위전절제술을 받은 위암 환자에서 조기경장영양요법과 총비경구영양요법의 무작위 전향적 비교연구

Background/Aims: Early enteral nutrition (EEN) has benefits in reducing infectious complication, length of stay (LOS) and preserving liver function. There are few data about the effect of EEN in the patients who had total gastrectomy. The aim of this randomized and prospective study was to evaluate the effect of EEN after total gastrectomy on nutritional status, liver function, complications and LOS, compared to total parenteral nutrition (TPN) in patients with gastric cancer. Methods: Among 56 patients with gastric cancer, 36 and 20 were randomly assigned to EEN and TPN groups, and finally 17 and 16 completed EEN and TPN schedules, respectively. The nutritional parameters, liver function, LOS and abdominal symptoms were compared between 2 groups on pre-operative day and post-operative 7th day. Results: There was no significant difference in the nutritional parameters, liver function between EEN and TPN groups. Vomiting and abdominal distention were more frequent in EEN than TPN group (2 vs. 0 cases, p=0.485; 1 vs. 0 case, p=1.000, respectively), while increased AST, ALT and total bilirubin were more common in TPN than EEN group (4 vs. 2 cases, p=0.398; 1 vs. 0 case, p=0.485, respectively without statistical significance). LOS was shorter in EEN than TPN group without statistical significance (12 vs. 13 days, p=0.289). Conclusions: No significant differences were found in the nutritional status parameters, liver function, complications and LOS between EEN and TPN groups on 7th day after total gastrectomy. Further large scale studies on the advantages and disadvantages of EEN after total gastrectomy are warranted.ope

Combined Endoscopic Transpapillary Biopsy and Exfoliative Cytology for the Diagnosis of Bile Duct Cancer

Background/Aims: In the management of patients with extrahepatic bile duct carcinoma, histologic diagnosis is crucial to determine therapeutic modalities, to predict their outcomes, and to avoid an unnecessary operation. Though various methods were developed, none of them yielded satisfactory results. A combination of those methods was reported to yield superior sensitivity and specificity to a single method. To evaluate the diagnostic efficacy, endoscopic transpapillary biopsy (ETPB) and exfoliative bile aspiration cytology (BAC) was performed in 40 patients with extrahepatic bile duct carcinoma. Methods: After visualization of the biliary tree and the lesion by endoscopic retrograde cholangiopancreatography (ERCP), ETPB (n=40) and BAC (n=28) was done in one session with or without endoscopic sphincterotomy (EST) and the results of two methods were analyzed. Results: The final diagnoses were made by surgical pathology and by clinical follow-ups of more than a year. The locations of the 40 bile duct carcinomas were in the upper area in 25, the middle in 14 and the lower in 1. ETPB was performed in all patients and BAC in 28 patients. The overall sensitivity of the ETPB was 65.0% (26/40). According to the morphology and location, the sensitivity of ETPB was 65.6% (11/32) for sclerotic, 60.0% (3/5) for papillary, and 66.7% (2/3) for the protruding type, and 68.0% (17/25) for the upper bile duct lesion, 64.3% (9/14) for the middle, and 0% (0/1) for the lower. The overall sensitivity of the BAC was 71.4% (20/28). According to the morphology and location, the sensitivity of BAC was 80.0% (16/20) for sclerotic, 20% (1/5) for papillary, and 100% (3/3) for the protruding type, and 82.4% (14/17) for the upper bile duct lesion and 54.5% (6/11) for the middle bile duct lesion. When the two tests were combined, the sensitivity rose to 96.4% (27/28). Conclusions: A combination of ETPB and BAC is useful in making a histologic diagnosis in patients with bile duct carcinoma.ope

Late Periampullary Metastasis of Renal Cell Carcinoma

Metastases to pancreas or duodenum are rarely occurring event. At autopsy, the pancreas has been found to be the site of metastases in approximately 2% of patients with malignant tumors that had originated most commonly from primary tumors located in breast, lung, and kidney. The natural history of renal cell carcinoma has been the subject of intensive study, yet its behavior remains unpredictable and poorly understood. Renal cell carcinoma may remain stable for long periods of time without growing or metastasizing, has the second highest spontaneous regression rate of all solid tumors, and metastases may develop many years after removal of the primary lesion. In patients with pancreatic mass, it is important to differentiate a secondary pancreatic tumor from primary one because satisfactory survival can be expected after surgical excision of secondary pancreatic tumor, especially when the primary tumor is renal cell carcinoma. Recently magnetic resonance image was reported to be useful in differentiating primary from secondary pancreatic tumor originated from kidney. We present a case of resectable solitary pancreatic and duodenal metastasis from renal cell carcinoma presenting as gastrointestinal bleed.ope

A Comparison of Endoscopic Ultrasonography with Transabdominal Ultrasonography of Water-Filled Stomach in the Accuracy of Staging of Gastric Cancer

Background/Aims: There was no single method satisfying accuracy, patient compliance and cost in preoperative staging of gastric cancer. A transabdominal ultrasonography of water-filled stomach (TUS) was compared with endoscopic ultrasonography (EUS) for TN staging in operated gastric cancer. Methods: We performed EUS conventionally and TUS immediately after 600 mL deaerated water ingested in 40 patients with gastric cancer prior to operation. All the cases were operated and the histological findings were compared with the results of preoperative TN staging. Results: The overall T-staging accuracy rate of TUS was 62.5% and 55.0% for EUS. Both TUS and EUS could differentiate EGC from AGC in 85.0%. There was no statistical difference in the accuracy for the depth of cancer invasion between EUS and TUS. Differentiation of the cancer defined within the gastric wall (T3) from the cancer invading adjacent organs (T4) was possible in 92.5% for TUS and 87.5% for EUS. The accuracy of determining the depth of invasion was tent to be lower in fundus than in antrum and body. Lymph node metastasis was correctly diagnosed in 67.5% for TUS and in 70.0% for EUS. Conclusions: TUS may be a considered to be a relatively accurate and simple method for preoperative staging of gastric cancer in the absence of available EUS.ope

Effect of Biliary Drainage on the Diagnostic Values of Serum and Bile CEA and CA19-9 in Patients with Obstructive Jaundice anchor Acute Cholangitis

Background/Aims : It is controversial to use serum cartinoembryonic antigen (CEA), serum CA 19-9, bile CEA, and bile CA19-9 in diagnosing malignant pancreaticobiliary diseases. The aim of this study was to determine whether a short-term biliary drainage affects the values of serum CEA, serum CA19-9, bile CEA, and bile CA19-9 and thus, improves diagnostic values. Methods : Thirteen patients with benign causes of obstructive jaundice and/or acute cholangitis and 24 patients with malignant causes were examined. All patients underwent endoscopic or percutaneous biliary drainage. Serum and bile samples were obtained at the time of biliary drainage procedure and at 2 and 7 days of post-drainage. Then, the values of CEA and CA19-9 were measured. Results : Biliary drainage did not change serum CEA in benign and malignant diseases. The specificity and positive predictive value (PPV) of serum CEA were increased after drainage, whereas its sensitivity, negative predictive value (NPV), and accuracy were decreased. Serum CA19-9 was significantly decreased at 7 days of post-drainage in benign diseases (p=0.0018). The specificity, PPV, NPV, and accuracy of serum CA 19-9 increased after drainage, whereas its sensitivity was decreased. The values of bile CEA and CA19-9 were not affected by ciliary drainage and showed no difference between benign and malignant diseases. Conclusions : Biliary drainage affects the diagnostic valves of serum CEA and CA19-9. Bile CEA and CA19-9 have no diagnostic roles.ope

Serous Cystadenoma of the Pancreas

Background/Aims: Pancreatic cystic tumors, accounting for 9-10% of pancreatic cystic lesions and 1% of primary pancreatic malignant tumors, are largely categorized into serous cystadenoma and mucinous cystic neoplasm. Whereas serous cystadenoma is almost always benign in nature, mucinous cystic neoplasm indicates an overt or latent malignancy. They are usually differentiated from each other by clinical and radiological findings, but exceptions also exist. The purpose of this study was to define clinical and radiological characteristics of serous cystadenoma. Method: Seven patients were diagnosed as having serous cystadenoma from January 1981 to April 1997. We reviewed medical record and radiologic findings, and carried out follow-up interviews by telephone. Results: All patients were women and their mean age was 42.2 (28-70) years. Abdominal pain was the most common symptom presented by three patients. One case was detected by routine checkup. Ultrasonography revealed cystic masses in 6 patients. on computed tomography (CT) done in 5 patients, all lesions were detected without difficulty. Endoscopic retrograde cholangiopancreatography (ERCP) done in 4 patients and magnetic resonance cholangiopancreatography (MRCP) done in 1 patient showed ductal displacement by tumor mass in 2 patients and pancreatic ductal compression in one of them. There was no commuication between main pancreatic duct and cyst. The average size of the tumors was 5.0 cm (range 2.4-11.0) and the most common location was pancreatic head (85.7%). Six patients underwent surgical resection. One case was confirmed by needle aspiration biopsy. All patients were followed by telephone and are alive. Conclusion: Because almost all serous cystadenomas are benign, provided that radiologic study reveals typical findings of serous cystadenoma, regular follow-up may be suffice. However, if differentiation from mucinous cystic neoplasm or from other tumors is not ensured, surgical resection should be considered.ope

Factor Influencing the Recurrence of CBD Stones after an Endoscopic Sphincteromy

Background/Aims: Long term results of an endoscopic sphincterotomy (EST) have still been poorly estimated. The aim of this study was to assess late complications of EST. Methods: The rate of late complications were retrospectively evaluated in with 91 patients (mean age, 59.1 years; range, 28∼86 years; M：F, 44：47), who underwent EST for choledocholithiasis. Results: Forty six patients (50.5%) had their gallbladder in situ, and 45 patients (49.5%) underwent cholecystectomy. Early complications (＜30 days) such as hemorrhage, pancreatitis, and perforation occurred in 7 patients (7.7%). During a mean period of 53.4 months (range, 24∼134 months), 26 patients (28.0%) developed late complications, including a recurrence of CBD stones in 20 patients (22.0%) (8-gallbladder in situ, 12-cholecystectomized). An univariate analysis of risk factors for stone recurrence revealed dilated ducts, stone sizes, and stone numbers which were not related with stone recurrence. The history of choledocholithotomy with cholecystectomy was significantly related to stone recurrence. Conclusions: After EST for bile duct stones, late complications occurred in a significant proportion of patients and it was determined that a history of choledocholithotomy with cholecystectomy was significantly correlated with stone recurrence.ope

Clinical Characteristics of One-year Survivors of Pancreatic Cancer

Objectives: Ductal adenocarcinoma of the pancreas is a lethal disease with poor prognosis. 5-year survival of pancreatic adenocarcinoma was less than 5%. To determine which factors effect the prognosis in the patients of pancreatic adenocarcinoma, the authors reviewed the data of the patients who were diagnosed and treated as pancreatic adenocarcinoma and analyzed the difference between survival groups more than 1 year and less than 1year. Method: The records of 242 patients who were diagnosed and treated as pancreatic adenocarcinoma from January 1991 to January 1996 were reviewed retrospectively. Survival and survival time were confirmed by patients interview, letter, hospital chart, and personal contact with the attending physician. Results: 166 of the 242 patients were male and 76 patients female. Mean age of 242 patients was 60.4 years. Overall 1-year survival was 14%. 1-year survival of patients with stage I(n=16) was 54%, stage II(n=37) 19%, stage III(n=63) 17%, and stage IV(n=126) 5%. Median survival time of the patients with ECOG grade 0(n=10) was 14 months, grade 1(n=96) 7 months, grade 2(n=70) 4 months, grade 3(n=45) 2 months, and grade 4(n=20) 1 month. When survival groups more than 1 year(n=34) and less than 1 year(n=208) were compared, the patients of survival group more than 1 year had better general health condition(ECOG grade), less tumor size(2.4±0.7 vs 3.4±2.2 cm), less lymph node involvement(35.3 vs 64.9%) and less distant metastasis(14.7 vs 56.7%) than the patients of survival group less than 1 year. One-year survival of the patients who underwent curative resection(n=23) was 51%, palliative resection(n=33) 25% and no resection(n=186) 7%. The patients of survival group more than 1year were treated by more aggressive and multimodality therapy(operation, chemotherapy, radiotherapy) than the patients of survival group less than 1year. All 5 patients of stage IV who survived more than 1year were belonged to ECOG grade 1. No metastatic lesion was found by radiologic study before operation but metastatic lesions were found at operation in all 5 patients. All 5 patients were treated by adjuvant chemotherapy after operation. Conclusion: The patients of survival group more than 1 year had better general health condition(ECOG grade), less tumor size, less lymph node involvement, less distant metastasis and were treated more aggressive therapy than the patients of survival group less than 1year.ope

The Clinical Utility of Serum Lipase/Amylase Ratio in Diagnosis of Acute Pancreatitis

Background/Aims: The serum lipase/amylase ratio has been proposed to distinguish acute episodes of alcoholic from nonalcoholic pancreatitis. We assessed the clinical utility of this ratio in differential diagnosis of etiologies of acute pancreatitis. Methods: We retrospectively reviewed all records with the diagnosis of acute pancreatitis at the Yonsei University Severance Hospital between January 1990 and June 1995. A total of 138 charts were reviewed. For a patient to be included in the subsequent analysis, the following criteria were met: 1) the patient had typical symptoms of pancreatitis, and serum levels of amylase or lipase were elevated, 2) serum lipase and amylase were analyzed within 48 hours of the onset of symptom, 3) serum creatinine was less than 2.5 mg/dL on admission. Twenty one patients satisfied the requirement for inclusion in the study. Data collected from the charts included age, sex, serum amylase and lipase (from this the lipase/amylase ratio was calculated), duration of abdominal pain before admission, length of hospital stay, various laboratory parameters, severity according to the Atlanta classification and positive scores according to Ranson’s criteria. The lipase/amylase ratio was calculated on serum amylase and lipase (expressed as multiples of the upper limit of normal), each of which was obtained at least within 48 hours of the onset of symptom. Eleven patients had acute alcoholic pancreatitis and the remaining 10 patients had acute biliary pancreatitis. Results: All patients with alcoholic pancreatitis were male, while there were 4 male and 6 female patients in biliary pancreatitis group. There was no difference in the serum amylase, lipase and lipase/amylase ratio (p=0.4813) between the two groups. The sensitivity of a lipase/amylase ratio of >2.0 in detecting acute alcoholic pancreatitis was 81.8%, the specificity was 0%. The sensitivity and specificity of a ratio of >3.0 were same to those of a ratio of >2.0. The serum levels of aspartate aminotransferase and alkaline phosphatase were significantly higher(p=0.0004, 0.0003) and hospital stay was much longer(p=0.0198) in patients with biliary pancreatitis than in those with alcoholic pancreatitis. But there was no significant difference in duration of symptoms, Ranson scores, severity and other clinical parameters between the two groups. Conclusion: The lipase/amylase ratio is not useful in distinguishing acute episodes of alcoholic from acute biliary pancreatitis.ope

Non-surgical Treatment of Extrahepatic Bile Duct Stones: Choice of Management Modality

Background: With the greater improvement in endoscopic techniques and lithotripsy devices, the extrahepatic bile duct stones can be managed preferentially by non-surgical modality including endoscopic sphincterotomy(EST). But 10-15% of extrahepatic bile duct stones cannot be removed by non-surgical modality. This study is conducted to evaluate the cause of failure of endoscopic treatment of extrahepatic bile duct stones and its risk factors and decide the guide an index to choice of management modality according to risk factors. Method: We retrospectively reviewed the clinical records of 387 of patients with extrahepatic bile duct stones who were managed by non-surgical modality including EST, mechanical lithotripsy(ML), electrohydrauric lithotripsy(EHL), extracorporeal shock wave lithotripsy(ESWL), endoscopic balloon sphincteroplasty(EBS) between Jan. 1986 and June 1996. Result: The extrahepatic bile duct stones were removed successfully by EBS(10 cases), EST only(26 cases), EST with ballon & basket(252 cases), mechanical lithotriptor(15 cases), and peroral cholangioscope with EHL(5 cases) in 308 cases. The success rate of transpapillary approach for extrahepatic bile duct stones removal was 79.6%. In the remaining 79 cases extrahepatic bile duct stones were removed in 21 cases by ESWL(14 cases) or PTCS with EHL(7 cases). The overall success rate of non-surgical treatment for extrahepatic bile duct stone removal was 85.0%(329/387 cases). The causes of failure for stones removal by transpapillary approach were the failure of EST in 25 cases, failure to capture of stones by basket in 10 cases, large stone in 30 cases, impacted stone in 14 cases. Statistically significant risk factor for failure of extrahepatic bile duct stones removal by transpapillary approach was only size of stones. stones removal was tried by EBS, EST only, and EST with balloon & basket in 96.5% of cases with size of stones less than 20 mm(330/342 cases) but was tried by ML or EHL in 44.4% of cases(20/45 cases) with size of stones more than 20 mm. Complication associated with the procedure were bleeding in 16 cases, acute pancreatitis in 10 cases, perforation in 2 cases, cholangitis/sepsis in 1 case, and acute cholecystitis in 1 case. No mortality was noted. Conclusions: In the cases with size of stone less than 11 mm EBS maybe useful and in size of stone less than 20 mm EST with basket and balloon is more useful to remove the extrahepatic bile duct stones. But stone fragmentation by ML, ESWL, EHL as additional method should be considered in the cases with size of stone more than 20 mm.ope