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Summary Background and aims Since there is a shortage of liver donors, we investigated recurrence patterns and outcomes after liver resection (LR) to determine the feasibility of salvage liver transplantation (SLT). Methods We analyzed 468 patients with hepatocellular carcinoma (HCC) within the Milan criteria (MC) who were mainly associated with Hepatitis B virus infection (76.3%) and had undergone curative LR as an initial treatment. Results The overall survival (OS) rates were 86.6% and 67.4% at 5 and 10 years after LR, respectively. During a median follow-up of 59 months, 211 patients experienced recurrences including 175 (37.4%) within MC and 36 (7.7%) beyond MC. Survival was lowest in patients with beyond MC-recurrence followed by within MC- and no-recurrence groups (26.5%, 86.6%, and 94.7% at 5 years, respectively, P Conclusion Curative LR achieved a 5-year survival of > 85% in patients with transplantable HCC, but early SLT after recurrence within MC is advocated because of poor survival and high risk of progression thereafter. Further, prophylactic LT could be considered for those with high risk of recurrence.

Background/Aims Gastric electrical stimulation (GES) is a feasible modality for the treatment of gastroparesis; however, the presently available device requires invasive surgical implantation for long-term stimulation and repeated surgical procedure after a period of time. This study is aimed at developing a wireless miniature GES device and testing its endoscopic insertion in animal models. Methods Endoscopic gastric implantation of the GES device was performed on 5 healthy weaner pigs under general anesthesia. We created an endoscopic submucosal pocket and inserted the gastro-electrical stimulator. In vivo gastric slow waves were recorded and measured during electrical stimulation. A multi-channel recorder, called an electrogastrogram, was used to record the gastric myoelectrical activity in the study. Results The gastric slow waves on the electrogastrogram were more consistent with GES on the gastric tissues compared to no stimulation. The frequency-to-amplitude ratio was also significantly altered after the electrical stimulation. Conclusions GES is feasible with our minimally invasive wireless device. This technique has the potential to increase utilization of GES as a treatment alternative. (J Neurogastroenterol Motil 2020;26:410-416)

Patient compliance during bowel preparation is important for successful colonoscopy. Bowel preparation with polyethylene glycol (PEG), the most commonly used solution for cleansing, involves the unpleasant ingestion of a large amount of liquid. Sodium picosulfate magnesium citrate (SP-MC) solution is an alternative option with better palatability than PEG. Therefore, in this study, we compared the efficacy and patient tolerability among the following three bowel preparation protocols: 2 L PEG-ascorbic acid (ASc), 1 L PEG-ASc plus bisacodyl, and SP-MC 340 mL plus bisacodyl. We conducted a randomized prospective endoscopist-blinded study between August 2018 and January 2019. A total of 311 patients were randomly classified into three groups according to the above-described bowel preparation protocols. To evaluate the efficacy of bowel cleansing, we used the Boston Bowel Preparation Scale. The degree of symptoms and the patients’ satisfaction with each bowel preparation method were investigated using a questionnaire completed before sedation for colonoscopy. The baseline characteristics were similar among the three groups. There was no significant difference in the bowel preparation quality among the three groups. However, the incidence of symptoms, such as abdominal fullness and pain, was significantly lower (P=0.006 and 0.027, respectively) while the patients’ satisfaction rate was significantly higher (P=0.012) in the SP-MC plus bisacodyl group than in the two PEG groups. In this study, the efficacy of the SP-MC plus bisacodyl solution was similar to that of the PEG solutions. However, patient tolerability and satisfaction were better in the SP-MC plus bisacodyl group than in the other groups. In conclusion, the use of SP-MC plus bisacodyl bowel preparation solution might be a better method for providing good intestinal cleansing and improving patient compliance.

Background/Aims: Recent studies have demonstrated that etomidate is a safe sedative drug with noninferior sedative effects. In our recent study, we revealed that etomidate/mid azolam was more hemodynamically stable than propofol/midazolam in elderly patients undergoing colonoscopies. We aimed to investigate whether compared with propofol/mid azolam, etomidate/midazolam causes fewer cardiopulmo nary adverse events with noninferior efficacy for screening colonoscopies in patients of all ages. Methods: In this single-center, randomized, double-blind study, we prospectively enrolled 200 patients. The patients were divided into etomi date and propofol groups. The primary outcome was the oc currence of cardiopulmonary adverse events. The secondary outcomes were the proportion of patients with fluctuations in vital signs (oxygen desaturation and transient hypotension), adverse events interrupting the procedure, and sedation-related outcomes. Results: Adverse cardiopulmonary events were more common in the propofol group than the etomi date group (65.0% vs 51.0%, respectively; p=0.045). Forty-six patients (46.0%) in the propofol group and 29 (29.0%) in the etomidate group experienced fluctuations in their vital signs (p=0.013). The proportions of patients experiencing adverse events that interrupted the procedure, including myoclonus, were not significantly different between the two groups (etomidate: 20.0% vs propofol: 11.0%; p=0.079). Both groups had similar sedation-related outcomes. Multi variate analysis revealed that compared with the propofol groups, the etomidate group had a significantly lower risk of fluctuations in vital signs (odds ratio, 0.427; 95% confidence interval, 0.230 to 0.792; p=0.007). Conclusions: Compared with using propofol/midazolam, using etomidate/mid azolam for screening colonoscopies results in more stable hemodynamic responses in patients of all ages; therefore, we recommend using etomidate/midazolam for colonosco pies in patients with cardiovascular risk factors. (Gut Liver 2019;13:649-657)

Irreversible electroporation (IRE) is a newly developed non-thermal ablative therapy. During the IRE procedure, the permeability of the cell membrane is irreversibly changed by application of high-energy pulses across the tissue. This induces the breakdown of cell homeostasis, and thereby cell death. Here, we present an in vivo study to demonstrate IRE ablation of gastric tissue and characterize the changes that occur with time therein. No significant complications were observed in the test rats during the experiment. The electroporated tissues exhibited apoptosis at 10, 24 and 48 h after IRE ablation. The apoptosis peaked at 10 h after IRE and then declined, suggesting that the ablated tissue rapidly recovered owing to intense metabolic activity. In addition, the electroporated tissues exhibited morphological changes such as pyknosis and karyorrhexis, while histological analysis showed that the blood vessels were preserved. Interestingly, electroporation greatly affected the mucosa and muscularis propria, but not the submucosa and serosa. This study suggests that IRE could potentially be used as a minimally invasive treatment for early gastric cancer that does not exhibit lymph node metastasis or dysplasia.

Background/aims Suboptimal bowel function can negatively affect colon cleansing for colonoscopy after surgery. Very few studies have compared the relationship between the colorectal resection and the bowel preparation quality. We postulated that the colon cleansing quality in patients with a history of colorectal surgery might not be inferior to that of patients with no resection history. Materials and methods Overall, 200 patients were enrolled in the study and distributed into two groups: the resection group (RG) and the control group. The surgical maneuvers were classified as right colectomy, left colectomy, and rectosigmoidectomy. The bowel preparation was performed using 2-L low-volume or 4-L high-volume regimens, and the preparation quality was evaluated using the modified Boston Bowel Preparation Scale (BBPS). Results There were no significant differences in achieving adequate cleansing observed between the RG and the control group (modified BBPS of 6-9; 88% vs. 88%). According to the logistic regression analysis of the RG, patients with a left colon resection had an odds ratio (OR) of 0.27 (p=0.003) for achieving a successful cleansing, and the low-volume preparation (OR=3.092, p=0.023) was the main predictor of a successful cleansing procedure. However, a longer time between colonoscopy and surgery was not related to unsuccessful bowel cleansing. Conclusion Our study demonstrates that a history of colorectal surgery is not a risk factor for inadequate colon cleansing.

Bowel cleansing is a major patient complaint during colonoscopy. Adding laxatives to the bowel preparation is effective in replacing a portion of bowel preparation solution and reducing its volume. Prucalopride is a serotonin receptor agonist that stimulates gastrointestinal motility and provides propulsive force for defecation. This study aimed to compare 1 L polyethylene glycol (PEG) with ascorbic acid (Asc) plus 2 mg prucalopride (1LP/AP) and 2 L PEG with Asc (2LP/A) for colonoscopy preparation with respect to bowel-cleansing quality and side effects.A single-center, randomized, prospective study was conducted with 260 outpatients administered either 1LP/AP or 2LP/A. The primary endpoint was bowel preparation quality, which was evaluated using the Boston Bowel Preparation Scale and Aronchick Bowel Preparation Scale, and the secondary endpoints were patient tolerability and acceptability, assessed by a questionnaire-based survey.The adequate bowel preparation rates were 88.5% and 83.1% in the 2LP/A and 1LP/AP groups, respectively, and the efficacy of 1LP/AP was equivalent to the control regimen (p=.216). Other colonoscopic variables including adenoma detection rate were similar in both groups. Patient tolerability and acceptability were not significantly different, but patients in the 1LP/AP group were more willing to repeat the same regimen (p=.039).Bowel preparation quality with 1LP/AP was equivalent to that with 2LP/A, which did not increase the occurrence of side effects, but it reduced the volume of the solution ingested, and increased patient satisfaction.

AIM To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy. METHODS In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying (DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed. RESULTS Technical success was achieved in all patients (100%). Early symptom improvement was observed in 15 of 20 patients (75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d (range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients (70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients (95%). CONCLUSION Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Dyskinesia of the gallbladder is a motility disorder characterized by biliary pain with a normal gallbladder structure. Because of difficulties in diagnosis, the true prevalence of gallbladder dyskinesia is unknown, but its incidence appears to have increased over time. Its etiology and pathophysiology have been studied, but are still poorly understood and controversial. Gallbladder dyskinesia can be considered in patients with biliary pain after excluding organic causes of pain, such as gallstones or other structural abnormalities. Laboratory tests, transabdominal ultrasound, endoscopic ultrasound, esophagogastroduodenoscopy, and bile microscopic examination can be useful tools for differential diagnosis, and gallbladder scintigraphy can be performed to evaluate the gallbladder ejection fraction, if gallbladder dyskinesia is suspected. If the gallbladder ejection fraction is abnormal, cholecystectomy can be considered for the treatment of gallbladder dyskinesia, but if the ejection fraction is normal, continued clinical observation with medical treatment is recommended. However, treatment recommendations are still controversial, due to the lack of supportfrom large, well-designed, prospective studies.

Irreversible electroporation (IRE) is a newly developed non-thermal ablative therapy. During the IRE procedure, the permeability of the cell membrane is irreversibly changed by application of high-energy pulses across the tissue. This induces the breakdown of cell homeostasis, and thereby cell death. Here, we present an in vivo study to demonstrate IRE ablation of gastric tissue and characterize the changes that occur with time therein. No significant complications were observed in the test rats during the experiment. The electroporated tissues exhibited apoptosis at 10, 24 and 48 h after IRE ablation. The apoptosis peaked at 10 h after IRE and then declined, suggesting that the ablated tissue rapidly recovered owing to intense metabolic activity. In addition, the electroporated tissues exhibited morphological changes such as pyknosis and karyorrhexis, while histological analysis showed that the blood vessels were preserved. Interestingly, electroporation greatly affected the mucosa and muscularis propria, but not the submucosa and serosa. This study suggests that IRE could potentially be used as a minimally invasive treatment for early gastric cancer that does not exhibit lymph node metastasis or dysplasia.

Most bariatric treatments employ gastric volume reduction. However, there has been no appropriate tool that could assess the anatomical factors of the stomach, and few studies have investigated proper stomach measurement for bariatric treatment. Thus, this study aimed to objectively estimate the individual stomach using three-dimensional (3D) computed tomography (CT) gastrography for the possible acquisition of information that could facilitate bariatric treatment and to validate these factors. A total of 100 consecutive patients with different degrees of obesity who underwent 3D CT gastrography were enrolled. Using semiautomatic and manual segmentation tools, 3D volume-rendered images were constructed, and the total volume of the distended stomach, abdominal diameter, and abdominal fat volume (visceral and subcutaneous fat) were measured. Data on patients’ baseline characteristics and laboratory findings were collected. The stomach volume measured using 3D CT gastrography ranged from 268 to 751 mL, whereas the stomach capacity was 572 ± 301.6 mL and 438.5 ± 163.4 mL in patients with body mass index (BMI) ≥ 25 kg/m2 and

Background Chemotherapy-induced alimentary mucositis (AM) is difficult to prevent and treatment is rarely effective. Recent study have been showed that glucagon-like peptide (GLP)-1 and GLP-2 has protective in chemotherapy-induced AM. While the DPP-4 enzyme degrades this GLP-1, the DPP-4 inhibitor blocks the degradation process and raises the concentration of GLP-1. This study aimed to assess the role of DPP-4 inhibitor, a well-known hypoglycemic agent, on chemotherapy-induced AM. Methods Twenty-four 6-week-old male C57BL/6 mice were divided into 4 groups: control, 5-fluorouracil (5-FU), DPP-4 inhibitor, and saline (DPP-4i), and DPP-4 inhibitor and 5-FU (DPP-4i + 5-FU). Mucositis was induced by intraperitoneal injection of 5-FU (400 mg/kg). DPP-4 inhibitor (50 mg/kg) was administered orally for four days starting the day before 5-FU administration. Post 72 h of 5-FU injection, mice were sacrificed and body weight change, diarrhea score, villus height, villus/crypt ratio, histologic characteristics including goblet cell count, and mRNA expression of inflammatory cytokines tumor necrosis factor (TNF)-α and interleukin (IL)-6, were assessed. Results Daily body weight change was not statistically significant between the 5-FU and the DPP-4i + 5-FU group (P = 0.571). Diarrhea score was significantly different between these two groups (P = 0.033). In the 5-FU group, the villus height was not maintained well, the epithelial lining was irregular, and inflammatory cell infiltration was observed. Goblet cell count in the DPP-4i + 5-FU group was significantly higher than in the 5-FU group (P = 0.007). However, in the DPP-4i + 5-FU group, the villus height, epithelial lining, and crypt structure were better maintained than in the 5-FU group. Compared with the control group, mRNA expression of TNF-α was significantly up-regulated in the 5-FU group. Moreover, mRNA expression of TNF-α in the DPP-4i + 5-FU group was down-regulated compared to the 5-FU group. However, IL-6 in the 5-FU group was significantly down-regulated compared to the control, there was no significant difference in expression of IL-6 between the 5-FU and DPP4i + 5-FU group. Conclusion DPP-4 inhibitor can improve 5-FU induced AM and, therefore, has potential as an alternative treatment for chemotherapy-induced AM.

Background Subepithelial tumors (SETs) originating from the muscularis propria layer are unlikely to be resected completely and safely. We developed the Forcep Strip Method (FSM) for the resection of SETs in the stomach. Aims This study aimed to evaluate the feasibility and safety of the FSM. Methods Endoscopic SET resection using electrical forceps was performed in 11 consecutive patients with clinical indications for lesion removal. Following injection around the tumor, the adjacent mucosa or submucosa was grasped with the hot forceps and pulled away to form a “tent”. The tumor was dissected from the muscularis propria layer and carefully removed using coagulating forceps. Results The FSM was successful in 10 of the 11 patients in the series; one patient required surgery due to respiratory depression during the procedure. The complete resection rate was 100% and no major complications including bleeding and perforation occurred. Mean procedure time was 39.3 ± 14.7 min, mean hospitalization time was 5.0 ± 1.2 days, and mean tumor size was 17.1 ± 4.7 mm. Conclusion FSM was found to be an easy, safe, and effective procedure for the treatment of gastric SETs originating from the muscularis propria layer.

We report our experience with a synchronous case of gastrointestinal stromal tumor (GIST) and intraductal papillary neoplasm of the bile duct (IPNB) in an elderly woman with neurofibromatosis type 1 (NF-1). A 72-year-old woman presented with a 2-mo history of right upper abdominal pain unrelated to diet and indigestion. Fourteen years earlier, she had been diagnosed with NF-1, which manifested as café au lait spots and multiple nodules on the skin. Computed tomography (CT) revealed a multilocular low-density mass with septation, and mural nodules in the right hepatic lobe, as well as a 1.7-cm-sized well-demarcated enhancing mass in the third portion of the duodenum. The patient subsequently underwent right hepatectomy and duodenal wedge resection. We present here the first report of a case involving a synchronous IPNB and GIST in a patient with NF-1. Our findings demonstrate the possibility of various tumors in NF-1 patients and the importance of diagnosis at an early stage.

BACKGROUND/AIMS Patients may feel embarrassed during colonoscopy. Our study aimed to assess changes in patient preference, over the past decade, for the sex of their colonoscopist. METHODS Prospective studies were performed at a single health center from July to September 2008, and from July to September 2016. Subjects included colonoscopy patients (2008: 354, 2016: 304) who were asked to complete a questionnaire before colonoscopy. RESULTS In 2016, 69 patients (24.9%) expressed a sex preference, compared with 46 patients (14.6%) in 2008. By 2016, female patient preference for a female colonoscopist had significantly increased to 95% (odds ratio [OR], 2.678; 95% confidence interval [CI], 1.418- 5.057; P=0.002). In multivariate analysis, patient sex (OR, 4.404; P=0.000), patient age (OR, 0.977; 95% CI, 0.961-0.992; P=0.004), and year of procedure (OR, 1.674; 95% CI, 1.028-2.752) were statistically significant factors in sex preference. Between 2008 and 2016, female patients preferred a female colonoscopist because of embarrassment. Male patients also preferred a male colonoscopist, and the primary reason shifted from expertise to patient embarrassment (2008: 29%, 2016: 63%). CONCLUSIONS Patients have an increased gender preference for the colonoscopist because of embarrassment. Taking this into account can increase patient satisfaction during colonoscopy.

Background and aim In a recent study, microsatellite variations (GCA tandem repeats) in the promoter region of the (kidney-type) glutaminase gene were associated with the development of hepatic encephalopathy (HE) in Spanish patients with cirrhosis. The objective of this study was to validate the relation between microsatellite variations in the glutaminase promoter region and the development of overt HE in Korean patients with liver cirrhosis. Methods We performed a prospective cohort study of 154 cirrhotic patients who underwent a glutaminase microsatellite study without previous overt HE history at baseline. The primary endpoint was the first episode of overt HE. The microsatellite length was categorized into three groups based on its repeated number, with a cutoff value of 14; 65 (42.2%), 70 (45.5 %), and 19 (12.3%) patients had the short-short, short-long, and long-long alleles, respectively. Results Over a median 3.5 years of follow-up (range = 0.1 – 4.4), overt HE developed in 28 patients (18.2 %). The 3-year cumulative incidence of overt HE was 18.4%. Multivariate Cox model indicated that past hepatocellular carcinoma history, alcoholic etiology for cirrhosis, higher model for end-stage liver disease scores and their deterioration, and serum ammonium levels were independently associated with HE development. However, microsatellite length was not associated with the development of overt HE. Conclusions In Korean patients with cirrhosis, microsatellite variations in the glutaminase promoter region were not associated with development of overt HE. Thus additional studies are needed to identify other genetic factors related to glutaminase activity in Asians with overt HE.

Background and aim Considering that inflammation and fibrosis are major factors for the indication of antiviral treatment, liver stiffness measurements could help identify patients who require antiviral treatment. This study evaluated factors that best identify patients who require antiviral treatment and to develop a new indicator for chronic hepatitis B (CHB). Methods Patients with CHB were randomly classified into a training or validation group, and a model for predicting necroinflammatory activity ≥ A3 or fibrosis grade ≥ F2 (A3F2) was established in the training group using binary regression analysis and validated in the validation group. Predictive efficacy was compared using area under the receiver-operating characteristics curve analysis. Results Four-hundred ninety-two patients were enrolled. In the training group, female sex, aspartate aminotransferase-to-platelet count ratio index (APRI), and liver stiffness were independent predictors of A3F2 on multivariate analysis. These variables were used to construct a novel model, called the LAW (liver stiffness, APRI, woman) index, as follows: 1.5 × liver stiffness value (kPa) + 3.9 × APRI + 3.2 if female. The LAW index was a better predictor of A3F2 than the APRI or liver stiffness measurement in both training group (0.870; 95% confidence interval, 0.822-0.910) and validation group (0.862; 95% confidence interval, 0.813-0.903). Conclusions The LAW index was able to accurately identify patients with CHB who required antiviral treatment. A LAW index of >10.1 could be a strong indicator for the initiation of antiviral treatment in patients with CHB.

Diet restriction is one of the difficult parts of bowel preparation for colonoscopy, and many patients do not follow instructions properly. Few studies have evaluated the impact of dietary restriction in real clinical setting. The aim of this study was to study the effect of diet control on bowel preparation with detailed investigation of unacceptable food list in order to reveal what kind of foods are most problematic in clinical practice. Prospective observational study was carried out at a university-affiliated hospital. Around 4 L polyethylene glycol solution was used for bowel preparation on the day of colonoscopy. Patients were allowed to have regular diet until lunch the day before colonoscopy and educated to control diet from 3 days before colonoscopy with information regarding an unacceptable foods list. Factors associated with inadequate bowel preparation were analyzed using univariate statistics and multivariate logistic regression analysis. Of the 245 patients included in the study, 68 patients (27.8%) followed the diet instructions. Fiber-rich vegetables were the most commonly taken unacceptable foods (N = 143, 58.4%). Inadequate bowel preparation (fair and poor by Aronchick scale) was 47.3%. In multivariate analysis, diabetes [odds ratio (OR) 2.878, 95% confidence interval (CI) 1.242–6.671], preparation to colonoscopy interval (OR 1.003, 95% CI 1.000–1.005) and consumption of foods disturbing bowel preparation (OR 2.142, 95% CI 1.108–4.140) were independent predictors of inadequate bowel preparation. We could identify substantially low compliance to diet instructions in real clinical practice. Consumption of any foods disturbing bowel preparation was significant factor predicting inadequate bowel preparation, even though we could not select specific food list compromising preparation significantly. Favorable bowel preparation was achieved in the subgroup compliant to diet restriction, suggesting that regular diet avoiding specific kinds of foods can be possible option for diet restriction before colonoscopy.

Inflammatory bowel disease (IBD) in Asia has become increasingly prevalent. As a treatment of IBD, many immunomodulators and biological agents were introduced and shown to be effective in inducing and maintaining remission. However, many cases with treatment failure were reported. To overcome the failure, combination therapy of immunomodulatory and biologics have emerged, showing better outcomes by optimizing biologic pharmacokinetics and minimizing immunogenicity. Adversely, rates of tuberculosis (TB) have been increased as a result. The aim of this study is to compare the risk of TB according to the therapy using large population data. We used data from the South Korean Health Insurance and Review Agency over the period 2008–2016 and calculated the hazard ratio (HR) for TB in IBD. We compared the risk of TB according to the medication: infliximab only, azathioprine only (AZA), combination of azathioprine and infliximab (CAI), azathioprine monotherapy and infliximab monotherapy (AIM), and azathioprine and infliximab whether simultaneously or separately (AISS). In IBD patients, a total of 249 patients were identified as active TB. After one-to-one matching with age, sex and disease duration, the risks of TB were significantly higher in AZA group (HR, 2.06; 95% CI, 1.35–3.12, P

The present study investigated benexate hydrochloride betadex (BHB)-mediated ulcer healing, and changes to microcirculation modulated through nitric oxide synthase (NOS) and anti-inflammatory activity. A rat model of gastric mucosal injury was established through injection of a 60% acetic acid solution into the stomach. Following ulcer induction, the rats were administered BHB orally for 5 days at doses of 0, 100, 300 or 1,000 mg/kg. The highest dose of BHB was also administered with or without L-NG-nitroarginine methyl ester (L-NAME). The area of gastric ulcers was determined by planimetry, and expression of cyclooxygenases (COX), cytokines and NOS in stomach tissues were measured using western blotting. Compared with the control group, gastric ulcer size was significantly decreased in the 1,000 mg/kg BHB-treated group (P

Pseudoaneurysm is one of life-threatening complications of chronic or acute pancreatitis. It can lead to massive bleeding into the abdominal cavity, the retroperitoneum, or the gastrointestinal tract. Hemosuccus pancreaticus, meaning hemorrhage through the pancreatic duct into the duodenum is an important diagnostic clue suggesting the presence of pancreatic pseudoaneurysm. A 74-yearold man presented with hematochezia and active bleeding from the ampulla of Vater was noted on upper endoscopy. Abdominal computed tomography scan demonstrated a nodular enhancing lesion within the pancreatic duct. Celiac trunk angiography also showed a nodular enhancing lesion suggesting pseudoaneurysm in the pancreas. However, due to the difficulty of identifying the feeder artery of pseudoaneurysm by selective angiography, embolization was not feasible. Therefore, distal pancreatectomy was performed and ruptured pseudoaneurysm within the pancreatic duct could be confirmed. Herein, we report a case of hemosuccus pancreaticus due to ruptured intraductal pseudoaneurysm that was successfully treated by surgical management. Korean J Pancreatobiliary 2016;21(1):40-44

AIMS Pancreatic cystic neoplasms (PCN) with malignant potential are thought to be less aggressive than ordinary ductal adenocarcinoma, even in the setting of malignant transformation. Therefore, deciding whether or not to carry out surgery is very difficult, especially in elderly and asymptomatic patients, because of the high risk of perioperative morbidities. The aim of the present study was to examine clinical outcomes of PCN patients aged 65 years or older. METHODS This retrospective analysis included patients with incidentally detected PCN with follow-up durations >1 year. Patients diagnosed with obvious simple cysts, pseudocysts or pancreatic cancer and patients with a history of pancreatic disease were excluded from the study. RESULTS The present study included 201 patients (older group 104 patients ≥65 years; younger group 97 patients

Background and Aims. Cardiac varices (CVs) in patients with type 1 gastroesophageal varices (GOV1s) usually disappear with treatment for esophageal varices (EVs) by endoscopic injection sclerotherapy (EIS). However, whether this applies to patients treated with endoscopic band ligation (EBL) for EVs remains unclear. We evaluated the effect of EVs eradication by EBL on CVs.Methods. We included cirrhotic patients whose EVs had been eradicated using EBL and excluded those who had been treated using EIS, those who had received endoscopic therapy for CVs, and those who were combined with hepatocellular carcinoma.Results. A total of 123 patients were enrolled. The age was 59.7 ± 11.7 years, and 96 patients (78.0%) were men. Thirty-eight patients (30.9%) had EVs only, while 85 (69.1%) had GOV1s. After EVs eradication, the CVs disappeared in 55 patients (64.7%). EVs recurred in 40 patients, with recurrence rates at 1, 2, and 3 years of 16.0%, 29.6%, and 35.6%, respectively, the recurrence being more frequent in patients who had undergone EBL for secondary prophylaxis and in those with persisting CVs after EVs eradication (P=0.003).Conclusions. CVs frequently disappeared when EVs were eradicated using EBL in patients with GOV1s. Persistence of CVs after EVs eradication by EBL was associated with EVs recurrence.

Rationale Biliary drainage is essential to resolve jaundice in patients with malignant biliary obstruction. Recently, a biliary self-expandable metal stent (SEMS) with an antireflux valve was developed to prevent enteric-biliary reflux. Its antireflux valve was made of expanded polytetrafluoroethylene (ePTFE), a biostable and biocompatible material. Changes of the ePTFE membrane of medical devices are rarely reported in clinical practice. Patient concerns A 59-year-old woman was admitted with a complaint of jaundice. Around 1 month before, she underwent endoscopic biliary stenting using a SEMS with an antireflux valve. Diagnosis Acute cholangitis due to stent clogging was detected on abdominal computed tomography. Interventions Endoscopic retrograde cholangiopancreatography and removal of the SEMS with deformity were performed. Outcomes The obstructive jaundice was rapidly resolved after the removal of the clogged stent. Lessons Although the ePTFE membrane is widely used to make medical devices, unexpected changes could occur after the membrane is exposed to bile juice in the duodenum. When performing biliary stenting using a SEMS with an antireflux valve, both the risk of early malfunction and the benefit of the antireflux effect should be considered.

386 Background: Laparoscopic surgery for gastrointestinal tumors requires fast and precise tumor localization. As tumor palpation is not possible during laparoscopic surgery, tumor identification is often difficult for some cases. Despite various methods, such as tattooing or endo-clipping, have been introduced for the localization of tumors, these methods own clear limitations. To overcome the drawbacks of these conventional marking methods, we designed a magnetic marking device linked to an endo-clip(MMC, Magnetic Marking Clip) for endoscopy. We performed preoperative endoscopic clipping with MMC and analyzed the intraoperative localization efficacy and safety during laparoscopic surgery. Methods: Study enrolled 30 patients with gastric and colorectal neoplasms scheduled to undergo endoscopic clipping before laparoscopic surgery at the Korea University Medical Center, Korea, between August 2017 and June 2019. A silicone-coated high-power neodymium marking device (ring or rod type) was fixed together with an endo-clip and applied on the center of the lesion during preoperative endoscopy. During laparoscopic surgery, a detecting magnetic body was inserted through a laparoscopic trocar and was used to localize the tumor that is marked with MMC. The time needed for endoscopists to place MMC at the lesion, laparoscopic clip detection time and success rate were studied. Results: Endoscopists placed MMC within 30 seconds. It was possible to find MMC in all cases of laparoscopic surgery. Time needed to find the MMC laparoscopically was relatively shorter than the time conventionally taken just with an endo-clip itself. There was no reported dislodgement of the clip before the surgery or any other adverse events associated with the MMC procedure. Conclusions: The MMC method enabled simple and fast tumor localization and showed excellent outcomes in efficacy of tumor localization. The MMC method may help surgeons localize GI tumor lesions easily and safely during laparoscopic surgery.

153 Background: About 10-25% patients of colorectal cancer suffer from acute colonic obstruction. Traditional management of acute malignant bowel obstruction has focused on emergency resection but showed high mortality and morbidity rates. Recently, placement of a self-expanding metal stent(SEMS) was widely used and SEMS seems to be as a safe and effective “bridge to surgery” and to offer good palliation. But there is concern about long-term survival after the use of SEMS. Theoretically, tumor cell seeding can occur due to mechanical force during the stent insertion. To identify this theoretical validity, we surveyed long-term survival of malignant colonic obstruction using SEMS placement. Methods: This retrospective study included 303 patients who presented in Korea University Anam Hospital between 2006 and 2014 with obstructing CRC, and underwent surgical resection. Patients were devided into two group: the “SEMS” group included 148 patients who underwent endoscopic stent as a bridge to surgery, and the surgery group included 155 patients who underwent emergency or elective surgery without stenting. In addition, candidates for curative resection were identified (98 patients in “SEMS” group vs 101 patients in “surgery” group). The clinicopathologic characteristics, overall survival(OS), and recurrence-free survival (RFS) were compared between the two groups. Results: There was no significant difference in demographics, tumor stage between the two group. The median follow-up times were 48.5 months (IQR, 19.1-73.1 months) for the SEMS group and 39.4 months (IQR, 15.1-39.4 months) for the surgery group. There was no significant difference in 5-year OS rate between two groups (59.6% vs 56.8%; p = 0.3). The 5-year RFS rate did not significantly differ between two groups (71.0% vs. 61.3%; p = 0.221). The long-term oncologic safety did not significantly differ between two groups in either the 5-year OS rate (79.5% vs 74.5%; P= 0.6). or the 5-year RFS rate (95.8% vs 95.8%; P = 0.3). Conclusions: SEMS as bridge to surgery in obstructive CRC did not worsen the long-term oncologic outcomes compared to those of the primary surgery.

541 Background: Irreversible electroporation (IRE) is a relatively new ablative method. However, the application of IRE ablation has not been attempted for the treatment of biliary disease. Minimally invasive approach using endoscopic retrograde cholangio-pancreatography (ERCP) can be a novel therapeutic modality for IRE ablation. In this study, we investigated the feasibility and effect of endoscopic IRE for biliary tract in animal model. Methods: A new catheter electrode was developed for endoscopic IRE ablation of biliary tract. The electrode for IRE ablation has two band-shaped electrodes on catheter tip. We performed ERCP and endoscopic IRE ablations on normal common bile duct in 6 Yorkshire pigs. Experimental parameters of IRE were 500V/cm, 1000V/cm and 2000V/cm (under 50 pulses, 100 µs length). Animals were sacrificed after 24 hours and ablated bile duct were collected. H & E stain, immunohistochemistry and western blot were performed. Results: Well-demarcated focal color changes were observed on the mucosa of the common bile duct under all experimental parameters. After IRE ablation, bile duct epithelium was disappeared around ablated area and it showed fibrotic change in H&E stain. Depth of change after IRE was different between each experimental parameters. Apoptotic change of bile duct was localized around mucosa in 500V. Diffuse transmural fibrosis of bile duct was shown after IRE ablation with 2000V. TUNEL immunohistochemistry showed the cell death of bile duct mucosa and submucosa along the electrode. Within 24 hours, no complication was observed in pigs after endoscopic IRE ablation. Conclusions: Endoscopic IRE ablation using ERCP was successfully performed on common bile duct by using catheter-shaped electrode. It can be a potential therapeutic option as minimally invasive ablation for treatment of biliary tumors.