Objective Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy. Materials and methods From July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n = 17) or endoscopic gallbladder stenting (EGBS) (n = 18) group. Results Bile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18), p = 0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18), p = 0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16), p = 0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p = 0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy. Conclusions Single-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy.
Pancreatic neuroendocrine tumors (pNETs) are diverse diseases with different prognosis. The American Joint Committee on Cancer (AJCC) and the European Neuroendocrine Tumor Society (ENETS) introduced 2 different tumor node metastasis (TNM) stages, and the World Health Organization (WHO) proposed WHO 2010 grading system for pNETs. Therefore, we aimed to validate the prognostic relevance of these 3 systems for pNETs in South Korea.The Korean Society of Gastrointestinal Cancer created a retrospective registry of pNETs in 153 patients from 15 hospitals between 2002 and 2012.On the basis of the WHO 2010 grade, 2-year progression-free-survival (PFS) rates for G1, G2, and G3 were 92%, 62%, and 25% (P < 0.01). According to ENETS and AJCC staging, 2-year PFS rates for stages I through IV were 94%, 87%, 49%, 20%, and 92%, 61%, 60%, 20%, respectively (P < 0.01). A Cox multivariate regression analysis revealed that the only statistically significant prognostic factor was the TNM classification of either the AJCC or the ENETS stage (P < 0.01). In addition, the κ value between the AJCC and the ENETS stages was 0.46 indicating a "moderate" agreement (P < 0.01).The AJCC and ENETS TNM classifications for pNETs are prognostic for PFS and can be adopted in clinical practice in South Korea.
Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a precancerous lesion of cholangiocarcinoma, for which surgical resection is the most effective treatment. We evaluated the predictors of malignancy in IPNB according to anatomical location and the prognosis without surgery. Methods: A total of 196 IPNB patients who underwent pathologic confirmation by surgical resection or endoscopic retrograde cholangiography or percutaneous transhepatic cholangioscopic biopsy were included. Clinicopathological findings of IPNB with invasive carcinoma or mucosal dysplasia were analyzed according to anatomical location. Results: Of the 116 patients with intrahepatic IPNB (I-IPNB) and 80 patients with extrahepatic IPNB (E-IPNB), 62 (53.4%) and 61 (76.3%) were diagnosed with invasive carcinoma, respectively. Multivariate analysis revealed that mural nodule > 12 mm (p = 0.043) in I-IPNB and enhancement of mural nodule (p = 0.044) in E-IPNB were predictive factors for malignancy. For pathologic discrepancy before and after surgery, IPNB has a 71.2% sensitivity and 82.3% specificity. In the non-surgical IPNB group, composed of nine I-IPNB and seven E-IPNB patients, 43.7% progressed to IPNB with invasive carcinoma within 876 days. Conclusions: E-IPNB has a higher rate of malignancy than I-IPNB. The predictive factor for malignancy is mural nodule > 12 mm in I-IPNB and mural nodule enhancement in E-IPNB.
There are various causes of splenic infarction. Antiphospholipid antibody is associated with numerous thromboembolic phenomena. We report a case of young male who presented with acute abdominal pain and was diagnosed as a case of splenic infarction and acute pancreatitis with antiphospholipid syndrome. He was positive for anticardiolipin antibody, showed splenic infarction on abdominal CT scan. The patient's clinical, laboratory and imaging finding were consistent with splenic infarction and acute pancreatitis associated with antiphospholipid syndrome.
Background:The authors experienced a case of Strasberg type E3 (Injury at the confluence; confluence intact) + E5 (Injury to aberrant right hepatic duct) injury that was treated by segmentectomy 5 and hepaticojejunostomy and report here with an operative video.Methods: A 36 years old female patient was referred to UUH due to jaundice after laparoscopic cholecystectomy (LC).She underwent LC 9 days ago at other hospital and suffered from jaundice and AST/ALT elevation from the day after LC.Serum bilirubin level rose to 7.7 mg/dL on day 7.She was transferred to another hospital.MRCP revealed complete disconnection of extrahepatic bile duct at the hilar level.Communication between the right and left ducts was preserved only at the roof of the bifurcation.There was no common hepatic duct stump.PTBD was tried.But only the bile duct of one segment of right liver where no communication exist with other segments was puncture and drained.Trial to puncture the left bile duct was failed.She was transferred to UUH and 2nd PTBD was inserted into the left liver on the day.On cone-beam CT, the isolated bile duct was identified as B5.This was a case of Strasberg type E3 + E5 injury where complete transection of the confluence happened with concomitant separate transection of the aberrant B5.Since early (within 6 weeks) bile duct repair is reported to be associated with increased rates of repair failure, postoperative complications, and biliary stricture, delayed repair was decided.Results: After waiting 7 weeks after the LC, she underwent open segmentectomy 5 and hepaticojejunostomy.The mucosa of the B5 (the separated duct) was destroyed so deeply (by 2 large metal clips) that a safe mucosa-to-mucosa anastomosis to the jejunum was impossible.Segmentectomy 5 was performed by Glissonean approach guided by the first PTBD.The aberrant B5, P5 and A5 were separately closed.After removing all the scar tissues surrounding the previous clipped site on common hepatic duct, hepaticojejunostomy was done with some extension (3 mm) of the left hepatic duct.Operation time was 375 minutes.Estimated blood loss was 100 mL.There was no postoperative complication.Postoperative hospital stay was 11 days.Conclusions: For injury of an aberrant right duct with concomitant injury of main bile duct, delayed repair after more than 6 weeks of the injury seems offer a good chance of sound repair if on-table repair was not possible.When the injured aberrant right segmental duct is not repairable, Glissonean approach guided by the PTBD make precision segmentectomy possible.
Although pancreatic stent insertion is recommended for the prevention of post-procedure pancreatitis during endoscopic papillectomy, insertion of the stent after the procedure can be technically difficult. The aim of the present study was to determine the feasibility and safety of inserting a newly developed insulated pancreatic stent before endoscopic papillectomy.We conducted a prospective pilot study involving 11 consecutive patients with adenomas of the major duodenal papilla. After a 5F polytetrafluoroethylene-insulated pancreatic stent was inserted through the tumor, the stent and tumor were simultaneously grasped with a snare. After resection of the tumor with the stent in place, the tumor was incised perpendicularly along the edge of the stent for retrieval of the specimen.In all patients, the insulated pancreatic stents were successfully inserted before endoscopic papillectomy and were resistant to electrical current; retrieval of the specimen was technically feasible and successful without stent migration. There were no stent-related complications, but five papillectomy-related complications (including mild bleeding [n = 4] and late papillary stenosis [n = 1]) occurred without any episodes of acute pancreatitis or perforation.Pre-resection stenting with a polytetrafluoroethylene-insulated stent in patients with adenomas of the major duodenal papilla is a feasible and useful technique to prevent pancreatitis.
Drain fluid amylase is commonly used as a predictor of pancreatic fistula after pancreaticoduodenectomy (PD). This study aimed to determine the ideal cut-off value of drain fluid amylase on postoperative day 1 (DFA1) for predicting pancreatic fistula after pancreaticogastrostomy (PG).Prospective data of 272 consecutive patients undergoing PG between 2010 and 2020 was collected and analysed to determine the postoperative pancreatic fistula (POPF) risk factors.The incidence of POPF was 143 cases (52.6%). The median DFA1 in patients with POPF was significantly higher than that of patients with NO-POPF (5483 versus 311, P < 0.001). DFA1 correlated with POPF in the area under the curve (AUC) of 0.84 (P < 0.001). When DFA1 was 2300 U/L, Youden index was the highest, with a sensitivity of 72.7% and a specificity of 82.9%. Logistic regression analysis showed that DFA1 ≥ 2300 U/L was an independent predictor of POPF (P < 0.001; OR: 12.855; 95% CI: 7.019-23.544). The AUC of DFA1 and clinically relevant postoperative pancreatic fistula (CR-POPF) was 0.674 (P < 0.001).DFA1 ≥ 2300 U/L can be used as an independent predictor of POPF after PG. DFA1 ≥ 3000 U/L can predict the occurrence of CR-POPF, when DFA1 ≥ 3000 U/L, the patients should be observed closely active for complications.
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