Clinical Endoscopy

Successive Suture Device for Gastrointestinal Endoscopes: Chang Won Baeck, M.D., Hoon Jai Chun, M.D., Yoon Tae Jeen, M.D., Beom Jae Lee, M.D., Sanghoon Park, M.D., Hwang Rae Chun, M.D., Yong Sik Kim, M.D., Kyu Back Lee, Ph.D.*, Moon ki Cho^†, Chang Yang Lee^†, Dae Hie Hong, Ph.D.^†,; Korean J Gastrointest Endosc 2005;31(6):363-367. Published online December 30, 2005

Abstract PDF: Background
/Aims: Recently, treatment using an endoscopic device is actively being developed. Techniques for incision and bleeding control have been developed, but endoscopic suturing remains to be perfected. Using an endoscopic suturing technique, a variety of diseases could be managed noninvasively. We have attempted to use a new endoscopic suturing device which enables a continuous suture using a flexible upper endoscope. Methods: A suturing device was designed where a semicircular needle could sew through tissue by rotation making a continuous suture possible. Results: We successfully sutured the stomach tissue of a dog using an optimized suturing device model. Conclusions: The initial model was found to have some problems. However, we hope to develop a continuous suturing device for flexible upper endoscope procedures in Korea. (Korean J Gastrointest Endosc 2005;31:363⁣367)

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Comparison of 4 L of PEG Versus Combination of 2 L of PEG and 45 mL of Sodium Phosphate for Colonoscopy Colon Cleansing: A Prospective Randomized Trial: Jong Jin Hyun, M.D., Yoon Tae Jeen, M.D., Sang Hoon Park, M.D., Beom Jae Lee, M.D., Jong Hwan Choi, M.D., Hwang Rae Chun, M.D., Rok Son Choung, M.D., Yong Sik Kim, M.D., Hoon Jai Chun, M.D., Hong Sik Lee, M.D., Soon Ho Um, M.D., Sang Woo Lee, M.D., Jai Hy; Korean J Gastrointest Endosc 2005;31(6):368-373. Published online December 30, 2005

Abstract PDF: Background
/Aims: Polyethyleneglycol (PEG) is safe but its large volume and bad taste reduces patients' compliance. Sodium phosphate (NaP) is a hyperosmotic agent and its small volume can increase patients' compliance but electrolyte imbalance is a problem. Therefore, we conducted a study to determine whether patients' compliance can be enhanced and electrolyte imbalance reduced by combining these two agents. Methods: Forty-one admitted patients receiving colonoscopy at Korea University Hospital from June 28, 2004 to August 14, 2004 were randomly divided into two groups for colon cleansing with either PEG 4 L (n=21) or PEG 2 L plus NaP 45 mL (n=20). Patients were assessed for patient tolerance, quality of preparation, and changes of biochemical parameters. Results: Overall discomfort was statistically lower in the combination group, PEG 2 L plus NaP 45 mL (p=0.035). Although patients in the combination group reported less fullness (p=0.076) and nausea (p=0.087), the findings were not statistically significant. The quality of the preparation was comparable between the two groups (p=0.872). The phosphorus level in the combination group showed a statistically significant increase (0.58⁑0.46) after colon cleansing (p=0.020) but was not clinically significant. Conclusions: The combination of NaP 45 mL and PEG 2 L showed less overall discomfort with comparable quality of preparation and without serious electrolyte abnormality compared to 4 L of PEG. Therefore, the combination of NaP 45 mL and PEG 2 L could be used as an alternative colonoscopic colon cleansing agent when patients have trouble taking 4 L of PEG alone. (Korean J Gastrointest Endosc 2005;31:368⁣373)

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Forecasting and Retreatment of Unsuccessful Endoscopic Mechanical Lithotripsy in Patients with Difficult Bile Duct Stones: Sang Hyub Lee, M.D., Joo Kyung Park, M.D., Won Jae Yoon, M.D., Jun Kyu Lee, M.D., Ji Kon Ryu, M.D., Yong-Tae Kim, M.D. and Yong Bum Yoon, M.D.; Korean J Gastrointest Endosc 2005;31(6):374-382. Published online December 30, 2005

Abstract PDF: Background
/Aims: Endoscopic removal of a bile duct stone becomes more difficult with increasing stone size. The endoscopic mechanical lithotripsy is frequently used to overcome this problem. However, it is necessary to predict its outcome and determine the optimal treatment when it does fail. This study examined the predictors and optimal treatment for an unsuccessful endoscopic mechanical lithotripsy. Methods: One hundred and twenty five patients who underwent endoscopic mechanical lithotripsy, were retrospectively evaluated. Various predictive factors and procedure-related complications were analyzed. In addition, the clinical outcome of retreatment for unsuccessful endoscopic mechanical lithotripsy was evaluated. Results: Endoscopic mechanical lithotripsy was successful in 97 patients (77.6%). An impacted stone(s), stone size (≥30 mm) and stone size/bile duct diameter (＞1.0) were significant factors forecasting failure, with an estimated odds ratio 26.67, 5.94 and 5.99, respectively. More frequent complications related with the failure were not observed. When the procedure did fail, all were retreated successfully with various modalities including surgery. Despite the short hospitalization period, non-surgical treatment had a similar clinical outcome to that of surgery. Conclusions: An impacted stone, stone size (≥ 30 mm) or stone size/bile duct diameter (＞1.0) in difficult choledocholithiasis are indicators of unsuccessful endoscopic mechanical lithotripsy. Alternative non-surgical treatment might be considered to manage difficult choledocholithiasis when endoscopic mechanical lithotripsy fails. (Korean J Gastrointest Endosc 2005;31:374⁣382)

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A Case of Synchronous Esophageal Basaloid Squamous Carcinoma and Cancer of the Base of Tongue: Joo Hoon Kim, M.D., Ji Eun Park, M.D., Ji Hyun Nam, M.D., Hyun Jung Lim, M.D., Ji Yeon Kim, M.D., Seun Ja Park, M.D., Min Jung Jung, M.D.*, Hee Kyung Jang, M.D.* and Kang Dea Lee, M.D.^†; Korean J Gastrointest Endosc 2005;31(6):383-386. Published online December 30, 2005

Abstract PDF: Basaloid squamous cell carcinoma occurs in various organs including the upper respiratory tract, the base of the tongue, pharynx, larynx, breast, uterine cervix and anus. It is a rare tumor, but it must be distinguished from other malignancies because of its aggressive clinical behavior. Many cases present in the advanced stage at the time of diagnosis. We present here a case of esophageal basaloid squamous cancer that was diagnosed in 75-year-old male patient who had dysphagia and throat pain, and this was accompanied by squamous cell cancer of the tongue base, as was determined by laryngoscopic and esophagogastroscopic examination. (Korean J Gastrointest Endosc 2005; 31:383⁣386)

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A Case of Primary Esophageal Small Cell Carcinoma with Intraperitoneal Multiple Lymph Node Metastasis: Hong Jun Kim, M.D., Hyun Jin Kim, M.D., Hyun Chin Cho, M.D., Su Nyoung Choi, M.D., Mi Yeon Kang, M.D., Tae Hyo Kim, M.D., Woon Tae Jung, M.D. and Jeong-Hee Lee, M.D.*; Korean J Gastrointest Endosc 2005;31(6):387-393. Published online December 30, 2005

Abstract PDF: Two cases of esophageal small cell carcinoma were reported on for the first time in 1952. There have been only a few published series on the patients with esophageal small cell carcinoma, and only 19 cases have been reported in Korea. As in the case of small cell carcinoma of the lung, the esophageal small cell carcinoma is known to show rapid progression and early metastasis. Yet much remains to be uncovered about the clinical features, optimal treatment and natural history of this disease. We report here on a case of primary esophageal small cell carcinoma with intraperitoneal multiple lymph node metastasis. The size of the tumor was markedly decreased by combination chemotherapy. (Korean J Gastrointest Endosc 2005;31:387⁣393)

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A Case of Primary Esophageal Small Cell Carcinoma with Gastric Metastasis: Ji Hwan Kim, M.D., Mi Jeong Park, M.D., Chang Sue Park, M.D., Jong Yun Cheong, M.D., Won Il Park, M.D., Jin Kwang An, M.D., Kwang Jin Kim, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2005;31(6):394-398. Published online December 30, 2005

Abstract PDF: Gastric metastasis of malignant tumors is relatively rare but has been reported in cases of malignant melanoma, lung cancer, breast cancer and squamous cell carcinoma of the esophagus. Primary small cell carcinoma of the esophagus is very rare and is an extremely aggressive tumor. Regional lymph node involvement, and distant metastasis to other organs including liver, bone, skin, lung, bone marrow, and brain are common at the time of initial diagnosis. To date, there has been no case reported of gastric metastasis from primary esophageal small cell carcinoma. A 72-year-old man presented with dysphagia for 2 months. An esophagogastroduodenoscopy revealed esophageal carcinoma with a submucosal tumor in the upper body of the stomach. Pathologic examination revealed an esophageal small cell carcinoma, and gastric submucosal infiltration of the small cell carcinoma was noted. We report a case of primary esophageal small cell carcinoma with submucosal tumor like gastric metastasis. (Korean J Gastrointest Endosc 2005; 31:394⁣398)

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Two Cases of Adenocarcinoma Arising from Gastric Hyperplastic Polyp: Won Seok Heo, M.D., Kyung Hoon Chae, M.D., Jae Hoon Jung, M.D., Yoon Sae Kang, M.D., Yeon Soo Kim, M.D., Seok Hyun Kim, M.D., Jae Kyu Sung, M.D., Byung Seok Lee, M.D., Hyun Yong Jeong, M.D. and Gyu Sang Song, M.D.*; Korean J Gastrointest Endosc 2005;31(6):399-403. Published online December 30, 2005

Abstract PDF: Epithelial gastric polyps can be categorized as being either hyperplastic or adenomatous. Hyperplastic polyps accounts for 75∼90% of gastric polyps. In contrast to the adenomatous polyps, the potential of a malignant transformation of hyperplastic polyps was originally believed to be quite low (an incidence of 1.5∼2.1%), which is considerably lower than that of an adenoma of the stomach. Most of reported cases of a hyperplastic gastric polyp with a transformation to adenocarcinoma were well differentiated histopathologically. There are few reports of a hyperplastic polyp in which malignant changes developed during the endoscopic surveillance. We report a rare case of a 1.2 cm sized moderately differentiated adenocarcinoma arising in a hyperplastic polyp on the cardia in the stomach with a brief review of the relevant literature. (Korean J Gastrointest Endosc 2005;31:399⁣403)

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A Case of Submucosal Tumor-like Early Gastric Adenocarcinoma Diagnosed by Endoscopic Mucosal Resection: Se Yune Kim, M.D., Jong-Jae Park, M.D., Yongik Cho*, M.D., Jong Hwan Choi, M.D., Ji Hyun Kim, M.D., Byung Kyu Kim, M.D., Ji Hoon Kim, M.D., Yun Jung Chang, M.D., Cheol Hyun Kim, M.D., Youn Suk Seo, M.D., Jin Yong Kim, M.D., Jae Seon Kim, M.D. and Young-Ta; Korean J Gastrointest Endosc 2005;31(6):404-408. Published online December 30, 2005

Abstract PDF: In rare cases, early gastric cancer resembles the endoscopic features of a submucosal tumor (SMT). A correct histological diagnosis is difficult with repeated biopsy specimens because they are covered with normal mucosa. Some features known to suggest malignant SMT include a size greater than 3 to 5 cm, a rapid growth rate, echoheterogeneity and irregular margins on endoscopic ultrasonography (EUS). Various techniques including US- guided biopsy, partial removal by an endoscopic snare excision, as well as EUS with a fine needle aspiration were used to enhance the diagnostic accuracy. We recently experienced a case of early gastric cancer, presenting as a submucosal tumor-like lesion, which was confirmed by endoscopic mucosal resection. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2005;31:404⁣408)

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Synchronous Double Primary Cancer: Gastric Hepatoid Adenocarcinoma and Rectal Adenocarcinoma: Woo Hyun Cho, M.D., Jung Sup Kim, M.D., Sung Yik Lee, M.D., Bo Hyun Kim, M.D., Su Jin Lee, M.D., Jung Hyun Lee, M.D., Tae Oh Kim, M.D., Yun Seong Kim, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2005;31(6):409-413. Published online December 30, 2005

Abstract PDF: Hepatoid adenocarcinoma (HAC) of the stomach is a rare neoplasm consisting of both adenocarcinomatous and hepatocellular carcinoma (HCC)-like foci; the latter of which showed the full spectrum of morphological and functional features of HCC. Numerous cases of HAC have been reported in a variety of primary organs, the stomach is one of the most common sites. HAC is associated with an increased serum alpha-fetoprotein (AFP) level and a strong tendency for lymphatic and venous invasion. Because of early hepatic metastasis, prognosis seems less favorable than more common types of adenocarcinoma. Here, we report a case of synchronous double primary cancer, consisting of hepatoid adenocarcinoma of the stomach and adenocarcinoma of the rectum. (Korean J Gastrointest Endosc 2005;31:409⁣413)

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Case of Malignant Duodeno-Colic Fistula Showing Typical Endoscopic Findings: Jin-Min Park, M.D., Woo-Chul Chung, M.D., Kang Moon Lee, M.D., Bo-In Lee, M.D., Ji-Sung Chun, M.D., Young-Sik Woo, M.D., U-Im Chang, M.D., Jin Mo Yang, M.D., Kyu-Yong Choi, M.D. and In-Sik Chung, M.D.; Korean J Gastrointest Endosc 2005;31(6):414-418. Published online December 30, 2005

Abstract PDF: Malignant duodeno-colic fistula is a rare complication of advanced colon cancer. The right colon cancer adjacent to the hepatic flexure can occasionally invade into the pancreas or duodenum, but the formation of fistula between the duodenum and colon is very rare. The patients usually complain chronic diarrhea, vomiting and belching of foul smelling gas. This results in physiologic complications such as weight loss, malnutrition, and electrolyte imbalance. It is well known that the barium enema is the most useful diagnostic procedure. We experienced the case of duodeno- colic fistula that arose from the right colon cancer, and the fistula was directly confirmed by an endoscopic examination. (Korean J Gastrointest Endosc 2005;31:414⁣418)

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A Case of Enteritis Cystica Profunda in the Duodenal Bulb: Hee Jong Chang, M.D., Jae Il Jung, M.D., Myung Chan Kim, M.D., Dong Hui Cho, M.D., Dong Sik Cho, M.D., Sang Hun Lee, M.D., Si Woo Kim, M.D., Sung Chul Cha, M.D., Yu Gin Cho, M.D., Yun Chul Seok, M.D., Sung Seog Ki, M.D. and Haeng Ji Kang, M.D.*; Korean J Gastrointest Endosc 2005;31(6):419-422. Published online December 30, 2005

Abstract PDF: Enteritis cystica profunda (ECP) is characterized by mucin-filled cystic spaces that are partially lined by non-neoplastic columnar epithelium, and these are found in the wall of the small bowel. This is a very rare disease compared to cystica profunda involving the stomach or colon. The cause of ECP is still unclear. Most ECP is related to or it may accompany other intestinal diseases. We encountered one case of ECP of the duodenal bulb that presented as polyp, and this was not related to adenocarcinoma or any other intestinal diseases like Crohn's disease or ulcerative colitis. Endoscopic polypectomy was done and the ECP was later confirmed through histological evaluation. (Korean J Gastrointest Endosc 2005;31:419⁣422)

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A Case of Small Bowel Obstruction due to Multiple Trichobezoars: Sang Won Park, M.D., Yun Sok Yang, M.D., Ho Sup Lee, M.D., Jyung Hyun Kim, M.D., Chang Goo Lee, M.D. and Jin Kwan Lee, M.D.; Korean J Gastrointest Endosc 2005;31(6):423-426. Published online December 30, 2005

Abstract PDF: Trichobezoars are gastric concretions that are composed of hair or fibers. They are more common in children and adolescents and are usually associated with a pica, emotional disturbance, or mental retardation. Trichobezoar is quite rare in Korea. In most cases, trichobezoars tend to form a cast of the stomach. However, in rare cases, portions of the trichobezoar may separate from the gastric mass, migrate distally, and obstruct the small bowel. We report a case of small bowel obstruction due to multiple trichobezoars in a 14 year-old-girl who had a habit of swallowing hairs until 12 years of age. The patient was treated successfully surgically. (Korean J Gastrointest Endosc 2005;31:423⁣426)

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A Case of Coffee Enema-Induced Colitis: Jin Woo Choi, M.D., Yun Ju Jo, M.D., Sung Cheol Kim, M.D., Seok Jin Myung, M.D., Han Hyo Lee, M.D., Moon Hee Song, M.D., Seong Hwan Kim, M.D., Young Sook Park, M.D., Jong Eun Joo, M.D.* and Sung Won Park, M.D.^†; Korean J Gastrointest Endosc 2005;31(6):427-431. Published online December 30, 2005

Abstract PDF: A coffee enema which has been suggested as a part of a cancer treatment, has been misused as a treatment for obesity and constipation among the general population. Its proponents claim that caffeine is absorbed in the colon, which leads to vasodilatation in the liver and stimulation of the hepatocellular function to detoxify the products of the tumor cell metabolism. However, the clinical efficacy of the anti-cancer effect of coffee enemas has not been demonstrated. Many side effects of coffee enemas have been reported. These include severe electrolyte imbalance, polymicrobial enteric septicemia, and even death. We experienced a patient who presented with abdominal pain and a bloody stool after receiving a coffee enema to relieve constipation. We report this case of coffee enema-induced colitis with a review of the relevant. (Korean J Gastrointest Endosc 2005;31:427⁣431)

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A Case of Cholelithiasis with Massive Lower Gastrointestinal Bleeding: Dong Won Ahn, M.D., Sun Jung Myung, M.D., Cheol Min Shin, M.D., Su Jong Yu, M.D., Ji Won Yoo, M.D., Soo Jeong Cho, M.D., Jae Hyun Cho, M.D., Ji Kon Ryu, M.D., Yong-Tae Kim, M.D., Yong Bum Yoon, M.D. and Jin Young Jang, M.D.*; Korean J Gastrointest Endosc 2005;31(6):432-436. Published online December 30, 2005

Abstract PDF: Cholelithiasis is a relatively common disease and can present with various clinical manifestations and complications such as no symptoms, biliary pain, acute cholecystitis, biliary pancreatitis, acute cholangitis, gallstone ileus and biliary enteric fistula. However, cholelithiasis presenting with intra-gallbladder bleeding and massive gastrointestinal bleeding are relatively rare in the worldwide literature and there have been only a few reported case studies. We present here an interesting case of a 63 year-old women with gallstone, active intra-gallbladder bleeding and massive hematochezia who underwent open cholecystectomy, resection and anastomosis of the transverse colon. This patient's pathologic evaluation revealed a finding of acute and chronic cholecystitis with marked hemorrhage and transmural fibrinoid necrosis in the transverse colon. (Korean J Gastrointest Endosc 2005;31:432⁣436)

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A Case of Synchronous Double Cancer -Klatskin's Tumor and Ampullary Adenocarcinoma-: Beom Jae Lee, M.D., Hong Sik Lee, M.D., Jong Jin Hyun, M.D., Kyung Jin Kim, M.D., Min Jeong Kim, M.D., Rok Son Choung, M.D., Yong Sik Kim, M.D., Hyung Jun Lim, M.D., Yoon Tae Jeen, M.D., Hoon Jai Chun, M.D., Soon Ho Um, M.D., Sang Woo Lee, M.D., Jai Hyun; Korean J Gastrointest Endosc 2005;31(6):437-442. Published online December 30, 2005

Abstract PDF: Multiple cancers in the extrahepatic biliary tree are relatively rare. Many such cases are a double cancer of the common bile duct and the gallbladder. We report a case of a double primary cancer that occurred synchronously at the hilum of the extrahepatic duct and the ampulla of Vater with a review of the relevant literature. A 57-year-old man was admitted to our institution after a 15 day of painless jaundice and a urine color change. Ultrasonography showed a dilation of both intrahepatic ducts. Upper endoscopy revealed a protruding ulcerative mass at the ampulla of Vater and endoscopic retrograde cholangiography showed a dilated common bile duct and a mildly dilatated pancreatic duct, but both intrahepatic bile ducts were not visualized. An upper abdominal CT scan showed a dilation of both intrahepatic bile ducts and an infiltrating mass at the bifurcation area. Magnetic resonance cholangiopanreatography showed narrowing bile duct lumen that was obstructed by the tumor at the hepatic duct bifurcation, which dilated both intrahepatic ducts. A histological examination of the ampulla of Vater revealed a well differentiated adenocarcinoma of the ampulla of Vater. The final diagnosis was a synchronous double cancer of Klatskin's tumor and an adenocarcinoma of the ampulla of Vater. (Korean J Gastrointest Endosc 2005;31:437⁣442)

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