Management after endoscopic snare papillectomy for ampullary adenomas

BACKGROUND/AIMS

This study was designed to investigate clinicopathological features of patients who underwent endoscopic snare papillectomy (ESP) and to suggest how to manage patients after the procedure according to the pathological findings.

METHODOLOGY

Seventy-nine patients underwent ESP for ampullary tumors in 7 tertiary medical centers in Korea. We retrospectively reviewed the medical records of each patient and analyzed the data.

RESULTS

Complete resection and complication rates of ESP were 76% and 21.7%, respectively; and pancreatitis rate was 11.5%. ESP-related mortality rate was 2.5% (n=2; 1 perforation and 1 pancreatitis). According to the pathological findings, endoscopic management was performed in 62/65 (95.4%) of low grade dysplasia (LGD) and 9/14 (64.3%) of high grade dysplasia (HGD)/cancer on pre-ESP; in 57/62 (92.0%) of LGD and 13/16 (81.3%) of HGD/cancer on ESP; and in 11/13(84.7%) of LGD and 0/6(0%) of HGD/cancer on follow-up biopsy. The rates of incomplete resection according to the pre-ESP pathological findings were 18.4% (12/65) in the LGD group and 50% (7/14) in the HGD/cancer group (p=0.033).

CONCLUSIONS

HGD or cancer required surgical management. Moreover, pre-procedural HGD/cancer was associated with a high rate of incomplete resection after ESP. Therefore, if the pre-ESP pathological results revealed HGD/cancer, a careful endoscopic follow-up with imaging study or an early surgical intervention should be considered.

Comparison of clinical outcomes in hepatitis B virus-positive kidney transplant recipients with or without pretransplantation antiviral therapy

BACKGROUND

Antiviral agents have improved the outcomes of hepatitis B virus (HBV)-positive kidney transplant recipients (KTRs). Preemptive therapy has been the main approach to forestall HBV reactivation. We sought to compare prophylactic and preemptive approaches.

METHODS

We divided the 69 HBV-positive KTRs into treatment and historical control groups, according to the time of starting pretransplantation antiviral therapy. The treatment group was further divided into prophylactic and preemptive therapy groups.

RESULTS

The treatment group showed a significant improvement in 10-year graft (82% vs 34%) and patient (91% vs 57%) survivals. Among the historical control group, the main causes of graft failure were patient deaths (68%), which were mostly caused by liver diseases. In contrast, there was no liver-related death in the treatment group. In addition, there was no difference in graft or patient survival between the prophylactic and preemptive groups, but the incidence of HBV reactivation was lower in the prophylactic group. Antiviral therapy was an independent factor for the improved patient survival (P = .005).

CONCLUSIONS

Pretransplantation antiviral therapy is essential to improve clinical outcomes. Prophylactic may be better than preemptive antiviral therapy to decrease HBV reactivation.

A randomised, double-blind, parallel design, multi-institutional, non-inferiority phase IV trial of imidafenacin versus fesoterodine for overactive bladder

AIMS

Our objective was to compare the efficacy and safety of imidafenacin over fesoterodine in patients with overactive bladder (OAB).

METHODS

This study is a randomised, double-blind, parallel-group, fesoterodine-controlled study in patients with continuous OAB symptoms for ≥ 3 months, daily mean voiding frequency (DMVF) ≥ 8, and daily mean urgency or urgency incontinence frequency ≥ 2. A twice-daily 0.1 mg imidafenacin with placebo, or once-daily 4 mg fesoterodine with placebo were administered for 12 weeks. The primary efficacy end-point was the difference in DMVF at 12 weeks. The secondary efficacy end-points were differences in daily mean: (i) voiding frequency at 4 and 8 weeks; (ii) urgency frequency; (iii) urgency incontinence frequency; (iv) incontinence frequency; (v) nocturia frequency; and (vi) quality of life score. The variables for safety analysis were adverse events, vital signs, residual urine volume and clinical laboratory tests. An efficacy analysis was conducted in per-protocol patients and the safety analysis was conducted in all randomised patients.

RESULTS

The differences in DMVF at 12 weeks were -3.38 ± 3.63 and -2.45 ± 3.73 in the imidafenacin and fesoterodine groups, respectively, and the difference was not significant between the two groups. Imidafenacin was non-inferior to fesoterodine, and the lower limit of 95% two-sided confidence intervals was -0.53. The other six secondary end-points and variables for safety analysis showed no difference between the two groups.

CONCLUSIONS

Imidafenacin was non-inferior to fesoterodine in terms of efficacy, and showed no significant difference in terms of safety.

Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone

Background/Aims

Between endoscopic sphincterotomy (ES) alone and combined endoscopic sphincterotomy and large balloon dilation (ES-LBD) groups, efficacy and long-term complications, difference in biliary stone recurrence rate, and risk factors of stone recurrence were compared.

Methods

Medical records of 222 patients who underwent ERCP for biliary stone removal were retrospectively reviewed. Patients with dilated CBD ≥11 mm and follow-up longer than 6 months were included.

Results

There were 101 patients in ES-LBD group and 121 patients in ES group. Mean follow-up duration was 25.0 (6-48) months and 13.0 (6-43) months, respectively (p=0.001). There was no difference in number of ERCP sessions, brown pigment stones, angle between mid and distal common bile duct (CBD angle) <135°, and lithotripsy rate. Complete retrieval success rate was excellent in both groups (100% vs. 99%). Early complication rate of ES-LBD and ES alone group was 4 and 4.1%, respectively (p=1.000). One patient in ES-LBD group died from delayed bleeding. Late complication rate was 5.9 and 3.3%, respectively (p=1.000). Stone recurrence rate was 6.9% and 5.8%, respectively (p=0.984). The only Independent risk factor of stone recurrence was presence of periampullary diverticulum.

Conclusions

Late complication and stone recurrence rates were similar between ES-LBD and ES alone groups.

Clinical course and proposed treatment strategy for ERCP-related duodenal perforation: a multicenter analysis

BACKGROUND AND STUDY AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is rare but can cause high mortality. Our aim was to assess the clinical outcomes of these events.

METHOD

A total of 59 patients who were diagnosed as having ERCP-related duodenal perforation at six institutions between 2000 and 2007 were enrolled in this multicenter retrospective study. We evaluated complications and mortality associated with ERCP-related duodenal perforation according to injury detection time (IDT), peritoneal irritation signs (PIS), systemic inflammation signs (SIS), and treatment modality in these patients.

RESULTS

Of the 59 patients, 41 (69.5 %) and 18 (30.5 %) underwent medical and surgical treatment, respectively. Duodenal perforation-related death was observed in five patients, who had received medical therapy (n = 2) and surgical therapy (n = 3). Among medically treated patients, seven patients (17.1 %) underwent endoscopic clipping immediately after the injury; surgery was not required as a salvage therapy and there were no complications or deaths among these patients. The remaining 34 patients received antibiotics combined with therapeutic fasting and intravenous hydration. Duodenal perforation-related complications depended significantly on IDT (P = 0.0001), treatment modality (P = 0.008), PIS (P = 0.003), and SIS (P = 0.010). The duodenal perforation-related mortality was significantly related to IDT (P = 0.008) and PIS (P = 0.001).

CONCLUSIONS

IDT, PIS, and SIS appear to be important prognostic factors following ERCP-related duodenal perforation. Medical therapy can be suggested as an initial treatment strategy for ERCP-related duodenal perforation, and if possible, endoscopic clipping is strongly recommended. However, surgical treatment should be considered if the perforation is not expected to seal spontaneously, or if the continuing leakage causes PIS or SIS.

Clinical outcomes and risk factors of post-polypectomy coagulation syndrome: a multicenter, retrospective, case-control study

BACKGROUND AND STUDY AIMS

Post-polypectomy coagulation syndrome (PPCS) is a well known complication of colonoscopic polypectomy. However, no previous studies have reported on the clinical outcomes or risk factors of PPCS. The aim of the current study was to analyze the clinical outcomes and risk factors of PPCS developing after a colonoscopic polypectomy.

PATIENTS AND METHODS

Data for all patients who underwent colonoscopic polypectomies and required hospitalization in nine university hospitals were analyzed retrospectively. The incidence, clinicopathological characteristics, and clinical outcomes of PPCS cases were examined. Additionally, patients who developed PPCS were compared with controls who were matched by age and sex, in order to assess for possible risk factors.

RESULTS

The rate of PPCS that required hospitalization after colonoscopic polypectomy was 0.7/1000. All patients with PPCS were treated medically without the need for surgical interventions. The median durations of therapeutic fasting, hospitalization, and antibiotic use were 3 days, 5.5 days, and 7 days, respectively. The rates of major PPCS and mortality were 2.9 % and 0 %, respectively. On multivariate analysis, hypertension (OR = 3.023, 95 %CI 1.034 - 8.832), large lesion size (OR = 2.855, 95 %CI 1.027 - 7.937), and non-polypoid configuration (OR = 3.332, 95 %CI 1.029 - 10.791) were found to be independent risk factors related to the development of PPCS.

CONCLUSIONS

In this study, the rates of major PPCS and mortality were only 2.9 % and 0 %, respectively. Hypertension, large lesion size, and non-polypoid configuration of the lesion were independently associated with PPCS. Therefore, patients may be reassured by the excellent prognosis of PPCS, while endoscopists should be especially careful when performing colonoscopic polypectomies in patients with hypertension or large and non-polypoid lesions.

Pancreaticoduodenectomy for advanced gastric carcinoma patients

OBJECTIVE

The prognosis for patients with gastric carcinoma that has invaded adjacent organs, especially the pancreas, is very poor. We evaluated the survival of patients following pancreaticoduodenectomy (PD) and the survival benefit of intravenous chemotherapy in these patients.

METHODS

We reviewed the hospital records of 16 gastric carcinoma patients who underwent PD during the period from 2001 to 2005.

RESULTS

Half of the patients undergoing PD had Borrmann type III gastric carcinoma (8/16; 50%). Using Cox's proportional hazards regression model, only one factor was identified as an independent, statistically significant prognosticator intravenous chemotherapy (risk ratio, 0.054; 95% confidence interval, 0.01-0.45; p < 0.01). The 5-year survival rate was higher for patients who had intravenous chemotherapy than for patients who did not (22.2% vs. 0%; p < 0.01).

CONCLUSION

The results highlight the improved survivorship of gastric carcinoma patients with PD who received intravenous chemotherapy compared with those who did not. We recommend resection in these patients and the administration of intravenous chemotherapy to improve their survival.

Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series

BACKGROUND

Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones.

AIMS

We sought to identify factors predictive of adverse events (AEs) following EPLBD.

METHODS

This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12-20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan.

RESULTS

Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015).

CONCLUSIONS

EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Prospective evaluation of the partially covered nitinol "ComVi" stent for malignant non hilar biliary obstruction

BACKGROUND

Biliary partially covered self-expandable metal stents (PC-SEMS) offer prolonged relief of symptoms of biliary obstruction but may induce complications including pancreatitis, cholecystitis and migration.

AIMS

To assess efficacy and safety of the ComVi partially covered self-expandable metal stents as primary palliative treatment of distal malignant biliary obstruction.

METHODS

Seventy patients (mean age 69.2 years) with distal malignant biliary strictures were prospectively included and underwent endoscopic retrograde cholangio-pancreatography and partially covered self-expandable metal stents placement. Follow-up was done for 12 months. self-expandable metal stents patency, survival and complication-rate after partially covered self-expandable metal stents placement were evaluated.

RESULTS

Overall median survival time was 190 days (30-856). Forty-four patients (62.8%) died after median 175.5 days (30-614) without signs of stent dysfunction; 37 patients (52.8%) were alive after 6 months without signs of self-expandable metal stents occlusion. Survival rapidly dropped between 8 and 12 months after treatment. Survival was not influenced by sex (P = 0.1) or type of neoplasia (P = 0.178). Median survival was longer (254 days [44-836]) in patients who underwent chemotherapy (P < 0.0001). Partially covered self-expandable metal stents occlusion had 24 (35.7%) patients 154 days (35-485) after treatment. Median survival after re-treatment was 66 days (13-597). Cholecystitis occurred in one patient (1.7%).

CONCLUSIONS

The ComVi partially covered self-expandable metal stents is effective for palliation of biliary obstruction secondary to distal malignant biliary strictures. Self-expandable metal stents patency during follow-up is satisfactory without significant complications.

A retrospective study of clinical outcomes of α-blocker or finasteride monotherapy followed by combination therapy: determination of the period of combination therapy of α-blocker and finasteride

AIMS

We investigated outcomes after discontinuing alpha-blockers or finasteride in patients who initially received combination therapy and compared differences by duration of combination therapy.

METHODS

Patients with international prostate symptom score ≥ 8, serum prostatic-specific antigen (PSA) < 4 ng/ml, prostate volume > 25 cm(3) and combination therapy of alpha-blockers and finasteride for more than 6 months were classified into three groups. Group 1 continued combination therapy; group 2, alpha-blockers monotherapy; and group 3, finasteride monotherapy. All parameters were evaluated before and after changing to monotherapy. Patients who received combination therapy for 6-9 months and those who received combination therapy for longer were comparatively analysed.

RESULTS

Mean age of the 106 patients was 66.9 ± 7.8 years. No significant differences in baseline symptom scores, PSA or prostate volume were found. Following combination therapy, symptom scores, and quality of life (QoL) decreased for all groups. Group 1 maintained decreased PSA and prostate volume, and improved uroflowmetric profiles. No differences in uroflowmetric parameters were found after 6 months. Group 2 maintained improved symptoms, QoL and uroflowmetric profiles, although PSA and prostate volume returned to baseline. Group 3 maintained lowered PSA and prostate volume, whereas Qmax returned to baseline. QoL scores showed no change. Patients who received combination therapy for ≥9 months improved more in symptoms and QoL than those who received shorter combination therapy.

CONCLUSIONS

Discontinuation of alpha-blockers or finasteride after combination therapy for ≥ 6 months maintained improvements in symptoms. The appropriate period of combination therapy was ≥ 9 months.

Efficacy of a metallic stent covered with a paclitaxel-incorporated membrane versus a covered metal stent for malignant biliary obstruction: a prospective comparative study

BACKGROUND

The placement of a self-expandable metallic stent (SEMS) is a widely used nonsurgical treatment method in patients with unresectable malignant biliary obstructions but SEMS is susceptible to occlusion by tumor ingrowth or overgrowth.

AIM

The efficacy and safety of a metallic stent covered with a paclitaxel-incorporated membrane (MSCPM) in which paclitaxel provided an antitumoral effect was compared prospectively with those of a covered metal stent (CMS) in patients with malignant biliary obstructions.

METHODS

Patients with unresectable distal malignant biliary obstructions (n = 106) were prospectively enrolled in this study at multiple treatment centers. A MSCPM was inserted endoscopically in 60 patients, and a CMS was inserted in 46 patients. Patients underwent systemic chemotherapy regimens alternatively according to disease characteristics.

RESULTS

The two groups did not differ significantly in mean age, male to female ratio, or mean follow-up period. Stent occlusion due to tumor ingrowth occurred in 12 patients who received MSCPMs and in eight patients who received CMSs. Stent patency and survival time did not differ significantly between the two groups (p = 0.116, 0.981). Chemotherapy had no influence on stent patency, but gemcitabine-based chemotherapy was a significant prognostic factor for survival time (p = 0.012). Complications, including cholangitis and pancreatitis, were found to be acceptable in both groups.

CONCLUSIONS

Although the use of a MSCPM produced no significant differences in stent patency or patient survival in patients with malignant biliary obstructions compared with the use of a CMS, this study demonstrated that MSCPM can be used safely in humans.

Endoscopic submucosal dissection with sentinel node navigation surgery for early gastric cancer

We combined endoscopic submucosal dissection (ESD) and sentinel node navigation surgery with the purpose of achieving complete resection of early gastric cancer while preserving the organ and assessing pathological nodal status. A total of 13 patients with cT1( ≤ 3 cm)N0 early gastric cancer underwent combined ESD and sentinel node navigation surgery (ESN) at a single tertiary referral center. Sentinel node navigation surgery using indocyanine green was performed during ESD and all suspected sentinel nodes were removed laparoscopically and examined intraoperatively. ESN was converted to gastrectomy with D2 dissection if there was evidence of metastasis on frozen section. ESN was completed in 12 patients and in 1 patient was converted to gastrectomy after sentinel node navigation surgery. En bloc tumor resection was achieved in all cases. Two patients underwent additional gastrectomy because they had tumor-positive vertical margins. In all cases ESN was conducted without intraoperative or postoperative adverse events. ESN is a feasible minimally invasive procedure that allows en bloc tumor resection to be achieved while assessing the pathological status of the lymph nodes.

Sketch of international digestive endoscopy network 2012 meeting: overview

International Digestive Endoscopy Network (IDEN) is an international meeting covering scientific subjects of diverse topics about upper gastrointestinal (GI) endoscopy, colonoscopy, endoscopic ultrasonography, and PB endoscopy. IDEN is organized by Korean Society of Gastrointestinal Endoscopy and the Korean Gastrointestinal Endoscopy Research Foundation, and took its first step in 2011 in Seoul, Korea. IDEN inaugurated a new era of diagnostic and therapeutic GI endoscopy. IDEN 2012 was designed to offer participants from all over the world with opportunities to share up-to-date knowledge about basic and clinical aspects of GI endoscopy and to engage in in-depth discussion with worldwide well-known experts. During the 2 days of meeting, there were 62 invited lectures, 28 case-based discussions, 20 video lectures, and 6 breakfast with the experts. There were a total of 598 participants registered from 12 countries, including Asian countries, Europe, and USA as well as Korea.

Clinical usefulness of 3-dimensional computerized tomographic renal angiography to detect transplant renal artery stenosis

OBJECTIVE

The aim of this study was to evaluate whether 3-dimensional computerized tomographic angiography (3D-CTA) is useful to detect transplant renal artery stenosis (TRAS).

METHODS

Fourteen patients with clinically suspected TRAS underwent color Doppler ultrasonography (CDU) and 3D-CTA before renal angiography. We compared 3D-CTA and CDU for accuracy based on the results of renal angiography. The safety of 3D-CTA was investigated by measuring the estimated glomerular filtration rate (eGFR) before and after the 3D-CTA examination.

RESULTS

The 10 men and 4 women who participated in this study showed a mean eGFR of 75 mL/min/1.73 m(2) (range 60-94). Of these, 9 patients were diagnosed with TRAS. 3D-CTA detected stenoses in all 9 patients, but CDU failed to detect it in 3, including, 2 with end-to-side arterial anastomoses, which may be more challenging to detect compared with end-to-end anastomoses. The stenotic area in 3D-CTA was similar to that detected by renal angiography (70 ± 12 vs 68 ± 11). The eGFR did not differ significantly before versus after the 3D-CTA examination; 72 ± 13 vs 69 ± 14 mL/min/1.73 m(2).

CONCLUSIONS

3D-CTA was an effective safe method to detect renal artery stenosis among transplant recipients with an eGFR >60 mL/min/1.73 m(2).

Outcome and safety of self-expandable metallic stents for malignant colon obstruction: a Korean multicenter randomized prospective study

BACKGROUND

Newly developed uncovered stents are designed to have varied radial force and high conformability to improve clinical outcome and safety. This study aimed to determine and compare the clinical outcome and safety of the Taewoong D-type uncovered stent and the Boston Scientific Wallfex stent.

METHODS

Patients with acute malignant colonic obstruction were treated with a colonic stent. For the purpose of palliation, patients were randomly allocated. For the purpose of bridging, the type of stent was determined by the discretion of the individual doctors. Technical and clinical success and complication occurrence were measured as primary outcomes.

RESULTS

From 12 university hospitals, 123 patients with malignant colonic obstruction were enrolled. Of these 123 patients, 58 were treated with colonic stents for palliative purposes. The technical and clinical success rate was 100 % for both stents in the palliative group. Perforation occurred for one patient (3.6 %) in the Wallflex stent group (n = 28) on day 5 and for no patients in the D-type stent group (n = 30). Two cases of migration occurred: one with the Wallflex stent and one with the D-type stent. Stent restenosis occurred for one patient with the Wallflex stent. Preoperative bridging stents were placed in 65 patients. The median time to surgery was 10 days. The technical success rate was 93.4 %, and clinical success was achieved for 86.2 % of the patients. Perforation occurred for five patients: four with the Wallflex stent and one with the D-type stent. The efficacy and safety of the two stents did not differ statistically.

CONCLUSIONS

The D-type colonic uncovered stent and the Wallflex colonic uncovered stent are effective and safe for both palliative and preoperative bridging therapy used to treat acute malignant colonic obstruction.

A comparative study on the efficacy of covered metal stent and plastic stent in unresectable malignant biliary obstruction

Background/Aims

The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent.

Methods

We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate.

Results

There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182).

Conclusions

The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.

Screening of plant extracts for human tyrosinase inhibiting effects

Screening for tyrosinase (TYR) inhibitors potentially useful for control of skin pigmentation has been hampered by the limited availability of human TYR. To overcome this hurdle, we have established human embryonic kidney (HEK293)-TYR cells that constitutively express human TYR. In the current study, we assayed human TYR inhibition activities of 50 plant extracts using the lysates of transformed HEK293-TYR cells. The strongest inhibition of human TYR was shown by the extract of Vaccinium bracteatum Thunberg, followed by the extract of Morus bombycis Koidzumi. The former extract did not inhibit mushroom TYR activity whereas significant inhibition was observed with the latter extract, demonstrating the importance of using human TYR in the screening for human TYR inhibitors. Upon liquid-liquid partitioning of the extract from V. bracteatum, the active constituents were enriched in the ethyl acetate fraction, and the subsequent preparatory thin-layer chromatography identified p-coumaric acid (PCA) as the main active constituent. The hypo-pigmentation of PCA was verified in the MelanoDerm™ Skin Model. This study demonstrates that transformed HEK293-TYR cells could expedite the discovery of human TYR-specific inhibitors from natural sources which might be useful in the control of skin pigmentation.

Adenosine triphosphate-based chemotherapy response assay-guided chemotherapy in unresectable colorectal liver metastasis

BACKGROUND

This study aims to evaluate the effectiveness of adenosine triphosphate-based chemotherapy response assay (ATP-CRA)-guided neoadjuvant chemotherapy for increasing resectability in patients with unresectable colorectal liver metastasis.

PATIENTS AND METHODS

Patients were randomised into two groups: Group A was treated by conventional chemotherapy regimen and Group B was treated by chemotherapy regimen according to the ATP-CRA. Three chemotherapeutic agents (5-fluorouracil, oxaliplatin and irinotecan) were tested by ATP-CRA and more sensitive agents were selected. Either FOLFOX or FOLFIRI was administered. Between Group A and B, treatment response and resectability were compared.

RESULTS

Between November 2008 and October 2010, a total 63 patients were randomised to Group A (N=32) or Group B (N=31). FOLFOX was more preferred in Group A than in Group B (26 out of 32 (81.3%) vs 20 out of 31 (64.5%)). Group B showed better treatment response than Group A (48.4% vs 21.9%, P=0.027). The resectability of hepatic lesion was higher in Group B (35.5% vs 12.5%, P=0.032). Mean duration from chemotherapy onset to the time of liver resection was 11 cycles (range 4-12) in Group A and 8 cycles (range 8-16) in Group B.

CONCLUSION

This study showed that tailored-chemotherapy based on ATP-CRA could improve the treatment response and resectability in initially unresectable colorectal liver metastasis.

A computer-aided diagnosis system for quantitative scoring of extent of lung fibrosis in scleroderma patients

OBJECTIVES

To evaluate an improved quantitative lung fibrosis score based on a computer-aided diagnosis (CAD) system that classifies CT pixels with the visual semi-quantitative pulmonary fibrosis score in patients with scleroderma-related interstitial lung disease (SSc-ILD).

METHODS

High-resolution, thin-section CT images were obtained and analysed on 129 subjects with SSc-ILD (36 men, 93 women; mean age 48.8±12.1 years) who underwent baseline CT in the prone position at full inspiration. The CAD system segmented each lung of each patient into 3 zones. A quantitative lung fibrosis (QLF) score was established via 5 steps: 1) images were denoised; 2) images were grid sampled; 3) the characteristics of grid intensities were converted into texture features; 4) texture features classified pixels as fibrotic or non-fibrotic, with fibrosis defined by a reticular pattern with architectural distortion; and 5) fibrotic pixels were reported as percentages. Quantitative scores were obtained from 709 zones with complete data and then compared with ordinal scores from two independent expert radiologists. ROC curve analyses were used to measure performance.

RESULTS

When the two radiologists agreed that fibrosis affected more than 1% or 25% of a zone or zones, the areas under the ROC curves for QLF score were 0.86 and 0.96, respectively.

CONCLUSIONS

Our technique exhibited good accuracy for detecting fibrosis at a threshold of both 1% (i.e. presence or absence of pulmonary fibrosis) and a clinically meaningful threshold of 25% extent of fibrosis in patients with SSc-ILD.

The Significance of p53 and K-ras Immunocytochemical Staining in the Diagnosis of Malignant Biliary Obstruction by Brush Cytology during ERCP

BACKGROUND/AIMS

Brush cytology during ERCP can provide a pathologic diagnosis in malignant biliary obstruction. K-ras and p53 mutations are commonly found in biliary and pancreatic cancers. We evaluated the diagnostic yield of brush cytology and the changes obtained by adding p53 and K-ras staining.

METHODS

One hundred and forty patients with biliary obstruction who underwent ERCP with brush cytology during a 7-year period were included. The sensitivity and specificity of brush cytology only and with the addition of p53 and K-ras staining were obtained.

RESULTS

Malignant biliary obstruction was confirmed in 119 patients. The sensitivity and specificity of brush cytology were 78.2% and 90.5%, respectively. The sensitivity of cytology was 77.3% at the ampulla-distal common bile duct (CBD), 92.6% at the mid common hepatic duct (CHD), and 94.7% at the proximal CBD-CHD (p<0.05); these values did not differ with the degree or the length of the obstruction. In the 97 patients who received additional p53 and K-ras staining, the sensitivity of cytology plus p53 was 88.2%, cytology plus K-ras was 84.0%, and cytology plus p53 and K-ras was 88.2%. The sensitivity of cytology plus p53 was higher than that of brush cytology only (95% confidence interval: 83.69-92.78 vs 72.65-83.65) but not that of cytology plus K-ras.

CONCLUSIONS

Brush cytology for malignant biliary obstruction has a high diagnostic accuracy. Adding p53 staining can further improve the diagnostic yield, whereas K-ras staining does not.

A case of cyclic vomiting syndrome responding to gonadotropin-releasing hormone analogue

Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent episodes of incapacitating nausea and vomiting interspersed with symptom free periods. Common triggers of cyclic vomiting include noxious stress, excitement, fatigue and menstrual period. Here, we report a case of cyclic vomiting syndrome in adult patient characterized by stereotypical vomiting attack, occurring in every menstruation period. Recurrent vomiting episodes began 6 years ago and we treated this patient with subcutaneous injection of goserelin, a gonadotropin-releasing hormone analogue (GnRHa) and oral estrogen. After 4 months of therapy, she was symptom free for the following 5 years, even with the resumed normal menstruation. Recurrence of vomiting attack with same pattern occurred 1 month before readmission. Treatment with intravenous lorazepam aborted vomiting, but could not prevent recurrences of vomiting and epigastric pain. We treated the patient with GnRHa and oral estradiol again which effectively prevented recurrence of the symptoms.

Prevalence of clonorchiasis in patients with gastrointestinal disease: A Korean nationwide multicenter survey

AIM: To investigate prevalence of Clonorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea.

METHODS: Consecutive patients who had been admitted to the Division of Gastroenterology with gastrointestinal symptoms were enrolled from March to April 2005. Of those who had been diagnosed with clonorchiasis, epidemiology and correlation between infection and hepatobiliary diseases were surveyed by questionnaire.

RESULTS: Of 3080 patients with gastrointestinal diseases, 396 (12.9%) had clonorchiasis and 1140 patients (37.2%) had a history of eating raw freshwater fish. Of those with a history of raw freshwater fish ingestion, 238 (20.9%) patients had clonorchiasis. Cholangiocarcinoma was more prevalent in C. sinensis-infected patients than non-infected patients [34/396 (8.6%) vs 145/2684 (5.4%), P = 0.015]. Cholangiocarcinoma and clonorchiasis showed statistically significant positive cross-relation (P = 0.008). Choledocholithiasis, cholecystolithiasis, cholangitis, hepatocellular carcinoma, and biliary pancreatitis did not correlate with clonorchiasis.

CONCLUSION: Infection rate of clonorchiasis was still high in patients with gastrointestinal diseases in Korea, and has not decreased very much during the last two decades. Cholangiocarcinoma was related to clonorchiasis, which suggested an etiological role for the parasite.

Development of a Nested Polymerase Chain Reaction Assay for Detection of Colletotrichum acutatum on Symptomless Strawberry Leaves

A nested polymerase chain reaction (PCR) assay was developed for detection of Colletotrichum acutatum on symptomless strawberry leaves. In pure culture, the assay detected as little as 1.0 fg of DNA extracted from mycelium and as few as 1.5 conidia ml^-1 when conidial suspensions were sonicated. On detached inoculated leaves, three alternative protocols to dislodge the pathogen were assessed: (i) immersion of whole leaves in 0.05% Tween 20 and manual agitation in plastic bags for 1 min (A); (ii) immersion in Tween 20, sonication for 30 min, then agitation for 1 min (SA); and (iii) freezing for 3 h, incubation for 2 days at 27°C, immersion in Tween 20, then sonication for 30 min and agitation for 1 min (FISA). Each method removed significantly (P ≤ 0.05) more conidia from leaves than the nontreated control; however, removal of appressoria did not vary among assays. In composite samples of noninoculated and inoculated (1.5 ×10³ conidia ml^-1) strawberry leaves, the nested PCR assay using the FISA protocol detected C. acutatum in as few as 1 infested leaf in 50 noninfested leaves. In a strawberry field, the assay detected the presence of C. acutatum in samples of asymptomatic strawberry leaves, showing potential as a powerful tool for reliable diagnosis of the pathogen in the field.

Potential of two entomopathogenic nematodes for suppression of plum curculio (Conotrachelus nenuphar, Coleoptera: Curculionidae) life stages in northern climates

Plum curculio, Conotrachelus nenuphar, is a major pest of pome and stone fruits in North America. We evaluated the potential efficacy of two entomopathogenic nematode species for suppression of plum curculio in northern regions, targeting life stages that reside in soil during spring and summer. A strain of Heterorhabditis bacteriophora isolated from soil infested with plum curculio in northern Utah and a commercially available strain of Steinernema feltiae known to tolerate cool temperatures were tested in the laboratory against three life stages of plum curculio. Bioassays used the southern strain of plum curculio because availability of the northern strain from the field was inadequate. H. bacteriophora was more virulent than S. feltiae to all plum curculio life stages. Adults and pupae were more susceptible than larvae. Temperature bioassays were conducted with a surrogate host: last instars of Galleria mellonella. The two nematodes exhibited different, but overlapping, thermal activity ranges. Both species performed best at 20 degrees C: virulence and reproductive potential was higher; however, H. bacteriophora was superior to S. feltiae at 30 degrees C and vice versa at 10 degrees C. The reproductive potential of H. bacteriophora was > 2.5 times greater than for S. feltiae, and H. bacteriophora required fewer individuals to initiate a successful host infection. S. feltiae was a better fit for temperatures expected in northern climates, but H. bacteriophora was more virulent to plum curculio and produced more infective juveniles that may benefit nematode recycling and continuation and spread of insect suppression in the field.

First Report of Anthracnose Fruit Rot Caused by Colletotrichum acutatum on Strawberry in Korea

Symptoms typical of anthracnose fruit rot; sunken, dark brown lesions on maturing fruits, were found in a commercial field of strawberry (Fragaria × ananassa) cv. Cal Giant in Yangyang County, Korea in May 2007. Masses of conidia were produced in acervuli in the center of lesions. The fungus was isolated on potato dextrose agar (PDA). Colonies grown on PDA were pale to mouse gray and became dark green to black in reverse. Conidia were formed in orange-to-salmon pink masses in the center of the culture. The average size of conidia on PDA was 15.2 × 4.6 μm, and they were hyaline, straight, cylindrical, with pointed ends, and aseptate (1). The fungus did not form an ascigerous stage in culture. Mycelial growth rate was 7.5 mm per day at 25°C on PDA. The identity of two isolates was confirmed as Colletotrichum acutatum J.H. Simmonds by PCR amplification using species-specific primers TBCA and TB5 (2), resulting in a characteristic 330-bp band on agarose gel. Morphological characters were in accordance with previous reports on C. acutatum. A pathogenicity test was conducted with five healthy plants of cvs. Cal Giant, Maehyang, Seolhyang, Kumhyang, Akihime, and Redpearl. After fruits and flowers were sprayed with a conidia suspension (10⁵ conidia per ml), the plants were maintained at 10 to 25°C and 100% relative humidity in a greenhouse. As a control, five healthy plants were sprayed with sterile distilled water and incubated under the same conditions. Dark brown, water-soaked spots appeared on mature fruits of all cultivars after 5 days, and lesions on green fruits appeared on individual achenes. Flowers developed dark lesions, dried out, and died. No symptoms were found on the control plants. After the pathogen was reisolated from fruits and flowers lesions, the morphological characters developed in culture as described above. To our knowledge, this is the first report of C. acutatum causing strawberry anthracnose in Korea. References: (1) B. J. Smith and L. L. Black. Plant Dis. 74:69, 1990. (2) P. Talhinhas et al. Appl. Environ. Microbiol. 71:2987, 2005.

[Clinical significance of white bile (bilirubin-free bile) in malignant bile duct obstruction]

BACKGROUND/AIMS

White bile is colorless, translucent fluid found occasionally in malignant bile duct obstruction (MBO). Little information is available on the cause and effect of white bile. The aim of this study was to determine the frequency and clinical significance of white bile in MBO.

METHODS

Bile was aspirated during endoscopic retrograde cholangiopancreatography in consecutive patients with MBO. White bile was defined as bile bilirubin <1.5 mg/dL and yellow bile was defined as bile bilirubin >or=1.5 mg/dL in the bile. Two groups were compared prospectively for the duration of jaundice, itching, cholangitis, level of obstruction, and decremental rate of bilirubin after the insertion of 7 Fr endoscopic nasobiliary drainage until the insertion of metal stent or 10 Fr plastic stent.

RESULTS

Among 60 patients with MBO, 16 (26.7%) had white bile. WBC count in blood was higher (9,456/mm3 vs. 7,400/mm3, p=0.029) and cholangitis was more common (11/16 vs. 7/44, p=0.000) in white than yellow bile group. Proximal portion of MBO had no communication with GB in 9/16 patients with white bile group and 17/44 patients with yellow bile group (p>0.05). Mean survival of the inoperable 35 patients was 242 days in yellow bile and 227 days in white bile group (p>0.05).

CONCLUSIONS

White bile in MBO was not rare and was associated with cholangitis. Gallbladder did not seem to play a role in the formation of white bile. Further study for the pathogenesis and prognosis of white bile in MBO will be necessary.

Correlation between the in vitro ATP-based chemosensitivity assay and HER2/neu expression in women with breast cancer

Several in vitro chemosensitivity tests have been developed to predict the chemotherapeutic response of tumours prior to initiation of individualized treatment for breast cancer. This study investigated whether the in vitro chemosensitivity response of cell lines derived from breast cancer patients was affected by HER2/neu expression. We cultured breast cancer cell lines from 50 patients and the adenosine triphosphatebased chemotherapy response assay (ATPCRA) was performed with 5-fluorouracil, gemcitabine, docetaxel, doxorubicin, methotrexate, vinorelbine and paclitaxel. 5-fluorouracil combined a high median cell death rate (32.4%) with the narrowest range of cytotoxic effects (7.3-65.7%). In addition, gemcitabine showed significantly greater activity in HER2/neupositive patients. In contrast, docetaxel was significantly less effective in HER2/neu-positive patients. No significant correlation was found between the other agents and HER2/neu expression. The use of the ATP-CRA test for metastatic tissue from patients with recurrent disease might be a useful approach to determine the most effective chemotherapy regimen.

Acaricidal activity of Thymus vulgaris oil and its main components against Tyrophagus putrescentiae, a stored food mite

The acaricidal activities of compounds derived from Thymus vulgaris (thyme) oil against Tyrophagus putrescentiae were assessed using an impregnated fabric disk bioassay, and were compared with those of the synthetic acaricides, benzyl benzoate and N,N-diethyl-m-toluamide. The observed responses differed according to dosage and chemical components. The 50% lethal dose (LD50) value of the T. vulgaris oil against T. putrescentiae was 10.2 microg/cm2. Biologically active constituents derived from T. vulgaris oil were purified by using silica gel chromatography and high-performance liquid chromatography. The structures of acaricidal components were analyzed by gas chromatography-mass spectrometry, 1H nuclear magnetic resonance (NMR), 13C NMR, 1H-13C COSY-NMR, and DEPT-NMR spectra, and were subsequently identified as carvacrol and thymol. Carvacrol was the most toxic compound with LD50 values (4.5 microg/cm2) significantly different from thymol (11.1 microg/cm2), benzyl benzoate (11.3 microg/cm2), and N,N-diethyl-m-toluamide (13.9 microg/cm2). Linalool was as toxic as was N,N-diethyl-m-toluamide. The lower LD50 of carvacrol indicates that it may be the major contributor of the toxicity of T. vulagaris oil against the stored food mite, although it only constitutes 14.2% of the oil. From this point of view, carvacrol and thymol can be very useful as potential control agents against stored food mite.

A phase II trial of S-1 and cisplatin in patients with metastatic or relapsed biliary tract cancer

BACKGROUND

Optimal chemotherapy for advanced biliary tract cancer (BTC) is yet to be defined. We carried out this study to evaluate the efficacy and toxicity of combination chemotherapy with S-1 and cisplatin in metastatic or relapsed BTC.

PATIENTS AND METHODS

Patients with pathologically proven BTC were eligible. The chemotherapy regimen consisted of S-1 (40 mg/m(2) p.o. b.i.d. from D1-14) and cisplatin (60 mg/m(2) on D1), repeated every 3 weeks.

RESULTS

Fifty-one BTC patients (metastatic:relapsed = 37:14, Gall-bladder:intrahepatic bile ducts:extrahepatic bile ducts = 16:25:10) were enrolled from January 2005 to December 2006. Median age was 57 years (range, 31-71) and most patients had a good performance status. The overall response rate was 30% [95% confidence interval (CI), 17.3-42.7] and complete response was observed in two patients (4%), partial response in 13 (26%), stable disease in 21 (42%), and progressive disease in 9 (18%). With a median follow-up of 12.4 months, the median time to progression was 4.8 months (95% CI, 3.3-6.3) and median overall survival was 8.7 months (95% CI, 6.0-11.4). Major toxic effects were grade 3/4 neutropenia (8.9% of all cycles) and febrile neutropenia was observed in six cycles (2.7% of all cycles).

CONCLUSION

Combination chemotherapy with S-1 and cisplatin was a moderately effective outpatient-based regimen in BTC patients. Toxic effects were moderate but manageable.

Human application of a metallic stent covered with a paclitaxel-incorporated membrane for malignant biliary obstruction: multicenter pilot study

BACKGROUND

Paclitaxel, with its antitumor effect, may improve the function of metallic stents used for biliary drainage. However, clinical studies that use metallic stents covered with a paclitaxel-incorporated membrane (MSCPM) in the biliary tract of human beings have not been previously carried out.

OBJECTIVE

To evaluate the safety and efficacy of an MSCPM for patients with malignant biliary obstruction.

DESIGN AND SETTING

A case series that includes 4 endoscopy centers.

PATIENTS

From July 2003 to August 2006, a total of 21 patients diagnosed with unresectable malignant biliary obstruction.

INTERVENTION

Endoscopic placement of an MSCPM.

MAIN OUTCOME MEASUREMENTS

Stent occlusion, complications, stent patency, patient survival, and the periodic mean concentration of paclitaxel in the blood.

RESULTS

Occlusion of the MSCPM was observed in 9 patients and was caused by bile sludge or clog in 4, tumor overgrowth in 3, and tumor ingrowth in 2. Complications included obstructive jaundice in 6, cholangitis in 3, and 1 patient showed stent migration with cholecystitis. The mean patency of a MSCPM was 429 days (median 270 days, range 68-810 days) and cumulative patency rates at 3, 6, and 12 months were 100%, 71%, and 36%, respectively. The mean survival of patients was 350 days (median 281 days, range 68-811 days). The highest concentration of paclitaxel in the blood was found between 1 and 10 days after insertion.

LIMITATIONS

Small number of patients and low rate of pathologic diagnosis.

CONCLUSIONS

The endoscopic insertion of MSCPM is technically feasible, safe, and effective in patients with malignant biliary obstruction. In addition, MSCPM may exert local antitumor activity because of the steady release of paclitaxel.

[A case of biliary cast syndrome after cadaveric liver transplantation]

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.

Efficacy of aminocandin in the treatment of immunocompetent mice with haematogenously disseminated fluconazole-resistant candidiasis

OBJECTIVES

The objective of this study was to compare the activity of aminocandin, a new echinocandin with broad-spectrum activity against Candida spp., with that of amphotericin B, caspofungin and fluconazole, in an immunocompetent murine model of haematogenously disseminated candidiasis caused by a fluconazole-resistant Candida albicans.

METHODS

Mice were infected with a fluconazole-resistant strain of C. albicans and treated with aminocandin 5 and 10 mg/kg intravenously (iv) once and twice weekly, amphotericin B 0.5 mg/kg iv every other day for 5 days, fluconazole 20 mg/kg orally (po) once a day for 5 days and caspofungin 0.5 mg/kg intraperitoneally (ip) once daily for 5 days.

RESULTS

Treatment with aminocandin, given iv twice a week, resulted in 100% survival. Further, the tissue fungal burden of the aminocandin group was equivalent to that of amphotericin B (administered every other day) and caspofungin (administered daily).

CONCLUSIONS

Aminocandin may be an effective addition to the arsenal of antifungal compounds for the treatment of candidiasis caused by fluconazole-resistant C. albicans.

PLCγ contributes to metastasis of in situ-occurring mammary and prostate tumors

Phospholipase C-gamma (PLCgamma) has been implicated in tumor cell motility required for invasiveness and metastasis. Diminished tumor dissemination has been demonstrated in xenograft models, but studies in naturally-occurring tumors are lacking, having been limited by the timing of the interventions. Therefore, we generated mice that express a doxycycline (DOX)-inducible dominant-negative fragment of PLCgamma, PLCz; this approach avoids the in utero lethality caused by the absence of PLCgamma. As we targeted two de novo-occurring carcinomas of the mammary (MMTV-driven polyoma middle T antigen model, PyVmT) and prostate (TRAMP model) glands, we limited expression to these epithelial cells by driving DOX transactivator from the prostatein C3 promoter. This avoids the confounding variable of potentially abrogating motility in stromal and endothelial cells. These mice developed normally in the presence of DOX, except for limited mammary development if treated before 6 weeks and immaturity of the prostate gland if treated before 2 weeks of age. DOX-mediated induction of PLCz from age 8 to 16 weeks in PyVmT mice decreased the number of lung metastases by >10-fold (P<0.06) without a detectable effect on in situ tumor cell proliferation or tumor size. Lung metastases were also significantly decreased in the TRAMP model in which the mice expressed the PLCz fragment (P<0.05). DOX treatment itself had no effect on tumor size or metastasis in control mice, nor did it affect tumor dissemination in nontransgenic littermates. In conclusion, abrogation of the PLCgamma signaling pathway can limit the metastatic potential of carcinomas.

[A case of primary adenosquamous carcinoma of the liver with formation of colonic fistula]

Primary adenosquamous carcinoma of the liver is generally considered as an extremely rare subtype of cholangiocarcinoma. It has been reported mostly in a form of case studies. As far as we know, there was only one case report on tumor related with biliary fistula. Recently, we experienced a case of primary adenosquamous carcinoma of liver with a formation of tumor-colonic fistula. A 54-year-old man was transferred to our hospital due to liver mass detected by abdominal ultrasonogram. Dynamic computed tomogram of liver showed a large irregular hypodense mass without rim enhancement in right lobe of liver and also suggested a fistula formation between the tumor and hepatic flexure of right colon. Colonoscopic examination showed a large colonic wall defect in hepatic flexure and a friable, nodular mucosa around the defected colonic wall. Extended right lobectomy and right hemicolectomy were done. Microscopically, the tumor was composed of squamous cell carcinoma mainly with foci of the adenocarcinoma component.

Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction

BACKGROUND

Cholecystitis related to metal stent placement is a morbid event.

OBJECTIVE

This study evaluated the risk factors of cholecystitis after metal stenting for malignant biliary obstruction.

PATIENTS

Between December 1997 and April 2003, 155 patients who were treated with a metal stent for malignant biliary obstruction were retrospectively enrolled.

MAIN OUTCOME MEASUREMENTS

The incidence and characteristics of patients with cholecystitis were evaluated and compared with those of patients without cholecystitis. Patient characteristics and tumor or procedure-related data were recorded for the following variables: sex, age, tumor and stent length, stent type (covered vs uncovered), cholangitis before ERCP, degree of gallbladder filling with contrast medium during ERCP, primary disease type (Klatskin vs others), presence of gallbladder stones, and the relationship of the cystic duct orifice to the location of the tumor (across vs others).

RESULTS

There were 15 (9.7%) patients diagnosed with cholecystitis after metal stent insertion. The onset of cholecystitis was on average 4.6 days (range 1 to 26) after the procedure. We found that an obstruction across the cystic duct orifice by tumor (P < .01, odds ratio 12.7) and the presence of gallbladder stone (P = .01, odds ratio 6.6) were positively related to the cholecystitis after metal stent insertion.

LIMITATIONS

The limitations of the study were the use of multiple types of stents and the retrospective design.

CONCLUSIONS

This study demonstrated that an obstruction across the cystic duct by tumor and the presence of gallbladder stone were risk factors for the development of cholecystitis after metal stent placement.

Growth-inhibiting activity of active component isolated from Terminalia chebula fruits against intestinal bacteria

The growth-inhibitory activity of materials derived from the fruit of Terminalia chebula was evaluated against six intestinal bacteria by means of an impregnated paper disk agar diffusion method. The butanol fraction of T. chebula extract had profound growth-inhibitory activity at a concentration of 5 mg per disk. The biologically active component isolated from the T. chebula fruits was identified with a variety of spectroscopic analyses as ethanedioic acid. The growth responses varied in accordance with the bacterial strain, chemical, and dosage tested. In a test with concentrations of 2 and 1 mg per disk, ethanedioic acid had strong and moderate inhibitory activity against Clostridium perfringens and Escherichia coli, respectively, with no associated adverse effects on the growth of the four tested lactic acid-producing bacteria. Ellagic acid derived from T. chebula fruits exerted a potent inhibitory effect against C. perfringens and E. coli, but little or no inhibition was observed with treatments of behenic acid, P-caryophyllene, eugenol, isoquercitrin, oleic acid, ca-phellandrene, 3-sitosterol, stearic acid, a-terpinene, terpinen-4-ol, terpinolene, or triacontanoic acid. These results may be an indication of at least one of the pharmacological properties of T. chebula fruits.

Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse inner-city obstetric population

OBJECTIVE

This study assessed the prevalence of antenatal psychiatric illness in low-income, ethnically diverse patients in an urban obstetric clinic and examined associations between positive psychiatric screens and inadequate utilization of prenatal care.

METHODS

Bilingual research assistants administered the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the Mood Disorder Questionnaire to 154 English- and Spanish-speaking pregnant patients attending routine prenatal visits. We assessed associations between patient characteristics, current and past psychiatric diagnoses, and utilization of prenatal care.

RESULTS

Forty-five (29%) women screened positive for criteria for current psychiatric disorders with the highest rates for major or minor depression (26%) and anxiety disorders (10%). Inadequate prenatal care utilization was significantly associated with past psychiatric history and domestic abuse in the last year, but not with current psychiatric diagnosis, alcohol abuse, age, primiparity, marital status, receipt of government assistance, or unplanned pregnancy. Even after adjustment for possible confounding risk factors (e.g. past substance abuse, single marital status, unstable housing, education less than high school, and having other children), past psychiatric history was still significantly associated with inadequate prenatal care utilization and delayed initiation of care.

CONCLUSIONS

A high percentage of disadvantaged pregnant women meet screening criteria for psychiatric disorders when screened during routine prenatal visits. Screening for past psychiatric history in routine prenatal visits could identify patients at risk for inadequate utilization of prenatal care.

[Glutathione S-transferases (GSTM1, GSTT1 and GSTP1) and N-acetyltransferase 2 polymorphisms and the risk of gastric cancer]

OBJECTIVES

Polymorphisms of genes from glutathione S-transferases (GSTs) and N-acetyltransferase 2 (NAT2) have been associated with increased susceptibility to various cancers. Previous results showed that East Asians such as Koreans, Japanese and Chinese have a much higher frequency of the GSTM1 and GSTT1 null genotypes and NAT2 rapid acetylator type. Therefore, we investigated the association between the polymorphic types of GSTs (GSTM1, GSTT1, GSTP1) and NAT2 and the incidence of gastric cancer which is one of the most prevalent cancers among the East Asians.

METHODS

It was performed in a case-control study consisting of 238 healthy subjects and 108 cancer patients (54 distal and 54 proximal carcinomas). We also evaluated the association between GSTs and NAT2 and the risk factors for gastric cancer such as alcohol consumption, smoking, H. pylori infection, family history of gastric cancer, and tumor location.

RESULTS

In our study, the percentage of cases whose hometown was rural was higher than those of controls (odds ratio (OR) = 2.88; 95% CI = 1.72-4.76), and the frequency of the lower socio-economic status increased significantly in patients (OR = 2.53; 95% Cl = 1.59-4.02). There was no significant difference in the GST polymorphic types between the cases and controls. However, NAT2 rapid or intermediate acetylator types were frequently detected in the cases with family history of gastric cancer (OR = 1.92; 95% CI = 1.79-26.0).

CONCLUSIONS

These results suggest that the hometown and socio-economic status are important environmental factors for gastric carcinogenesis, and NAT2 polymorphic types could be associated with familial gastric carcinoma.

Clinical features of chronic pancreatitis in Korea: a multicenter nationwide study

BACKGROUND/AIMS

No reliable nationwide clinical data about chronic pancreatitis (CP) was available in Korea. The etiology and clinical features of CP were investigated using a multicenter nationwide study.

METHODS

814 cases of CP were enrolled retrospectively over the past 4 years at 13 hospitals. The following data were obtained from all patients: etiology, symptoms, complications, and surgery.

RESULT

Alcohol (64.3%) was the major cause of CP and idiopathic CP (20.8%) was the second most common form. Mean patient age was 50.6 years and the male:female ratio was 6:1 (24:1 for alcoholic CP vs. 2:1 in idiopathic CP, p < 0.001). Diabetes (31.6%), pseudocysts (28.4%), biliary stricture (13.9%), and pancreatic ascites (6.6%) were the main complications. Of these, diabetes (35 vs. 26%) and pseudocyst (33.7 vs. 21.9%) were more frequent in alcoholic than in idiopathic CP. Pancreatic cancer developed in 25 patients (3.1%) during follow-up and their mean age was 59.1 years.

CONCLUSIONS

In Korea, alcohol is the most common etiology of CP. Moreover, diabetes and pseudocysts are frequent complications, especially in alcoholic CP, and pancreatic cancer development is not infrequent.

[Biliary cystic neoplasm: biliary cystadenoma and biliary cystadenocarcinoma]

Biliary cystic tumors, such as cystadenoma and cystadenocarcinoma, are rare cystic tumors of liver accounting for fewer than 5% of all intrahepatic cysts of biliary origin. Most biliary cystic tumors arise from intrahepatic bile duct and 10-20% arise from extrahepatic bile duct like common hepatic duct, common bile duct, and gallbladder. The first case report of biliary cystic neoplasm in Korea dated back to 1975 by Bae et al, and over 40 cases of cystadenoma and 35 cases of cystadenocarcinoma were reported since then. These tumors usually present in middle-aged women with a mean age of 50 years. Biliary cystadenomas are lined by single layer of cuboidal or columnar epithelium and are very often multilocular with septal or papillary foldings. Over 80% of cystadenoma have dense mesenchymal stroma composed of dense spindle cells, like ovary. The epithelial lining of cystadenocarcinoma exhibits cellular atypia, mitotic activity, and infiltrative growth, but part of lining epithelium retain the feature of cystadenoma, which support the adenoma-carcinoma sequence. The size of tumors varies from 1.5 to 35 cm. Many patients are asymptomatic, except for the presence of palpable mass. When symptoms are present, they include epigastric or right upper quadrant pain or jaundice by enlarged mass. Biliary cystic tumor should be considered when a single or multilocular cystic lesion with papillary infoldings is detected in the liver by computed tomogram (CT) or ultrasound (US). Cystic wall and internal foldings can be seen enhanced by enhanced CT. US reveals a hypoechoic cystic mass with echogenic septation or papillary infoldings. Cystadenocarcinoma should be suspected when there is elevated mass or nodule in the wall or foldings, or thickened cystic wall on CT or US. But it is extremely difficult to differentiate between cystadenoma and cystadenocarcinoma by imaging alone. Increased tumor markers, carcinoembryonic antigen and carbohydrate antigen 19-9, in serum or cystic fluid have been reported in biliary cystic tumor. But tumor markers cannot distinguish cystadenocarcinoma from cystadenoma or both from other cystic lesions of liver. Malignant cells are not usually recovered in patients with cystadenocarcinoma who underwent cystic fluid cytology before and during surgery. The treatment of choice is radical excision of the mass by means of lobectomy or wide tumor excision. Aspiration, marsupialization, and drainage must be avoided. Inadequate excision of both cystadenoma and cystadenocarcinoma may lead to recurrence. Prognosis after complete excision is excellent.

Factors Affecting the Long-term Patency of Crossover Femorofemoral Bypass Graft

OBJECTIVES

To determine the factors affecting long-term patency of crossover femorofemoral bypass (FFB) graft.

DESIGN

A retrospective clinical study of a prospectively registered database.

MATERIALS

Two hundred and sixteen FFBs performed for 192 patients with atherosclerotic iliac occlusive disease.

METHODS

The clinical and surgical variables influencing graft patency were assessed with log-rank test and Cox's proportional hazard analysis.

RESULTS

The primary patency rates of all FFB grafts at 3 and 5 years were 73+/-4 and 65+/-5%, respectively. By multivariate analysis, hypertension (Odds ratio 2.8, P=0.002) and critical ischemia (Odds ratio 0.42, P=0.01) significantly (P<.05) influenced long-term patency of FFB grafts.

CONCLUSION

The long-term patency of FFB grafts was not affected by procedural modifications. Graft patency was inferior in patients with severe lower limb ischemia but superior in patients with hypertension. Further study is required to clarify the mechanism of an unexpected beneficial effect of hypertension on FFB graft patency.