Optimized nerve block techniques while performing percutaneous hepatic ablation:

Percutaneous image guided thermal ablation has become a cornerstone of therapy for patients with oligometastatic disease and primary liver malignancies. Evolving from percutaneous ethanol injection (PEI), thermal ablation utilizing radiofrequency ablation (RFA) and microwave ablation (MWA) have become the standard approach in the treatment of isolated lesions that fit within the size criteria for curative intent therapy (typically 3-4cm). With the evolution of more intense thermal ablation, such as MWA, the dramatic increase in both the size of ablation zone and intensity of heat generation have extended the limits of this technique. As a result of these innovations, intra-procedural and post-procedural pain have also significantly increased, requiring either higher levels of intravenous sedation or, in some institutions, general anesthesia. In addition to the increase in therapeutic intensity, the use of intravenous sedation during aggressive ablation procedures carries the risk of over-sedation when the noxious insult (i.e. the ablation) is removed, adding further difficulty to post-procedural recovery and management. Furthermore, high subdiaphragmatic lesions become challenging in this setting due to issues relating to sedation and compliance with breath hold/breathing instructions. Although general anesthesia may mitigate these complications, the added resources associated with providing general anesthesia during ablation is not cost effective and may result in substantial delays in treatment. The reduction of Aerosol Generating Medical Procedures (AGMP), such as intubation due to the COVID-19 Pandemic, must also be taken into consideration. Due to the potential increased risk of infection transmission, alternatives to general anesthesia should be considered when safe and possible. Upper abdominal regional nerve block techniques have been used to manage pain related to trauma, surgery, and cancer; however, blocks of this nature are not well described in the interventional radiology literature. The McGill University group has developed experience in using such blocks as splanchnic, celiac and hepatic hilar nerve blocks to provide peri-procedural pain control [1]. Since incorporating these techniques (along with hydrodissection with tumescent anesthesia), we have also observed in our high volume ablation center a dramatic decrease in the amount of sedatives administered during the procedure, a decrease in patient discomfort during localization and ablation, as well as decreased pain post-procedure. Faster time to discharge and overall reduction in room procedural time serve as added benefits. The purpose of this publication is to outline and illustrate the practical application and use of nerve block/regional anesthesia techniques with respect to percutaneous hepatic thermal ablation.

Inducible T-cell co-stimulator ligand (ICOSL) blockade leads to selective inhibition of anti-KLH IgG responses in subjects with systemic lupus erythematosus

Objectives

To evaluate the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of single-dose and multiple-dose administration of AMG 557, a human anti-inducible T cell co-stimulator ligand (ICOSL) monoclonal antibody, in subjects with systemic lupus erythematosus (SLE).

Methods

Patients with mild, stable SLE (n=112) were enrolled in two clinical trials to evaluate the effects of single (1.8–210 mg subcutaneous or 18 mg intravenous) and multiple (6 –210 mg subcutaneous every other week (Q2W)×7) doses of AMG 557. Subjects received two 1 mg intradermal injections 28 days apart of keyhole limpet haemocyanin (KLH), a neoantigen, to assess PD effects of AMG 557. Safety, PK, target occupancy, anti-KLH antibody responses, lymphocyte subset analyses and SLE-associated biomarkers and clinical outcomes were assessed.

Results

AMG 557 demonstrated an acceptable safety profile. The PK properties were consistent with an antibody directed against a cell surface target, with non-linear PK observed at lower concentrations and linear PK at higher concentrations. Target occupancy by AMG 557 was dose dependent and reversible, and maximal occupancy was achieved in the setting of this trial. Anti-AMG 557 antibodies were observed, but none were neutralising and without impact on drug levels. A significant reduction in the anti-KLH IgG response was observed with AMG 557 administration without discernible changes in the anti-KLH IgM response or on the overall IgG levels. No discernible changes were seen in lymphocyte subsets or in SLE-related biomarkers and clinical measures.

Conclusions

The selective reduction in anti-KLH IgG demonstrates a PD effect of AMG 557 in subjects with SLE consistent with the biology of the ICOS pathway and supports further studies of AMG 557 as a potential therapeutic for autoimmune diseases.

Trial registration numbers

NCT02391259 and NCT00774943.

A novel disposable, transnasal esophagoscope: a pilot trial of feasibility, safety, and tolerance

A novel disposable transnasal esophagoscope, the E.G. Scan (IntroMedic Co. Ltd., Seoul, Korea), was developed for the evaluation of esophageal diseases while eliminating the inconvenience associated with sterilization, portability, patient monitoring, complications, and the economic burden of sedation. The feasibility, safety, and tolerability of the first version of the E.G. Scan was evaluated in this pilot study. Nasal esophagoscopy was performed successfully in 46 patients with known or suspected esophageal diseases. At least 50% of the Z-line was visualized by the E.G. Scan in 38 (82.6%) of 46 patients. Abnormalities were identified in 27 patients: erosive esophagitis (n=18), Barrett's esophagus (n=1), esophageal varices (n=7), and esophageal candidiasis (n=1). Nasal pain was absent or mild in most patients, and adverse events were not observed. Further technical improvement of the E.G. Scan would increase the diagnostic usefulness in future clinical practice.

Histologic diagnosis based on forceps biopsy is not adequate for determining endoscopic treatment of gastric adenomatous lesions

BACKGROUND AND STUDY AIMS

Controversy persists around the treatment of gastric low-grade dysplasia (LGD). The aim of this study was to investigate possible indications for the endoscopic resection of gastric LGD through analysis of the histologic discrepancies between specimens of gastric LGD obtained by forceps biopsy and by endoscopic mucosal resection (EMR), and of their clinicopathologic characteristics.

PATIENTS AND METHODS

The study involved 293 gastric LGD that were histologically proven on the basis of forceps biopsy in Severance Hospital between January 2004 and December 2007. Twenty cases were regularly followed up, and the remaining 273 were resected by EMR. We performed univariate and multivariate analyses of clinical and endoscopic characteristics including lesion size, number of biopsy fragments, and endoscopic appearance, in order to analyze the factors affecting histologic discrepancies.

RESULTS

Of the 273 lesions resected by EMR, 207 (75.8 %) showed concordant histology, whereas for 51 (18.7 %) the histology was upgraded after endoscopic resection. Lesion size, absence of whitish discoloration, and the presence of spontaneous bleeding were found by univariate analysis to be statistically significant factors predicting an upgraded histology after EMR ( P = 0.026, P < 0.001, and P = 0.025, respectively). Multivariate analysis also showed absence of whitish discoloration to be a statistically significant factor influencing histologic discrepancies ( P = 0.001, odds ratio 5.29, 95 % confidence interval 1.95 - 14.37). Perforation and bleeding rates associated with EMR for LGD were 0.7 % and 6.2 %, respectively. Twenty patients who did not undergo EMR were followed up for a mean of 22 months, and 3 were revealed to have adenocarcinoma and 1 high-grade dysplasia on the latest histologic exam.

CONCLUSIONS

We should consider endoscopic resection for gastric LGD that are 2 cm or more in size and do not have whitish discoloration.

Treatment outcomes of 70 cases of early esophageal carcinoma: 12 years of experience

Early esophageal cancer (EEC) has an excellent prognosis compared to advanced esophageal cancer. Nowadays, endoscopic mucosal resection (EMR) may offer another alternative to cure early cancers of the gastrointestinal tract. We aimed to evaluate the clinical outcomes of EEC in Korea after curative treatments; EMR or surgery. We retrospectively reviewed the medical records of patients diagnosed as EEC from January 1994 to August 2005 at Yonsei University Medical Center, Seoul, Korea. Among 888 patients diagnosed with esophageal cancer, 70 (7.9%) were included as EEC. Among them, 10 patients (14.3%) were treated by EMR, and 50 (71.4%) by operation. The treatment outcomes of EEC in relation to various clinicopathologic factors along with survival rates were analyzed. There were 18 cases (30%) of mucosal lesions and 42 cases (70%) of submucosal lesions. Overall 5-year survival rate was 84.3%. When comparing treatment outcomes between EMR-treated and operated groups, there were no significant differences in complete remission (80%vs. 84%), recurrence (20%vs. 16%) and 5-year survival rate (100%vs. 78.3%). EEC is a potentially curable entity with a good clinical prognosis. EMR can be considered as another treatment arm for EEC, along with surgical resection.

Endoscopic resection of benign tumors of the papilla of vater

Most benign papillary tumors are adenomas which can potentially undergo the adenoma-carcinoma-sequence making complete removal mandatory for curative therapy. Endoscopic resection (papillectomy) of these lesions is being increasingly performed as a less traumatic alternative to surgery. Available data shows endoscopic papillectomy to be effective and safe in experienced hands with usually little morbidity and virtually no mortality. Success rates are around 80 % for lesions without intraductal involvement. Selected cases of limited distal intraductal involvement accessible after sphincterotomy may also be managed curatively by endoscopic resection. Endoscopic snare resection of entire lesions should be primarily regarded as a diagnostic procedure. It allows for an accurate histological diagnosis based on examination of the entire specimen rather than forceps biopsies and thus a reliable assessment of the need for surgical therapy. Subsequent surgery in operable patients is not precluded by previous endoscopic resection. Surgery is indicated in case of incomplete removal and if malignancy is present. The curative role of endoscopic papillectomy for early invasive carcinoma needs to be established. Histological features and individual risk for surgery are factors to be considered. Inoperable patients may still benefit from palliative endoscopic stenting. After endoscopic papillectomy has been completed, regular follow-up examinations including biopsies are warranted because of the risk of local recurrence. For benign looking papillary tumors, endoscopic papillectomy serves as a diagnostic tool and should be considered as first line procedure regardless of age. The following article details the approach to patients with benign papillary tumor and the technique of endoscopic papillectomy.

The experiences of hilar skeletonization for the treatment of locally advanced proximal bile duct cancer

BACKGROUND/AIMS

Because proximal bile duct cancer easily involves the surrounding tissue, tumor cells often remain after apparent macroscopically complete radical resection. We evaluated the effect of resective modality of these tumors on prognosis and the effect of postoperative radiotherapy on survival of patients with microscopic residual tumor following local resection in locally advanced proximal bile duct cancer.

METHODOLOGY

From November, 1990 to October, 1993, 45 proximal bile duct cancer patients who received local excision were entered onto this prospective, nonrandomized study. The patients were divided into three groups after operation, 16 patients with curative resection; 15 noncurative resection; and 14 nonresection. Patients who had positive lymph nodes or microscopic cancer cells in resection margin or adjacent major vessels, were treated with postoperative external radiotherapy, 5040 cGy for 40 days.

RESULTS

The overall 1-, 2-, and 5-year survival of the patients was 62.2%, 24.4%, and 15.6%, respectively. The overall mean and median survival of patients was 24.1 +/- 3.98 (mean +/- SE) months and 13 +/- 0.74 months, respectively. Survival rates between resection and nonresection showed a statistically significant difference (P < 0.05). However, survival rates between curative resection and noncurative resection with postoperative radiotherapy were not statistically significant (P > 0.05).

CONCLUSIONS

The resection is the treatment of choice for locally advanced proximal bile duct cancer, if resectable and the noncurative resection followed by postoperative external radiotherapy may be beneficial to the patients with locally advanced proximal bile duct cancer.

Cutting edge: differential sequestration of plasma membrane-associated B cell antigen receptor in mature and immature B cells into glycosphingolipid-enriched domains

Glycosphingolipid-enriched domains (GEDs) are believed to act as platforms for transduction of B cell Ag receptor (BCR)-induced signals from the cell surface. We sought to study whether differential sequestration of BCR into GEDs may contribute to the described intrinsic signaling differences between mature and immature B cells. In this study we found that mature B cells copolarize the BCR with GEDs following BCR aggregation, whereas transitional immature B cells do not. Although anti-BCR treatment leads to receptor aggregation by immature stage B cells, the aggregated complexes do not colocalize with GEDs. We found this difference to be independent of the isotype of the receptor, thereby associating this difference in BCR-GED colocalization to the developmental stage of the B cell. These findings suggest a structural basis for the developmentally regulated differences observed in Ag receptor-mediated signal transduction.

Loss of pendimethalin in runoff and leaching from turfgrass land under simulated rainfall

A field study was undertaken to investigate runoff and leaching loss of the herbicide pendimethalin in turfgrass land of loamy sand soil. A series of plots constructed in a golf course fairway were surface-applied with pendimethalin SC formulation at the rate of 2. 25 or 4.50 kg a.i./ha and subjected to simulated rainfall at 2.0 cm/day for 10 consecutive days. Runoff losses of pendimethalin were the highest at the first rainfall and then gradually decreased with time. The first runoff event contained pendimethalin in its highest concentration, and in subsequent runoff samples the concentration decreased exponentially. The ranges of pendimethalin concentration were 80.9-18.2 and 177.4-48.6 microgram/L in the standard and double doses, respectively. Total losses by 20 cm of rainfall for 10 days reached 0.81 and 1.22% of the initial deposits at 2.25 and 4.50 kg a. i./ha, respectively. Pendimethalin concentration in the leachate collected at 30-cm soil depth was quite lower than that in the runoff, and the concentration rapidly decreased from 4.3-4.7 to 0. 2-0.4 microgram/L during the 10 days of rainfall treatment. Soil residue analysis at 45 and 90 days after pendimethalin treatment showed that more than 90% of the residue remained at the top 10 cm of soil depth. Low runoff and leaching confirmed that lateral and downward movement of the herbicide should be limited in turf soil. The half-life of pendimethalin under field conditions was 23-30 days and was not affected by application dose and rainfall treatment, but longer persistence was observed under laboratory conditions. Considering low runoff and leaching, as well as relatively short persistence in soil, it is concluded that little environmental carryover of pendimethalin would be expected in turfgrass land.

Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegner's granulomatosis undergoing immunosuppressive therapy

OBJECTIVE

To assess the incremental cost-effectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR.

METHODS

A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually.

RESULTS

No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased quality-adjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%.

CONCLUSION

Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.

A case of minute intraductal papillary mucinous tumor of the pancreas presenting with recurrent acute pancreatitis

Intraductal papillary mucinous tumor (IPMT) of the pancreas, a lesion consisting of mucin-producing cells with neoplastic potential, is characterized by duct ectasia, mucin hypersecretion, often extensive papillary intraductal growth, varying degrees of cytologic atypia, and relatively indolent growth. The clinical presentation of IPMT of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. Less commonly these lesions may be detected as asymptomatic radiographic abnormalities. Interestingly, a case of a minute IPMT (2 mm in height and 7 mm in length, adenoma) in the main pancreatic duct presenting with acute pancreatitis in a 55 year-old man has been reported in the Japanese literature. Recently, we also experienced a case of a minute IPMT in a branch pancreatic duct causing repeated bouts of acute pancreatitis in a 75 year-old man. A filling defect at the neck of the main pancreatic duct seen on an endoscopic retrograde pancreatogram performed after recovery of the second attack of acute pancreatitis led the patient to undergo an exploratory laparotomy. After a near-total pancreatectomy was carried out, a minute (3 x 7 mm) IPMT of borderline malignancy was discovered in a branch duct at the head portion near the pancreatic neck without any lesions in the main pancreatic duct. Surprisingly, despite the resective surgery the patient died of carcinomatosis 8.5 months after the operation. We herein report a case of a minute but aggressive IPMT of the pancreas with a review of the literature.

Endoscopic snare resection for tumors of the ampulla of Vater

Though surgical resection has been the traditional treatment for tumors of the ampulla of Vater, endoscopic maneuvers such as snare resection, laser photodestruction and electrofulguration have recently been introduced to avoid operation-related morbidity and mortality. From 1994 to 1996, 6 patients with ampullary tumor were managed by endoscopic snare resection and regularly followed. Endoscopic snare resection of the ampullary tumor was technically feasible in all patients and each procedure was performed in a single session. Histologic diagnoses of the resected specimens were adenoma in 4 patients and adenoma with coexistent adenocarcinoma in 2 patients. Resection margins were negative in all patients except 1 with coexistent adenocarcinoma and a radical pancreaticoduodenectomy was performed in that case. For the other patient with adenocarcinoma foci, no further treatment was persued since he was 72-year-old and refused operation. Acute pancreatitis developed in 2 patients after endoscopic therapy, but was resolved with conservative management. There was no procedure-related death. Surveillance duodenoscopy performed at 1 and 6 months after endoscopic resection revealed no evidence of recurrent tumor in 4 patients with adenoma. Among them, 3 patients are alive without evidence of recurrence at 16-37 months after resection, but 1 patient was lost after 9 months of follow-up. The patient with adenocarcinoma in whom a pancreaticoduodenectomy was performed, has been alive without recurrence for 12 months. Oral 5-fluorouracil was administered for the other patient with adenocarcinoma foci. Though he experienced local recurrence at 13 months after the procedure, he has been alive for 28 months after resection. In conclusion, endoscopic snare resection may be applied as a viable alternative to surgery in selected patients with small ampullary tumors.

Radiologic findings of Mirizzi syndrome with emphasis on MRI

We have reported a case of Mirizzi syndrome preoperatively diagnosed using MR cholangiopancreatography. MRCP and T2-weighted image using a single-shot fast spin-echo sequence accurately depicted all components of Mirizzi syndrome, including impacted stone in the neck of the gallbladder compressing the common hepatic duct and wall-thickening of the gallbladder without any evidence of malignancy. The combination of MRCP and T2-weighted image can be counted on to replace conventional modalities of diagnosing Mirizzi syndrome without any loss of diagnostic accuracy.

Tissue plasminogen activator and plasminogen activator inhibitor-1 in human choledochal bile

Fibrinolytic properties have been detected in animal and human gallbladder (GB) bile. Plasminogen activator inhibitor-1 (PAI-1) has been reported in greater concentration in GB stone bile and may be a nucleating factor in the pathogenesis of GB stone formation. It is unknown whether or not human choledochal bile has similar properties, which could have a role in choledocholithiasis. The aims of this study were to determine the presence of fibrinolytic properties of human choledochal bile and to compare those properties among normal, acalculous, and calculous-infected choledochal bile. Tissue plasminogen activator (t-PA) and PAI-1 of choledochal bile were measured by enzyme linked immunosorbent assay in patients with cholangitis due to acalculous bile duct obstructions (n = 9), choledocholithiasis with cholangitis (n = 20), and normal bile (n = 7). The t-PA concentration of choledochal bile was no different among the three groups (acalculous-infected bile, median 4.61 ng/ml, and calculous-infected bile, 4.61 ng/ml, versus normal bile, 7.33 ng/ml). PAI-1 was detected in choledochal bile in significantly greater concentrations in patients with acalculous cholangitis due to bile duct obstructions and choledocholithiasis with cholangitis (acalculous-infected bile, median 0.36 ng/ml, and calculous-infected bile, 0.1 ng/ml, versus normal bile, 0.02 ng/ml, p < 0.05), but the bile concentration of PAI-1 was no different between the acalculous and calculous-infected choledochal bile. Human choledochal bile possesses t-PA and PAI-1. PAI-1 was present in greater concentrations in both acalculous and calculous-infected choledochal bile. Increased levels of PAI-1 may be an epiphenomenon of cholangitis rather than a factor in the pathogenesis of choledocholithiasis.

Endoscopic retrograde pancreatographic findings of pancreatic lipomatosis

Pancreatic lipomatosis is characterized by fatty infiltration or replacement of the pancreas, and has been associated with many conditions. We recently experienced two cases of pancreatic lipomatosis in patients with pancreatic pseudocyst and a case of lipomatosis in diabetes mellitus. In these patients, abrupt obstruction of the main pancreatic duct with smooth tapering is a typical endoscopic retrograde pancreatography (ERP) finding of pancreatic lipomatosis and must be differentiated with pancreatic carcinoma.

Non-alcoholic duct-destructive chronic pancreatitis: recognition before definitive treatment

Non-alcoholic duct-destructive chronic pancreatitis is a new entity that differs morphologically and pathogenetically from alcoholic chronic pancreatitis. Some clinical and imaging features of this entity resemble those of pancreatic cancer, and hence most of the reported cases underwent pancreatic resections including an invasive pancreaticoduodenectomy. Recognition of this new entity before a definitive treatment is therefore important to avoid an unnecessary pancreatic resection. Recently, we experienced a case of non-alcoholic duct-destructive chronic pancreatitis in an 80-year-old man presenting with obstructive jaundice and whose radiologic features were characteristic as originally described. Recognition of this new entity before definitive treatment enabled us to manage this patient optimally. In addition, the relation between non-alcoholic duct-destructive chronic pancreatitis and chronic pancreatitis with diffuse irregular narrowing of the main pancreatic duct is discussed.

Epidemiological study on Korean gallstone disease: a nationwide cooperative study

To clarify the epidemiological characteristics of gallstone disease in Korea and to evaluate the chronological changes in gallstone disease, the authors performed this first prospective nationwide cooperative study. The subjects were 1263 gallstone patients who were admitted at 19 hospitals in Korea from February to July 1997. Questionnaires were recorded on 1263 patients and gallstones were harvested from 1133 patients. The proportion of patients with gallbladder (GB), common bile duct (CBD), and intrahepatic duct (IHD) stones among total gallstone patients was 64.0%, 21.9%, and 14.1%, respectively. GB stones were categorized as cholesterol (58.1%), black pigment (25.2%), and brown pigment (12.1%) stones. CBD stones were classified as brown pigment (76.1%), cholesterol (18.4%), and black pigment (3.5%) stones. IHD stones were classified as brown pigment (61.4%) and mixed (35.6%) stones. Intrahepatic mixed stones had mean cholesterol and bilirubin contents of 63.4 +/- 20.8% and 23.1 +/- 9.9%, respectively. In contrast, IHD brown pigment stones had mean cholesterol and bilirubin contents of 35.1 +/- 20.5% and 39.6 +/- 17.4%, respectively. Our study showed that the type and composition of gallstones in Korea was somewhat different compared with those in the West. This study also demonstrated that there have been chronological changes in the type and composition of gallstones when compared with previous domestic data. Another nationwide cooperative study may be needed to elucidate and confirm the changing pattern of gallstone disease.

Gallbladder adenomyomatosis: findings on MRI

BACKGROUND

To describe the characteristic magnetic resonance imaging (MRI) findings of gallbladder adenomyomatosis in two cases.

METHODS

Two patients had abdominal MRI findings of gallbladder adenomyomatosis confirmed at cholecystectomy.

RESULTS

The surgical specimen showed findings typical of adenomyomatosis, including marked thickening of both epithelial and muscular elements with multiple Rokitansky-Aschoff sinuses. On gadolinium-enhanced spoiled gradient-echo images and single-shot fast spin-echo images, mild gallbladder wall thickening with multiple intramural cystic components from Rokitansky-Aschoff sinuses were readily visualized.

CONCLUSION

Adenomyomatosis of the gallbladder can be detected and diagnosed from MRI findings.

Obstructive jaundice and acute cholangitis due to papillary stenosis

Papillary stenosis is characterized by fixed fibrosis leading to structural outflow obstruction and it is usually secondary to inflammation and fibrosis from the chronic passage of gallstones, episodes of acute pancreatitis, chronic pancreatitis, sclerosing cholangitis, peptic ulcer disease, and cholesterolosis. However, obstructive jaundice with or without acute cholangitis which leads the physician to suspect the presence of malignancy as a cause is a rare manifestation of papillary stenosis. We report here a case of papillary stenosis presenting with obstructive jaundice and acute cholangitis. The lesion was so difficult to exclude the presence of malignancy preoperatively and intraoperatively that a pylorus-preserving pancreaticoduodenectomy was performed. Histologic examination of the resected specimen revealed fibrosis, adenomatoid ductal hyperplasia, and mild chronic inflammation of the papilla of Vater and distal common bile duct.

Villous adenoma of the bile ducts: a case report and a review of the reported cases in Korea

Villous adenomas are benign epithelial lesions with malignant potential which can occur at any site in the gastrointestinal tract. They are usually encountered in the rectum and colon, less frequently in the small bowel and very rarely in the biliary trees. Nine cases of bile duct villous adenomas have been reported in the literature. However, 4 cases of bile duct villous adenomas have been reported in the Korean literature. Recently, we experienced a case of villous adenoma in the common hepatic duct in a 77-year-old man presenting with obstructive jaundice in which preoperative histologic diagnosis of villous adenoma played a critical role in managing this patient. Herein, we present a case report of bile duct villous adenoma and a review of the reported cases in Korea to help define and manage this rare disease entity in the bile ducts. In addition, confusing nomenclature of bile duct adenomas is discussed.

Comparative study of bentiromide test and endoscopic retrograde pancreatography in patients with chronic pancreatitis

We performed a bentiromide test in 25 patients with chronic pancreatitis and 7 normal controls to evaluate pancreatic exocrine function, and compared the test results of patients with their endoscopic retrograde pancreatography(ERP) findings. The cumulative 6-hour recovery rate of para-aminobenzoic acid(PABA) in the urine was significantly lower in patients with chronic pancreatitis(55.8 +/- 24.2%) than in controls(82.0 +/- 10.0%). Among 25 patients with chronic pancreatitis, however, 7 patients showed normal recovery rates of PABA. Pancreatograms of the patients represented 4 mild changes, 5 moderate changes, and 16 marked changes. The average 6-hour recovery rates of PABA of the groups were 56.9 +/- 21.6%, 78.4 +/- 10.5%, and 47.2 +/- 23.7%, respectively. Urinary PABA recovery rates were found subnormal as follows: 3(75%) in the mild changes group; 1(20%) in the moderate changes group; and 14(87.5%) in the marked changes group. We found hardly any correlation between the degree of functional impairment and the changes noted by ERP. These findings suggest that both the pancreatic function test and morphologic study are required to evaluate the degree of functional impairment in patients with chronic pancreatitis.

Comparison of the hemostatic effect of endoscopic injection with fibrin glue and hypertonic saline-epinephrine for peptic ulcer bleeding: a prospective randomized trial

BACKGROUND AND STUDY AIMS

Although endoscopic injection therapy using various agents has been considered the least expensive and most effective technique in obtaining hemostasis in peptic ulcer bleeding, most of these agents induce tissue necrosis or degeneration. Theoretically the injection of fibrin glue (FG) to halt peptic ulcer bleeding may be safer than the use of other agents, but randomized clinical trials to compare the efficacy of FG and other agents are rare. The aim of this study was to compare the hemostatic efficacy between FG and hypertonic saline-epinephrine (HSE) in peptic ulcer bleeding.

PATIENTS AND METHODS

From March 1992 to December 1993 we conducted a prospective randomized trial in 127 patients with peptic ulcer bleeding, in whom a visible vessel or active bleeding was identified. Patients were randomized into two groups, an FG group comprising 64 patients who received FG injections, and an HSE group, comprising 63 patients who received HSE injections.

RESULTS

The two groups were comparable with regard to age, sex, bleeding focus and bleeding stigma. Permanent hemostasis using only endoscopic treatment was achieved in 59 cases (92.2 %) in the FG group and in 54 cases (85.7 %) in the HSE group. Rebleeding occurred in seven cases (10.9%) in the FG group and in 14 cases (22.2%) in the HSE group (P=0.087); emergency surgery was undertaken in four (6.3%) and seven cases (11.1%), respectively (P = 0.33); death occurred in one case (1.6%) and four cases (6.3%), respectively (P = 0.165).

CONCLUSIONS

These results suggest that endoscopic injection of FG is an effective method in the control of peptic ulcer bleeding. However, even though there is a strong trend supporting the hypothesis that fibrin glue is superior to HSE, no statistically significant differences are noted. A trial involving larger numbers may produce a positive result.

Nitinol self-expanding stents: when severe twisting occurs, self-expansion may ensue after a waiting period

One of the major disadvantages of nitinol endocoil stents is said to be incomplete deployment leading to twisting and stent dysfunction. We report a patient with irresectable pancreatic head cancer where severe twisting of the nitinol stent occurred which resolved on the day after stent insertion; the stent took its normal shape ten days later, whereafter the patient lived without stent-related problems for one year until his death. This shows that prospective management rather than immediate stent extraction may be warranted in such cases of stent dysfunction.

Evaluation of therapeutic regimens for the treatment of Helicobacter pylori infection

Helicobacter pylori (H. pylori) is currently considered the most important exogenous factor in the genesis of gastritis and peptic ulcer disease. However, the optimum regimen for the eradication of H. pylori remains unclear. The purpose of this study was to evaluate the eradication rate of H. pylori, the side effects, and the patients' compliance with regard to various drug regimens. We also analyzed factors influencing the eradication of H. pylori. One hundred and eighty patients were included and divided into four groups: 42 patients (Group I) received tripotassium dicitrato bismuthate (240 mg b.i.d.), metronidazole (250 mg t.i.d.) and amoxicillin (500 mg t.i.d.) for 14 days; 55 patients (Group 2) received omeprazole (20 mg b.i.d.) and amoxicillin (1000 mg b.i.d.) for 14 days; 36 patients (Group 3) were treated with omeprazole (20 mg b.i.d.), metronidazole (250 mg t.i.d.) and amoxicillin (500 mg t.i.d.) for 14 days; and 47 patients (Group 4) received omeprazole (20 mg q.d.) and amoxicillin (500 mg t.i.d.) for 14 days and then tripotassium dicitrato bismuthate (240 mg b.i.d.) and nizatidine (150 mg q.d.) for 14 days. The diagnosis of H. pylori was made by histology. The eradication of H. pylori was defined both by histology (H&E and Giemsa stain) and by rapid urease test (CLOR) showing negative for H. pylori 4 weeks after the completion of therapy. Of the 180 patients, 95 patients had non-ulcer dyspepsia, 40 patients had gastric ulcer and 45 patients had duodenal ulcer. The eradication rate of H. pylori was highest (89.3%) in Group 3, as compared with Group 1 (68.9%), Group 2 (65.4%), and Group 4 (48.9%). The eradication rate was significantly higher in Group 3 than in Groups 2 and 4 (p < 0.05). There was no significant difference in the eradication rate among clinical diagnosis, sex and age. But, in the conventional triple therapy (Group 1), the eradication rate was higher in male (78.6%) than in female (46.2%). The side effects in order, were nausea (22.1%), dizziness (19.5%), abdominal pain (11.6%) and diarrhea (97%), and there was no difference among the drug regimens. The compliance of the patients was good (more than 80% irrespective of drug regimen). On the basis of these findings, the side effects of the drugs seemed minimal, and the compliance of patients was good irrespective of the drug regimen. In conclusion, the triple therapy with omeprazole, metronidazole and amoxicillin was the most effective regimen and could be recommended for H. pylori eradication.

p53 protein expression in extrahepatic bile duct cancer

p53 mutations, a tumor suppressor gene located on chromosome 17p, are the most common genetic alterations found in human cancers. Although the p53 expression or mutation has been investigated in a variety of cancers there have been very few studies in extrahepatic bile duct cancers. In this study, we investigated the immunohistochemical expression of p53 in formalin fixed paraffin embedded archival specimens of 36 extrahepatic bile duct cancers in which p53 expression was found in eighteen (50%) cases. There was no significant difference in age, gender, size of tumor, histologic grade, extent of tumor involvement, lymph node metastasis and tumor resectability according to p53 immunoreactivity. Comparison of survival duration according to p53 expression showed no significant difference. In conclusion, we reported 50 percent of p53 expression in extrahepatic bile duct cancers by immunohistochemical staining and we found no prognostic significance of p53 expression in dinicopathologic parameters.

Combined use of tamoxifen, cyclosporin A, and verapamil for modulating multidrug resistance in human hepatocellular carcinoma cell lines

The intensive use of chemotherapeutic agents for the treatment of cancer has resulted in the cure or improved survival of many patients. But unfortunately, many cancers including human hepatocellular carcinoma (HCC) don't respond to chemotherapy. One of the major mechanisms for the drug resistance in the HCC is an elevated MDR1 RNA expression which makes cells become multidrug resistant. To overcome the multidrug resistance (MDR) phenotype, a high dose of verapamil is required both clinically and experimentally. Accordingly we have examined the MDR modulating effects with combinations of tamoxifen, cyclosporin A, and verapamil in vitro with the physiologically achievable concentrations of each agent, i.e., 2.0 microM/L for tamoxifen, 1.6 microM/L for cyclosporin A, and 2.5 microM/L for verapamil respectively in HCC lines. As expected, verapamil alone with the physiologically achievable concentration at which we tested didn't enhance the doxorubicin cytotoxicity in the HCC lines. Furthermore, any verapamil combination with cyclosporin A or tamoxifen was not effective in overcoming the doxorubicin resistance in the high MDR1 expressor (Hep-G2) line. However tamoxifen reduced the IC50 of doxorubicin by a factor of 1.9 in the low MDR1 expressor (SK-Hep1) and 1.1 in the high MDR1 expressor line (p < 10(-5) respectively). Of interest, combinations of tamoxifen and cyclosporin A showed a significant reduction in the IC50 of doxorubicin in both HCC lines. The IC50 of doxorubicin was reduced by a factor of 3.9 and 1.3, i.e., from 0.023943 micrograms/ml to 0.006157 micrograms/ml (p < 10(-5)) in the SK-Hep1 cell line, and 0.068819 micrograms/ml to 0.052442 micrograms/ml (p < 10(-5)) in Hep-G2 respectively when tamoxifen and cyclosporin A were administered together. Both the estrogen and progesterone receptors in the SK-Hep1 and Hep-G2 lines were less than 0.01 fmol/mg of cytosol protein, respectively. It is therefore suggested that the reversal of doxorubicin resistance is unrelated to their anti-estrogenic activity in the HCC lines. Three modulator combinations of tamoxifen, cyclosporin A, and verapamil were not more effective than the combination of tamoxifen and cyclosporin A on the sensitivity to doxorubicin. MDR modulators of tamoxifen, cyclosporin A, and verapamil didn't reduce the IC50 of cisplatin to the clinically achievable concentration range in HCC lines. In summary, the combination of tamoxifen and cyclosporin A at the concentrations normally seen after clinical administration of these modulators showed significant synergism on the sensitivity to doxorubicin in both low and high MDR1 expressor HCC lines. These data indicate the need for in vivo trials.

Intestinal neurofibromatosis in von Recklinghausen's disease: presenting as chronic anemia due to recurrent intestinal hemorrhage

Neurofibromatosis (von Recklinghausen's disease) is a neuroectodermal disorder characterized by pigmentary changes of the skin (café-au-lait spots), cutaneous and visceral tumors (neurofibromas) and systemic abnormalities. The involvement of gastrointestinal tract in neurofibromatosis is not common. The most common symptoms, refer able to lesions in the gut, are hematemesis, melena and abdominal pain. We experienced a case of intestinal neurofibroma in von Recklinghausen's disease. The patient was a 39 year-old female who had suffered from chronic iron deficiency anemia and recurrent gastrointestinal hemorrhage due to two neurofibromas of jejunum for 3 years, which was diagnosed by superior mesenteric and ileal arteriogram and 99mTc pertechnetate-labelled RBC scan, and treated by segmental resection of jejunum with end to end anastomosis.

Histologic study of chronic active hepatitis C; comparison with chronic active hepatitis B

Reports on the histologic findings of chronic active hepatitis C (CAH-C) have been rare, and the characteristic histologic findings of CAH-C have been not yet determined. To compare the differences in the histologic findings between CAH-C and chronic active hepatitis B (CAH-B) group, we analyzed the histologic findings of 19 patients with CAH-C, who had positive tests for HCV-antibody by EIA, and 19 patients with CAH-B who had negative tests for HCV-antibody but positive tests for HBsAg by RIA. Histologic features were analyzed between the CAH-C and CAH-B groups using a scoring system which is modified from Knodell's histologic activity index-looking at portal inflammation, periportal necroinflammation, portal fibrosis, focal necrosis, regeneration, polyploid nuclear change, sinusoidal lymphocytic reaction and fatty change. Portal inflammatory cell infiltrations with prominent lymphocytes and follicular arrangement were more frequent in the CAH-C group (10 of 19 cases) than in the CAH-B group (5 of 19 cases). Severe sinusoidal lymphocytic reactions were also more prominent in the CAH-C group (11 of 19 cases) than in the CAH-B group (6 of 19 cases). However, periportal necroinflammation, portal fibrosis, focal hepatic necrosis, regeneration and polyploid nuclear changes were more prominent in the CAH-B group than in the CAH-C group. In conclusion, follicular portal inflammation and severe sinusoidal lymphocytic reactions were common histologic findings in serologically proven CAH-C when compared to CAH-B.

Adjuvant treatment of operable stomach cancer with polyadenylic.polyuridylic acid in addition to chemotherapeutic agents: a preliminary report

A randomized trial of polyadenylic.polyuridylic acid [poly(A).poly(U)] in addition to chemotherapy was undertaken in patients with stomach cancer following curative gastrectomy. They were randomized into a group of 108 patients receiving chemotherapy plus poly(A).poly(U) and a control group of 116 patients receiving chemotherapy alone. Chemotherapy consisted of injections of 5-fluorouracil, 12 mg/kg once weekly and adriamycin, 40 mg/m2 once every 3 weeks, continuously after operation. Poly(A).poly(U) was infused in a 100 mg dose, once a week six times from 5 days after the first injection of chemotherapeutic agents and 6 months later in a half dose similarly. At 55 months after initiation of the trial, the mean follow-up periods were 24 months for both groups. It has been revealed that patients who received the combined treatment postoperatively showed a lesser mortality and lower rate of recurrence, both reflecting significant increases in overall (P less than 0.05) and relapse-free (P less than 0.02) survivals as compared to those who received chemotherapy alone. This effect is more pronounced in patients having moderately advanced lymphnode involvement (N1) than in patients without (N0) or more advanced (N2) involvement. Thus, poly(A).poly(U) appears to be an effective agent when used postoperatively with chemotherapy in stomach cancers.

Endoscopic injection sclerotherapy in patients with bleeding esophageal varices: a retrospective analysis

Endoscopic injection sclerotherapy has been accepted as the procedure of choice for patients with variceal hemorrhage. To evaluate the efficiency of endoscopic injection sclerotherapy in patients with bleeding esophageal varices, we did a retrospective study of 52 patients (non-sclerotherapy group) with bleeding esophageal varices who were admitted to hospitals and did not receive sclerotherapy and of 50 patients (sclerotherapy group) who received sclerotherapy with ethanolamine oleate. The mortality (sclerotherapy group vs. non-sclerotherapy group: 18.0% vs. 32.7%) during index hospitalization, the bleeding risk factor (the number of rebleeds per patient/month; 1.56 +/- 2.76 vs. 4.96 +/- 9.99: mean +/- SEM) and the mortality due to bleeding (14.0% vs. 36.5%) were higher in the non-sclerotherapy group than in the sclerotherapy group. Only those in Child's class C who received sclerotherapy had a significantly better survival rate than the non-sclerotherapy group (p less than 0.05). Although formal comparisons were not made because of the retrospective nature of this study, endoscopic injection sclerotherapy is effective and appears to be superior to conventional medical treatments.

Submucosal lymphatic cyst of the stomach--a case report

A submucosal lymphatic cyst is a thin-walled cyst, lined by flattened lymphatic endothelium, containing thin serous fluid. It rarely causes clinical symptoms, and it is incidentally discovered during fiberoptic panendoscopy or radiologic study in most cases. It is an extremely rare benign tumor of the stomach; however, a submucosal lymphatic cyst should be considered if a pliable and benign submucosal lesion is detected during fiberoptic panendoscopy. We report a case of submucosal lymphatic cyst of the stomach which showed a typical clinical picture. This report is the first case of submucosal lymphatic cyst of the stomach in Korea to the best of our knowledge.

Percutaneous fine needle aspiration biopsy of pancreatic cancer guided by ultrasonography

Fine needle aspiration biopsy guided by ultrasonography was performed in 39 patients with pancreatic cancer to evaluate the value of the technique for establishing a proved histologic diagnosis. Aspirated material suitable for cytologic evaluation of smear preparation was obtained from 33 patients (84.6%). Among the 33 patients, cytologic diagnosis of pancreatic cancer was possible in 28 patients (84.9%). There was mild abdominal pain only in one patient (2.6%). In conclusion, percutaneous fine needle aspiration biopsy guided by ultrasonography proved to be a safe and useful method for histologic diagnosis of pancreatic cancer.

A case of pancreatico-colo-cutaneous fistula; management guided by endoscopic retrograde cholangio-pancreatography

A report of a 67-year-old man, who had been suffering from an enterocutaneous fistula after a left hemicolectomy due to colon cancer is presented. He had sudden intermittent upper abdominal pain and a high amylase level in the drainage fluid. The fistulogram showed a colocutaneous fistula with an abnormal cavity in the left upper quadrant. ERCP was performed to demonstrate the relationship between the pancreatic duct and the colocutaneous fistula connected with the abnormal cavity, and showed a pancreatico-colo fistula which was connected with the abnormal cavity. From the results of the above two studies, a diagnosis of the pancreatico-colocutaneous fistula could be drained, and a distal pancreatectomy, splenectomy and closing of the colonic opening were performed. After the operation, the patient was discharged without problem. We report herein a case of pancreaticocolocutaneous fistula which was confirmed by ERCP preoperatively and surgically treated successfully.

The normal endoscopic pancreatogram in Koreans

The establishment of endoscopic retrograde cholangiopancreatography (ERCP) as a valuable procedure in diagnostic evaluation of patients with suspected pancreatic disease requires the precise delineation of normal pancreatography. Therefore, to establish normal standards in Koreans of pancreatic ductal morphology, such as course, diameter and length including the shape of the ampulla and the success rate of the ERCP procedure, we analyzed the pancreatograms of persons with proven normal pancreatic status. Of the 449 cases showing normal duodenal papilla, the hemispherical type of shape (49.7%) was the most common, followed by the papillary type (36.5%) and flat type (13.8%) in order of frequency. The success rate of ERCP procedure (1,020 cases) was 95.3%, and the selective success rate was 90.9% for the pancreatic duct and 79.3% for the biliary tree. In the course of the pancreatic duct (286 cases), the ascending type of extension (51.7%) was the most common followed by the sigmoid type (25.2%), horizontal type (22.4%) and descending type (0.7%). The diameter of the pancreatic duct was 3.3 +/- 0.8 mm in the head, 2.4 +/- 0.5 mm in the body and 1.5 +/- 0.5 mm in the tail portion, and there was a tendency that the diameter of the pancreatic duct progressively increased with age. The length of the pancreatic duct was 17.5 +/- 2.8 cm. In conclusion we hope that, by utilizing these various parameters of the normal endoscopic retrograde pancreatogram, precise diagnosis will be possible.

Hyperpigmentation in megaloblastic anemia

Hyperpigmentation of the hands and feet developed in a 65-year-old Korean woman who had undergone a total gastrectomy and esophagojejunostomy due to early gastric cancer 7 years previously. A diagnosis of megaloblastic anemia due to vitamin B12 deficiency was made. In the areas of pigmentation, there were abnormally large nuclei in the keratinocytes. All of these findings were reversible upon the administration of vitamin B12. Ultrastructurally, there were many intracytoplasmic desmosomes, numerous aggregated bundles of tonofilaments, and highly condensed keratohyalin granules. The pathophysiologic mechanism of vitamin B12 deficiency associated with pigmentary disturbances and change of nuclear size is discussed.

Analysis of cases of nonvisualized gallbladder by ultrasonography

To define the significance of nonvisualization of the gallbladder by ultrasonography, we studied follow-up data on 31 cases in which the gallbladder could not be identified despite adequate fasting. Thirty one cases of gallbladder disease included 15 cases of chronic cholecystitis due to cholelithiasis (13 cases) and choledocholithiasis (2 cases), 4 cases of cholelithiasis which were not surgerized, and 3 cases of cancer. There were 4 cases of diagnostic error in which gallbladder nonvisualization occurred despite a demonstrable lumen. The etiology of disease was not determined in the 5 remaining cases. Therefore 22 of 26 cases were found to have diseased gallbladders. The resasons for nonvisualization of the gallbladder by ultrasonography in the 19 cases which underwent surgicl exploration were: 17 cases due to chronic cholecystitis with cholelithiasis (13 cases), choledocholithiasis (2 cases) and cancer (2 cases), obliteration of the lumen due to cancer of the gallbladder in one cases, and technical error due to an unusual location of the gallbladder in one case. The mechanisms of diagnostic error in 4 cases seemed technical error due to an unusual location of the gallbladder in 3 cases and the obscured gallbladder by intestinal gas in one case. In conclusion, we feel that careful examination should be done to detect a gallbladder located unusually or obscured by intestinal gas in order to decrease the rate of diagnostic error when the gallbladder is not visualized by ultrasonography. Also, we recommend an oral cholecystography or ERCP for ultrasonic nonvisualized gallbladder.