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Background/Aims: Recently, recombinant human soluble thrombomodulin (rTM) has been developed as a new drug for disseminated intravascular coagulation (DIC). This study aims to evaluate the clinical benefit of rTM in patients with sepsis-induced DIC caused by acute cholangitis who underwent biliary drainage. Methods: Patients were divided into two groups: the rTM therapy group and the non-rTM therapy group. The primary outcome was the DIC resolution rate at 7 days, and the secondary outcome was 28-day mortality rate. Results: Thirty-five patients were treated by rTM, and 36 patients were treated without rTM for DIC. The rate of resolution of DIC at day 7 was significantly higher in the rTM group than in the non-rTM group (82.9% vs 55.6%, p=0.0012). Compared with the non-rTM group, the 28-day survival rate of the r-TM group was significantly higher (rTM vs non-rTM, 91.4% vs 69.4%, p=0.014). According to multivariate analysis, non-rTM (hazard ratio [HR], 2.681) and CRP (HR, 2.370) were factors related to decreased survival. Conclusions: rTM treatment may have a positive impact on improving DIC and survival rates in patients with severe acute cholangitis. [ABSTRACT FROM AUTHOR]

Background/Aims: Electrohydraulic lithotripsy (EHL) under endoscopic retrograde cholangiopancreatography (ERCP) guidance can be an option to treat difficult stones. Recently, a digital, single-operator cholangioscope (SPY-DS) has become available. Peroral transluminal cholangioscopy (PTLC) using SPY-DS has also been reported. In this retrospective study, the technical feasibility and clinical effectiveness of EHL for difficult bile duct stones under ERCP guidance and under PTLC guidance was examined. Methods: In this pilot study, patients with difficult bile duct stones between July 2016 and July 2017 were retrospectively enrolled. Results: Forty-two consecutive patients underwent EHL using a SPYDS; 34 patients underwent EHL under ERCP guidance, and the other 8 patients underwent EHL under PTLC guidance. Median procedure time was 31 minutes (range, 19 to 66 minutes). The median number of EHL sessions was 1 (range, 1 to 2), and that of ERCP sessions was also 1 (range, 1 to 3). The rate of complete stone clearance was 98% (41/42). Adverse events such as cholangitis and acute pancreatitis were seen in 14% (6/42), which could be treated conservatively. Conclusions: EHL using SPY-DS was technically feasible, not only under ERCP guidance, but also PTLC guidance. A prospective clinical study of EHL using SPY-DS is needed. [ABSTRACT FROM AUTHOR]

Background/Aims Approach technique for Hepaticojejunostomy anastomosis stricture (HJAS) is attempted under enteroscopy. However, long time procedure may be required for this approach, and adverse events including perforation and relatively low technical success rate may be disadvantages. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been emerged. Although various adverse events including stent migration has been reported, technical success rate may be high according to previous report. EUS-BD for HJAS has not been enough reported. In this study, we evaluated clinical impact of EUS-BD for HJAS, and also of antegrade stent deployment for HJAS site through EUS-BD route. Methods Between September 2016 and October 2017, patients who were complicated with HJAS were enrolled. In this study, EUS-BD was firstly performed. And after 1 week, antegrade stent deployment for HJAS site was performed through EUS-BD route. As antegrade stent, fully covered metal stent (8 mm×3 cm, M-Intraductal) was used. After 1 month, this stent was removed through EUS-BD route. Results A total of 21 patients were retrospectively enrolled. Among them, the intrahepatic bile duct puncture was failed in two patients due to bile duct dilatation was not seen. Among 19 patients, EUS-BD could be successfully performed (technical success, 90.4%). Antegrade stent deployment was successfully performed in all cases. And stent removal through EUS-BD route was also successfully performed in all cases. During clinical follow- up (median, 280 days), recurrence of HJAS was not seen in any patients. Conclusions Although long-term outcome should be evaluated, antegrade stent deployment for HJAS through EUS-BD route may be one of option as the treatment for HJAS. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative to failed endoscopic biliary drainage, percutaneous transhepatic biliary drainage or inaccessible papilla. Generally, this novel method, especially EUS-guided hepaticogastrostomy (EUS-HGS), was indicated for extrahepatic bile duct obstruction or isolated left intrahepatic bile duct (IHBD) obstruction because we can only puncture the left IHBD to access IHBD tree on transgastric imaging of EUS. Therefore, EUS-BD is not normally indicated for right IHBD. We evaluated the technical feasibility and clinical efficacy of novel EUS-BD for right IHBD obstruction. Methods A total 34 patients who were histologically diagnosed unresectable carcinoma and obstructive jaundice due to right IHBD obstruction were included. From left IHBD route, after uncovered metallic stent was placed from right IHBD to left IHBD, EUS-HGS was performed. From right IHBD route, following deployment of the uncovered metallic stent from right IHBD to the hepatic parenchyma, we also placed fully covered metallic stent from uncovered metallic stent to the duodenal bulb or stomach. Results The causes of obstructive jaundice were cholangiocarcinoma (n=29), pancreatic cancer (n=3), gastric cancer (n=1), and colon cancer (n=1). Twenty-seven patients underwent EUS-BD from left hepatic bile duct, and 11 patients underwent EUS-BD from right hepatic bile duct. Mean procedure time was 31.2±10.0 minutes. Technical success rate was 90%, and functional success was obtained in all patients who underwent EUS-BD, and adverse events were seen in only one patient (bile peritonitis). Conclusions Presented novel method appears safely and effectively for right IHBD obstruction. [ABSTRACT FROM AUTHOR]

Background/Aims In present study we evaluated association of diabetes mellitus for branch-duct intraductal papillary mucinous neoplasms (BD-IPMN) along IPMN guideline 2017 for at least over 5 years followed BD-IPMN. Methods The 239 BD-IPMN followed cases (mean age, 67.5 years; gender, male/female of 104/135; mean follow-up time, 109.5 months [range, 60.1 to 343.2 months]) were enrolled. These cases were divided in two groups with or without diabetes mellitus. Diabetes case was recognized as case having diabetes at initial diagnosis for IPMN and appeared diabetes during follow up. IPMN classification along IPMN guideline 2017 was used in this present study. We retrospectively analyzed proportions of imaging progression and IDC appearance between diabetes cases and non-diabetes cases. Results Diabetes cases was 37 and non-diabetes case was 202. Age and proportion of male were 68.2 years (48.7%) and 67.3 years (42.6%) in diabetes and non-diabetes case respectively. Proportion of high risk stigmata and worrisome features were 0% and 40.5% in diabetes case and those were 2.0% and 31.2% in non-diabetes case. Proportion of imaging progression was 40.5% in diabetes case, whereas that was 17.8% in non-diabetes case (p=0.0019). Proportion of appearance of invasive ductal carcinoma was 8.1% in diabetes case, whereas that was 1.0% in non-diabetes case (p=0.0054). Time to imaging progression and appearance of invasive ductal carcinoma were not significantly different between diabetes and non-diabetes case. Conclusions Diabetes case were high risk of imaging progression and appearance of invasive ductal carcinoma for BD-IPMN in long term follow-up. [ABSTRACT FROM AUTHOR]