Clinical Endoscopy

Volume 41(3); September 2010

Natural Orifice Transluminal Endoscopic Surgery (NOTES): Current Status and Future Prospects: Yong Sik Kim, M.D. and Hoon Jai Chun, M.D.; Korean J Gastrointest Endosc 2010;41(3):129-133. Published online September 30, 2010

Abstract PDF: The attempt to observe intraperitoneal organs with an endoscope using a trans- gastric approach in 2004 by Kalloo et al. heralded the commencement of a new era in endoscopy, which has led to the introduction of natural orifice transluminal endoscopic surgery (NOTES). NOTES has the potential to become an integral part of the field of medicine. So far, many techniques using NOTES have been reported through animal experiments, using diverse apparatus such as suture devices and multitasking platforms. Since a cholecystectomy was performed via a transvaginal route in a human in 2007 by Marescaux et al. from France, clinical experience is also growing. However, much has yet to be learned and many obstacles must be overcome before NOTES can be applied to clinical practice. As mentioned in the whitepaper by NOSCAR in 2005, secure sealing of the orifice after the procedure, development of appropriate instruments for the procedures, selection of suitable access to the peritoneal cavity, and adequate measures to prevent infection and complications still remain unresolved problems. Nevertheless, just as laparoscopic surgery has eventually been recognized as an important surgical technique, NOTES is expected to occupy an important place as an invaluable therapeutic modality for managing gastrointestinal disorders in the near future. (Korean J Gastrointest Endosc 2010;41:129-133)

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The Adequate Induction Dose of Propofol for Conscious Sedation During Esophagogastroduodenoscopy in Persons 60 Years or Older: Hyeung Cheol Moon, M.D., Gun Young Hong, M.D., Du Jin Kim, M.D., Sang Chul Choi, M.D., Sang Wook Park, M.D. and Yeun Keun Lim, M.D.; Korean J Gastrointest Endosc 2010;41(3):134-139. Published online September 30, 2010

Background/Aims: Propofol is an effective sedative drug in endoscopic procedures, but it has potentially serious adverse effects, so close monitoring of the vital signs should be performed during endoscopy. This study was undertaken to determine the adequate induction dose of propofol for safe and effective sedation during esophagogastrodudenoscopy (EGD) in persons 60 years or older.

Methods: Three hundred patients who visited our hospital for EGD were randomly assigned to three groups (A,B and C). An initial induction dose of 0.5 mg/kg, 0.75 mg/kg and 1.0 mg/kg of propofol was allocated to groups A, B and C, respectively.

Results: The 0.5 mg/kg, 0.75 mg/kg and, 1 mg/kg dose of propofol were all safe as an initial dose of propofol for achieving sedation during EGD in persons 60 years or older. There was no difference in the total amount of propofol among the three groups. Group C had a significantly shorter induction time and a lower dose was required for an additional injection of propofol without increasing adverse events, as compared to the two other groups.

Conclusions: We suggest that 1 mg/kg of propofol is an effective induction dose for sedation during EGD in persons 60 years or older. (Korean J Gastrointest Endosc 2010;40:134-139)

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A Single Institution's Experience of Ten Pediatric Patients with Endoscopic Retrograde Cholangiopancreatography: Jin Woo Park, M.D., Sang-Heum Park, M.D., Tae Hoon Lee, M.D., Yun Suk Shim, M.D., Soon Oh Hwang, M.D., Sang Pil Kim, M.D., Jun Young Lee, M.D., Seo Whan Lee, M.D., Chang Kwun Lee, M.D., Do Hyun Park, M.D.*, Suck Ho Lee, M.D., Il Kwun Chung, M.D., Hong Soo; Korean J Gastrointest Endosc 2010;41(3):140-146. Published online September 30, 2010

Abstract PDF

Background/Aims: ERCP is being used increasingly as a diagnostic and therapeutic tool for children with pancreaticobiliary disorders. Differences between thirteen pediatric ERCPs and adult ERCPs were reviewed with respect to their indications, method of anesthesia, choice of endoscope and complications.

Methods: The medical records of 13 ERCPs for 10 children (age: 23 months to 14 years) done between 2005 and 2008 were reviewed retrospectively.

Results: ERCP was indicated for gallstone pancreatitis (6), choledocholithiasis (3), and unexplained pain (1). The method of anesthesia was intravenous sedation with a single agent or a combination of midazolam, propofol or ketamine. The quality of sedation was satisfactory in 10 cases and unsatisfactory in three cases. These 3 cases were less than 8 years old and sedated with a combination of midazolam and propofol. Selective biliary cannulation was successful in 92.3% (12/13) of attempts. Therapeutic ERCP included sphincterotomy (4), endoscopic papillary balloon dilatation (3), and both (5). Complications occurred in 7.7% of attempts (1/13; 1 duodenal perforation) which was successfully managed by surgery.

Conclusions: Pediatric ERCP is a feasible and useful technique. Special caution is needed, however, because of differences with adult ERCP in terms of the effectiveness of intravenous sedation, complications, and size of the gastrointestinal tract. (Korean J Gastrointest Endosc 2010;41:140-146)

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Two Cases of Oropharyngeal Edema Caused by a Bee Sting: Wang Guk Oh, M.D., Ji Woong Kim, M.D., Ki Hoe Kim, M.D., Jeong Gwan Kim, M.D., Ji Eun Song, M.D., So Hyun Gil, M.D., Sang Hoon Park, M.D. and Jin Woong Cho, M.D.; Korean J Gastrointest Endosc 2010;41(3):147-150. Published online September 30, 2010

Abstract PDF: Hymenoptera stings can result in local and systematic symptoms due to their toxic and allergic contents. Although serious sequela are rare, the occurrence of an anaphylactic reaction is considered to be very dangerous and can potentially cause death. Oropharyngeal stings, though infrequent, can cause local edema and airway obstruction due to an anaphylactic reaction and requires immediate epinephrine, antihistamine, steroid treatment and close observation over several days. Careful observation of the oropharyngeal and laryngopharyngeal area using upper gastrointestinal endoscopy is highly recommended, especially for detection of possible edematous swelling in the arytenoid cartilage area. Here we report two cases of patients complaining pain due to edematous swelling in the arytenoid cartilage area caused by hymenoptera stings after accidentally drinking water with a bee in it. (Korean J Gastrointest Endosc 2010;41:147-150)

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A Case of Fishbone-induced Esophageal Perforation Closed by Endoscopic Clipping: Joung Muk Leem, M.D., Joung-Ho Han, M.D.*, Byeong Seong Ko, M.D.*, Mi Sung Kim, M.D.*, Ji Young Park, M.D.*, Woo Hyung Choi, M.D.*, Sei Jin Youn, M.D. and Seon Mee Park, M.D.; Korean J Gastrointest Endosc 2010;41(3):151-154. Published online September 30, 2010

Abstract PDF: Esophageal perforation continues to be associated with high mortality - 20% to 30% - despite advances in surgical techniques. Traditional surgery has been the mainstay of treatment for perforation, but recent advances in endoscopic closure devices has increased therapeutic options for selected patients. Our patient had a fishbone-induced esophageal perforation. He was treated successfully with endoscopic clipping, antibiotics and parenteral nutrition. We report this case and provide a review of the relevant literature. (Korean J Gastrointest Endosc 2010; 41:151-154)

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A Case of Ectopic Sebaceous Glands in the Esophagus: Hyung Bok Park, M.D., Hyeon Geun Cho, M.D., Yu Jin Kim, M.D., Kyung Suk Park, M.D., Myoung Lyeol Woo, M.D., Geun Jun Ko, M.D., Hwa Eun Oh, M.D.* and Sang Yeop Yi, M.D.*; Korean J Gastrointest Endosc 2010;41(3):155-158. Published online September 30, 2010

Abstract PDF: A 42-year-old man without any signs or symptoms of illness underwent esophago- gastroduodenoscopy (EGD) for a routine health check up. On esophagogastroduo- denoscopy, multiple small and yellowish mucosal plaques were detected in the mid to distal esophagus. These plagues proved to be ectopic sebaceous glands of the esophagus according to the histologic examination. On the immunohistochemical staining with anti-Keratin 14, the basal cells and the heterotopic sebaceous glands were immunoreactive for keratin 14. The histogenesis of this extremely rare lesion is not completely clear. There have been some reports on ectopic esophagus sebaceous glands combined with esophageal cancer or gastric cancer. However, malignant transformation of the ectopic sebaceous gland itself has not yet been reported on. This case was regularly followed up for 12 months, and no interval change or malignant transformation was found both endoscopically and histologi- cally. (Korean J Gastrointest Endosc 2010;41:155-158)

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A Large Hematoma Due to Benign Ulcer Perforation of the Gastric Fundus Resembling Submucosal Tumor: Nam Yong Kim, M.D., Jung Hwan Oh, M.D., Soo Jin Choi, M.D., Seung Kyoung Kim, M.D., Youn Mi Song, M.D., Byung Soo Jie, M.D., Seung Hyun Oh, M.D. and Sang Wook Choi, M.D.; Korean J Gastrointest Endosc 2010;41(3):159-162. Published online September 30, 2010

Abstract PDF: The gastric fundus is a rare site for benign ulcer and perforation to occur. A 47 year-old male presented to the emergency department with epigastric pain. An endoscopic examination revealed a submucosal tumor-like lesion with friable, superficial ulceration in the high body of the stomach. We performed surgical resection to rule out malignancy because of the lesion's large size and we found chronic gastric ulcer perforation, which was pathologically diagnosed. We presumed that the formation of the large hematoma, which mimicked a submucosal tumor, was a result of repeated bleeding, perforation and healing. We report here on a case of a large hematoma due to a benign gastric ulcer perforation in the fundus, and this all mimicked a submucosal tumor. (Korean J Gastrointest Endosc 2010;41:159-162)

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A Case of Endoscopic Enucleation for Gastric Lymphoepithelioma-like Carcinoma: Hak Woo, M.D., Sung Jae Shin, M.D., Young Bae Kim, M.D.*, Yoon Chul Lee, M.D., Dong Youb Cha, M.D., Jae Chul Hwang, M.D., Kee Myung Lee, M.D. and Jin Hong Kim, M.D.; Korean J Gastrointest Endosc 2010;41(3):163-167. Published online September 30, 2010

Abstract PDF: Lymphoepithelioma-like carcinoma (LELC) is a rare cancer and it makes up about 1∼4% of all gastric malignancies. The main histologic feature of LELC is a lymphoid stroma. LELC is rare in that its shape is similar to that of submucosal tumor (SMT). Although SMT can be divided into malignant and benign tumors, using endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration, there are still many cases that can't be discriminated, and it is especially difficult to obtain specimens due to the small size of SMT. There have been some recent trials to endoscopic remove small SMTs for the purpose of making an exact diagnosis and guiding therapy. We report here a case of gastric LELC that exhibited the features of a submucosal tumor, and this LELC was removed by endoscopic enucleation. We also briefly review the relevant medical literature. (Korean J Gastrointest Endosc 2010;41:163-167)

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A Case of Gastro-colic Fistula with Peritonitis Due to Ingested Magnets: Yong Duck Cho, M.D., Young Woon Chang, M.D., Chang Hyun Cho, M.D., Young Hwangbo, M.D., Jaejoon Shim, M.D., Jae Young Jang, M.D., Hyo Jong Kim, M.D. and Byung Ho Kim, M.D.; Korean J Gastrointest Endosc 2010;41(3):168-171. Published online September 30, 2010

Abstract PDF: The ingestion of a foreign body is common in children. But in adults, especially in those who have a mental illness, dysphagia, and consciousness disorders often occur. If a patient ingests more than two magnets, he can develop numerous complications such as bowel necrosis, perforation, and fistula formation. Here we report a case of a 32-year-old patient with gastro-colic fistula and peritonitis following ingestion of multiple magnets. In accidental ingestion of multiple magnets, early exploration should be considered. (Korean J Gastrointest Endosc 2010;41:168-171)

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A Case of Colonic Intussusception Occurring after Colonoscopic Polypectomy: Sa Il Kim, M.D., Yong Cheol Jeon, M.D., Gil Woo Lee, M.D., Young Taek Kim, M.D., Tae Yeob Kim, M.D., Chang Soo Eun, M.D., Dong Soo Han, M.D. and Joo Hyun Sohn, M.D.; Korean J Gastrointest Endosc 2010;41(3):172-175. Published online September 30, 2010

Abstract PDF: Intestinal intussusception in adults is a rare disease. Most of the cases of adult intussusception are secondary to a definable lesion, and so surgical treatment generally needed. Intussusception that occurs after colonoscopic polypectomy is apparently a rare malady. A 77-year old man undergoing colonoscopic polypectomy was diagnosed as having colonic intussusception at the hepatic flexure. As there was no clinical improvement with conservative treatment, he underwent segmental resection of the ascending and transverse colon. Pathologic examination revealed that the colonoscopic polypectomy site was a leading point of the intussusception. (Korean J Gastrointest Endosc 2010;41:172-175)

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A Case of a Successful Band Ligation of a Colonic Perforation during Diagnostic Colonoscopy: Heon Nam Lee, M.D., Eui Joo Kim, M.D., Sung Keun Park, M.D., Mi Ryoung Seo, M.D., Jong Joon Lee, M.D., Young Jun Lee, M.D., Kyong Yong Oh, M.D. and Dong Gun Park, M.D.; Korean J Gastrointest Endosc 2010;41(3):176-179. Published online September 30, 2010

Abstract PDF: Colonoscopy is a relatively safe tool for diagnosis and treatment of colorectal disease. But colonic perforation during colonoscopy is a severe complication and sometimes becomes a life-threatening condition. It occurs with a frequency of 0.07% among patients having diagnostic colonoscopy and in up to 0.40% of patients having therapeutic colonoscopy. In these cases, surgical treatment is needed but endoscopic repair and conservative management could reduce the need for immediate operations. Endoscopic clipping has been the principal method for non-operative treatment of iatrogenic colonic perforation, but it has important limitations. One of them is that it is technically difficult to clip when the angle of approach is tangential. Here we report a case of an iatrogenic colonic perforation treated with endoscopic band ligation rather than endoscopic clipping, because of approach difficulties. (Korean J Gastrointest Endosc 2010;41:176-179)

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Magnet Compression Anastomosis for Bilioenteric Anastomotic Stricture after Removal of a Choledochal Cyst: A Case Report: Hyun Chul Lim, M.D., Dong Ki Lee, M.D., Hong Kyu Choi, M.D., Kyo Tae Jung, M.D., Keun Man Lee, M.D., Jae Hoon Jahng, M.D., Joon Sung Park, M.D.* and Jong Yun Won, M.D.^†; Korean J Gastrointest Endosc 2010;41(3):180-184. Published online September 30, 2010

Abstract PDF: Magnet compression anastomosis is a nonsurgical method that uses two magnets to treat bilio-biliary and bilio-enteric anastomotic strictures after a living donor transplantation. The compression pressure of the two magnets induces ischemic necrosis at the anastomostic stricture and creates a fistula at the stricture site. A choledochal cyst is an uncommon congenital anomaly characterized by dilatation of the biliary tree and can cause obstructive jaundice, cholangitis, biliary stones, and cholangiocelluar carcinoma. Treatment for choledochal cyst is essentially surgical including total excision of the cyst with hepaticoenterostomy, but there can be complications such as postoperative intrahepatic stones and recurrent cholangitis due to a stricture at the site of the anastomosis. Endoscopic and fluoroscopy-guided radiologic interventions can be applied to resolve the anastomotic stricture, and re-operation is possible as the method of last resort. We report here a first case, trial magnet compression anastomosis in Korea of a bilioenteric anastomotic stricture after excision of a choledochal cyst and hepaticojejunostomy. (Korean J Gastrointest Endosc 2010;41:180-184)

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A Case of Duodenal Diverticulitis Mimicking Cholangitis: Young Lan Kwon, M.D., Kwang Bum Cho, M.D., Eun Soo Kim, M.D., Kyung Sik Park, M.D., Min Joung Kim, M.D., Kyung Hun Kim, M.D., Joung Eun Lee, M.D. and Kyung In Lee, M.D.; Korean J Gastrointest Endosc 2010;41(3):185-188. Published online September 30, 2010

Abstract PDF: The duodenum ranks second to the colon as the most common site of diverticulosis in the gastrointestinal tract with a prevalence of more than 20%. It is usually asymptomatic, and rarely requires treatments for complications, including diverticulitis, hemorrhage, and luminal obstructions. Unlike diverticulosis, duodenal diverticulitis is extremely rare. Given that the radiological appearance and clinical presentation of duodenal diverticulitis often mimic those of pancreaticobiliary neoplasms or inflammations, it is a challenge for clinicians to diagnose it correctly, which often leads to misdiagnosis and inappropriate management. Here we report a case of a 69 year-old female patient with duodenal diverticulitis, whose clinical symptoms and radiological images were similar to those of acute cholangitis. We also briefly review the literature. (Korean J Gastrointest Endosc 2010;41:185-188)

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