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Background Endoscopic ultrasound-elastography (EUS-EG) is a non-invasive complementary diagnostic method for the differential diagnosis of solid pancreatic lesions (SPL). However, the optimal strain ratio (SR) value and diagnostic performance of EUS-EG have not yet been determined in pancreatic neuroendocrine neoplasm (PNEN), mass-forming pancreatitis (MFP), and pancreatic ductal adenocarcinoma (PDAC). We aimed to determine the optimal SR value in EUS-EG for differential diagnosis of SPLs. Methods A total 134 patients who underwent EUS-EG to evaluate SPL were retrospectively investigated. Patients were divided into 3 groups – PNEN (n=10), MFP (n=37), and PDAC (n=87). Baseline characteristics and results of EUS-EG were compared between groups and statistical analyses were performed for differential diagnosis. Results The mean SR values of each group were 11.85±7.56 (PNEN), 11.45±5.97 (MFP), and 22.50 ± 13.19 (PDAC), respectively. There was significant association between SR value increase and PDAC diagnosis (PNEN versus PDAC, p=0.0216; MFP versus PDAC, p=0.0006) in multinomial logistic regression analysis. SR value of 17.14 was confirmed as the optimal cut-off value for differential diagnosis between MFP and PDAC. Conclusions Differential diagnosis of SPL could be performed using EUS-EG. The cut-off SR value presented in this study is expected to be useful in differential diagnosis. Clinical trial registration number: https://cris.nih.go.kr/cris : KCT0002082

Background and Aims Contrast-enhanced harmonic EUS (CEH-EUS) is useful in the differential diagnosis of solid pancreatic lesions (SPLs). However, there is lack of verification about the usefulness of CEH-EUS–guided FNA/fine-needle biopsy (FNB) sampling. This study aimed to investigate the usefulness of CEH-EUS–guided FNA/FNB sampling without on-site cytopathology. Methods Patients with SPLs were prospectively enrolled and randomly assigned (1:1) to 2 parallel groups, the interventional group (CEH-EUS) or the control group (conventional EUS). The diagnostic sensitivity and optimal number of needle passes for pathologic diagnosis were investigated and compared between groups. Results Two hundred forty patients were enrolled from March 2016 to September 2019, with 120 patients assigned to each group. Pancreatic malignancies and neuroendocrine tumors were found in 202 (90.83%) and 9 (3.75%) patients, respectively. There was no statistically significant difference between the groups in terms of age, sex, lesion size (30.96 ± 12.09 mm in the CEH-EUS group vs 33.09 ± 16.39 mm in the conventional EUS group; P = .252), lesion location, adverse event rate, and disease distribution. The diagnostic sensitivity values in the CEH-EUS and conventional EUS groups were 85.8% and 88.3%, respectively (P = .564). All patients in the conventional EUS group and most in the CEH-EUS group received a pathologic diagnosis within 3 needle passes. Conclusions Diagnostic sensitivity for SPLs was not different between the CEH-EUS and conventional EUS groups, and no independent factors were found that could improve diagnostic sensitivity. CEH-EUS–guided FNA/FNB sampling does not need to be used routinely and may be selectively considered for small, indeterminate lesions. (Clinical trial registration number: KCT 0001840.)

Hypertriglyceridemia (HTG) is a well-known cause of acute pancreatitis (AP) and elevation of serum triglycerides (TG) to ≥1000 mg/dl is strongly indicative of HTG-induced AP (HTG-AP). HTG-AP is potentially associated with persistent organ failure and poor prognosis. Here, we compared differences in clinical features and outcomes between patients with HTG-AP and patients with AP due to other causes.A prospective AP registry was constructed in Gil Medical Center between June 2014 and May 2018. In total, 499 patients with AP were included for whom serum TG data at admission were available.HTG-AP was present in 52 patients (10.4%); these patients were younger than patients with AP due to other causes (39.62 ± 10.12 vs. 51.62 ± 17.41, p 0.001). After propensity score matching adjusted by age, the factors associated with severity were more common in the HTG-AP group; these factors included the presence of systemic inflammatory response syndrome, Ranson's score ≥3, acute physiology, age, chronic health evaluation (APACHE) II score ≥8 at admission, and C-reactive protein level10 mg/dl after 24 h of hospitalization. There were no significant differences in complications or severity based on the revised Atlanta classification 2012. In addition, recurrence was more frequent in the HTG-AP group (25.0% vs. 6.4%, p 0.001).HTG-AP occurred in younger patients and showed more frequent recurrences than AP with other causes. Although factors related to severe feature were more common in HTG-AP during early phase, overall severity and prognosis were not different between the two groups.

Background and Aims Endobiliary radiofrequency ablation (EB-RFA) is a new adjunctive method for biliary drainage restoration. However, a concern remains about long-term adverse events of this procedure, such as biliary stricture, perforation, and hemorrhage. Therefore, we aimed to assess the long-term effects of in vivo EB-RFA in a swine model. Methods Six mini-pigs were divided into 2 groups: 10-W/33-mm EB-RFA and 7-W/18-mm EB-RFA. Endoscopic retrograde cholangiography–guided temperature controlled EB-RFA (80°C, 7-10 W, 120 seconds) was performed. After 28 days all mini-pigs underwent follow-up ERC and were killed to assess the long-term effects of EB-RFA. Results All mini-pigs developed biliary stricture (median length, 10.5 mm; range, 6-15) with jaundice (total bilirubin, 5.84 mg/dL; range, 4.3-9.2) and purulent bile at 1 month after EB-RFA. A significant difference was found in the length of stricture on cholangiogram between the 10 W/33-mm and 7 W/18-mm EB-RFA groups (median, 14 vs 6 mm; P = .034); however, no differences were found in the width of the stricture and laboratory findings. Histologic examination revealed marked thickening of bile duct with severe damage of whole layers replaced with reactive myofibroblastic proliferation, dense collagen laydown, chronic and acute inflammation, and fat necrosis. However, long-term adverse events, such as perforation or hemorrhage, were not found. Conclusions As a long-term result of EB-RFA, segmental biliary stricture with cholangitis develops in proportion to the power/length of the RFA electrode. Therefore, biliary stents should be placed to maintain biliary drainage after EB-RFA.

Background: Contrast‐enhanced harmonic endoscopic ultrasound (CEH‐EUS) is useful in the differential diagnosis of solid pancreatic lesions (SPLs). This study aimed to investigate the usefulness of CEH‐EUS-guided fine-needle aspiration/biopsy (FNA/B), without on-site cytopathology. Methods: This randomised controlled trial was conducted at two university hospitals in Korea. Patients with SPLs were prospectively enrolled and randomly assigned (1:1) using a table of random sampling numbers, to two parallel groups, the interventional group (CEH-EUS) or the control group (conventional EUS). The investigators, endoscopists, patients, and pathologists were unmasked to the group assigned. The diagnostic sensitivity and optimal number of needle passes for pathologic diagnosis were investigated and compared between groups. Clinical trial number: KCT0001840. Findings: In total, 252 patients with SPLs were screened and 240 were enrolled from March 2016 to September 2019, with 120 patients assigned to each group. Pancreatic malignancies and neuroendocrine tumours were found in 202 (90·83%) and nine (3·75%) patients, respectively. There was no statistically significant difference between the groups in terms of age, sex, lesion size (30·96±12·09 mm in the CEH-EUS group vs 33·09±16·39 mm in the conventional EUS group; p=0·252), location, adverse event rate (2·5% vs 2·5%; p=0·999), and disease distribution (malignancy, neuroendocrine tumour, and benign masses, p=0·395). The diagnostic sensitivity values in the CEH-EUS and conventional EUS groups were 85·8% and 88·3%, respectively (p=0·564). All the patients in the conventional EUS group and most of those in the CEH-EUS group received a pathological diagnosis within three needle passes. Interpretation: This prospective, randomised trial showed that the diagnostic sensitivity for SPLs was not different between the CEH‐EUS and conventional EUS groups, and there were no independent factors that could improve diagnostic sensitivity. CEH-EUS-guided FNA/B will not need to be used routinely for the diagnosis of SPLs. CEH-EUS may be selectively considered in small, indeterminate lesion. Trial Registration: (Clinical trial registration at https://cris.nih.go.kr/cris; KCT0001840) Funding Statement: None. Declaration of Interests: There are no conflicts of interest to declare. Ethics Approval Statement: This study was approved by the Institutional Review Board (GAIRB2016-026) and conducted in accordance with the principles set forth in the Declaration of Helsinki. Written informed consent was obtained from all patients.

Background: Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. ERCP is essential to demonstrate a choledochocele. The aim of this study was to investigate the duodenoscopic and cholangiographic findings during ERCP. Methods: Over a 4-year period, 17 symptomatic patients (8 men, 9 women; age range 45 to 83 years) were identified as having choledochoceles. The diagnosis of choledochocele was made by both duodenoscopic and cholangiographic findings. Results: As a characteristic duodenoscopic finding, the enlarged bulging papilla was noted in 8 patients (47%), whereas a normal-appearing papilla was noted in 9 patients (53%) before the injection of contrast media. However, in all 17 patients progressive enlargement or ballooning of the papilla was noted during contrast injection. The maximum diameter of the choledochocele, determined by cholangiography, was significantly larger (19 ± 4 mm) in patients with initially bulging papilla than in those with normal-appearing papilla (9 ± 3 mm) ( p Conclusions: Ballooning of the papilla during contrast injection may be a specific duodenoscopic finding for choledochocele. To avoid missing the diagnosis of a choledochocele, especially when it is small, it is important to watch the papilla carefully during contrast injection. (Gastrointest Endosc 1998;48:258-62.)

When we read the recent article by Palomba and colleagues (Palomba et al., 2015), we found that their systematic review did not compare all the risks and benefits of minilaparotomy versus laparoscopic minimally invasive surgery for myomectomy. Gynecologists are interested in surgical techniques for treatment of uterine disorders (Jeong, 2014), and should consider the advantages and safety of minilaparotomy for myomectomy. When laparoscopy-assisted hysterectomy was developed, gynecologists compared laparoscopy and laparotomy for hysterectomy. Then robotic surgery was introduced and gynecologists compared laparoscopic hysterectomy or myomectomy with robot-assisted surgery. Gynecologists have reported the safety of new technologies and advanced operating methods for hysterectomy and myomectomy. Minimally invasive surgery has the advantages of safety, quick recovery, and cosmetic satisfaction. Most gynecologists and their patients would undoubtedly opt for minimally invasive surgery. Gynecologists who still perform open myomectomy or total abdominal hysterectomy are sometimes thought to be unskilled or guilty of causing cosmetic problems. Currently, however, the cutting technique used for hysterectomy and myomectomy is a hot issue. Power morcellation can spread uterine sarcoma or other cancers. The United State FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy in minimally invasive surgery. Johnson & Johnson recalled their morcellation devices worldwide. Many lawyers advertise for patients who underwent morcellation of the uterus. Many hospitals now require completion of a morcellation consent form before laparoscopic hysterectomy and myomectomy. Gynecologists now need to obtain informed consent regarding the cutting method, such as morcellation, used in uterine surgery. This factor should be considered in future clinical research.

Is Endoscopic Band Ligation More Effective Than Electrocoagulation in the Treatment of Bleeding Dieulafoy’s Lesion? Moon Gi Chung, Yu Kyung Kim, Hwa Min Kim, Kwang An Kwon, Dong Kyun Park, Oh Sang Kwon, Sun Suk Kim, Yeon Suk Kim, So Young Kwon, Yang Suh Ku, Duck Joo Choi, Ju Hyun Kim Background and Aims: Dieulafoy’s lesion is a relatively rare but important cause of gastrointestinal bleeding. With the advance of endoscopic techniques, the management of Dieulafoy’s lesion has moved from surgical procedure to endoscopic therapy. However, there are few studies comparing the hemostatic efficacy of different endoscopic methods and there is no consensus regarding the best method of endoscopic therapy in the treatment of Dieulafoy’s lesion. The present study was therefore carried out in order to compare the hemostatic efficacy and safety of endoscopic band ligation and electrocoagulation in the treatment of bleeding Dieulafoy’s lesion. Patients and Methods: Between July 2000 and June 2004, a total of 1650 patients underwent emergent endoscopy for upper gastrointestinal bleeding and 42 patients with bleeding Dieulafoy’s lesion were enrolled and randomly assigned to receive endoscopic band ligation (EBL, n Z 19) or monopolar electrocoagulation (MEC, n Z 23). All patients received acid suppressive therapy for four weeks after endoscopic therapy. Demographic characteristics and outcome parameters including rates of hemostasis and recurrent bleeding were analyzed. Results: There were no significant differences in age, gender, comorbidity, shock, hemoglobin level, coagulopathy, blood transfusion or stigmata of bleeding between two groups. Initial hemostasis was achieved in 90% and 91% of EBL and MEC group, respectively and 4 patients who failed initial hemostasis by EBL or MEC were required additional endoscopic techniques, such as hemoclipping or injection, for control of bleeding. Recurrent bleeding developed in 11% and 22% of EBL and MEC group, respectively (p Z 0.29), however, rebleeding rate of EBL group was lower than that of MEC group (13% of EBL vs. 36% of MEC, p Z 0.04) in subgroup analysis of the patient with coagulopathy. The mean hemostatic procedure time of EBL was shorter than that of MEC group (6.7 min. in EBL vs. 11.5 min. in MEC, p Z 0.08). The mean number of band used was 1.15 in EBL group. None of the 42 patients underwent surgery or angiographic embolization. One patient died due to massive rebleeding after initial hemostasis by MEC. No other major procedure related complication occurred in either group. Conclusions: Bleeding from Dieulafoy’s lesion was well controlled by endoscopic therapy with EBL or MEC, however, EBL is more effective, simple and safe than MEC, especially in the patients who have coagulopaphy. M1319 Clinical Evaluation of the ‘‘M2A Patency Capsule’’ System Before a Capsule Endoscopy Procedure (VCE), in Patients with Suspected Intestinal Stenosis Michel Delvaux, Emmanuel Ben Soussan, Valerie Laurent, Eric Lerebours, Gerard Gay The main complication of VCE is the blockade of the capsule by a digestive stenosis. The ‘‘patency capsule’’ (Given Imaging, Yoqneam, Israel) is made of a self-dissolving capsule having the same size as VCE, equipped with a metallic label allowing its detection with a metal detector placed on the abdominal wall. When blocked by a stenosis, the patency capsule dissolves in 40 to 80 h after ingestion. The aim of this study was to evaluate the usefulness of this system in patients with suspected intestinal stenosis but requiring a VCE. Patients and Method: 22 patients (15 diagnosed or suspected Crohn, 5 suspected intestinal tumour, and 2 on NSAIDs, 46 G 18 y. -; 16 men) were first investigated with an abdominal CT+enteroclysis (CT, n Z 15) or a small bowel follow-through (SBFT, n Z 7). The patency capsule was then administered around 9am to fasting patients. The presence of the patency capsule in the digestive tract was assessed 30 h later with the metal detector. When the patency capsule was detected, a plain film of the abdomen was obtained and was repeated every 24 h, until capsule expulsion. Results: 30 hours after ingestion, the patency capsule was detected in 15 patients (62.5%): in the area of the small intestine in 7 and in the colon, in 8. In all patients with the capsule blocked in the small intestine, the stenosis was suspected on CT or SBFT. In 3 patients, the delay in progression of the patency capsule led to cancel the VCE procedure. In 3, the patency capsule induced a symptomatic intestinal occlusion, which resolved spontaneously in 1 and required emergency surgery in 2. Although these 2 patients would have been operated on for their primary disease, the procedure had to be anticipated. In 1 patient, the capsule passed through the stenosis without isymptoms. All patients in whom the progression of the patency capsule was delayed had an established or suspected diagnosis of Crohn’s disease. Conclusions: The current technical development of the patency capsule limits its use in clinical practice as it did not detect stenoses not diagnosed by CT or SBFT. Its dissolution starting 40 h after ingestion is too slow to prevent an episode of intestinal occlusion. Patients with Crohn’s disease are most likely at risk of blockade of the capsule progression and should benefit from a CT before VCE. However, a careful interview about medical history and symptoms of the patient remains the most useful indicator that an intestinal stenosis has to be suspected.