Clinical Endoscopy

Predictors of Rebleeding after Hemoclip Therapy for Treating High-risk Bleeding Ulcers: Hemoclip Therapy Alone was Comparable to Combination Treatmentwith Epinephrine Injection: Hyo Jeong Oh, M.D., Tae Hyeon Kim, M.D., Geom Seog Seo, M.D., Chang Soo Choi, M.D., Eun Young Cho, M.D., Ki Hoon Kim, M.D., Sung O Seo, M.D., Ji Hye Kweon, M.D., Han Seung Ryu, M.D.,Suck Chei Choi, M.D., Haak Cheoul Kim, M.D. and Sae Ron Shin, M.D.*; Korean J Gastrointest Endosc 2008;37(2):83-89. Published online August 30, 2008

Abstract PDF: Background/Aims: Active bleeding and non-bleeding visible vessels in patients with bleeding peptic ulcer are associated with a high risk of rebleeding. The aim of our study was to define the risk factors associated with failure of endoscopic hemostasis and rebleeding in patients with active peptic ulcer bleeding. Methods: We retrospectively reviewed 119 patients (90 men and 29 women; mean age, 60.14±14.67 years) with active peptic ulcer bleeding (spurting, oozing and/or non-bleeding visible vessel) and who were treated in Wonkwang Medical Center from January 2002 to January 2007. They were classified to endoscopic hemoclipping alone group (n=75) or endoscopic hemoclipping combined with epinephrine injection group (n=44), according to the therapeutic modality. Results: Initial hemostasis was achieved in the two groups (100%), and permanent hemostasis was achieved 71.4% in all the patients. Operation was done in eight patients (6.7%), and six patients (5%) in the two groups, respectively, died within 1 month after initial hemostasis because of bleeding related complications. Recurrent bleeding, the duration of the hospital stay, blood transfusion requirements, complications and the operation and mortality rates were not statistically different between the hemoclip alone and combination groups. Univariate analysis showed that rebleeding was related to the presence of shock on admission (p=0.01), complication (p=0.00), the pulse rate (＞100/min) on admission (p=0.04), single ulcer (p=0.032), the level of hemoglobin (＜8 g/dL) (p=0.02) and the volume of transfusion (＞3 units) after the procedure (p=0.005) in all the patients. On the multivariate analysis that was adjusted for age and gender, the hemoglobin level (＜8 g/dL) (odds ratio = 10.5) was the only significant predictor for early rebleeding. Conclusions: This result may suggest that the combination method does not provide a substantial advantage over hemoclipping alone for the hemostatic management of active peptic ulcers bleeding. A low hemoglobin level on admission may be useful to predict rebleeding after initial endoscopic hemostasis in patients with active peptic ulcer. However, this study was designed retrospectively, so the comparison between these two groups should be re-evaluated prospectively in a large, multicenter trial. (Korean J Gastrointest Endosc 2008;37:83-89)

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Diagnostic Accuracy of Computed Tomography for the Lymph Node Staging of Endoscopically Resectable Early Gastric Cancer: Tae-Hoon Oh, M.D., Ban-Suck Lee, M.D., Min-Geun Kim, M.D., Jeong Soo Ahn, M.D., Tae Joo Jeon, M.D., Dong Dae Seo, M.D., Won Choong Choi, M.D., Won Chang Shin, M.D., Myeong-Ja Jeong, M.D.* and Hyun-Jung Kim, M.D.^†; Korean J Gastrointest Endosc 2008;37(2):90-96. Published online August 30, 2008

Abstract PDF: Background/Aims: Accurate staging of the lymph nodes (LNs) before endoscopic mucosal resection (EMR) is important. We evaluated the accuracy of CT for LN staging in patients the endoscopically resectable early gastric cancer (EGC). Methods: The medical records of 155 EGCs patients who had undergone an operation were analyzed. The pre-operatively performed multidetector CT scans and the post-operative histopathologic findings were reviewed for comparing the LN staging with that using the Japanese classification system. Endoscopically resectable EGC was defined as EGC without LN metastasis and also the EGC that satisfied the EMR criteria according to the Japanese guideline. Results: The diagnostic efficacy of CT for LN staging of all the enrolled EGC patients was as follow: accuracy 65.2%, overstaging rate 29.7%, understaging rate 5.2%. The overall accuracy and the overstaging rate of CT for LN staging of endoscopically resectable EGC were as follows: EGC without LN metastasis [69.8% (97/139), 30.2% (42/139)], EGC satisfying extended criteria [72.5% (58/80), 27.5% (22/80)] and EGC satisfying limited criteria [79.2% (19/24), 20.8% (5/24)]. The accuracy of the EMR criteria for predicting node negative EGC were as follows: the extended criteria 98.8% (79/80), the limited criteria 100% (24/24). Conclusions: Our study showed that prediction of LN metastasis before EMR according to CT staging had limited value due to the tendency of overestimation. Therefore, we should preferentially consider the treatment strategy according to the EMR criteria. (Korean J Gastrointest Endosc 2008;37:90-96)

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Nonsurgical Treatment of Gastric Perforation Complicated by Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection: Seok Guen Lee, M.D., Kwang Bum Cho, M.D., Yoon Suk Hong, M.D., Hyun Woong Lee, M.D., Jung Min Lee, M.D., Byoung Kuk Jang, M.D., Woo Jin Chung, M.D., Kyung Sik Park, M.D., Jae Seok Hwang, M.D. and Eun Jee Park, M.D.*; Korean J Gastrointest Endosc 2008;37(2):97-104. Published online August 30, 2008

Abstract PDF: Background/Aims: Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) are novel techniques used for the treatment of early gastric cancer and precancerous lesions of the stomach. However, complications such as bleeding and perforation may occur during the procedure, and these complications may raise the morbidity and mortality rates. EMR/ESD-induced perforations can be treated with conservative medical or non-surgical methods. Furthermore, an increasing number of reports have addressed conservative management of EMR/ESD-induced perforations. We evaluated the effectiveness and safety of implementing conservative treatment for perforations associated with EMR and ESD. Methods: We reviewed 482 patients with 507 lesions who underwent EMR or ESD due to early gastric cancers or gastric adenomas between February 2003 and December 2007. We identified 14 perforations occurring as complications of EMR/ESD and investigated their clinical outcomes. Results: Fourteen perforations (14/507 [2.8%]) occurred, 11 of which were immediately clipped during the procedure, and 3 of which were diagnosed after the procedure when free air was visualized on the radiograph. All patients were managed conservatively with fluid resuscitation and antibiotics (mean, 5.8 days). They recovered without surgery and were discharged in stable condition at a mean of 7.2 days post-procedure. Conclusions: Endoscopic clip application might be an effective and safe option for conservative management of EMR/ESD-induced perforations. (Korean J Gastrointest Endosc 2008;37:97-104)

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Clinical Observation of Colorectal Polyps: Won Ook Ko, M.D., Jong In Kim, M.D., Ju Yeon Nam, M.D., Jung Im Jung, M.D., Jin Kwang An, M.D., Kwang Jin Kim, M.D., Hyung Wook Kim, M.D., Won Il Park, M.D. and Ung Suk Yang, M.D.; Korean J Gastrointest Endosc 2008;37(2):105-111. Published online August 30, 2008

Abstract PDF: Background/Aims: The detection and removal of colorectal polyps are important for secondary prevention of colorectal cancer. We investigated the characteristics and histopathologic finding of polyps to better plan their management. Methods: We analyzed 334 patients who underwent polypectomies for 770 colorectal polyps between October, 2005 and April, 2007 at Bong Seng Memorial Hospital. Results: Colorectal polyps were frequent in the sixth decade in both sexes. The ratio of male to female patients was 1.72:1. Abdominal pain/discomfort was the most common symptom (34.4%), and the most common site of polyp localization was the rectosigmoid colon. Histopathologic examination showed tubular adenomas (54.6%), hyperplastic polyps (36.4%), and inflammatory polyps (5.6%). Adenomatous polyps were more common in patients with multiple polyps than in patients with a single polyp. Adenomatous polyps with villous histology were more common in patients with large polyps than in patients with small polyps. Non-neoplastic polyps were common before the fifth decade. Neoplastic polyps were common past the fifth decade. Conclusions: In this study, tubular adenomas were frequently found on histopathologic examination, sessile type were frequently found on gross examination, and colorectal polyps were found principally in the rectosigmoid colon. Neoplastic polyps were more frequent in patients beyond the fifth decade. There fore colonoscopy examination is recommended for secondary prevention of colon cancer. (Korean J Gastrointest Endosc 2008;37:105-111)

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A Case of Retrograde Jejunogastric Intussusception Diagnosed by Gastroscopy: Hyeug Lee, M.D., Eun Ok Kim, M.D., Juyoung Shin, M.D., Seung Hyun Oh, M.D., Hong Seok Song, M.D., Eun Jung Jeon, M.D., Jung Hwan Oh, M.D., Jeong Jo Jeong, M.D., Sang Wook Choi, M.D., Sung Geun Kim, M.D.*, Sang Seob Yun, M.D.* and Seong Lee, M.D.*; Korean J Gastrointest Endosc 2008;37(2):112-115. Published online August 30, 2008

Abstract PDF: Retrograde intussusception of the jejunum into the stomach through the stroma of a gastroenterostomy is a very rare, but potentially fatal complication after gastrectomy. Once symptoms develop, the mortality rate is high if this is not treated within 48 hours, so making an early diagnosis with a high index of suspicion and administering prompt treatment are mandatory. Gastroscopy could be a useful diagnostic tool for patients with a history of gastrectomy and who present with abdominal pain and hematemesis, and with considering the possibility of intussusception. A 65-year-old man with a history of Billroth II gastrectomy that was done 35 years ago due to gastric ulcer perforation was admitted with abdominal pain and hematemesis. A necrotic mucosa that was suspicious of an intussuscepted small bowel tissue was detected on gastroscopy. Subsequent open reduction and small bowel resection was performed with successful results. We report here on a case of postoperative retrograde jejunogastric intussusception that occurred 35 years after Billroth II gastrectomy, and it was first diagnosed by performing gastroscopy. (Korean J Gastrointest Endosc 2008;37:112-115)

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A Case of Successful Closure using Endoscopic Hemostatic Clips with a Detachable Snare and Fibrin Glue Injection for a Gastro-Cutaneous Fistula following Buried Bumper Syndrome: Hye Jeong Kim, M.D., Jae Woo Kim, M.D., Il Young Lee, M.D., Kyong Won Park, M.D., Hearn Kook Kim, M.D., Ki Tae Suk, M.D., Moon Young Kim, M.D. and Soon Koo Baik, M.D.; Korean J Gastrointest Endosc 2008;37(2):116-121. Published online August 30, 2008

Abstract PDF: The buried bumper syndrome is a well-recognized long-term complication of a percutaneous endoscopic gastrostomy (PEG). Most of the buried bumpers are removed by making an external incision over the PEG site under local anesthesia or during a laparotomy. Recently, endoscopic removal is usually attempted. While the removal of the PEG tube is usually followed by spontaneous closure of the gastrostomy tract, a non-healing gastro- cutaneous fistula is difficult to manage. The fistula is generally treated with bowel rest and total parenteral nutritional support, suppression of gastric acid secretion, and occasionally, surgical exploration and wedge excision of the fistula site are performed. However, in debilitated patients, surgical management is accompanied with high morbidity and mortality. Recently, the use of nonsurgical alternative methods, such as endoscopic therapy using tissue adhesives or hemostatic clips, has emerged with recent advances in endoscopic technology. We report a case of successful closure using endoscopic hemostatic clips with a detachable snare and fibrin glue injection for a gastro-cutaneous fistula following buried bumper syndrome. (Korean J Gastrointest Endosc 2008;37:116-121)

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Endoscopic Resection of a Large Colonic Lipoma: Hye Suk Son, M.D., Young Seok Cho, M.D., Jin Soo Kim, M.D., Hyung Keun Kim, M.D., Chang Hyuk Ahn, M.D.*, Sung Soo Kim, M.D., Hiun Suk Chae, M.D. and Kyu Yong Choi, M.D.; Korean J Gastrointest Endosc 2008;37(2):122-126. Published online August 30, 2008

Abstract PDF: Although colonic lipomas constitute the most common nonepithelial neoplasms of the gastrointestinal tract, colonic lipomas are rare benign tumors. Most colonic lipomas are asymptomatic and are incidentally identified at the time of endoscopy or surgery. Lipomas may cause symptoms such as bleeding, obstruction or intussusception when the size of a tumor exceeds 2 cm. Surgical resection is recommended for larger lipomas to relieve symptoms or exclude a malignancy. There are few published reports on the endoscopic removal of colonic lipomas. Endoscopic snare polypectomy has been used to treat clinically symptomatic colonic lipomas. However, removal of lipomas 2 cm or greater in diameter has been associated with a greater risk of perforation. Using a detachable snare or hemoclipping may reduce the risk of complications after a polypectomy. We report a case of a large colonic lipoma that was treated with endoscopic polypectomy using a detachable snare and hemoclipping. (Korean J Gastrointest Endosc 2008;37:122-126)

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A Case of an Eosinophilic Granuloma Mimicking a Submucosal Tumor in the Ascending Colon Probably Caused by Anisakis: Sang Chul Choi, M.D., Kang Kim, M.D., Kyung Rok Lee, M.D., Jun Ho Cho, M.D., Sang Wook Park, M.D., Gun Young Hong, M.D., Kang Suk Seo, M.D. and Yeun Keun Lim, M.D.; Korean J Gastrointest Endosc 2008;37(2):127-131. Published online August 30, 2008

Abstract PDF: Anisakiasis in the gastrointestinal tract is caused by the ingestion of raw marine fish that contain Anisakis lavae. In rare cases, Anisakiasis is found as an eosinophilic granuloma that mimics a submucosal tumor. The diagnosis is usually made after surgical resection. Several cases of gastric anisakiasis imitating a submucosal lesion have been reported. However, colonic anisakiasis forming a submucosal lesion is very rare and only a few cases have been reported. All of the cases were confirmed after surgery. Recently, we encountered a male patient with a submucosal lesion on the ascending colon during a health screening. Several biopsies were performed on the same site as the lesion. The pathological finding was eosinophilic granuloma. We tentatively diagnosed the patient with eosinophilic granuloma due to Anisakis as the patient consumed raw seafood and eosinophilia was detected on a laboratory test. We decided not to perform any procedure. One month later, the eosinophilic granuloma disappeared as seen on a follow-up colonoscopy. (Korean J Gastrointest Endosc 2008;37:127-131)

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A Case of Multiple Carcinoid Tumors of the Rectum: Jae Myung Cha, M.D., Joung Il Lee, M.D., Jae Won Choe, M.D., Kwang Ro Joo, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D. and Jong Wook Hong, M.D.*; Korean J Gastrointest Endosc 2008;37(2):132-136. Published online August 30, 2008

Abstract PDF: Carcinoid tumors are rare and arise from enterochromaffin cells of the gastrointestinal tract. The rectum is the most common site for gastrointestinal carcinoids. The tumor usually present as small solitary submucosal nodules and multicentricity is rare, occurring in only a few percent of cases. The treatment for a rectal carcinoid tumor is based on the size of the lesion and depth of invasion. Although the present treatment guidelines for multiple rectal carcinoids are controversial, each small lesion of less than 1 cm without evidence of a metastasis can be adequately treated by local resection such as an endoscopic mucosal resection. We experienced a case of multiple rectal carcinoids that were completely resected after a hot biopsy and endoscopic mucosal resection. (Korean J Gastrointest Endosc 2008;37:132-136)

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A Case of Laterally Spreading Tumor Resected with Double Balloon Enteroscopy in a Severely Redundant Colon: Jae Hong Ahn, M.D., Dong Il Kim, M.D., Ja Seol Koo, M.D., Hong Sik Lee, M.D., Sang Woo Lee, M.D., Chang Duck Kim, M.D., Jai Hyun Choi, M.D. and Ho Sang Rhu, M.D.; Korean J Gastrointest Endosc 2008;37(2):137-141. Published online August 30, 2008

Abstract PDF: The incidence of colon cancer and cancer-related deaths has been increased in Korea. Because most colon cancers arise from colonic adenomatous polyps, it is important to detect these early and to resect such lesions, and so the incidence of endoscopic polypectomy has increased in Korea since 1970's. At present, conventional colonoscopy is the standard for evaluating the colon, and especially for the screening and treatment of colon tumor. However, the entire colon cannot be visualized during conventional colonoscopy in 5∼15% of patients due to a redundant colon, an excessive loop or a history of abdominal surgery. To overcome these difficulties, many radiologic and endoscopic studies have been conducted and there are several recent reports that double balloon enteroscopy has been successfully used in cases of failed conventional colonoscopy. We report here on a case of laterally spreading tumor that was resected with double balloon enteroscopy in a severely redundant colon. (Korean J Gastrointest Endosc 2008;37:137-141)

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A Case of Fibrolipoma of the Colon: Young Jae Lee, M.D., Jin Woong Cho, M.D., Gum Mo Jung, M.D., Ji Woong Kim, M.D., Yong Keun Cho, M.D., Myoung Jin Ju, M.D.* and Yong Ung Lee, M.D.; Korean J Gastrointest Endosc 2008;37(2):142-145. Published online August 30, 2008

Abstract PDF: Lipomas of the gastrointestinal tract are rare, and most of them are frequently seen in the colon. This tumor is classified into subtypes by the proportion of the inner mesenchymal components. Fibrolipoma, as a variant type of lipoma, is rich in the fibrous component. It is generally detected incidentally, but sometimes symptoms such as bleeding, abdominal pain or anemia can be observed according to the size, shape and location of the tumor. It can be resected surgically or endoscopically, and then it can be confirmed by the pathologic diagnosis. Recurrence can occur, so follow-up evaluation is needed. We report here on a case of a fibrolipoma of the colon, and the tumor was endoscopically resected. (Korean J Gastrointest Endosc 2008;37:142-145)

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Endoscopic Treatment of Main Pancreatic Duct Transection, Accompanied with Pseudocyst after Abdominal Trauma, with Using Pancreatic Duct Stent: A Case Report: Tae Joo Jeon, M.D., Hyun Park, M.D., Dong Dae Seo, M.D., Tae-Hoon Oh, M.D., Won Chang Shin, M.D., Won-Choong Choi, M.D. and Ki Hwan Kim, M.D.*; Korean J Gastrointest Endosc 2008;37(2):146-150. Published online August 30, 2008

Abstract PDF: Pancreatic trauma is uncommon, but this is associated with high mortality and morbidity rates. Unrecognized main pancreatic duct injury results in early complications such as fistula, pseudocyst, abscess, hemorrhage and pancreatitis. The management of traumatic pseudocyst includes observation, external drainage, internal drainage and operation. The treatment modality is determined by the site and extent of the injury to the main pancreatic duct. Pancreatic stents have been widely used to treat pancreatic diseases such as pancreatitis, pseudocyst, fistula and stricture. Pancreatic stenting has been proven to be effective in the treatment of traumatic pseudocyst associated with the partial rupture of the main pancreatic duct. Surgical treatment is currently the main stay of therapy for complete transection of the main pancreatic duct accompanied with pseudocyst, but the role of pancreatic stenting has not been established. Herein we present our clinical experience with endoscopic treatment for main pancreatic duct transection, accompanied with pseudocyst after abdominal trauma, with using a pancreatic stent. (Korean J Gastrointest Endosc 2008;37:146-150)

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4 Cases of Transgastric Endoscopic Cholecystectomy in Canine and Porcine Models: Won Young Cho, M.D., Jin Oh Kim, M.D., Joo Young Cho, M.D., Hyun Gun Kim, M.D., Sung Woo Cho, M.D.*, Yong Jin Kim, M.D.*, Kyung Yul Hur, M.D.* and Jae Joon Kim, M.D.*; Korean J Gastrointest Endosc 2008;37(2):151-155. Published online August 30, 2008

Abstract PDF: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel therapeutic strategy. This procedure stands on the cutting edge of minimal invasive abdominal surgery that accesses the abdominal organ through natural orifices such as mouth, anus and vagina with performing gastrointestinal endoscopy. There are many animal experiments and clinical trials of NOTES along with the development of better instruments. We report here on 4 cases of transgastric endoscopic cholecystectomy in canine and porcine models, and these procedures were done through natural orifices with performing conventional endoscopy and using endoscopic devices and laparoscopic trocars. (Korean J Gastrointest Endosc 2008;37:151-155)

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A Case of a Foreign Body in the Common Bile Duct Caused by Lipiodol: Kwan Woo Nam, M.D., Dae Soon Kwon, M.D., Hee Seok Moon, M.D., Seok Hyun Kim, M.D., Byung Seok Lee, M.D., Heon Young Lee, M.D., Jae Kyu Seong, M.D. and Hyun Yong Jeong, M.D.; Korean J Gastrointest Endosc 2008;37(2):156-158. Published online August 30, 2008

Abstract PDF: Finding a foreign body in the common bile duct (CBD) is very rare. Transcatheter arterial chemoembolization (TACE) has been widely used for the treatment of hepatocellular carcinoma and metastatic liver tumors, and especially when the tumors are not surgically resectable. We experienced a patient with a CBD foreign body 47 days after performing TACE for single hepatic metastasis of adrenal cortical carcinoma. The foreign body in the common bile duct was high attenuated on the pre-enhanced computed tomography (CT) and it was not observed on the previous CT. We successfully extracted it via a basket after performing endoscopic sphincterotomy; this foreign body was dark black color, flexible and smooth. It was not observed on the follow-up CT scan after one month. The foreign body in the common bile duct was tumor tissue that contained lipiodol and it was near the bile duct. We report here on a rare case of a foreign body in the common bile duct, and it was caused by lipiodol after performing TACE. (Korean J Gastrointest Endosc 2008;37:156-159)

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