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Background/Aims : Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is challenging to gastrointestinal endoscopists. The aim of this study was to evaluate the impact of scope exchange from a long single balloon enteroscope (SBE) to a gastroscope during SBE-assisted ERCP (SBE-ERCP) in patients with SAA. Methods Patients who underwent SBE-ERCP between February 2019 and October 2020 were retrospectively identified. Intubation success, scope exchange success, cannulation success, and therapeutic success were analyzed along with complications. Results Fifty-six patients with various SAAs underwent SBE-ERCP procedures, including Billroth II subtotal gastrectomy (B-II, n=13), pylorus-preserving pancreato-duodenectomy (PPPD, n=6), Roux-en-Y hepaticojejunostomy (REY HJ, n=4), and total gastrectomy with REY anastomosis (TG REY, n=33). Overall intubation, cannulation, and therapeutic success rates were 89.3%, 82.1%, and 82.1%, respectively. Therapeutic success rates did not differ significantly among the type of SAA. Successful scope exchange rate after successful intubation was significantly higher in native papilla (B-II and TG REY, 83.3%, 35/42) compared to bilioenteric anastomosis (PPPD and REY HJ, 0%, 0/8, p

BACKGROUND Cytomegalovirus (CMV) colitis is usually seen in immunocompromised patients with risk factors such as human immunodeficiency virus infection, solid organ transplant, inflammatory bowel disease, or malignancy. Therefore, many clinicians usually do not consider the possibility of CMV colitis in immunocompetent patients. We reported a rare case of segmental colonic hypoganglionosis associated with CMV colitis in an immunocompetent patient. CASE SUMMARY A 48-year-old woman with no underlying disease was admitted to our hospital for severe abdominal pain and constipation. Computed tomography of the abdomen showed diffuse dilatation of the small intestine and the entire colon. Initial sigmoidoscopic findings and result of polymerase chain reaction (PCR) for CMV revealed the compatible findings of CMV colitis, the patient was treated with intravenous ganciclovir. After treatment, sigmoidoscopic findings and CMV PCR results improved. However the patient continued to suffered from constipation. Eight months after the initial admission, patient visited the emergency department with severe abdominal pain and imaging revealed aggravation of fecal impaction and bowel dilatation. We performed subtotal colectomy to control patient’s symptom. Histological examination of the resected specimen showed significantly reduced number of mature ganglion cells in the sigmoid colon compared to that in the proximal colon. CONCLUSION Our case demonstrates that CMV colitis can develop even in patients with no other underlying disease, and that CMV colitis can be one of the causes for developing colonic hypoganglionosis.

Background/Aims: The study aimed to investigate the current practice patterns in the management of pancreatic cystic neoplasms in Korea.Methods: An electronic survey was systematically distributed by email to members of the Korean Pancreatobiliary Association from December 2019 to February 2020.Results: In total, 115 (110 gastroenterologists, five surgeons) completed the survey, 72.2% of whom worked in a tertiary/academic medical center. Most (65.2%) followed the 2012/2017 International Association of Pancreatology guidelines for the management of pancreatic cystic neoplasms. A gadolinium-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography was the most common first-line diagnostic modality (42.1%), but a contrast-enhanced computed tomography scan was preferred as a subsequent surveillance tool (58.3%). Seventy- four percent of respondents routinely performed endoscopic ultrasound-guided fine needle aspiration for pancreatic cystic neoplasms with suspicious mural nodules. Endoscopic ultrasound-guided fine needle aspiration cytology (94.8%) and cystic fluid carcinoembryonic antigen (95.7%) were used for cystic fluid analysis. Most (94%) typically recommended surgery in patients with high-risk stigmata, but 18.3% also considered proceeding with surgery in patients with worrisome features. Most (96.5%) would continue surveillance of pancreatic cystic neoplasms for more than 5 years.Conclusions: According to this survey, there was variability in the management of pancreatic cystic neoplasms among the respondents. These results suggest that the development of evidence-based guidelines for pancreatic cystic neoplasms that fit the Korean practice is needed to create an optimal approach to the management of pancreatic cystic neoplasms.

Background Endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA or FNB) has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety. To the best of our knowledge, no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described. Herein, we report a rare case of septic shock after EUS-FNB of a splenic mass. Case summary A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass. A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging. EUS of the spleen showed a 6 cm-sized, relatively well-demarcated, heterogeneous mass, and EUS-FNB with a 22G needle was performed. Ten days after the procedure patient developed septic shock and a splenic abscess was identified. Blood culture revealed growth of Granulicatella adiacens. After the treatment with antibiotics the patient underwent surgical resection, and the pathological examination showed diffuse large B-cell lymphoma. The patient received chemotherapy and he is in complete remission. Conclusion Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient’s anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.

Background/Aims Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms. Methods Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T½) and incidence of cardiovascular events following GES. Results The mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE (P = 0.015). Univariate analysis showed that GE T½ was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12-2.69; P = 0.014). In a multivariate model, association between GE T½ and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21-3.12; P = 0.006). Conclusion A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms. (J Neurogastroenterol Motil 2019;25:387-393)

Various core biopsy needles have previously been developed for endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). However, the properties of needle gauge in the diagnostic outcomes of solid pancreatic lesions remain unknown. This trial compared the procurement rates of histologic cores from solid pancreatic lesions with EUS-FNB using 20- and 25-gauge (G) FNB needles. In a prospective randomized multicenter clinical trial, patients with solid pancreatic lesions underwent EUS-FNB with either a 20-gauge or a 25-gauge FNB needle. The rates of histologic core procurement, overall diagnostic accuracy, and adverse events were compared between the two groups (20-gauge or 25-gauge FNB needle). In total, 88 patients (48 men, 40 women, mean age 65.7 years) were enrolled. No significant differences were found in the demographic characteristics between the two groups (20-gauge or 25-gauge FNB needle). The procurement rate of histologic cores in the 20-guage FNB needle group (41/45, 91.1%) was significantly higher than that in the 25-guage FNB needle group (32/43, 74.4%, P = 0.037). However, no significant differences were found in the overall diagnostic accuracy between 20-guage FNB needle (40/45, 88.9%) and 25-guage FNB needle (34/43, 79.1%, P = 0.208). No procedure-related adverse events were observed in either group. Although both FNB needles provided high overall diagnostic accuracy, the reliability of the 20-guage FNB needle is better than the 25-guage FNB needle when retrieving samples for histological analysis.

Unmanned aerial vehicle (UAV) communications over cellular networks are currently gaining increased interest because it can enable real-time control of UAVs and wide-area coverage. We discuss various challenges for future UAV cellular networks, where cellular networks with down-tilted antennas optimized for terrestrial users can extend terrestrial cellular services to aerial users. To overcome challenges such as large channel variation and UAV power consumption in UAV cellular networks, we propose a technique of preamble design for these networks using scalable sequences. Specifically, three types of scalable sequences are proposed for efficient use of battery power in UAVs, namely, maximum-length scalable sequence, Zadoff–Chu scalable sequence, and linear frequency modulated (LFM) scalable sequence. The properties of these scalable sequences are analyzed and compared through simulations in different channel environments.

Background Silibinin is a flavonoid with antihepatotoxic properties, and exhibits pleiotropic anticancer effects. However, the molecular mechanisms responsible for its anticancer actions in pancreatic cancer cells, and the effects on such cells and normal pancreatic cells, remain unclear. The objective of this study was to determine the effect of silibinin on human pancreatic cancer cells and normal ductal cells.Methods Human pancreatic cancer cells (MIA PaCa-2 and PANC-1) and normal ductal cells (hTERT-HPNE) were cultured with 0–400 μM silibinin for 48 h. Thereafter, the proliferation, invasion, apoptosis, and signaling pathways of the pancreatic cells were evaluated.Results Silibinin significantly inhibited the proliferation, invasion, and spheroid formation of human pancreatic cancer cells in vitro in a dose-dependent manner (p < 0.05). It also induced apoptosis in a dose-dependent manner. Western blot analysis showed that silibinin downregulated extracellular signaling-regulated kinase (ERK) and serine/threonine protein kinase (AKT) in human pancreatic cancer cells. It also upregulated microtubule associated protein 1 light chain 3 β (LC3B) and cleaved caspase-3 via c-Jun N-terminal kinases (JNK) signaling. On the other hand, silibinin increased the mRNA and protein levels of c-Jun, Twist-related protein 1, and Snail. It also decreased exogenous p53 levels, but increased endogenous c-Jun protein levels in human pancreatic cancer cells. However, silibinin did not affect cell viability and endogenous c-Jun levels in pancreatic normal ductal cells. It increased exogenous p53 levels, but decreased stemness-related gene expression in pancreatic normal ductal cells. Silibinin increased Ki-67 levels in pancreatic cancer cells, but decreased them in pancreatic normal ductal cells.Conclusion Silibinin not only exerted anticancer effects by inhibiting AKT–ERK and JNK signaling, but also upregulated cancer stemness–related genes in human pancreatic cancer cells. These results suggest that silibinin should be used as a therapeutic agent for human pancreatic cancer with caution.

Background Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. Methods This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. Results A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. Conclusion Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.

Background Little information is available about the relationship between restoration of common bile duct (CBD) diameter after endoscopic stone retraction and recurrence of CBD stones in elderly patients. The present study was to determine whether restoration of CBD diameter is a preventive factor for CBD stone recurrence in elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). Methods From January 2006 to December 2010, 238 patients underwent the first and the second session of ERCP for the removal of CBD stones. Among them, 173 were over 65 years old. These patients were divided into recurrent group and non-recurrent group. Restoration of CBD diameter and patients’ characteristics were compared. Results There was no statistical difference in patients’ characteristics, associated diseases, or ERCP-related complications between the two groups. Reduction of CBD diameter was significantly larger in the non-recurrent group (2.7 ± 1.7 mm) compared to that in the recurrent group (1.4 ± 2.3 mm, P = 0.002). The proportion of patients with restoration of CBD diameter were significantly lower in the recurrent group (6/42, 14.3%) compared with that in the non-recurrent group (67/131, 51.1%) (P Conclusions There is an inverse relationship between restoration of CBD diameter and CBD stone recurrence. Therefore, patients without restoration of CBD diameter within 2 weeks after endoscopic stone removal should be monitored more frequently.

Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10-20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.

Anorectal variceal bleeding is a rare occurrence; however, in such event, it could be fatal due to large size and high blood flow rate of varices. However, to date, there is no standardized treatment modality. Although endoscopic treatment can be provided, in cases of recurrent anorectal variceal bleeding, other therapeutic modalities for hemostasis are necessary. Here, we present a case of 58-year-old female patient with liver cirrhosis, who suffered from massive bleeding of anorectal varices. Endoscopic variceal band ligation was performed for primary hemostasis. Additionally, transjugular intrahepatic portosystemic shunt (TIPS) with embolization was performed to reduce the risk of rebleeding. Following the procedure, she had no further bleeding episodes, and the size of anorectal varices decreased, as seen on an abdomino-pelvic computed tomography. Our case illustrates the effectiveness of combined radiological intervention of TIPS with embolization after endoscopic hemostasis, for variceal obliteration and prevention of rebleeding.

In this paper, a design technique of random access preamble (RAP) for high-velocity users (HVUs) in millimeter-wave (mmWave) cellular networks is proposed. After demonstrating the inefficiency of the conventional long-term evolution (LTE)-based RAP for HVUs in mmWave networks, linear-frequency-modulation-based RAP (LFM RAP) is proposed for the detection of HVUs. The correlation of LTE-based RAP, and ambiguity and extended-ambiguity functions of LFM RAP are analyzed to examine their properties affected by the high-velocity of the user. The performance of RAPs is evaluated through detection and false alarm probabilities in a high-velocity and multiuser environment. The results show that the LFM RAP is appropriate for HVUs in mmWave cellular networks because of its high-detection probability in a high-speed environment.

Background Transdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied. Case presentation A 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications. Conclusions Herein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

The word ‘bezoar’ comes from either the Persian word ‘padzahr’ or the Arabic word ‘badzehr’ both of which denote ‘antidote.’ This word meant a hard stone found in the stomach of the Syrian goat and believed to prevent poisoning1.

Future fifth-generation (5G) New Radio (NR) services consider positioning an integral part of a system that provides high precision using millimeter-wave (mmWave) cellular networks. While the 5G standard for positioning is not fully defined yet, the positioning reference signal (PRS) used in long-term evolution (LTE) system is being considered. Since the conventional LTE PRS is designed for LTE systems below 6 GHz, it is more sensitive and inefficient for high-speed vehicle (HSV) experiencing a high Doppler effect in mmWave cellular systems. In this paper, a new sequence, called an oscillatory pulse sequence (OPS), is proposed for the positioning of HSVs in mmWave cellular systems. The ambiguity function (AF) and cross-ambiguity function of OPS are analyzed to examine its autocorrelation and cross-correlation properties in the existence of Doppler shift. The performance of the proposed OPS is compared with the performance of LTE PRS, Zadoff-Chu, and linear-frequency modulated waveforms with respect to correlation, time ambiguity, and Doppler tolerance. The analytic and simulation results show that the OPS provides an accurate timing (distance) estimation in the existence of a high Doppler shift, which is the ideal characteristic of the AF for positioning. The OPS is especially suitable for orthogonal frequency division multiplexing (OFDM) systems because it can be easily multiplexed with other signals in the frequency domain.

Pancreatic pseudocyst is a common complication of acute pancreatitis. Pseudocysts are commonly observed in the lesser sac and retroperitoneum; they are rarely seen in the liver. Herein, we report a case of intrahepatic pseudocyst, complicated by asymptomatic groove pancreatitis, that has successfully been treated with hepatic resection. A 70-year-old woman was referred to our hospital with severe upper abdominal pain. Abdominal computed tomography scan showed 11x10 cm sized cystic lesion in the left lateral section of the liver. Appearance of the pancreas was relatively normal. Endoscopic aspiration revealed a high level of amylase in the cystic fluid. After endoscopy, signs of peritonitis were observed; then, a left hemihepatectomy was performed. Pathologic examination revealed an intrahepatic pancreatic pseudocyst. The presence of intrahepatic cystic lesion in patients with suspected pancreatitis should raise the suspicion of intrahepatic pseudocyst. Intrahepatic pancreatic pseudocysts may be the only clinical manifestation even without an episode of acute pancreatitis.

Rationale Endoscopic ultrasonography-guided tissue acquisition (EUS-TA) has become the norm for the diagnosis of pancreatic solid lesions. EUS-TA is relatively safe, but various complications can occur. Infected pancreatic necrosis (IPN) is a rare but serious complication. The latest guidelines suggest that all invasive interventions in patients with IPN should be delayed until walled-off necrosis appears. Patient concerns A 73-year-old man was referred to our hospital with double primary cancers including gallbladder and pancreas. We performed EUS-TA on metastatic pancreatic tail cancer to confirm histologic diagnosis. Six days after the procedure, he developed abdominal pain and fever. Diagnoses The patient's laboratory findings showed leukocytosis and C-reactive protein elevation. Fluid collection around pancreas tail and stomach was detected in computed tomography (CT) scan, and the patient was diagnosed with IPN. Interventions and outcomes EUS-guided endoscopic transmural drainage (EUS-TD) was performed for the treatment of IPN. Two days after the procedure with antibiotics, his CRP level decreased abruptly, and he received chemotherapy for the treatment of pancreatic ductal adenocarcinoma (PDAC) 5 days after the procedure. He was discharged from our hospital without complications 15 days after chemotherapy. Lessons In selected patients with PDAC, early endoscopic drainage may be recommended as treatment for IPN resulting from complications of EUS-TA.

A small-cell network SCN constructed by splitting a macro-cell into numerous small cells using an active antenna array system is studied. A synchronization signal appropriate for the SCN, virtually generated by an eNodeB with 3D beamforming, is proposed for efficient handover in SCNs. The virtual cell synchronization signal VCSS carries a macro-cell ID MCID and virtual-cell ID VCID in a hierarchical manner, allowing us to distinguish between an intra-cell handover virtual cell handover within a cell without changing the serving eNodeB and inter-cell handover virtual cell handovers across cells while changing the serving eNodeB in SCNs. Using the signal metrics obtained by the VCSS, an efficient handover measurement technique is proposed which can significantly reduce the processing time and overhead by distinguishing between the intra-cell/inter-cell handovers. The performance of the proposed technique is evaluated by simulating two different deployment scenarios of LTE-based SCN with 3D beamforming. Copyright © 2017 John Wiley & Sons, Ltd.

Several studies have demonstrated a correlation between the expression of early growth response gene-1 (EGR-1) and the progression of gastric cancers at advanced stages. However, the effects of EGR-1 expression on human gastric cancer progression, particularly on precancerous lesions, have not been investigated. In this study, we evaluate EGR-1 expression levels in target mucosa from patients with early gastric cancer and precancerous lesions, and assess whether EGR-1 expression affects the oncogenic phenotypes of human gastric cancer cells. EGR-1 protein levels were measured in tissues from subjects with normal mucosa (n=6), low-grade dysplasia (n=6), high-grade dysplasia (n=4) and adenocarcinoma (n=3) using enzyme-linked immunosorbent assay and immunohistochemistry analyses. We also investigated the role of EGR-1 in tumor cell behavior by transiently expressing a dominant active EGR-1 variant in cultured cells. A positive correlation was observed between EGR-1 expression and gastric carcinogenesis (P=0.016). Furthermore, there was an increase in nuclear and cytoplasmic expression of EGR-1 in accordance with the histological grade (P for trends=0.003 and 0.003, respectively), and a positive association between the sum of the nuclear and cytoplasmic EGR-1 expression values and the histological grade (P=0.003). In addition, transient overexpression of EGR-1 enhanced cell proliferation, stimulated cell migration, and promoted the phosphorylation of p38 MAPK and AKT in gastric cancer cells in vitro. Our findings demonstrate that EGR-1 may contribute to the early stages of gastric carcinogenesis via the alteration of tumor cell behaviors.

Background/Aims: Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultrasonography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholangiography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extrahepatic biliary obstruction. Methods: A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between October 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates. Results: The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC-ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups. Conclusions: IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

Transdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied.A 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications.Herein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

Background Eradication rate for Helicobacter pylori (H. pylori) has decreased due to antibiotic resistance. Therefore, new strategies are needed to enhance H. pylori eradication, especially for H. pylori with high antibiotic resistance. The objective of this study was to evaluate anti-H. pylori activities of constituents from key lime (Citrus aurantifolia) and their possible inhibitory effects on urease activity of H. pylori. Methods Helicobacter pylori strain ATCC 43526 and triple drug resistant (TDR) H. pylori strains were used in this study. Urease activities of H. pylori strains were measured by ammonia colorimetrical quantification using ELISA reader. Minimum inhibitory concentrations were determined by agar dilution method for antibiotics and by modified media dilution method for each constituent of Citrus aurantifolia (C. aurantifolia). Results Citrus aurantifolia extract decreased the number of colonies of H. pylori strain ATCC 43526 and TDR H. pylori stains. An increasing concentration of C. aurantifolia extract attenuated urease activities of H. pylori strain ATCC 43526 and TDR H. pylori strains. Among constituents of C. aurantifolia, citral and 4-hexen-3-one were found to be able to inhibit the growth of H. pylori strain ATCC 43526 and TDR H. pylori strains. Furthermore, citral and 4-hexen-3-one inhibited urease activities of H. pylori strain ATCC 43526 and TDR H. pylori strains in a dose-dependent manner. Conclusion Citrus aurantifolia has antimicrobial effect on TDR H. pylori strains, suggesting that C. aurantifolia might have therapeutic potential to control antibiotic-resistant H. pylori strains that cause eradication failure using other antibiotics.

Intraductal US (IDUS) is an examination of the bile duct by using a thin-caliber ultrasonic probe, yielding real-time, high-quality cross-sectional images. We prospectively evaluated the feasibility and safety of IDUS-directed stone removal without radiocontrast cholangiography (RC) in naïve patients with common bile duct (CBD) stones.A total of 38 naïve patients with suspected CBD stones (20 mm) were enrolled in this study. If IDUS showed CBD stones, we performed endoscopic sphincterotomy and removed the identified CBD stones without RC. The primary outcome was success rate of CBD stone removal without RC. The secondary outcomes were conversion rate to conventional ERCP with RC, fluoroscopy time, clinical responses, and adverse events.IDUS was successfully performed in all enrolled patients (38/38, 100%). No echogenic material was observed in 3 patients (1 Mirizzi syndrome, 2 spontaneous passages of CBD stones). After endoscopic sphincterotomy, IDUS-directed stone removal was successfully performed without RC in 26 patients (74.3%) in the first session. In the 9 patients, after deployment of plastic stents, IDUS-directed stone removal was successfully completed without RC in a second session. There was no conversion to conventional ERCP with RC. Median fluoroscopy time was 10 seconds. There were no immediate and delayed adverse events related to the IDUS-directed stone removal. However, asymptomatic hyperamylasemia developed in 3 patients (7.9%), who recovered without adverse events.IDUS-directed stone removal without RC is feasible and safe for patients with CBD stones. We anticipate a potentially important role of IDUS in the field of various therapeutic interventions.

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery. Cite this article: Bone Joint J 2015;97-B:1525–32.

Objective The incidence of nonsteroidal anti-inflammatory drugs (NSAIDs)-induced enteropathy is currently increasing. However, the predictors of small bowel bleeding (SBB) associated with NSAIDs are unknown. This study aimed to assess the risk factors of SBB in chronic NSAIDs users. Methods We retrospectively compared the medical records of 147 patients receiving NSAIDs in a tertiary-care setting (31 with SBB and 116 without previous bleeding events) and analyzed the predictors of SBB. Results In total, 31 patients underwent video capsule endoscopy to detect SBB, 74.2% of whom showed the evidence of SBB. Non-invasive treatment was performed in 90.3% of the patients. Multivariate logistic regression analysis revealed that the presence of coronary artery disease [adjusted odds ratio (aOR) 12.43, 95% confidence interval (CI) 1.19–130.34, P = 0.04], use of thienopyridine (aOR 16.93, 95% CI 3.78–75.72, P

Twenty-four-hour multichannel intraluminal impedance (MII) and pH monitoring is used for detecting reflux episodes in patients with gastroesophageal reflux (GER) disease. However, the clinical significance of baseline impedance levels (BILs) has not been well studied. We aimed to evaluate whether BILs are related to various reflux events or acid-related parameters and to determine whether BILs during specific intervals could be substituted for 24-h BILs.One-hundred forty-two patients GER symptoms underwent 24-h pH/impedance monitoring. We measured pH [(5 cm above the low esophageal sphincter (LES)] and BILs from three sites (3, 5, and 15 cm above the LES).Eighty-one subjects (57.0%) were diagnosed with gastroesophageal reflux disease, and 53 (37.3%) had acid reflux and 28 (19.7%) had nonacid reflux. The 24-h BILs at distal sites were lower in the "reflux" group than in the "no reflux" group (p0.001) and lower in the "acid reflux" group than in the "nonacid reflux" group (p0.001). However, there was no significant difference in 24-h BILs at the proximal site among the "no reflux", "acid reflux", and "nonacid reflux" groups. The interclass correlation coefficient value of 24-h BILs with daytime 6-h BILs was 0.916 (95% CI 0.882-0.940) and that with nighttime 6-h BILs was 0.909 (95% CI 0.871-0.935).BILs are related to GER, especially acid reflux. Location and duration of assessment for BILs needs to be standardized. Six-hour BILs could be substitutes for 24-h BILs. During analysis of MII-pH, more attention should be paid to BILs in the lower esophagus.

BACKGROUND/AIMS: Colon transit time (CTT) is a useful diagnostic tool in chronic constipation, but requires good patient compliance. We analyzed the correlation between the gas volume score (GVS) and CTT in patients with chronic constipation. METHODS: The study included 145 consecutive patients (65 men) with chronic constipation. The primary outcome was the correlation be-tween the colon GVS and CTT. Secondary outcomes were the differences in colon GVS according to CTT and subtypes of chronic constipation. RESULTS: There were 81 patients with "CTT < 45 hours" and 64 patients with "CTT ≥ 45 hours." In addition, 88 patients were classi-fied as having functional constipation and 57 were classified as having constipation predominant irritable bowel syndrome (IBS-C). There was no significant correlation between CTT and colon GVS. However, the right colon GVS showed a positive cor-relation with right CTT (r = 0.255, P = 0.007). The median total colon GVS was significantly higher in patients with "CTT ≥ 45 hours" than in those with "CTT < 45 hours" (5.65% vs 4.15%, P = 0.010). There were no significant differences in colon GVS between the functional constipation and IBS-C. CONCLUSIONS: We were unable to detect a correlation between GVS and CTT in patients with chronic constipation. However, total colon GVS may be a method of predicting slow transit in patients with chronic constipation.

In this paper, the effect of time difference of arrival (TDoA) is investigated for distributed nodes in OFDMA-based wireless mesh networks (WMNs). In order to minimize the interferences caused by TDoA in WMNs, the optimal starting point of FFT window at the receiver side of a node is derived by maximizing the effective SINR for each subcarrier. Also, a signal detection technique, called two dimensional ordered successive interference cancellation (TD-OSIC), is proposed for WMNs with TDoAs. It was shown via simulation that the proposed technique can achieve effective SINR and BER performances similar to the ideal case (no TDoA), even in WMNs with large TDoAs.