIONS： The methods and timing used for biliary drainage and severity of cholangitis are the major determinants of mortality and hospital stay in elderly and very elderly patients with acute cholangitis. Urgent successful ERCP is mandatory for favorable prognosis in these patients.

Bile-derived circulating extracellular mi R-30d-5p and mi R-92a-3p as potential biomarkers for cholangiocarcinoma

Background: Cholangiocarcinoma (CCA) is from cholangiocytes, and therefore bile is a potentially rich source of biomarkers for CCA. The aim of the study was to identify and validate microRNAs (miRNAs) in bile samples that are differentially expressed between benign biliary disease (BBD) and CCA. Methods: Bile samples from 106 patients with obstructive biliary disease were allocated consecutively to a discovery set (10 patients with BBD and 11 with CCA) and then a validation set (48 patients with BBD and 37 with CCA). An miRNA microarray platform was used to screen 1209 miRNAs in the discovery set. Quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) was used to validate the pro ling results in the discovery and validation sets. In addition, the levels of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were determined from patient serum samples. Results: Microarray pro ling showed that miR-30d-5p and miR-92a-3p were signi cantly upregulated in bile from the CCA group compared with those from the BBD group. qRT-PCR results indicated that the expression levels of miR-30d-5p and of miR-92a-3p were signi cantly upregulated in the CCA group compared to the BBD group, validating the miRNA microarray results. Pathway analysis suggested that putative target genes of miR-30d-5p and of miR-92a-3p were involved in CCA-associated signalling path- ways, such as Hippo, Wnt, p53, MAPK, and EGFR. Receiver operating curve analysis revealed that the areas under the curve for bile miR-30d-5p, miR-92a-3p, serum CA19-9, and CEA were 0.730, 0.652, 0.675, and 0.603, respectively, and bile miR-30d-5p showed the best diagnostic performance with a sensitivity of 81.1% and a speci city of 60.5%. Conclusions: The levels of extracellular miR-30d-5p and miR-92a-3p in bile were signi cantly higher in patients with CCA than those in patients with BBD. Bile-derived circulating extracellular miR-30d-5p and miR-92a-3p are potential biomarkers for discriminating CCA from BBD.

Rescue endoscopic band ligation of iatrogenic gastric perforations following failed endoclip closure

Iatrogenic gastric perforation is one of the most serious complications during therapeutic endoscopy,despite significant advances in endoscopic techniques and devices.This case study evaluated the clinical efficacy and safety of the rescue endoscopic band ligation (EBL) technique in iatrogenic gastric wall perforation following the failure of primary endoclip closure.Five patients were enrolled in this study.These patients underwent emergency endoscopy following the onset of acute gastric wall perforation during endoscopic procedures.The outcome measurements were primary technical success and immediate or delayed procedure-related complications.Successful endoscopic closure using band ligation was reported in all patients,with no complication occurring.We conclude that EBL may be a feasible and safe alternate technique for the management of acute gastric perforation,especially in cases where closure is difficult with endoclips.

Accuracy of an administrative database for pancreatic cancer by international classification of disease 10th codes: A retrospective large-cohort study

BACKGROUND Korean National Health Insurance(NHI)claims database provides large-cohort.However,studies regarding accuracy of administrative database for pancreatic cancer(PC)have not been reported.We aimed to identify accuracy of NHI database regarding PC classified by international classification of disease(ICD)-10 codes.AIM To identify the accuracy and usefulness of administrative database in PC and the accurate ICD codes for PC with location.METHODS Study and control groups were collected from 2003 to 2016 at Seoul National University Bundang Hospital.Cases of PC were identified in NHI database by international classification of diseases,10th revision edition(ICD-10 codes)supported with V codes.V code is issued by medical doctors for covering 95%of medical cost by Korean government.According to pathologic reports,definite or possible diagnoses were defined using medical records,images,and pathology.RESULTS A total of 1846 cases with PC and controls were collected.Among PC,only 410(22.2%)cases were identified as specific cancer sites including head in 234(12.7%)cases,tail in 104(5.6%)cases and body in 72(3.9%)cases.Among PC,910(49.3%)cases were diagnosed by definite criteria.Most of these were adenocarcinoma(98.0%).The rates of definite diagnosis of PC were highest in head(70.1%)followed by body(47.2%)and tail(43.3%).False-positive cases were pancreatic cystic neoplasm and metastasis to the pancreas.In terms of the overall diagnosis of PC,sensitivity,specificity,positive predictive value,and negative predictive value were 99.95%,98.72%,98.70%,and 99.95%,respectively.Diagnostic accuracy was similar both in terms of diagnostic criteria and tumor locations.CONCLUSION Korean NHI claims database collected according to ICD-10 code with V code for PC showed good accuracy.

Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater

AIM: To determine the efficacy of a cap-assisted endoscopy (CAE) to completely visualize the ampulla of Vater (AV) in patients failed by conventional endoscopy. METHODS: A prospective study was conducted on 120 patients > 20 years of ages who visited the Health Promotion Center of Chungbuk National University Hospital for conscious sedation esophagogastroduodenoscopy (EGD) as a screening test from July to October, 2011. First, forward-viewing endoscopy was performed with reasonable effort using a push and pull method. We considered complete visualization of the AV when we could observe the entire AV including the orifice clearly, and reported the observation as complete or incomplete (partial or not found at all). Second, in cases of complete failure of the observation, an additional AV examination was conducted by attaching a short cap (D-201-10704, Olympus Medical Systems, Tokyo, Japan) to the tip of a forward-viewing endoscope. Third, if the second method failed, we replaced the short cap with a long cap (MH-593, Olympus Medical Systems) and performed a re-examination of the AV. RESULTS: Conventional endoscopy achieved complete visualization of the AV in 97 of the 120 patients (80.8%) but was not achieved in 23 patients (19.2%). Age (mean ± SD) and gender [male (%)] were not significantly different between the complete observation and the incomplete observation groups. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma. CONCLUSION: CAE is safe to use as a salvage method to achieve complete visualization of the AV when a regular EGD examination fails.

Efficacy and safety of a patient-positioning device(EZ-FIX)for endoscopic retrograde cholangiopancreatography

AIM: To assess the efficacy and safety of a patientpositioning device(EZ-FIX) for endoscopic retrograde cholangiopancreatography(ERCP).METHODS: A total of 105 patients were randomized to the EZ-FIX(n = 53) or non-EZ-FIX(n = 52) group in this prospective study. Midazolam and propofol,titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision.Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients.RESULTS: There was no significant difference in the rate of hypoxia, but there was a statistical trend(EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%,P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group(89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025).In addition, the EZ-FIX group had a shorter mean recovery time(11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P< 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX.FIX group than in the nonEZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively(P = 0.856).Procedure-related complications did not differ by group(11.32% vs 13.46%, respectively, P = 0.735).CONCLUSION: Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.

Corticotropin-releasing factor stimulates colonic motility via muscarinic receptors in the rat

AIM To measure exogenous corticotropin-releasing factor(CRF)-induced motility of the isolated rat colon and to demonstrate the effect of pharmacologic inhibition on CRF-induced motility. METHODS The isolated vascularly-perfused rat colon was used. Luminal pressure was monitored via microtip catheter pressure transducers in the proximal and distal colon. At first, exogenous CRF was administered in a stepwise manner and the concentration of CRF yielding maximal colonic motility was selected. After recording basal colonic motility, hexamethonium, phentolamine, propranolol, atropine and tetrodotoxin were infused into the isolated colon. Initially, only the test drug was infused; then, CRF was added. The motility index was expressed as percentage change over basal level. RESULTS Administration of 1.4, 14.4, 144 and 288 pmol/L CRF progressively increased colonic motility in the proximal and distal colon. Infusion of atropine or tetrodotoxin reduced CRF-induced motility of both the proximal and distal colon, whereas hexamethonium, phentolamine and propranolol had no effect.CONCLUSION CRF-induced colonic motility appears to be mediated by local cholinergic signaling via muscarinic receptors. Muscarinic receptors are potential targets for counteracting CRF-induced colonic hypermotility.

Diagnostic accuracy of administrative database for bile duct cancer by ICD-10 code in a tertiary institute in Korea

Background:Administrative database provides valuable information for large cohort studies,especially when tissue diagnosis is rather difficult such as the diagnosis for bile duct cancer(BDC).The aim of this study was to evaluate the diagnostic accuracy of administrative database for BDC by International Classification of Diseases(ICD)-10 codes in a tertiary institute.Methods:BDC and control groups were collected from 2003 to 2016 at Seoul National University Bundang Hospital.Cases of BDC were identified in the National Health Insurance Service(NHIS)database by ICD 10-code supported by V code.The control group was selected from cases without ICD-10 codes for BDC.A definite or possible diagnosis was defined according to pathologic reports.Medical records,images,and pathology reports were analyzed to evaluate ICD-10 codes for BDC.Sensitivity,specificity,positive predictive value,and negative predictive value for BDC were analyzed according to diagnostic criteria and cancer locations.Results:A total of 1707 patients with BDC and 1707 controls were collected.Among those with BDC,1320(77.3%)were diagnosed by definite criteria.Most(99.4%)of them had adenocarcinoma.Rate of definite diagnosis was the highest for ampulla of Vater(88.9%),followed by that for extrahepatic(84.9%)and intrahepatic(68.3%)BDCs.False positive cases commonly had hepatocellular carcinomas.For overall diagnosis of BDC,sensitivity,specificity,positive predictive value,and negative predictive value were 99.94%,98.33%,98.30%,and 99.94%,respectively.Diagnostic accuracies were similar regardless of diagnostic criteria or tumor locations.Conclusions:Administrative database for BDC collected according to ICD-10 code with V code shows good accuracy.