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Oral Presentation - PBS

Clin Endosc Vol. 45 Suppl 1, 2012 62nd Congress of the Korean Society of Gastrointestinal Endoscopy S121

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Changes in Causative Pathogens of Acute Cholangitis Proved after Biliary Drainage and Their Antimicrobial Susceptibility over a Period of 6 Years

Jeong Seok Kwon, Jimin Han, Jung Nam Cho, Kyung Ho Ha, Tae Won Kim, Dae Young Yun, Hyun Hee Kwon, Jin Tae Jung, Joong Goo Kwon, Eun Young Kim, Ho Gak Kim Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea

Background/Aims: We evaluated changes of bacteria from bile

and blood cultures and antimicrobial susceptibility over six

years at our institution.

Patients/Methods: From August 2006 to August 2012, medical

records of patients with acute cholangitis who received biliary

drainage were retrospectively reviewed. Acute cholangitis was

diagnosed when one or more of the followings were present: 1)

purulent bile in gross appearance 2) leukocytes in bile≥

50/HPF 3) positive growth in bile culture. Total of 1596 cases

were included. Cases were divided into community-acquired

cholangitis (n=199, 12.5%) and hospital-acquired cholangitis

(n=1,397, 87.5%). The cases were also divided according to

time period: Group A (August 2006 - December 2008, and

their antimicrobial susceptibility was evaluated in each group.

Results: Mean age of the patients was 68.0 ± 13.8 years. There

were 908 male patients (56.9%). Of 1596 cases of bile culture,

growth was detected in 1520 cases (95.2%). Gram-negative

bacteria were isolated in 1428 cases (94%). Most frequently

isolated Gram-negative bacteria were ESBL-producing

Escherichia coli (E. coli) (n=485, 34%), E. coli (n=211, 14.8%),

Citrobacter freundii (n=110, 7.7%), Klebsiella pneumoniae

(K. pneumoniae) (n=99, 6.9%), and ESBL-producing K.

pneumoniae (n=91, 6.4%). In hospital-acquired cholangitis

group, prevalence of ESBL-producing E. coli and Citrobacter

freundii was higher (52.1 vs. 31.5%, p=0.00; 13.7 vs. 6.8%,

p=0.001). In Group B, prevalence of E. coli has decreased sig-

nificantly (p=0.017). Antimicrobial agents with high suscepti-

bility were as follows: amikacin (85.2%), piper-

acillin-tazobactam (70.2%), cefotetan (77.5%), and imipenem

(95.8%). In Group B, susceptibility to piperacillin-tazobactam

has decreased significantly (59 vs. 71.9%, p=0.001).

Conclusions: Prevalence of ESBL-producing E. coli and K.

pneumoniae in cholangitis has increased over 6 years. In hospi-

tal-acquired cholangitis, prevalence of ESBL-producing E. coli

and Citrobacter freundii is higher. Susceptibility to piper-

acillin-tazobactam has decreased over recent years.

Key Words: Acute cholangitis, Bile culture, Antimicrobial sus-

ceptibility, Antimicrobial resistance, Biliary drainage

PBS-2

The Safety of Pre-Stenting Biliary Sphinterotomy in Malignant Biliary Obstruction

Soo Yong Lee, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan National University School of Medicine pusan National University Yangsan Hospital, Yangsan, Korea

Objectives: Pre-stenting biliary sphinterotomy is known to fa-

cilitate complex stenting procedure, but still controversial on

safety concerns. The aim of this study was to evaluate the safety

of endoscopic sphincterotomy (EST) before endoscopic biliary

drainage (EBD) Patients and Methods 203 patients were tried

to perform EST before EBD for malignant biliary obstruction

between November 2008 and August 2012 in a single ter-

tiary-care medical center. After exclusion of 33 patients(7

failed, 18 previous EST, 8 non-EST), 170 patients were eligible.

Acute procedure complications were defined as post-endo-

scopic retrograde cholangiopancreatography (ERCP) pan-

creatitis, bleeding, stent migration, sepsis and perforation ac-

cording to Cotton’s criteria.

Results: The etiologies of malignant biliary obstruction were

bile duct cancer (99/170, 58.2%), pancreatic cancer (43/170,

25.3%), ampullary cancer (10/170, 5.9%), metastatic cancer

(8/170, 4.7%), gallbladder cancer (7/170, 4.1%) and other type

cancer (HCC, lymphoma, 3/170, 1.8%). The methods of EBD

were self-expanding metal stent (SEMS)-uncovered (47/170,

27.6%) , SEMS-covered (4/170, 2.4%), single plastic stent

(63/170, 37.1%) , dual plastic stents (47/170, 27.6%) and naso-

biliary drainage (9/170, 5.3%). The acute complication devel-

oped in 4.7%(9/170) of patients, 2 were pancreatitis (1.2%), 3

were bleeding(1.8%), 2 were sepsis(1.2%) and 1 was stent mi-

gration(0.6%).

Conclusion: EST before EBD in malignant biliary obstructions

seems to be done safely. Keywords: retrograde cholangiopancreatog-

raphy, endoscopic biliary drainage, endoscopic sphincter-

otomy, pancreatobiliary malignancy

Key Words: ERCP, EBD, EST

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Systemic Chemotherapy May Prolong the Biliary Metal Stents Patency in Pancreatic Cancer with Distal Biliary Obstruction Joon Hyuk Choi, Do Hyun Park, Seung Uk Jeong, Byung Uk Lee, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim Department of Gastroenterology, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Objective: The placement of self-expandable metal stent


S122 62nd Congress of the Korean Society of Gastrointestinal Endoscopy Clin Endosc Vol. 45 Suppl 1, 2012

(SEMS) has been widely used for pancreatic cancer with distal

biliary obstruction. Although the recent improvement in che-

motherapeutic agents has prolonged survival in patients with

pancreatic cancer, little is known about the role of systemic

chemotherapy influencing SEMS patency in pancreatic cancer.

We had investigated the role of systemic chemotherapy as a

predictive factor for malfunction of SEMS in pancreatic cancer

with distal biliary obstruction.

Materials and Methods: Patients with pancreatic cancer who

received distal biliary stents between April 2008 and May 2012

were reviewed. Time to malfunction was defined as the period

between stent placement and malfunction or death if stent

malfunction was not observed until death. Follow-up data

were obtained until August 2012. Various prognostic factors

including systemic chemotherapy were analyzed. Only patients

receiving palliative or neoadjuvant chemotherapy after stent

placement were categorized as chemotherapy group. Stent

malfunction was defined as stent occlusion, migration, and

non-occlusion cholangitis.

Univariate Multivariate

OR [95%CI]

P value OR [95%CI]

P value

Sex (male) 0.99(0.70-1.39)

0.990

Age > 67 1.49(1.05-2.10)

0.022 1.35(0.93-1.97)

0.113

Tumor size > 34 mm 1.54(1.10-2.17)

0.012 1.72(1.19-2.47)

0.003

Stricture length > 20 mm

1.20(0.86-1.68)

0.280

Stent diameter (10 mm)

1.17(0.70-1.96)

0.537

Liver metastasis 2.12(1.50-3.00)

<0.001 2.39(1.67-3.41)

<0.001

Ascites 1.65(1.05-2.59)

0.029 1.50(0.95-2.39)

0.082

Duodenal invasion 0.78(0.53-1.14)

0.200

Covered stent 1.34(0.92-1.95)

0.118

Systemic chemotherapy

0.39(0.27-0.56)

<0.001 0.40(0.27-0.59)

<0.001

Total bilirubin > 5.6 mg/dl

0.95(0.68-1.34)

0.802

Cholangitis 1.62(0.98-2.68)

0.056

Table 1. Factors Associated with Stent Malfunction in Univariate and Multivariate Analysis

Results: A total of 200 patients with pancreatic cancer were

enrolled. The 137 patients of total 200 participants were com-

prised in the time to malfunction group. Food impaction in the

stent (11%, 15 of 137) and stent migration (11%, 15 of 137)

were most frequent causes of stent malfunction except death.

Tumor size more than 34mm, liver metastasis and non-chemo-

therapy after stent placement were independent risk factors in

multivariate analysis. And patients who received chemo-

therapy after stent placement (68 of 200) were less complicated

by stent malfunction (odds ratio 0.40; 95% CI, 0.27-0.59;

p<0.001). The median time to malfunction was 94 days in

non-chemotherapy group and 190 days in chemotherapy

group(p<0.001).

Conclusions: Systemic chemotherapy after stent placement

may prolong SEMS patency in pancreatic cancer with distal

biliary obstruction.

Key Words: Pancreatic cancer, Self expandable metal stents,

Chemotherapy, Obstrucive jaundice, Stent patency

PBS-4

Development of a Swine Benign Biliary Strictrure Model Using Endobiliary Radiofrequency Ablation

Seong Hyun Kim¹, Seok Jeong¹, Don Haeng Lee¹, Joon Mee Kim², Se Chul Lee³, Sung-Gwon Kang³ ¹Department of Internal Medicine,²Department of Pathology, Inha University School of Medicine, Incheon, ³Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea

Objective: To develop a porcine benign biliary stricture (BBS)

model using endobiliary radiofrequency ablation (RFA).

Animals and Methods: 14-month-old, female mini pigs (Sus

scrofa), each approximately 30 kg, were used. Endoscopic ret-

rograde cholangiography (ERC) was performed in 12 swine.

The animals were allocated to three groups (100 W, 80 W, and

60 W) according to the electrical power level. Endobiliary RFA

was applied to the distal common bile duct for 60 seconds us-

ing by RFA probe which could be endoscopically inserted. ERC

was repeated two and four weeks respectively after the RFA to

identify BBS. After the strictures were identified, the animals

were sacrificed and bile duct samples were achieved to evaluate

the pathologic finding.

Results: BBS were verified in all animals. Cholangitis were de-

tected on endoscopic findings of day 14 in all the animals of 3

groups, but not significant. Bile duct perforations occurred in

1 swine (n= 1, 100%) for 100 W group, and 1 swine (n=7, 14.3%)

for 80 W group. There was no major complication (n=4, 0%) in

60 W group. All benign strictures were proven pathologically.

The pathologic findings looked like BBS in human.

Conclusion: The application of endobiliary RFA resulted in a

safe and reproducible swine model of BBS.

Key Words: Radiofrequency Catheter Ablation, Benign Biliary

Stricture



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Bilateral Drainage, More Effective Approach for Klatskin Tumor

Jin Hyun Park, Dae Hwan Kang, Hyung Wook Kim,Cheol Woong Choi, Su Bum ParkDepartment of Internal Medicine, Pusan University School of Medicine, Busan, Korea

Background/Aim: Biliary drainage is one of the most im-

portant treatment in palliation with Klatskin tumor. There is

still uncertainty about optimal choice of either unilateral or bi-

lateral drainage with hilar biliary obstruction. The aim of this

study was to compare clinical outcomes of bilateral drainage

with unilateral drainage in hilar biliary obstruction.

Method: We retrospectively reviewed 72 patients with un-

resectable Klatskin tumor who underwent metal stent between

January 2009 to September 2012. All cases were beyond

Bismuth type II . 41 patients were drained bilaterally ,whereas

31 patients were performed unilateral stent.

Results: Bilateral drainage had superiority over unilateral

drainage in median survival time (256 ± 154 days vs 196 ± 80

days, p<0.05) and median stent patency time ( 230 ± 139 days

vs 165 ± 68 days , p<0.05). Cholangitis occurred more fre-

quently after unilateral drainage ( 6/31, 19% vs 1/41, 2.4% ).

Conclusion: Bilateral drainage seems to more effective method

for palliation in hilar biliary obstruction, although its technical

difficulty.

Key Words: Klatskin tumor, Stent, Bilateral, Unilateral

PBS-6

Cross Wired Metallic Stents for Triple Branched Stent in Stent Placement in High-Grade Malignant Hilar Biliar Stricture

Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea

Background and Aims: Endoscopic triple branched stent-in-

stent placement of metallic stents (MS) is technically demand-

ing procedure. However, triple placement with MS is needed

for the effective biliary drainage in selected patients with

high-grade malignant hilar biliary stricture (MHBS). Cross

wired metalic stent (CWMS, BONA-M Hilar, Standard

Sci.Tech) can facilitate contralateral second stenting and allow

multiple stenting with stent in stent fashion. The aim of this

study was to evaluate the efficacy and safety of endoscopic tri-

ple branched stent-in-stent placement of CWMS for the pa-

tients with high-grade MHBS.

Patients and Methods: A total of 18 patients with MHBS with

type IIIa or IV of Bismuth’s classification were enrolled. All pa-

tients had histologically proven inoperable biliary tract cancer.

Third CWMS was inserted on Rt. IHD using a stent-in-stent

deployment method after bilateral stent-in-stent placement in

11 patients as a primary drainage. Third stenting was per-

formed as a revisionary drainage after occlusion of bilateral

stent-in-stent placement in 7 patients.

Results: The technical and functional success rates of endo-

scopic triple branched stent-in-stent placement of MS was

88.9% (16/18), and 77.8% (14/18). Functional success rate was

81.8% in patients with primary drainage, and 71.4% in pa-

tients with a revisionary drainage. Significant complications

were not observed during procedures. Median stent patency

was 196 days. Cholecystitis was developed in two patients dur-

ing follow-up. Stent dysfunction occurred in 35.7% of patients

with functionally successful stent placement.

Conclusions: Endoscopic triple branched stent-in-stent place-

ment using of cross wired metallic stents was technically fea-

sible and safe in selected patients with high-grade malignant

hilar biliary strictures. Further study is needed to confirm the

clinical effectiveness.

Key Words: Klatskin tumor, Metallic stent, Hilar biliary stricture

PBS-7

Comparison of Outcomes between Internal Stent Placement and PTBD in Patients with Planned CRT for Perihilar Cholangioca

Seung Woo Yi1, Jae Hee Cho2, JeongYoup Park1, Jae bock Chung1, Seung Woo Park1, Seungmin Bang1, Si Yong Song1 1Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, 2Division of Gastroenterology, Department of Internal Medicine, Myongji Hospital, Goyang, Korea

Background: The optimal biliary decompression method in re-

sectable perihilar-cholangiocarcinoma has been authorized as

percutaneous transhepatic biliary drainage (PTBD). In case of

locally advanced perihilar-cholangiocarcinoma, malignant

biliary obstruction is judged to have palliation of jaundice by

placement of an internal stents or PTBD. We aimed to inves-

tigate the efficacy of internal placement of biliary stent com-

pared with PTBD for patients planned CRT in locally advanced

perihilar-cholangiocarcinoma.

Patients and Methods: The patients who are histologically pro-

ven locally advanced perihilar-cholangiocarcinoma between

Jan. 1995 and Dec. 2011 at single tertiary medical center in Korea,

retrospectively analyzed. The perihilar cholangiocarcinoma

was defined as disease occurring above the junction of the cyst-



ic duct up to the secondary branches of the hepatic duct.

Results Among one hundred seventy six locally advanced peri-

hilar-cholangiocarcinoma patients, CRT was performed in 79

patients; endoscopic biliary decompression was forty six pa-

tients (26.14%), and PTBD was thirty three patients (18.75%).

The mean period of internal stent indwelling is 152 days

whereas 222 days in PTBD group (p=0.675). The R0 operative

rate after the CRT was 23.9% in endoscopic stenting group,

and 12.1% in PTBD group (p=0.174). The median overall sur-

vivals were 463days at endoscopic stenting group and 439days

in PTBD group, respectively (p=0.874). Repeated biliary de-

compression procedure was performed at endoscopic decom-

pression group 26 patients (56.5%), 12 patients in PTBD

group (36.4%) (p = 0.077). In the subgroup analysis of endo-

scopic stenting group, there were 25 cases of SEMS, and 21 cas-

es of biliary drainage using the plastic stent. The stent dysfunc-

tion was found 20 patients (80.0%) in plastic stent whereas 6

patients (28.6%) in SEMS group (p=0.001). Median stent pa-

tency time was 111 days and 402 days in the plastic stent and

SEMS, respectively (p=0.002). Post-operative major complica-

tions were not seen in both cases.

Conclusions: The endoscopic placement of internal stent might

be useful method for biliary decompression in patients with

planed CRT for locally advanced perihilar-cholangiocarcinoma,

compared to PTBD. In case of biliary endoscopic drainage, the

pre-CRT SEMS had lower rate for repeated endoscopic proce-

dure than plastic stent in perihilar-cholangiocarcinoma.

Key Words: Self-expanding metal stents, Plastic sten, PTBD,

Chemoradiotherapy

PBS-8

Risk Factors for Cholecystitis after Bilateral Biliary Stent Placement in Patients with Klatskin tumor

Young Mi Hong, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan University School of Medicine, Busan, Korea

Background/Aims: Endoscopic bilateral metal stenting is a

rapidly evolving technique which allows the palliative treat-

ment of malignant hilar obstruction including Klatskin tumor.

But cholecystitis in patients with Klatskin tumor is bothersome

event to patients and physicians. Biliary stent may be associated

with cholecystitis for several reasons. The aim of this study to

evaluate the prevalence and risk factors of cholecystitis after bi-

lateral matal stent placement, especially in Klatskin tumor.

Patients/Methods: August 2005 to June 2012, 102 patients

treated with a metal stent for Klatskin tumor were enrolled.

The incidence and characteristics of patients with cholecystitis

were evaluated and compared with those of patients without

cholecystitis. We retrospectively reviewed following variables :

sex, age, Bismuth type, gallbladder filling by contrast medium

during endoscoic retrograde cholangiopancreatography (ERCP),

cholangitis before ERCP, cystic duct involvement of tumor mass

on computed tomography (CT), presence of gallbladder stones.

Results: There were 28(27.5%) patients diagnosed with chol-

ecystitis after bilateral metal stent insertion.In cholecystitis,

108.9 days were, on average, taken (ranging from 1 to 310 days)

since metal stent placement to the onset of cholecystitis. We

found that cystic duct involvement of tumor mass on CT was

associated with cholecystitis (p=0.015) and others were not re-

lated with development of cholecystitis.

Conclusions: This study suggested that cholecystitis after bi-

lateral metal stent insertion in klatskin tumor is associated with

cystic duct involvement of the tumor. To prevent or manage

cholecystitis, effective modalities should be sought.

Key Words: Klatskin tumor, Bilateral metal stent, Complication,

Cholecystitis

PBS PL-9

DGT vs Precut Papillotomy with Pancreatic Stent in Initial Pd Cannulation by Chance; Prospective Randomize Muti-Center

Eun Taek ParK¹, Sang-Woo Cha², Kyo-Sang Yoo³ ¹Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, ²Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University School of Medicine, Seoul, 3Department of Internal Medicine, Hanyang University School of Medicine, Kuri Hospital, Kuri, Korea

Background/Aim: Successful cannulation of the common bile

duct (CBD) is an important benchmark of ERCP. Repeated

cannulation for CBD is one of the main risk factors for

post-ERCP pancreatitis. Recently, pancreatic duct guidewire

assisting bile duct cannulation (double guidewire technique,

DGT group) or precut papillotomy with a incision over a pan-

creatic stent (PP-PS group) have been considered a promising

alternative approach in difficult cannulation situations. The

aim of this study was to compare the performance of DGT with

the PP-PS in the patients in whom pancreatic duct cannulation

was performed initially.

Patients/Methods: When guidewire was placed in the pancreatic

duct by chance, the patients were then randomized into DGT or

PP-PS groups. After this, bile duct cannulation was retried us-

ing DGT or PP-PS. Main outcome measurements were fre-

quency of successful CBD cannulation and post-procedure re-

lated complications.



Results: The groups were similar with regard to patient

demographics. A total of 70 patients were enrolled. 31 patients

were assigned to the DGT group and 39 to the PP-PS group.

Successful CBD cannulation was achieved in 22 (70.9%) of 31

patients in the DGT group and 37 (94.8%) of 39 patients in the

PP-PS group. The mean cannulation time was 18.4 minutes in

the DGT group and 11 minutes in the PP-PS group (p<0.005).

There was significant difference in the successful CBD cannu-

lation rate or mean cannulation time after p-duct cannulation

between two groups (p< 0.05). Post-procedure hyperamylasemia

was significantly higher in DGT group (p<0.001). The overall

incidence of post-procedure pancreatitis was 15.4% (6/31) in

the DGT group, and 6.6% (2/30) in the PP-PS group (p <0.005).

Conclusion: In patients with pancreatic duct cannulation ini-

tially by chance, compare to DGT group, PP-PS group facili-

tate biliary cannulation and the success rates. The incidence of

post-procedure hyperamylasemia and post-procedure pan-

creatitis were also higher in the DGT group.

Key Words: ERCP, Pancreatitis, Double Guidewire, Precut

Papillotomy, Pancreatic Stent

PBS PL-10

Photodynamic Therapy (PDT) with Ts-1 vs. PDT for Unresectable Cholangiocarcinoma: Preliminary Results of Randomized Trial

So-Eun Park¹, Do Hyun Park², Sang Soo Lee², Dong-Wan Seo², Sung Koo Lee² and Myung-Hwan Kim² ¹Division of Gastroenterology, Asan Medical Center, ²Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea

Backgroud/Aims: In patients with unresectable hilar chol-

angiocarcinoma (UHC), photodynamic therapy (PDT) with

biliary stent has been known for palliation of jaundice and im-

proving survival. Recently orally available chemotherapeutic

agent, TS-1 was reported as effective in patients with advanced

biliary tract cancer. The aims of this study was to evaluate the

combined effect of photodynamic therapy and TS-1.

Methods: In patients with histologically confirmed UHC, en-

doscopic or percutaneous stenting was performed. Patients

fulfilling inclusion criteria were randomized to group A

(biliary stenting and subsequent PDT with TS-1) and group B

(biliary stenting and subsequent PDT). For the refusal to par-

ticipation in this clinical trial, patients were enrolled to

open-label group (biliary stenting and PDT with systemic che-

motherapy except TS-1). The primary outcome parameter was

the overall survival. Secondary outcome parameter was the

progression-free survival.

Results: A total of 52 patients with UHC were screened during

study period (from April 2008 to August 2012). Four patients

refused PDT. Twelve patients refused the participation of this

clinical trial and enrolled open-label group. Finally, 36 patients

were randomized to PDT with TS1 (group A, n=17) or PDT

alone (group B, n=19). PDT with TS-1 group resulted in the

prolongation of overall survival compared with PDT alone

group (mean overall survival time, 17.4 months vs. 8.4

months, p=0.008 by Kaplan-Meier curve, Fig.-1). In open label

group, the overall survival was similar to that of PDT with TS-1

(15 months vs. 17.5 months). Group A had a tendency towards

longer progression-free survival compared with group B (8.3±

8.9 months vs. 5.3 ± 8.9 months, p=.054).

Conclusions: In this prospective randomized trial, PDT with

TS-1 improved overall survival in patients with UHC com-

pared with PDT alone. PDT with systemic chemotherapy may

be warranted for the palliative treatment of patients with UHC.

Key Words: Photodynamic therapy, Cholangiocarcinoma, Systemic

chemotherapy

PBS PL-11

Prospective Randomized Trial Comparing Covered Metal Stent Placed Above and Across the Sphincter of Oddi in Malignant Biliary Obstruction: A Multi-Nation, Multi-Center Study

Jung Nam Cho¹, Jimin Han¹, Ho Gak Kim¹, Im Hee Shin², Sang Heum Park³, Jong Ho Moon³, Jin Hong Kim⁴, Don Haeng Lee5, Iruru Maetani6, Hiroyuki Maguchi7, Keiji Hanada8, Ichiro Yasuda9, Hiroyuki Isayama10, Dong Ki Lee11 Department of ¹Internal Medicine, ²Medical Statistics, Catholic University of Daegu School of Medicine, Daegu, ³Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Choenan, 4Department of Gastroenterology, Ajou University School of Medicine, Suwon, 5Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea, 6Department of Gastroenterology, Toho University Medical Center Ohashi Hospital, Tokyo, 7Department of Gastroenterology, Teine-Keijinkai Hospital, Sapporo, 8Department of Gastroendoscopy, Onomichi General Hospital, Onomichi, 9Department of Internal Medicine, Gifu University, Gifu, 10Department of Gastroenterology, The University of Tokyo, Tokyo, Japan,11Department of Internal Medicine, Yonsei University College of Medicine Kangnam Severance Hospital, Seoul, Korea



Aims: To compare stent patency and overall survival of patients

with malignant biliary obstruction inserted covered self-ex-

pandable metallic stent (C-SEMS) between placement above

the sphincter of Oddi (SOD) without sphincterotomy (Group

A) and across the SOD after sphinterotomy (Group B).

Patients and Methods: From February 2010 to September

2012, this study was conducted in 6 centers from Korea and 5

centers from Japan. Total of 83 patients with unresectable ma-

lignant biliary obstruction were randomized into either Group

A or B. Biliary obstruction was defined as bile duct obstruction

located at least 2.0 cm distal from hilar bifurcation and 0.5 cm

proximal to the ampulla.

Results: There were 1 case of common hepatic bile duct cancer,

27 common bile duct cancer, 11 gallbladder cancer, 41 pancre-

atic cancer and 4 of extrinsic compression from metastatic

lymph node. There were 40 patients in Group A and 43 in

Group B. Technical success was 100% in both groups and func-

tional failure occurred in 1 and 2 cases in Group A and B.

Median follow-up period was 177.0 and 178.5 days. Mean stent

patent period were 140.1 and 132.9 days (p=0.835), and mean

period of overall survival was 212.4 and 218.8 days (p=0.873)

in Group A and B. Stent occlusion was recognized in

15(39.5%) and 14(37.8%) in group A and B. During fol-

low-up, occlusion-free survival rates per year were 40.2% and

22.2% in Group A and B. Cholangitis without stent occlusion

occurred 1 and 2 cases in Group A and B. There were no sig-

nificant differences in complications after procedure in both

groups. Distal migration occurred in three cases in only Group B.

Conclusion: Theoretically, placement of C-SEMS above the

SOD may reduce duodenobiliary reflux and result in longer

stent patency, and reduced rate of cholangitis without

occlusions. However, in this study, there was no significant dif-

ference in stent patency and cholangitis between C-SEMS

placement above and across the SOD.

Key Words: Malignant biliary obstruction, Metal stent, Stent

patency, Survival

PBS PL-12

Optimal Duration of Placement of a Fully Covered Self-Expandable Metal Stent for Common Bile Duct: A Canine Study

Tae Jun Song¹, Sang Soo Lee², Do Hyun Park², Dong Wan Seo², Sung Koo Lee², Myung-Hwan Kim² ¹Department of Internal Medicine, Inje University Ilsan Paik hospital, Koyang, ²Department of Internal Medicine, University of Ulsan College of medicine, Asan Medical Center, Seoul, Korea

Background and Aim: Recently, endoscopic placement of a

fully covered self-expandable metal stent (FCSEMS) has been

used for the treatment not only of malignant biliary ob-

struction but also benign biliary stricture. However, since there

are few studies on the histopathological changes of a bile duct

due to FCSEMS placed inside a bile duct over the long term, it

is difficult to determine the optimal stenting duration of how

long stents should be placed inside a bile duct. The purpose of

this study is to identify the histopathological changes of a bile

duct resulting from long-term placement of an FCSEMS.

Methods: In May of 2010, FCSEMSs were inserted into the

common bile ducts of 12 canines. Post euthanasia, necropsy

was performed to examine histopathological changes of the

bile ducts after one month (n = 3), three months (n = 3), six

months (n = 3), and nine months (n = 3) respectively. A single

blinded pathologist examined histopathological changes of the

normal bile duct in which a stent was not inserted, and the

proximal portion, the middle portion, and the distal portion of

the stented bile duct.

Results: FCSEMSs could be successfully inserted in all animals.

The results of liver function tests, which were performed before

necropsy, were within the normal range in all animals. The re-

sults of necropsy showed that the covered membranes of

FCSEMSs were intact and FCSEMSs were easily removed from

the bile ducts in all animals except one. Severe epithelial hyper-

plasia of the stented bile duct occurred in one animal in which

an FCSEMS was placed for three months, and as a result, a dis-

ruption of the covered membrane and epithelial ingrowth into

the stent were observed. In this animal, the removal of the

FCSEMS was very difficult, and the most severe inflammatory

change of the stented bile duct was found on histopathological

examination. On histopathological examinations, when com-

pared with the non-stented bile ducts, mild inflammatory

changes were observed in the stented bile ducts, and there was

no significant difference between the animals inserting an

FCSEMS for one month, three months, six months, and nine

months. Among the 12 animals, de novo stricture was found in

5 animals.

Conclusion: It was found that an FCSEMS might be inserted

into the bile duct without severe histopathological changes of

the stented bile duct until 9 months after the insertion.

Key Words: Stents, Common Bile Duct, Cholangiopancreato-

graphy Endoscopic Retrograde, Dogs



PBS PL-13

The Role of EUS-FNA after Negative Transpapillary Forceps Biopsy in Patients with Malignant Biliary Strictures

Dong Choon Kim¹, Jong Ho Moon¹, Hyun Jong Choi¹, Hee Kyung Kim², Yoon La Young¹, Tae Hoon Lee¹, Sang Woo Cha¹, Young Deok Cho¹, Sang Heum Park¹, Sun Joo Kim¹ Digestive Disease Center, ¹Department of Internal Medicine, ²Department of Pathology Soon Chun Hyang University College of Medicine, Korea

Background/Aim: Transpapillary forceps biopsy (TFB) on

ERCP is a usual tissue sampling technique for the histopatho-

logical diagnosis of malignant biliary strictures (MBS).

However, the detection rate of this method has been

unsatisfactory. The aim of this study was to retrospectively

evaluate the diagnostic yield of endoscopic ultrasound-guided

fine-needle aspiration (EUS-FNA) in patients with MBS who

had negative results of TFB.

Methods: 75 consecutive patients with MBS underwent endo-

scopic TFB during ERCP. EUS-FNA was performed in patients

with negative results for histopathological reports. The gold

standard of malignancy was histopathologic results by tissue

sampling or operation. We investigated the EUS-FNA results,

level of stricture lesions and influence of the EUS-FNA results

on treatment modalities.

Results: In 75 patients, 42 patients had distal bile duct (BD)

strictures and the others were proximal BD strictures.

Malignancy was confirmed on endoscopic TFB in 59 of 75 pa-

tients (78.6%). 56 patients were adenocarcinoma, and 3 pa-

tients were neuroendocrine carcinoma. EUS-FNA was per-

formed in 16 patients with negative results by endoscopic TFB.

Of 16 patients, 11 patients had distal BD strictures and 5 pa-

tients had proximal BD strictures. FNA specimens were suc-

cessfully obtained in all patients, and the histopathological re-

sults confirmed malignancy in 15 cases (14 cases: adenocarcinoma,

1 case: neuroendocrine carcinoma) and the other 1 case was

negative for malignancy. Of 15 patients, 8 patients were treated

by chemotherapy, 4 patients were supportive care, 2 patients

were operation, and 1 patient was photodynamic therapy. In

case with negative result by EUS-FNA, was confirmed malig-

nancy (adenocarcinoma) as a result of surgery.

Conclusions: In patients with MBS who had negative results by

endoscopic TFB, EUS-FNA is useful for the histopathologic

confirmation.

Key Words: EUS-FNA, Malignant Biliary Strictures, Transpapillary

forceps biopsy

PBS PL-14

Differential Diagnosis of Pancreatic Cysts Using Proteomics

Hwan sic Yun¹, Woo Ik Change¹, Kwang Hyuck Lee¹, Kyu Taek Lee¹, Soo Youn Lee², Poong-Lyul Rhee¹, Jong Kyun Lee¹ ¹Department of Internal Medicine, Sungkyunkwan University School of Medicine, ²Department of Laboratory Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea

Objectives: Pancreatic cysts display a wide spectrum of

histology. However, differential diagnosis of pancreatic cysts is

still challenging. This study was aimed to evaluate and validate

cyst fluid CEA and proteomics markers in differentiating 1)

pancreatic pseudocyst, 2) benign non-mucinous pancreatic

cyst, 3) benign or malignant mucinous pancreatic cyst.

Methods: From February 2008 to March 2012, we collected 57

patients who had pancreatic cysts. We analyzed endoscopic ul-

trasound (EUS) findings, cystic fluid tumor markers (CEA, CA

19-9) and proteomics markers that could help differentiating

non-mucinous cysts and mucinous cysts.

Results: Fifty seven patients (17 pseudocysts, 22 benign

non-mucinous cysts, 18 benign or malignant mucinous cysts)

were enrolled. Mean age was 52.1 (20-76). All of them under-

went endoscopic ultrasound (EUS) and nineteen (33.3%) pa-

tients got surgery. One patient (1.8%) had complication of

pancreatitis after EUS guided fine needle aspiration

(EUS-FNA). Both CEA and CA 19-9 showed statistical sig-

nificance in differentiating non-mucinous cysts and mucinous

cysts (p<0.001, p=0.009). Diagnostic sensitivity and specificity

of CEA in differentiating mucinous cysts was 100% and 87% in

6.3 ng/ml cut-off value. And CA19-9 showed 72.2% sensitivity

and 69.2% specificity in 954.1 ng/ml cut-off value. Among

proteomics markers, twenty four markers showed statistical

significance in differentiating between non-mucinous cysts

and mucinous cysts. Assuming the cut-off value of CEA that

differentiates non-mucinous and mucinous was 192 ng/ml, as

previous reports, the diagnostic accuracy became very low

(50% sensitivity, 100% specificity). However joining with pro-

teomics marker polymeric immunoglobulin receptor A1, the

sensitivity and specificity became 94.4% and 86.4% in

respectively. Also joining with proteomics marker polymeric

immunoglobulin receptor A3, the sensitivity and specificity

were 88.9% and 83.4%.

Conclusions: In this study, cystic CEA showed very high sensi-

tivity and specificity in differentiating non-mucinous and mu-

cinous cysts. However cut-off value was 6.3 ng/ml, in which

was very low compared to the previous reports. Assuming the

cut-off value as 192 ng/ml as previous study, proteomics mark-



ers could be very helpful for differentiating between non-muci-

nous and mucinous cysts.

Key Words: Pancreatic Cyst, Mucinous Cyst, Proteomics

PBS-15

EPLBD for the Removal of Common Bile Duct Stones Does Not Increase the Risk of Post-ERCP Pancreatitis

Yoon Jeong Nam, Tae Nyeun Kim, Jun Suk Park, Min Geun Gu, Jae Young Lee, Kook Hyun Kim, Kyung Ok Kim, Si Hyung Lee, Byung Ik Jang Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

Background and Aims: Endoscopic sphicterectomy (ES) and

endoscopic papillary large balloon dilation (EPLBD) are fre-

quently used procedures for the treatment of common duct

stones. EPLBD is known to increase the risk of post-ERCP pan-

creatitis in some studies. The aims of this study were to evaluate

whether EPLBD increases the risk of post-ERCP pancreatitis

and to find the risk factors influencing post-ERCP pancreatitis.

Methods: A total of 434 patients who underwent ERCP for the

treatment of common duct stones larger than 1cm in diameter

from January 2006 to December 2011 were reviewed retrospectively.

Patients were divided into 4 groups; ES group (n=190), EPLBD

combined with limited ES group (n=129), EPLBD without ES

group (n=85), and EPLBD with previous history of ES group

(n=30). Post-ERCP pancreatitis was defined as the develop-

ment of abdominal pain with more than 3 times elevation of

serum amylase or lipase.

Results: Of the total 434 patients, post-ERCP pancreatitis was

developed in 12 patients (2.8%). Endoscopic biliary stenting

was an independent risk factor of pancreatitis by univariate

(p=0.004) and multivariate analysis (p=0.004, OR 5.713, 95%

Cl, 1.770~18.469). Age, sex, BMI, history of cholecystectomy,

stone size, mechanical lithotripsy, CBD and P-duct diameter,

balloon size and duration of balloon dilation were not sig-

nificantly related with post-ERCP pancreatitis. Incidence of

post-ERCP pancreatitis was 1.6%, 3.1%, 5.9%, 0% in ES

group, EPLBD combined with limited ES group, EPLBD with-

out ES group, EPLBD with previous history of ES group,

respectively. There was no significant difference in the in-

cidence of post-ERCP pancreatitis among 4 groups (p=0.218).

Conclusion: Endoscopic papillary large balloon dilation does

not increase the risk of post-ERCP pancreatitis compared to

endoscopic sphicterectomy. Endoscopic biliary stenting seems

to be an independent risk factor of post-ERCP pancreatitis.

Key Words: EPLBD, ERCP, Pancreatitis

PBS-16

Percutaneous Papillary Large Balloon Dilation For Treatment of Large Bile-Duct Stones: A Feasibility Study

Jee Young Han, Seok Jeong, Don Haeng Lee, Byoung Wook Bang, Jung Il Lee, Jin-Woo Lee, Kye Sook Kwon, Hyung Gil Kim, Yong Woon Shin, Young Soo Kim Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea

Background: When the access to major duodenal papilla or en-

doscopic retrograde cholangiopancreatography (ERCP) is

failed, percutaneous transhepatic cholangioscopic lithotripsy

(PTCS-L) may be useful to remove common bile duct (CBD)

stones. However, the feasibility and usefulness of percutaneous

transhepatic papillary large-balloon dilation (PPLBD) performed

during PTCS-L for the removal of large CBD stones, is not estab-

lished yet. The aim of this study was to investigate the safety and

efficacy of PPLBD for the treatment of large CBD stones.

Methods: Eleven patients with large CBD stones in whom the

access to major papilla or ERCP had failed in a tertiary referral

center between September 2011 and August 2012 were enrolled

prospectively. Papillary dilation using large-bored (12-20 mm)

balloon dilation catheter was performed through the percuta-

neous transhepatic route. We analyzed the efficacy of the stone

retrieval and post-procedure complications after the procedure.

Results: The success rate for the complete duct clearance was

100%. There was no patient who needs use of basket to remove

the stone after PPLBD. Electrohydraulic lithotripsy was re-

quired in 2 (18.2%) patients. The median time to complete

stone removal after PPLBD was 17.8 minutes. There was no

complications occurred after PPLBD. Asymptomatic hyper-

amylasemia did not occur in all patients.

Conclusion: The current data suggested that PPLBD is safe and

effective for removal of large CBD stones.

Key Words: Balloon Dilation, Choledocholithiasis

PBS-17

Endoscopic Papillary Balloon Dilation and Endoscopic Sphincterotomy for Removal of Bile Duct Stones in Young Patients

Yu Ri Seo, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea

Objectives: Endoscopic biliary sphincterotomy (EBS) is the

standard treatment for bile duct (BD) stones. However, EBS



can cause permanent loss of sphincter function that long-term

complications are still unknown. Younger patients having lon-

ger life expectancy are risky for developing late complications.

Endoscopic papillary balloon dilation (EPBD) is an alternative

procedure preserving the sphincter function, although it is

generally known has a higher risk of pancreatitis than EBS. We

conducted a prospective study to compare safety and outcomes

of EPBD with EBS for removal of BD stones in patients young-

er than 40 years of age.

Methods: Total 132 patients were enrolled in this study, 62 pa-

tients who underwent EPBD (EPBD group, mean age: 31.1

years) and 70 patients who underwent EBS (EBS group, mean

age: 35.2 years) for extraction of BD. Inclusion criteria was 1)

Age < 41 at first ERCP performed 2) CBD stones were con-

firmed by ERCP 3) stone maximum diameter <13 mm.

Resuts: 1) EPBD and EBS were successfully performed in all

patients. 2) Complete endoscopic clearance of the bile duct was

achieved in all patients. 3) Complete stone removal at a single

endoscopic session was achieved in 59 (95.2%) EPBD group

and in 61 (87.1%) EBS group. 4) Mechanical lithotripsy was

needed to fragment stones in 5 (8.1%) EPBD group and in 9

(12.9%) EBS group. 5) Early complication rate was 9.7% (6

pancreatitis ; mid 5, moderate 1) in EPBD group and 11.4% (6

pancreatitis ; mid 5, moderate 1, 1 bleeding, 1 perforation) in

EBS group. 6) Late complication rate was 1.6% (1 recurred

stone with cholangitis) in EPBD group and 5.7% (4 recurred

stone with 3 cholangitis) in EBS group.

Conclusions: Endoscopic papillary balloon dilation is a safe

and effective procedure for the removal of BD stones in young

patients expecting longer survival.

Key Words: EPBD, Endoscopic biliary sphincterotomy

PBS-18

Long-Term Results after Treatment of Hepatolithiasis and Predictive Factors for Cholangiocarcinoma

Kwang Duck Ryu¹, Dong Uk Kim¹, Seong Oh Park¹, Hye Kyung Jeon¹, Gwang Ha Kim¹, Jeong Heo¹, Geun Am Song¹ Departemtn of Internal Medicine, Pusan National University School of Medicine, Busan, Korea

Aims: Hepatolithiasis is one of risk factors of cholangiocarcinoma

and is usually treated with operative and non-operative proce-

dure (Percutaneous transhepatic cholangioscopic lithotomy,

PTCSL). We examined the long-term results of patients with

hepatolithiasis treated by operation or PTCSL and predictive

factors for cholangiocarcinoma associated hepatolithiasis.

Methods: We performed a retrospective study of medical re-

cords of patients with hepatolithiasis in Pusan national uni-

versity hospital from April 1988 to July 2012. Of 363 patients

with hepatolithiasis, 78 underwent operative procedure, 113

underwent PTCSL, and 172 underwent medical treatment or

observation. The median follow-up period was 22.2months

(range,1-257months).

Results: Female (62.3%) was dominant in patients with

hepatolithiasis. We observed cholangiocarcinoma in 8.3%

(30/363), secondary biliary cirrhosis in 8.8% (32/363), stric-

ture in 16.5% (60/363) and secondary sclerosing cholangitis in

0.5% (2/363) as the complications associated hepatolithiasis.

Complete stone clearance was achieved in 84.6% (66/78) of

operation and in 70.8% (80/113) of PTCSL. During follow-up

period after treatment, recurrent rate of stones was 16.4%;

18.6% (12/66) of operation and 15.0% (12/80) of PTCSL and

late development rate of cholangiocarcinoma was 3.1%; 1.2%

(1/78) of operation and 4.4% (5/113) of PTCSL. In multivate

analysis, liver atrophy is only significantly associated with chol-

angiocarcinoma (p=0.006; Odds ratio, 2.01; 95% CI, 1.797-

31.022).

Conclusion: Operation had a superior trend than PTCSL in

complete stone clearance and recurrence rate of hepatolithiasis

was similar in both operation and PTCSL. Liver atrophy with

hepatolithiasis might be a predictive factor of development of

cholangiocarcinoma.

Key Words: Hepatolithiasis, Cholangiocarcinoma, Operation,

PTCSL

PBS-19

Therapeutic Saline Irrigation of the Bile Duct after the Endoscopic Removal of Common Bile Duct Stones

Sang Eon Jang¹, Sang Hyub Lee², Ban Seok Lee³, Dong-Won Ahn⁴, Jin-Hyeok Hwang² ¹Department of Internal Medicine, Cheongju St. Mary’s Hospital, Cheongju, ²Department of Internal Medicine, Seoul National University Bundang Hospital, Sungnam, ³Ddepartment of Internal Medicine, Cheju Halla Hospital, Cheju, 4Department of Internal Medicine, Boramae Medical Center, Seoul, Korea

Background: Small stone fragments after an endoscopic stone

extraction for choledocholithiasis may act as the nidus for re-

current choledocholithiasis. Therefore, efforts to eliminate the

nidus might reduce the recurrence of choledocholithiasis and

cholangitis related to choledocholithiasis.

Aim: To determine whether an additional therapeutic saline ir-

rigation of the bile duct (TSIB) after the endoscopic removal of

common bile duct (CBD) stones would decrease residual CBD

stones and the recurrence of cholangitis.

Methods: A retrospective analysis was performed for the con-



secutively collected data about the patients who underwent the

complete endoscopic treatment for CBD stone.

Results: Among 99 patients, 45 patients underwent TSIB.

Residual CBD stones were detected in 18 patients (18.2%). The

incidences of residual CBD stones were 8.9% (4 or 45 patients)

in the irrigation group and 25.9% (14 of 54 patients) in the

non-irrigation group (p=0.037). In multivariate analysis, TSIB

was found to be the only significant factors for the decrease of

residual CBD stones (HR=0.258, p=0.039). When analyzing

the occurrence of recurrent cholangitis and the procedure re-

lated to complications, there were no significant differences ac-

cording to the performance of TSIB.

Conclusion: TSIB could reduce the residual CBD stones with-

out complications.

Key Words: Therapeutic Irrigation, Common Bile Duct Stone,

Cholangitis

PBS-20

The Role of IDUS for the Management of Acute Biliary Pancreatitis with No Evidence of Choledocholithiasis on ERCP

La Young Yoon, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea

Background and Aim: ERCP has been considered the standard

for the evaluation and management of acute biliary pan-

creatitis (ABP). Identifying a bile duct (BD) stone in patients

with ABP is important for the management and prevention of

recurrent attack of pancreatitis. But, small BD stones may not

be detected on ERCP. The aim of this study was to pro-

spectively evaluate the usefulness of intraductal US (IDUS) in

patients with suspicious ABP having no evidence of chol-

edocholithiasis on ERCP.

Patients and Methods: A total 92 patients suspected with ABP

without evidence of BD stones on imaging studies including

ERCP were enrolled. Wire guided IDUS was performed during

ERCP in all patients. Stones or sludge detected by IDUS were

confirmed after endoscopic sphincterotomy (EST) and

extraction.

Results: IDUS successfully performed in all patients. Among

the 92 patients, IDUS revealed BD stones in 33 (35.8%) and

biliary sludge in 26 (28.2%) patients. The results of IDUS were

consistent with those of EST and stone extraction. During the

mean follow-up of 24 months, recurrent pancreatitis did not

occur in 54 (91.5%) of 59 patients with BD stone or biliary

sludge on IDUS after endoscopic therapy.

Conclusion: IDUS improves diagnostic accuracy for the de-

tection of occult BD stones in patients suspicious ABP. IDUS

guided endoscopic treatment can help prevent recurrent

pancreatitis.

Key Words: Choledocholithiasis, Acute biliary pancreatitis,

Intraductal US

PBS-21

Safety and Efficacy of Extracorporeal Shockwave Lithotripsy with Endotherapy for the Treatment of Pancreatic Duct Stones

Byung Uk Lee, Myung-Hwan Kim, Seung Uk Jung, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Aim: A retrospective analysis was performed to evaluate the

safety and efficacy of extracorporeal shock wave lithotripsy

(ESWL) as a treatment of pancreatic stones.

Method: Between March 2008 and July 2012, 77 patients with

pancreatic stone presenting with pain and large pancreatic

duct stone not amenable to extraction with an endoscopic ret-

rograde cholangio pancreatography (ERCP) were selected for

ESWL. The ESWL was performed with an electroconductive

lithotripter (Sonolith VISION, EDAP-TMS) equipped with

both fluoroscopic and ultrasound target system. Analgesia

(pethidine) was administrated intravenously to control the

pain during ESWL. Fragmented calculi were cleared by fol-

lowed endotherapy. The success rates, complications and pre-,

during- and post-ESWL pain scale (visual analogue scale, VAS)

were evaluated.

Result: A mean pancreatic stone size was 14.2mm and a mean

of 4.6 ESWL (range: 1~10) session was performed for each pa-

tient with mean of 3,025 shocks (range: 2,500~4,750) at a pow-

er setting of 12.8 kV (range: 11.8~13.5) were employed.

Fragmentation of the stones were achieved in 74/77 (96.1%)

patients, and overall clearance of the stones were 72/77

(93.5%) patients. Complete clearance of the main pancreatic

duct was achieved in 52 patients (67.5%) and partial clearance

in 20 patients (25.9%). Three patients (3.9%) developed acute

pancreatitis. Complete relief of pain without pancreatic stent-

ing achieved in 63/74 (85.1%) patients. The mean pre-, dur-

ing- and post- ESWL VAS score was 5.75, 2.03, 0.45 (p<0.01).

Three patients were undergoing pancreatic surgery due to per-

sistent pain with remnant stone. A mean dose of pethidine

used during ESWL was 56.2mg (range: 25~100) per session.

Conclusion: Without general or epidural anesthesia, large pan-



creatic stone can be managed safely and effectively by the com-

bination of ESWL and endotherapy.

Key Words: Pancreatic Stone, ESWL(extracorporeal Shockwave

Lithotripsy)

PBS-22

Comparison Outcomes for Unresectable Hilar Cholangiocarcinoma Treated with Definitive Photodynamic Therapy (PDT) Combined with Gemcitabine-Based Chemotherapy

Eun Taek Park, Sang Uk Lee, Byung Hoon Han, Byung Cheol Yun Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, Korea

Background/ Aims: Hilar cholangiocarcinoma (CC) has an ex-

tremely poor prognosis with less than 5% of patients surviving

5 years. Preliminary clinical studies have suggested that PDT

maybe beneficial for palliation of hilar CC. PDT for hilar CC

revealed that the tumoricidal depth of PDT using porfimer so-

dium (Photofrin®; Axan Pharma Inc., Canada) is limited to 4-

to 4.5-mm of tissue penetration, which cannot eradicate a pri-

mary tumor when invasion extends to a depth of over 6mm.

The aim of this study to assess the efficacy that the percutanous

transhepatic cholangioscopy (PTCS) guided compelling dila-

tation of malignant stricture before PDT for improving the

depth of tissue penetration (definitive PDT) and then retro-

spectively analyzed the outcome of possible treatment modal-

ity with definitive photodynamic therapy (PDT) combined

with gemcitabine-based chemotherapy and conservative treat-

ment in hilar CC.

Material And Methods: Forty-seven patients with unresectable

hilar CC were included in this study. 24 patients underwent

conservative treatment alone (Group A) including drainage

procedure, 23 patients treated with definitive PTD with che-

motherapy including drainage procedure (Group B) were ana-

lyzed retrospectively. Before PDT, group B patients were per-

formed PTCS guided compelling dilatation with balloon cath-

eter or bouginator on malignant stricture site and immediate

insertion of 18Fr plastic catheter. PDT was performed after 7

days. And then drainage procedure (including uncovered met-

al stent) performed after 1 session of PDT and gemcita-

bine-based chemotherapy was done for 6 cycles.

Results: The Group A and B were comparable due to age, gen-

der, performance status, pretreatment bilirubin level and hilar

CC stage. Overall survival rate of Group A and B were 63% and

94% at 1 year, respectively (p<0.001). The mean survival peri-

od of patients with of Group A and B was 8.2 months and 16.3

months, respectively (p<0.001). The metal stent patency of

Group A and B was 167 days and 283 days, respectively

(p=0.003). Definitive PDT related complications were ob-

served in 2 patients related to balloon dilatation including 1 he-

mobilia and 1 bile duct leakage. But no patient developed acute

serious complication.

Conclusion: Compelling dilatation of malignant stricture site

before PDT (definitive PDT) with chemotherapy is sig-

nificantly improved the survival rate and metal stent patency

due to tissue penetrating and increased tumoricidal depth in

hilar CC. The side effects secondary to compelling dilatation

with PDT are very rare and clinically insignificant in this study.

We concluded that this procedure seemed to be more effective

and safe than conservative treatment alone in unresectable hi-

lat CC.

Key Words: Photodynamic Therapy, Unresectable Klatskin

Tumor, Gemcitabine

PBS-23

Longterm Outcome of PDT with Chemotherapy Compared with PDT Alone and ERND Only in Patients with Cholangiocarcinoma Mi Jin Hong, Young Koog Cheon, Cho I Lee, Eung Jun Lee, Tae Yoon Lee, Chan Sup ShimDepartment of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea

Aims: Cholangiocarcinoma (CC) is the primary cancer of bile

duct. Patients usually present at an advanced stage, with more

than 50% of cases being unresectable at the time of diagnosis.

As a result, a large proportion of patients are beyond the scope

of curative treatment upon diagnosis. Recently photodynamic

therapy (PDT) has been evaluated as a palliative and neo-

adjuvant modality. However, it is not known that combination

with photodynamic therapy and chemotherapy is promising

activity, most notably gemcitabine-based combinations.

Materials and Methods: A total of 232 atients with hilar chol-

angiocarcinoma diagnosed between Feburuary 1999 and

September 2009 were evaluated. 16 were treated with PDT and

gemcitabine or/and another (Group A), 58 were treated with

PDT only (Group B) and 71 patients were treated with endo-

scopic biliary drainage alone (Group C). These data were col-

lected prospectively and analysed retrospectively.

Results: Median survival was 538 days (95% CI, 475.3-600.7)

in group A, 334 days (95% CI, 252.5-415.5) in group B, and

220 days (95% CI, 143.7-296,3) (p = 0.001). There was no stat-

istically significant difference between group A and B. Whether

of lymph node metastasis (p=0.037), serum bilirubin level of-

pretreatment (p=0.040), TNM stage (p=0.048), treatment

methods (PDT with chemotherapy, PDT alone, vs. ERBD



alone, p=0.031), and time to treatment of PDT (p=0.033)

wereprognostic factors with statistical significance in the uni-

variate analysis. However, there were no significant variables in

the multivariate analysis.

Conclusions: PDT with chemotherapy and PDT alone resulted

in longer survival compared with stenting alone. PDT with

chemotherapy showed tendency to be longer survival than

those of PDT alone,however, it did not showstatistically

significance.

Key Words: Advanced cholangiocarcinoma, Photodynamic

therapy, Systemic chemotherapy, ERBD

PBS-24

Evaluation of Different Strategies Using Infundibulotomy and Transpancreatic Septotomy in Difficult Biliary Cannulation

Yun Gyoung Park, Kwang Hyuck Lee, Kyu Taek Lee, Jong Kyun Lee Divsion of Gastroenterology, Department of Internal Medicine, Sungkyunkwan Universtiy of Medicine,samsung Medical Center, Seoul, Korea

Backgrounds: Selective biliary cannulation is the most im-

portant step for successful therapeutic biliary endoscopy, but

still in 5~10% of cases, selective cannulation fails. Several pre-

cut techniques have been used to gain biliary access for those

difficult cases. Additionally, it has been proposed that early in-

stitution of precut techniques could be safe. However, different

approach should be considered in each patient, especially ac-

cording to the presence or absence of unintended repeated

pancreatic cannulation.

Aim: The aim of this study was to evaluate the success and

complication rate of two precut techniques, needle knife in-

fundibultomy (NKI) and transpancreatic septotomy (TPS) for

difficult biliary cannulation. Patients and

Methods: We performed a prospective study of the different

strategies for two groups divided by the presence of unin-

tended pancreatic cannulation from January 2009 and August

2012 at Samsung medical center. The patients who need biliary

intervention because of such as stone, malignancy, or benign

stricture were enrolled. If there were more than five unin-

tended pancreatic cannulations, TPS was performed. And if

deep cannulation was not achieved within 5 minutes for any

duct, NKI was performed. If fail, we crossed over to the other

technique in second attempt.

Results: A total of 61 patients (NKI = 16, TPS = 45) were

included. The baseline characteristics such as age, sex, and clin-

ical presentation were similar in two groups. The total success

rate of biliary cannulation was 88.5%. The success rate was

93.8% for NKI and 86.7% for TPS group. After crossing over

the techniques, the final success rate was 96.7%. The complica-

tion rate was 6.3% in patients with NKI was 11.1% in patients

with TPS: 0% versus 4.4%, for acute pancreatitis, 6.3% versus

2.2%, for bleeding, 0% versus 0%, for perforation, 0% versus

4.4% for cholangitis, respectively. But there was no severe pan-

creatitis and no fatal cases. There was no significant difference

in two groups.

Conclusions: Our result suggests that the application of differ-

ent strategies based on the presence of unintended pancreatic

cannulation may assist to increase the success rate for difficult

biliary cannulation without increasing complication rates.

Key Words: ERCP, Difficult biliary cannulation, Needle knife

infundibulotomy, Transpancreatic septotomy

PBS-25

Fistulotomy Using a Cap-Assisted Forward-View Endoscope in Difficult Biliary Cannulation

Dae-Seong Myung, Chang-Hwan Park, Chung-Hwan Jun, Ho-Seok Ki, Seon-Young Park, Sung-Bum Cho, Young-Eun Joo, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.

Background: Even in experienced hands, a common problem

at endoscopic retrograde cholangiopancreatography is diffi-

culty in selective cannulation. Selective cannulation is more

difficult in patients with surgically altered gastrointestinal

anatomy or peri-ampullary diverticulum. We report our expe-

rience about fistulotomy using a cap-assisted forward-view en-

doscope in difficult biliary cannulation.

Patient and Method: Patients who underwent fistulotomy us-

ing a cap-assisted forward-view endoscope in difficult biliary

cannulation were eligible for this study. From september 2007

to september 2012, 23 patients were recruited. Cause of diffi-

cult cannulation is as follows; Billroth II (12), Billroth II with

periampullary diverticulum (4), periampullary diverticulum

(5), IPMN (1), duodenal deformity (1).

Result: In all cases, we successfully performed fistulotomy us-

ing a cap-assisted forward-view endoscope in patients with diffi-

cult biliary cannulation. After selective biliary cannulation, ther-

apeutic procedures were successfully performed in all cases.

Therapeutic procedures was as follows; endoscopic sphincter-

otomy (23), endoscopic retrograde biliary drain insertion (19),

stone removal (18), biopsy (3). Among the 23 patients, 2 had

minor bleeding which stopped spontaneously. There was no

procedure-related death.

Conclusion: Fistulotomy using a cap-assisted forward-view



endoscope is safe and effective in patients with difficult biliary

cannulation

Key Words: Fistulotomy, Cap, Forward, Cannulation, ERCP

PBS-26

New Technique of ES with Iso-Tome to Incise the Distal Papillary Roof in PTS with Choledocholithiasis and with CDF on AV

Young Sin Cho, Sang-Heum Park, Tae Hoon Lee, Dae Yeon Kim, Kyung-hee Hyun, Hyun Jong Choi, Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Sun-Joo Kim Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Cheonan Hospital, Cheonan, Korea

Background/Aims: Occasionally endoscopic incision on the

distal papillary roof is not easy in patients with chol-

edocholithiasis and with spontaneous or artificial chol-

edochoduodenal fistula (CDF) on the ampulla of Vater (AV).

We evaluated the efficacy and feasibility of down- or/and

up-ward papillotomy by using Iso-Tome to incise completely

the distal papillary roof for removing CBD stones.

Methods: From May 2003 to July 2012, this technique was ap-

plied to patients with choledocholithiasis and with sponta-

neous or artificial CDF on AV. Artificial CDF(fistulomy) was

made by using needle-knife papillotome. Downward incision

from the orifice of CDF or/and up-ward incision from the or-

ifice of AV were performed by using Iso-Tome until the distal

papillary roof was completely cut. Main outcome measure-

ments were the success rate of this technique, the number of

incision for achieving successful cutting, the electric damage

on pink intrapapillary mucosa, the success rate of bile duct

stone clearance, and complications.

Results: A total of 35 patients (15 male, 20 female) with a mean

age of 66.1 (range, 27-92) years were consecutively enrolled.

Spontaneous or artificial CDF were in 4 and 31, respectively.

The direction of incision was downward in 27, upward in 3,

and combined in 5. This technique was successful in

94.3%(33/35). Mean number of incision was 1.4(range, 1-4)

and only one incision was enough to incise completely the dis-

tal papillary roof in 74.3%(26/35). There was no case of the

electric damage on the pink intrapapillary mucosa and ther-

apeutic success rate for CBD stone removal was 96.8% (32/33).

Of the 35 patients, 1 (2.9%) had mild bleeding, which was

managed medically.

Conclusions: Down- or/and up-ward papillotomy with Iso-Tome

is a feasible and useful new technique of endoscopic sphincter-

otomy to incise completely the distal papillary roof in patients

with spontaneous or artificial CDF for the treatment of CBD

stones.

Key Words: Endoscopic sphincterotomy, Iso-Tome, Choledoc-

holithiasis, Choledochoduodenal fistula, Distal papillary roof

PBS-27

Is Double-Guidewire Technique Really Useful for Difficult Biliary Cannulation?

Su Jin Kim, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea

Background and Aim: Double-guidewire technique (DGT)

has been reported to be useful for difficult biliary cannulation.

Needle-knife fistulotomy (NKF) is also used in failed standard

biliary cannulation. The aim of this study was to compare the

success rate and complications between the DGT and NKF in

patients with difficult biliary cannulations.

Methods: Patient who underwent endoscopic retrograde chol-

angiopancreatography (ERCP) between January 2009 and

September 2012 were eligible for this study. DGT or NKF were

perfomed if deep biliary cannulation was not achieved despite

of five mininutes of attempted cannulationthan or more than

three attempted unintentional pancreatic cannulations. Patients

with unsuccessful DGT underwent NKF as alternative

procedure. The success rate of cannulation and the frequency

of post-ERCP pancreatitis (PEP) were investigated.

Result: A total 1550 ERCP cases were analyzed, the total success

rate of selective biliary cannulation was 94.2% (1460/1550). Of

the 302 patients with unsuccessful standard cannulation tech-

nique, DGT was perfomed in 70 patients and NKF was per-

fomed in 199. The success rates in the DGT and NKF groups

were 41.4% (29/70) versus 81.4% (162/199) (p<0.01). Thirty

patients with unsuccessful DGT underwent NKF as alternative

procedure, biliary cannulation was achieved in 70.0% (21/30).

The incidence rate of PEP was significantly higher in DGT

group 20.0% (14/70) than in NKF group 8.0% (16/199)

(p<0.01). There was no significant difference in bleeding be-

tween the three groups.

Conclusion: DGT in patients with a difficult biliary cannula-

tion resulted in a low success rate of biliary cannulation and a

high incidence of PEP comparing with NKF. We suggest that

NKF should be considered as a first approach in difficult can-

nulation situations.

Key Words: ERCP, Cannulation



PBS-28

Sequential Prospective Protocol Analysis to Facilitate Selective Biliary Access for Difficult Biliary Cannulation

Soon Oh Hwang, Tae Hoon Lee, Sang-Heum Park, Yunho Jung, Suck-Ho Lee, Il-Kwun Chung, Hyun Jong Choi, Sang Woo Cha, Jong Ho Moon, Young Deok Cho, Sun-Joo Kim Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Cheonan Hospital, Cheonan, Korea

Background/Aim: In difficult biliary cannulation (DBC),

15-35% of cases fail even when performed by experts. Various

techniques have been attempted to improve the cannulation

success rate. However, standardized guidelines are not yet in

place. We therefore prospectively investigated a sequential pro-

tocol analysis of precut and wire-guided cannulation to facili-

tate selective biliary access for DBC.

Methods: We attempted selective biliary access for DBC ac-

cording to an algorithm (Fig. 1). An early precut fistulotomy

(EPF), a double wire-guided cannulation (DWC), and a precut

following pancreatic stent placement (PPS) were performed

sequentially. The technical success rate, procedure outcomes,

and complications in each group were recorded prospectively

from May 2010 to August 2012.

Results: A total of 711 patients with naïve papilla underwent

ERCP. The 140 patients (19.7%) failed under standard

wire-guided biliary cannulation. The EPF, DWC, and PPS were

performed in 71 (50.7%), 33 (23.6%), and 36 (25.7%) patients.

There was no significant difference in baseline characteristics.

The technical success rates were 94.4%, 96.9%, and 100% re-

spectively (p=.327). Post-ERCP pancreatitis developed in 14

(10%) patients, which was not statistically significant between

groups (p=.870) or compared with the conventional group

(p=.125). However, successful cannulation time was short in

the DWC group (p<.001). In the multivariate analysis, female

gender was a risk factor for pancreatitis (odds ratio 4.16, 95%

CI 1.108-15.645, p=.035).

Conclusions: Based on the sequential protocol analysis, EPF,

DWC, and PPS were safe and feasible in DBC. We suggest EPF

in DBC criteria, and PPS following DWC in unintentional

pancreas duct cannulation.

Key Words: Difficult biliary cannulation, Precut fistulotomy,

Double wire-guided cannulation, Pancreatic stent

PBS-29

Pancreatic Duct Stenting Versus Pancreatic Duct Guidewire Placement for Facilitating Biliary Cannulation

Jae Chul Hwang, Byung Jo Yoon, Eun Jung Jang, Dong Hoon Kim, Byung Moo Yoo, Jin Hong Kim Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

Background: In difficult cases of selective biliary cannulation,

several techniques including use of a pancreatic duct stent

(PDS) or guidewire (PDW) are available. This study compared

the effectiveness of a PDS versus a PDW to facilitate common

bile duct (CBD) cannulation.

Patients and Methods: A retrospective review of all ERCPs per-

formed at our institution from May, 2008 to August, 2012 was

performed to identify all cases in which a PDS or a PDW was

placed to guide CBD cannulation. In the PDS group,

wire-guided cannulation of the bile duct was attempted over

the PDS. In the PDW group, double guidewire technique was

attempted. The success rate of cannulation, frequency of pre-

cut sphincterotomy and complication rate were compared be-

tween these two groups.

Results: Successful CBD cannulation was achieved in 52 of 53

(98.1%) in the PDS group and 46 of 47 (97.9%) patients in the

PDW group (p=0.932). Precut sphincterotomy was required in

43.4% in the PDS group and 42.6% in the PDW group

(p=0.932). The incidence of post-ERCP pancreatitis and hy-

peramylasemia in the PDS and PDW groups were 15.1% ver-

sus 10.6% (p=0.508) and 37.7% versus 27.7% (p=0.297),

respectively. No significant bleeding and perforation occurred.

Conclusions: In difficult cannulation, use of a PDS facilitates

biliary cannulation and appears to be comparable to use of a

PDW for reducing the rate of precut sphincterotomy.

Key Words: Cannulation, ERCP, Stent, Pancreatic duct



PBS-30

Overtube Assisted Intraductal Balloon-Guided Direct Peroral Cholangioscopy by Ultra-Slim Upper Endoscope

Hyun Jong Choi, Jong Ho Moon, Dong Choon Kim, Yu Ri Seo, Dae Yong Kim, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea

Introduction: Consistantly successful direct peroral cholangio-

scopy (POC) by using an ultra-slim upper endoscope demands

assisting accessories. Although it has high success rate, intra-

ductal balloon-guided direct POC may be limited in interven-

tional procedures that should be performed without intra-

ductcal balloon. Overtube assisted direct POC enable one to

keep the working channel for procedures. The aim of this study

was to evaluate the usefulness of overtube assisted intraductal

balloon-guided direct POC for intraductal interventions.

Methods: Total 29 patients (mean age 64.2) with bile duct dis-

ease (24 bile duct stones, 3 biliary papillomatosis, and 2 CBD

malignancies) had undergone overtube assisted intraductal

balloon-guided direct POC by using an ultra-slim upper

endoscope. Indications of direct POC were difficult bile duct

stones requiring intraductal lithotripsy, indeterminated bile

duct lesions, or confirmation of bile duct clearance after stone

extraction. Diagnostic and/or therapeutic interventions under

POC were performed after retrieval of the intraductal balloon.

A successful POC was defined as one in which the endoscope

was advanced into the bifurcation or stenotic segment. A suc-

cessful intervention uncder POC was defined stable keeping

the position of endoscope until complete diagnostic and/or

therapeutic intraductal procedures.

Results: The overall success rate of direct POC was 96.6%

(28/29). The success rate of intraductal interventions under di-

rect POC was 82.1% (23/28). Intraductal interventions under

POC included 9 intraductal evaluation with narrow band

imaging after saline irrigation, 5 intraductal target biopsy, 5 in-

traductal laser lithotripsy, 3 direct removal of residual stones,

and one ablation therapy with argon plasma coagulation. No

procedure-related complication was occurred.

Conclusions: Intraductal balloon-guided direct POC is highly

successful. Application of overtube can be helpful to maintain

the scope position even after the withdrawal of intraductal

balloon.

Key Words: Peroral cholangioscopy, Ultra-slim endoscope,

Overtube, Intraductal balloon

PBS-31

Direct Peroral Cholangioscopy Using an Ultra-Slim Endoscope in Altered Gastrointestinal Anatomy

Ho-Seok Ki, Chang-Hwan Park, Seon-Young Park, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

Background and Study Aims: Peroral cholangioscopy provides

direct visualization of the bile duct and facilitates diagnostic

procedures and therapeutic interventions. The mother-baby

endoscopic system has several disadvantages during procedure

in altered anatomy. Therefore, we evaluated the feasibility of

direct peroral cholangioscopy using an ultra-slim endoscope in

altered gastrointestinal anatomy.

Patients and Methods: From March 2012 to September 2012, 8

patients with Billorth II gastrectomy (n=4), abnormally lo-

cated papilla of Vater in duodenal bulb (n=1), hep-

aticoduodenostomy (n=1), and choledochoenterostomy

(n=1), extremely J-shaped stomach (n=1) underwent direct

peroral direct cholangioscopy using an ultra-slim endoscope.

Results: The success rate of direct visualization of the bile duct

using an ultra-slim endoscopy was 100% (8/8). In cases of al-

tered anatomy, we overcome the case using an overtube. In cas-

es of successful access, therapeutic interventions including

stone extraction (n=6) and electrohydraulic lithotripsy (n=4)

were performed successfully. Immediate bleeding was occurred

in one case during electrohydraulic lithotripsy. But, Primary

hemostasis was achieved spontaneously.

Conclusion: Direct peroral cholangioscopy using an ultra-slim

endoscope was possible in altered gastrointestinal anantomy.

Overtube-assisted direct peroral cholangioscopy using an ul-

tra-slim endoscope enables easy access in patient with BII

anatomy.

Key Words: Endoscopic retrograde cholangiopancreatography,

Peroral cholangioscopy, Billroth II gastrectomy

PBS-32

Pancreatic Duct Stenting after Endoscopic Ampullectomy for Ampullary Neoplasm; Can It Prevent Pancreatitis?

Yun Kyeong Kim, Byung-Wook Kim, In-Seok Lee, Woo-Chul Chung, Tae-Ho Kim, Joon Sung Kim Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea

Background/Aims: Endoscopic ampullectomy for ampullary

neoplasm is known to be safe and effective alternatives for sur-



gical resection. However, post-procedural pancreatitis is quite

common and pancreatic duct stenting has been conducted for

prevention of this complication. The aim of this study was to

evaluate the effectiveness of pancreatic duct stenting after en-

doscopic ampullectomy in Korea.

Methods: Retrospective review was conducted in 4 institutes

affiliated to The Catholic University of Korea between October

2007 and May 2012. We compared the complication rate be-

tween the patients with pancreatic duct stent and without stent

after ampullectomy. Pancreatitis was defined as abdominal

pain after the procedure with increased serum amylase level

over 3 fold of reference value.

Results: Thirty five patients (13 females, 22 males) underwent

endoscopic ampullectomy during this period. The final histo-

logic diagnosis was tubule adenoma with low grade dysplasia

(42.8%), high grade dysplasia (22.8%), adenocarcinoma

(14.3%), tubullo-villous adenoma (2.8%), hyperplastic polyp

(2.8%), chronic inflammation (2.8%), and etc (11.4%).

Stenting was performed in 24 patients (68.6%), whereas 11 pa-

tients (31.4%) were remained without stent. In stenting group,

11 patients developed pancreatitis (45.8 %), whereas 4 patients

developed pancreatitis in patients without stenting (36.3%).

(p>0.05)

Conclusions: Pancreatic duct stenting cannot reduce the pro-

cedure-related pancreatitis. Further studies with large scaled

prospective trial are anticipated.

Key Words: Ampullectomy, Ampullary neoplasm

PBS-33

Prophylactic Pancreatic Duct Stenting after Papillectomy of Duodenal Papillary Tumor; Prospective, Randomized Study

Byung Hoo Lee, Sang-Woo Cha, Tae Hoon Lee, Soung Won Jeong, Jae Young Jang, Young Deok Cho, Sang-Heum Park Institute for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University, College of Medicine, Seoul, Korea

Introduction: Endoscopic snare papillectomy (ESP) is an effi-

cient treatment for benign tumors of the duodenal major

papilla. However, post-ESP pancreatitis is a common and seri-

ous complication. Since one prospective randomized con-

trolled trial showed that pancreatic duct stent placement re-

duced post-ESP pancreatitis, almost physicians have tried to

place pancreatic duct stent after EPS. The aim of this pro-

spective, randomized trial is to compare the rates of post-ESP

pancreatitis in patients who did or did not receive prophylactic

pancreatic duct stent placement.

Methods: Consecutive patients who were to undergo ESP were

randomized to pancreatic duct stent placement group (stent

group) after endoscopic snare papillectomy or to no pancreatic

duct stent placement group (no stent group).

Result: The groups were similar with regard to patient

demographics. In total, 24 patients were enrolled. Fourteen pa-

tients were assigned to the stent group and 10 patients to the no

stent group. Post-ESP pancreatitis developed in 5 patients

(20.8 %, 5/24), 3 cases occurred in the stent group and 2 case

occurred in the no stent group. One case of moderate grade

pancreatitis developed in the stent group. The overall incidence

of post-EPS pancreatitis was 21.4% (3/14) in the stent group

and 20.0 % (2/10) in the no stent group (p=0.932). The rates of

hyperamylasemia were 14.3% (2/14) in the stent group and

0.0% (0/10) in the no stent group (p=0.493).

Conclusion: There was no significant difference in the occur-

rence of post-ESP pancreatitis and hyperamylasemia between

patients with and without pancreatic duct stent placement af-

ter endoscopic snare papillectomy. Our findings suggest that a

pancreatic duct stent placement after ESP did not confer a pro-

tective effect in reducing post-ESP pancreatitis. Therefore,

more large scaled prospective, randomized controlled studies

regarding the effectiveness of pancreatic duct stent placement

to reduce the incidence rates of post-ESP pancreatitis are

needed.

Key Words: Endoscopic snare papillectomy, Pancreatitis,

Pancreatic duct stent, Ampullary tumor

PBS-34

Clinical Characteristics of Delayed Postpapillectomy Bleeding in Ampullary Neoplasm

Seung Uk Jeong, Myung-Hwan Kim, Do Hyun Park, Byung Uk Lee, Sung Hyun Won, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Background: Endoscopic papillectomy is a less invasive treat-

ment compared with surgical resection. However, it has rela-

tively high complication rate, such as bleeding, and there are

few studies about complication, especially delayed post-

papillectomy bleeding. We carried out this study to assess the

characteristics of delayed postpapillectomy bleeding and to in-

vestigate factors related to the delayed bleeding.

Methods: This retrospective study was conducted by analysis

of data for consecutive patients who underwent endoscopic

papillectomy for duodenal ampullary neoplasm between

January 2007 and August 2012. The technique of papillectomy,

medical history, laboratory findings and clinical outcomes

were analyzed. The delayed bleeding was defined as hemor-



rhage diagnosed by second-look endoscopy at the operation

site following cessation of papillectomy.

Results: Total 205 patents underwent the endoscopic papil-

lectomy and the delayed bleeding occurred in the 89 patients

(43.4%), with median time of 2 days (range 1 to 8 days). The

second-look endoscopy was performed in the 181 patients

(88.3%) and the delayed bleeding was detected by routine sec-

ond-look endoscopy in the 58 patients (65.2%) without symp-

tom and sign. The delayed bleeding was controlled by endo-

scopic hemostasis in the 86 patents (96.6%), except for 3 pa-

tients performed embolization. The average number of endo-

scopic hemostasis was 1.6 (range 1 to 9). The delayed bleeding

developed more frequently in the patents with bleeding during

papillectomy (51.0% vs 36.5%, p=0.034). In the patients with

submucosal injection (diluted epinephrine, 1:10,000), delayed

bleeding was significantly fewer than in those without sub-

mucosal injection. (35.1% versus 50.5%, p=0.034). However,

the occurrence of delayed bleeding was not different according

to age, sex, electrosurgical currents, thermalablation after pap-

illectomy, anticoagulation, coagulopathy and endoscopists.

Conclusion: The delayed postpapillectomy bleeding was very

common. It was also more frequent in the patents with bleed-

ing during papillectomy and in those without submucosal

injection. These results suggest that routine second-look en-

doscopy might be needed and support the necessity of sub-

mucosal injection to prevent delayed bleeding. Further larger

prospective study may be needed to confirm these results.

Key Words: Delayed postpapillectomy bleeding, Submucosal

injection, Second-look endoscopy, Ampullary neoplasm

PBS-35

Analysis of the Result of Endoscopic Papillectomy with Emphasis on Complication

Choong Nam Shim, Jeong Youp Park, Moon Jae Chung, Seung Min Bang, Seung Woo Park, Si Yong Song, Jae bock Chung Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea

Introduction: Endoscopic papillectomy has been currently

employed for feasible treatment for ampullary tumor. This

study aimed to assess factors associated to procedure-related

complications and to evaluate the clinical, endoscopic, and his-

tologic characteristics of complicated lesions.

Methods: This study included 35 patients underwent endo-

scopic papillectomy for ampullary adenoma between September

2006 and April 2012 in Severance Hospital, Yonsei University

College of Medicine. Patients grouped according to the occur-

rence of procedure-related complications: Group A (n=25)

without complication and Group B (n=10) with complication.

Results: The overall complication rate was 28.6 % (15 cases)

among the enrolled patients. The most common complication

was pancreatitis (n=6), followed by bleeding (n=4), perfo-

ration (n=2). Between group A and B, there was no significant

difference of demographic characteristics, use of antiplatelets

or anticoagulation, and underlying diseases. Endoscopic char-

acteristics including size and type of lesion, type of endoscopic

resection (polypectomy vs endoscopic mucosal resection), and

the deployment of pancreatic duct stent after procedure did

not reveal significant difference. In laboratory characteristics,

amylase (median 113.0 vs 316.0 IU/L, p value=0.023) and li-

pase levels (median 83.0 vs 495.5 IU/L, p value=0.017) at 24

hours after endoscopic papillectomy were significantly higher

in the group with complication than without complication.

Endoscopic outcomes including en block resection rate (n=22,

88% vs n=10, 100%, p value=0.542) and complete resection

rate (n=18, 72% vs n=9, 90%, p value=0.390) did not differ

significantly between two groups. Duration of antiprotease in-

jection during hostpital stay (median 2.0 vs 5.5 days, p val-

ue=0.038) was significantly longer in the complication group,

and hospital stay (median 6.0 vs 9.0 days, p value=0.059) tend-

ed to be longer in the complication group. Recurrence rate

(n=1, 5.6% vs n=2, 22.2%, p value=0.245) among the patients

with complete resection (n=27) during median follow up of

13.0 months was not significantly different.

Conclusion: Amylase and lipase levels at 24 hours after endo-

scopic papillectomy could help to predict the possibility of pro-

cedure-related complications. Group with complication may

need longer duration of antiprotease injection during hostpital

stay. Further studies are needed to reduce the complication rate

of papillectomy.

Key Words: Ampullary adenoma, Endoscopic papillectomy,

Endoscopic Retrograde Cholangiopancreatography, Complication

PBS-36

The Comparison between Midazolam Alone and the Combination Use of Midazolam and Propofol for Sedation during ERCP

Yu Seok Kim, Myung-Hwan Kim, Seung Uk Jeong, Byung Uk Lee, Do Hyun Park, Sang Soo Lee, Dong-Wan Seo, Sung Koo Lee Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Background/Aims: Endoscopic retrograde cholangiopancreato-

graphy (ERCP) is uncomfortable procedure, requiring adequate

sedation for successful conduction. We investigated the efficacy

and safety in the combination use of intravenous midazolam



and propofol for sedation during ERCP.

Methods: A total of 94 patients undergoing ERCP received one

of the two medication regimens administered by nurse with

supervision by the gastroenterologist. Patients in M group

(n=44) received only intravenous midazolam, titrated to ach-

ieve deep sedation. Patients in MP group ( n=50 ) received the

combination of intravenous midazolam and propofol initially,

and then propofol was titrated to achieve deep sedation.

Results: Time to initial sedation was shorter in MP group than

in M group ( p<0.001 ). Recovery was faster in MP group than

in M group ( p=0.031 ). There was no significant difference be-

tween the two groups with respect to frequency of adverse

events, pain of patient, discomfort of patient, degree of am-

nesia, gag reflex and satisfaction of procedure by endoscopist

respectively.

Conclusions: The combination use of intravenous midazolam

and propofol for sedation during ERCP is more effective than

midazolam alone with no difference in safety of procedure.

Key Words: Propofol, Midazolam, Sedation, Cholangiopan-

creatography, Endoscopic Retrograde

PBS-37

Sustained Use of Antiplatelet Agents Increase the Risk of Delayed Bleeding After Endoscopic Sphincterotomy

Min Geun Lee, Sang Hyub Lee, Seung June Lee, Yoon Suk Lee, Jin Hyeok Hwang Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

Objective: We aimed to investigate whether post-EST bleeding

is increased in patients who take antiplatelet agents.

Methods: Total 762 patients (56.4% men, mean age 69.3 years)

who underwent EST were enrolled and retrospectively ana-

lyzed: patients who never used antiplatelet agents (Group 1:

n=601), patients who interrupted antiplatelet agents use for

7days or more (Group 2: n=29) and patients who had con-

tinued antiplatelet therapy or had it interrupted less than 7 days

before EST (Group 3: n=132). The primary outcome was the

incidence of post-sphincterotomy bleeding.

Results: Post-EST bleeding occurred in 10.4% (79/762) overall

and 52 episodes were delayed bleeding (58.4%, mean 4.3 days;

range, 2-11 days). The incidences of post-sphincterotomy

bleeding in Groups 1, 2 and 3 were 10.5%, 10.3% and 9.8%, re-

spectively, with no significance at p=0.970. In subgroup analy-

sis among continuous antiplatelet users, aspirin users made up

the biggest proportion (86/132, 65.2%), followed by 13.6% for

dual antiplatelet users with aspirin and clopidogrel, 7 of the de-

layed bleeding episodes occurred in the uninterruption group

(14.3%), 2 in the interruption group the day before EST or of

enforcement (3.4%), and none in the 2- to 4-day interruption

group prior to EST, which showed a relationship between de-

layed bleeding and antiplatelet use (p=0.043). In the multi-

variate analysis, post-EST bleeding was significantly associated

with pre-EST jaundice (total bilirubin ≥3mg/dL) and endo-

scopically observed bleeding at the time of sphincterotomy.

(OR 4.618; 95% CI, 1.334-15.985 ; p=0.016 and OR 3.407; 95%

CI, 1.062-10.933; p=0.039, respectively).

Conclusions: In EST for antiplatelet users, uninterrupted use

of antiplatelet agents may increase the risk of delayed bleeding

after EST. However, routine cessation of antiplatelet agents in

patients before EST is not necessary because of favorable

outcome.

Key Words: Complications, Gastrointestinal hemorrhage,

Endoscopic sphincterotomy

PBS-38

Assessment of ERCP Feasibility Based on Performance Status in Elderly Patients

Ju Wan Kim¹, Hyoung Chul Oh¹, Jae Hyeok Do¹, Jeong Sik Choi² ¹Division of Gastroenterology, Chung-ang University College of Medicine, Seoul, ²Division of Gastroenterology, In-je University College of Medicine, Busan, Korea

Background: Endoscopic retrograde cholangiopancreatog-

raphy (ERCP) has been increasingly performed in the elderly

patients. There were few reports that suggested the objective

criteria to assess the feasibility for safe ERCP. This study eval-

uated the usefulness of an algorithm that assessed the patient’s

feasibility based on performance status and cardiopulmonary

parameters.

Methods: Patients older than 70 years who were indicated for

ERCP were prospectively enrolled and risk-stratified by assess-

ing their performance status by ECOG performance status,

ASA physical status, Duke activity status index (DASI), and

cardiopulmonary parameters (pulse oxymeter, ABGA, FEV1 if

necessary). ERCP-related parameters and complications were

monitored and compared between the 70s (A, n=145) and 80s

(B, n=64). <b>

Results: There was no significant difference in underlying dis-

eases and ERCP indications. ERCP was not performed in one

high-risk patient for procedure. For performance status, there

were significant differences in mean DASI (23.7 vs. 15.9,

p<0.01) and ECOG performance status(3-4, 33/145 vs. 25/64,

p<0.05) between A and B groups. Major ERCP-related compli-

cations (hypotension, myocardial infarction, cerebral in-

farction) occurred in five patients from group B and two from



group A, respectively. Post-ERCP pancreatitis occurred in one

patient from group A and bleeding in one from group B. In the

univariate analysis, old age (≥80), ASA score ≥ 3 and DASI

<10 were statistically significant predictors for major ERCP-re-

lated complications. In the multivariate analysis, DASI <10

and PaCO2 >45mmHg were independent predictors for major

ERCP-related complications.

Conclusion: DASI score and hypercapnea were useful pre-

dictors for the feasibility assessment of safe ERCP in the elderly

patients.

Key Words: ERCP, Elderly, Perfomance

PBS-39

Pancreatobiliary Endoscopy during Pregnancy

Jae June Lee, Sung Gu Lee, Sun Mok Kim, Hwan Yoon, Byung Uk Lee, Seung Uk Jung Department of Internal Medicine, Ulsan University School of Medicine, Asan Medical Center, Seoul, Korea

Background: Pancreatobiliary interventions during pregnancy

are associated with risks to both the pregnancy and the devel-

oping fetus. There are few data in the literature regarding the

safety of endoscopic management of pancreaticobiliary dis-

orders during pregnancy. Furthermore, there have been no

studies to show results of pancreatobiliary endoscopy in

Korean pregnant women. In this report we summarize our ex-

perience with pancreatobiliary endoscopy during pregnany.

Methods: Endoscopic retrograde cholangiopancreatographis

(ERCP) and Endoscopic ultrasound (EUS) performed be-

tween January 2000 through August 2012 were identified from

our database, and cases of ERCP and EUS were reviewed.

Records were reviewed for indication, endoscopic inter-

ventions, use of fluoroscopy, postprocedure complications,

and pregnancy outcomes.

Results: 8 ERCPs and 4 EUSs were performed in 12 pregnant

patients. The mean patient age was 30.7 yr (22-41 yr). Their

mean gestational period was 16.4 weeks (5-32 wk); four pa-

tients were in the first, seven in the second, and one in the third

trimester. The indications of ERCP were obstructive jaun-

dice(n=3), cholangitis(n=1), gallstone pancreatitis(n=3), trau-

matic pancreatitis(n=1). And indications of EUS were pan-

creas cyst(n=1), acute cholecystitis(n=2), choledochal cyst(n=1).

Among patients, two experienced complications after proce-

dure; one had acute pulmonary edema related with adverse

drug reaction and the other had transient hyperamylasemia.

Term pregnancy was achieved in 7 patients. Two pregnant

women had uncomplicated preterm delivery, and low birth

weight newborn was only one of them. There were two artifi-

cial abortions; one at the request of the mother, and the other

for medical indication.

Conclusion: Like other studies regarding safety of pancreatobiliary

endoscopy in the Western pregnant women, ERCP and EUS in

Korean pregnant women seem to be safe for both mother and

fetus when performed in experienced experts and with intra-

procedure safety measures.

Key Words: Endoscopic Retrograde Cholangiopancreatogra-

phy, Endoscopic Ultrasound, Pregnancy

PBS-40

Endoscopic Retrograde Cholangiopancreatoscopy on Outpatient Basis

Eun Jung Jang, Jin Hong Kim, Byung Moo Yoo, Jae Chul Hwang, Dong Hoon Kim, Byung Jo Yoon Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

Background: ERCP is performed routinely after admission be-

cause of potential post-procedure complications. However,

cases whose post-procedure complication rate is expected to be

low, are sometimes performed on an out-patient basis. Aim

The purpose of this study was to evaluate the feasibility and

safety of outpatient ERCP and the incidence of post-procedure

complications.

Method: ERCP on an outpatient basis was performed in pa-

tients who required diagnostic or minimal invasive therapeutic

ERCP and were known not to be at a high risk of post-proce-

dure complications. We retrospectively assessed the results of

ERCP on an outpatient basis performed over a 9 year period

from 2003 to 2011.

Results: A total of 377 patients (42% female) with a mean age

of 52 (range 15 to 86) who received outpatient ERCP were in-

cluded in this study, 196 patients (52%) for diagnostic pur-

poses and 181 (48%) for therapeutic intervention. Diagnostic

ERCP was done in 116 patients with bile duct evaluation, 46

with pancreatic duct evaluation, and 2 with prominent duode-

nal ampulla. Therapeutic intervention included endoscopic

biliary sphincterotomy (EST) in 53, small CBD stone removal

after EST in 76, and stent-related procedures in 84. Complications

necessitating hospitalization developed in 24 patients (6.2%);

pancreatitis 14, bleeding 4, cholangitis 2, sepsis 2, transient hy-

potension 1, and perforation 1. ERCP-related mortality did not

occur. Complication rates of therapeutic ERCP tended to be

higher than diagnostic ERCP (11% vs 2%) although there were

no statistical differences. 14 patients were admitted immedi-

ately after ERCP, and 10 patients admitted via emergency

room. The mean duration of hospital stay among patients ad-

mitted due to a complication was 5.5±3.3 days (range, 3 to



16days)

Conclusion: ERCP on an outpatient basis is suitable, feasible

and safe, if it is performed in selected patients who required di-

agnostic or minimal invasive therapeutic ERCP and were known

not to be at a high risk of post-procedure complications.

Key Words: ERCP, Outpatient

PBS-41

Therapeutic Outcomes of Endoscopic Papillectomy for Ampullary Neoplasms : Retrospective Analysis of a Multicenter Study

Sung Hoon Kang¹, Kook Hyun Kim¹, Min Kyu Jung², Chang Min Cho², Kwang Bum Cho³, Ji min Han⁴, Ho Gak Kim⁴, Hyun Soo Kim5, Tae Nyeun Kim¹ Department of Internal Medicine, ¹Yeungnam University College of Medicine, ²Kyungpook National University School of Medicine, ³Keimyung University School of Medicine, ⁴Catholic University of Daegu School of Medicine, 5Daegu Fatima Hospital, Daegu, Korea

Background/Aims: Endoscopic papillectomy(EP) is reported

to be relatively safe and reliable for complete resection of am-

pullary neoplasms. There were no large-scale studies concern-

ing the effectiveness and complications related to EP. This

study aimed to evaluate the therapeutic outcomes and compli-

cations of EP for ampullary neoplasms.

Methods: From Jan 2007 to Aug 2012, 84 patients who received

EP for ampullary neoplasms were retrospectively identified at 5

participating centers in Daegu, Korea. EP was performed by

snare resection with/without saline lifting of the lesion.

Results: The mean age of the total 84 patients was 60.2±12.5

years, and the male-to-female ratio was 2:1. The median fol-

low-up period was 462 days. A biliary and pancreatic stent was

placed in 32 patients and in 44 patients, respectively. En bloc

resection was possible in 75 patients (89.3%). The mean size of

the resected specimens was 13.5±6.1 mm. Histology of re-

sected specimen was as follows: low grade adenoma (42.7%),

high grade adenoma (17.1%), adenocarcinoma(18.3%), hy-

perplastic polyp (9.8%), and others (12.1%). A pathologically

incomplete resection was noted in 10 cases (11.9%). Of the 56

cases with low grade adenoma on biopsy specimen, 25%

turned out to have high grade adenoma (12.5%) or ad-

enocarcinoma (12.5%). After papillectomy, 5 patients with ad-

enocarcinoma and 1 patient with high grade adenoma and 1

patient with carcinoid tumor underwent surgery due to pos-

itive resection margin. Procedure-related complications devel-

oped in 28 patients (33.4%): bleeding (15 cases), pancreatitis

(13 cases), and perforation (7 cases). Of the 28 complication

cases, 25 patients (89%) improved with medical treatment,

while 2 patients recovered and 1 patient died after surgery.

Pancreatic duct stent significantly increased the risk of pan-

creatitis by univariate and multivariate analysis. Pre-EP ERCP,

saline lifting, sphincterotomy, biliary stenting, specimen size,

and cauterization were not related with post EP complications.

During follow up, residual tumors were found in 7 patients on

endoscopy of which 6 patients were treated with EP and/or

APC and 1 patient underwent surgery.

Conclusions: EP seems to be a safe and effective treatment for

ampullary neoplasms and can be considered as an alternative

to surgery. However, risk of the procedure related complica-

tions is a problem that must be considered.

Key Words: Ampullary neoplasms, Endoscopic papillectomy

PBS-42

Endoscopic Ampullectomy for Ampullary Tumor in a Single Center

Hoon Ki Baek, Mi Young Jang, Wang Guk Oh, Sung Jun Go, Shang Hoon Han, Young Jae Lee, Gum Mo Jung, Ji Woong Kim, Young Keun Cho, Jin Woong Cho Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea

Background and Aims: Endoscopic ampullectomy is being

performed in the tretment of ampullary neoplasm such as ad-

enoma or other benign diseases . We investigate the clinical

outcomes of endoscopic ampullectomy and complications.

Methods: We analyzed medical records of consecutive patients

who received endocopic ampullectomy in our hospital from

2004 to 2011 retrospectively.

Results: Thirty two patients (24 men: mean age 60.2years,

range 26-83years) who underwent endoscopic ampullectomy

(adenoma-21, hyperplastic polyp-3, harmatoma-5, CIS-1,

others-2). Techinical success was accomplished in 31 (96%)

and treatment success were achived in 31 (96%). One of those

in endoscopic ampullectomy has APC due to capture failure.

Complication occurred: delayed bleeding in 4 patients, micro-

perforation in one patient, acute pancreatitis in 16 patients,

acute cholangitis in 2 patients.Pancreatic drainage (pancreatic

stent and pancreatic EST) reduced post procedure acute pan-

creatitis after ampullectomy (OR 17.05, CI 1.145-26.41 p<0.05).

Conclusions: Endoscopic ampullectomy was effective treat-

ment method for ampullary neoplasm. Pancreatic drainage

may reduce post ampullectomy acute pancreatitis.

Key Words: Endoscopic ampullectomy, Pancreatic stent,

Pancreatic sphincterotomy



PBS-43

The Usefulness of Argon Plasma Coagulation for Remnant Tissues after Endoscopic Resection of Ampullary Neoplasms

Dong Uk Kim, Gwang Ha Kim, Dae Hwan Kang, Geun Am Song Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea

Aims: To evaluate the usefulness of the argon plasma coagu-

lation (APC) for remnat tissues after endoscopic resection of

ampullary neoplasms.

Patients and Methods: Endoscopic snare papillectomy was per-

formed in 34 patients with ampullary neoplasms (32 ampul-

lary adenoma and 2 ampullary adenocarcinoma). In 12 pa-

tients with grossly remnant tissues after endoscopic resection,

the APC was introduced simultaneously for the remnant

tissues. Eight patiens were treated by the APC at 7-10 days after

endoscopic resection because of the microscopic remnant

tissue.

Results: Eighteen patients had adenoma, and 2 had adenocarcinoma.

Median follow-up periods was 13.4 months (reange: 3-37

months). Early complications occurred in 7 of 20 patients

(35%, major bleeding, 3; perforation, 1; pancreatitis 3; chol-

ecystitis,1). Late complications occurred in 3 of 20 patients

(15%, bile duct stone, 2; pancreatitis, 1). One patient (5%) ex-

perienced the local recurrence, which was successfully treated

with repeated APC.

Conclusion: The APC is the additionally modified technique

of endoscopic snare papillectomy, which is thought to contrib-

ute to decreasing rate of local recurrences.

Key Words: Endoscopic papillectomy, Argon plasma coagu-

lation, Ampullary neoplasms

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