Clinical Endoscopy

Prospective Evaluation of Ultrathin Transnasal Esophagogastroduodenoscopy:Its Feasibility, Safety and Tolerance: Jai Hak Jeung, M.D., Seong Hyeon Jeung, M.D., Hyeok Choon Kwon, M.D., Byong Joon Park, M.D., Jong Dae Han, M.D., Jae Chul Hwang, M.D., Sung Jae Shin, M.D., Jae Youn Cheong, M.D., Kee Myung Lee, M.D., Byung Moo Yoo, M.D., Kwang Jae Lee, M.D. and Jin Hong K; Korean J Gastrointest Endosc 2008;36(6):329-335. Published online June 30, 2008

Abstract PDF: Background
/Aims: We performed a prospective study to compare the feasibility, safety and tolerance among ultrathin transnasal (UT-N), thin transnasal (T-N) and ultrathin oral (UT-O) esophagogastroduodenoscopy. Methods: Two narrow diameter endoscopes (Ø=5.2 mm for UT-N and UT-O, Ø=6.5 mm for T-N) were used. The operator factors and patient factors were quantified by a visual analogue scale. Results: The procedure was successfully completed in 100 of 100 patients in the UT-O group. The T-N group, when compared with the UT-N group, accounted for a significantly higher portion of failure (14% vs 3%, respectively, p=0.000), more cases of epistaxis (11% vs 3%, respecttively, p=0.013) and more complaints of nasal pain (17% vs 6%, p=0.016). The overall quality of the exam was significantly higher in the UT-N group (UT-N, 8.7; T-N, 8.1; UT-O, 8.2, p=0.04). The frequency of a incurring a gag reflex was significantly lower in the UT-N group (UT-N, 1.26; T-N, 1.48; UT-O, 2.94, p= 0.000). The patients' score for overall general satisfaction was higher in the UT-N group (UT-N, 8.5; T-N, 7.8; UT-O, 7.7, p=0.006). Nausea was significantly reduced the in UT-N group (UT-N, 8.2; T-N, 7.8; UT-O, 7.3, p= 0.003). Patients in the UT-N group were more willing to repeat the same procedure (UT-N, 82%; T-N, 65%; UT-O, 71%, p=0.046). Conclusions: Ultrathin transnasal endoscopy is more feasible, safe and comfortable compared with the thin transnasal endoscopy or when compared with either instrument that was passed orally. (Korean J Gastrointest Endosc 2008;36:329-335)

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The Use of Uncovered Self-Expandable Metallic Stents for Palliation ofGastric Outlet Obstruction Caused by Stomach Cancer: Dae Soon Kwon, M.D., Pyung Gohn Goh, M.D., Se Woong Hwang, M.D., Kwan Woo Nam, M.D., Hee Seok Moon, M.D., Jae Hoon Jung, M.D., Jae Kyu Seong, M.D. and Hyun Yong Jeong, M.D.; Korean J Gastrointest Endosc 2008;36(6):336-340. Published online June 30, 2008

Abstract PDF: Background
/Aims: The purpose of this study is to investigate the effectiveness and safety of the use of uncovered self-expandable metallic stents as a palliative therapy for gastric outlet obstruction caused by stomach cancer. Methods: A total of 36 patients who underwent uncovered stent insertion were investigated. Hanarostents (uncovered pyloric/duodenal stents, M.I. Tech Co., Ltd.) were used in the procedures. The technical success rate, clinical success rate, presence of clinical symptoms and complications were estimated during the study period. Results: The technical success rate for stent replacement was 97.2% (35 out of 36 patients) and the clinical success rate was 91.7% (33 out of 36 patients). The mean dysphagia scores before and after the procedures were 2.44 and 0.92, respectively. The median hospital stay after stenting was 10 days and the mean follow-up period was 91 days. Thirteen patients died during the follow-up period (mean survival, 70 days). The complication rate was 22.2% (8 out of 36 patients). Restenosis occurred in four cases, bleeding in two cases, pain in one case and stent migration in one case. There were no deaths related to the procedures. Conclusions: These findings suggest that placement of uncovered self-expandable metallic stents for gastric outlet obstruction caused by stomach cancer results in good symptomatic improvement with a low rate of complications. (Korean J Gastrointest Endosc 2008;36:336-340)

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Traction with using a Rubber Band and Clips for Effective Endoscopic Submucosal Dissection: Bo-In Lee, M.D., Byung-Wook Kim, M.D., Hwang Choi, M.D., Jeong-Seon Ji, M.D., Woo-Chul Chung, M.D., Kang-Moon Lee, M.D., In-Seok Lee, M.D., Jin-Il Kim, M.D., Myung-Gyu Choi, M.D., Kyu-Yong Choi, M.D., In-Sik Chung, M.D. and Lee-So Maeng, M.D.*; Korean J Gastrointest Endosc 2008;36(6):341-348. Published online June 30, 2008

Abstract PDF: Background
/Aims: Traction with using a rubber band and clips may be helpful for performing endoscopic submucosal dissection (ESD) by keeping adequate tissue tension and satisfactory submucosal exposure. Methods: 17 patients with noninvasive neoplasias or intramucosal cancers (16 gastric lesions and 1 colonic lesion) were included to evaluate this technique's feasibility (3), because of a difficult location for dissection (11), unsatisfactory mucosal elevation despite adequate submucosal injection (2), and a high risk of perforation from the thin colonic wall (1). Submucosal dissection was performed after traction was applied, with a using a rubber band and clips, to a precut margin of the lesion. Results: The mean sizes of the 16 gastric neoplasias and the corresponding resected specimens were 16±9 mm (6∼40) and 37±9 mm (18∼50), respectively, and the sizes of the colonic intramucosal cancers and the resected specimens were 41 mm and 51 mm), respectively. Both the en-bloc resection rate and the complete resection rate were 77%. Complete ESD without snaring was preformed in 10 cases (59%). The traction was assessed as useful in eleven cases (65%), not useful in two (12%), and annoying in four (23%). Conclusions: Traction with using a rubber band and clips can be useful for performing ESD. (Korean J Gastrointest Endosc 2008;36:341-348)

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Clinical Features and Prognostic Factors in Ischemic Colitis: Sung Hoon Jung, M.D., Kang Moon Lee, M.D., Jeong Seon Ji, M.D., Woo Chul Chung, M.D., Chang Nyol Paik, M.D., Bo In Lee, M.D., Jeong Rok Lee, M.D., Hwang Choi, M.D., You Joung Kim, MPH*, Jin Mo Yang, M.D. and Kyu Yong Choi, M.D.; Korean J Gastrointest Endosc 2008;36(6):349-353. Published online June 30, 2008

Abstract PDF: Background
/Aims: Ischemic colitis mainly occurs in elderly patients and encompasses a wide clinical spectrum from mild, transient to severe and gangrenous forms. Since life expectancy is now increasing, more often physicians will encounter patients with this disease entity. Our aim was to review the clinical features of ischemic colitis and to analyze the effect of clinical factors on the duration of hospital stay and evaluate predictive factors of poor prognosis. Methods: We retrospectively analyzed the medical records of 294 patients diagnosed with ischemic colitis during 10 years from March 1997 to February 2007. Results: The mean hospital stay was 12.4±6.6 days. According to the use of multiple regression analysis, age, sex, clinical symptoms, hypertension, constipation, use of laxatives or antibiotics did not affect hospital stay. Factors that significantly increased hospital stay were diabetes mellitus (p= 0.007), colonic involvement of more than three segments (p=0.009) and the presence of an ulcer on a colonoscopic finding (p=0.008). Conclusions: Diabetes mellitus, colonic involvement of more than three segments and the presence of an ulcer on a colonoscopic finding are important predictive factors of poor prognosis in patients with ischemic colitis. In cases with one of these factors, more intensive treatment options should be adapted. (Korean J Gastrointest Endosc 2008;36:349-353)

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A Preliminary Study on the Usefullness of a Zilver Stent for Bilateral Stenting in Patients with Advanced Hilar Cholangiocarcinoma: Jae Sup Eum, M.D., Dae Hwan Kang, M.D. and Cheol Woong Choi, M.D.; Korean J Gastrointest Endosc 2008;36(6):354-360. Published online June 30, 2008

Abstract PDF: Background
/Aims: Hilar cholangiocarcinomas have an extremely poor prognosis. Although endoscopic bilateral metal stenting with the "stent in stent" technique using a Y stent is currently employed to treat patients with an unresectable hilar cholangiocarcinoma, this method has limited application in cases of tight strictures. Furthermore, insertion of stents into the Y stent side (first stent side) is problematic in cases of tumor recurrence. We evaluated the clinical efficacy of the use of endoscopic bilateral metal stenting with the Zilver stent. Methods: Seven patients with an unresectable Bismuth type III or IV hilar cholangiocarcinoma were included in this study. For endoscopic bilateral metal stenting, we first inserted a Y stent with a central wide-open mesh. The Zilver stent was placed into the contralateral hepatic duct through the central portion of the Y stent. Results: Both technical and functional success was achieved in seven patients (100%). The early complication rate was 0%, and late complications due to tumor recurrence occurred in 2 out of 7 (28.6%) patients. These patients were managed by the placement of additional stents or with the use of percutaneous transhepatic biliary drainage. Conclusions: We suggest that a combination technique using Y and Zilver stents improves bilateral stenting for patients with advanced hilar cholangiocarcinoma and facilitates stent reinsertion in cases of tumor recurrence. (Korean J Gastrointest Endosc 2008; 36:354-360)

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A Case of Esophageal Benign Schwannoma Removed by Endoscopic Mucosal Resection: Seok Cho, M.D., Chang Hwan Park, M.D., Dae Yeul Ryang, M.D., Sung Ryoun Lim, M.D., Kyoung Myeun Chung, M.D., Hye Kyong Jeong, M.D., Phil Jin Jung, M.D., Seung Hwan Lee, M.D., Kyoung Won Yoon, M.D., Hyun Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew,; Korean J Gastrointest Endosc 2008;36(6):361-365. Published online June 30, 2008

Abstract PDF: Esophageal schwannoma is a very rare neoplasm. The differentiation of schwannoma from the other submucosal tumors such as GISTs or leiomyoma is very difficult to do on the preoperative examination with performing esophagoscopy and computed tomography. The diagnosis is generally not confirmed until the histologic and immunohistochemical tests of the tumor are performed. A 38- year-old man presented to us with neck discomfort. The endoscopy showed a middle esophageal submucosal tumor that measured 12 mm in size and there were no mucosal changes. The endoscopic ultrasonography showed a tumor in the muscluaris mucosa layer without lymphadenopathy. After band ligation of the lower part of the tumor, it was removed by performing endoscopic mucosal resection and using a snare. A definitive diagnosis of esophageal benign schwannoma was made from the pathologic findings, which included positive immunohistochemical staining for S-100 protein and negative staining for C-kit, CD34 and actin. We report here on an esophageal benign schwannoma that was removed by endoscopic mucosal resection. (Korean J Gastrointest Endosc 2008;36:361-365)

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A Case of Esophageal Perforation Cured by Conservative Management after Stent Insertion: Yong Seok Jang, M.D., Kwang Bum Cho, M.D., Yo Sig Shin, M.D., Seung Hyun Lee, M.D., Byoung Kuk Jang, M.D., Woo Jin Chung, M.D., Kyeong Sig Park, M.D. and Jae Seok Hwang, M.D.; Korean J Gastrointest Endosc 2008;36(6):366-370. Published online June 30, 2008

Abstract PDF: Esophageal cancer may induce progressive dysphagia. Insertion of a self-expandable metallic stent is widely used to relieve dysphagia. There are previous case reports that have described the use of membrane-covered stents to seal esophageal perforations. Complications of the use of an esophageal stent include bleeding, fistula formation, perforation, pain, tumor ingrowth and migration of the stent. A perforation may occur during or after the insertion of a stent from a contact ulcer due to the sharp ends of the metallic stents. We report a case of esophageal perforation after the insertion of a membrane-covered esophageal stent, which showed perforation at the middle portion of stent due to expansion of the stent. The perforation was sealed without surgical treatment or additional stent insertion. (Korean J Gastrointest Endosc 2008;36:366-370)

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A Case of a False Positive FDG-PET/CT Scan in Esophageal Leiomyoma: Eun Ju Song, M.D., Seong Hwan Kim, M.D., Myong Ha Lee, M.D., Sang Ryul Lee, M.D., Sung Hyuk Lee, M.D., Dae Won Jun, M.D., Moon Hee Song, M.D., Yun Ju Jo, M.D., Young Sook Park, M.D. and Boo Whan Hong, M.D.*; Korean J Gastrointest Endosc 2008;36(6):371-375. Published online June 30, 2008

Abstract PDF: Esophageal leiomyoma is relatively rare disease, but can appears with a high uptake of fluorodeoxuglucose (FDG), a false-positive finding on a FDG PET/CT scan. A 64- year-old woman after a total thyroidectomy due to papillary and follicular carcinoma showed a high uptake of FDG in the distal esophagus on a subsequent FDG PET/ CT scan. The presence of an esophageal leiomyoma was suspicious from preoperative findings of endoscopic ultrasound and computed tomography, and an esophagectomy and proximal gastrectomy were performed, as the presence of a malignant lesion could not be excluded. As high uptake of FDG in the lesion on an FDG PET/CT scan corresponds to an esophageal cancer, an esophagectomy and proximal gastrectomy were performed and the lesion was confirmed as an esophageal leiomyoma after surgical biopsies. We report this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2008;36:371-375)

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A Case of a Gastric Hyperplastic Polyp with a Signet Ring Cell Carcinoma: Han Seung Ryu, M.D., Sae Ron Shin, M.D.*, Ki Hoon Kim, M.D., Geom Seog Seo, M.D. and Suck Chei Choi, M.D.; Korean J Gastrointest Endosc 2008;36(6):376-379. Published online June 30, 2008

Abstract PDF: Gastric polyps can be categorized as hyperplastic or adenomatous. Hyperplastic gastric polyps account for 28∼77% of gastric polyps. Adenomatous polyps are recommended for removal due to their premalignant potential. However, there is no consensus on treatment and endoscopic surveillance of hyperplastic gastric polyps. The incidence of malignant neoplasms found in hyperplastic polyps has been reported to be about 2.1%; most of the reported cases of hyperplastic gastric polyps with malignant transformation were histologically well differentiated. We report a rare case of a gastric hyperplastic polyp with a signet ring cell carcinoma, with a review of the literature. (Korean J Gastrointest Endosc 2008;36:376-379)

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A Case of Double Pylorus Caused by Peptic Ulcer in a Diabetic Patient: Ji Hun Roh, M.D., Dae Gwan Im, M.D., Won Moon, M.D.*, Seun Ja Park, M.D.*, Moo In Park, M.D.*, Kyu Jong Kim, M.D.* and Yoon Jung Kim, M.D.^†; Korean J Gastrointest Endosc 2008;36(6):380-384. Published online June 30, 2008

Abstract PDF: A double pylorus, a fistulous communication between the gastric antrum and duodenal bulb, is a very rare anomaly. It appears as an acquired lesion in the majority of cases and mainly occurs in males with chronic obstructive pulmonary disease, chronic renal failure, chronic rheumatism, systemic lupus erythematosus, or diabetes. However, there are no previous reports of a double pylorus combined with diabetes mellitus in Korea. Recently we experienced a case of double pylorus caused by a peptic ulcer in 74-year-old man who had diabetes mellitus with complications. We report this case with a review of the literature. (Korean J Gastrointest Endosc 2008;36:380-384)

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A Case of Esophageal Small Cell Carcinoma with Gastric Metastasis andwithout Regional Lymph Node Involvement: Sang Min Yum, M.D., Sung Kyu Choi, M.D., Ho In Hwang, M.D., Seok Lee, M.D., Seok Cho, M.D., Kyeong Won Yun, M.D., Sung Bum Cho, M.D., Hyeong Cheon Park, M.D., Seon Yeong Park, M.D., Wan Sik Lee, M.D., Chang Hwan Park, M.D., Hyeon Su Kim, M.D. and Jong Sun; Korean J Gastrointest Endosc 2008;36(6):385-389. Published online June 30, 2008

Abstract PDF: Small cell carcinoma is most frequently described as occurring in the bronchial tree. Extrapulmonary small cell carcinoma is a very rare disease and it has been reported in the esophagus, stomach, small intestine, pancreas, uterus, salivary gland and prostate. Primary esophageal small cell carcinoma with gastric metastasis and without regional lymph node involvement is very rare. We have experienced a case of primary esophageal small cell carcinoma with gastric metastasis and without regional lymph node involvement. The patient was treated with chemotherapy and this patient is alive at 40 months after the treatment. (Korean J Gastrointest Endosc 2008;36:385-389)

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A Case of Liver Abscess Associated with Duodenal Perforation by a Toothpick: Sang Jun Park, M.D., Chang Goo Lee, M.D., Sang Eok Kim, M.D., Jung Hyun Kim, M.D., Kwang Hee Lee, M.D., Ki Yong Kim, M.D., Jin Woo Yun, M.D. and Sun Young Kim, M.D.*; Korean J Gastrointest Endosc 2008;36(6):390-394. Published online June 30, 2008

Abstract PDF: The ingestion of foreign bodies into the gut is rather common. Most these foreign bodies are passed out spontaneously without complications. Our patient was hospitalized for fever, nausea and vomiting for one week. On the initial endoscopic examination, a toothpick was seen to be impacted in the wall of the duodenal bulb. Air bubbles were noted at the site where the toothpick was removed. The duodenal perforation was treated with endoscopic hemoclipping. Abdominal CT showed free air in the periduodenum and there was a liver abscess. Therefore, liver abscess associated with duodenal perforation by the toothpick was diagnosed. On the cytology of the aspirated materials from the liver abscess, sulfur granule formation was noted and hepatic actinomycosis was diagnosed. The liver abscess was successfully treated with CT-guided abscess drainage and antibiotics. We report here on an unusual case of a liver abscess associated with duodenal perforation by a toothpick, along with a review of the literature. (Korean J Gastrointest Endosc 2008;36:390-394)

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A Case of Transverse Colon Perforation after Colonoscopy in a Patient withEnterocolitis Caused by Non-typhoidal Group D Salmonella: Ki Hoon Kim, M.D., Suck Chei Choi, M.D., Tae Hyeon Kim, M.D., Geom Seog Seo, M.D., Chang Soo Choi, M.D., Sung O Seo, M.D., Mi Jin Song, M.D. and Ji Hyun Cho*, M.D.; Korean J Gastrointest Endosc 2008;36(6):395-400. Published online June 30, 2008

Abstract PDF: Clinical manifestations of Salmonella infection are variable such as enterocolitis, bacteremia, enteric fever, focal infection and asymptomatic carrier status. Among these presentations, enterocolitis is the most common clinical manifestation and can be diagnosed by the use of fecal specimens. Patients with severe infectious colitis are at increased risk of developing a colon perforation after colonoscopy due to colon trauma. We report a case of a 31-year-old woman with transverse colon perforation after colonoscopy that was diagnosed with enterocolitis caused by infection with non-typhoidal group D Salmonella. (Korean J Gastrointest Endosc 2008;36:395-400)

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An Incidentally Detected Remnant Cystic Duct Carcinoma during the Evaluation of a Duodenal Submucosal Tumor (SMT) Lesion: Jung Ho Bae, M.D., Gwang Ha Kim, M.D., Jin Hyun Park, M.D., Bong Eun Lee, M.D., Jae Sup Eum, M.D., Dae Hwan Kang, M.D., Do Youn Park, M.D.* and Geun Am Song, M.D.; Korean J Gastrointest Endosc 2008;36(6):401-404. Published online June 30, 2008

Abstract PDF: Carcinoma of the cystic duct remnant is a rare disease. We report a case of a remnant cystic duct carcinoma in a male patient who had undergone cholecystectomy for cholecystolithiasis 20 years previously. A 53-yr-old man visited our hospital for the evaluation of a submucosal tumor on the duodenum. During the evaluation, we detected a mass in the cystic duct remnant by the use of endoscopic ultrasonography. Based on the pathology, the mass was confirmed as a carcinoma of the cystic duct remnant by intraductal ultrasonography and an intraductal biopsy. (Korean J Gastrointest Endosc 2008;36:401-405)

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