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Purpose: Supportive interventions to improve breastfeeding practice are needed in nursing. This study investigated the effects of pectoralis major myofascial release massage (MRM) on breast pain and engorgement among breastfeeding mothers and on breast milk intake and sleep patterns among newborns. Methods: Breastfeeding mothers who had delivered between 37 and 43 weeks and had 7- to 14-day-old newborns were recruited from a postpartum care center in Gunpo, Korea. Participants were randomized to the MRM or control group. The outcome variables were breast pain and breast engorgement among breastfeeding mothers and breast milk intake and sleep time among newborns. The experimental treatment involved applying MRM to separate the pectoralis major muscle and the underlying breast tissue in the chest. After delivery, the first MRM session (MRM I) was provided by a breast specialist nurse, and the second (MRM II) was administered 48 hours after MRM I. Results: Following MRM, breast pain (MRM I: t=−5.38, p

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

Malignant hilar biliary obstruction (MHBO) frequently accompanies cholestasis and cholangitis, and requires biliary stent placement. To prevent stent occlusion and prolong survival, local ablation therapy can be considered adjunctive to stent placement. Intraductal radiofrequency ablation (ID-RFA) is a recently developed local therapy for malignant biliary obstruction that can be easily performed employing endoscopic retrograde cholangiography. The use of ID-RFA to treat MHBO (as distinct from distal biliary obstruction) was suggested to be associated with severe adverse events. However, recent comparative studies have shown that ID-RFA is feasible and safe, and acceptably efficacious, in patients with advanced MHBO; newer temperature-controlled ID-RFA devices may enhance safety further. Regularly repeated ID-RFA with stent exchange affords better survival than stenting alone. However, the optimal ID-RFA strategy for MHBO remains inconclusive given the lack of data. Further large-scale clinical trials are needed.

Background/aims The endoscopic step-up approach is accepted as the preferred treatment for complicated or symptomatic walled-off necrosis (WON). Direct endoscopic necrosectomy (DEN) is an effective therapeutic option, but few reports describe long-term follow-up in this patient population. Thus, we aim to assess the long-term outcomes of DEN following severe necrotizing pancreatitis. Methods The data of all acute pancreatitis patients who underwent DEN following endoscopic transmural drainage from six referral centers between 2007 and 2017 were retrospectively collected. Results Sixty patients (76.7% male, mean age 48.3 years) underwent a median of 4 sessions of DEN starting at a median of 45.5 days after the onset of acute pancreatitis. Clinical success was achieved in 51 patients (85%), with a 35% complication rate and a 5% mortality rate. Using multivariate analysis, the risk factor associated with DEN failure or major DEN complications requiring intervention or surgery was an identified bacterial/fungal WON infection (odds ratio, 19.3; 95% confidence interval, 1.5 to 261.7). During the median follow-up period of 27 months, complicated WON recurrence was observed in 5.3% of patients, and long-term complications occurred in 24.6% of patients (four exocrine insufficiency, nine newly developed diabetes mellitus, one recurrent small bowel obstruction, one chylous ascites). Conclusions Considering that long-term complications are similar to those observed after pancreatectomy, DEN should be performed meticulously while minimizing damage to the viable pancreatic parenchyma with adequate antibiotic escalation.

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

IntroductionDocosahexaenoic acid (DHA) supplementation has been reported to negatively correlate with cancer cell proliferation and tumour development in many cancer types. Although cumulative evidence has demonstrated the apoptotic effect and cytotoxicity of DHA against tumour development in many cell types, the precise cellular and biochemical mechanisms of DHA-induced apoptosis in human endometrial cancer cells have not been investigated.Material and methodsMTT assay was performed to confirm the degree of apoptosis by combining treatment with DHA and triacsin C in endometrial cancer cell line. The synergistic effects of triacsin C and DHA were identified by performing flowcytometry and immunoblotting analysis.ResultsCombined treatment with DHA and triacsin C significantly induced apoptosis in RL95-2 endometrial carcinoma cells. Combined treatment with 125 µM DHA and 5 µM triacsin C significantly increased the sub-G1 population and apoptotic fragments in endometrial carcinoma cells. It was also demonstrated that DHA and triacsin C induced apoptosis through mitochondrial pathways via caspases-9, -3, and -7 as well as through the extrinsic pathway by activation of caspase-8/BID.ConclusionsFurther elucidation of the apoptotic mechanisms involving DHA treatment with ACS ablation could shed light on possible new treatment strategies for endometrial cancer. In addition, further research into the mechanisms of DHA and triacsin C-induced apoptotic mechanisms may lead to the development of therapeutic strategies for endometrial cancer.

Background and study aims Although routine preoperative biliary drainage (PBD) in patients with distal malignant biliary obstruction is generally not recommended, there are still various situations where it may be necessary. The current study aims to compare between the uncovered self-expandable metal stent (uSEMS) and plastic stent (PS), where PBD may be necessary. Patients and methods In this multicenter prospective randomized study, patients with resectable periampullary cancer with cholangitis, deep jaundice, or expected long waiting time for surgery were included. PBD was performed endoscopically, but percutaneous drainage was allowed if the initial endoscopic drainage was not feasible. The primary outcome was the reintervention rate; the secondary outcomes were the complication rates, rate of decrease of total bilirubin, waiting time for surgery, and postoperative hospital stay. Results Of the 60 enrolled patients, 53 were included for analysis (26 PS and 27 uSEMS). Common bile duct cancer was the most common (27, 50.9%), followed by pancreatic head cancer (20, 37.7%). Regarding PBD indication, 36 (67.9%) had cholangitis and 21 (39.6%) had a total bilirubin level of more than 10mg/dL at randomization; 10 (18.9%) were included due to delayed surgery by more than seven days. Fifty (94.3%) patients received pancreaticoduodenectomy, and one (1.9%) patient received palliative hepaticojejunostomy. The median waiting time for surgery was 11.0 days. There was no difference in the reintervention rate (3.8% and 3.8% in PS and uSEMS, P > 0.999), PBD-related complication rate (23.1% and 22.2%, P > 0.999), PBD- or surgery-related complication rate (57.7% and 48.1%, P = 0.674), and the rate of decrease of total bilirubin (P=0.541). The median hospital stay after surgery was 13.0 days without significant difference. Conclusion For patients who received surgery within the first two weeks from receiving PBD, there was no superiority of uSEMS to PS. According to the expected waiting time for surgery, selective approach for stent choice should be considered.

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

In a recent randomized controlled trial, a double bare metal stent (DBS) showed better stent patency than single-layer metal stents. However, clear evidence comparing the efficacy of uncovered (UCDBS) and partially covered (PCDBS) DBSs for distal malignant biliary obstruction (MBO) is lacking. Therefore, we compared the clinical outcomes including stent patency of UCDBSs versus PCDBSs.A multicenter, randomized study was performed in patients with distal MBO. The primary endpoint was stent patency. Secondary endpoints were the proportion of patients with patent stents at 6 months, risk factors for stent dysfunction, overall survival, technical and clinical success rates of stent placement, and other adverse events (AEs).Among 258 included patients, 130 were randomly assigned to the PCDBS group and 128 to the UCDBS group. The mean duration of stent patency of the PCDBS (421.2 days; 95% confidence interval [CI], 346.7-495.7) was longer than that of the UCDBS (377.4 days; 95% CI, 299.7-455.0), although total stent dysfunction and stent dysfunction within 6 months were not different between groups. Multivariate analysis indicated that chemotherapy after stent placement was a significant factor for overall survival (hazard ratio, .570; 95% CI, .408-.796) and had a marginal impact on stent patency (hazard ratio, 1.569; 95% CI, .923-2.667). There were no remarkable differences in AEs, including pancreatitis, cholecystitis, and stent migration, between the 2 groups.The use of PCDBSs compared with UCDBSs in patients with distal MBO has unclear benefits regarding stent patency and overall survival, although PCDBSs have a lower rate of tumor ingrowth. (Clinical trial registration number: NCT02937246.).

Background: This study explored the effects of a virtual reality exercise program on overweight middle-aged women. Methods: This randomized controlled trial included women 40–65 years of age with a body mass index (BMI) of 23 kg/m2 or more living in Daejeon City. The virtual reality environment was set up by attaching an IoT sensor to an indoor bicycle and linking it with a smartphone, enabling exercise in an immersive virtual reality through a head-mounted display. Results: In the virtual reality exercise group, the BMI was significantly decreased after the 8-week intervention compared with the baseline value (F = 59.491, p < 0.001). The depression scores were significantly different among the three groups, with the intervention effect being more significant in the virtual reality exercise group than in the indoor bicycle exercise and control groups (F = 3.462, p < 0.001). Furthermore, the levels of exercise fun (F = 12.373, p < 0.001) and exercise immersion (F = 14.629, p < 0.001) were significantly higher in the virtual reality exercise group than in the indoor bicycle exercise and control groups. Conclusions: The virtual reality exercise program positively affected the BMI and the levels of depression, exercise fun, and exercise immersion in overweight middle-aged women. It is an effective home exercise program for obesity management in this population.

Mucin family members mucin 1 (MUC1) and mucin 4 (MUC4) play an important role in transformation and adhesion, and are known markers for the detection of cancer. However, the pathophysiology of endometriosis associated with the mucin gene is unclear. In this study, we analyzed the relationship between MUC1 and MUC4 single-nucleotide polymorphisms (SNPs) and the risk for endometriosis. We performed a case–controlled study of 29 endometriosis clinical samples and 27 functional cysts as control. Sixteen SNPs (rs145224844, rs139620330, rs144273480, rs1611770, rs146141676, rs201798179, rs201815857, rs199840128, rs200788986, rs141460657, rs183700327, rs199768496, rs191544901, rs200639498, rs148332231, and rs11465209) of MUC1 gene and eight SNPs (rs1104760, rs1106502, rs882605, rs2291651, rs2291652, rs2291653, rs2291654, and rs375068067) of the MUC4 gene were identified. We amplified SNP sites by polymerase chain reaction (PCR) using specific primer sets followed by DNA sequencing. The single mutation analysis of MUC4 showed that MUC4 mutations had no effect on the risk for endometriosis, but the frequencies of haplotypes [T/T + T/T + C/C] (rs2291653, 2291654 and rs375068067) were associated with endometriosis. The MUC1 genotype may not be correlated with endometriosis susceptibility. However, MUC4 polymorphisms are associated with the risk for endometriosis in Korean women.

Background/aims Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). Methods Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. Results Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. Conclusions The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Background/aim To determine the mechanism of vitamin D3-induced modulation of antioxidant-related factors in endometrial cancer, we investigated their role in apoptosis of human endometrial cancer cells exposed to vitamin D3 Materials and Methods: The survival rate of human endometrial cancer cells was estimated after treatment with activated vitamin D3 Reactive oxygen species (ROS) levels were measured using flow cytometry. The levels of VDR, Trx, TXNIP and apoptosis-related proteins were investigated using western blotting and immunocytochemistry in human tissues. Results Treatment with D3 induced apoptotic cell death and cell-cycle arrest by increasing ROS concentration. Vitamin D3 inhibited proliferation of human endometrial cancer cells. It regulated intracellular ROS concentration in endometrial cancer cells via increased TXNIP expression. Conclusion Antioxidant regulation via TXNIP is an important cell death mechanism in human endometrial cancer, and occurs via induction by vitamin D3.

Chronic pancreatitis (CP) related main pancreatic duct (MPD) stricture has been a challenge for endoscopists. Fully covered self-expandable metal stents (FC-SEMS) has been tried in CP patients, but the efficacy and safety are still controversial. Thus, we aim to compare the long-term clinical efficacy of FC-SEMS vs. plastic stent placement in persistent MPD strictures secondary to CP. Between 2007 and 2018, 80 chronic pancreatitis patients (58 males, median age 49 years), who underwent endoscopic placement of FC-SEMS (n = 26) and plastic stent (n = 54) for persistent MPD strictures after at least 3 months of initial single plastic stenting, were retrospectively analyzed during a median follow-up duration of 33.7 months. As a result, MPD stricture resolution rate was statistically higher in FC-SEMS group (87.0% vs. 42.0%, p p = 0.902), spontaneous migration (26.9%) and de novo strictures (23.1%) were pronounced delayed complications in FC-SEMS group. Pain relief during follow-up was significantly higher in FC-SEMS group (76.9% vs. 53.7%, p = 0.046). The total procedure cost was similar in both groups ($1,455.6 vs. $1,596.9, p = 0.486). In comparison with plastic stent, FC-SEMS placement for persistent MPD strictures had favorable long-term clinical efficacy, with its typical complications like spontaneous migration and de novo strictures.

Background Hand hygiene is paramount in preventing healthcare-associated infections in medical environments and the spread of infectious diseases in non-medical environments. Aims This study used a randomized controlled trial to investigate the effects of a tea tree (Melaleuca alternifolia) oil disinfectant on hand disinfection and skin condition. Methods A tea tree oil group received 5 ml of 10% tea tree oil disinfectant mixed in a ratio of 2:2:1:15 of Melaleuca alternifolia oil, solubilizer, glycerin, and sterile distilled water. Data collection took place between April 9 and April 13, 2018. The subjects were 112 healthy adults. An alcohol group received 2 ml of a gel-type hand sanitizer comprising 83% ethanol used without water; a benzalkonium chloride group received 0.8 ml of a foam-type hand sanitizer containing benzalkonium chloride used without water; a control group received no treatment. Subjective skin condition, transepidermal water loss, and adenosine triphosphate were assessed, and a microbial culture test was performed following treatment. Results The general characteristics and the pre-treatment dependent variables did not differ significantly by group. Post-treatment adenosine triphosphate log10 values significantly differed across all four groups (F=3.23, p=.025). Similarly, post-treatment bacterial density log10 values differed significantly across the tea tree oil, alcohol, benzalkonium chloride, and control groups (F=91.71, p Conclusion The study confirmed that tea tree oil disinfectant is effective for hand disinfection. Accordingly, tea tree oil disinfectants may be introduced to nursing practice as a new hand hygiene product to prevent and reduce healthcare-associated infections.

Intramural hematoma of the gastrointestinal tract is a rare disease entity. Pancreatitis-induced intramural gastric hematoma (IGH) is far more seldom reported. Here, we report a rare case of a giant IGH occurring as a delayed complication of pancreatitis in a 51-year-old man. The diagnosis was made using computed tomography (CT) and endoscopic ultrasonography. The patient was conservatively managed, and follow-up abdominal CT showed marked decreases in the size of the IGH.

To verify the different expression of G protein-coupled estrogen receptor 1 (GPER1) among normal uterine, leiomyoma, and adenomyosis tissues. Normal uterine, leiomyoma, and adenomyosis tissue samples were obtained from women aged 35-52 years from a tertiary university hospital. The tissue samples were subjected to immunohistochemical, Western blot, and reverse-transcription polymerase chain reaction (RT-PCR) analyses of GPER1. GPER1 protein expression was confirmed in the tissues by immunohistochemical and Western blot analyses and compared with GPER1 mRNA levels using RT-PCR. GPER1 was detected in the tissue samples of leiomyoma and adenomyosis, which are estrogen-dependent diseases. GPER1 expression was similar between normal uterine and leiomyoma tissues but was reduced in adenomyosis tissue. The level of phosphorylated extracellular signal-regulated kinases 1/2 was lower and higher in leiomyoma and adenomyosis tissues, respectively, than in normal tissue, but the differences among the groups were not statistically significant. Our immunohistochemical, Western blot, and RT-PCR results suggest that GPER1 expression is involved in cell proliferation in leiomyoma and in cell invasion and migration in adenomyosis. Functional studies of GPER1 involving larger sample sizes should be performed to confirm the adenomyosis and leiomyoma disease mechanisms and eventually to develop new therapeutic interventions for these diseases.

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

Objectives: Atrophic vaginitis (AV), which is common in postmenopausal women, is characterized by vaginal dryness, dyspareunia, and discomfort. There are a variety of therapeutic agents for the treatment of AV, besides hormone replacement therapy. We performed this systematic review to compare the effectiveness of various therapies for symptom improvement in AV patients. Methods: We searched the Cochrane Library, EMBASE, MEDLINE, and other literature (Google Scholar, Web of Science, and hand search) for studies published between January 2010 and March 2015. AV was evaluated by the following outcomes: vaginal pH, dyspareunia, vaginal dryness, or cytological change (endometrial thickness, percentages of superficial cells and parabasal cells). They measured treatment efficacy with various outcomes pertaining to AV symptoms. Results: Meta-analysis suggested that ospemifene was effective against dyspareunia, vaginal dryness, endometrial thickness, and percentage changes in superficial and parabasal cells. Vaginal pH was most affected by soy isoflavone vaginal gel. Ospemifene was effective for AV symptoms. Conclusions: This systematic review compared the effects of several therapeutic agents on symptoms of AV through a network meta-analysis. This study provides objective evidence for clinical treatment and efficacy management in AV. (J Menopausal Med 2018;24:1-10)

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.

OBJECTIVES The aim of this study was to confirm the value of the revised Atlanta classification for predicting the severity of post-endoscopic retrograde choloangiopancreatography pancreatitis (PEP) and to validate the risk factors for moderately severe and severe PEP. METHODS Among 2672 patients, 86 with PEP and 172 randomly selected control patients were included in this study. Post-endoscopic retrograde choloangiopancreatography pancreatitis was evaluated according to Cotton criteria and the revised Atlanta classification. The agreements between the 2 sets of criteria were compared, and the risk factors for moderately severe and severe PEP were identified. RESULTS According to the revised Atlanta classification, 72 patients (83.7%) had mild, 11 (12.8%) had moderately severe, and 3 (3.5%) had severe disease. The agreement between the revised Atlanta classification and Cotton criteria was fair (κ = 0.285). Statistically significant risk factors for PEP were difficult cannulation and dye injection in the pancreatic duct, including acinarization. For moderately severe or severe PEP, obesity (hazard ratio, 3.384 [95% confidence interval, 1.023-11.191]) was the only statistically significant risk factor. CONCLUSIONS The revised Atlanta classification of acute pancreatitis is an effective and feasible classification system for predicting PEP severity. Obesity was identified as an important risk factor predicting moderately severe and severe PEP.

Background and Aim Endoscopic ultrasound elastography (EUS-EG) constitutes a novel imaging procedure that allows for the quantification of tissue stiffness with high degrees of accuracy in pancreatic disease. However, the optimal cut-off and reference strain ratio (SR) value of quantitative EUS-EG for differential diagnosis in patients with pancreatic disease remains unclear. This study aimed to clarify these values of normal pancreas, chronic pancreatitis, or pancreatic cancer in an Asian population. Methods Between December 2014 and November 2015, 398 patients without pancreatic disease, 67 patients with chronic pancreatitis, and 90 patients with pancreatic cancer who underwent EUS were enrolled prospectively. Elastographic evaluation was measured using the quotient B/A (SR value). Results The mean SR was 3.78 ± 1.35 for normal pancreas, 8.21 ± 5.16 for chronic pancreatitis, and 21.80 ± 12.23 for pancreatic cancer (P

BACKGROUND AND AIM Endobiliary radiofrequency ablation (EB-RFA) is a new endoscopic palliation and adjunctive tool. Although EB-RFA is performed worldwide, a possibility of iatrogenic thermal injury leading to perforation or bleeding still remains. Therefore, we aimed to assess the effects of thermal and coagulation injury after in vivo EB-RFA using a new catheter with a temperature sensor in a swine model. METHODS Twelve mini pigs were divided into four groups according to power (33 mm 10 W electrode vs. 18 mm 7 W electrode) and RFA target temperature (75°C vs. 80°C). All mini pigs underwent endoscopic retrograde cholangiography and target temperature controlled EB-RFA for 120 s. Additional cholangiogram was taken immediately after RFA, and all pigs were sacrificed after 24 h to assess the macroscopic/microscopic RFA injury. RESULTS Microscopic maximal injury depth and ablation area of EB-RFA using a 33-mm 10 W RFA electrode were significantly deeper and larger than those of EB-RFA using an 18-mm 7 W electrode (median; 2.7 vs. 2.1 mm, P = 0.004, 48.9 vs. 36.2 mm2 , P = 0.016). However, there were no significant differences in microscopic ablation parameters between two different RFA target temperatures (75°C vs. 80°C). In addition, a post-RFA cholangiogram and assessment of the resected specimen at 24 h after the RFA showed no adverse events such as perforation or bleeding. CONCLUSIONS EB-RFA using a temperature controlled RFA catheter successfully ablates the bile duct wall without adverse events in a swine model.

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

Background and study aims Intraductal radiofrequency ablation (ID-RFA) is a recently developed method widely used for treatment of malignant extrahepatic biliary tract obstructions. However, its safety in hilar application has yet to be clearly demonstrated. The aim of this study was to evaluate the safety of ID-RFA in the treatment of malignant hilar obstruction. Patients and methods Endoscopic retrograde cholangiography followed by temperature-controlled ID-RFA at the hilar area using different probe lengths (11, 18, and 22 mm) and settings (7 or 10 W for 60 – 120 s) was performed in six mini-pigs. In addition, patients with malignant hilar obstruction who underwent palliative ID-RFA were retrospectively evaluated. Results In the animal study using different ID-RFA settings, post-ID-RFA fluoroscopic radiocontrast leakage and microscopic bile duct perforation with hepatic abscess were observed in four of the six mini-pigs. Only two of the them, in which an 11-mm ID-RFA probe at a target temperature of 80 °C, power of 7 W, and duration of 60 s was used, underwent successful ID-RFA without any immediate adverse events (AEs). Clinically, ID-RFA was performed using the 11-mm probe with the setting of 80 °C, 7 W, and 60 – 120 s for malignant hilar obstruction, and total of 11 patients underwent successful ID-RFA without AEs. Conclusions Our study suggests that ID-RFA performed using a short-length probe with settings of 80 °C, 7 W and 60 – 120 s is a safe and feasible palliative treatment for malignant hilar obstruction.

To determine the mechanism of vitamin DTreatment with DAntioxidant regulation via TXNIP is an important cell death mechanism in human endometrial cancer, and occurs via induction by vitamin D

Background/Aims When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings. Methods Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group. Results EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis. Conclusions An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.

Pancreatic neuroendocrine tumors (pNETs) are diverse diseases with different prognosis. Among available various therapeutic options, curative resection should be considered for localized tumors and in some selected cases of metastatic disease. Somatostatin analogs are used to control hormonal symptoms and also effective to inhibit the tumor progression in specific settings. The molecular targeted agents such as sunitinib and everolimus are efficacious treatments for metastatic WHO grade 1/2 pNETs. Chemotherapy is generally used in highly symptomatic and rapidly growing pNETs such as WHO grade 3. In addition, local ablative therapy should be considered in patients with hepatic predominant unresectable metastatic pNETs, and peptide receptor radionucleotide therapy, which is unavailable in Korea, could be considered after failure of initial medical therapy. The most important of all is a multidisciplinary approach to pNETs. This is essential to optimal management of pNETs regarding the diverse disease nature

Today, almost 20% of female cancers are gynecological in nature. In particular, uterine cervical cancer and endometrial cancer (which have been intensively studied) seriously compromise female health. One of the ezrin-radixin-moesin (ERM) proteins, ezrin, has been associated with cancer in prior studies, including the two cancers mentioned above. Ezrin expression increases, as does the expression of other factors, in uterine cervical cancer; ezrin may promote cancer development by influencing the actions of the other factors. Also, an increase in ezrin level contributes to the development of diseases such as endometrial cancer.