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Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S121
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Changes in Causative Pathogens of Acute Cholangitis Proved after Biliary Drainage and Their Antimicrobial Susceptibility over a Period of 6 Years
Jeong Seok Kwon, Jimin Han, Jung Nam Cho, Kyung Ho Ha, Tae Won Kim, Dae Young Yun, Hyun Hee Kwon, Jin Tae Jung, Joong Goo Kwon, Eun Young Kim, Ho Gak Kim Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
Background/Aims: We evaluated changes of bacteria from bile
and blood cultures and antimicrobial susceptibility over six
years at our institution.
Patients/Methods: From August 2006 to August 2012, medical
records of patients with acute cholangitis who received biliary
drainage were retrospectively reviewed. Acute cholangitis was
diagnosed when one or more of the followings were present: 1)
purulent bile in gross appearance 2) leukocytes in bile≥
50/HPF 3) positive growth in bile culture. Total of 1596 cases
were included. Cases were divided into community-acquired
cholangitis (n=199, 12.5%) and hospital-acquired cholangitis
(n=1,397, 87.5%). The cases were also divided according to
time period: Group A (August 2006 - December 2008, and
their antimicrobial susceptibility was evaluated in each group.
Results: Mean age of the patients was 68.0 ± 13.8 years. There
were 908 male patients (56.9%). Of 1596 cases of bile culture,
growth was detected in 1520 cases (95.2%). Gram-negative
bacteria were isolated in 1428 cases (94%). Most frequently
isolated Gram-negative bacteria were ESBL-producing
Escherichia coli (E. coli) (n=485, 34%), E. coli (n=211, 14.8%),
Citrobacter freundii (n=110, 7.7%), Klebsiella pneumoniae
(K. pneumoniae) (n=99, 6.9%), and ESBL-producing K.
pneumoniae (n=91, 6.4%). In hospital-acquired cholangitis
group, prevalence of ESBL-producing E. coli and Citrobacter
freundii was higher (52.1 vs. 31.5%, p=0.00; 13.7 vs. 6.8%,
p=0.001). In Group B, prevalence of E. coli has decreased sig-
nificantly (p=0.017). Antimicrobial agents with high suscepti-
bility were as follows: amikacin (85.2%), piper-
acillin-tazobactam (70.2%), cefotetan (77.5%), and imipenem
(95.8%). In Group B, susceptibility to piperacillin-tazobactam
has decreased significantly (59 vs. 71.9%, p=0.001).
Conclusions: Prevalence of ESBL-producing E. coli and K.
pneumoniae in cholangitis has increased over 6 years. In hospi-
tal-acquired cholangitis, prevalence of ESBL-producing E. coli
and Citrobacter freundii is higher. Susceptibility to piper-
acillin-tazobactam has decreased over recent years.
Key Words: Acute cholangitis, Bile culture, Antimicrobial sus-
ceptibility, Antimicrobial resistance, Biliary drainage
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The Safety of Pre-Stenting Biliary Sphinterotomy in Malignant Biliary Obstruction
Soo Yong Lee, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan National University School of Medicine pusan National University Yangsan Hospital, Yangsan, Korea
Objectives: Pre-stenting biliary sphinterotomy is known to fa-
cilitate complex stenting procedure, but still controversial on
safety concerns. The aim of this study was to evaluate the safety
of endoscopic sphincterotomy (EST) before endoscopic biliary
drainage (EBD) Patients and Methods 203 patients were tried
to perform EST before EBD for malignant biliary obstruction
between November 2008 and August 2012 in a single ter-
tiary-care medical center. After exclusion of 33 patients(7
failed, 18 previous EST, 8 non-EST), 170 patients were eligible.
Acute procedure complications were defined as post-endo-
scopic retrograde cholangiopancreatography (ERCP) pan-
creatitis, bleeding, stent migration, sepsis and perforation ac-
cording to Cotton’s criteria.
Results: The etiologies of malignant biliary obstruction were
bile duct cancer (99/170, 58.2%), pancreatic cancer (43/170,
25.3%), ampullary cancer (10/170, 5.9%), metastatic cancer
(8/170, 4.7%), gallbladder cancer (7/170, 4.1%) and other type
cancer (HCC, lymphoma, 3/170, 1.8%). The methods of EBD
were self-expanding metal stent (SEMS)-uncovered (47/170,
27.6%) , SEMS-covered (4/170, 2.4%), single plastic stent
(63/170, 37.1%) , dual plastic stents (47/170, 27.6%) and naso-
biliary drainage (9/170, 5.3%). The acute complication devel-
oped in 4.7%(9/170) of patients, 2 were pancreatitis (1.2%), 3
were bleeding(1.8%), 2 were sepsis(1.2%) and 1 was stent mi-
gration(0.6%).
Conclusion: EST before EBD in malignant biliary obstructions
seems to be done safely. Keywords: retrograde cholangiopancreatog-
raphy, endoscopic biliary drainage, endoscopic sphincter-
otomy, pancreatobiliary malignancy
Key Words: ERCP, EBD, EST
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Systemic Chemotherapy May Prolong the Biliary Metal Stents Patency in Pancreatic Cancer with Distal Biliary Obstruction Joon Hyuk Choi, Do Hyun Park, Seung Uk Jeong, Byung Uk Lee, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim Department of Gastroenterology, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
Objective: The placement of self-expandable metal stent
Oral Presentation - PBS
S122 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
(SEMS) has been widely used for pancreatic cancer with distal
biliary obstruction. Although the recent improvement in che-
motherapeutic agents has prolonged survival in patients with
pancreatic cancer, little is known about the role of systemic
chemotherapy influencing SEMS patency in pancreatic cancer.
We had investigated the role of systemic chemotherapy as a
predictive factor for malfunction of SEMS in pancreatic cancer
with distal biliary obstruction.
Materials and Methods: Patients with pancreatic cancer who
received distal biliary stents between April 2008 and May 2012
were reviewed. Time to malfunction was defined as the period
between stent placement and malfunction or death if stent
malfunction was not observed until death. Follow-up data
were obtained until August 2012. Various prognostic factors
including systemic chemotherapy were analyzed. Only patients
receiving palliative or neoadjuvant chemotherapy after stent
placement were categorized as chemotherapy group. Stent
malfunction was defined as stent occlusion, migration, and
non-occlusion cholangitis.
Univariate Multivariate
OR [95%CI]
P value OR [95%CI]
P value
Sex (male) 0.99(0.70-1.39)
0.990
Age > 67 1.49(1.05-2.10)
0.022 1.35(0.93-1.97)
0.113
Tumor size > 34 mm 1.54(1.10-2.17)
0.012 1.72(1.19-2.47)
0.003
Stricture length > 20 mm
1.20(0.86-1.68)
0.280
Stent diameter (10 mm)
1.17(0.70-1.96)
0.537
Liver metastasis 2.12(1.50-3.00)
<0.001 2.39(1.67-3.41)
<0.001
Ascites 1.65(1.05-2.59)
0.029 1.50(0.95-2.39)
0.082
Duodenal invasion 0.78(0.53-1.14)
0.200
Covered stent 1.34(0.92-1.95)
0.118
Systemic chemotherapy
0.39(0.27-0.56)
<0.001 0.40(0.27-0.59)
<0.001
Total bilirubin > 5.6 mg/dl
0.95(0.68-1.34)
0.802
Cholangitis 1.62(0.98-2.68)
0.056
Table 1. Factors Associated with Stent Malfunction in Univariate and Multivariate Analysis
Results: A total of 200 patients with pancreatic cancer were
enrolled. The 137 patients of total 200 participants were com-
prised in the time to malfunction group. Food impaction in the
stent (11%, 15 of 137) and stent migration (11%, 15 of 137)
were most frequent causes of stent malfunction except death.
Tumor size more than 34mm, liver metastasis and non-chemo-
therapy after stent placement were independent risk factors in
multivariate analysis. And patients who received chemo-
therapy after stent placement (68 of 200) were less complicated
by stent malfunction (odds ratio 0.40; 95% CI, 0.27-0.59;
p<0.001). The median time to malfunction was 94 days in
non-chemotherapy group and 190 days in chemotherapy
group(p<0.001).
Conclusions: Systemic chemotherapy after stent placement
may prolong SEMS patency in pancreatic cancer with distal
biliary obstruction.
Key Words: Pancreatic cancer, Self expandable metal stents,
Chemotherapy, Obstrucive jaundice, Stent patency
PBS-4
Development of a Swine Benign Biliary Strictrure Model Using Endobiliary Radiofrequency Ablation
Seong Hyun Kim¹, Seok Jeong¹, Don Haeng Lee¹, Joon Mee Kim², Se Chul Lee³, Sung-Gwon Kang³ ¹Department of Internal Medicine,²Department of Pathology, Inha University School of Medicine, Incheon, ³Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
Objective: To develop a porcine benign biliary stricture (BBS)
model using endobiliary radiofrequency ablation (RFA).
Animals and Methods: 14-month-old, female mini pigs (Sus
scrofa), each approximately 30 kg, were used. Endoscopic ret-
rograde cholangiography (ERC) was performed in 12 swine.
The animals were allocated to three groups (100 W, 80 W, and
60 W) according to the electrical power level. Endobiliary RFA
was applied to the distal common bile duct for 60 seconds us-
ing by RFA probe which could be endoscopically inserted. ERC
was repeated two and four weeks respectively after the RFA to
identify BBS. After the strictures were identified, the animals
were sacrificed and bile duct samples were achieved to evaluate
the pathologic finding.
Results: BBS were verified in all animals. Cholangitis were de-
tected on endoscopic findings of day 14 in all the animals of 3
groups, but not significant. Bile duct perforations occurred in
1 swine (n= 1, 100%) for 100 W group, and 1 swine (n=7, 14.3%)
for 80 W group. There was no major complication (n=4, 0%) in
60 W group. All benign strictures were proven pathologically.
The pathologic findings looked like BBS in human.
Conclusion: The application of endobiliary RFA resulted in a
safe and reproducible swine model of BBS.
Key Words: Radiofrequency Catheter Ablation, Benign Biliary
Stricture
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S123
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Bilateral Drainage, More Effective Approach for Klatskin Tumor
Jin Hyun Park, Dae Hwan Kang, Hyung Wook Kim,Cheol Woong Choi, Su Bum ParkDepartment of Internal Medicine, Pusan University School of Medicine, Busan, Korea
Background/Aim: Biliary drainage is one of the most im-
portant treatment in palliation with Klatskin tumor. There is
still uncertainty about optimal choice of either unilateral or bi-
lateral drainage with hilar biliary obstruction. The aim of this
study was to compare clinical outcomes of bilateral drainage
with unilateral drainage in hilar biliary obstruction.
Method: We retrospectively reviewed 72 patients with un-
resectable Klatskin tumor who underwent metal stent between
January 2009 to September 2012. All cases were beyond
Bismuth type II . 41 patients were drained bilaterally ,whereas
31 patients were performed unilateral stent.
Results: Bilateral drainage had superiority over unilateral
drainage in median survival time (256 ± 154 days vs 196 ± 80
days, p<0.05) and median stent patency time ( 230 ± 139 days
vs 165 ± 68 days , p<0.05). Cholangitis occurred more fre-
quently after unilateral drainage ( 6/31, 19% vs 1/41, 2.4% ).
Conclusion: Bilateral drainage seems to more effective method
for palliation in hilar biliary obstruction, although its technical
difficulty.
Key Words: Klatskin tumor, Stent, Bilateral, Unilateral
PBS-6
Cross Wired Metallic Stents for Triple Branched Stent in Stent Placement in High-Grade Malignant Hilar Biliar Stricture
Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
Background and Aims: Endoscopic triple branched stent-in-
stent placement of metallic stents (MS) is technically demand-
ing procedure. However, triple placement with MS is needed
for the effective biliary drainage in selected patients with
high-grade malignant hilar biliary stricture (MHBS). Cross
wired metalic stent (CWMS, BONA-M Hilar, Standard
Sci.Tech) can facilitate contralateral second stenting and allow
multiple stenting with stent in stent fashion. The aim of this
study was to evaluate the efficacy and safety of endoscopic tri-
ple branched stent-in-stent placement of CWMS for the pa-
tients with high-grade MHBS.
Patients and Methods: A total of 18 patients with MHBS with
type IIIa or IV of Bismuth’s classification were enrolled. All pa-
tients had histologically proven inoperable biliary tract cancer.
Third CWMS was inserted on Rt. IHD using a stent-in-stent
deployment method after bilateral stent-in-stent placement in
11 patients as a primary drainage. Third stenting was per-
formed as a revisionary drainage after occlusion of bilateral
stent-in-stent placement in 7 patients.
Results: The technical and functional success rates of endo-
scopic triple branched stent-in-stent placement of MS was
88.9% (16/18), and 77.8% (14/18). Functional success rate was
81.8% in patients with primary drainage, and 71.4% in pa-
tients with a revisionary drainage. Significant complications
were not observed during procedures. Median stent patency
was 196 days. Cholecystitis was developed in two patients dur-
ing follow-up. Stent dysfunction occurred in 35.7% of patients
with functionally successful stent placement.
Conclusions: Endoscopic triple branched stent-in-stent place-
ment using of cross wired metallic stents was technically fea-
sible and safe in selected patients with high-grade malignant
hilar biliary strictures. Further study is needed to confirm the
clinical effectiveness.
Key Words: Klatskin tumor, Metallic stent, Hilar biliary stricture
PBS-7
Comparison of Outcomes between Internal Stent Placement and PTBD in Patients with Planned CRT for Perihilar Cholangioca
Seung Woo Yi1, Jae Hee Cho2, JeongYoup Park1, Jae bock Chung1, Seung Woo Park1, Seungmin Bang1, Si Yong Song1 1Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, 2Division of Gastroenterology, Department of Internal Medicine, Myongji Hospital, Goyang, Korea
Background: The optimal biliary decompression method in re-
sectable perihilar-cholangiocarcinoma has been authorized as
percutaneous transhepatic biliary drainage (PTBD). In case of
locally advanced perihilar-cholangiocarcinoma, malignant
biliary obstruction is judged to have palliation of jaundice by
placement of an internal stents or PTBD. We aimed to inves-
tigate the efficacy of internal placement of biliary stent com-
pared with PTBD for patients planned CRT in locally advanced
perihilar-cholangiocarcinoma.
Patients and Methods: The patients who are histologically pro-
ven locally advanced perihilar-cholangiocarcinoma between
Jan. 1995 and Dec. 2011 at single tertiary medical center in Korea,
retrospectively analyzed. The perihilar cholangiocarcinoma
was defined as disease occurring above the junction of the cyst-
Oral Presentation - PBS
S124 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
ic duct up to the secondary branches of the hepatic duct.
Results Among one hundred seventy six locally advanced peri-
hilar-cholangiocarcinoma patients, CRT was performed in 79
patients; endoscopic biliary decompression was forty six pa-
tients (26.14%), and PTBD was thirty three patients (18.75%).
The mean period of internal stent indwelling is 152 days
whereas 222 days in PTBD group (p=0.675). The R0 operative
rate after the CRT was 23.9% in endoscopic stenting group,
and 12.1% in PTBD group (p=0.174). The median overall sur-
vivals were 463days at endoscopic stenting group and 439days
in PTBD group, respectively (p=0.874). Repeated biliary de-
compression procedure was performed at endoscopic decom-
pression group 26 patients (56.5%), 12 patients in PTBD
group (36.4%) (p = 0.077). In the subgroup analysis of endo-
scopic stenting group, there were 25 cases of SEMS, and 21 cas-
es of biliary drainage using the plastic stent. The stent dysfunc-
tion was found 20 patients (80.0%) in plastic stent whereas 6
patients (28.6%) in SEMS group (p=0.001). Median stent pa-
tency time was 111 days and 402 days in the plastic stent and
SEMS, respectively (p=0.002). Post-operative major complica-
tions were not seen in both cases.
Conclusions: The endoscopic placement of internal stent might
be useful method for biliary decompression in patients with
planed CRT for locally advanced perihilar-cholangiocarcinoma,
compared to PTBD. In case of biliary endoscopic drainage, the
pre-CRT SEMS had lower rate for repeated endoscopic proce-
dure than plastic stent in perihilar-cholangiocarcinoma.
Key Words: Self-expanding metal stents, Plastic sten, PTBD,
Chemoradiotherapy
PBS-8
Risk Factors for Cholecystitis after Bilateral Biliary Stent Placement in Patients with Klatskin tumor
Young Mi Hong, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan University School of Medicine, Busan, Korea
Background/Aims: Endoscopic bilateral metal stenting is a
rapidly evolving technique which allows the palliative treat-
ment of malignant hilar obstruction including Klatskin tumor.
But cholecystitis in patients with Klatskin tumor is bothersome
event to patients and physicians. Biliary stent may be associated
with cholecystitis for several reasons. The aim of this study to
evaluate the prevalence and risk factors of cholecystitis after bi-
lateral matal stent placement, especially in Klatskin tumor.
Patients/Methods: August 2005 to June 2012, 102 patients
treated with a metal stent for Klatskin tumor were enrolled.
The incidence and characteristics of patients with cholecystitis
were evaluated and compared with those of patients without
cholecystitis. We retrospectively reviewed following variables :
sex, age, Bismuth type, gallbladder filling by contrast medium
during endoscoic retrograde cholangiopancreatography (ERCP),
cholangitis before ERCP, cystic duct involvement of tumor mass
on computed tomography (CT), presence of gallbladder stones.
Results: There were 28(27.5%) patients diagnosed with chol-
ecystitis after bilateral metal stent insertion.In cholecystitis,
108.9 days were, on average, taken (ranging from 1 to 310 days)
since metal stent placement to the onset of cholecystitis. We
found that cystic duct involvement of tumor mass on CT was
associated with cholecystitis (p=0.015) and others were not re-
lated with development of cholecystitis.
Conclusions: This study suggested that cholecystitis after bi-
lateral metal stent insertion in klatskin tumor is associated with
cystic duct involvement of the tumor. To prevent or manage
cholecystitis, effective modalities should be sought.
Key Words: Klatskin tumor, Bilateral metal stent, Complication,
Cholecystitis
PBS PL-9
DGT vs Precut Papillotomy with Pancreatic Stent in Initial Pd Cannulation by Chance; Prospective Randomize Muti-Center
Eun Taek ParK¹, Sang-Woo Cha², Kyo-Sang Yoo³ ¹Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, ²Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University School of Medicine, Seoul, 3Department of Internal Medicine, Hanyang University School of Medicine, Kuri Hospital, Kuri, Korea
Background/Aim: Successful cannulation of the common bile
duct (CBD) is an important benchmark of ERCP. Repeated
cannulation for CBD is one of the main risk factors for
post-ERCP pancreatitis. Recently, pancreatic duct guidewire
assisting bile duct cannulation (double guidewire technique,
DGT group) or precut papillotomy with a incision over a pan-
creatic stent (PP-PS group) have been considered a promising
alternative approach in difficult cannulation situations. The
aim of this study was to compare the performance of DGT with
the PP-PS in the patients in whom pancreatic duct cannulation
was performed initially.
Patients/Methods: When guidewire was placed in the pancreatic
duct by chance, the patients were then randomized into DGT or
PP-PS groups. After this, bile duct cannulation was retried us-
ing DGT or PP-PS. Main outcome measurements were fre-
quency of successful CBD cannulation and post-procedure re-
lated complications.
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S125
Results: The groups were similar with regard to patient
demographics. A total of 70 patients were enrolled. 31 patients
were assigned to the DGT group and 39 to the PP-PS group.
Successful CBD cannulation was achieved in 22 (70.9%) of 31
patients in the DGT group and 37 (94.8%) of 39 patients in the
PP-PS group. The mean cannulation time was 18.4 minutes in
the DGT group and 11 minutes in the PP-PS group (p<0.005).
There was significant difference in the successful CBD cannu-
lation rate or mean cannulation time after p-duct cannulation
between two groups (p< 0.05). Post-procedure hyperamylasemia
was significantly higher in DGT group (p<0.001). The overall
incidence of post-procedure pancreatitis was 15.4% (6/31) in
the DGT group, and 6.6% (2/30) in the PP-PS group (p <0.005).
Conclusion: In patients with pancreatic duct cannulation ini-
tially by chance, compare to DGT group, PP-PS group facili-
tate biliary cannulation and the success rates. The incidence of
post-procedure hyperamylasemia and post-procedure pan-
creatitis were also higher in the DGT group.
Key Words: ERCP, Pancreatitis, Double Guidewire, Precut
Papillotomy, Pancreatic Stent
PBS PL-10
Photodynamic Therapy (PDT) with Ts-1 vs. PDT for Unresectable Cholangiocarcinoma: Preliminary Results of Randomized Trial
So-Eun Park¹, Do Hyun Park², Sang Soo Lee², Dong-Wan Seo², Sung Koo Lee² and Myung-Hwan Kim² ¹Division of Gastroenterology, Asan Medical Center, ²Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
Backgroud/Aims: In patients with unresectable hilar chol-
angiocarcinoma (UHC), photodynamic therapy (PDT) with
biliary stent has been known for palliation of jaundice and im-
proving survival. Recently orally available chemotherapeutic
agent, TS-1 was reported as effective in patients with advanced
biliary tract cancer. The aims of this study was to evaluate the
combined effect of photodynamic therapy and TS-1.
Methods: In patients with histologically confirmed UHC, en-
doscopic or percutaneous stenting was performed. Patients
fulfilling inclusion criteria were randomized to group A
(biliary stenting and subsequent PDT with TS-1) and group B
(biliary stenting and subsequent PDT). For the refusal to par-
ticipation in this clinical trial, patients were enrolled to
open-label group (biliary stenting and PDT with systemic che-
motherapy except TS-1). The primary outcome parameter was
the overall survival. Secondary outcome parameter was the
progression-free survival.
Results: A total of 52 patients with UHC were screened during
study period (from April 2008 to August 2012). Four patients
refused PDT. Twelve patients refused the participation of this
clinical trial and enrolled open-label group. Finally, 36 patients
were randomized to PDT with TS1 (group A, n=17) or PDT
alone (group B, n=19). PDT with TS-1 group resulted in the
prolongation of overall survival compared with PDT alone
group (mean overall survival time, 17.4 months vs. 8.4
months, p=0.008 by Kaplan-Meier curve, Fig.-1). In open label
group, the overall survival was similar to that of PDT with TS-1
(15 months vs. 17.5 months). Group A had a tendency towards
longer progression-free survival compared with group B (8.3±
8.9 months vs. 5.3 ± 8.9 months, p=.054).
Conclusions: In this prospective randomized trial, PDT with
TS-1 improved overall survival in patients with UHC com-
pared with PDT alone. PDT with systemic chemotherapy may
be warranted for the palliative treatment of patients with UHC.
Key Words: Photodynamic therapy, Cholangiocarcinoma, Systemic
chemotherapy
PBS PL-11
Prospective Randomized Trial Comparing Covered Metal Stent Placed Above and Across the Sphincter of Oddi in Malignant Biliary Obstruction: A Multi-Nation, Multi-Center Study
Jung Nam Cho¹, Jimin Han¹, Ho Gak Kim¹, Im Hee Shin², Sang Heum Park³, Jong Ho Moon³, Jin Hong Kim⁴, Don Haeng Lee5, Iruru Maetani6, Hiroyuki Maguchi7, Keiji Hanada8, Ichiro Yasuda9, Hiroyuki Isayama10, Dong Ki Lee11 Department of ¹Internal Medicine, ²Medical Statistics, Catholic University of Daegu School of Medicine, Daegu, ³Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Choenan, 4Department of Gastroenterology, Ajou University School of Medicine, Suwon, 5Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea, 6Department of Gastroenterology, Toho University Medical Center Ohashi Hospital, Tokyo, 7Department of Gastroenterology, Teine-Keijinkai Hospital, Sapporo, 8Department of Gastroendoscopy, Onomichi General Hospital, Onomichi, 9Department of Internal Medicine, Gifu University, Gifu, 10Department of Gastroenterology, The University of Tokyo, Tokyo, Japan,11Department of Internal Medicine, Yonsei University College of Medicine Kangnam Severance Hospital, Seoul, Korea
Oral Presentation - PBS
S126 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
Aims: To compare stent patency and overall survival of patients
with malignant biliary obstruction inserted covered self-ex-
pandable metallic stent (C-SEMS) between placement above
the sphincter of Oddi (SOD) without sphincterotomy (Group
A) and across the SOD after sphinterotomy (Group B).
Patients and Methods: From February 2010 to September
2012, this study was conducted in 6 centers from Korea and 5
centers from Japan. Total of 83 patients with unresectable ma-
lignant biliary obstruction were randomized into either Group
A or B. Biliary obstruction was defined as bile duct obstruction
located at least 2.0 cm distal from hilar bifurcation and 0.5 cm
proximal to the ampulla.
Results: There were 1 case of common hepatic bile duct cancer,
27 common bile duct cancer, 11 gallbladder cancer, 41 pancre-
atic cancer and 4 of extrinsic compression from metastatic
lymph node. There were 40 patients in Group A and 43 in
Group B. Technical success was 100% in both groups and func-
tional failure occurred in 1 and 2 cases in Group A and B.
Median follow-up period was 177.0 and 178.5 days. Mean stent
patent period were 140.1 and 132.9 days (p=0.835), and mean
period of overall survival was 212.4 and 218.8 days (p=0.873)
in Group A and B. Stent occlusion was recognized in
15(39.5%) and 14(37.8%) in group A and B. During fol-
low-up, occlusion-free survival rates per year were 40.2% and
22.2% in Group A and B. Cholangitis without stent occlusion
occurred 1 and 2 cases in Group A and B. There were no sig-
nificant differences in complications after procedure in both
groups. Distal migration occurred in three cases in only Group B.
Conclusion: Theoretically, placement of C-SEMS above the
SOD may reduce duodenobiliary reflux and result in longer
stent patency, and reduced rate of cholangitis without
occlusions. However, in this study, there was no significant dif-
ference in stent patency and cholangitis between C-SEMS
placement above and across the SOD.
Key Words: Malignant biliary obstruction, Metal stent, Stent
patency, Survival
PBS PL-12
Optimal Duration of Placement of a Fully Covered Self-Expandable Metal Stent for Common Bile Duct: A Canine Study
Tae Jun Song¹, Sang Soo Lee², Do Hyun Park², Dong Wan Seo², Sung Koo Lee², Myung-Hwan Kim² ¹Department of Internal Medicine, Inje University Ilsan Paik hospital, Koyang, ²Department of Internal Medicine, University of Ulsan College of medicine, Asan Medical Center, Seoul, Korea
Background and Aim: Recently, endoscopic placement of a
fully covered self-expandable metal stent (FCSEMS) has been
used for the treatment not only of malignant biliary ob-
struction but also benign biliary stricture. However, since there
are few studies on the histopathological changes of a bile duct
due to FCSEMS placed inside a bile duct over the long term, it
is difficult to determine the optimal stenting duration of how
long stents should be placed inside a bile duct. The purpose of
this study is to identify the histopathological changes of a bile
duct resulting from long-term placement of an FCSEMS.
Methods: In May of 2010, FCSEMSs were inserted into the
common bile ducts of 12 canines. Post euthanasia, necropsy
was performed to examine histopathological changes of the
bile ducts after one month (n = 3), three months (n = 3), six
months (n = 3), and nine months (n = 3) respectively. A single
blinded pathologist examined histopathological changes of the
normal bile duct in which a stent was not inserted, and the
proximal portion, the middle portion, and the distal portion of
the stented bile duct.
Results: FCSEMSs could be successfully inserted in all animals.
The results of liver function tests, which were performed before
necropsy, were within the normal range in all animals. The re-
sults of necropsy showed that the covered membranes of
FCSEMSs were intact and FCSEMSs were easily removed from
the bile ducts in all animals except one. Severe epithelial hyper-
plasia of the stented bile duct occurred in one animal in which
an FCSEMS was placed for three months, and as a result, a dis-
ruption of the covered membrane and epithelial ingrowth into
the stent were observed. In this animal, the removal of the
FCSEMS was very difficult, and the most severe inflammatory
change of the stented bile duct was found on histopathological
examination. On histopathological examinations, when com-
pared with the non-stented bile ducts, mild inflammatory
changes were observed in the stented bile ducts, and there was
no significant difference between the animals inserting an
FCSEMS for one month, three months, six months, and nine
months. Among the 12 animals, de novo stricture was found in
5 animals.
Conclusion: It was found that an FCSEMS might be inserted
into the bile duct without severe histopathological changes of
the stented bile duct until 9 months after the insertion.
Key Words: Stents, Common Bile Duct, Cholangiopancreato-
graphy Endoscopic Retrograde, Dogs
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S127
PBS PL-13
The Role of EUS-FNA after Negative Transpapillary Forceps Biopsy in Patients with Malignant Biliary Strictures
Dong Choon Kim¹, Jong Ho Moon¹, Hyun Jong Choi¹, Hee Kyung Kim², Yoon La Young¹, Tae Hoon Lee¹, Sang Woo Cha¹, Young Deok Cho¹, Sang Heum Park¹, Sun Joo Kim¹ Digestive Disease Center, ¹Department of Internal Medicine, ²Department of Pathology Soon Chun Hyang University College of Medicine, Korea
Background/Aim: Transpapillary forceps biopsy (TFB) on
ERCP is a usual tissue sampling technique for the histopatho-
logical diagnosis of malignant biliary strictures (MBS).
However, the detection rate of this method has been
unsatisfactory. The aim of this study was to retrospectively
evaluate the diagnostic yield of endoscopic ultrasound-guided
fine-needle aspiration (EUS-FNA) in patients with MBS who
had negative results of TFB.
Methods: 75 consecutive patients with MBS underwent endo-
scopic TFB during ERCP. EUS-FNA was performed in patients
with negative results for histopathological reports. The gold
standard of malignancy was histopathologic results by tissue
sampling or operation. We investigated the EUS-FNA results,
level of stricture lesions and influence of the EUS-FNA results
on treatment modalities.
Results: In 75 patients, 42 patients had distal bile duct (BD)
strictures and the others were proximal BD strictures.
Malignancy was confirmed on endoscopic TFB in 59 of 75 pa-
tients (78.6%). 56 patients were adenocarcinoma, and 3 pa-
tients were neuroendocrine carcinoma. EUS-FNA was per-
formed in 16 patients with negative results by endoscopic TFB.
Of 16 patients, 11 patients had distal BD strictures and 5 pa-
tients had proximal BD strictures. FNA specimens were suc-
cessfully obtained in all patients, and the histopathological re-
sults confirmed malignancy in 15 cases (14 cases: adenocarcinoma,
1 case: neuroendocrine carcinoma) and the other 1 case was
negative for malignancy. Of 15 patients, 8 patients were treated
by chemotherapy, 4 patients were supportive care, 2 patients
were operation, and 1 patient was photodynamic therapy. In
case with negative result by EUS-FNA, was confirmed malig-
nancy (adenocarcinoma) as a result of surgery.
Conclusions: In patients with MBS who had negative results by
endoscopic TFB, EUS-FNA is useful for the histopathologic
confirmation.
Key Words: EUS-FNA, Malignant Biliary Strictures, Transpapillary
forceps biopsy
PBS PL-14
Differential Diagnosis of Pancreatic Cysts Using Proteomics
Hwan sic Yun¹, Woo Ik Change¹, Kwang Hyuck Lee¹, Kyu Taek Lee¹, Soo Youn Lee², Poong-Lyul Rhee¹, Jong Kyun Lee¹ ¹Department of Internal Medicine, Sungkyunkwan University School of Medicine, ²Department of Laboratory Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
Objectives: Pancreatic cysts display a wide spectrum of
histology. However, differential diagnosis of pancreatic cysts is
still challenging. This study was aimed to evaluate and validate
cyst fluid CEA and proteomics markers in differentiating 1)
pancreatic pseudocyst, 2) benign non-mucinous pancreatic
cyst, 3) benign or malignant mucinous pancreatic cyst.
Methods: From February 2008 to March 2012, we collected 57
patients who had pancreatic cysts. We analyzed endoscopic ul-
trasound (EUS) findings, cystic fluid tumor markers (CEA, CA
19-9) and proteomics markers that could help differentiating
non-mucinous cysts and mucinous cysts.
Results: Fifty seven patients (17 pseudocysts, 22 benign
non-mucinous cysts, 18 benign or malignant mucinous cysts)
were enrolled. Mean age was 52.1 (20-76). All of them under-
went endoscopic ultrasound (EUS) and nineteen (33.3%) pa-
tients got surgery. One patient (1.8%) had complication of
pancreatitis after EUS guided fine needle aspiration
(EUS-FNA). Both CEA and CA 19-9 showed statistical sig-
nificance in differentiating non-mucinous cysts and mucinous
cysts (p<0.001, p=0.009). Diagnostic sensitivity and specificity
of CEA in differentiating mucinous cysts was 100% and 87% in
6.3 ng/ml cut-off value. And CA19-9 showed 72.2% sensitivity
and 69.2% specificity in 954.1 ng/ml cut-off value. Among
proteomics markers, twenty four markers showed statistical
significance in differentiating between non-mucinous cysts
and mucinous cysts. Assuming the cut-off value of CEA that
differentiates non-mucinous and mucinous was 192 ng/ml, as
previous reports, the diagnostic accuracy became very low
(50% sensitivity, 100% specificity). However joining with pro-
teomics marker polymeric immunoglobulin receptor A1, the
sensitivity and specificity became 94.4% and 86.4% in
respectively. Also joining with proteomics marker polymeric
immunoglobulin receptor A3, the sensitivity and specificity
were 88.9% and 83.4%.
Conclusions: In this study, cystic CEA showed very high sensi-
tivity and specificity in differentiating non-mucinous and mu-
cinous cysts. However cut-off value was 6.3 ng/ml, in which
was very low compared to the previous reports. Assuming the
cut-off value as 192 ng/ml as previous study, proteomics mark-
Oral Presentation - PBS
S128 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
ers could be very helpful for differentiating between non-muci-
nous and mucinous cysts.
Key Words: Pancreatic Cyst, Mucinous Cyst, Proteomics
PBS-15
EPLBD for the Removal of Common Bile Duct Stones Does Not Increase the Risk of Post-ERCP Pancreatitis
Yoon Jeong Nam, Tae Nyeun Kim, Jun Suk Park, Min Geun Gu, Jae Young Lee, Kook Hyun Kim, Kyung Ok Kim, Si Hyung Lee, Byung Ik Jang Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
Background and Aims: Endoscopic sphicterectomy (ES) and
endoscopic papillary large balloon dilation (EPLBD) are fre-
quently used procedures for the treatment of common duct
stones. EPLBD is known to increase the risk of post-ERCP pan-
creatitis in some studies. The aims of this study were to evaluate
whether EPLBD increases the risk of post-ERCP pancreatitis
and to find the risk factors influencing post-ERCP pancreatitis.
Methods: A total of 434 patients who underwent ERCP for the
treatment of common duct stones larger than 1cm in diameter
from January 2006 to December 2011 were reviewed retrospectively.
Patients were divided into 4 groups; ES group (n=190), EPLBD
combined with limited ES group (n=129), EPLBD without ES
group (n=85), and EPLBD with previous history of ES group
(n=30). Post-ERCP pancreatitis was defined as the develop-
ment of abdominal pain with more than 3 times elevation of
serum amylase or lipase.
Results: Of the total 434 patients, post-ERCP pancreatitis was
developed in 12 patients (2.8%). Endoscopic biliary stenting
was an independent risk factor of pancreatitis by univariate
(p=0.004) and multivariate analysis (p=0.004, OR 5.713, 95%
Cl, 1.770~18.469). Age, sex, BMI, history of cholecystectomy,
stone size, mechanical lithotripsy, CBD and P-duct diameter,
balloon size and duration of balloon dilation were not sig-
nificantly related with post-ERCP pancreatitis. Incidence of
post-ERCP pancreatitis was 1.6%, 3.1%, 5.9%, 0% in ES
group, EPLBD combined with limited ES group, EPLBD with-
out ES group, EPLBD with previous history of ES group,
respectively. There was no significant difference in the in-
cidence of post-ERCP pancreatitis among 4 groups (p=0.218).
Conclusion: Endoscopic papillary large balloon dilation does
not increase the risk of post-ERCP pancreatitis compared to
endoscopic sphicterectomy. Endoscopic biliary stenting seems
to be an independent risk factor of post-ERCP pancreatitis.
Key Words: EPLBD, ERCP, Pancreatitis
PBS-16
Percutaneous Papillary Large Balloon Dilation For Treatment of Large Bile-Duct Stones: A Feasibility Study
Jee Young Han, Seok Jeong, Don Haeng Lee, Byoung Wook Bang, Jung Il Lee, Jin-Woo Lee, Kye Sook Kwon, Hyung Gil Kim, Yong Woon Shin, Young Soo Kim Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
Background: When the access to major duodenal papilla or en-
doscopic retrograde cholangiopancreatography (ERCP) is
failed, percutaneous transhepatic cholangioscopic lithotripsy
(PTCS-L) may be useful to remove common bile duct (CBD)
stones. However, the feasibility and usefulness of percutaneous
transhepatic papillary large-balloon dilation (PPLBD) performed
during PTCS-L for the removal of large CBD stones, is not estab-
lished yet. The aim of this study was to investigate the safety and
efficacy of PPLBD for the treatment of large CBD stones.
Methods: Eleven patients with large CBD stones in whom the
access to major papilla or ERCP had failed in a tertiary referral
center between September 2011 and August 2012 were enrolled
prospectively. Papillary dilation using large-bored (12-20 mm)
balloon dilation catheter was performed through the percuta-
neous transhepatic route. We analyzed the efficacy of the stone
retrieval and post-procedure complications after the procedure.
Results: The success rate for the complete duct clearance was
100%. There was no patient who needs use of basket to remove
the stone after PPLBD. Electrohydraulic lithotripsy was re-
quired in 2 (18.2%) patients. The median time to complete
stone removal after PPLBD was 17.8 minutes. There was no
complications occurred after PPLBD. Asymptomatic hyper-
amylasemia did not occur in all patients.
Conclusion: The current data suggested that PPLBD is safe and
effective for removal of large CBD stones.
Key Words: Balloon Dilation, Choledocholithiasis
PBS-17
Endoscopic Papillary Balloon Dilation and Endoscopic Sphincterotomy for Removal of Bile Duct Stones in Young Patients
Yu Ri Seo, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
Objectives: Endoscopic biliary sphincterotomy (EBS) is the
standard treatment for bile duct (BD) stones. However, EBS
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S129
can cause permanent loss of sphincter function that long-term
complications are still unknown. Younger patients having lon-
ger life expectancy are risky for developing late complications.
Endoscopic papillary balloon dilation (EPBD) is an alternative
procedure preserving the sphincter function, although it is
generally known has a higher risk of pancreatitis than EBS. We
conducted a prospective study to compare safety and outcomes
of EPBD with EBS for removal of BD stones in patients young-
er than 40 years of age.
Methods: Total 132 patients were enrolled in this study, 62 pa-
tients who underwent EPBD (EPBD group, mean age: 31.1
years) and 70 patients who underwent EBS (EBS group, mean
age: 35.2 years) for extraction of BD. Inclusion criteria was 1)
Age < 41 at first ERCP performed 2) CBD stones were con-
firmed by ERCP 3) stone maximum diameter <13 mm.
Resuts: 1) EPBD and EBS were successfully performed in all
patients. 2) Complete endoscopic clearance of the bile duct was
achieved in all patients. 3) Complete stone removal at a single
endoscopic session was achieved in 59 (95.2%) EPBD group
and in 61 (87.1%) EBS group. 4) Mechanical lithotripsy was
needed to fragment stones in 5 (8.1%) EPBD group and in 9
(12.9%) EBS group. 5) Early complication rate was 9.7% (6
pancreatitis ; mid 5, moderate 1) in EPBD group and 11.4% (6
pancreatitis ; mid 5, moderate 1, 1 bleeding, 1 perforation) in
EBS group. 6) Late complication rate was 1.6% (1 recurred
stone with cholangitis) in EPBD group and 5.7% (4 recurred
stone with 3 cholangitis) in EBS group.
Conclusions: Endoscopic papillary balloon dilation is a safe
and effective procedure for the removal of BD stones in young
patients expecting longer survival.
Key Words: EPBD, Endoscopic biliary sphincterotomy
PBS-18
Long-Term Results after Treatment of Hepatolithiasis and Predictive Factors for Cholangiocarcinoma
Kwang Duck Ryu¹, Dong Uk Kim¹, Seong Oh Park¹, Hye Kyung Jeon¹, Gwang Ha Kim¹, Jeong Heo¹, Geun Am Song¹ Departemtn of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
Aims: Hepatolithiasis is one of risk factors of cholangiocarcinoma
and is usually treated with operative and non-operative proce-
dure (Percutaneous transhepatic cholangioscopic lithotomy,
PTCSL). We examined the long-term results of patients with
hepatolithiasis treated by operation or PTCSL and predictive
factors for cholangiocarcinoma associated hepatolithiasis.
Methods: We performed a retrospective study of medical re-
cords of patients with hepatolithiasis in Pusan national uni-
versity hospital from April 1988 to July 2012. Of 363 patients
with hepatolithiasis, 78 underwent operative procedure, 113
underwent PTCSL, and 172 underwent medical treatment or
observation. The median follow-up period was 22.2months
(range,1-257months).
Results: Female (62.3%) was dominant in patients with
hepatolithiasis. We observed cholangiocarcinoma in 8.3%
(30/363), secondary biliary cirrhosis in 8.8% (32/363), stric-
ture in 16.5% (60/363) and secondary sclerosing cholangitis in
0.5% (2/363) as the complications associated hepatolithiasis.
Complete stone clearance was achieved in 84.6% (66/78) of
operation and in 70.8% (80/113) of PTCSL. During follow-up
period after treatment, recurrent rate of stones was 16.4%;
18.6% (12/66) of operation and 15.0% (12/80) of PTCSL and
late development rate of cholangiocarcinoma was 3.1%; 1.2%
(1/78) of operation and 4.4% (5/113) of PTCSL. In multivate
analysis, liver atrophy is only significantly associated with chol-
angiocarcinoma (p=0.006; Odds ratio, 2.01; 95% CI, 1.797-
31.022).
Conclusion: Operation had a superior trend than PTCSL in
complete stone clearance and recurrence rate of hepatolithiasis
was similar in both operation and PTCSL. Liver atrophy with
hepatolithiasis might be a predictive factor of development of
cholangiocarcinoma.
Key Words: Hepatolithiasis, Cholangiocarcinoma, Operation,
PTCSL
PBS-19
Therapeutic Saline Irrigation of the Bile Duct after the Endoscopic Removal of Common Bile Duct Stones
Sang Eon Jang¹, Sang Hyub Lee², Ban Seok Lee³, Dong-Won Ahn⁴, Jin-Hyeok Hwang² ¹Department of Internal Medicine, Cheongju St. Mary’s Hospital, Cheongju, ²Department of Internal Medicine, Seoul National University Bundang Hospital, Sungnam, ³Ddepartment of Internal Medicine, Cheju Halla Hospital, Cheju, 4Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
Background: Small stone fragments after an endoscopic stone
extraction for choledocholithiasis may act as the nidus for re-
current choledocholithiasis. Therefore, efforts to eliminate the
nidus might reduce the recurrence of choledocholithiasis and
cholangitis related to choledocholithiasis.
Aim: To determine whether an additional therapeutic saline ir-
rigation of the bile duct (TSIB) after the endoscopic removal of
common bile duct (CBD) stones would decrease residual CBD
stones and the recurrence of cholangitis.
Methods: A retrospective analysis was performed for the con-
Oral Presentation - PBS
S130 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
secutively collected data about the patients who underwent the
complete endoscopic treatment for CBD stone.
Results: Among 99 patients, 45 patients underwent TSIB.
Residual CBD stones were detected in 18 patients (18.2%). The
incidences of residual CBD stones were 8.9% (4 or 45 patients)
in the irrigation group and 25.9% (14 of 54 patients) in the
non-irrigation group (p=0.037). In multivariate analysis, TSIB
was found to be the only significant factors for the decrease of
residual CBD stones (HR=0.258, p=0.039). When analyzing
the occurrence of recurrent cholangitis and the procedure re-
lated to complications, there were no significant differences ac-
cording to the performance of TSIB.
Conclusion: TSIB could reduce the residual CBD stones with-
out complications.
Key Words: Therapeutic Irrigation, Common Bile Duct Stone,
Cholangitis
PBS-20
The Role of IDUS for the Management of Acute Biliary Pancreatitis with No Evidence of Choledocholithiasis on ERCP
La Young Yoon, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
Background and Aim: ERCP has been considered the standard
for the evaluation and management of acute biliary pan-
creatitis (ABP). Identifying a bile duct (BD) stone in patients
with ABP is important for the management and prevention of
recurrent attack of pancreatitis. But, small BD stones may not
be detected on ERCP. The aim of this study was to pro-
spectively evaluate the usefulness of intraductal US (IDUS) in
patients with suspicious ABP having no evidence of chol-
edocholithiasis on ERCP.
Patients and Methods: A total 92 patients suspected with ABP
without evidence of BD stones on imaging studies including
ERCP were enrolled. Wire guided IDUS was performed during
ERCP in all patients. Stones or sludge detected by IDUS were
confirmed after endoscopic sphincterotomy (EST) and
extraction.
Results: IDUS successfully performed in all patients. Among
the 92 patients, IDUS revealed BD stones in 33 (35.8%) and
biliary sludge in 26 (28.2%) patients. The results of IDUS were
consistent with those of EST and stone extraction. During the
mean follow-up of 24 months, recurrent pancreatitis did not
occur in 54 (91.5%) of 59 patients with BD stone or biliary
sludge on IDUS after endoscopic therapy.
Conclusion: IDUS improves diagnostic accuracy for the de-
tection of occult BD stones in patients suspicious ABP. IDUS
guided endoscopic treatment can help prevent recurrent
pancreatitis.
Key Words: Choledocholithiasis, Acute biliary pancreatitis,
Intraductal US
PBS-21
Safety and Efficacy of Extracorporeal Shockwave Lithotripsy with Endotherapy for the Treatment of Pancreatic Duct Stones
Byung Uk Lee, Myung-Hwan Kim, Seung Uk Jung, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Aim: A retrospective analysis was performed to evaluate the
safety and efficacy of extracorporeal shock wave lithotripsy
(ESWL) as a treatment of pancreatic stones.
Method: Between March 2008 and July 2012, 77 patients with
pancreatic stone presenting with pain and large pancreatic
duct stone not amenable to extraction with an endoscopic ret-
rograde cholangio pancreatography (ERCP) were selected for
ESWL. The ESWL was performed with an electroconductive
lithotripter (Sonolith VISION, EDAP-TMS) equipped with
both fluoroscopic and ultrasound target system. Analgesia
(pethidine) was administrated intravenously to control the
pain during ESWL. Fragmented calculi were cleared by fol-
lowed endotherapy. The success rates, complications and pre-,
during- and post-ESWL pain scale (visual analogue scale, VAS)
were evaluated.
Result: A mean pancreatic stone size was 14.2mm and a mean
of 4.6 ESWL (range: 1~10) session was performed for each pa-
tient with mean of 3,025 shocks (range: 2,500~4,750) at a pow-
er setting of 12.8 kV (range: 11.8~13.5) were employed.
Fragmentation of the stones were achieved in 74/77 (96.1%)
patients, and overall clearance of the stones were 72/77
(93.5%) patients. Complete clearance of the main pancreatic
duct was achieved in 52 patients (67.5%) and partial clearance
in 20 patients (25.9%). Three patients (3.9%) developed acute
pancreatitis. Complete relief of pain without pancreatic stent-
ing achieved in 63/74 (85.1%) patients. The mean pre-, dur-
ing- and post- ESWL VAS score was 5.75, 2.03, 0.45 (p<0.01).
Three patients were undergoing pancreatic surgery due to per-
sistent pain with remnant stone. A mean dose of pethidine
used during ESWL was 56.2mg (range: 25~100) per session.
Conclusion: Without general or epidural anesthesia, large pan-
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Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S131
creatic stone can be managed safely and effectively by the com-
bination of ESWL and endotherapy.
Key Words: Pancreatic Stone, ESWL(extracorporeal Shockwave
Lithotripsy)
PBS-22
Comparison Outcomes for Unresectable Hilar Cholangiocarcinoma Treated with Definitive Photodynamic Therapy (PDT) Combined with Gemcitabine-Based Chemotherapy
Eun Taek Park, Sang Uk Lee, Byung Hoon Han, Byung Cheol Yun Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, Korea
Background/ Aims: Hilar cholangiocarcinoma (CC) has an ex-
tremely poor prognosis with less than 5% of patients surviving
5 years. Preliminary clinical studies have suggested that PDT
maybe beneficial for palliation of hilar CC. PDT for hilar CC
revealed that the tumoricidal depth of PDT using porfimer so-
dium (Photofrin®; Axan Pharma Inc., Canada) is limited to 4-
to 4.5-mm of tissue penetration, which cannot eradicate a pri-
mary tumor when invasion extends to a depth of over 6mm.
The aim of this study to assess the efficacy that the percutanous
transhepatic cholangioscopy (PTCS) guided compelling dila-
tation of malignant stricture before PDT for improving the
depth of tissue penetration (definitive PDT) and then retro-
spectively analyzed the outcome of possible treatment modal-
ity with definitive photodynamic therapy (PDT) combined
with gemcitabine-based chemotherapy and conservative treat-
ment in hilar CC.
Material And Methods: Forty-seven patients with unresectable
hilar CC were included in this study. 24 patients underwent
conservative treatment alone (Group A) including drainage
procedure, 23 patients treated with definitive PTD with che-
motherapy including drainage procedure (Group B) were ana-
lyzed retrospectively. Before PDT, group B patients were per-
formed PTCS guided compelling dilatation with balloon cath-
eter or bouginator on malignant stricture site and immediate
insertion of 18Fr plastic catheter. PDT was performed after 7
days. And then drainage procedure (including uncovered met-
al stent) performed after 1 session of PDT and gemcita-
bine-based chemotherapy was done for 6 cycles.
Results: The Group A and B were comparable due to age, gen-
der, performance status, pretreatment bilirubin level and hilar
CC stage. Overall survival rate of Group A and B were 63% and
94% at 1 year, respectively (p<0.001). The mean survival peri-
od of patients with of Group A and B was 8.2 months and 16.3
months, respectively (p<0.001). The metal stent patency of
Group A and B was 167 days and 283 days, respectively
(p=0.003). Definitive PDT related complications were ob-
served in 2 patients related to balloon dilatation including 1 he-
mobilia and 1 bile duct leakage. But no patient developed acute
serious complication.
Conclusion: Compelling dilatation of malignant stricture site
before PDT (definitive PDT) with chemotherapy is sig-
nificantly improved the survival rate and metal stent patency
due to tissue penetrating and increased tumoricidal depth in
hilar CC. The side effects secondary to compelling dilatation
with PDT are very rare and clinically insignificant in this study.
We concluded that this procedure seemed to be more effective
and safe than conservative treatment alone in unresectable hi-
lat CC.
Key Words: Photodynamic Therapy, Unresectable Klatskin
Tumor, Gemcitabine
PBS-23
Longterm Outcome of PDT with Chemotherapy Compared with PDT Alone and ERND Only in Patients with Cholangiocarcinoma Mi Jin Hong, Young Koog Cheon, Cho I Lee, Eung Jun Lee, Tae Yoon Lee, Chan Sup ShimDepartment of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
Aims: Cholangiocarcinoma (CC) is the primary cancer of bile
duct. Patients usually present at an advanced stage, with more
than 50% of cases being unresectable at the time of diagnosis.
As a result, a large proportion of patients are beyond the scope
of curative treatment upon diagnosis. Recently photodynamic
therapy (PDT) has been evaluated as a palliative and neo-
adjuvant modality. However, it is not known that combination
with photodynamic therapy and chemotherapy is promising
activity, most notably gemcitabine-based combinations.
Materials and Methods: A total of 232 atients with hilar chol-
angiocarcinoma diagnosed between Feburuary 1999 and
September 2009 were evaluated. 16 were treated with PDT and
gemcitabine or/and another (Group A), 58 were treated with
PDT only (Group B) and 71 patients were treated with endo-
scopic biliary drainage alone (Group C). These data were col-
lected prospectively and analysed retrospectively.
Results: Median survival was 538 days (95% CI, 475.3-600.7)
in group A, 334 days (95% CI, 252.5-415.5) in group B, and
220 days (95% CI, 143.7-296,3) (p = 0.001). There was no stat-
istically significant difference between group A and B. Whether
of lymph node metastasis (p=0.037), serum bilirubin level of-
pretreatment (p=0.040), TNM stage (p=0.048), treatment
methods (PDT with chemotherapy, PDT alone, vs. ERBD
Oral Presentation - PBS
S132 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
alone, p=0.031), and time to treatment of PDT (p=0.033)
wereprognostic factors with statistical significance in the uni-
variate analysis. However, there were no significant variables in
the multivariate analysis.
Conclusions: PDT with chemotherapy and PDT alone resulted
in longer survival compared with stenting alone. PDT with
chemotherapy showed tendency to be longer survival than
those of PDT alone,however, it did not showstatistically
significance.
Key Words: Advanced cholangiocarcinoma, Photodynamic
therapy, Systemic chemotherapy, ERBD
PBS-24
Evaluation of Different Strategies Using Infundibulotomy and Transpancreatic Septotomy in Difficult Biliary Cannulation
Yun Gyoung Park, Kwang Hyuck Lee, Kyu Taek Lee, Jong Kyun Lee Divsion of Gastroenterology, Department of Internal Medicine, Sungkyunkwan Universtiy of Medicine,samsung Medical Center, Seoul, Korea
Backgrounds: Selective biliary cannulation is the most im-
portant step for successful therapeutic biliary endoscopy, but
still in 5~10% of cases, selective cannulation fails. Several pre-
cut techniques have been used to gain biliary access for those
difficult cases. Additionally, it has been proposed that early in-
stitution of precut techniques could be safe. However, different
approach should be considered in each patient, especially ac-
cording to the presence or absence of unintended repeated
pancreatic cannulation.
Aim: The aim of this study was to evaluate the success and
complication rate of two precut techniques, needle knife in-
fundibultomy (NKI) and transpancreatic septotomy (TPS) for
difficult biliary cannulation. Patients and
Methods: We performed a prospective study of the different
strategies for two groups divided by the presence of unin-
tended pancreatic cannulation from January 2009 and August
2012 at Samsung medical center. The patients who need biliary
intervention because of such as stone, malignancy, or benign
stricture were enrolled. If there were more than five unin-
tended pancreatic cannulations, TPS was performed. And if
deep cannulation was not achieved within 5 minutes for any
duct, NKI was performed. If fail, we crossed over to the other
technique in second attempt.
Results: A total of 61 patients (NKI = 16, TPS = 45) were
included. The baseline characteristics such as age, sex, and clin-
ical presentation were similar in two groups. The total success
rate of biliary cannulation was 88.5%. The success rate was
93.8% for NKI and 86.7% for TPS group. After crossing over
the techniques, the final success rate was 96.7%. The complica-
tion rate was 6.3% in patients with NKI was 11.1% in patients
with TPS: 0% versus 4.4%, for acute pancreatitis, 6.3% versus
2.2%, for bleeding, 0% versus 0%, for perforation, 0% versus
4.4% for cholangitis, respectively. But there was no severe pan-
creatitis and no fatal cases. There was no significant difference
in two groups.
Conclusions: Our result suggests that the application of differ-
ent strategies based on the presence of unintended pancreatic
cannulation may assist to increase the success rate for difficult
biliary cannulation without increasing complication rates.
Key Words: ERCP, Difficult biliary cannulation, Needle knife
infundibulotomy, Transpancreatic septotomy
PBS-25
Fistulotomy Using a Cap-Assisted Forward-View Endoscope in Difficult Biliary Cannulation
Dae-Seong Myung, Chang-Hwan Park, Chung-Hwan Jun, Ho-Seok Ki, Seon-Young Park, Sung-Bum Cho, Young-Eun Joo, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.
Background: Even in experienced hands, a common problem
at endoscopic retrograde cholangiopancreatography is diffi-
culty in selective cannulation. Selective cannulation is more
difficult in patients with surgically altered gastrointestinal
anatomy or peri-ampullary diverticulum. We report our expe-
rience about fistulotomy using a cap-assisted forward-view en-
doscope in difficult biliary cannulation.
Patient and Method: Patients who underwent fistulotomy us-
ing a cap-assisted forward-view endoscope in difficult biliary
cannulation were eligible for this study. From september 2007
to september 2012, 23 patients were recruited. Cause of diffi-
cult cannulation is as follows; Billroth II (12), Billroth II with
periampullary diverticulum (4), periampullary diverticulum
(5), IPMN (1), duodenal deformity (1).
Result: In all cases, we successfully performed fistulotomy us-
ing a cap-assisted forward-view endoscope in patients with diffi-
cult biliary cannulation. After selective biliary cannulation, ther-
apeutic procedures were successfully performed in all cases.
Therapeutic procedures was as follows; endoscopic sphincter-
otomy (23), endoscopic retrograde biliary drain insertion (19),
stone removal (18), biopsy (3). Among the 23 patients, 2 had
minor bleeding which stopped spontaneously. There was no
procedure-related death.
Conclusion: Fistulotomy using a cap-assisted forward-view
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S133
endoscope is safe and effective in patients with difficult biliary
cannulation
Key Words: Fistulotomy, Cap, Forward, Cannulation, ERCP
PBS-26
New Technique of ES with Iso-Tome to Incise the Distal Papillary Roof in PTS with Choledocholithiasis and with CDF on AV
Young Sin Cho, Sang-Heum Park, Tae Hoon Lee, Dae Yeon Kim, Kyung-hee Hyun, Hyun Jong Choi, Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Sun-Joo Kim Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
Background/Aims: Occasionally endoscopic incision on the
distal papillary roof is not easy in patients with chol-
edocholithiasis and with spontaneous or artificial chol-
edochoduodenal fistula (CDF) on the ampulla of Vater (AV).
We evaluated the efficacy and feasibility of down- or/and
up-ward papillotomy by using Iso-Tome to incise completely
the distal papillary roof for removing CBD stones.
Methods: From May 2003 to July 2012, this technique was ap-
plied to patients with choledocholithiasis and with sponta-
neous or artificial CDF on AV. Artificial CDF(fistulomy) was
made by using needle-knife papillotome. Downward incision
from the orifice of CDF or/and up-ward incision from the or-
ifice of AV were performed by using Iso-Tome until the distal
papillary roof was completely cut. Main outcome measure-
ments were the success rate of this technique, the number of
incision for achieving successful cutting, the electric damage
on pink intrapapillary mucosa, the success rate of bile duct
stone clearance, and complications.
Results: A total of 35 patients (15 male, 20 female) with a mean
age of 66.1 (range, 27-92) years were consecutively enrolled.
Spontaneous or artificial CDF were in 4 and 31, respectively.
The direction of incision was downward in 27, upward in 3,
and combined in 5. This technique was successful in
94.3%(33/35). Mean number of incision was 1.4(range, 1-4)
and only one incision was enough to incise completely the dis-
tal papillary roof in 74.3%(26/35). There was no case of the
electric damage on the pink intrapapillary mucosa and ther-
apeutic success rate for CBD stone removal was 96.8% (32/33).
Of the 35 patients, 1 (2.9%) had mild bleeding, which was
managed medically.
Conclusions: Down- or/and up-ward papillotomy with Iso-Tome
is a feasible and useful new technique of endoscopic sphincter-
otomy to incise completely the distal papillary roof in patients
with spontaneous or artificial CDF for the treatment of CBD
stones.
Key Words: Endoscopic sphincterotomy, Iso-Tome, Choledoc-
holithiasis, Choledochoduodenal fistula, Distal papillary roof
PBS-27
Is Double-Guidewire Technique Really Useful for Difficult Biliary Cannulation?
Su Jin Kim, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
Background and Aim: Double-guidewire technique (DGT)
has been reported to be useful for difficult biliary cannulation.
Needle-knife fistulotomy (NKF) is also used in failed standard
biliary cannulation. The aim of this study was to compare the
success rate and complications between the DGT and NKF in
patients with difficult biliary cannulations.
Methods: Patient who underwent endoscopic retrograde chol-
angiopancreatography (ERCP) between January 2009 and
September 2012 were eligible for this study. DGT or NKF were
perfomed if deep biliary cannulation was not achieved despite
of five mininutes of attempted cannulationthan or more than
three attempted unintentional pancreatic cannulations. Patients
with unsuccessful DGT underwent NKF as alternative
procedure. The success rate of cannulation and the frequency
of post-ERCP pancreatitis (PEP) were investigated.
Result: A total 1550 ERCP cases were analyzed, the total success
rate of selective biliary cannulation was 94.2% (1460/1550). Of
the 302 patients with unsuccessful standard cannulation tech-
nique, DGT was perfomed in 70 patients and NKF was per-
fomed in 199. The success rates in the DGT and NKF groups
were 41.4% (29/70) versus 81.4% (162/199) (p<0.01). Thirty
patients with unsuccessful DGT underwent NKF as alternative
procedure, biliary cannulation was achieved in 70.0% (21/30).
The incidence rate of PEP was significantly higher in DGT
group 20.0% (14/70) than in NKF group 8.0% (16/199)
(p<0.01). There was no significant difference in bleeding be-
tween the three groups.
Conclusion: DGT in patients with a difficult biliary cannula-
tion resulted in a low success rate of biliary cannulation and a
high incidence of PEP comparing with NKF. We suggest that
NKF should be considered as a first approach in difficult can-
nulation situations.
Key Words: ERCP, Cannulation
Oral Presentation - PBS
S134 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
PBS-28
Sequential Prospective Protocol Analysis to Facilitate Selective Biliary Access for Difficult Biliary Cannulation
Soon Oh Hwang, Tae Hoon Lee, Sang-Heum Park, Yunho Jung, Suck-Ho Lee, Il-Kwun Chung, Hyun Jong Choi, Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Sun-Joo Kim Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Cheonan Hospital, Cheonan, Korea
Background/Aim: In difficult biliary cannulation (DBC),
15-35% of cases fail even when performed by experts. Various
techniques have been attempted to improve the cannulation
success rate. However, standardized guidelines are not yet in
place. We therefore prospectively investigated a sequential pro-
tocol analysis of precut and wire-guided cannulation to facili-
tate selective biliary access for DBC.
Methods: We attempted selective biliary access for DBC ac-
cording to an algorithm (Fig. 1). An early precut fistulotomy
(EPF), a double wire-guided cannulation (DWC), and a precut
following pancreatic stent placement (PPS) were performed
sequentially. The technical success rate, procedure outcomes,
and complications in each group were recorded prospectively
from May 2010 to August 2012.
Results: A total of 711 patients with naïve papilla underwent
ERCP. The 140 patients (19.7%) failed under standard
wire-guided biliary cannulation. The EPF, DWC, and PPS were
performed in 71 (50.7%), 33 (23.6%), and 36 (25.7%) patients.
There was no significant difference in baseline characteristics.
The technical success rates were 94.4%, 96.9%, and 100% re-
spectively (p=.327). Post-ERCP pancreatitis developed in 14
(10%) patients, which was not statistically significant between
groups (p=.870) or compared with the conventional group
(p=.125). However, successful cannulation time was short in
the DWC group (p<.001). In the multivariate analysis, female
gender was a risk factor for pancreatitis (odds ratio 4.16, 95%
CI 1.108-15.645, p=.035).
Conclusions: Based on the sequential protocol analysis, EPF,
DWC, and PPS were safe and feasible in DBC. We suggest EPF
in DBC criteria, and PPS following DWC in unintentional
pancreas duct cannulation.
Key Words: Difficult biliary cannulation, Precut fistulotomy,
Double wire-guided cannulation, Pancreatic stent
PBS-29
Pancreatic Duct Stenting Versus Pancreatic Duct Guidewire Placement for Facilitating Biliary Cannulation
Jae Chul Hwang, Byung Jo Yoon, Eun Jung Jang, Dong Hoon Kim, Byung Moo Yoo, Jin Hong Kim Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
Background: In difficult cases of selective biliary cannulation,
several techniques including use of a pancreatic duct stent
(PDS) or guidewire (PDW) are available. This study compared
the effectiveness of a PDS versus a PDW to facilitate common
bile duct (CBD) cannulation.
Patients and Methods: A retrospective review of all ERCPs per-
formed at our institution from May, 2008 to August, 2012 was
performed to identify all cases in which a PDS or a PDW was
placed to guide CBD cannulation. In the PDS group,
wire-guided cannulation of the bile duct was attempted over
the PDS. In the PDW group, double guidewire technique was
attempted. The success rate of cannulation, frequency of pre-
cut sphincterotomy and complication rate were compared be-
tween these two groups.
Results: Successful CBD cannulation was achieved in 52 of 53
(98.1%) in the PDS group and 46 of 47 (97.9%) patients in the
PDW group (p=0.932). Precut sphincterotomy was required in
43.4% in the PDS group and 42.6% in the PDW group
(p=0.932). The incidence of post-ERCP pancreatitis and hy-
peramylasemia in the PDS and PDW groups were 15.1% ver-
sus 10.6% (p=0.508) and 37.7% versus 27.7% (p=0.297),
respectively. No significant bleeding and perforation occurred.
Conclusions: In difficult cannulation, use of a PDS facilitates
biliary cannulation and appears to be comparable to use of a
PDW for reducing the rate of precut sphincterotomy.
Key Words: Cannulation, ERCP, Stent, Pancreatic duct
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S135
PBS-30
Overtube Assisted Intraductal Balloon-Guided Direct Peroral Cholangioscopy by Ultra-Slim Upper Endoscope
Hyun Jong Choi, Jong Ho Moon, Dong Choon Kim, Yu Ri Seo, Dae Yong Kim, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
Introduction: Consistantly successful direct peroral cholangio-
scopy (POC) by using an ultra-slim upper endoscope demands
assisting accessories. Although it has high success rate, intra-
ductal balloon-guided direct POC may be limited in interven-
tional procedures that should be performed without intra-
ductcal balloon. Overtube assisted direct POC enable one to
keep the working channel for procedures. The aim of this study
was to evaluate the usefulness of overtube assisted intraductal
balloon-guided direct POC for intraductal interventions.
Methods: Total 29 patients (mean age 64.2) with bile duct dis-
ease (24 bile duct stones, 3 biliary papillomatosis, and 2 CBD
malignancies) had undergone overtube assisted intraductal
balloon-guided direct POC by using an ultra-slim upper
endoscope. Indications of direct POC were difficult bile duct
stones requiring intraductal lithotripsy, indeterminated bile
duct lesions, or confirmation of bile duct clearance after stone
extraction. Diagnostic and/or therapeutic interventions under
POC were performed after retrieval of the intraductal balloon.
A successful POC was defined as one in which the endoscope
was advanced into the bifurcation or stenotic segment. A suc-
cessful intervention uncder POC was defined stable keeping
the position of endoscope until complete diagnostic and/or
therapeutic intraductal procedures.
Results: The overall success rate of direct POC was 96.6%
(28/29). The success rate of intraductal interventions under di-
rect POC was 82.1% (23/28). Intraductal interventions under
POC included 9 intraductal evaluation with narrow band
imaging after saline irrigation, 5 intraductal target biopsy, 5 in-
traductal laser lithotripsy, 3 direct removal of residual stones,
and one ablation therapy with argon plasma coagulation. No
procedure-related complication was occurred.
Conclusions: Intraductal balloon-guided direct POC is highly
successful. Application of overtube can be helpful to maintain
the scope position even after the withdrawal of intraductal
balloon.
Key Words: Peroral cholangioscopy, Ultra-slim endoscope,
Overtube, Intraductal balloon
PBS-31
Direct Peroral Cholangioscopy Using an Ultra-Slim Endoscope in Altered Gastrointestinal Anatomy
Ho-Seok Ki, Chang-Hwan Park, Seon-Young Park, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
Background and Study Aims: Peroral cholangioscopy provides
direct visualization of the bile duct and facilitates diagnostic
procedures and therapeutic interventions. The mother-baby
endoscopic system has several disadvantages during procedure
in altered anatomy. Therefore, we evaluated the feasibility of
direct peroral cholangioscopy using an ultra-slim endoscope in
altered gastrointestinal anatomy.
Patients and Methods: From March 2012 to September 2012, 8
patients with Billorth II gastrectomy (n=4), abnormally lo-
cated papilla of Vater in duodenal bulb (n=1), hep-
aticoduodenostomy (n=1), and choledochoenterostomy
(n=1), extremely J-shaped stomach (n=1) underwent direct
peroral direct cholangioscopy using an ultra-slim endoscope.
Results: The success rate of direct visualization of the bile duct
using an ultra-slim endoscopy was 100% (8/8). In cases of al-
tered anatomy, we overcome the case using an overtube. In cas-
es of successful access, therapeutic interventions including
stone extraction (n=6) and electrohydraulic lithotripsy (n=4)
were performed successfully. Immediate bleeding was occurred
in one case during electrohydraulic lithotripsy. But, Primary
hemostasis was achieved spontaneously.
Conclusion: Direct peroral cholangioscopy using an ultra-slim
endoscope was possible in altered gastrointestinal anantomy.
Overtube-assisted direct peroral cholangioscopy using an ul-
tra-slim endoscope enables easy access in patient with BII
anatomy.
Key Words: Endoscopic retrograde cholangiopancreatography,
Peroral cholangioscopy, Billroth II gastrectomy
PBS-32
Pancreatic Duct Stenting after Endoscopic Ampullectomy for Ampullary Neoplasm; Can It Prevent Pancreatitis?
Yun Kyeong Kim, Byung-Wook Kim, In-Seok Lee, Woo-Chul Chung, Tae-Ho Kim, Joon Sung Kim Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
Background/Aims: Endoscopic ampullectomy for ampullary
neoplasm is known to be safe and effective alternatives for sur-
Oral Presentation - PBS
S136 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
gical resection. However, post-procedural pancreatitis is quite
common and pancreatic duct stenting has been conducted for
prevention of this complication. The aim of this study was to
evaluate the effectiveness of pancreatic duct stenting after en-
doscopic ampullectomy in Korea.
Methods: Retrospective review was conducted in 4 institutes
affiliated to The Catholic University of Korea between October
2007 and May 2012. We compared the complication rate be-
tween the patients with pancreatic duct stent and without stent
after ampullectomy. Pancreatitis was defined as abdominal
pain after the procedure with increased serum amylase level
over 3 fold of reference value.
Results: Thirty five patients (13 females, 22 males) underwent
endoscopic ampullectomy during this period. The final histo-
logic diagnosis was tubule adenoma with low grade dysplasia
(42.8%), high grade dysplasia (22.8%), adenocarcinoma
(14.3%), tubullo-villous adenoma (2.8%), hyperplastic polyp
(2.8%), chronic inflammation (2.8%), and etc (11.4%).
Stenting was performed in 24 patients (68.6%), whereas 11 pa-
tients (31.4%) were remained without stent. In stenting group,
11 patients developed pancreatitis (45.8 %), whereas 4 patients
developed pancreatitis in patients without stenting (36.3%).
(p>0.05)
Conclusions: Pancreatic duct stenting cannot reduce the pro-
cedure-related pancreatitis. Further studies with large scaled
prospective trial are anticipated.
Key Words: Ampullectomy, Ampullary neoplasm
PBS-33
Prophylactic Pancreatic Duct Stenting after Papillectomy of Duodenal Papillary Tumor; Prospective, Randomized Study
Byung Hoo Lee, Sang-Woo Cha, Tae Hoon Lee, Soung Won Jeong, Jae Young Jang, Young Deok Cho, Sang-Heum Park Institute for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University, College of Medicine, Seoul, Korea
Introduction: Endoscopic snare papillectomy (ESP) is an effi-
cient treatment for benign tumors of the duodenal major
papilla. However, post-ESP pancreatitis is a common and seri-
ous complication. Since one prospective randomized con-
trolled trial showed that pancreatic duct stent placement re-
duced post-ESP pancreatitis, almost physicians have tried to
place pancreatic duct stent after EPS. The aim of this pro-
spective, randomized trial is to compare the rates of post-ESP
pancreatitis in patients who did or did not receive prophylactic
pancreatic duct stent placement.
Methods: Consecutive patients who were to undergo ESP were
randomized to pancreatic duct stent placement group (stent
group) after endoscopic snare papillectomy or to no pancreatic
duct stent placement group (no stent group).
Result: The groups were similar with regard to patient
demographics. In total, 24 patients were enrolled. Fourteen pa-
tients were assigned to the stent group and 10 patients to the no
stent group. Post-ESP pancreatitis developed in 5 patients
(20.8 %, 5/24), 3 cases occurred in the stent group and 2 case
occurred in the no stent group. One case of moderate grade
pancreatitis developed in the stent group. The overall incidence
of post-EPS pancreatitis was 21.4% (3/14) in the stent group
and 20.0 % (2/10) in the no stent group (p=0.932). The rates of
hyperamylasemia were 14.3% (2/14) in the stent group and
0.0% (0/10) in the no stent group (p=0.493).
Conclusion: There was no significant difference in the occur-
rence of post-ESP pancreatitis and hyperamylasemia between
patients with and without pancreatic duct stent placement af-
ter endoscopic snare papillectomy. Our findings suggest that a
pancreatic duct stent placement after ESP did not confer a pro-
tective effect in reducing post-ESP pancreatitis. Therefore,
more large scaled prospective, randomized controlled studies
regarding the effectiveness of pancreatic duct stent placement
to reduce the incidence rates of post-ESP pancreatitis are
needed.
Key Words: Endoscopic snare papillectomy, Pancreatitis,
Pancreatic duct stent, Ampullary tumor
PBS-34
Clinical Characteristics of Delayed Postpapillectomy Bleeding in Ampullary Neoplasm
Seung Uk Jeong, Myung-Hwan Kim, Do Hyun Park, Byung Uk Lee, Sung Hyun Won, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
Background: Endoscopic papillectomy is a less invasive treat-
ment compared with surgical resection. However, it has rela-
tively high complication rate, such as bleeding, and there are
few studies about complication, especially delayed post-
papillectomy bleeding. We carried out this study to assess the
characteristics of delayed postpapillectomy bleeding and to in-
vestigate factors related to the delayed bleeding.
Methods: This retrospective study was conducted by analysis
of data for consecutive patients who underwent endoscopic
papillectomy for duodenal ampullary neoplasm between
January 2007 and August 2012. The technique of papillectomy,
medical history, laboratory findings and clinical outcomes
were analyzed. The delayed bleeding was defined as hemor-
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S137
rhage diagnosed by second-look endoscopy at the operation
site following cessation of papillectomy.
Results: Total 205 patents underwent the endoscopic papil-
lectomy and the delayed bleeding occurred in the 89 patients
(43.4%), with median time of 2 days (range 1 to 8 days). The
second-look endoscopy was performed in the 181 patients
(88.3%) and the delayed bleeding was detected by routine sec-
ond-look endoscopy in the 58 patients (65.2%) without symp-
tom and sign. The delayed bleeding was controlled by endo-
scopic hemostasis in the 86 patents (96.6%), except for 3 pa-
tients performed embolization. The average number of endo-
scopic hemostasis was 1.6 (range 1 to 9). The delayed bleeding
developed more frequently in the patents with bleeding during
papillectomy (51.0% vs 36.5%, p=0.034). In the patients with
submucosal injection (diluted epinephrine, 1:10,000), delayed
bleeding was significantly fewer than in those without sub-
mucosal injection. (35.1% versus 50.5%, p=0.034). However,
the occurrence of delayed bleeding was not different according
to age, sex, electrosurgical currents, thermalablation after pap-
illectomy, anticoagulation, coagulopathy and endoscopists.
Conclusion: The delayed postpapillectomy bleeding was very
common. It was also more frequent in the patents with bleed-
ing during papillectomy and in those without submucosal
injection. These results suggest that routine second-look en-
doscopy might be needed and support the necessity of sub-
mucosal injection to prevent delayed bleeding. Further larger
prospective study may be needed to confirm these results.
Key Words: Delayed postpapillectomy bleeding, Submucosal
injection, Second-look endoscopy, Ampullary neoplasm
PBS-35
Analysis of the Result of Endoscopic Papillectomy with Emphasis on Complication
Choong Nam Shim, Jeong Youp Park, Moon Jae Chung, Seung Min Bang, Seung Woo Park, Si Yong Song, Jae bock Chung Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
Introduction: Endoscopic papillectomy has been currently
employed for feasible treatment for ampullary tumor. This
study aimed to assess factors associated to procedure-related
complications and to evaluate the clinical, endoscopic, and his-
tologic characteristics of complicated lesions.
Methods: This study included 35 patients underwent endo-
scopic papillectomy for ampullary adenoma between September
2006 and April 2012 in Severance Hospital, Yonsei University
College of Medicine. Patients grouped according to the occur-
rence of procedure-related complications: Group A (n=25)
without complication and Group B (n=10) with complication.
Results: The overall complication rate was 28.6 % (15 cases)
among the enrolled patients. The most common complication
was pancreatitis (n=6), followed by bleeding (n=4), perfo-
ration (n=2). Between group A and B, there was no significant
difference of demographic characteristics, use of antiplatelets
or anticoagulation, and underlying diseases. Endoscopic char-
acteristics including size and type of lesion, type of endoscopic
resection (polypectomy vs endoscopic mucosal resection), and
the deployment of pancreatic duct stent after procedure did
not reveal significant difference. In laboratory characteristics,
amylase (median 113.0 vs 316.0 IU/L, p value=0.023) and li-
pase levels (median 83.0 vs 495.5 IU/L, p value=0.017) at 24
hours after endoscopic papillectomy were significantly higher
in the group with complication than without complication.
Endoscopic outcomes including en block resection rate (n=22,
88% vs n=10, 100%, p value=0.542) and complete resection
rate (n=18, 72% vs n=9, 90%, p value=0.390) did not differ
significantly between two groups. Duration of antiprotease in-
jection during hostpital stay (median 2.0 vs 5.5 days, p val-
ue=0.038) was significantly longer in the complication group,
and hospital stay (median 6.0 vs 9.0 days, p value=0.059) tend-
ed to be longer in the complication group. Recurrence rate
(n=1, 5.6% vs n=2, 22.2%, p value=0.245) among the patients
with complete resection (n=27) during median follow up of
13.0 months was not significantly different.
Conclusion: Amylase and lipase levels at 24 hours after endo-
scopic papillectomy could help to predict the possibility of pro-
cedure-related complications. Group with complication may
need longer duration of antiprotease injection during hostpital
stay. Further studies are needed to reduce the complication rate
of papillectomy.
Key Words: Ampullary adenoma, Endoscopic papillectomy,
Endoscopic Retrograde Cholangiopancreatography, Complication
PBS-36
The Comparison between Midazolam Alone and the Combination Use of Midazolam and Propofol for Sedation during ERCP
Yu Seok Kim, Myung-Hwan Kim, Seung Uk Jeong, Byung Uk Lee, Do Hyun Park, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
Background/Aims: Endoscopic retrograde cholangiopancreato-
graphy (ERCP) is uncomfortable procedure, requiring adequate
sedation for successful conduction. We investigated the efficacy
and safety in the combination use of intravenous midazolam
Oral Presentation - PBS
S138 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
and propofol for sedation during ERCP.
Methods: A total of 94 patients undergoing ERCP received one
of the two medication regimens administered by nurse with
supervision by the gastroenterologist. Patients in M group
(n=44) received only intravenous midazolam, titrated to ach-
ieve deep sedation. Patients in MP group ( n=50 ) received the
combination of intravenous midazolam and propofol initially,
and then propofol was titrated to achieve deep sedation.
Results: Time to initial sedation was shorter in MP group than
in M group ( p<0.001 ). Recovery was faster in MP group than
in M group ( p=0.031 ). There was no significant difference be-
tween the two groups with respect to frequency of adverse
events, pain of patient, discomfort of patient, degree of am-
nesia, gag reflex and satisfaction of procedure by endoscopist
respectively.
Conclusions: The combination use of intravenous midazolam
and propofol for sedation during ERCP is more effective than
midazolam alone with no difference in safety of procedure.
Key Words: Propofol, Midazolam, Sedation, Cholangiopan-
creatography, Endoscopic Retrograde
PBS-37
Sustained Use of Antiplatelet Agents Increase the Risk of Delayed Bleeding After Endoscopic Sphincterotomy
Min Geun Lee, Sang Hyub Lee, Seung June Lee, Yoon Suk Lee, Jin Hyeok Hwang Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
Objective: We aimed to investigate whether post-EST bleeding
is increased in patients who take antiplatelet agents.
Methods: Total 762 patients (56.4% men, mean age 69.3 years)
who underwent EST were enrolled and retrospectively ana-
lyzed: patients who never used antiplatelet agents (Group 1:
n=601), patients who interrupted antiplatelet agents use for
7days or more (Group 2: n=29) and patients who had con-
tinued antiplatelet therapy or had it interrupted less than 7 days
before EST (Group 3: n=132). The primary outcome was the
incidence of post-sphincterotomy bleeding.
Results: Post-EST bleeding occurred in 10.4% (79/762) overall
and 52 episodes were delayed bleeding (58.4%, mean 4.3 days;
range, 2-11 days). The incidences of post-sphincterotomy
bleeding in Groups 1, 2 and 3 were 10.5%, 10.3% and 9.8%, re-
spectively, with no significance at p=0.970. In subgroup analy-
sis among continuous antiplatelet users, aspirin users made up
the biggest proportion (86/132, 65.2%), followed by 13.6% for
dual antiplatelet users with aspirin and clopidogrel, 7 of the de-
layed bleeding episodes occurred in the uninterruption group
(14.3%), 2 in the interruption group the day before EST or of
enforcement (3.4%), and none in the 2- to 4-day interruption
group prior to EST, which showed a relationship between de-
layed bleeding and antiplatelet use (p=0.043). In the multi-
variate analysis, post-EST bleeding was significantly associated
with pre-EST jaundice (total bilirubin ≥3mg/dL) and endo-
scopically observed bleeding at the time of sphincterotomy.
(OR 4.618; 95% CI, 1.334-15.985 ; p=0.016 and OR 3.407; 95%
CI, 1.062-10.933; p=0.039, respectively).
Conclusions: In EST for antiplatelet users, uninterrupted use
of antiplatelet agents may increase the risk of delayed bleeding
after EST. However, routine cessation of antiplatelet agents in
patients before EST is not necessary because of favorable
outcome.
Key Words: Complications, Gastrointestinal hemorrhage,
Endoscopic sphincterotomy
PBS-38
Assessment of ERCP Feasibility Based on Performance Status in Elderly Patients
Ju Wan Kim¹, Hyoung Chul Oh¹, Jae Hyeok Do¹, Jeong Sik Choi² ¹Division of Gastroenterology, Chung-ang University College of Medicine, Seoul, ²Division of Gastroenterology, In-je University College of Medicine, Busan, Korea
Background: Endoscopic retrograde cholangiopancreatog-
raphy (ERCP) has been increasingly performed in the elderly
patients. There were few reports that suggested the objective
criteria to assess the feasibility for safe ERCP. This study eval-
uated the usefulness of an algorithm that assessed the patient’s
feasibility based on performance status and cardiopulmonary
parameters.
Methods: Patients older than 70 years who were indicated for
ERCP were prospectively enrolled and risk-stratified by assess-
ing their performance status by ECOG performance status,
ASA physical status, Duke activity status index (DASI), and
cardiopulmonary parameters (pulse oxymeter, ABGA, FEV1 if
necessary). ERCP-related parameters and complications were
monitored and compared between the 70s (A, n=145) and 80s
(B, n=64). <b>
Results: There was no significant difference in underlying dis-
eases and ERCP indications. ERCP was not performed in one
high-risk patient for procedure. For performance status, there
were significant differences in mean DASI (23.7 vs. 15.9,
p<0.01) and ECOG performance status(3-4, 33/145 vs. 25/64,
p<0.05) between A and B groups. Major ERCP-related compli-
cations (hypotension, myocardial infarction, cerebral in-
farction) occurred in five patients from group B and two from
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Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S139
group A, respectively. Post-ERCP pancreatitis occurred in one
patient from group A and bleeding in one from group B. In the
univariate analysis, old age (≥80), ASA score ≥ 3 and DASI
<10 were statistically significant predictors for major ERCP-re-
lated complications. In the multivariate analysis, DASI <10
and PaCO2 >45mmHg were independent predictors for major
ERCP-related complications.
Conclusion: DASI score and hypercapnea were useful pre-
dictors for the feasibility assessment of safe ERCP in the elderly
patients.
Key Words: ERCP, Elderly, Perfomance
PBS-39
Pancreatobiliary Endoscopy during Pregnancy
Jae June Lee, Sung Gu Lee, Sun Mok Kim, Hwan Yoon, Byung Uk Lee, Seung Uk Jung Department of Internal Medicine, Ulsan University School of Medicine, Asan Medical Center, Seoul, Korea
Background: Pancreatobiliary interventions during pregnancy
are associated with risks to both the pregnancy and the devel-
oping fetus. There are few data in the literature regarding the
safety of endoscopic management of pancreaticobiliary dis-
orders during pregnancy. Furthermore, there have been no
studies to show results of pancreatobiliary endoscopy in
Korean pregnant women. In this report we summarize our ex-
perience with pancreatobiliary endoscopy during pregnany.
Methods: Endoscopic retrograde cholangiopancreatographis
(ERCP) and Endoscopic ultrasound (EUS) performed be-
tween January 2000 through August 2012 were identified from
our database, and cases of ERCP and EUS were reviewed.
Records were reviewed for indication, endoscopic inter-
ventions, use of fluoroscopy, postprocedure complications,
and pregnancy outcomes.
Results: 8 ERCPs and 4 EUSs were performed in 12 pregnant
patients. The mean patient age was 30.7 yr (22-41 yr). Their
mean gestational period was 16.4 weeks (5-32 wk); four pa-
tients were in the first, seven in the second, and one in the third
trimester. The indications of ERCP were obstructive jaun-
dice(n=3), cholangitis(n=1), gallstone pancreatitis(n=3), trau-
matic pancreatitis(n=1). And indications of EUS were pan-
creas cyst(n=1), acute cholecystitis(n=2), choledochal cyst(n=1).
Among patients, two experienced complications after proce-
dure; one had acute pulmonary edema related with adverse
drug reaction and the other had transient hyperamylasemia.
Term pregnancy was achieved in 7 patients. Two pregnant
women had uncomplicated preterm delivery, and low birth
weight newborn was only one of them. There were two artifi-
cial abortions; one at the request of the mother, and the other
for medical indication.
Conclusion: Like other studies regarding safety of pancreatobiliary
endoscopy in the Western pregnant women, ERCP and EUS in
Korean pregnant women seem to be safe for both mother and
fetus when performed in experienced experts and with intra-
procedure safety measures.
Key Words: Endoscopic Retrograde Cholangiopancreatogra-
phy, Endoscopic Ultrasound, Pregnancy
PBS-40
Endoscopic Retrograde Cholangiopancreatoscopy on Outpatient Basis
Eun Jung Jang, Jin Hong Kim, Byung Moo Yoo, Jae Chul Hwang, Dong Hoon Kim, Byung Jo Yoon Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
Background: ERCP is performed routinely after admission be-
cause of potential post-procedure complications. However,
cases whose post-procedure complication rate is expected to be
low, are sometimes performed on an out-patient basis. Aim
The purpose of this study was to evaluate the feasibility and
safety of outpatient ERCP and the incidence of post-procedure
complications.
Method: ERCP on an outpatient basis was performed in pa-
tients who required diagnostic or minimal invasive therapeutic
ERCP and were known not to be at a high risk of post-proce-
dure complications. We retrospectively assessed the results of
ERCP on an outpatient basis performed over a 9 year period
from 2003 to 2011.
Results: A total of 377 patients (42% female) with a mean age
of 52 (range 15 to 86) who received outpatient ERCP were in-
cluded in this study, 196 patients (52%) for diagnostic pur-
poses and 181 (48%) for therapeutic intervention. Diagnostic
ERCP was done in 116 patients with bile duct evaluation, 46
with pancreatic duct evaluation, and 2 with prominent duode-
nal ampulla. Therapeutic intervention included endoscopic
biliary sphincterotomy (EST) in 53, small CBD stone removal
after EST in 76, and stent-related procedures in 84. Complications
necessitating hospitalization developed in 24 patients (6.2%);
pancreatitis 14, bleeding 4, cholangitis 2, sepsis 2, transient hy-
potension 1, and perforation 1. ERCP-related mortality did not
occur. Complication rates of therapeutic ERCP tended to be
higher than diagnostic ERCP (11% vs 2%) although there were
no statistical differences. 14 patients were admitted immedi-
ately after ERCP, and 10 patients admitted via emergency
room. The mean duration of hospital stay among patients ad-
mitted due to a complication was 5.5±3.3 days (range, 3 to
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S140 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012
16days)
Conclusion: ERCP on an outpatient basis is suitable, feasible
and safe, if it is performed in selected patients who required di-
agnostic or minimal invasive therapeutic ERCP and were known
not to be at a high risk of post-procedure complications.
Key Words: ERCP, Outpatient
PBS-41
Therapeutic Outcomes of Endoscopic Papillectomy for Ampullary Neoplasms : Retrospective Analysis of a Multicenter Study
Sung Hoon Kang¹, Kook Hyun Kim¹, Min Kyu Jung², Chang Min Cho², Kwang Bum Cho³, Ji min Han⁴, Ho Gak Kim⁴, Hyun Soo Kim5, Tae Nyeun Kim¹ Department of Internal Medicine, ¹Yeungnam University College of Medicine, ²Kyungpook National University School of Medicine, ³Keimyung University School of Medicine, ⁴Catholic University of Daegu School of Medicine, 5Daegu Fatima Hospital, Daegu, Korea
Background/Aims: Endoscopic papillectomy(EP) is reported
to be relatively safe and reliable for complete resection of am-
pullary neoplasms. There were no large-scale studies concern-
ing the effectiveness and complications related to EP. This
study aimed to evaluate the therapeutic outcomes and compli-
cations of EP for ampullary neoplasms.
Methods: From Jan 2007 to Aug 2012, 84 patients who received
EP for ampullary neoplasms were retrospectively identified at 5
participating centers in Daegu, Korea. EP was performed by
snare resection with/without saline lifting of the lesion.
Results: The mean age of the total 84 patients was 60.2±12.5
years, and the male-to-female ratio was 2:1. The median fol-
low-up period was 462 days. A biliary and pancreatic stent was
placed in 32 patients and in 44 patients, respectively. En bloc
resection was possible in 75 patients (89.3%). The mean size of
the resected specimens was 13.5±6.1 mm. Histology of re-
sected specimen was as follows: low grade adenoma (42.7%),
high grade adenoma (17.1%), adenocarcinoma(18.3%), hy-
perplastic polyp (9.8%), and others (12.1%). A pathologically
incomplete resection was noted in 10 cases (11.9%). Of the 56
cases with low grade adenoma on biopsy specimen, 25%
turned out to have high grade adenoma (12.5%) or ad-
enocarcinoma (12.5%). After papillectomy, 5 patients with ad-
enocarcinoma and 1 patient with high grade adenoma and 1
patient with carcinoid tumor underwent surgery due to pos-
itive resection margin. Procedure-related complications devel-
oped in 28 patients (33.4%): bleeding (15 cases), pancreatitis
(13 cases), and perforation (7 cases). Of the 28 complication
cases, 25 patients (89%) improved with medical treatment,
while 2 patients recovered and 1 patient died after surgery.
Pancreatic duct stent significantly increased the risk of pan-
creatitis by univariate and multivariate analysis. Pre-EP ERCP,
saline lifting, sphincterotomy, biliary stenting, specimen size,
and cauterization were not related with post EP complications.
During follow up, residual tumors were found in 7 patients on
endoscopy of which 6 patients were treated with EP and/or
APC and 1 patient underwent surgery.
Conclusions: EP seems to be a safe and effective treatment for
ampullary neoplasms and can be considered as an alternative
to surgery. However, risk of the procedure related complica-
tions is a problem that must be considered.
Key Words: Ampullary neoplasms, Endoscopic papillectomy
PBS-42
Endoscopic Ampullectomy for Ampullary Tumor in a Single Center
Hoon Ki Baek, Mi Young Jang, Wang Guk Oh, Sung Jun Go, Shang Hoon Han, Young Jae Lee, Gum Mo Jung, Ji Woong Kim, Young Keun Cho, Jin Woong Cho Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
Background and Aims: Endoscopic ampullectomy is being
performed in the tretment of ampullary neoplasm such as ad-
enoma or other benign diseases . We investigate the clinical
outcomes of endoscopic ampullectomy and complications.
Methods: We analyzed medical records of consecutive patients
who received endocopic ampullectomy in our hospital from
2004 to 2011 retrospectively.
Results: Thirty two patients (24 men: mean age 60.2years,
range 26-83years) who underwent endoscopic ampullectomy
(adenoma-21, hyperplastic polyp-3, harmatoma-5, CIS-1,
others-2). Techinical success was accomplished in 31 (96%)
and treatment success were achived in 31 (96%). One of those
in endoscopic ampullectomy has APC due to capture failure.
Complication occurred: delayed bleeding in 4 patients, micro-
perforation in one patient, acute pancreatitis in 16 patients,
acute cholangitis in 2 patients.Pancreatic drainage (pancreatic
stent and pancreatic EST) reduced post procedure acute pan-
creatitis after ampullectomy (OR 17.05, CI 1.145-26.41 p<0.05).
Conclusions: Endoscopic ampullectomy was effective treat-
ment method for ampullary neoplasm. Pancreatic drainage
may reduce post ampullectomy acute pancreatitis.
Key Words: Endoscopic ampullectomy, Pancreatic stent,
Pancreatic sphincterotomy
Oral Presentation - PBS
Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S141
PBS-43
The Usefulness of Argon Plasma Coagulation for Remnant Tissues after Endoscopic Resection of Ampullary Neoplasms
Dong Uk Kim, Gwang Ha Kim, Dae Hwan Kang, Geun Am Song Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
Aims: To evaluate the usefulness of the argon plasma coagu-
lation (APC) for remnat tissues after endoscopic resection of
ampullary neoplasms.
Patients and Methods: Endoscopic snare papillectomy was per-
formed in 34 patients with ampullary neoplasms (32 ampul-
lary adenoma and 2 ampullary adenocarcinoma). In 12 pa-
tients with grossly remnant tissues after endoscopic resection,
the APC was introduced simultaneously for the remnant
tissues. Eight patiens were treated by the APC at 7-10 days after
endoscopic resection because of the microscopic remnant
tissue.
Results: Eighteen patients had adenoma, and 2 had adenocarcinoma.
Median follow-up periods was 13.4 months (reange: 3-37
months). Early complications occurred in 7 of 20 patients
(35%, major bleeding, 3; perforation, 1; pancreatitis 3; chol-
ecystitis,1). Late complications occurred in 3 of 20 patients
(15%, bile duct stone, 2; pancreatitis, 1). One patient (5%) ex-
perienced the local recurrence, which was successfully treated
with repeated APC.
Conclusion: The APC is the additionally modified technique
of endoscopic snare papillectomy, which is thought to contrib-
ute to decreasing rate of local recurrences.
Key Words: Endoscopic papillectomy, Argon plasma coagu-
lation, Ampullary neoplasms