Clinical Endoscopy

Effectiveness of Through-the-scope Self-expandable Metal Stent in Malignant Upper Gastrointestinal Obstruction: Eun Soon Kim, M.D.*, Jeong Seop Moon, M.D., You Sun Kim, M.D., Il Kim, M.D., Jin Kwang Lee, M.D., Seong Eun Kim, M.D., Soo Hyung Ryu, M.D. and Jung Whan Lee, M.D.; Korean J Gastrointest Endosc 2005;31(1):1-9. Published online July 30, 2005

Abstract PDF: Background
/Aims: Self-expandable metal stents (SEMS) have been used in the palliation of malignant obstruction. The purpose of this study was to evaluate the effectiveness, safety, and outcome of SEMS using through-the- scope (TTS) method in the patients with malignant upper gastrointestinal obstruction including recurrent gastric cancer after gastrectomy. Methods: Thirty one patients (36 stents) were treated with SEMS between October 2000 and June 2004; nineteen had inoperable malignant gastric outlet obstruction, ten had recurrent gastric cancer after gastrectomy, and two had metastatic duodenal cancer. We analyzed the technical and clinical success, complication, and outcome. Results: The technical success rate was 88.8% (32/36 stents) in total cases; 95.0% (19/20) in malignant gastric outlet obstruction, 84.6% (11/13) in recurrent gastric cancer after gastrectomy, and 66.7% (2/3) in metastatic duodenal cancer. The success rate of dietary intake was 86.1% (31/36 stents). Complications occurred in 7 of 36 stents (19.4%), including stent migration (1 patient), aspiration pneumonia (1 patient), and recurrent obstruction (5 patients). The mean survival duration period was 118.1⁑180.2 days and mean patency period was 92.2⁑89.9 days. Conclusions: SEMS using TTS is an effective, safe, and less invasive palliative treatment in malignant upper gastrointestinal obstruction including recurrent gastric cancer after surgery. (Korean J Gastrointest Endosc 2005;31:1⁣9)

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Results of Endoscopic Mucosal Resection for Early Gastric Cancer-Factors Influencing Complete Resection-: Beom Jin Kim, M.D., Jae J. Kim, M.D., Ji Hyang Kim, M.D., Jeong-Chae Yang, M.D., Jun Haeng Lee, M.D., Sang Kun Shim, M.D., Young-Ho Kim, M.D., Poong-Lyul Rhee, M.D., Seung Woon Paik, M.D., Jong Chul Rhee, M.D. and Chul Keun Park, M.D.*; Korean J Gastrointest Endosc 2005;31(1):10-16. Published online July 30, 2005

Abstract PDF: Background
/Aims: The aim of the study is to evaluate the results of endoscopic mucosal resection (EMR) for early gastric cancer (EGC) and to investigate the factors with influence the complete resection. Methods: We retrospectively analyzed 109 lesions from 108 patients with EGC treated by EMR at Samsung medical center from November 1994 to June 2003. We compared completely resected group with incompletely resected group with regards to size, location, histologic types before and after EMR, methods of procedure, and complication. Results: The mean size of lesions was 11.3⁑6.5 mm. Eighty two of them were located in the antrum and angle, twenty six in the body, and one in the cardia of stomach. Endoscopically elevated lesions (type I, IIa) were 52 cases and depressed lesions (type IIc) were 40 cases. Histologically curative resection was done in 74 of 109 cases (67.9%). All but one cases have been observed without recurrence for a mean period of 11.1 months. Histologically incomplete resection in 35 cases included 9 positive cancer cell in resection margin, 25 submucosal cancer infiltration, 2 reconstruction failure, 1 lymphatic involvement and 1 signet ring cell type cancer. Complications related to EMR included 9 cases of bleeding and 3 cases of perforation. In comparison of two groups, complete resection rate was significantly higher when tumor was located in the antrum or angle than body or cardia of stomach (p=0.006). Conclusions: Our results show that EMR is one effective curative treatment modality in highly selected patient with EGC and location of lesion is an important factor influencing the success of complete resection. (Korean J Gastrointest Endosc 2005;31:10⁣16)

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Revaprazan (RevanexⰒ), a Novel Acid Pump Antagonist, for Duodenal Ulcer: Results of a Double-Blind, Randomized, Parallel, Multi-Center Phase III Clinical Trial: In-Sik Chung, M.D.*, Myung-Gyu Choi, M.D.*, Soo-Heon Park, M.D.*, Sung-Kook Kim, M.D.†, Rhyn Chang, M.D.‡,
Jin-Hai Hyun, M.D.§, Sang-Young Han, M.D.∥, Geun-Am Song, M.D.¶, Chan-Sup Shim, M.D.**, Ki-Baik Hahm, M.D.††, Hyun-Soo Kim, M.D.‡‡,; Korean J Gastrointest Endosc 2005;31(1):17-24. Published online July 30, 2005

Abstract PDF: Background
/Aims: To assess the comparative efficacy and safety of revaprazan, a novel acid pump antagonist, versus omeprazole in patients with duodenal ulcer, we performed a randomized, double-blind, phase III, multicenter trial. Methods: Two hundred and twenty eight patients were randomized to 4 weeks of treatment with either revaprazan 200 mg or omeprazole 20 mg once daily. Primary efficacy parameter was complete ulcer healing by endoscopy, and secondary parameter was the improvement in the severity of daytime and nighttime pain. Results: Healing rates at 4 weeks (intention-to-treat analysis) were 91.7% with revaprazan 200 mg and 91.3% with omeprazole 20 mg; there were no significant differences between two groups (p=0.9228). In per-protocol analysis, healing rates of revaprazan 200 mg and omeprazole 20 mg were 94.4% and 92.3%, respectively. There was no significant difference in healing rate between two groups (p=0.5666). There was no significant difference between two groups in improvement rates of daytime and nighttime pain. Both drugs were well tolerated. Conclusions: Revaprazan 200 mg was equivalent to omeprazole 20 mg for both ulcer healing and symptom relief, and was well tolerated in patients with duodenal ulcer. (Korean J Gastrointest Endosc 2005;31:17⁣24)

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Patients' Gender Preference for Colonoscopist: Ji Hyang Kim, M.D., Jun Haeng Lee, M.D., Eun-Ha Park, M.D., Min Hyung Kim, M.D., Young-Ho Kim, M.D., Hee Jung Son, M.D., Poong-Lyul Rhee, M.D., Jae J. Kim, M.D., Seung Woon Paik, M.D., Sang Goon Shim, M.D.* and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2005;31(1):25-31. Published online July 30, 2005

Abstract PDF: Backgound/Aims: Colonoscopy is anticipated as embarrassing and uncomfortable procedure. However, the patients' gender preference for doctor has not been well evaluated in those undergoing colonoscopy. This study was to assess patients' preference for gender and age of colonoscopist. Methods: A total of one hundread and ninety eight patients (118 males and 80 females) scheduled for colonoscopy were prospectively asked to answer the questionnaires consisting of patient characteristics, preference for gender of colonoscopist, and the period they can wait until their preferred colonoscopist would be acceptable. Results: Among male patients, 51% expressed a gender preference (47% for male and 4% for female colonoscopist) and 52% of female expressed two gender preference (26% for male and 26% for female colonoscopist), and colonoscopists in their forties were preferred the most. Aged female patients and male patients with family history of colorectal cancer preferred a male colonoscopist. The strength of gender preference shown by the period they could wait was weak. Conclusions: Half of the female and male patients showed gender preference in choosing a colonoscopist. Among the patients expressing a gender preference, most male patients preferred the same gender whereas half of female preferred the opposite gender. (Korean J Gastrointest Endosc 2005; 31:25⁣31)

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Patient-Controlled Sedation versus Nurse-Administered Sedation with Propofol during Colonoscopy: Jee Hyun Oh, M.D., Hoon Cho, M.D., Yeung Muk Kim, M.D., Mu Yeul Lee, M.D., Guang Soon An, M.D., Hyun Jeung Kim, M.D., Hyun Gwang Jung, M.D., Kang Min Kim, M.D. and Joon Sang Lee, M.D.; Korean J Gastrointest Endosc 2005;31(1):32-38. Published online July 30, 2005

Abstract PDF: Background
/Aims: Patient-controlled sedation (PCS) allows the patients to titrate the dosages of sedative drug according to their needs. The objective of this study was to compare the safety and the efficacy of nurse-administered propofol sedation (NAPS) with those of PCS. Methods: Eighty one patients were randomly assigned to two groups. All patients received meperidine 25 mg and propofol 40 mg as an initial dose for sedation. Patients in PCS group were subsequently infused with propofol 15 mg over 80 seconds through infusion pump whenever they required. Patients in NAPS group were injected with 10∼20 mg propofol by nurse with supervision by endoscopist. The dosage of propofol, cardiopulmonary parameters, procedure time, sedation score, pain score, the patients' and endoscopists' satisfaction scores were assessed. Results: With regard to blood pressure, pulse rate and oxygen saturation, serious complications were not observed. Especially, there was no significant difference of mean total dose between two groups (NAPS group and PCS group received 76.7⁑24.7 mg and 82.5⁑26.6 mg respectively). Pain score was higher in woman than in man (p=0.03). Conclusions: 1.2∼1.5 mg/kg of propofol with small dose of opioid during colonoscopy was effective and safe. NAPS was more practical and useful method of sedation than PCS during colonoscopy. (Korean J Gastrointest Endosc 2005;31:32⁣38)

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Interobserver Agreement among Experts in Determining the Depth of Invasion of Early Colorectal Carcinoma: Jeong Seon Ji, M.D., Hwang Choi, M.D., Kyu Yong Choi, M.D., Bo In Lee, M.D., Kyoung Mee Kim, M.D.*, Byung Wook Kim, M.D., Se Hyun Cho, M.D., Seong Hyun Son, M.D., Hiun Suk Chae, M.D. and In Sik Chung, M.D.; Korean J Gastrointest Endosc 2005;31(1):39-43. Published online July 30, 2005

Abstract PDF: Background
/Aims: Discrimination between mucosal and submucosal colorectal cancer is important because of different therapeutic plan. Although many characteristic endoscopic findings suggesting submucosal cancer were demonstrated, there are few reports about diagnostic accuracy and interobserver agreement among experienced endoscopists. So we studied about diagnostic accuracy and interobserver agreement about the diagnosis of submucosal invasive colorectal carcinoma by endoscopic findings. Methods: Fifty patients (58% male, mean age 64 years) diagnosed pathologically as early colorectal carcinoma after polypectomy and operation were randomly selected. Fifteen cases were submucosal invasive colorectal carcinoma. Three experienced endoscopists (A, B and C) blinded to the patient's data reviewed photographs. Results: Diagnostic accuracy of submucosal cancer by A, B and C were 82%, 74% and 78%, respectively. A to B and A to C showed moderate agreement in the diagnosis of submucosal invasion (kappa=0.504 and kappa=0.649). However, agreement power between B and C was somewhat weak (kappa=0.298). Among endoscopic findings, three experts strongly agreed on the features of white spots, hemorrhage and exudate (kappa=0;73, kappa=0.649 and kappa=0.641, respectively). Conclusions: Interobserver agreement in the diagnosis of submucosal colorectal carcinoma was moderate among three experts. More meticulous effort to improve interobserver agreement and accuracy in the diag-nosis of submucosal invasive colorectal carcinoma is mandatory. (Korean J Gastrointest Endosc 2005;31:39⁣43)

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A Case of Acute Phlegmonous Gastritis Treated with Antibiotics Alone: Tae Hee Lee, M.D., Gi Se Lee, M.D., Euyi Hyeog Im, M.D., Kyu Chan Huh, M.D., Young Woo Kang, M.D., Hyun Yong Jeong, M.D.* and Young Woo Choi, M.D.; Korean J Gastrointest Endosc 2005;31(1):44-48. Published online July 30, 2005

Abstract PDF: Acute phlegmonous gastritis is a rare disorder in which bacterial infection occurs in the gastric wall. Gastrectomy involving the affected area has been thought to be an effective form of treatment. The mortality rate remains extremely high despite therapy with antibiotics. The authors report a case of a 59-year-old man who had severe abdominal pain with signs of peritonitis. Endoscopy showed edematous and thickened mucosal fold with narrow lumen and yellow, whitish exudate-like materials on mucosal surface in the whole stomach. Gastric juice culture revealed the growth of Enterococcus faecalis. Contrast-enhanced CT scan of abdomen showed diffuse extensive mural thickening with hypodense area from the fundus to the antrum. The lumen was narrowed, but there was no gastric outlet obstruction. There was marked thickening of gastric wall (submucosal layer) on EUS examination. Through early diagnosis without laparotomy, the patient was successfully treated with antibiotics alone without complication. (Korean J Gastrointest Endosc 2005;31:44⁣48)

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A Case of Crohn's Disease Confined to the Appendix: Chang-Bai Lee, M.D., Sung-Ae Jung, M.D., Hye-Jung Yeom, M.D., Jong-Soo Lee, M.D., Yoo-Kyung Cho, M.D., Seong-Eun Kim, M.D., Ki-Nam Shim, M.D., Tae-Hun Kim, M.D., Kwon Yoo, M.D. and Il-Hwan Moon, M.D.; Korean J Gastrointest Endosc 2005;31(1):49-52. Published online July 30, 2005

Abstract PDF: Crohn's disease is a condition of chronic inflammation involving potentially any location in alimentary tract, but it is worldwide the rare when primary lesion with its extent is confined to the appendix alone. Because clinical manifestations of the Crohn's disease of the appendix dose not differ from those of acute appendicitis, it is difficult to diagnose preoperatively or intraoperatively, so it is usually diagnosed by postoperative pathologic examination. Because Crohn's disease confined to the appendix has favorable prognosis than typical Crohn's disease, it is considered a separate disease entity from Crohn's disease, and a new diagnostic term-"idiopathic granulomatous appendicitis"-has gained wide acceptance in recent years. We experienced a case of Crohn's disease confined to the appendix or idiopathic granulomatous appendicitis and review, we reported the care with review of the literatures. (Korean J Gastrointest Endosc 2005;31:49⁣52)

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A Case of Chronic Recurrent Small Bowel Bleeding in Neurofibromatosis Type 1 Diagnosed by Capsule Endoscopy: Byung Min John, M.D., Sang Jeong Yoon, M.D., Ana Kim, M.D., Hyun Ung Yang, M.D., Chang Nam Kim, M.D.,* Ju Hun Kim, M.D.† and Seong Kyu Park, M.D.‡; Korean J Gastrointest Endosc 2005;31(1):53-57. Published online July 30, 2005

Abstract PDF: Small bowel diseases comprised of neoplasm, inflammatory disease, vascular abnormality, absorption dysfunction, and iatrogenic causes. Among those, vascular abnormality is perhaps the most important clinical disease entity. Obscure gastrointestinal bleeding accounts for 5% of chronic gastrointestinal bleeding, but conventional endoscopy and radiologic study may fail to diagnose the cause in certain cases. Patients with neurofibromatosis type 1 have a lot of gastrointestinal tumor, with a high incidence of small bowel involvement. We experienced a case presenting with chronic bleeding due to jejunal gastrointestinal stromal tumor diagnosed by capsule endoscopy in a seventy- two year old female patient with sporadic neurofibromatosis type 1. (Korean J Gastrointest Endosc 2005;31:53⁣57)

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A Case of Limy Bile Associated with Cholangitis and Calcified Gallbladder: Gyu Yup Hwang, M.D., Anna Kim, M.D., Sang Jeong Yoon, M.D., Sung Hee Jung, M.D., Byeong Seong Ko, M.D., Hyeon Woong Yang, M.D. and Byung Min John, M.D.; Korean J Gastrointest Endosc 2005;31(1):58-61. Published online July 30, 2005

Abstract PDF: Limy bile is characterized by excessive precipitation of calcium carbonate, and generally preceded by gallbladder obstruction. Three case reports have been found in the domestic literatures. It is rare that limy bile syndrome associates cholangitis or calcified gallbladder. We report the case of a patient with limy bile, located in the gallbladder, common bile duct, and intrahepatic duct, with association of calcified gallbladder. This case showed characteristic radiologic and endoscopic findings. The patient was treated by endoscopic sphincterotomy and laparoscopic cholecystectomy. (Korean J Gastrointest Endosc 2005;31:58⁣61)

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A Case of Acute Acalculous Cholecystitis Complicating Endoscopic Retrograde Cholangiopancreatography: Byeong Kab Yoon, M.D., In Suh Park, M.D.*, Yong Sun Jeon, M.D.†, Jin-Woo Lee, M.D., Seok Jeong, M.D., Jung Il Lee, M.D., Kye Sook Kwon, M.D., Don Haeng Lee, M.D., Pum-Soo Kim, M.D., Hyung Gil Kim, M.D., Yong Woon Shin, M.D. and Young Soo Kim, M.D.; Korean J Gastrointest Endosc 2005;31(1):62-67. Published online July 30, 2005

Abstract PDF: Endoscopic retrograde cholangiopancreatography (ERCP) has gained wide acceptance as a valuable tool for the diagnosis and management of disease of the pancreas and biliary tract. Complications associated with ERCP include bleeding, perforation, pancreatitis, and cholangitis, and the incidence is about 5∼10%. Acute acalculous cholecystitis can be developed rarely after ERCP. It tends to have more complicated course, resulting in higher morbidity and mortality. We report a case of acute acalculous cholecystitis complicating therapeutic ERCP in a 52-year-old man with primary common bile duct stone. He underwent open cholecystectomy because of uncontrolled infection and rapid progression to septic shock. Although acute acalculous cholecystitis is one of rare complications developed after ERCP, it should be considered as one of the differential diagnosis in patients who complain of abdominal pain after ERCP because of high mortality rate and the need for prompt surgical management. (Korean J Gastrointest Endosc 2005;31:62⁣67)

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Lymphogenous Pancreatic Metastasis of Gastric Cancer Detected by Elevated CA 19-9 Level: Chang Won Choi, M.D., Hong Sik Lee, M.D., Beom Jae Lee, M.D., Keong Jin Kim, M.D., Min Jeong Kim, M.D., Rok Son Choung, M.D., Hyung Joon Yim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Soon Ho Um, M.D., Sang Woo Lee, M.D., Jai Hyun Choi, M.D., Chang; Korean J Gastrointest Endosc 2005;31(1):68-72. Published online July 30, 2005

Abstract PDF: Pancreatic metastasis of gastric cancer almost takes the form of direct continous invasion to the pancreas from the primary lesions or dissemination. Isolated lymphogenous pancreatic metastasis of stomach cancer is rare. A 39- year-old woman was admitted to our institution due to high serum CA 19-9 level. Abdominal computed tomography showed a diffusely enlarged pancreas, and endoscopic retrograde cholangiopancreatography revealed a segmental stricture of pancreatic duct on mid-body. Ultrasonography guided pancreatic biopsy revealed a metastatic poorly differentiated adenocarcinoma with lymphatic tumor emboli. We perfomed esophagogastroduodenoscopy and total colonoscopy. There was a ulcerative lesion at the posterior wall of high body with clubbing change of surrounding mucosal folds. Endoscopic biopsy of the stomach lesion revealed a poorly differentiated adenocarcinoma. Positron emission tomography-computed tomography scan revealed bone metastasis in the sternum. Herein, we report a case of 39 year old female with the diagnosis of gastric adenocarcinoma, with lymphogenous pancreatic metastasis and solitary sternal metastasis detected by elevated serum CA 19-9 level. (Korean J Gastrointest Endosc 2005;31:68⁣72)

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클립으로 불완전하게 봉합된 천공을 박리성 올가미의 추가 시술로 완전히 막을 수 있는가?: Korean J Gastrointest Endosc 2005;31(1):73-75. Published online July 30, 2005

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