Clinical Endoscopy

Usefulness of Double Esophageal Stent for Malignant Esophageal Stricture: Jin Hyun Park, M.D., Cheul Woong Choi, M.D., Kyung Yup Kim, M.D., Hyung Ryul Park, M.D., Ji Young Kim, M.D., Do Hoon Kim, M.D., Hye Jeong Lee, M.D., Il Du Kim, M.D., Jong Ho Hwang, M.D., Gwang Ha Kim, M.D., Geun Am Song, M.D. and Dae Hwan Kang, M.D.; Korean J Gastrointest Endosc 2007;35(4):211-215. Published online October 30, 2007

Abstract PDF: Background
/Aims: Endoscopic self expandable metallic stent (SEMS) has become the palliative treatment of choice for inoperable malignant esophageal stricture. However, covered and uncovered stents carry limitations such as stent migration and tumor ingrowth, respectively. A double esophageal stent has been developed to overcome these problems. The aim of this study was to evaluate the usefulness of double esophageal stent (outer uncovered stent and inner covered stent) for palliation of malignant esophageal stricture. Methods: Between February 2001 and November 2006, 32 patients with malignant esophageal stricture were treated with double esophageal stents. The patients were retrospectively assessed for the technical outcome, the clinical outcome and the complications of the process. Results: Stent implantation was successful in all 32 patients (100%). The dysphasia score significantly improved from a mean of 3.22 to 1.63 (p＜0.001) for all 32 patients. Eight patients had recurrent dysphagia due to stent overgrowth (6/32, 18%), stent migration (1/32, 3%) and tumor ingrowth (1/32, 3%). Symptomatic gastroesophageal reflux occurred in six patients (18%). Aspiration pneumonia occurred in two patients (6%). Conclusions: Double esophageal stent is effective for symptomatic relief of malignant esophageal stricture. It seems to reduce tumor ingrowth and stent migration, but it has limitations such as tumor overgrowth and GERD. (Korean J Gastrointest Endosc 2007;35:211-215)

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The Eradication Rate of Helicobacter pylori on the Remnant Stomach after Curative Resection for Gastric Cancer and the Influence of Eradication: In Kyoung Kim, M.D., Woo Hyun Paik, M.D., Jae Kyung Lee, M.D., Goh Eun Chung, M.D., Youn Joo Kim, M.D., Chang Hyun Lee, M.D., Kyoung Sup Hong, M.D., Sang Hyub Lee, M.D.*, Young-Soo Park, M.D.*, Jin-Hyeok Hwang, M.D.*, Jin-Wook Kim, M.D.*, Sook Hyang Jung,; Korean J Gastrointest Endosc 2007;35(4):216-220. Published online October 30, 2007

Abstract PDF: Background
/Aims: There are few reports on the rate of H. pylori eradication and the influence of this eradication in the remnant stomach after a curative resection for a gastric carcinoma. Methods: The medical records of patients who had undergone curative gastrectomy for carcinoma between May, 2003 and June, 2006 were reviewed to evaluate the serial H. pylori status. The eradication regimen was a proton pump inhibitor (PPI) based triple therapy (PPI, amoxicillin, clarithromycin). After eradication, the histological changes were reviewed based on the updated Sidney system. In addition, a CLO test and urea breath test were used for the evaluation. Results: Eighty five patients were found to be positive for a H. pylori infection after the curative gastrectomy. Fifty two patients received eradication therapy and the other 33 patients did not. The eradication rate in patients who received therapy was 82.7% and spontaneous resolution rate in the patients who did not receive therapy was 78.8% (p=0.654). After eradication, the remnant stomach showed a significant decrease in the inflammation and activity scores. Conclusions: The eradication rate of H. pylori by PPI based triple therapy in the remnant stomach is similar to that in a non-surgical stomach. The decrease in the inflammation and activity score suggests that the eradication may prevent H. pylori related carcinogenesis. However, the high spontaneous negative conversion rate (78.8%) in the remnant stomach after gastrectomy will require further study. (Korean J Gastrointest Endosc 2007;35:216-220)

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Treatment of Gastric Outlet Obstruction by Stomach Cancer with using Double-layered Pyloric Stent: Soo Hyoung Lee, M.D., Dae Hwan Kang, M.D.*, Yong Mock Bae, M.D., Cheul Woong Choi, M.D.*, Tai In Ha, M.D.*, Chan Ho Park, M.D.*, Hyoung Yoel Park, M.D.*, Sun Mi Lee, M.D.*, Gwang Ha Kim, M.D.* and Geun Am Song, M.D.*; Korean J Gastrointest Endosc 2007;35(4):221-227. Published online October 30, 2007

Abstract PDF: Backgroud/Aims: Endoscopic stent placement is widely used to treat an unresectable malignant gastric outlet obstruction. The covered stent has the disadvantage of an increased risk of migration, and the uncovered stent has an increased risk of ingrowth. This study examined the technical and clinical efficiency of stent placement of a double-layered combination pyloric stent that was newly designed to reduce tumor ingrowth and stent migration. Methods: Fifteen patients with a gastric outlet obstruction caused by unresectable stomach cancer were treated with the endoscopic placement of a double-layered combination pyloric stent (an outer uncovered stent to reduce migration and an inner PTEF-covered stent to prevent tumor ingrowth). The technical success, clinical success, and complication especially tumor ingrowth and stent migration were analyzed. Results: Technical success was achieved in 15 out of 15 (100%) patients. Among the 15 patients in whom endoscopic stenting was placed successfully, the clinical success rate was 93.3%, the incidence of tumor ingrowth was 0%, the rate of migration was 6.7%, and tumor overgrowth was observed in 13.3%. The median stent patency period was 105 days. Conclusions: The placement of a double- layered pyloric combination stent appears to be effective in overcoming the disadvantage of the increased migration observed for a covered stent and the increased ingrowth observed for the uncovered stent. (Korean J Gastrointest Endosc 2007;35:221-227)

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Usefulness of Endoscopic Ultrasonography for Diagnosing Choledocholithiasis in Patients with Gallbladder Stones: Ja Seol Koo, M.D., Hong Sik Lee, M.D., Sung Woo Jung, M.D., Woo Sik Han, M.D., Jong Sup Lee, M.D., Hyung Joon Yim, M.D., Sang Woo Lee, M.D., Jai Hyun Choi, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;35(4):228-234. Published online October 30, 2007

Abstract PDF: Background
/Aims: CBD stones (CBDS) are generally thought to originate from the gallbladder. Recently, EUS appears to be the best imaging method for making the diagnosis of CBDS. We conducted this study to evaluate the role of EUS for detecting CBDS in patients with gallbladder stones (GBS) and to determine the parameters for predicting CBDS. Methods: From April 2003 to March 2005, 117 GBS patients were enrolled. The patients' clinical and laboratory findings and the radiologic findings of US, EUS, CT and ERCP were reviewed. The sensitivity, specificity, PPV and NPV of EUS for detecting CBDS were evaluated by using ERCP and intraoperative CBD exploration as the gold standard for diagnosing CB. Results: A total 117 patients received EUS and no complications were encountered. After performing ERCP and/or intraoperative exploration, 62 of the patients were examined for determining the presence or absence of CBDS. EUS shows 95% sensitivity and 95% specificity for identifying CBDS. The overall agreement between EUS and ERCP was 94.8%. The patients with CBDS were older than those without CBDS. Fever, jaundice and cholangitis were more prevalent in the patients with CBDS. The results of liver function tests were elevated more frequently in the patients with CBDS (p＜0.05). Conclusions: EUS is an accurate and minimally invasive method for diagnosing CBDS. Evaluating CBD in patients with gallstones is selectively recommended according to clinical and laboratory findings. (Korean J Gastrointest Endosc 2007;35:228-234)

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Role of Multidetector Computerized Tomography (MDCT) in Identification of Common Bile Duct Stone: Comparison with ERCP: Dong Il Kim, M.D., Hong Sik Lee, M.D., Jin Nam Kim, M.D., Sung Woo Jung, M.D., Ja Seol Koo, 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 Duck Kim, M.D., Seung Hwa Le; Korean J Gastrointest Endosc 2007;35(4):235-242. Published online October 30, 2007

Abstract PDF: Background
/Aims: MDCT, which provides high resolution and various reconstructing images, has recently become widely available and is a promising tool for imaging the bile duct with precision. In order to evaluate the diagnostic value of multidetector computerized tomography (MDCT) for a common bile duct (CBD) stone, this study compared the diagnostic accuracy of MDCT with that of ERCP. Methods: The medical records of the patients undergoing both MDCT and ERCP consecutively from June 2006 to January 2007 were retrospectively reviewed. One hundred and sixty four patients (164 cases) were enrolled in this study. The final diagnoses were based mainly on the ERCP findings. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of MDCT and ERCP for choledocholithiasis were identified and compared. Results: Of the 164 cases, 47 cases were diagnosed with choledocholithiasis. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for choledocholithiasis were 89.4%, 98.3%, 95.5%, 95.8%, 95.7% in MDCT and 97.9%, 99.1%, 97.9%, 99.1%, 98.8% in ERCP, respectively. There were no statistically significant differences in the diagnostic accuracy between the two methods (p=0.206). Conclusions: MDCT has high sensitivity and specificity for diagnosing stones in the bile duct and should be performed in preference to ERCP in patients suspected of having choledocholithiasis. (Korean J Gastrointest Endosc 2007;35:235-242)

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Two Cases of Gastric Schwannomas - with Ulcer and without Ulcer -: Pyo Jun Kim, M.D., Gwang Ha Kim, M.D., Jin Kang, M.D., Tae Ik Park, M.D., Dong Hoon Shin, M.D., Tae Yong Jeon, M.D. and Geun Am Song, M.D.; Korean J Gastrointest Endosc 2007;35(4):243-249. Published online October 30, 2007

Abstract PDF: A Schwannoma is a benign tumor that originates from Schwann cells in the gastric wall. The tumor is mainly asymptomatic but sometimes can cause bleeding of the upper GI tract. We encountered a Schwannoma that was identified by gastroscopy as a submucosal mass that might be malignant. Therefore, surgery was considered as the primary treatment. The Schwannoma was confirmed retrospectively by a pathologic examination after excising the mass. This case report is a comparative study into Schwanoma with and without central ulceration. Pathologically, atypia of the cell was discovered in the case accompanied by an ulcer, which is a secondary phenomenon caused by the degeneration that does not indicate the malignancy. (Korean J Gastrointest Endosc 2007; 35:243-249)

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A Case of Early Gastric Adenocarcinoma Mimiking a Submucosal Tumor: Joon Hyuk Lee, M.D., Jeong Eun Shin, M.D., Bae Hwan Kim, M.D., Dong Woo Kim, M.D., Ki Chul Shin, M.D., Se Young Yun, M.D., Suk Bae Kim, M.D., Il Han Song, M.D., Chang Hwan Lee, M.D.* and Won Ae Lee, M.D.^†; Korean J Gastrointest Endosc 2007;35(4):250-253. Published online October 30, 2007

Abstract PDF: Early gastric adenocarcinoma with the endoscopic features resembling a submucosal tumor is extremely rare and is characterized by erythema, central depression and erosion on the surface of the lesion, which can be distinguished from submucosal tumor. When a tumor is completely covered with normal mucosa, it is extremely difficult to obtain endoscopic biopsy specimens from the underlying lesion. EUS alone is not necessarily diagnostic. Various techniques have been advocated to overcome this problem, including US-guided biopsy, partial removal by an endoscopic snare excision, endoscopic mucosal resection as well as EUS with FNA. We encountered a case of an early gastric adenocarcinoma with well differentiation, presenting as a submucosal tumor. The early gastric adenocarcinoma was evaluated by endoscopy and EUS, and was confirmed by a surgical resection. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2007;35:250-253)

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A Case of Duodenal GIST Accompanied with Neurofibromatosis-1, Presenting with Gastrointestinal Bleeding: Sung O Seo, M.D., Hyo Jung Oh, M.D., Ki Hoon Kim, M.D., Chang Soo Choi, M.D., Geom Seog Seo, M.D., Tae Hyeon Kim, M.D., Ki Jung Yun, M.D.* and Suck Chei Choi, M.D.; Korean J Gastrointest Endosc 2007;35(4):254-257. Published online October 30, 2007

Abstract PDF: Gastrointestinal stroma tumors (GISTs) are CD117- positive primary mesenchymal tumors of the gastrointestinal tract and are noted to have a possible non-random association with neurofibromatosis-1 (NF-1, Von Recklinghausen disease). We report a case of a duodenal GIST presenting with gastrointestinal bleeding in a 74-year-old female, and this condition was accompanied with NF-1. A upper gastrointestinal endoscopy and abdominal computed tomography scan revealed several submucosal tumors in the duodenum, jejunum and ileum. Histological and immunohistochemical studies on the surgical resection specimen revealed gastrointestinal stromal tumors of an uncommitted type. The patient was treated with local excision of the tumors and is now in a favorable state. (Korean J Gastrointest Endosc 2007;35:254-257)

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A Case of a Bleeding Dieulafoy's Lesion in a Duodenal Diverticulum Treated by Endoscopic Hemoclipping: Nang Hee Kim, M.D., Kyu-Jong Kim, M.D., Seo Ryong Han, M.D., Ji Eun Park, M.D., Ji Hyeon Nam, M.D., Sung Hoon Kim, M.D., Eun Kyung Shin, M.D., Do Hyun Kim, M.D., Jun Young Song, M.D., Sung Eun Kim, M.D., Won Moon, M.D., Moo In Park, M.D. and Seun Ja Park,; Korean J Gastrointest Endosc 2007;35(4):258-261. Published online October 30, 2007

Abstract PDF: A duodenal diverticulum is common and usually originates in the second portion of the duodenum. The majority of diverticula are asymptomatic; however, they may sometimes present with symptoms such as obstruction, hemorrhage, perforation, jaundice and pancreatitis. Active bleeding from a duodenal diverticulum is rare, and moreover, Dieulafoy's lesion as a cause is quite rare with very few cases reported so far. The use of endoscopic methods instead of surgery in achieving hemostasis has been on the increase with the widespread use and improvement in endoscope instrumentation and accessories. Of these methods, the use of endoscopic hemoclipping for Dieulafoy's lesion is considered more effective and safe than the use of other methods, such as injection and thermal methods. We report here a case of a bleeding Dieulafoy's lesion in a duodenal diverticulum treated by endoscopic hemoclipping. (Korean J Gastrointest Endosc 2007;35:258-261)

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A Case of Acute Injury in the Stomach and Duodenum after Cyberknife Therapy: Jae Hyuck Chang, M.D., Myung Gyu Choi, M.D., Chan Ran You, M.D., Kwan Woo Nam, M.D., Jung Hyun Kwon, M.D., Jung Pil Suh, M.D., Ho Sung Park, M.D., Chang Nyol Paik, M.D., Jae Myung Park, M.D., Yu Kyung Cho, M.D., In Seok Lee, M.D., Sang Woo Kim, M.D. and I; Korean J Gastrointest Endosc 2007;35(4):262-266. Published online October 30, 2007

Abstract PDF: Therapeutic radiation therapy has developed new technologies that use a high dose of radiation with three- dimensional targeting for a few days instead of conventional radiation therapy that uses small doses of radiation for a longer period of time. A Cyberknife is an image- guided robotic system for stereotactic radiosurgery. The Cyberknife was first developed for the treatment of intracranial lesions, and recently has been used for tumors in the chest and abdomen. A Cyberknife can use a high dose of radiation for treatment of a hepatocellular carcinoma and can be employed to minimize radiation injury around the tumor. However, in a large tumor, the therapeutic efficacy is reduced and injury can occur around the organs. We report a case of acute injury in the stomach and duodenum after Cyberknife treatment of a hepatocellular carcinoma near the hepatic portal area. (Korean J Gastrointest Endosc 2007;35:262-266)

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A Case of Pancreaticobiliary Duct Obstruction due to Pancreatic Tuberculosis Combined with a Colon Adenocarcinoma and Tuberculous Colitis: Lae Seok Hwang, M.D., Seong Woo Nam, M.D., Seong Eun Lee, M.D., Nak Hyun Kwon, M.D., Hyo Sung Kang, M.D., Sung Hoon Kim, M.D., Kee Suk Nam, M.D., Kyung Deuk Hong, M.D., Se Woon Ham, M.D., Young Woong Jeon, M.D.*, Se Hyuk Park, M.D.*, Sung Chan Jin, M.D.^†,Hae Sun Ahn, M.D.^‡; Korean J Gastrointest Endosc 2007;35(4):267-271. Published online October 30, 2007

Abstract PDF: Systemic manifestation of tuberculosis is common, but tuberculous biliary obstruction of the pancreas and a colon adenocarcinoma with combined colonic tuberculosis is an uncommon disorder. We encountered a case of the above condition in 63-year-old male that was admitted to our hospital because of fever, diffuse abdominal pain and rigidity. Abdominal computed tomography showed biliary and pancreatic duct dilatation with left colonic wall thickening and surrounding peritoneal infiltration. Emergency segmental resection of the descending colon with intraoperative T-tube choledochostomy was performed due to the colon mass and biliary obstruction. A colonofiberoscopy was performed for low abdominal pain and hematochezia at 12 days after surgery. It showed multiple colonic ulcerations with a partial stricture. A colonic biopsy showed granulomatous inflammation with acid-fast bacilli. The cause of the biliary obstruction was also revealed as pancreatic tuberculosis by an intraoperative pancreatic and mesenteric biopsy. The patient improved after antituberculous treatment and the patient has been in good health until the last outpatient follow-up visit. (Korean J Gastrointest Endosc 2007;35:267-271)

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A Case of Primary Rectal MALT Lymphoma Presented as Multiple Submucosal Tumors: Hee Sun Mun, M.D., Hyo Jin Park, M.D., Ki Byung Lee, M.D., In Su Jung, M.D., Woo Ick Yang, M.D.*, Soon Won Hong, M.D.* and Jung Hwan Kim, M.D.^†; Korean J Gastrointest Endosc 2007;35(4):272-276. Published online October 30, 2007

Abstract PDF: MALT (mucosa-associated lymphoid tissue) lymphomas are the most common primary gastrointestinal (GI) lymphomas. MALT lymphomas of the GI tract tend to occur most commonly in the stomach, followed by the small intestine, ileocecal area, colon and the esophagus. However, MALT lymphomas of the large intestine are rare. Previously, a diagnosis was commonly established by the surgical specimens but endoscopic biopsy specimens are currently used to make a diagnosis. A 61-year-old woman was found to have multiple submucosal tumors of the rectum during a screening colonoscopy. The tumors were removed by a polypectomy. The histology revealed the diffuse infiltration of centrocyte-like cells and a lymphoepithelial lesion. Immunohistochemical staining confirmed the diagnosis of a low grade B cell lymphoma of the MALT type. No other site of involvement was identified on the CT of the chest, abdomen and pelvis. (Korean J Gastrointest Endosc 2007;35:272-276)

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A Case of Acute Cholangitis with Intraluminal Gallbladder Hematoma after Percutaneous Liver Biopsy: Sang Hoon Lee, M.D., Tae Nyeun Kim, M.D., Jun Young Lee, M.D., Hee Jung Moon, M.D., Jong Ryul Eun, M.D., Byung Ik Jang, M.D.; Korean J Gastrointest Endosc 2007;35(4):277-280. Published online October 30, 2007

Abstract PDF: Percutaneous liver biopsy is valuable for making the diagnosis and follow-up of many liver diseases. Complications after ultrasonography-guided liver biopsy are rare, but a few serious complications have been reported. We report here on a 43-year-old man with acute cholangitis and gallbladder hematoma secondary to hemobilia; these occurred 4 days after performing ultrasonography guided percutaneous liver biopsy for the evaluation of multiple liver nodules. (Korean J Gastrointest Endosc 2007;35: 277-280)

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A Case of Biliary Cast Syndrome with a Biliary Stricture and Suppurative Cholangitis after Liver Transplantation: Jung Pil Suh, M.D., In Seok Lee, M.D., Jae Hyuck Chang, M.D., Jung Hyun Kwon, M.D., Won Haing Hur, M.D., Si Hyun Bae, M.D., Myung Gyu Choi, M.D., In Sik Chung, M.D. and Dong Goo Kim, M.D.*; Korean J Gastrointest Endosc 2007;35(4):281-286. Published online October 30, 2007

Abstract PDF: Biliary complications after liver transplantation occur in 13∼35% of patients. Biliary cast syndrome, cast formation of biliary sludge along the bile duct, can develop in 4∼18% of liver transplant recipients, although the incidence rate is significantly decreasing due to the improvement of graft harvesting and preservation. It is very important that early diagnosis and effective management of biliary cast syndrome be performed when there is a bile duct stricture or dilatation associated with jaundice and cholangitis in the recipient after liver transplantation, due to the possibility of retransplantation and death of the patient from graft loss. We report a case of a biliary cast formed with suppurative cholangitis and extracted incidentally with a plastic biliary stent during an endoscopic procedure after cadaveric liver transplantation, in which the ERCP findings revealed a stricture at the anastomosis site of the common bile duct and cholangitis. (Korean J Gastrointest Endosc 2007;35:281-286)

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A Case of Surgical Treatment of Tuberculous Cholangitis and Lymphadenitis with Obstructive Jaundice due to Progressive Stricture of Bile Duct: Kil Hyun Kim, M.D., Yang Suh Ku, M.D., Koen Kuk Kim, M.D.*, Hyun Ok Kim, M.D., Geum Ha Kim, M.D., Kwang Il Ko, M.D., Nak So Chung, M.D., Sang Kyun Yu, M.D., Dong Kyun Park, M.D., Kwang An Kwon, M.D., Yeon Suk Kim, M.D., Yu Kyung Kim, M.D. and Ju Hyun Kim,; Korean J Gastrointest Endosc 2007;35(4):287-291. Published online October 30, 2007

Abstract PDF: Obstructive jaundice is most commonly attributed to a malignancy or stones affecting the common bile duct. Biliary tuberculosis and lymphadenitis around the periportal area have also been implicated but cases are quite rare. A 24 year old man presented with jaundice and abdominal pain for 3 days. Abdominal CT and ERCP revealed a stricture of the extrahepatic bile duct with multiple enlarged lymph nodes showing necrotic foci located at the periportal area. The colonoscopic biopsy showed evidence of M. tuberculosis. The patient was treated with ERBD insertion and oral anti-tuberculosis therapy. However, the abdominal pain recurred and there was progressive stenosis of the common bile duct. A bile duct resection with choledochojejunostomy was subsequently performed. Frozen sections revealed granulomatous inflammation with caseation necrosis, which was consistent with tuberculosis. We report a case of tuberculous cholangitis and lymphadenitis with obstructive jaundice that was managed surgically due to the progressive stricture of the bile duct. (Korean J Gastrointest Endosc 2007;35:287-291)

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대장 점막하 침윤암의 림프절 전이의 위험인자와 심달도의 절대적 분류: Korean J Gastrointest Endosc 2007;35(4):292-294. Published online October 30, 2007

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