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This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea.The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021.The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively.Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones.

Background/aims The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea. Methods The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP. Results Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%. Conclusions Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.

Although endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) are widely used for tissue acquisition of pancreatic solid mass, the optimal strategy of this procedure has not been established yet. The aim of this nationwide study was to investigate the current practice patterns of EUS-FNA/FNB for pancreatic solid mass in Korea.The Policy-Quality Management of the Korean Pancreatobiliary Association (KPBA) developed a questionnaire containing 22 questions. An electronic survey consisting of the questionnaire was distributed by e-mail to members registered to the KPBA.A total of 101 respondents completed the survey. Eighty respondents (79.2%) performed preoperative EUS-FNA/FNB for operable pancreatic solid mass. Acquire needles (60.4%) were used the most, followed by ProCore needles (47.5%). In terms of need size, most respondents (80%) preferred 22-gauge needles regardless of the location of the mass. Negative suction with a 10-mL syringe (71.3%) as sampling technique was followed by stylet slow-pull (41.6%). More than three needle passes for EUS-FNA/FNB was performed by most respondents (80%). The frequency of requiring repeated procedure was significantly higher in respondents with a low individual volume (5 per month, p=0.001). Prophylactic antibiotics were routinely used in 39 respondents (38.6%); rapid on-site pathologic evaluation was used in 6.1%.According to this survey, practices of EUS-FNA/FNB for pancreatic solid mass varied substantially, some of which differed considerably from the recommendations present in existing guidelines. These results suggest that the development of evidence-based quality guidelines fitting Korean clinical practice is needed to establish the optimal strategy for this procedure.

Background/Aims: Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic cough. The aims of this study were to evaluate the diagnostic usefulness of multichannel intraluminal impedance combined with pH monitoring (MII/pH monitoring) in patients with suspected symptoms of gastroesophageal reflux disease (GERD) and to assess the correlation between GER symptoms and refl ux nature. Methods: Seventy patients with suspected symptoms of GERD (such as heartburn, acid regurgitation, noncardiac chest pain, globus and chronic cough) were enrolled. All patients were asked to discontinue medications that would infl uence esophageal motor function and gastric acid secretion at least one week ago. All subjects underwent MII/pH monitoring. Results: Forty-five patients (64.3%) were diagnosed with GERD. Among these patients, eleven patients (15.7%) had pathologic acid refl ux by pH data and thirty-four patients (48.6%) had pathologic bolus exposure by impedance. Subjects with chronic cough had a higher De- Meester score (p=0.009), percentage of acid exposure time (p=0.007), acid bolus exposure % time (p=0.027), distal acid refl ux episodes (p=0.015) and proximal acid refl ux episodes (p=0.030) than subjects without chronic cough. Conclusions: The results of this study showed that the impedance monitoring enhanced diagnostic sensitivity than pH-monitoring alone by 48.6%. In addition, refl ux episodes at the distal and proximal esophagus were noted to be important factors associated with chronic cough. (Gut Liver 2012;6:197-202)

Although arteriovenous malformations (AVM) occur frequently in digestive organs, pancreatic AVM is rare. The clinical symptoms of pancreatic AVM are variable and include gastrointestinal bleeding, abdominal pain, jaundice, portal hypertension, pancreatitis, and duodenal ulcer. However, choledochoduodenal or pancreaticoduodenal fistulas complicated with ascending infection and pancreatitis is extremely rare. Herein, we report a case of pancreaticoduodenal fistula associated with a pancreatic AVM that induced recurrent anemia and ascending infection.

Background/Aims: Food residue is frequently observed in the gastric remnant after distal gastrectomy, despite adequate preparation. We devised a water-intake method to reduce food residue in the gastric remnant by drinking large quantities of water in a short time. The aims of this study were to identify the risk factors for food residue and to study the effectiveness of this new method for endoscopy preparation. Methods: A cohort of 708 patients who underwent distal gastrectomy for gastric cancer was reviewed prospectively. Sixty patients with large amounts of food residue were randomly divided into two groups: a water-intake group (n=40) and a prolonged fasting group (n=20). Results: The incidences of a large amount of food residue were 15.7%, 5.8%, 7.5%, and 2.8% at 3, 12, 24, and 36 months, respectively, after distal gastrectomy. Independent risk factors for food residue were endoscopy at 3 months, diabetes mellitus, a body mass index of ＜19.5, and laparoscopic surgery. The proportion of successful preparations at follow-up endoscopy was higher for the water-intake group (70%) than for the prolonged fasting group (40%, p=0.025). Conclusions: The water- intake method can be recommended as a preparation for endoscopy in patients who have had repetitive food residue or risk factors after distal gastrectomy. (Gut and Liver 2009;3:186-191)

Background/Aims: Irritable bowel syndrome (IBS) is a biopsychosocial disorder. 5-Hydroxytryptamine (5-HT) plays a crucial role in the control of gastrointestinal motility, sensation, and secretion. This study investigated changes in platelet-depleted plasma 5-HT and their correlation with psychopathology in IBS patients and healthy subjects. Methods: This study involved 21 subjects with IBS and 13 healthy subjects. Fasting and 1-hr postprandial plasma 5-HT concentrations were measured. The SCL-90R symptom checklist was used for the assessment of current psychological symptoms. Results: Fasting and postprandial plasma 5-HT concentrations were significantly higher in IBS patients (15.11±13.51 ng/mL and 16.31±14.21 ng/mL, respectively) than in healthy subjects (5.55±4.14 ng/mL and 6.25±4.82 ng/mL, respectively; p＜0.05). There were no significant changes between fasting and 1-hr postprandial 5-HT concentration in IBS subtypes and healthy subjects. Scores on all SCL-90R subscales except for the interpersonal-sensitivity subscale were significantly higher in IBS patients than in healthy subjects. No correlation was found between SCL-90R items and platelet-depleted plasma 5-HT concentration. Conclusions: 5-HT might play a critical role in IBS, and psychopathological factors are correlated with IBS. (Gut and Liver 2009;3:26-30)