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Endoscopic submucosal dissection is recommended as an alternative therapy for early esophageal cancer. However, achieving curative resection in this procedure remains controversial since precise prediction of lymph node metastasis can be difficult. Here, we present the preliminary results of endoscopic submucosal dissection followed by concurrent chemoradiotherapy for early esophageal cancer with a high risk of lymph node metastasis. From May 2006 to January 2014, six patients underwent concurrent chemoradiotherapy after endoscopic submucosal dissection with a median follow-up period of 63 months. No complications were encountered during concurrent chemoradiotherapy. Although local recurrence did not occur in all patients, two patients were diagnosed with metachronous cancer. Overall, the survival rate was 100%. Thus, endoscopic submucosal dissection followed by concurrent chemoradiotherapy may be a feasible treatment for early esophageal cancer in patients with a high risk of lymph node metastasis. Future prospective large-scale studies are warranted to confirm our results.

Background/Aims Using an appropriate guidewire can increase the success rate of selective cannulation in endoscopic retrograde cholangiopancreatography. The purpose of this technical study was to investigate the characteristics of each guidewire type and to evaluate its efficiency and rapidity of insertion. Methods We conducted a three-point bending test using a universal testing machine to investigate the flexibility and bending features of each guidewire. 3D-printed silicone tubes with various types of stricture and a hand-made biliary tree silicone model with six-stranded intrahepatic ducts were used to evaluate the success rate and insertion time of each guidewire. Results In the three-point bending test, the characteristics of each guidewire were classified. We found that the bending strengths and times were independent of shaft thickness. Using two in vitro biliary duct models, we determined that the success rate and total insertion time were better for guidewires with a resilient shaft and angled tip than for other types of guidewires (p

Background/Aims Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for the treatment of common bile duct (CBD) stones. However, there is no established consensus on the optimal balloon dilation duration (BDD). We prospectively evaluated the efficacy and post-endoscopic retrograde cholangiopancreatography (ERCP) complications between the 20- and 60-second EPBD groups. Methods A total of 228 patients with small CBD stones (≤12 mm) were randomly assigned to undergo EPBD with a 20- or 60-second duration at six institutions. We evaluated baseline patient characteristics, endoscopic data, clinical outcomes, and procedure-related complications. In addition, we analyzed risk factors for postprocedural pancreatitis. Results CBD stones were removed successfully in 107 of 109 patients (98.1%) in the 20-second group and in 112 of 119 patients (94.1%) in the 60-second group (p=0.146). Post-ERCP pancreatitis developed in seven patients (6.4%) in the 20-second group and nine patients (7.5%) in the 60-second group (p=0.408). In multivariate analysis, contrast dye injection into the pancreatic duct is a significant risk factor for post-EPBD pancreatitis. Conclusions Based on the data showing that there were no significant differences in safety and efficacy between the two BDD groups, 20 seconds of BDD may be adequate for treatment of small CBD stones with EPBD.

Background/Aims: Some factors like stent wires, balloon dilatation and use of guide wires seems to increase perforation after self-ex pandable metal stent (SEMS) placement, but few studies mentioned about the relationship between angulation of malignant stricture and perforation. The present study aimed to confirm that more angular positioning of stents increases perforation. Methods: This study was conducted with retrospectively evaluation at Digestive Disease Center, CHA Bundang Medical Center, CHA University. Between January 2002 and August 2011, SEMS was inserted in 130 patients with malignant colorectal obstruction. We studied the difference in the angle of stenosis between perforation and non-perforation groups using fluorography images. Results: SEMS insertion was performed in 130 cases of obstruction due to colon cancer. Perforation occurred in eight patients (6.2%) of them. Thirteen cases were excluded from the analysis due to poor fluoroscopic images. Among the eight patients with perforation, the mean stenosis angle was 109.9° compared to 153.1° in the nonperforation group, indicating that the angle was more acute in the perforation group (p=0.016). Conclusions: This study shows that more angular positioning of stent increases bowel perforation after SEMS placement for malignant colorectal obstruction.

Background/Aims: Colonoscopic perforations have been managed with exploratory laparotomy, and have resulted in some morbidity and mortality. Recently, laparoscopic surgery is commonly performed for this purpose. The aim of this study was to compare the outcomes of several management strategies for iatrogenic colonoscopic perforations. Methods: We retrospectively reviewed the medical records of patients who had been treated for colonoscopic perforation between January 2004 and April 2013 at CHA Bundang Medical Center in Korea. Results: A total of 41 patients with colonoscopic perforation were enrolled. Twenty patients underwent conservative management with a success rate of 90%. Surgical management was performed in 23 patients including two patients who were converted to surgical management after the failure of the initial conservative management. Among 14 patients who underwent surgery at 8 hours after the perforation, there was no considerable difference in adverse outcomes between the laparotomy group and the laparoscopic surgery group. The medical costs and claim rate were 1.45 and 1.87 times greater in the exploratory laparotomy group, respectively. Conclusions: Conservative management of colonoscopic perforation could be an option for patients without overt symptoms of peritonitis or with a small defect size. If surgical management is required, laparoscopic surgery may be considered as the initial procedure even with a delayed diagnosis.

Esophageal duplication (ED) is rarely diagnosed in adults and is usually asymptomatic. Especially, ED that is connected to the esophagus through a tubular communication and combined with bronchoesophageal fistula (BEF) is extremely rare and has never been reported in the English literature. This condition is very difficult to diagnose. Although some combinations of several modalities, such as upper gastrointestinal endoscopy, esophagography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, can be used for the diagnosis, the results might be inconclusive. Here, we report on a patient with communicating tubular ED that was incidentally diagnosed on the basis of endoscopy and esophagography during the postoperational evaluation of BEF.

Introduction of endoscopic submucosal dissection (ESD) has brought about a renaissance in therapeutic endoscopy. For the globalization and universalization of ESD, the number of physicians who can perform ESD has rapidly increased with general ex vivo and in vivo training using animal models and hand-on courses. In this focused review series, world-renowned ESD experts described the published studies or their own precious experiences about ESD training and performing ESD with accurate and safe techniques. First, Dr. Adolfo Parra-Blanco reviewed on ex vivo and in vivo models for ESD training. Next, Dr. Joo Young Cho described detailed practical settings and current status of hands-on courses using ex vivo and in vivo models in Korea. Dr. Takashi Toyonaga described quality controlled ESD and basic techniques to prevent complications. Dr. Tsuneo Oyama reviewed recently published methods to facilitate ESD. Dr. Jae-Young Jang reviewed the usefulness of magnifying and narrow band imaging to measure the depth of invasion before ESD.

Imaging mass spectrometry (IMS) is currently receiving large attention from the mass spectrometric community, although its use is not yet well known in the clinic. As matrix-assisted laser desorption/ionization time-of-flight (MALDI)-IMS can show the biomolecular changes in cells as well as tissues, it can be an ideal tool for biomedical diagnostics as well as the molecular diagnosis of clinical specimens, especially aimed at the prompt detection of premalignant lesions much earlier before overt mass formation, or for obtaining histologic clues from endoscopic biopsy. Besides its use for pathologic diagnosis, MALDI-IMS is also a powerful tool for the detection and localization of drugs, proteins, and lipids in tissue. Measurement of parameters that define and control the implications, challenges, and opportunities associated with the application of IMS to biomedical tissue studies might be feasible through a deep understanding of mass spectrometry. In this focused review series, new insights into the molecular processes relevant to IMS as well as other field applications are introduced.

Endoscopic retrograde cholangiopancreatography (ERCP)-induced complications, once occurred, can lead to significant morbidity. Commonly 5% to 10% of patients experience procedure related complications such as post-ERCP pancreatitis, biliary hemorrhage, and cholangitis, in descending order. However, complications such as perforation, pneumothorax, air embolism, splenic injury, and basket impaction are rare but are associated with high mortality if occurred. Such unexpected unusual complications might extend the length of hospitalization, require urgent surgical intervention, and put the patient in miserable condition leading to permanent disability or mortality. Although these ERCP-induced complications can be minimized by a skilled operator using advanced techniques and devices, the occurrence of unusual complications are hard to expect and induce very difficult management condition. In this review, we will focus on the uncommon complications related to ERCP. This review is also aimed at suggesting optimal endoscopic treatment strategies for several complications based on our institutional experiences.

Colonic lipoma, a very rare form of benign tumor, is typically detected incidentally in asymptomatic patients. The size of lipoma is reported variously from 2 mm to 30 cm, with higher likelihood of symptoms as the size is bigger. Cases with symptom or bigger lesion are surgically resected in principle; endoscopic resection, which has developed recently with groundbreaking advance of endoscopic excision technology, is being used more often but with rare report of success due to high chance of complications such as bowel perforation or bleeding. The authors report here, together with a literature review, our experiences of three cases of giant colonic lipomas showing complete remission after aggressive unroofing technique, at certain intervals, using snare catheter at the origin of the lipoma so that the remaining lipoma could be drained out of the exposed surface spontaneously, in order to reduce complications.

BACKGROUND/AIMS In order to reduce the procedure time and the number of accessory changes during endoscopic submucosal dissection (ESD), we developed a novel versatile knife, which has the combined advantages of several conventional knives. The aim of this study was to compare the efficacy, safety, and histological quality of ESD performed using this novel versatile knife and a combination of several conventional knives. METHODS This was an in vivo animal study comparing two different modalities of ESD in mini-pigs. Completion time of each resection was documented, and the resected specimens were retrieved and evaluated for completeness. To assess the quality control of the procedures and adverse events, detailed histopathological examinations were performed. RESULTS A total of 18 specimens were dissected by ESD safely and easily (nine specimens using the new versatile knife; nine specimens by mixing conventional knives). All resections were completed as en bloc resections. There was no significant difference in procedure time between the 2 modalities (456 seconds vs. 355 seconds, p=0.258) and cutting speed (1.983 mm(2)/sec vs. 1.57 mm(2)/sec, p=1.000). The rate of adverse events and histological quality did not statistically differ between the modalities. CONCLUSIONS ESD with a versatile knife appeared to be an easy, safe, and technically efficient method.

Recent advances in optical molecular imaging allow identification of morphologic and biochemical changes in tissues associated with gastrointestinal (GI) premalignant lesions earlier and in real-time. This focused review series introduces high-resolution imaging modalities that are being evaluated preclinically and clinically for the detection of early GI cancers, especially Barrett esophagus and esophageal adenocarcinoma. Although narrow band imaging, autofluorescence imaging, and chromoendoscopy are currently applied for this purpose in the clinic, further adoptions of probe-based confocal laser endomicroscopy, high-resolution microendoscopy, optical coherence tomography, and metabolomic imaging, as well as imaging mass spectrometry, will lead to detection at the earliest and will guide predictions of the clinical course in the near future in a manner that is beyond current advancements in optical imaging. In this review article, the readers will be introduced to sufficient information regarding this matter with which to enjoy this new era of high technology and to confront science in the field of molecular medical imaging.

A 17-year-old man was diagnosed as Peutz-Jeghers syndrome (PJS) because of pigmented lip and multiple gastrointestinal polyps. He had anemia and underwent polypectomy on the duodenum and colon. His maternal family members were patients with PJS. His mother used to be screened with endoscopy to remove large polyps. One and half years later, he underwent jejunal segmental resection due to intussusceptions. He underwent endoscopic polypectomy every 2 to 3 years. When he was 23 years old, high-grade dysplasia was found in colonic polyp and his mother underwent partial pancreatectomy due to intraductal papillary mucinous carcinoma. When he was 27 years old, diffuse gastric polyps on the greater curvature of corpus expanded and grew. Therefore, wide endoscopic polypectomy was done. Histological examination revealed focal intramucosal carcinoma and low-grade dysplasia in hamartomatous polyps. We report cases of cancers occurred in first-degree relatives with PJS.

Endoscopic biliary stenting is widely used to palliate malignant obstruction or to treat benign biliary diseases. The technique is less invasive and guarantees high clinical success rates with low morbidity.1,2 In particular, a precise measurement of the length of stenotic area from the papilla makes it possible to place the stent successfully under fluoroscopic monitoring. Although previously taken abdominal computed tomography or magnetic resonance cholangiopancreatography might be helpful, simultaneous measurement using dedicated instruments during endoscopic retrograde cholangiopancreatography can be clinically most helpful.3 For this purpose, we employed a balloon catheter marked with a scale that allowed us to make direct endoscopic measurement of the length from the stenotic area to the papilla. The balloon catheter (Escort II double lumen extraction balloon; Cook Endoscopy, Winston-Salem, NC, USA), marked in advance with a scale, was one that we generally used as a retrieval catheter for biliary stone extraction. The followings are the step-by-step methods for measuring the length from the stenotic area to the papilla and stent insertion: 1) After the biliary stenosis was identified with cholangiography, a guide wire was inserted in advance through the stenosis; 2) The balloon catheter could pass through the stenosis over the guide wire and advance far enough along to pass the proximal margin of the stenosis; 3) Once the inflated balloon catheter was pulled back until it reached the proximal end of the stenosis (Fig. 1), we could endoscopically measure the length from the stenotic area to the papilla with the scale marked on the balloon cathether (Fig. 2); 4) After removing the balloon catheter, leaving the guide wire, a stent of adequate size was positioned through the stenosis. Fig. 1 Cholangiography showing an obstruction of 3 cm in length at the proximal extrahepatic biliary tract. The first step begins with the insertion of a guide wire that is introduced inside the balloon catheter into the stenotic area. Once it has passed the ... Fig. 2 Endoscopic image of balloon catheter assisted measurement. The length from the stenotic area to the papilla is directly and precisely measured with the scale on the surface of the catheter. Inset; balloon catheter with marked scale. The balloon catheter ...

Biliary stents are widely used not only for palliative treatment of malignant biliary obstruction but also for benign biliary diseases. Each plastic stent or self-expandable metal stent (SEMS) has its own advantages, and a proper stent should be selected carefully for individual condition. To compensate and overcome several drawbacks of SEMS, functional self-expandable metal stent (FSEMS) has been developed with much progress so far. This article looks into the outcomes and defects of each stent type for benign biliary stricture and describes newly introduced FSEMSs according to their functional categories.

See "Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation Are Similar to Those after Endoscopic Sphincterotomy Alone" by Ka Young Kim, Jimin Han, Ho Gak Kim, et al., on page 637-642 Since endoscopic papillary large balloon dilatation (EPLBD) was first introduced by Ersoz et al.1 in 2003, a lot of studies have reported a good therapeutic effect of EPLBD for the removal of difficult common bile duct (CBD) stones. Most of these studies evaluated a success rate of EPLBD compared with the existing endoscopic sphincterotomy (EST) or acute complications of EPLBD in terms of overcoming the burden of the procedure itself.2 With a success rate as high as 94% to 100% and a complication rate as low as 0% to 17%, EPLBD has become an easier and safer modality for managing difficult stones.3 No guideline has yet been established for the application of EPLBD, and issues have recently emerged regarding the selection of appropriate patients and how to minimize complications. Lack of sufficient data on long-term outcome also calls for a large prospective study on the long-term effectiveness of EPLBD. According to a recently published meta-analysis, EPLBD was found to achieve an overall successful clearance of bile duct stones, stone clearance at the first endoscopic retrograde cholangiopancreatography session, and removal of large stones, comparable with those achieved via EST. Based on the relatively low frequency of requiring mechanical lithotripsy and low rate of complications such as hemorrhage, the authors concluded that EPLBD can be considered for the removal of difficult common bile stones in patients with underlying coagulopathy or requiring anticoagulation therapy.4-6 What are the long-term complications of EPLBD? Most of the published studies investigated stone recurrence, and studies on other late complications are either lacking or unknown. In a recent study about the long-term outcome of EPBD, cholangitis and cholecystitis were reported in 0.8% and 3.4% of patients, respectively, over a mean follow-up period of 4.4 years.7 In an issue of Clinical Endoscopy, Kim et al.8 reported that no difference in late complication rates of recurrent cholangitis and cholecystitis was observed between to the EPLBD and EST groups (5.9% and 3.3%; p=1.000). Before I have mentioning on a stone recurrence which is most common long term complication after EPLBD, I will make a short comment for a stone recurrence. The reported stone recurrence rate after CBD stone removal is approximately 4% to 24%, and various factors, including older age, periampullary diverticulum, gallbladder stone, angulated CBD, mechanical lithotripsy, and severe bile duct dilatation, are known to affect stone recurrence.9-13 Compared with endoscopic papillary balloon dilatation (EPBD), which retains sphincter function to a certain degree, EPLBD has been speculated to have a greater effect on stone recurrence because it dilates the biliary orifice to a much greater extent. EPLBD may completely destroy the functionality of the sphincter of Oddi, although no observational study has provided data to support this. Due to this, the pressure gradient between the CBD and duodenum is removed, resulting in frequent occurrence of subsequent duodenobiliary reflux, hence the hypothesis that EPLBD will cause additional complications during the long term.3 EPBD has been reported to be associated with a lower rate of recurrent bile duct stones for long-term outcome compared with EST. After a median follow-up of 6.7 years in a previous study, the overall biliary complication rate was 10.1% in the EPBD group, compared to 25.0% in the EST group. Meanwhile, the stone recurrence rates were 8.0% and 17.4% in the EPBD and EST groups, respectively, indicating a statistically significant difference between both groups.14 The authors implicated additional late complications caused by biliary sphincter dysfunction from EST during the long-term follow-up period as a cause of this difference. Papillary functions were confirmed to be preserved in 70% of the patients after EPBD.15 Considering the impossibility of preserving papillary function with EPLBD, stone recurrence after EPLBD is speculated to be higher than that after EPBD or comparable with that after EST; few studies have been published on this issue, but reports so far state that EPLBD itself does not increase stone recurrence.16,17 In an issue of Clinical Endoscopy and in contrast to previous reports, Kim et al.8 reported a comparable or lower rate of posttreatment bile duct stone recurrence (6.9%) when comparing EPLBD with EST, albeit without significant differences. The results suggested that unlike in EST, previously known factors rather than EPLBD itself were associated with the increased stone recurrence rate. The finding of this study is significant in that it can be cited as evidence of the long-term safety of EPLBD. EPLBD was first introduced as a modality for a more comfortable removal of difficult CBD stones. Since its introduction, a number of early studies have been conducted and reported to clarify the issue that EPLBD might increase the risk for serious adverse events such as acute pancreatitis and perforation, compared with EST. Over the past 10 years, the technical methods and safety of EPLBD have been established and the indication has been expanded. Development of guidelines for the application of EPLBD has been an ongoing effort to minimize the occurrence of any potential serious adverse events and to allow for a safer procedure by analyzing the fundamental causes of such serious adverse events. In addition to such efforts, 10 years after the introduction of EPLBD, more studies on long-term safety of EPLBD, as those reported in this issue, are necessary. Hopefully, with the accumulated evidence of positive effects from the increasing number of previous and ongoing studies investigating the outcomes of EPLBD, the modality would be recognized worldwide as a safe and important therapy in the field of ERCP.

Obstructive jaundice is very rarely caused by impaction of a pancreatic stone in the papilla. We report here on a case of obstructive jaundice with acute cholangitis that was caused by an impacted pancreatic stone in the papilla in a patient with chronic pancreatitis. A 48-year-old man presented with acute obstructive cholangitis. Abdominal computed tomography with the reconstructed image revealed distal biliary obstruction that was caused by a pancreatic stone in the pancreatic head, and there was also pancreatic ductal dilatation and parenchymal atrophy of the pancreatic body and tail with multiple calcifications. Emergency duodenoscopy revealed an impacted pancreatic stone in the papilla. Precut papillotomy using a needle knife was performed, followed by removal of the pancreatic stone using grasping forceps. After additional sphincterotomy, a large amount of dark-greenish bile juice gushed out. The patient rapidly improved and he has remained well.