Background:The efficacy of adjuvant treatment(AT)in ampullary cancer(AmC)remains controversial.This systematic review and meta-analysis aimed to evaluate the role of AT for AmC.Data sources:A comprehensive systematic ...Background:The efficacy of adjuvant treatment(AT)in ampullary cancer(AmC)remains controversial.This systematic review and meta-analysis aimed to evaluate the role of AT for AmC.Data sources:A comprehensive systematic search was performed in PubMed,EMBASE,Cochrane Library,and Web of Science databases.Studies comparing overall survival(OS)and recurrence-free survival(RFS)of patients who underwent AT or not following AmC resection were included.Results:A total of 3971 patients in 21 studies were analyzed.Overall pooled data showed no significant difference in effect on the OS by AT[hazard ratio(HR)=0.998,95%confidence interval(CI):0.768–1.297].No significant difference in recurrence between the AT and non-AT(nAT)groups was noted(HR=1.158,95%CI:0.764–1.755).In subgroup analysis,patients who received AT showed favorable outcomes in the OS compared with those who received nAT in nodal-positive AmC(HR=0.627,95%CI:0.451–0.870).Neither AT consisted of adjuvant chemotherapy with radiotherapy(HR=0.804,95%CI:0.563–1.149)nor AT with adjuvant chemotherapy(HR=0.883,95%CI:0.642–1.214)showed any significant effect on the OS.Conclusions:The effect of AT in AmC on survival and recurrence did not show a significant benefit.Furthermore,effectiveness according to AT strategies did not show enhancement in survival.AT had an advantage in survival compared with nAT strategy in nodal-positive AmC.In cases of AmC with positive lymph nodal involvement,AT may be warranted regardless of detailed strategies.展开更多
AIM: To identify clinical and pathological differences between serum immunoglobulin G4 (IgG4)-positive (SIP) and IgG4-negative (SIN) type 1 autoimmune pancreatitis (AIP) in South Korea. METHODS: AIP was diagnosed by t...AIM: To identify clinical and pathological differences between serum immunoglobulin G4 (IgG4)-positive (SIP) and IgG4-negative (SIN) type 1 autoimmune pancreatitis (AIP) in South Korea. METHODS: AIP was diagnosed by the international consensus diagnostic criteria. The medical records and pathology were retrospectively reviewed and IgG4-positive cells were counted in a high power field (HPF). Type I AIP was defined as a high serum level of IgG4or histological finding. SIN type 1 AIP was defined as a histological evidence of type 1 AIP and a normal serum IgG4 level. The clinical and pathological findings were compared between the two groups. The analysis was performed using Student's t test, Fischer's exact test and Mann-Whitney's U test. A P value of < 0.05 was considered statistically significant. As repeated com- parison was made, P values of less than 5% (P < 0.05) were considered significant. RESULTS: Twenty five patients with definite type 1 AIP (19 histologically and six serologically diagnosed cases) were enrolled. The mean tissue IgG4 concentrations were significantly higher in SIP than SIN group (40 cells per HPF vs 18 cells per HPF, P = 0.02). Among eight SIN patients, the tissue IgG4 concentrations were less than 15 cells per HPF in most of cases, except one. The sensitivity of serum IgG4 was 68% (17 SIP and eight SIN AIP). Other organ involvement was more frequent- ly associated with SIP than SIN AIP (59% vs 26%, P = 0.016). However, the relapse rate and diffuse swelling of the pancreas were not associated with serum IgG4 level. The concentrations of IgG4-positive cells per HPF were higher in SIP than SIN AIP (40 vs 18, P = 0.02). CONCLUSION: The sensitivity of serum IgG4 was 68% in type 1 AIP. High serum IgG4 level was associated with other organ involvement and tissue IgG4 concentration but did not affect the relapse rate in type 1 AIP.展开更多
AIM： To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin＇s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage （ERBD）, external...AIM： To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin＇s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage （ERBD）, external percutaneous transhepatic biliary drainage （EPTBD） and internal biliary stenting via the PTBD tract （IPTBD）. METHODS： The initial success rate, cumulative patency rate, and complication rate were compared retrospectively, according to the Bismuth type and ERBD, EPTBD, and IPTBD. Patency was defined as the duration for adequate initial bile drainage or to the point of the patient＇s death associated with inadequate drainage. RESULTS： One hundred thirty-four patients （93 men, 41 women; 21 Bismuth type Ⅱ, 47Ⅲ, 66 Ⅳ; 34 ERBD, 66 EPTBD, 34 IPTBD） were recruited. There were no differences in demographics among the groups. Adequate initial relief of jaundice was achieved in 91% of patients without a significant difference in the results among different procedures or Bismuth types. The cumulative patency rates for ERBD and IPTBD were better than those for EPTBD with Bismuth type Ⅲ. IPTBD provided an excellent response for Bismuth type IV. However, there was no difference in the patency rate among drainage procedures for Bismuth type Ⅱ. Procedure-related cholangitis occurred less frequently with EPTBD than with ERBD and IPTBD. CONCLUSION： ERBD is recommended as the firstline drainage procedure for the palliation of jaundice in patients with inoperable Klatskin＇s tumor of Bismuth type Ⅱ or Ⅲ, but IPTBD is the best option for Bismuth type Ⅳ.展开更多
AIM： To investigate prevalence of C/onorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea. METHODS： Consecutive patients w...AIM： To investigate prevalence of C/onorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea. METHODS： Consecutive patients who had been admitted to the Division of Gastroenterology with gastrointestinal symptoms were enrolled from March to April 2005. Of those who had been diagnosed with clonorchiasis, epidemiology and correlation between infection and hepatobiliary diseases were surveyed by questionnaire. RESULTS： Of 3080 patients with gastrointestinal diseases, 396 （12.9%） had clonorchiasis and 1140 patients （37.2%） had a history of eating raw freshwater fish. Of those with a history of raw freshwater fish ingestion, 238 （20.9%） patients had clonorchiasis. Cholangiocarcinoma was more prevalent in C. sinensis-infected patients than nonnfected patients [34/396 （8.6%） vs 145/2684 （5.4%）, P = 0.015]. Cholangiocarcinoma and clonorchiasis showed statistically significant positive cross-relation （P = 0.008）. Choledocholithiasis, cholecystolithiasis, cholangitis, hepatocellular carcinoma, and biliary pancreatitis did not correlate with clonorchiasis. CONCLUSION： Infection rate of clonorchiasis was still high in patients with gastrointestinal diseases in Korea, and has not decreased very much during the last two decades. Cholangiocarcinoma was related to clonorchiasis, which suggested an etiological role for the parasite.展开更多
AIM: To identify the risk factors for organ failure(OF) in cholangitis with bacteriobilia.METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage betwe...AIM: To identify the risk factors for organ failure(OF) in cholangitis with bacteriobilia.METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.RESULTS: There were 24 cases(13.2%) of OF and five deaths(2.7%). Bile culture was positive for microbial growth in 130 out of 138(94.2%) patients. In multivariate analysis of 130 patients with positivebile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase(ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation:(2.7 × ESBL organisms in blood cultures) +(1.8 × pre-existing renal dysfunction) +(1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific(99.1%) and had a positive predictive value of 86.2%.CONCLUSION: ESBL organisms in blood cultures, preexisting renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.展开更多
BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage...BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. METHODS: Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. RESULTS: Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).CONCLUSION: Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.展开更多
AIM:To compare the efficacy of self-expandable metal stents(SEMSs) with 10F plastic stents(PSs) in the endoscopic management of occluded SEMSs.METHODS:We retrospectively reviewed the medical records of 56 patients who...AIM:To compare the efficacy of self-expandable metal stents(SEMSs) with 10F plastic stents(PSs) in the endoscopic management of occluded SEMSs.METHODS:We retrospectively reviewed the medical records of 56 patients who underwent SEMS insertion for palliation of unresectable malignant biliary obstruction between 2000 and 2007 and subsequent endoscopic retrograde biliary drainage(ERBD) with SEMS or PS for initial SEMS occlusion between 2000 and 2008.RESULTS:Subsequent ERBD with SEMS was performed in 29 patients and with PS in 27.The median time to stent occlusion after subsequent ERBD was 186 d in the SEMS group and 101 d in the PS group(P= 0.118).Overall median stent patency was 79 d for the SEMS group and 66 d for the PS group(P = 0.379).The mean number of additional biliary drainage procedures after subsequent ERBD in patients that died(n = 50) during the study period was 2.54 ± 4.12 for the SEMS group and 1.85 ± 1.95 for the PS group(P = 0.457).The mean total cost of additional biliary drainage procedures after the occlusion of subsequent SEMS or PS was $410.04 ± 692.60 for the SEMS group and $630.16 ± 671.63 for the PS group(P = 0.260).Tumor ingrowth as the cause of initial SEMS occlusion was the only factor associated with a shorter time to subsequent stent occlusion(101 d for patients with tumor ingrowth vs 268 d for patients without tumor ingrowth,P = 0.008).CONCLUSION:Subsequent ERBD with PSs offered similar patency and number of additional biliary drainage procedures compared to SEMSs in the management of occluded SEMS.展开更多
AIM: To investigate the prognostic factors determining the success rate of non-surgical treatment in the management of post-operative bile duct injuries (BDIs).
Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients consider...Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery.The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event(AE).Methods:A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital.The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA.The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain.Results:A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows:serous cystic neoplasm(32.2%),mucinous cystic neoplasm(26.6%),branch duct type intraductal papillary mucinous neoplasm(BD-IPMN)(29.4%),and pseudocyst(11.7%).Three patients(1.4%)experienced severe AEs.Overall,AEs occurred in 71(33.2%)patients.BD-IPMN(OR:2.87;95%CI:1.05–7.84;P=0.040),multilocular cysts(OR:3.59;95%CI:1.09–11.85;P=0.036),suspected ethanol leakage during procedure(OR:10.68;95%CI:1.98–57.53;P=0.006),and sticky cystic fluid(OR:3.83;95%CI:1.20–12.24;P=0.024)were predictive factors for post-procedural acute pancreatitis.PCLs of uncinate process(OR:2.99;95%CI:1.22–7.35;P=0.017)and PCLs with exophytic portion(OR:3.70;95%CI:1.96–7.01;P<0.001)were predictive factors for post-procedural abdominal pain.Conclusions:EUS-EA is a safe procedure with a very low rate of severe AEs.It seems possible to predict the AEs according to the features of the procedure and PCLs.展开更多
AIM： To evaluate the clinicopathologic characteristics of patients with metastases to the gallbladder （MGBs）. METHODS： We performed a single-center retrospective study of 20 patients with MGBs diagnosed pathologic...AIM： To evaluate the clinicopathologic characteristics of patients with metastases to the gallbladder （MGBs）. METHODS： We performed a single-center retrospective study of 20 patients with MGBs diagnosed pathologically from 1999 to 2007. RESULTS： Among 417 gallbladder （GB） malignancies, 20 （4.8%） were MGBs. The primary malignancies originated from the stomach （n = 8）, colorectum （n = 3）, liver （n = 2）, kidney （n = 2）, skin （n = 2）, extrahepatic bile duct （n = 1）, uterine cervix （n = 1）, and appendix （n = 1）. Twelve patients were diagnosed metachronously, presenting with cholecystitis （n = 4）, abdominal pain （n = 2）, jaundice （n = 1）, weight loss （n = 1）, and serum CA 19-9 elevation （n = 1）; five patients were asymptomatic. The median survival after the diagnosis of MGB was 8.7 mo. On Cox regression analysis, R0 resection was the only factor associated with a prolonged survival [hazard ratio （HR）： 0.01, P = 0.002]; presentation with cholecystitis was associated with poor survival （HR： 463.27, P = 0.006）. CONCLUSION： MGBs accounted for 4.8% of all pathologically diagnosed GB malignancies. The most common origin was the stomach. The median survival of MGI3 was 8.7 mo.展开更多
AIM: To evaluate the anti-tumor effect of clobenpropit, which is a specific H<sub>3</sub> antagonist and H<sub>4</sub> agonist, in combination with gemcitabine in a pancreatic cancer cell line.
Background:Stent insertion for biliary decompression to relieve jaundice and subsequent biliary infection is necessary for patients with biliary obstruction caused by pancreatic cancer,and it is important to keep the ...Background:Stent insertion for biliary decompression to relieve jaundice and subsequent biliary infection is necessary for patients with biliary obstruction caused by pancreatic cancer,and it is important to keep the stent patent as long as possible.However,few studies have compared stent patency in terms of chemotherapy in patients with pancreatic cancer.This study aimed to evaluate the differences in stent patency in terms of recently evolving chemotherapy.Methods:Between January 2015 and May 2017,161 patients with pancreatic cancer who had undergone biliary stent insertion with a metal stent were retrospectively analyzed.The relationship between chemotherapy and stent patency was assessed.Additionally,overall survival according to the treatment,risk factors for stent patency,and long-term adverse events were evaluated.Results:Median stent patency was 42 days for patients with the best supportive care and 217 days for patients with chemotherapy(conventional gemcitabine-based chemotherapy and folfirinox)(P<0.001).Furthermore,the folfirinox group showed the longest median stent patency and overall survival,with 283 days and 466 days,respectively(P<0.001)despite higher adverse events rate.Patients who underwent folfirinox chemotherapy after stent insertion had better stent patency in multivariate analysis(HR=0.26;95%CI:0.12–0.60;P=0.001).Conclusions:Compared with patients who received best supportive care only,patients who underwent chemotherapy after stent insertion had better stent patency.More prolonged stent patency can be expected for patients with folfirinox than conventional gemcitabine-based chemotherapy.展开更多
BACKGROUND The adjuvant treatment for patients with resected pancreatic cancer(PC)is not yet standardized.Because the prognosis differs according to the American Joint Committee on Cancer(AJCC)stage,a tailored approac...BACKGROUND The adjuvant treatment for patients with resected pancreatic cancer(PC)is not yet standardized.Because the prognosis differs according to the American Joint Committee on Cancer(AJCC)stage,a tailored approach to establish more aggressive treatment plans in high-risk patients is necessary.However,studies comparing the efficacy of adjuvant treatment modalities according to the AJCC stage are largely lacking.AIM To compare the efficacy of chemotherapy and chemoradiation therapy according to AJCC 8th staging system in patients with PC who underwent surgical resection.METHODS A total of 335 patients who underwent surgical resection and adjuvant treatment for PC were included.Patients were divided into three groups:Chemoradiation therapy(CRT)group,systemic chemotherapy(SCT)group and combined treatment of chemoradiation plus chemotherapy therapy(CRT-SCT)group.The primary outcomes were differences in overall survival(OS)between the three groups.The secondary outcomes were differences in recurrence-free survival,recurrence pattern and adverse events between the three groups.RESULTS Patients received CRT(n=65),SCT(n=62)and CRT-SCT(n=208).Overall median OS was 33.3 mo(95%confidence interval(CI):27.4-38.6).In patients with stage I/II,the median OS was 27.0 mo(95%CI:2.06-89.6)in the CRT group,35.8 mo(95%CI:26.9-NA)in the SCT group and 38.6 mo(95%CI:33.3-55.7)in the CRT SCT group.Among them,there was no significant difference in OS between the three groups.In 59 patients with stage III,median OS in the SCT group[19.0 mo(95%CI:12.6-NA)]and the CRT-SCT group[23.4 mo(95%CI:22.0-44.4)]was significantly longer than that in the CRT group[17.7 mo(95%CI:6.8-NA);P=0.011 and P<0.001,respectively].There were no significant differences in incidence of locoregional and distant recurrences between the three groups(P=0.158 and P=0.205,respectively).Incidences of grade 3 or higher hematologic adverse events were higher in the SCT and CRT-SCT groups than in the CRT group.CONCLUSION SCT and CRT-SCT showed significantly longer OS and recurrence-free survival than CRT in patients with AJCC stage III,while there was no significant difference in OS between the CRT,SCT and CRT-SCT groups in patients with AJCC stage I/II.Different adjuvant therapy according to AJCC stage can be applied in patients with PC.展开更多
BACKGROUND:Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) has become a crucial diagnostic technique for pancreatic malignancies.The specimen obtained by EUS-FNA can be prepared for either cytological or ...BACKGROUND:Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) has become a crucial diagnostic technique for pancreatic malignancies.The specimen obtained by EUS-FNA can be prepared for either cytological or histological examinations.This study was to compare diagnostic performance of cytological and histological preparations using EUSFNA in the same lesions when pancreatic malignancies were suspected.METHODS:One hundred and eighteen patients who underwent EUS-FNA for suspected pancreatic malignancies were consecutively enrolled.All procedures were conducted by a single echoendoscopist under the same conditions.Four adequate preparations were obtained by 22-gauge needles with 20 to-and-fro movements for each pass.The 4 preparations included 2 cytological and 2 histological specimens.The pathologic reviews of all specimens were conducted independently by a single experienced cytopathologist.Sensitivity,specificity,and accuracy of the 2 preparations were compared.RESULTS:The enrolled patients consisted of 62 males(52.5%),with the mean age of 64.6±10.5 years.Surgery was performed in 23(19.5%) patients.One hundred and sixteen(98.3%) lesions were classified as malignant,while 2(1.7%) were benign.Sensitivity of cytology and histology were 87.9% and 81.9%,respectively,with no significant difference(P=0.190).Accuracy was also not significantly different.Cytological preparation was more sensitive when the size of lesion was <3 cm(86.7% vs 68.9%,P=0.033).CONCLUSIONS:Our results suggested that the diagnostic performances of cytological and histological preparations are not significantly different for the diagnosis of pancreatic malignancies.However,cytological preparation might be more sensitive for pancreatic lesions <3 cm.展开更多
Background: Endoscopic biliary decompression using bilateral self-expandable metallic stent(SEMS) placed using the stent-in-stent(SIS) technique is considered favorable for unresectable malignant hilar biliary obstruc...Background: Endoscopic biliary decompression using bilateral self-expandable metallic stent(SEMS) placed using the stent-in-stent(SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction(MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. Methods: From January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. Results: The technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. Conclusions: Revision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.展开更多
BACKGROUND： Bilateral stent-in-stent （SIS） self-expandable metal stent placement is technically chghallenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell...BACKGROUND： Bilateral stent-in-stent （SIS） self-expandable metal stent placement is technically chghallenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell type biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent. This study aimed to assess the technical success and clinical effectiveness of this technique with a uniform large cell type biliary stent. METHODS： Thirty-one patients who underwentlbilateral SIS placement using a large cell type stent were reviewed retrospectively. All patients showed malignant hilarl obstruction （Bismuth types Ⅱ, Ⅲ, Ⅳ） with different etiologies. RESULTS： Sixteen （51.6%） patients were male. The mean age of the patients was 67.0±14.0 years. Most patients were diagnosed as having hilar cholangiocarcinoma （58.1%） and gallbladder cancer （29.0%）. Technical success rate was 83.9%. Success was achieved more frequently in patients without masses obstructing the biliary confluence （MOC） than those with MOC （95.2% vs 60.0%, P=0.03）. Functional success rate was 77.4%. Complications occurred in 29.0% of the patients. These tended to occur more frequently in patients with MOC （50.0% vs 19.0%, P=0.11）. Median time to recurrent biliary obstruction was 188 days and median survival was 175 days. CONCLUSIONS： The large cell type stent can be used efficiently for bilateral SIS placement in malignant hilar obstruction. However, the risk of technical failure increases in patients with MOC, and caution is needed to prevent complications for these patients.展开更多
Background:Endoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction.Self-expandable metal stents have clinical advantages including an increased duration o...Background:Endoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction.Self-expandable metal stents have clinical advantages including an increased duration of patency that may be prolonged by acetylsalicylic acid(ASA)use.The aim of this study was to investigate whether ASA had a positive effect on the patency of self-expandable metal stents compared with placebo.Methods:This prospective,multicenter,double-blinded,and randomized placebo-controlled trial was conducted from October 2017 to May 2020 in Korea.Patients who underwent palliative endoscopic biliary drainage with self-expandable metal stents for malignant distal bile duct obstruction were enrolled,and allocated to ASA treatment or placebo.The study outcomes were the rate of stent dysfunction at 6 months,duration of stent patency,risk factors for stent dysfunction,and any adverse events.Results:Interim analysis included 24 and 28 patients in the ASA and placebo groups,respectively.There was no significant difference between the ASA and placebo groups in stent dysfunction(25.0%vs.20.7%,P=0.761)or the duration of stent patency(150.97±10.55 vs.158.07±8.70 days,P=0.497).Six patients experienced suspected ASA-related adverse events,and there was one lethal case.Conclusions:ASA did not prolong stent patency.This study was terminated early because of the possibility of serious adverse events related to ASA treatment of these patients receiving palliative care.展开更多
文摘Background:The efficacy of adjuvant treatment(AT)in ampullary cancer(AmC)remains controversial.This systematic review and meta-analysis aimed to evaluate the role of AT for AmC.Data sources:A comprehensive systematic search was performed in PubMed,EMBASE,Cochrane Library,and Web of Science databases.Studies comparing overall survival(OS)and recurrence-free survival(RFS)of patients who underwent AT or not following AmC resection were included.Results:A total of 3971 patients in 21 studies were analyzed.Overall pooled data showed no significant difference in effect on the OS by AT[hazard ratio(HR)=0.998,95%confidence interval(CI):0.768–1.297].No significant difference in recurrence between the AT and non-AT(nAT)groups was noted(HR=1.158,95%CI:0.764–1.755).In subgroup analysis,patients who received AT showed favorable outcomes in the OS compared with those who received nAT in nodal-positive AmC(HR=0.627,95%CI:0.451–0.870).Neither AT consisted of adjuvant chemotherapy with radiotherapy(HR=0.804,95%CI:0.563–1.149)nor AT with adjuvant chemotherapy(HR=0.883,95%CI:0.642–1.214)showed any significant effect on the OS.Conclusions:The effect of AT in AmC on survival and recurrence did not show a significant benefit.Furthermore,effectiveness according to AT strategies did not show enhancement in survival.AT had an advantage in survival compared with nAT strategy in nodal-positive AmC.In cases of AmC with positive lymph nodal involvement,AT may be warranted regardless of detailed strategies.
文摘AIM: To identify clinical and pathological differences between serum immunoglobulin G4 (IgG4)-positive (SIP) and IgG4-negative (SIN) type 1 autoimmune pancreatitis (AIP) in South Korea. METHODS: AIP was diagnosed by the international consensus diagnostic criteria. The medical records and pathology were retrospectively reviewed and IgG4-positive cells were counted in a high power field (HPF). Type I AIP was defined as a high serum level of IgG4or histological finding. SIN type 1 AIP was defined as a histological evidence of type 1 AIP and a normal serum IgG4 level. The clinical and pathological findings were compared between the two groups. The analysis was performed using Student's t test, Fischer's exact test and Mann-Whitney's U test. A P value of < 0.05 was considered statistically significant. As repeated com- parison was made, P values of less than 5% (P < 0.05) were considered significant. RESULTS: Twenty five patients with definite type 1 AIP (19 histologically and six serologically diagnosed cases) were enrolled. The mean tissue IgG4 concentrations were significantly higher in SIP than SIN group (40 cells per HPF vs 18 cells per HPF, P = 0.02). Among eight SIN patients, the tissue IgG4 concentrations were less than 15 cells per HPF in most of cases, except one. The sensitivity of serum IgG4 was 68% (17 SIP and eight SIN AIP). Other organ involvement was more frequent- ly associated with SIP than SIN AIP (59% vs 26%, P = 0.016). However, the relapse rate and diffuse swelling of the pancreas were not associated with serum IgG4 level. The concentrations of IgG4-positive cells per HPF were higher in SIP than SIN AIP (40 vs 18, P = 0.02). CONCLUSION: The sensitivity of serum IgG4 was 68% in type 1 AIP. High serum IgG4 level was associated with other organ involvement and tissue IgG4 concentration but did not affect the relapse rate in type 1 AIP.
基金Supported by a grant No. 2120040320 from the Seoul National University Hospital Research Fund
文摘AIM： To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin＇s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage （ERBD）, external percutaneous transhepatic biliary drainage （EPTBD） and internal biliary stenting via the PTBD tract （IPTBD）. METHODS： The initial success rate, cumulative patency rate, and complication rate were compared retrospectively, according to the Bismuth type and ERBD, EPTBD, and IPTBD. Patency was defined as the duration for adequate initial bile drainage or to the point of the patient＇s death associated with inadequate drainage. RESULTS： One hundred thirty-four patients （93 men, 41 women; 21 Bismuth type Ⅱ, 47Ⅲ, 66 Ⅳ; 34 ERBD, 66 EPTBD, 34 IPTBD） were recruited. There were no differences in demographics among the groups. Adequate initial relief of jaundice was achieved in 91% of patients without a significant difference in the results among different procedures or Bismuth types. The cumulative patency rates for ERBD and IPTBD were better than those for EPTBD with Bismuth type Ⅲ. IPTBD provided an excellent response for Bismuth type IV. However, there was no difference in the patency rate among drainage procedures for Bismuth type Ⅱ. Procedure-related cholangitis occurred less frequently with EPTBD than with ERBD and IPTBD. CONCLUSION： ERBD is recommended as the firstline drainage procedure for the palliation of jaundice in patients with inoperable Klatskin＇s tumor of Bismuth type Ⅱ or Ⅲ, but IPTBD is the best option for Bismuth type Ⅳ.
基金Supported by The Korean Society of Gastroenterology Research Fund, No. 2005-1
文摘AIM： To investigate prevalence of C/onorchis sinensis in patients with gastrointestinal symptoms, and the relation of the infection to hepatobiliary diseases in 26 hospitals in Korea. METHODS： Consecutive patients who had been admitted to the Division of Gastroenterology with gastrointestinal symptoms were enrolled from March to April 2005. Of those who had been diagnosed with clonorchiasis, epidemiology and correlation between infection and hepatobiliary diseases were surveyed by questionnaire. RESULTS： Of 3080 patients with gastrointestinal diseases, 396 （12.9%） had clonorchiasis and 1140 patients （37.2%） had a history of eating raw freshwater fish. Of those with a history of raw freshwater fish ingestion, 238 （20.9%） patients had clonorchiasis. Cholangiocarcinoma was more prevalent in C. sinensis-infected patients than nonnfected patients [34/396 （8.6%） vs 145/2684 （5.4%）, P = 0.015]. Cholangiocarcinoma and clonorchiasis showed statistically significant positive cross-relation （P = 0.008）. Choledocholithiasis, cholecystolithiasis, cholangitis, hepatocellular carcinoma, and biliary pancreatitis did not correlate with clonorchiasis. CONCLUSION： Infection rate of clonorchiasis was still high in patients with gastrointestinal diseases in Korea, and has not decreased very much during the last two decades. Cholangiocarcinoma was related to clonorchiasis, which suggested an etiological role for the parasite.
文摘AIM: To identify the risk factors for organ failure(OF) in cholangitis with bacteriobilia.METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.RESULTS: There were 24 cases(13.2%) of OF and five deaths(2.7%). Bile culture was positive for microbial growth in 130 out of 138(94.2%) patients. In multivariate analysis of 130 patients with positivebile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase(ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation:(2.7 × ESBL organisms in blood cultures) +(1.8 × pre-existing renal dysfunction) +(1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific(99.1%) and had a positive predictive value of 86.2%.CONCLUSION: ESBL organisms in blood cultures, preexisting renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.
文摘BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. METHODS: Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. RESULTS: Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).CONCLUSION: Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.
文摘AIM:To compare the efficacy of self-expandable metal stents(SEMSs) with 10F plastic stents(PSs) in the endoscopic management of occluded SEMSs.METHODS:We retrospectively reviewed the medical records of 56 patients who underwent SEMS insertion for palliation of unresectable malignant biliary obstruction between 2000 and 2007 and subsequent endoscopic retrograde biliary drainage(ERBD) with SEMS or PS for initial SEMS occlusion between 2000 and 2008.RESULTS:Subsequent ERBD with SEMS was performed in 29 patients and with PS in 27.The median time to stent occlusion after subsequent ERBD was 186 d in the SEMS group and 101 d in the PS group(P= 0.118).Overall median stent patency was 79 d for the SEMS group and 66 d for the PS group(P = 0.379).The mean number of additional biliary drainage procedures after subsequent ERBD in patients that died(n = 50) during the study period was 2.54 ± 4.12 for the SEMS group and 1.85 ± 1.95 for the PS group(P = 0.457).The mean total cost of additional biliary drainage procedures after the occlusion of subsequent SEMS or PS was $410.04 ± 692.60 for the SEMS group and $630.16 ± 671.63 for the PS group(P = 0.260).Tumor ingrowth as the cause of initial SEMS occlusion was the only factor associated with a shorter time to subsequent stent occlusion(101 d for patients with tumor ingrowth vs 268 d for patients without tumor ingrowth,P = 0.008).CONCLUSION:Subsequent ERBD with PSs offered similar patency and number of additional biliary drainage procedures compared to SEMSs in the management of occluded SEMS.
文摘AIM: To investigate the prognostic factors determining the success rate of non-surgical treatment in the management of post-operative bile duct injuries (BDIs).
文摘Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery.The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event(AE).Methods:A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital.The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA.The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain.Results:A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows:serous cystic neoplasm(32.2%),mucinous cystic neoplasm(26.6%),branch duct type intraductal papillary mucinous neoplasm(BD-IPMN)(29.4%),and pseudocyst(11.7%).Three patients(1.4%)experienced severe AEs.Overall,AEs occurred in 71(33.2%)patients.BD-IPMN(OR:2.87;95%CI:1.05–7.84;P=0.040),multilocular cysts(OR:3.59;95%CI:1.09–11.85;P=0.036),suspected ethanol leakage during procedure(OR:10.68;95%CI:1.98–57.53;P=0.006),and sticky cystic fluid(OR:3.83;95%CI:1.20–12.24;P=0.024)were predictive factors for post-procedural acute pancreatitis.PCLs of uncinate process(OR:2.99;95%CI:1.22–7.35;P=0.017)and PCLs with exophytic portion(OR:3.70;95%CI:1.96–7.01;P<0.001)were predictive factors for post-procedural abdominal pain.Conclusions:EUS-EA is a safe procedure with a very low rate of severe AEs.It seems possible to predict the AEs according to the features of the procedure and PCLs.
文摘AIM： To evaluate the clinicopathologic characteristics of patients with metastases to the gallbladder （MGBs）. METHODS： We performed a single-center retrospective study of 20 patients with MGBs diagnosed pathologically from 1999 to 2007. RESULTS： Among 417 gallbladder （GB） malignancies, 20 （4.8%） were MGBs. The primary malignancies originated from the stomach （n = 8）, colorectum （n = 3）, liver （n = 2）, kidney （n = 2）, skin （n = 2）, extrahepatic bile duct （n = 1）, uterine cervix （n = 1）, and appendix （n = 1）. Twelve patients were diagnosed metachronously, presenting with cholecystitis （n = 4）, abdominal pain （n = 2）, jaundice （n = 1）, weight loss （n = 1）, and serum CA 19-9 elevation （n = 1）; five patients were asymptomatic. The median survival after the diagnosis of MGB was 8.7 mo. On Cox regression analysis, R0 resection was the only factor associated with a prolonged survival [hazard ratio （HR）： 0.01, P = 0.002]; presentation with cholecystitis was associated with poor survival （HR： 463.27, P = 0.006）. CONCLUSION： MGBs accounted for 4.8% of all pathologically diagnosed GB malignancies. The most common origin was the stomach. The median survival of MGI3 was 8.7 mo.
基金Supported by Korean Society of Internal Medicine Research Fund(2012)the Seoul National University College of Medicine Research Fund(2011)
文摘AIM: To evaluate the anti-tumor effect of clobenpropit, which is a specific H<sub>3</sub> antagonist and H<sub>4</sub> agonist, in combination with gemcitabine in a pancreatic cancer cell line.
基金the Institutional Review Board of Seoul National University Hospital(No.1711–107–901).
文摘Background:Stent insertion for biliary decompression to relieve jaundice and subsequent biliary infection is necessary for patients with biliary obstruction caused by pancreatic cancer,and it is important to keep the stent patent as long as possible.However,few studies have compared stent patency in terms of chemotherapy in patients with pancreatic cancer.This study aimed to evaluate the differences in stent patency in terms of recently evolving chemotherapy.Methods:Between January 2015 and May 2017,161 patients with pancreatic cancer who had undergone biliary stent insertion with a metal stent were retrospectively analyzed.The relationship between chemotherapy and stent patency was assessed.Additionally,overall survival according to the treatment,risk factors for stent patency,and long-term adverse events were evaluated.Results:Median stent patency was 42 days for patients with the best supportive care and 217 days for patients with chemotherapy(conventional gemcitabine-based chemotherapy and folfirinox)(P<0.001).Furthermore,the folfirinox group showed the longest median stent patency and overall survival,with 283 days and 466 days,respectively(P<0.001)despite higher adverse events rate.Patients who underwent folfirinox chemotherapy after stent insertion had better stent patency in multivariate analysis(HR=0.26;95%CI:0.12–0.60;P=0.001).Conclusions:Compared with patients who received best supportive care only,patients who underwent chemotherapy after stent insertion had better stent patency.More prolonged stent patency can be expected for patients with folfirinox than conventional gemcitabine-based chemotherapy.
基金Supported by Seoul National University College of Medicine Research Fund(2017).
文摘BACKGROUND The adjuvant treatment for patients with resected pancreatic cancer(PC)is not yet standardized.Because the prognosis differs according to the American Joint Committee on Cancer(AJCC)stage,a tailored approach to establish more aggressive treatment plans in high-risk patients is necessary.However,studies comparing the efficacy of adjuvant treatment modalities according to the AJCC stage are largely lacking.AIM To compare the efficacy of chemotherapy and chemoradiation therapy according to AJCC 8th staging system in patients with PC who underwent surgical resection.METHODS A total of 335 patients who underwent surgical resection and adjuvant treatment for PC were included.Patients were divided into three groups:Chemoradiation therapy(CRT)group,systemic chemotherapy(SCT)group and combined treatment of chemoradiation plus chemotherapy therapy(CRT-SCT)group.The primary outcomes were differences in overall survival(OS)between the three groups.The secondary outcomes were differences in recurrence-free survival,recurrence pattern and adverse events between the three groups.RESULTS Patients received CRT(n=65),SCT(n=62)and CRT-SCT(n=208).Overall median OS was 33.3 mo(95%confidence interval(CI):27.4-38.6).In patients with stage I/II,the median OS was 27.0 mo(95%CI:2.06-89.6)in the CRT group,35.8 mo(95%CI:26.9-NA)in the SCT group and 38.6 mo(95%CI:33.3-55.7)in the CRT SCT group.Among them,there was no significant difference in OS between the three groups.In 59 patients with stage III,median OS in the SCT group[19.0 mo(95%CI:12.6-NA)]and the CRT-SCT group[23.4 mo(95%CI:22.0-44.4)]was significantly longer than that in the CRT group[17.7 mo(95%CI:6.8-NA);P=0.011 and P<0.001,respectively].There were no significant differences in incidence of locoregional and distant recurrences between the three groups(P=0.158 and P=0.205,respectively).Incidences of grade 3 or higher hematologic adverse events were higher in the SCT and CRT-SCT groups than in the CRT group.CONCLUSION SCT and CRT-SCT showed significantly longer OS and recurrence-free survival than CRT in patients with AJCC stage III,while there was no significant difference in OS between the CRT,SCT and CRT-SCT groups in patients with AJCC stage I/II.Different adjuvant therapy according to AJCC stage can be applied in patients with PC.
文摘BACKGROUND:Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) has become a crucial diagnostic technique for pancreatic malignancies.The specimen obtained by EUS-FNA can be prepared for either cytological or histological examinations.This study was to compare diagnostic performance of cytological and histological preparations using EUSFNA in the same lesions when pancreatic malignancies were suspected.METHODS:One hundred and eighteen patients who underwent EUS-FNA for suspected pancreatic malignancies were consecutively enrolled.All procedures were conducted by a single echoendoscopist under the same conditions.Four adequate preparations were obtained by 22-gauge needles with 20 to-and-fro movements for each pass.The 4 preparations included 2 cytological and 2 histological specimens.The pathologic reviews of all specimens were conducted independently by a single experienced cytopathologist.Sensitivity,specificity,and accuracy of the 2 preparations were compared.RESULTS:The enrolled patients consisted of 62 males(52.5%),with the mean age of 64.6±10.5 years.Surgery was performed in 23(19.5%) patients.One hundred and sixteen(98.3%) lesions were classified as malignant,while 2(1.7%) were benign.Sensitivity of cytology and histology were 87.9% and 81.9%,respectively,with no significant difference(P=0.190).Accuracy was also not significantly different.Cytological preparation was more sensitive when the size of lesion was <3 cm(86.7% vs 68.9%,P=0.033).CONCLUSIONS:Our results suggested that the diagnostic performances of cytological and histological preparations are not significantly different for the diagnosis of pancreatic malignancies.However,cytological preparation might be more sensitive for pancreatic lesions <3 cm.
基金supported by a grant from Daewoong Education Fund(800-20140081)
文摘Background: Endoscopic biliary decompression using bilateral self-expandable metallic stent(SEMS) placed using the stent-in-stent(SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction(MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. Methods: From January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. Results: The technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. Conclusions: Revision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.
基金supported by a grant from Daewoong Education Fund(800-20140081)
文摘BACKGROUND： Bilateral stent-in-stent （SIS） self-expandable metal stent placement is technically chghallenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell type biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent. This study aimed to assess the technical success and clinical effectiveness of this technique with a uniform large cell type biliary stent. METHODS： Thirty-one patients who underwentlbilateral SIS placement using a large cell type stent were reviewed retrospectively. All patients showed malignant hilarl obstruction （Bismuth types Ⅱ, Ⅲ, Ⅳ） with different etiologies. RESULTS： Sixteen （51.6%） patients were male. The mean age of the patients was 67.0±14.0 years. Most patients were diagnosed as having hilar cholangiocarcinoma （58.1%） and gallbladder cancer （29.0%）. Technical success rate was 83.9%. Success was achieved more frequently in patients without masses obstructing the biliary confluence （MOC） than those with MOC （95.2% vs 60.0%, P=0.03）. Functional success rate was 77.4%. Complications occurred in 29.0% of the patients. These tended to occur more frequently in patients with MOC （50.0% vs 19.0%, P=0.11）. Median time to recurrent biliary obstruction was 188 days and median survival was 175 days. CONCLUSIONS： The large cell type stent can be used efficiently for bilateral SIS placement in malignant hilar obstruction. However, the risk of technical failure increases in patients with MOC, and caution is needed to prevent complications for these patients.
基金supported by a grant from the Seoul National University Hospital Research Fund(0620173640)。
文摘Background:Endoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction.Self-expandable metal stents have clinical advantages including an increased duration of patency that may be prolonged by acetylsalicylic acid(ASA)use.The aim of this study was to investigate whether ASA had a positive effect on the patency of self-expandable metal stents compared with placebo.Methods:This prospective,multicenter,double-blinded,and randomized placebo-controlled trial was conducted from October 2017 to May 2020 in Korea.Patients who underwent palliative endoscopic biliary drainage with self-expandable metal stents for malignant distal bile duct obstruction were enrolled,and allocated to ASA treatment or placebo.The study outcomes were the rate of stent dysfunction at 6 months,duration of stent patency,risk factors for stent dysfunction,and any adverse events.Results:Interim analysis included 24 and 28 patients in the ASA and placebo groups,respectively.There was no significant difference between the ASA and placebo groups in stent dysfunction(25.0%vs.20.7%,P=0.761)or the duration of stent patency(150.97±10.55 vs.158.07±8.70 days,P=0.497).Six patients experienced suspected ASA-related adverse events,and there was one lethal case.Conclusions:ASA did not prolong stent patency.This study was terminated early because of the possibility of serious adverse events related to ASA treatment of these patients receiving palliative care.
