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Pancreatic acinar cell carcinoma (ACC) is a rare neoplasm accounting less than 1% of malignant pancreatic tumors. A 47-year-old male patient visited the emergency room with epigastric pain. Computed tomography or magnetic resonance imaging revealed a 4.7-cm heterogeneously enhanced solid and cystic mass with internal necrosis located in the head of the pancreas. Radiological diagnosis was borderline malignancy such as neuroendocrine tumor or solid pseudopapillary neoplasm. Two months later, the necrotic mass in the pancreas head had grown up to 11 cm, compressing the duodenum, superior mesenteric vein, and proximal transverse colon. Pylorus preserving pancreatoduodenectomy with segmental resection of transverse colon was performed. Histopathological examination revealed that the tumor was pancreatic ACC. The patient recovered without any complication and was doing well without recurrence for 12 months after surgery.

Background/Aims: A calcineurin inhibitor may alter pancreatic function and in flammatory reaction. This study aimed to determine the possible pharmacologic effect of the calcineurin inhibitor, tacrolimus, on pancreatic function, and to de termine its preventive effect on post-endoscopic retrograde cholangiopancreatog raphy (ERCP) pancreatitis in liver transplantation (LT) patients. Methods: The serum amylase and lipase values before and after LT were com pared. The frequency of post-ERCP pancreatitis was compared between non-LT and LT patients, using propensity score matching method. Results: Median serum amylase values (normal range, 19 to 86 U/L) were 49.0 U/L (38.0 to 68.0) before LT and 27.0 U/L (19.3 to 36.8) after LT, and median serum lipase values (normal range, 7 to 59 U/L) were 40.0 U/L (26.5 to 54.0) before LT and 10.5 U/L (6.0 to 21.0) after LT. Both serum amylase and lipase values significantly decreased after LT (p < 0.001), and to a level comparable to chronic pancreatitis. There was a marginal significant difference between the non-LT and LT groups before the propensity score matching with respect to frequency of post-ERCP pancreatitis (16 [3.2%] in non-LT group vs. 2 [0.9%] in LT group, p = 0.069). After propensity score matching, a marginal significant difference still existed with re spect to frequency of post-ERCP pancreatitis (7 [4.8%] in non-LT group vs. 1 [0.7%] in LT group, p = 0.067). Conclusions: The immunosuppression with calcineurin inhibitor may reduce not only the pancreatic enzyme dynamics but also inciting inflammatory event including post-ERCP pancreatitis.

Acute pancreatitis is the most common and feared adverse event associated with performance of endoscopic retrograde cholangiopancreatography (ERCP). Unremitting effort has been made for over 40 years to minimize the frequency and severity of this complication. Recently, the use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) have opened a new era for its prevention. This review focuses on the role of NSAIDs in pancreatitis, the pharmacokinetics of these agents, and summarizes the results of clinical trials with rectal NSAIDs alone and combination regimens in the prevention of post-ERCP pancreatitis.

The purpose of this study was to summarize and evaluate evidence on the effectiveness of perioperative magnesium as an adjuvant for postoperative analgesia. We conducted an umbrella review of the evidence across systematic reviews and meta-analyses of randomized controlled trials (RCTs) on the effect of perioperative magnesium on pain after surgical procedures. Two independent investigators retrieved pain-related outcomes and assessed the methodological quality of the evidence of included studies using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) tool, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In addition, an updated meta-analysis of postoperative pain-related outcomes with a trial sequential analysis (TSA) was conducted. Of the 773 articles initially identified, 17 systematic reviews and meta-analyses of 258 RCTs were included in the current umbrella review. Based on the AMSTAR tool, the overall confidence of the included systematic reviews was deemed critically low to low. Pain score, analgesic consumption, time to first analgesic request, and incidence of analgesic request were examined as pain-related outcomes. According to the GRADE system, the overall quality of evidence ranged from very low to moderate. While the updated meta-analysis showed the beneficial effect of perioperative magnesium on postoperative analgesia, and TSA appeared to suggest sufficient existing evidence, the heterogeneity was substantial for every outcome. Although the majority of included systematic reviews and updated meta-analysis showed a significant improvement in outcomes related to pain after surgery when magnesium was administered during the perioperative period, the evidence reveals a limited confidence in the beneficial effect of perioperative magnesium on postoperative pain.

Background/Aims: The adverse events associated with endoscopic retrograde cholangiopancreatography (ERCP) in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) have not been sufficiently evaluated. This study aimed to review the morbidity and mortality associated with ERCP in ESRD patients on HD using a systematic review and pooled analysis. Methods: A systematic review and pooled analysis were conducted on studies that evaluated the clinical outcomes of ERCP in patients on HD. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for nonrandomized studies. The publication bias was assessed. Results: A total of 239 studies were identified, and 12 studies comprising 7921 HD patients were included in the analysis. The pooled estimated frequency of bleeding associated with ERCP in HD patients was 5.8% (460/7921). In the subgroup analysis of seven comparative studies, the ERCP-related bleeding rate was significantly higher in HD patients than in non-HD patients (5.5% (414/7544) vs. 1.5% (6734/456,833), OR 3.84; 95% CI 4.26–25.5; p < 0.001). The pooled frequency of post-ERCP pancreatitis was 8.3%. The pooled frequency of bowel perforation was 0.3%. The pooled estimated mortality associated with ERCP was 7.1% The publication bias was minimal. Conclusion: This pooled analysis showed that ERCP-related morbidity and mortality are higher in HD patients than in non-dialysis patients.

Background/Aims: Different modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP.Methods: We performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities.Results: The NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer’s solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups.Conclusions: Rectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.

(1) Background: The AJCC Cancer Staging Manual, Eighth Edition, subdivided T2 GBC into T2a and T2b. However, there still exist a lack of evidence on the prognostic significance of tumor location. The aim of the present study was to examine the existing evidence to determine the prognostic significance of tumor location of T2 gallbladder cancer (GBC) and to evaluate the optimal surgical extent according to tumor location. (2) Methods: We searched for relevant literature published in the electronic databases PubMed, MEDLINE, Web of Science, Cochrane Library, and Embase before September 2020 using search terms related to gallbladder, cancer, and stage. Data were weighted and pooled using random-effects modeling. (3) Results: Seven studies were deemed eligible for inclusion, representing a cohort of 1789 cases of resected T2 GBC. The overall survival for T2b tumor was significantly worse than that for T2a tumor (HR, 2.141; 95% confidence interval (CI), 1.140 to 4.023; I2 = 71.4%; Pchi2 = 0.007). The rate of lymph node metastasis was lower in the T2a group (26.6%) than in the T2b group (36.6%) (OR, 2.164; 95% CI, 1.309 to 3.575). There was no evidence of a survival difference between the patients who underwent extended cholecystectomy and simple cholecystectomy in T2a GBC (OR, 0.802; 95% CI, 0.618 to 1.042) and T2b GBC (OR, 0.820; 95% CI, 0.620 to 1.083). (4) Conclusions: Hepatic side tumor was a significant poor prognostic factor in T2 GBC. Extended cholecystectomy and simple cholecystectomy showed comparable survival outcomes in T2 GBC, and additional large-scale prospective studies are warranted to establish evidence-based treatment guidelines for T2 GBC.

Background/Aims To compare the efficacy and safety of procedural sequence in same-day bidirectional endoscopy. Methods We searched OVID-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar to identify randomized controlled trials that compared the procedural sequences in same-day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy. The sedative and analgesic doses required, discomfort and satisfaction scores, procedure time, recovery time, adenoma detection rate, and failed cecal intubation were evaluated. Adverse effects, including respiratory and cardiovascular complications, were also assessed. Results We included six studies, with 1,848 patients in total. The requirement for sedative treatment was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (standardized mean difference [SMD], –0.39; 95% confidence interval [CI], –0.54 to –0.24; p = 0.12; I2 = 49%). Discomfort, scored by patients during the EGD procedure, was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, –0.45; 95% CI, –0.80 to –0.09; p = 0.02; I2 = 73%), while it was comparable during colonoscopy between the two sequences. Recovery time was significantly shorter in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, –0.47; 95% CI, –0.65 to –0.30; p = 0.28; I2 = 21%). Total procedure duration, EGD, colonoscopy, cecal intubation time and incidence, incidences of pathologic findings, and adenoma detection were comparable between the two sequences. There was no significant difference in the incidences of desaturation, hypotension, hypertension, bradycardia, and tachycardia between the two sequences. Conclusions When conducting same-day bidirectional endoscopy, EGD followed by colonoscopy is the most beneficial sequence to be used because patients require lower sedative doses, recover faster, and report lesser discomfort.

Desmoid fibromatosis is a rare benign tumor, but due to its rarity and diverse clinical course, treatment guidelines have not been established. However, since a good prognosis can be expected, an accurate diagnosis and appropriate treatment are required. We describe a rare case of desmoid fibromatosis on young female that presented as huge abdominal mass.A 28-year-old female with left upper abdominal pain 1 month ago was referred.Abdominal computed tomography and magnetic resonance imaging revealed a heterogeneous soft tissue mass approximately 29 × 17 cm in size in the left abdomen with abdominal wall invasion and pathological fracture in costochondral junction of the left 8th to 10th ribs.Surgical resection was performed.33 × 23 × 6 cm sized tumorous mass showed proliferation of bland fibromatosis and myofibroblast with nuclear β-catenin expression on pathological examination. Desmoid fibromatosis arising from intra-abdominal soft tissue with ribs and pericardium invasion was diagnosed.The mainstay of treatment of symptomatic desmoid fibromatosis is surgical resection, and in the case of abdominal tumor, it can be more dangerous when it invades adjacent organ. We report a case that required additionally multidisciplinary approach for surgery and postoperative treatment of huge abdominal desmoid tumor which infiltrate bone and pericardium beyond abdominal cavity.

Background and study aims In plastic stent insertion for treatment of post-cholecystectomy bile leak, stent migration may be more common due to the absence of a shelf to anchor the stent. We evaluated how adding a flap to straight plastic stents for this indication might influence the rate of stent migration when compared to use of conventional plastic stents. Patients and methods This is a retrospective study including patients referred for ERCP for treatment of post-cholecystectomy bile leak. Patients with a customized anti-migration flap stent had the additional flap created on the distal end of straight plastic stents, intended to aid in anchoring in the distal supra-sphincteric biliary duct. The primary endpoint is stent migration events. The secondary endpoint is bile leak resolution after first ERCP session. Results Thirty-two patients were treated with the experimental additional flap stents and 225 patients were treated with standard straight biliary stents. The total failure rate of bile leak resolution after a single endoscopic treatment for all treated was 10.5 % (27/257) and the total stent migration rate for all enrolled was 15.2 % (39/257). Stent migration rate was lower in the additional flap stent group than in the conventional group (3.1 % vs. 16.9 %, respectively, P = 0.04). Furthermore, significantly more patients had resolution of their bile leak after the first ERCP session in the group with the additional flap (100 % vs. 88 %, respectively, P = 0.03). Conclusion A plastic biliary stent with an extra flap may have improved performance with regard to stent migration and resolution of bile leak over standard plastic biliary stents.

Background/Aims This study aimed to determine the risk of post-endoscopic retrograde cholangiopancreatography (post-ERCP) bleeding among patients taking antiplatelet agents (APAs), particularly in the era of multiple APAs. Methods The primary outcomes were the frequency, type, and severity of ERCP-related bleeding according to the use of APAs. Results The frequencies of post-ERCP bleeding among the four different groups were 16 of 2,083 (0.8%) in the no drug group, 12 of 256 (4.7%) in the aspirin group, 3 of 48 (6.3%) in the single APA group, and 4 of 48 (8.3%) in the multiple APA group (p＜0.001). In the univariate analysis, post-ERCP bleeding was associated with age, pull-type sphincterotomy, and APA and was inversely associated with balloon dilation of the biliary orifice. In the multivariate analysis, pull-type sphincterotomy (odds ratio [OR], 7.829; 95% confidence interval [CI], 1.411 to 43.453; p=0.019) and country (Korea: OR, 0.124; 95% CI, 0.042 to 0.361; p＜0.001) were associated with post-ERCP bleeding. Conclusions The frequency of post-ERCP bleeding was statistically higher in patients on any APA within 6 days prior to ERCP. However, in the multivariate analysis, APA use was not associated with post-ERCP bleeding. Until a large, adequately powered study to detect differences is performed, caution is recommended when considering invasive procedures during ERCP in patients on APAs.

Background/Aims: This study aimed to evaluate the diag- nostic role of low serum amylase and lipase values in the detection of chronic pancreatitis. Methods: Patients under went endoscopic retrograde cholangiopancreatography and were diagnosed with non-calcific chronic pancreatitis (NCCP; n=99) and calcific chronic pancreatitis (CCP; n=112). Patient serum amylase and lipase values were compared with those of healthy controls (H; n=170). Results: The median serum amylase (normal range, 19 to 86 U/L) and lipase values (7 to 59 U/L) (P25-P75) were 47.0 (39.8 to 55.3) and 25.0 (18.0 to 35.0) for H, 34.0 (24.5 to 49.0) and 19.0 (9.0 to 30.0) for NCCP, and 30.0 (20.0 to 40.8) and 10.0 (3.0 to 19.0) for CCP, respectively. The cutoff values with the highest diagnos tic accuracy for discriminating NCCP from H were 40 U/L for amylase and 20 U/L for lipase, respectively, and for CCP from H were 38 U/L for amylase and 15 U/L for lipase, respec tively. For the diagnosis of NCCP with a criterion of serum amylase

Background/aims To compare the diagnostic accuracy of endoscopic ultrasound-guided core needle aspiration with that of standard fine-needle aspiration by systematic review and meta-analysis. Methods Studies using 22/25-gauge core needles, irrespective of comparison with standard fine needles, were comprehensively reviewed. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic curves for the diagnosis of malignancy were used to estimate the overall diagnostic efficiency. Results The pooled sensitivity, specificity, and DOR of the core needle for the diagnosis of malignancy were 0.88 (95% confidence interval [CI], 0.84 to 0.90), 0.99 (95% CI, 0.96 to 1), and 167.37 (95% CI, 65.77 to 425.91), respectively. The pooled sensitivity, specificity, and DOR of the standard needle were 0.84 (95% CI, 0.79 to 0.88), 1 (95% CI, 0.97 to 1), and 130.14 (95% CI, 34.00 to 495.35), respectively. The area under the curve of core and standard needle in the diagnosis of malignancy was 0.974 and 0.955, respectively. The core and standard needle were comparable in terms of pancreatic malignancy diagnosis. There was no significant difference in procurement of optimal histologic cores between core and standard needles (risk ratio [RR], 0.545; 95% CI, 0.187 to 1.589). The number of needle passes for diagnosis was significantly lower with the core needle (standardized mean difference, -0.72; 95% CI, -1.02 to -0.41). There were no significant differences in overall complications (RR, 1.26; 95% CI, 0.34 to 4.62) and technical failure (RR, 5.07; 95% CI, 0.68 to 37.64). Conclusions Core and standard needles were comparable in terms of diagnostic accuracy, technical performance, and safety profile.

Purpose To determine the prevalence of and investigate the risk factors for gallbladder (GB) polypoid lesions in a healthy population. Materials and methods A total of 23827 subjects who underwent abdominal ultrasonography in conjunction with health screening examinations were retrospectively analyzed. The prevalence of risk factors for GB polypoid lesions were evaluated. In addition, risk factors according to the number of polypoid lesions and the presence of stones with polypoid lesions were investigated. To analyze these risk factors, a control group was established with a 1:2 ratio matched for age and sex. Results The prevalence of GB polypoid lesions was identified as 9.96%. On multivariate analysis, chronic hepatitis B infection (CHB) and the presence of metabolic syndrome (MS) were risk factors for GB polypoid lesions. CHB and MS were also significant independent risk factors for multiple GB polypoid lesions when compared with solitary GB polypoid lesions. In addition, gastric Helicobacter pylori infection and MS were significant risk factors for GB polypoid lesions with stones when compared with GB polypoid lesions without stones. Conclusion The prevalence of GB polypoid lesions in a healthy Korean population was 9.96%. Patients with CHB and MS need to be carefully examined for such lesions.

Background and Aim: A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures. Methods: This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice. Results: Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032). Conclusions: The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

Background/aims Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Combination therapy w ith ora l udenafil and aceclofenac may reduce the occurrence of post-ERCP pancreatitis by targeting different pathophysiological mechanisms. We investigated whether combining udenafil and aceclofenac reduced the rates of post-ERCP pancreatitis. Methods A prospective, randomized, double-blind, placebo-controlled, multicenter study was conducted in four academic medical centers. Between January 2012 and June 2013, a total of 216 patients who underwent ERCP were analyzed for the occurrence of post-ERCP pancreatitis. Patients were determined to be at high risk for pancreatitis based on validated patient and procedure-related risk factors. Results Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. There were no significant differences in the rate (15.8% [17/107] vs. 16.5% [18/109], p = 0.901) and severity of post-ERCP pancreatitis between the udenafil/aceclofenac and placebo groups. One patient in each group developed severe pancreatitis. Multivariate analyses indicated that suspected dysfunction of the sphincter of Oddi and endoscopic papillary balloon dilation without sphincterotomy were associated with post-ERCP pancreatitis. Conclusions Combination therapy with udenafil and aceclofenac is not effective for the prevention of post-ERCP pancreatitis.

EUS started as an imaging tool for deeply seated organ and pathology. After introduction of EUS-guided fine needle aspiration (FNA), EUS became an important tool for histologic diagnosis of pancreatic, peripancreatic, mediastinal, retroperitoneal, and gastrointestinal tract lesions. Therapeutic and interventional EUS started by modification of EUS-FNA technology and EUS-guided pseudocyst drainage is increasingly used for the management of pancreatic pseudocyst. EUS-guided ablation of pancreatic solid mass is also tried by ethanol injection. Radiofrequency ablation has long been used to ablate hepatic tumors via percutaneous route. Recently, EUS-guided RFA probe was introduced and is cautiously applied for the ablation of pancreatic solid tumors. EUS-guided pancreatic cyst ablation has been investigated in a variety of clinical studies. EUS-guided pancreatic cyst ablation is safe and feasible and shows potential to become an alternative to surgery. In this chapter, EUS-guided ablation of pancreatic cysts, EUS-guided injection therapy of benign solid mass, and EUS-guided RFA will be discussed.

Pancreatic cystic lesions are being diagnosed with increasing frequency owing to the widespread use of cross-sectional imaging. Although most pancreatic cysts are detected incidentally, they represent a wide spectrum of histopathology, and neoplastic cysts appear to be more prevalent than previously estimated. Some histologic types have malignant potential. Considering the perioperative morbidity associated with surgical resection, deciding whether to operate or observe an indeterminate pancreatic cyst is challenging, and there is a strong clinical need to develop a minimally invasive approach. EUS-guided pancreatic cyst ablation has been investigated in several clinical trials, and may represent a viable alternative to surgical resection.

Background and Aim Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in the elderly patients, yet little is known concerning objective criteria of safety. This study aimed to determine the potential predictors for the procedure-related outcomes. Methods Two hundred eighty-one patients older than 70 years who were indicated for ERCP (group A [n = 195], 70–79 years of age; group B [n = 86], ≥ 80 years of age) were prospectively enrolled and analyzed for the development of serious adverse events related to ERCP. Results ERCP was not performed in six patients at high risk for the procedure. There were significant differences between group A and B in Duke Activity Status Index (DASI) (23.1 vs 14.9, P

Biliary decompression with antibiotic therapy is the mainstay treatment for acute cholangitis with bacteremia. A few studies have been conducted to investigate the optimal duration and route of antibiotic therapy in biliary tract infection with bacteremia. Patients with acute cholangitis with bacteremia who achieved successful biliary drainage were randomly assigned to an early oral antibiotic switch group (group A, n = 29) and a conventional intravenous antibiotics group (group B, n = 30). Patients were discharged when they were afebrile over 2 days after oral antibiotic switch and showed consecutive improvement in the laboratory index. They were followed up and assessed at 30 days after diagnosis to evaluate the eradication of bacteria, recurrence of acute cholangitis, and 30-day mortality rate. There were no statistically significant differences between the two groups in baseline characteristics, clinical and laboratory index, severity of acute cholangitis, bacteria isolated from blood cultures, and clinical outcomes. The rate of eradication of bacteria was 93.1 % in group A and 93.3 % in group B, respectively (p = 0.97). Using non-inferiority tests, the rate of eradication of bacteria in group A was not inferior to that in group B (95 % CI −0.13 to 0.14, p = 0.97). There was no statistically significant difference in the recurrence of acute cholangitis and a 30-day mortality rate between the two groups. Early switch to oral antibiotic therapy following adequate biliary drainage for treatment of acute cholangitis with bacteremia was not inferior to conventional 10-day intravenous antibiotic therapy.

Endoscopic ultrasonography (EUS)-guided pancreatic cyst ablation is a minimally invasive treatment modality. Local injection of ablative agents may rarely cause systemic effects in patients. This study aimed to evaluate the systemic effect of ablative agents by analyzing the plasma drug concentration. Ten patients with pancreatic cysts were enrolled. Cyst ablation was performed by 99 % ethanol lavage (2.5–70 mL) and paclitaxel (Genexol-polymeric micelle, 6.0–24.0) injection. Blood samples were collected at 0, 2, 4, 7 and 24 h. Plasma paclitaxel concentration was analyzed by a liquid chromatography-tandem mass spectrometry with the lowest limit of quantitation of 0.1 ng/mL. Procedure-related complications were closely monitored. Pancreatic cysts were located at the head in two, body in seven and tail in one patient. Eight cysts were septated. Median diameter and original volume were 39.5 mm (range 2.7–21.8) and 14.79 mL (3.42–343.30). Median cyst fluid CEA and amylase values were 17.10 ng/mL (0.5–14127.5) and 73.50 U/L (3.1–91,590). Peak plasma paclitaxel concentration values were observed between 2 and 7 h, ranging from 0.45 to 14.73 ng/mL. The highest concentration (17.10 ng/mL at 0 h) was observed in a patient who had intracystic bleeding. Mild abdominal pain occurred in five patients and vomiting in one patient during the first 48-h monitoring. Plasma paclitaxel concentration after EUS-guided pancreatic cyst ablation was nearly as low as the undetectable value and rarely caused systemic side-effect.

Highlights • We successfully resected 4.2 cm-sized cystic mass of pancreas through laparoscopic approach. • Pathologic examination revealed a dermoid cyst of pancreas. • Literature review showed that dermoid cysts of the pancreas are rare benign, and congenital tumors. • Preoperative diagnosis is challenging, and surgical resection is the standard treatment., Introduction Dermoid cyst of the pancreas, also called cystic teratoma, is a benign, well-differentiated, and extremely rare germ cell neoplasm. Preoperative diagnosis is challenging since there are no definitive preoperative diagnostic tests or pathognomonic findings. Presentation of case We report a case of a 54-year-old male who presented with an incidentally detected pancreatic cystic mass at the tail of the pancreas. Computerized tomography revealed a benign cystic mass such as oligocystic serous cystadenoma or a hemorrhagic cyst. However, a high CEA level from EUS guided aspirated fluid suggested mucinous cystic neoplasm. After laparoscopic spleen-preserving distal pancreatectomy, the final diagnosis was confirmed as a dermoid cyst of the pancreas. Conclusion Despite the benign nature of the dermoid cyst, complete surgical resection is mostly inevitable due to the difficulty of preoperative diagnosis as in the present case.

Objectives We aimed to determine the prevalence of cholesterol gallstones, the compositional changes of gallstones and its predisposing factors in Korea with this single-center study. Methods Data of 365 patients who underwent cholecystectomy for cholecystolithiasis from July 2008 to September 2011 were reviewed. Based on the compositional analysis of the gallstones, patients were assigned to either cholesterol gallstone group or pigment gallstone group. The characteristics of the patients and the gallstones were summarized and compared. Results After eight patients with mixed gallstones were excluded, 357 patients were enrolled in the study, including cholesterol gallstones in 175 (49.0%) and pigment gallstones in 182 (51.0%). The number of patients with cholecystolithiasis increased but the prevalence of cholesterol gallstone decreased with age. Compared with the pigment gallstone group, the cholesterol gallstone group was associated with young age (

Background Udenafil, a phosphodiesterase-5 inhibitor, may decrease sphincter of Oddi tone and allow efficient cannulation. Objective To determine whether prophylactic udenafil reduces the rates of occurrence of post-ERCP pancreatitis. Design Prospective, randomized, double-blind, placebo-controlled, multicenter study. Setting Three academic medical centers. Patients From November 2008 to November 2010, a total of 278 patients who underwent ERCP were analyzed. Intervention ERCP. Main Outcome Measurement Rate of post-ERCP pancreatitis. Results Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. The overall rate of pancreatitis was 7.9% (22/278). There was no significant difference in the rate (8.0% [11/137] vs 7.8% [11/141], P = .944) and severity of post-ERCP pancreatitis between the udenafil and placebo groups. Severe pancreatitis developed in 1 patient in the placebo group. On both univariate and multivariate analyses, age 40 years or younger, suspected sphincter of Oddi dysfunction, complete pancreatic duct opacification, and failed cannulation were associated with post-ERCP pancreatitis. Only mild udenafil-related complications occurred, including flushing (n = 3) and headache (n = 3). Limitations Unselected patient group, overestimation of the rate of pancreatitis in the placebo group. Conclusion Udenafil was not effective for prevention of post-ERCP pancreatitis in this study. (Clinical trial registration number: KCT0000021.)

Background & Aims Endoscopic ultrasonography (EUS)-guided interventions have been used to treat patients with cystic lesions of the pancreas (CLPs). We used EUS to guide injection and lavage of ethanol, followed by injection of paclitaxel, into cysts, and investigated treatment response and predictors. Methods Fifty-two patients were enrolled in the study using the following inclusion criteria: unilocular or oligolocular cysts, indeterminate cystic lesions that required EUS fine-needle aspiration, and cystic lesions that grew during the observation period. Forty-seven patients were followed up for more than 12 months and their outcomes were analyzed. Results The mean diameter of the CLPs was 31.8 mm (range, 17–68 mm) and the estimated volume was 14.09 mL (range, 1.16–68.74 mL). Twenty CLPs were oligolocular. The mean level of carcinoembryonic antigen was 463 ng/mL (range, 1–8190 ng/mL). The median follow-up period was 21.7 months. A complete response was observed in 29 patients, a partial response in 6 patients, and persistent cysts in 12 patients. Four of 12 patients with persistent cysts underwent surgery. The histopathologic degree of epithelial ablation varied from 0% to 100%. Based on univariate analysis, EUS diameter and original volume predicted cyst resolution; in multivariate analysis, only original volume predicted resolution. Mild pancreatitis and splenic vein obliteration each occurred in 1 patient. Conclusions EUS-guided injection and lavage of ethanol, followed by injection of paclitaxel, appears to be a safe method for treating pancreatic cysts; 62% of patients had complete resolution. Small cyst volume predicted complete resolution.

Background and Aim: This study aimed to determine the clinical characteristics of immunoglobulin G4 (IgG4)-associated sclerosing cholangitis (ISC) and provide clinical clues differentiating ISC from primary sclerosing cholangitis (PSC) or hilar cholangiocar- cinoma (CCC). Methods: Sixteen patients with ISC manifesting as hilar/intrahepatic strictures were ana- lyzed for clinical characteristics and compared with patients with PSC and hilar CCC as disease controls for histology and serum IgG4 levels. Results: Distinguished biliary imaging findings of ISC included multifocal biliary tree involvement (n = 14), concentric bile duct thickening with preserved luminal patency (n = 13), and relatively mild proximal dilatation, despite prominent bile duct thickening (n = 11). Serum IgG4 levels were elevated in 12 patients (75%), but not in any of the 25 patients with hilar CCC.Ten patients (63%) had a past or concurrent history of autoimmune pancreatitis (AIP). The significant infiltration of IgG4-positive cells was observed with endobiliary or liver biopsy in 11 of 16 patients (69%) with ISC, but not in any patients with PSC or hilar CCC. Extrabiliary organ involvement, including sialadenitis, inflammatory pseudotumor of the liver and kidney, and retroperitoneal fibrosis, was present in seven patients. Marked improvement of biliary strictures and/or extrabiliary involvement was observed in all ISC patients after steroid therapy. Conclusions: ISC should be considered in the differential diagnosis of hilar/intrahepatic biliary strictures. Past or concurrent AIP or extrabiliary organ involvement strongly sug- gests the possibility of ISC. Significant infiltration of IgG4-positive cells on endobiliary or liver biopsy specimens, and/or elevated serum IgG4 levels, highly support the diagnosis of ISC and provide the rationale for steroid therapy.

Endoscopic ultrasonography (EUS)-guided intervention has recently been tried in the treatment of cystic tumors of the pancreas. Factors that can influence the treatment response include cyst wall thickness and the presence of septation and mural nodules. This study aimed to evaluate the effectiveness of EUS-guided ethanol lavage with paclitaxel injection (EUS-EP) in the treatment of septated cystic tumors of the pancreas.Ten patients with oligolocular septated cystic tumors underwent EUS-EP and the treatment response was analyzed by measuring cyst volume before and more than 6 months after treatment.The 10 patients comprised 7 women and 3 men, of mean age 38.4 years (range 22-54 years). Median tumor diameter was 29.5 mm (range 20-68 mm), while median tumor volume was 5.07 ml (range 1.51-68.74 ml). Median carcinoembryonic antigen and amylase concentrations in the cyst fluid were 39.2 ng/ml (range 1-8,190 ng/ml) and 115.5 U/L (range 5-75,633 U/L), respectively. Three tumors were diagnosed as mucinous cystic neoplasms, four as serous cystadenomas, and three as indeterminate cysts. Median tumor volume had decreased to 0.54 ml (range 0.00-12.42 ml). Complete resolution was achieved in six patients and partial resolution in two, whereas two patients had persistent cysts. Two patients with persistent cysts underwent surgical resection, and focal remnant neoplastic epithelial lining was observed on the resected specimens.EUS-EP resulted in complete resolution in 6 of 10 patients with septated cystic tumors. Careful patient selection and tailored intervention are required to maximize the therapeutic efficacy of this procedure.

There is a wide variation in risk factors for intrahepatic cholangiocarcinoma (ICC) among various populations. Several studies have suggested that hepatitis C virus (HCV) infection may play a role in the development of ICC, whereas the role of hepatitis B virus (HBV) infection is less clear.To determine whether HBV or HCV infection is a risk factor of ICC, we compared baseline demographic and clinical factors in 622 patients diagnosed between 2000 and 2004 with histologically confirmed ICC and 2,488 healthy controls, matched 4:1 with ICC patients for sex and year of birth.HBV infection (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.6-3.3), but not HCV infection, was significantly related to ICC. Other significant risk factors for ICC included liver cirrhosis (OR 13.6), heavy alcohol consumption (OR 6.6), diabetes (OR 3.2), Clonorchis sinensis infection (OR 13.6), hepatolithiasis (OR 50.0), and choledochal cysts (OR 10.7).Our results indicate that development of ICC seems to be more closely related to HBV infection than to HCV infection in Korea, where both HBV and ICC are endemic.

Background Cystic tumors of the pancreas are frequently detected and encompass a wide pathologic spectrum, ranging from benign to malignant. A substantial proportion of cystic tumors cannot be histologically classified, even after extensive diagnostic evaluation, and, therefore, ultimately require surgical resection. Recently, complete resolution of cystic tumors by EUS-guided ethanol lavage was reported in a pilot study. Objectives The aim of this study was to evaluate the safety, feasibility, and response after EUS-guided ethanol lavage with paclitaxel injection (EUS-EP) for cystic tumors of the pancreas. Design A prospective study. Setting A tertiary care, academic medical center, from July 2005 to November 2006. Patients Fourteen patients who underwent EUS-EP were observed for more than 6 months. They were analyzed in terms of procedure safety, feasibility, and response. Intervention EUS-EP. Main Outcome Measurements To compare changes of cyst volume before and after an EUS-EP. Results An EUS-EP was successfully performed in all cases except one patient in whom the cyst fluid was so viscous that it could not be sufficiently aspirated. Acute pancreatitis occurred in one patient, and minor complications, including hyperamylasemia (n = 6) and vague abdominal pain (n = 1), were observed. Complete resolution of a cystic tumor was observed in 11 patients and partial resolution in two patients, and a cyst persisted in one patient. Limitations A small patient number, a short follow-up time, a single treatment arm. Conclusions EUS-EP appears to be a safe, feasible, and effective method for treating cystic tumors of the pancreas. Further studies that involve larger populations and longer follow-ups are warranted.

Cystic lesions of the pancreas are being recognized with increasing frequency and have become a common finding in clinical practice. Cystic lesions of the pancreas display a wide spectrum of histopathology and biologic behavior. Differentiating among lesions and choosing an optimal therapy is challenging, and evidence-based guidelines for diagnosis, management, and follow-up for cystic lesions of the pancreas are needed. This review describes the epidemiology and typical features of cystic lesions of the pancreas, including a summary of commonly used descriptive terms, as well as the primary issues in the differential diagnosis and management of these lesions.

Relations between host genetic factors and clinical outcomes of Helicobacter pylori infection are variable among ethnicities. The aim of this study was to examine gastric mucosal cytokines, matrix metalloproteinase 3 (MMP-3), and serum pepsinogen levels before and after eradication of H. pylori according to IL-1B genotypes and benign gastroduodenal phenotypes in a Korean population.A total of 349 Koreans including H. pylori-infected subjects (n=230) and H. pylori-negative controls (n=119) were enrolled. The former subjects were classified into groups according to the presence of non-atrophic gastritis (n=74), atrophic gastritis (n=56), gastric ulcer (n=37), and duodenal ulcer (n=63). IL-1B polymorphisms were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Gastric mucosal IL-1beta, IL-8, and MMP-3, and serum pepsinogen I and II levels were measured by ELISA and radioimmunoassay, respectively.There were no significant differences between the IL-1B-31/-511 haplotype (TT/CC, CT/CT, and CC/TT) frequencies among the H. pylori-positive and -negative groups. The genotypes of IL-1B-31/-511 polymorphisms did not affect clinical phenotypes, inflammatory cytokines, MMP-3, and pepsinogen secretion. Subjects with H. pylori-infected atrophic gastritis exhibited significantly higher basal levels of cytokines and a lower pepsinogen I/II ratio than those of other groups. Following H. pylori eradication, inflammatory cytokines significantly decreased and the pepsinogen I/II ratio increased in all groups.Mucosal inflammatory cytokines, MMP-3, and pepsinogen secretion are related to gastroduodenal phenotypes but not to IL-1B genotypes. Eradication of H. pylori can reduce mucosal inflammation and restore pepsinogen secretion.

Objectives: This study aimed to evaluate the adequacy of pancreatic core biopsy in histological diagnosis of autoimmune chronic pancreatitis (AIP). Methods: Histopathologic study as well as immunohistochemical staining using anti-IgG4 antibody was done with pancreatic tissue specimens of 26 AIP patients (19 transabdominal ultrasound (US)-guided core biopsies, 3 intraoperative wedge biopsies, and 4 surgical resections). Eight patients with alcoholic chronic pancreatitis and 10 patients with pancreatic cancer served as controls. Results: Lymphoplasmacytic sclerosing pancreatitis (LPSP) histology was observed in 26% (5/19) of US-guided core biopsy specimens, 33% (1/3) of open biopsy specimens, and all 4 resection specimens in AIP patients. None of the patients in the control group showed the full spectrum of changes of LPSP. Abundant IgG4-positive cells (>10 cells/high-power field) in the pancreas were observed in 21% (4/19) of AIP patients with US-guided core biopsy specimen. Abundant IgG4-positive cells in the pancreas were also observed in 2 of 8 patients with chronic alcoholic pancreatitis and 1 of 10 patients with pancreatic cancer. Conclusions: Transabdominal US-guided pancreatic core biopsy may not provide enough tissue to evaluate characteristic histopathologic features of AIP that include LPSP or abundant IgG4-positive cell infiltration. The LPSP histology may be specific to AIP, but abundant IgG4-positive cells in the pancreas may not.

Small pancreatic cancers (longest diameter

Serum immunoglobulin G (IgG) and/or IgG4 elevation is one of the notable characteristics of autoimmune chronic pancreatitis (AIP). The purpose of this study was to compare the sensitivity and specificity of IgG with those of IgG4 in the diagnosis of AIP.From December 2005 to March 2006, patients who were diagnosed as having ordinary chronic pancreatitis of a certain cause (n = 67) and pancreatic cancer (n = 76) in Asan Medical Center were enrolled. The IgG and IgG4 levels of these patients were compared with those of 35 AIP patients diagnosed in Asan Medical Center.The percentage of patients with serum IgG level more than 1800 mg/dL was 10.4% (7/67), 2.6% (2/76), and 54.3% (19/35) in patients with ordinary chronic pancreatitis, pancreatic cancer, and AIP, respectively. As for serum IgG4 levels more than 135 mg/dL, it was 11.9% (8/67), 1.3% (1/76), and 73.3% (22/30), respectively. The specificity of IgG at 1800 mg/dL and IgG4 at 135 mg/dL was both 93.7%. The serum IgG4 showed high specificity (98.7%) in differentiating AIP from pancreatic cancer. The IgG4 level at 141 mg/dL was determined as the most optimal cutoff value with resulting sensitivity and specificity of 73.3% and 95.1%, respectively (area under the curve, 0.816), whereas for IgG, it was determined as 1770 mg/dL, with sensitivity and specificity of 57.1% and 93.7% (area under the curve, 0.788).The sensitivity of serum IgG4 tended to be higher than that of IgG in the diagnosis of AIP. The IgG4 showed high specificity in the differential diagnosis of AIP from pancreatic cancer. Serum IgG4 should be included in the diagnostic workup for AIP.

Background/Aims: Various diagnostic advantages of percutaneous transhepatic cholangioscopy (PTCS) for the determination of the range of tumor and for the characterization of cholangioscopic findings have been reported. The aim of our study is to evaluate the diagnostic and therapeutic role of PTCS in patients with hilar strictures and to investigate its causes. Methods: We retrospectively studied the medical records and cholangioscopic reports of 177 patients who received PTCS for hilar strictures between January 2000 and December 2005 at Asan Medical Center, Seoul. For each patient, cholagnioscopy, biopsy result, computed tomography (CT) and magnetic resonance cholangiopancreaticography (MRCP), operation, and pathologic reports were collected. Results: Most patients had malignant hilar strictures or biliary papillomatosis while a few had benign hilar strictures. Presence of tumor vessel on PTCS was a useful diagnostic tool since direct observation of the tumor vessel strongly suggested a malignant tumor in the bile duct. The sensitivity of tumor vessel alone was 56.1%, and sensitivity of PTCS biopsy alone was 76.9%. However, sensitivity of biopsy combined with cholangioscopy of the tumor vessel was 88.4%, which was statistically significant compared with biopsy or tumor vessel alone. Conclusions: PTCS biopsy combined with cholangioscopic observation was useful in differential diagnosis of hilar strictures. PTCS also had a therapeutic role in some patients with incurable malignant hilar lesion. (Gut and Liver 2007;1:56-62)