Clinical Endoscopy

Therapeutic Small Bowel Endoscopy in Practice: Hyun Joo Jang, M.D.; Korean J Gastrointest Endosc 2009;39(2):59-65. Published online August 30, 2009

Abstract PDF: Since the first introduction of double balloon enteroscopy (DBE) in 2001, DBE has been refined for complete exploration of the small bowel and therapeutic interventions. Diagnostic DBE using a model EN-450P5 (Fujinon, Saitama, Japan) equipped with a small accessory channel is mainly used for endoscopic observation and limited therapeutic procedures including injection therapy, argon plasma coagulation and polypectomy. Therapeutic DBE utilizing a model EN-450T5 (Fujinon, Saitama, Japan) equipped with a larger accessory channel was developed for various endoscopic interventions. Recently, new enteroscopic techniques such as single balloon enteroscopy and spiral enteroscopy were introduced. These enteroscopic techniques are all used for the controlled observation, targeted tissue sampling for pathologic evaluation and various therapeutic interventions. The overall complication rate of DBE seems acceptable but that of therapeutic DBE is higher than diagnostic DBE and therapeutic colonoscopies because the small intestinal wall is much thinner than other intestinal wall. This review provides an overview concerning therapeutic interventions of DBE. (Korean J Gastrointest Endosc 2009;39:59-65)

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The Adequate Dose of Propofol for Inducing Sedation during Performance of Upper Gastrointestinal Endoscopy in Koreans: Gun Young Hong, M.D., Kang Seok Seo, M.D., Sang Wook Park, M.D., Hyeung Cheol Moon, M.D., Sang Chul Choi, M.D. and Yeun Keun Lim, M.D.; Korean J Gastrointest Endosc 2009;39(2):66-71. Published online August 30, 2009

Abstract PDF: Background
/Aims: Propofol sedation is increasingly being used when performing upper gastrointestinal endoscopy because of its rapid onset and good recovery profile. For achieving safe sedation during endoscopy, close monitoring of the vital signs is necessary because of the sedation's potentially serious adverse effects. There are only a few studies on the induction of sedation with using propofol for endoscopy in Korea. The present study was undertaken to evaluate the adequate initial injected dose of propofol for achieving safe and effective sedation when performing upper gastrointestinal endoscopy in Koreans.
Methods
From March 2008 to July 2008, 150 subjects who visited Kwangju Christian Hospital were randomized into 3 groups. An initial bolus dose of 0.5 mg/kg, 1.0 mg/kg and 1.5 mg/kg of propofol was allocated to groups A, B and C, respectively. The effectiveness and safety profiles of each injected dose of propofol were prospectively assessed by measuring various parameters of the vital signs and the adverse events.
Results
Group C had a significantly shorter induction time and the patients in group C did not require additional injections of propofol without increasing adverse events, as compared to that of the other 2 groups.
Conclusions
1.5 mg/kg of propofol was found to be more appropriate than 0.5 mg/kg or 1.0 mg/kg of propofol as the initial injected dose for induction of sedation during performance of upper gastrointestinal endoscopy in Koreans. (Korean J Gastrointest Endosc 2009;39:66-71)

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Clinical Features of Iatrogenic Mallory-Weiss Syndrome: In Key Choi, M.D., Sun Moon Kim, M.D., Jae Hyung Sun, M.D., Sang Yeol Cheon, M.D., Dae Seung Lim, M.D., Young Suk Kim, M.D., Tae Hee Lee, M.D., Euyi Hyeog Im, M.D., Kyu Chan Huh, M.D., Young Woo Choi, M.D. and Young Woo Kang, M.D.; Korean J Gastrointest Endosc 2009;39(2):72-77. Published online August 30, 2009

Abstract PDF: Background
/Aims: The detection of iatrogenic Mallory-Weiss syndrome during the course of upper GI endoscopy is apparently rare. The aim of this study was identify the clinical features of the disease and associated medical conditions.
Methods
We retrospectively analyzed 46 cases (0.08%) of iatrogenic Mallory- Weiss syndrome identified from 54,188 consecutive upper GI endoscopies performed at our institution during a period of 85 months.
Results
A total of 36 patients (78.2%) had retching or belching during the procedure. Hiatal hernias were noted in 20 patients (43.5%). We identified a difference of the attack rate by sex and age for iatrogenic Mallory-Weiss syndrome; the disorder developed predominantly in men. All of the patients had a mucosal tear and oozing and 16 patients underwent endoscopic hemostasis. After being diagnosed with iatrogenic Mallory-Weiss syndrome, 17 patients underwent follow- up endoscopy and all of the patients showed good results without rebleeding. No patient showed a complicated clinical course.
Conclusions
A small number of patients had iatrogenic Mallory-Weiss syndrome and most of the patients showed a good prognosis. If there is a predictable risk factor identified during an upper GI endoscopy or an associated medical condition, special care needs to be taken to minimize belching or retching. (Korean J Gastrointest Endosc 2009;39:72-77)

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A Survey on the Indication for Endoscopic Submucosal Dissection in Early Gastric Cancer: Chang Kyun Lee, M.D., Il-Kwun Chung, M.D., Joo Young Cho, M.D., Jae J. Kim, M.D.*, Hoon Jai Chun, M.D.^†, Hyun Yong Jeong, M.D.^‡ and Sang Young Seol, M.D.^§; Korean J Gastrointest Endosc 2009;39(2):78-84. Published online August 30, 2009

Abstract PDF: Background
/Aims: Endoscopic submucosal dissection (ESD) has become a widely accepted method for treating early gastric cancer (EGC) in Korea. However, there is not an established guideline for indications of ESD. The objective of this study was to assess the current status and practice patterns regarding indications for ESD in Korea.
Methods
A 17-item questionnaire about indications for ESD in EGC was presented to the participants of the 2^nd joint symposium of the Gastrointestinal Pathology Study Group of the Korean Society of pathologists. Keypad-based anonymous voting was carried out and the entire process was recorded.
Results
Endoscopic submucosal dissection for EGC fulfilling the classical indications was widely accepted as an effective therapeutic strategy comparable to surgery (114/115, agreement 99.5%). In our survey, Japanese extended criteria for ESD was still debated (70/111, 63.6%), but most respondents had performed ESD selectively in EGC corresponding to the extended criteria (105/109, 96.3%). They agreed that the current criteria for ESD would possibly require a revision considering various clinical indicators.
Conclusions
Our survey shows that there is still no consensus about indications for ESD in EGC. Therefore, more clinical outcome data with a long-term follow-up are needed to establish evidence-based consensus and guidelines for ESD indications in Korea. (Korean J Gastrointest Endosc 2009;39:78-84)

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Endoscopic Removal of an Impacted Fishhook That Was in the Esophagus for Two Months: So Young Bae, M.D., Jun Haeng Lee, M.D., Hye Jeong Kim, M.D., Young Kyung Sung, M.D., Song Yi Song, M.D., Jae J. Kim, M.D. and Jong Chul Rhee, M.D.; Korean J Gastrointest Endosc 2009;39(2):85-87. Published online August 30, 2009

Abstract PDF: An esophageal foreign body has clinical significance because it may cause serious complications such as esophageal perforation, mediastinitis and/or aorto-esophageal fistula. A prompt attempt to remove an esophageal foreign body via flexible endoscopy should be made when the shape of the foreign body is especially sharp and long as it can easily lead to esophageal perforation. We report here on a case of endoscopic removal of an impacted esophageal foreign body, a fishhook, that hade been present in the esophagus for two months, and there were no serious complications from the procedure. (Korean J Gastrointest Endosc 2009;39:85-87)

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A Case of Endoscopic Submucosal Dissection for Esophageal Adenocarcinoma Arising from Ultrashort-Segment Barrett's Esophagus: Pyung Gohn Goh, M.D., Hyun Yong Jeong, M.D., Hee Seok Moon, M.D., Jae Kyu Sung, M.D., Kyu Sang Song, M.D.*, Seung Moo Noh, M.D.^†, June Sik Cho, M.D.^‡ and Kyung Sook Shin, M.D.^‡; Korean J Gastrointest Endosc 2009;39(2):88-92. Published online August 30, 2009

Abstract PDF: Barrett's esophagus is defined as the replacement of normal squamous epithelium of distal esophagus with specialized columnar epithelium. This condition is considered to be a premalignant lesion of esophageal adenocarcinoma. Barrett's esophagus is classified into long-segment (≥3 cm in length) and short-segment (＜3 cm in length). Detection of the former is more difficult. Adenocarcinomas arising from short-segment Barrett's esophagus are uncommon in Korea. Barrett's adenocarcinoma restricted to the mucosa can be treated by endoscopic mucosectomy. In recent years, endoscopic submucosal dissection for early esophageal cancer has been extensively applied because it is a reliable method to achieve en bloc resection. In this paper, we report a case of esophageal adenocarcinoma arising from ultrashort-segment Barrett's esophagus, which was successfully resected by endoscopic submucosal dissection. (Korean J Gastrointest Endosc 2009;39:88-92)

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A Case of a Gastric Composite Tumor with an Adenocarcinoma and a Large Cell Neuroendocrine Carcinoma: Jin Hwan Jung, M.D., Yong Cheol Kim, M.D., Jeong Ho Kim, M.D., Hui Sung Chung, M.D., Dae Young Cheung, M.D., Jin Il Kim, M.D., Soo Heon Park, M.D. and Jae Kwang Kim, M.D.; Korean J Gastrointest Endosc 2009;39(2):93-96. Published online August 30, 2009

Abstract PDF: A 55 year-old man was admitted with epigastric pain of one-month duration. We performed an esophagogastroduodenoscopy that showed the presence of a 3 cm sized polypoid mass at the lesser curvature side of the antrum. A biopsy demonstrated the presence of a neuroendocrine carcinoma of the stomach. A subtotal gastrectomy with D2 lymph node dissection was performed and the microscopic features of the resected specimen confirmed the diagnosis of a composite large cell neuroendocrine carcinoma with an adenocarcinoma of the stomach. A gastric neuroendocrine carcinoma is extremely rare and a composite neuroendocrine carcinoma with an adenocarcinoma of the stomach has been rarely reported. We report a case of a gastric composite tumor with an adenocarcinoma and a large cell neuroendocrine carcinoma. (Korean J Gastrointest Endosc 2009;39:93-96)

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Periampullary Gangliocytic Paraganglioma Successfully Treated by Endoscopic Mucosal Resection: Seon Young Park, M.D., Young A Song, M.D., Nam Chul Jin, M.D., Jun Ho Cho, M.D., Young Eun Joo, M.D., Hyun Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2009;39(2):97-102. Published online August 30, 2009

Abstract PDF: Gangliocytic paraganglioma is a rare tumor that occurs nearly exclusively in the second portion of the duodenum. This tumor is usually considered to be benign. So, endoscopic resection may be the best procedure to facilitate the diagnosis and for treatment to avoid an unnecessary, invasive operation. To the best of our knowledge, this is the first report of a periampullary gangliocytic paraganglioma that was successfully treated by endoscopic mucosal resection in Korea. We report here a case of a 45-year-old man who was found to have a periampullary gangliocytic paraganglioma. This tumor was adequately treated by endoscopic mucosal resection. (Korean J Gastrointest Endosc 2009;39:97-102)

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Gastric Mucosal Injury after Ingestion of a Hot Liquid Diet via Gastric Feeding Tube: Il Soo Kim, M.D., Ji Ung Kim, M.D., Ji Hyun Cheon, M.D., Wook Kang, M.D., Jae Kyun Kim, M.D., Kyoung Chan Kim, M.D., Chang Hun Yoo, M.D. and Kuyng Im Pae, M.D.; Korean J Gastrointest Endosc 2009;39(2):103-105. Published online August 30, 2009

Abstract PDF: When a patient complains of gastrointestinal symptoms such as nausea, vomiting, and upper abdominal pain after ingestion of a substance such as a corrosive agent and certain drugs which can cause mucosal injury to the esophagus and stomach, we always keep in mind gastrointestinal injury and should perform an endoscopic procedure promptly and use the appropriate treatment. It is well known that common corrosive agents which can cause gastrointestinal injury are acidic and alkaline chemicals, and the common causative drug for gastrointestinal injury is NSAID. However, it is not well known that consuming hot food and drinks can cause gastrointestinal injury also. Up to now, there have only been a few case reports of esophageal mucosal injury due to the consumption of hot food and drinks. Gastric mucosal injury after ingesting hot food and drinks is rare and has not been reported often. So here, we report a case of gastric mucosal injury after ingesting a hot liquid diet via gastric feeding tube. (Korean J Gastrointest Endosc 2009;39:103-105)

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A Case of Bleeding from a Jejunal Gastrointestinal Stromal Tumor Diagnosed by Double Balloon Enteroscopy: Jeong Yoon Jang, M.D., Jae Myung Cha, M.D., Joung Il Lee, M.D., Kwang Ro Joo, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D. and Yu Jin Suh, M.D.; Korean J Gastrointest Endosc 2009;39(2):106-110. Published online August 30, 2009

Abstract PDF: Gastrointestinal bleeding from a small bowel lesion is uncommon, but it is the most common cause of obscure gastrointestinal bleeding and it can go undiagnosed using traditional upper endoscopy and colonoscopy. Recently, capsule endoscopy and double-balloon enteroscopy (DBE) were developed as new techniques for visualization of the entire small intestine and have improved access to the lesion site in patients with obscure gastrointestinal bleeding. In this report, we describe a 49-year male presenting with melena from a gastrointestinal stromal tumor (GIST) of the proximal jejunum that was diagnosed by DBE and resected by laparoscopic surgery. (Korean J Gastrointest Endosc 2009;39:106-110)

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Colonic Intussusception as a Complication after Colonoscopic Polypectomy: Byung Keun Kim, M.D., Dong Ho Lee, M.D., Na Yung Kim, M.D., Sang Hyup Lee, M.D. and Yung Soo Park, M.D.; Korean J Gastrointest Endosc 2009;39(2):111-114. Published online August 30, 2009

Abstract PDF: Intussusception in adults is not common unlike in pediatrics. It also differs from the pediatric intussusception in its origins, symptoms, and treatment. Since more than half of intussusception cases come from malignancy, laparotomy is considered to be the treatment of choice in most cases. This report deals with a patient who visited our hospital complaining of abdominal pain after colonoscopic polypectomy. The patient was diagnosed with colonic intussusception. After a conservative treatment regimen including antibiotics and fluid therapy, the intussusception was spontaneously reduced. (Korean J Gastrointest Endosc 2009;39:111-114)

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A Case of Penetration of Mesh after Rectopexy and This Was Found by Colonoscopy: Won Joon Lee, M.D., Chai Young Lee, M.D.*, Ji Yean Lee, M.D., Il Young Chon, M.D., Dong Joon Oh, M.D., Seung Jin Choi, M.D., Ke Ryun Ahn, M.D. and Byung Jun Lee, M.D.; Korean J Gastrointest Endosc 2009;39(2):115-118. Published online August 30, 2009

Abstract PDF: Rectal prolapse is a protrusion of the rectum beyond the anal canal. Since rectal prolapse is a surgical disease, it is mostly diagnosed and treated at the surgical department. However, when surgical complications occur or they are suspected after an operation for colorectal disease, colonoscopy may now have a role in diagnosing the actual status of the problem. We present here the case of penetration of mesh at the distal rectum that was incidentally diagnosed by colonoscopy and the patient had previously undergone presacral rectopexy for rectal prolapse. Only one such case has been reported abroad and there has been no such case report in Korea. We report here on a case for which colonoscopy had a crucial role in diagnosing an occult complication after a colorectal operation that used a prosthesis. (Korean J Gastrointest Endosc 2009;39:115-118)

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