Publications by authors named "Jae Hyuck Chang"

47 Publications

Unilateral versus bilateral Y-type stent-in-stent metal stent insertions in inoperable malignant hilar biliary strictures: A multicenter retrospective study.

Hepatobiliary Pancreat Dis Int 2021 Aug 14. Epub 2021 Aug 14.

Department of Internal Medicine, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.

Background: To date, there is controversy regarding unilateral versus bilateral stent placement in patients with malignant hilar biliary strictures (MHBSs). The aim of this study was to compare the clinical outcomes and complications of unilateral and bilateral (stent-in-stent method) stent placements for these patients.

Methods: We conducted a multicenter retrospective analysis of patients with inoperable MHBS who underwent endoscopic self-expandable metal stent (SEMS) placement from January 2009 to December 2019. Two groups classified according to the stent procedure method were compared for demographic, procedural, and postprocedure factors. Survival analysis for patency loss and overall survival was also conducted.

Results: A total of 236 subjects were included. A superior technical success rate was found in the unilateral stent group (98.8% vs. 82.5%, P < 0.001), whereas the clinical success rate was higher in the bilateral group (85.7% vs. 70.5%, P = 0.028). There was no significant difference with respect to complications or patency loss, and the bilateral group had better overall survival (P < 0.01). In the Cox proportional hazard model, MHBSs from lymph node compression were associated with a higher risk of death (HR = 9.803, P = 0.003). In contrast, bilateral SEMS insertion showed reduced postprocedural mortality (HR = 0.316, P = 0.001).

Conclusions: Y-type stent-in-stent bilateral SEMSs are technically difficult but demonstrated more favorable overall survival for palliative bile drainage of inoperable MHBS patients compared to unilateral insertions.
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http://dx.doi.org/10.1016/j.hbpd.2021.08.002DOI Listing
August 2021

A systematic review and meta-analysis of effects of menopausal hormone therapy on cardiovascular diseases.

Sci Rep 2020 11 26;10(1):20631. Epub 2020 Nov 26.

Department of Biomedical Sciences, Seoul National University Graduate School, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.

A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies was conducted to assess the association between menopausal hormone therapy and cardiovascular disease. The PubMed and EMBASE databases were searched for articles published from 2000 to 2019, using review methods based on a previous Cochrane review. Quality assessment of RCTs and observational studies was conducted using the Jadad scale and the Newcastle-Ottawa Scale, respectively. A total of 26 RCTs and 47 observational studies were identified. The study populations in the RCTs were older and had more underlying diseases than those in the observational studies. Increased risks of venous thromboembolism [summary estimate (SE), 95% confidence interval (CI): RCTs, 1.70, 1.33-2.16; observational studies, 1.32, 1.13-1.54] were consistently identified in both study types, whereas an increased risk of stroke in RCTs (SE: 1.14, 95% CI: 1.04-1.25) and a decreased risk of myocardial infarction in observational studies (SE: 0.79, 95% CI: 0.75-0.84) were observed. Differential clinical effects depending on timing of initiation, underlying disease, regimen type, and route of administration were identified through subgroup analyses. These findings suggest that underlying disease and timing of initiation should be carefully considered before starting therapy in postmenopausal women.
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http://dx.doi.org/10.1038/s41598-020-77534-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691511PMC
November 2020

The Safety of Radiofrequency Ablation Using a Novel Temperature-Controlled Probe for the Treatment of Residual Intraductal Lesions after Endoscopic Papillectomy.

Gut Liver 2021 Mar;15(2):307-314

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Background/aims: Treatment of residual intraductal lesions after endoscopic papillectomy for ampullary adenomas is relatively difficult. Few studies have been conducted using intraductal radiofrequency ablation (RFA) in the treatment of such lesions, and no study has aimed to reduce the side effects of excessive heat caused by RFA. Recently, a temperature-controlled RFA probe was developed to avoid excessive heat. This study aimed to investigate the safety of this new RFA probe in the treatment of intraductal lesions of ampullary adenoma.

Methods: Patients who received RFA for residual intraductal lesions after endoscopic papillectomy between November 2017 and June 2019 were retrospectively reviewed. A novel temperature- controlled probe (ELRA) was used for intraductal RFA, and clinical data including adverse events were collected.

Results: Ten patients were included in this study. Intraductal adenomas showed low-grade dysplasia in eight patients and high-grade dysplasia in two patients. The median diameter of intraductal adenomas was 9 mm (range, 5 to 10 mm) in the common bile duct and 5 mm (range, 4 to 11 mm) in the pancreatic duct. Adverse events occurred in three patients (30.0%), of which two were mild pancreatitis and one was asymptomatic biliary stricture. Over a median follow-up period of 253 days, only one patient underwent additional surgery, as the remainder showed no adenomatous lesions on follow-up biopsies.

Conclusions: The new temperature-controlled RFA probe can be used with acceptable safety for the treatment of residual intraductal lesions after endoscopic papillectomy. Further evaluation through future prospective studies is needed.
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http://dx.doi.org/10.5009/gnl20043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960966PMC
March 2021

Metachronous Development of Peritoneal Carcinomatosis in a Patient with Autoimmune Pancreatitis.

Korean J Gastroenterol 2020 06;75(6):356-361

Departments of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Autoimmune pancreatitis (AIP) is a rare and unique type of chronic pancreatitis. The prognosis of AIP, particularly when associated with pancreatic cancer or a related malignancy, is not known. Only a few cases, where metachronous pancreas-related cancer developed during follow-up, have been reported. Most of these patients either underwent surgery or steroid therapy. This paper reports a case of a 66-year-old woman with untreated type I AIP who developed peritoneal carcinomatosis more than 2 years later. Initially, the patient had a markedly elevated serum IgG4 level and a diffuse, infiltrative mass-like lesion in the pancreatic head, in which the biopsy results were consistent with type I AIP. The patient was not treated with steroids because of a cerebellar infarction. Twenty-eight months after the diagnosis of AIP, peritoneal carcinomatosis developed without noticeable changes in the pancreas from the initial findings.
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http://dx.doi.org/10.4166/kjg.2020.75.6.356DOI Listing
June 2020

Prolonged hyperamylasemia in patients with acute pancreatitis is associated with recurrence of acute pancreatitis.

Medicine (Baltimore) 2020 Jan;99(3):e18861

Department of Internal Medicine, College of Medicine, the Catholic University of Korea, Seoul, Korea.

Serum amylase levels in patients with acute pancreatitis often remain or fluctuate above the upper normal limit for over a week. This study investigated the clinical characteristics of patients with prolonged hyperamylasemia and their prognoses, including recurrence.We retrospectively analyzed patients with first attacks of acute pancreatitis in a single center between March 2010 and December 2016. Patients were divided into 2 groups according to normalization of the serum amylase levels within a week.A total of 313 patients were enrolled after exclusion. The serum amylase levels were normalized within a week in 205 patients (65.5%, group 1) and elevated over a week in 108 patients (34.5%, group 2). Group 2 was more related to alcohol, higher computed tomography (CT) severity index, local pancreatic complication, and moderately severe pancreatitis than group 1 (P < .05). Recurrent pancreatitis developed significantly more in group 2 (39.8%) than in group 1 (19.5%) (P < .001). The factors related to recurrent pancreatitis were amylase group, sex, alcohol, CT severity index, necrosis, and severity of pancreatitis (P < .05). Multivariate analysis showed that recurrent pancreatitis was independently associated with amylase group (odds ratio [OR] 2.123, 95% confidence interval [CI]= 1.227-3.673, P = .007) and alcohol (OR 2.023, 95% CI 1.134-3.611, P = .017).In conclusion, prolonged hyperamylasemia over a week is associated with recurrence of acute pancreatitis.
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http://dx.doi.org/10.1097/MD.0000000000018861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220070PMC
January 2020

Subsets associated with developing acute pancreatitis in patients with severe hypertriglyceridemia and the severity of pancreatitis.

Pancreatology 2019 Sep 10;19(6):795-800. Epub 2019 Aug 10.

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Background And Objectives: Hypertriglyceridemia (HTG) is a rare but well-recognized cause for acute pancreatitis (AP). This study aimed to determine subsets related to development of AP in patients with severe HTG and the severity of HTG-induced AP (HTG-AP).

Methods: Patients who had severe HTG (serum triglyceride level >1,000 mg/dL) more than once between Jan. 2010 and Dec. 2017 in a single institute were evaluated retrospectively. Patients were divided into two groups, with AP or without AP, and were compared. HTG-APs in patients with severe HTG were compared to APs due to other causes during the same period.

Results: Sixty-three patients (19.3%) presented with AP of a total 326 patients with severe HTG. The AP group displayed younger age, more alcohol consumption and diabetes mellitus, and higher initial/maximum serum levels of triglyceride, glucose, HbA1c, total cholesterol, and calculated non-high-density lipoprotein cholesterol (p < 0.05). HTG-APs were clinically more severe compared with 277 APs due to other causes in terms of CRP (p < 0.001), CT severity index (p = 0.002), revised Atlanta classification (p < 0.001), and hospital stay (p = 0.011). In logistic regression analysis, maximum serum triglyceride level (OR 2.706, p = 0.015), alcohol consumption amount (OR 5.292, p < 0.001), and age (OR 0.358, p = 0.017) were independently associated with development of AP in patients with severe HTG.

Conclusions: Development of AP in patient with severe HTG was independently associated with younger age, higher serum TG level, and more alcohol consumption. HTG-APs are clinically more severe than APs due to other causes.
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http://dx.doi.org/10.1016/j.pan.2019.08.002DOI Listing
September 2019

Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations.

Pancreatology 2019 Jun 19;19(4):488-499. Epub 2019 Apr 19.

First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary.

Background: Unwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis.

Methods: Four methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals.

Results: The systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31-82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy.

Conclusions: The authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.
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http://dx.doi.org/10.1016/j.pan.2019.04.003DOI Listing
June 2019

Organotypic slice cultures of pancreatic ductal adenocarcinoma preserve the tumor microenvironment and provide a platform for drug response.

Pancreatology 2018 Dec 26;18(8):913-927. Epub 2018 Sep 26.

Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Background: /Objective: The conventional models currently used to evaluate various anti-tumor therapeutic agents are not sufficient for representing human pancreatic ductal adenocarcinoma (PDA), which has a unique tumor microenvironment. We aimed to produce an organotypic slice culture model from human PDA that resembles the in vivo situation and to evaluate the responses of PDA slices to established cytotoxic drugs.

Methods: PDA tissues were obtained from 10 patients who underwent pancreatic resection. The tissues were sliced by a vibratome, and the tumor slices were then cultured. The viability of tumor slices during slice culture was evaluated using H&E and immunohistochemical staining, and stromal cells were demonstrated. The effects of cytotoxic drugs on PDA cell lines and slices were analyzed.

Results: Tumor slices maintained their surface areas and tissue viability for at least five days during culture. Preserved proliferation and apoptosis in tumor slices were observed by the expression of Ki-67 and cleaved caspase-3. Stromal cells including macrophages (CD68 and CD163), T cells (CD3, CD8, and FOXP3), and myeloid cells (CD11b) were present throughout the culture period. Staurosporine, gemcitabine, and cisplatin treatment of PDA cell lines and tumor slices exerted proportional cytotoxic effects in terms of MTT viability, tumor cell number, and Ki-67 and cleaved caspase-3 expression.

Conclusions: Organotypic human PDA slice cultures preserved their viability and tumor microenvironment for at least five days during slice culture. PDA slice culture appears to be a feasible preclinical test model to assess the response to anti-tumor agents.
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http://dx.doi.org/10.1016/j.pan.2018.09.009DOI Listing
December 2018

[Treatment of Pancreatic Fluid Collections].

Korean J Gastroenterol 2018 Sep;72(3):97-103

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.
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http://dx.doi.org/10.4166/kjg.2018.72.3.97DOI Listing
September 2018

Outcome of donor biliary complications following living donor liver transplantation.

Korean J Intern Med 2018 07 14;33(4):705-715. Epub 2018 Mar 14.

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Background/aims: Biliary complications are the most common donor complication following living donor liver transplantation (LDLT). The aim of this study is to investigate the long-term outcomes of biliary complications in right lobe adult-to-adult LDLT donors, and to evaluate the efficacy of endoscopic treatment of these donors.

Methods: The medical charts of right lobe donors who developed biliary complications between June 2000 and January 2008 were retrospectively reviewed.

Results: Of 337 right lobe donors, 49 developed biliary complications, including 36 diagnosed with biliary leakage and 13 with biliary stricture. Multivariate analysis showed that biliary leakage was associated with the number of right lobe bile duct orifices. Sixteen donors, five with leakage and 11 with strictures, underwent endoscopic retrograde cholangiography (ERC). ERC was clinically successful in treating eight of the 11 strictures, one by balloon dilatation and seven by endobiliary stenting. Of the remained three, two were treated by rescue percutaneous biliary drainage and one by conservative care. Of the five patients with leakage, four were successfully treated using endobiliary stents and one with conservative care. In overall, total 35 improved with conservative treatment. All inserted stents were successfully retrieved after a median 264 days (range, 142 to 502) and there were no recurrences of stricture or leakages during a median follow-up of 10.6 years (range, 8 to 15.2).

Conclusions: All donors with biliary complications were successfully treated non-surgically, with most improving after endoscopic placement of endobiliary stents and none showing recurrence on long term follow-up.
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http://dx.doi.org/10.3904/kjim.2017.264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6030404PMC
July 2018

Extracellular vesicles in bile: a game changer in the diagnosis of indeterminate biliary stenoses?

Hepatobiliary Surg Nutr 2017 Dec;6(6):408-410

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

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http://dx.doi.org/10.21037/hbsn.2017.10.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756769PMC
December 2017

Long-lived pancreatic ductal adenocarcinoma slice cultures enable precise study of the immune microenvironment.

Oncoimmunology 2017;6(7):e1333210. Epub 2017 May 25.

Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA.

Pancreatic ductal adenocarcinoma (PDA) remains a deadly disease that is rarely cured, despite many recent successes with immunotherapy for other malignancies. As the human disease is heavily infiltrated by effector T cells, we postulated that accurately modeling the PDA immune microenvironment would allow us to study mechanisms of immunosuppression that could be overcome for therapeutic benefit. Using viable precision-cut slices from fresh PDA, we developed an organotypic culture system for this purpose. We confirmed that cultured slices maintain their baseline morphology, surface area, and microenvironment after at least 6 d in culture, and demonstrated slice survival by MTT assay and by immunohistochemistry staining with Ki-67 and cleaved-Caspase-3 antibodies. Immune cells, including T cells (CD3, CD8, and FOXP3) and macrophages (CD68, CD163 and HLA-DR), as well as stromal myofibroblasts (αSMA) were present throughout the culture period. Global profiling of the PDA proteome before and after 6 d slice culture indicated that the majority of the immunological proteins identified remain stable during the culture process. Cytotoxic effects of drug treatment (staurosporine, STS and cycloheximide, CHX) on PDA slices culture confirmed that this system can be used to assess functional response and cell survival following drug treatment in both a treatment time- and dose-dependent manner. Using multicolor immunofluorescence, we stained live slices for both cancer cells (EpCAM) and immune cells (CD11b and CD8). Finally, we confirmed that autologous CFSE-labeled splenocytes readily migrate into co-cultured tumor slices. Thus, our present study demonstrates the potential to use tumor slice cultures to study the immune microenvironment of PDA.
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http://dx.doi.org/10.1080/2162402X.2017.1333210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5543820PMC
May 2017

Role of immune cells in pancreatic cancer from bench to clinical application: An updated review.

Medicine (Baltimore) 2016 Dec;95(49):e5541

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China Department of Surgery, University of Washington Medical Center, Seattle, University of Washington, Seattle, WA.

Background: Pancreatic cancer (PC) remains difficult to treat, despite the recent advances in various anticancer therapies. Immuno-inflammatory response is considered to be a major risk factor for the development of PC in addition to a combination of genetic background and environmental factors. Although patients with PC exhibit evidence of systemic immune dysfunction, the PC microenvironment is replete with immune cells.

Methods: We searched PubMed for all relevant English language articles published up to March 2016. They included clinical trials, experimental studies, observational studies, and reviews. Trials enrolled at Clinical trial.gov were also searched.

Results: PC induces an immunosuppressive microenvironment, and intratumoral activation of immunity in PC is attenuated by inhibitory signals that limit immune effector function. Multiple types of immune responses can promote an immunosuppressive microenvironment; key regulators of the host tumor immune response are dendritic cells, natural killer cells, macrophages, myeloid derived suppressor cells, and T cells. The function of these immune cells in PC is also influenced by chemotherapeutic agents and the components in tumor microenvironment such as pancreatic stellate cells. Immunotherapy of PC employs monoclonal antibodies/effector cells generated in vitro or vaccination to stimulate antitumor response. Immune therapy in PC has failed to improve overall survival; however, combination therapies comprising immune checkpoint inhibitors and vaccines have been attempted to increase the response.

Conclusion: A number of studies have begun to elucidate the roles of immune cell subtypes and their capacity to function or dysfunction in the tumor microenvironment of PC. It will not be long before immune therapy for PC becomes a clinical reality.
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http://dx.doi.org/10.1097/MD.0000000000005541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266022PMC
December 2016

Response to Zhao et al.

Am J Gastroenterol 2016 09;111(9):1361-2

Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea.

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http://dx.doi.org/10.1038/ajg.2016.295DOI Listing
September 2016

mRNA expression of CDH3, IGF2BP3, and BIRC5 in biliary brush cytology specimens is a useful adjunctive tool of cytology for the diagnosis of malignant biliary stricture.

Medicine (Baltimore) 2016 Jul;95(27):e4132

Department of Internal Medicine Institute of Clinical Medicine Research Department of Hospital Pathology Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Although advances have been made in diagnostic tools, the distinction between malignant and benign biliary strictures still remains challenging. Intraductal brush cytology is a convenient and safe method that is used for the diagnosis of biliary stricture, but, low sensitivity limits its usefulness. This study aimed to demonstrate the usefulness of mRNA expression levels of target genes in brush cytology specimens combined with cytology for the diagnosis of malignant biliary stricture. Immunohistochemistry for cadherin 3 (CDH3), p53, insulin-like growth factor II mRNA-binding protein 3 (IGF2BP3), homeobox B7 (HOXB7), and baculoviral inhibitor of apoptosis repeat containing 5 (BIRC5) was performed in 4 benign and 4 malignant bile duct tissues. Through endoscopic or interventional radiologic procedures, brush cytology specimens were prospectively obtained in 21 and 35 paitents with biliary strictures. In the brush cytology specimens, the mRNA expressions levels of 5 genes were determined by real-time polymerase chain reaction. Immunohistochemistry for CDH3, p53, IGF2BP3, HOXB7, and BIRC5 all showed positive staining in malignant tissues in contrast to benign tissues, which were negative. In the brush cytology specimens, the mRNA expression levels of CDH3, IGF2BP3, HOXB7, and BIRC5 were significantly higher in cases of malignant biliary stricture compared with cases of benign stricture (P = 0.006, P < 0.001, P < 0.001, and P = 0.001). The receiver-operating characteristic curves of these 4 mRNAs demonstrated that mRNA expression levels are useful for the prediction of malignant biliary stricture (P = 0.006, P < 0.001, P < 0.001, and P = 0.002). The sensitivity and specificity, respectively, for malignant biliary stricture were 57.1% and 100% for cytology, 57.1% and 64.3% for CDH3, 76.2% and 100% for IGF2BP3, 71.4% and 57.1% for HOXB7, and 76.2% and 64.3% for BIRC5. When cytology was combined with the mRNA levels of CDH3, IGF2BP3, or BIRC5, the sensitivity for malignant biliary stricture improved to 90.5%. The measurement of the mRNA expression levels of CDH3, IGF2BP3, and BIRC5 by real-time polymerase chain reaction combined with cytology was useful for the differentiation of malignant and benign biliary strictures in brush cytology specimens.
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http://dx.doi.org/10.1097/MD.0000000000004132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058855PMC
July 2016

Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation.

World J Gastroenterol 2016 Jan;22(4):1593-606

Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
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http://dx.doi.org/10.3748/wjg.v22.i4.1593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721991PMC
January 2016

Effect of Dynamic Position Changes on Adenoma Detection During Colonoscope Withdrawal: A Randomized Controlled Multicenter Trial.

Am J Gastroenterol 2016 Jan 3;111(1):63-9. Epub 2015 Nov 3.

Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Objectives: Adequate luminal distension is essential for improving adenoma detection during colonoscope withdrawal. A few crossover studies have reported that dynamic position changes maximize luminal distension and increase adenoma detection rates (ADR). We designed a multicenter, randomized, parallel-group trial to verify the effect of dynamic position changes on colonic adenoma detection.

Methods: This study was conducted at the six hospitals of the Catholic University of Korea. Patients aged 45-80 years who underwent a colonoscopy for the first time were included. In the position change group, the position changes during colonoscope withdrawal were as follows: cecum, ascending colon, and hepatic flexure: left lateral position; transverse colon: supine position; splenic flexure, descending colon, sigmoid colon, and rectum: right lateral position. In the control group, the examinations were performed entirely in the left lateral position during colonoscope withdrawal. The primary outcome measure was the ADR, which was defined as the proportion of patients with ≥1 adenoma.

Results: A total of 1,072 patients were randomized into the position change group (536 patients) or the control group (536 patients). The ADR was higher in the position change group than in the control group (42.4 vs. 33.0%, P=0.002). More adenomas were detected per subject in the position change group (0.90 vs. 0.67, P=0.01). Increases in the number of adenomas were observed in examinations of the transverse colon (0.22 vs. 0.13, P=0.016) and the left colon (0.37 vs. 0.27, P=0.045). A significant increase in the ADR was observed for endoscopists with a relatively low detection rate. For endoscopists with a high detection rate, non-significant changes in the ADR were observed.

Conclusions: Dynamic position changes during colonoscope withdrawal increased the ADR.
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http://dx.doi.org/10.1038/ajg.2015.354DOI Listing
January 2016

Interleukin-6 is associated with obesity, central fat distribution, and disease severity in patients with acute pancreatitis.

Pancreatology 2015 Jan-Feb;15(1):59-63. Epub 2014 Nov 18.

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Background/objective: Acute pancreatitis (AP) is a systemic inflammatory disease, and cytokines are suggested to be related to the course of AP. Obesity and central fat distribution are considered to have been associated with severe AP. This study investigated the profile of inflammatory cytokines in AP to determine how they are related to obesity, central fat distribution, and AP severity.

Methods: Fifty-nine patients with AP were prospectively enrolled in the study. Body mass index and waist circumference were obtained at admission. Serum levels of inflammatory cytokines, IL-Iβ, IL-1ra, IL-6, TNF-α, sTNFR-I, and sTNFR-II, were measured on day 1 and 2 of AP.

Results: Of the patients included in the study, 19 (32%) were overweight, 23 (39%) had central fat distribution, and 23 (39%) had moderate AP. IL-1ra and IL-6 were significantly higher in overweight patients compared with non-overweight patients. IL-1ra, IL-6, TNF-α, and sTNFR-I were significantly higher in patients with central fat distribution compared with patients with non-central fat distribution. IL-6, sTNFR-I, and sTNFR-II were significantly higher in patients with moderate pancreatitis compared to those with mild pancreatitis. Among the six cytokines, IL-6 was commonly elevated in patients with central fat distribution, overweight, and moderate AP. The areas under the receiver operating characteristic curves of IL-6 for predicting the association with overweight, central fat distribution, and AP severity were 0.678, 0.716, and 0.801, respectively (P < 0.05).

Conclusions: IL-6 is a good marker for AP severity and is associated with obesity and central fat distribution in AP patients.
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http://dx.doi.org/10.1016/j.pan.2014.11.001DOI Listing
October 2015

Size of recurrent symptomatic common bile duct stones and factors related to recurrence.

Turk J Gastroenterol 2014 Oct;25(5):518-23

Department of Internal Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.

Background/aims: Some common bile duct (CBD) stones recur after endoscopic stone extraction. Little information is available on the size and recurrence interval of recurrent symptomatic CBD stones or on ways to prevent recurrence.

Materials And Methods: Between January 2007 and December 2011, consecutive 481 patients undergoing endoscopic extraction of CBD stones at a single institute were enrolled. We selected 34 patients with recurrent symptomatic CBD stones and 63 patients who were followed up more than five years without recurrence.

Results: The sizes of the CBD stones increased during the recurrences: 10.1±5.2 mm, 13.5±7.3 mm, and 16.8±7.8 mm at the initial presentation, the first recurrence, and the second recurrence, respectively (p=0.016). Among CBD stone recurrences, 50% occurred within 2.3 years, and 80% occurred within 5.3 years. The recurrence group had a smaller proportion of patients under 50 years of age, larger CBD diameters, less histories of more than 10 mm endoscopic papillary large-balloon dilation (EPLBD), and more type I periampullary diverticula, compared with the non-recurrence group (p<0.05). Multivariate analysis revealed that EPLBD more than 10 mm and smaller CBD diameter were independently related to less recurrence of CBD stones (p=0.001 and 0.012, respectively).

Conclusion: The sizes of CBD stones increased during recurrences. EPLBD more than 10 mm and smaller CBD diameter were related to less recurrence of CBD stones.
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http://dx.doi.org/10.5152/tjg.2014.6457DOI Listing
October 2014

Rescue balloon dilation of the ampulla for retrieving an impacted biliary extraction basket.

J Dig Dis 2014 Nov;15(11):636-9

Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.

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http://dx.doi.org/10.1111/1751-2980.12181DOI Listing
November 2014

Undiagnosed Borrmann type II gastric cancer due to necrosis and regenerative epithelium.

World J Gastroenterol 2014 Jul;20(28):9621-5

Joon Hur, Jae Hyuck Chang, Hoon Young Ko, Jong Hwan Lee, Soo Jeong Kim, Mi Ae Song, Tae Ho Kim, Chang Whan Kim, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Bucheon 420-717, South Korea.

Endoscopic biopsy is essential to the proper diagnosis and treatment of gastric cancer. Unfortunately, the results of endoscopic biopsy are not always the same as what is expected based on gross endoscopic findings. The results of endoscopic biopsy can be negative for malignancy in Borrmann type IV advanced gastric cancer (AGCa) or gastric lymphoma. However, in the case of type II AGCa, repeated biopsies negative for malignancy have not been reported. A 49-year-old male patient underwent esophagogastroduodenoscopy three times due to large gastric ulcer suspected to be Borrmann type II cancer. However, three repeat endoscopic biopsies with multiple specimens showed necrosis and superficial regenerative epithelium without malignant findings. The patient underwent laparoscopic distal gastrectomy with D2 lymph node dissection. The surgical specimen revealed that the mucosal layer was completely replaced with regenerative epithelium without cancer cells.
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http://dx.doi.org/10.3748/wjg.v20.i28.9621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110598PMC
July 2014

Initial large diameter of common bile duct is associated with long-term dilatation of bile duct after endoscopic extraction of stones.

J Dig Dis 2014 Jan;15(1):35-41

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Objective: To investigate the time and extent of recovery of dilated common bile duct (CBD) after the extraction of CBD stones and to identify the factors related to the long-term dilatation of the CBD after stone removal.

Methods: Data of 329 consecutive patients undergoing endoscopic extraction of CBD stones from January 2008 to December 2012 were retrospectively reviewed. Finally, 44 patients were enrolled in the study.

Results: The CBD diameter significantly decreased after stone extraction (P < 0.001). However, the CBD diameter in patients who were followed up for 1 week and longer and <1 week did not differ significantly. The diameter decreased more in patients with an initial CBD diameter ≥ 15 mm than in those with an initial CBD diameter <15 mm before stone extraction (P = 0.007), but the normalization of dilated CBD was less frequent in patients with a large initial CBD diameter. The factors related to the long-term dilatation of CBD (>10 mm for >6 months) were initial CBD diameter, the largest diameter of CBD stone and endoscopic papillary large balloon dilatation. Initial CBD diameter was an independent factor with multivariate analysis (OR 1.754, P = 0.017).

Conclusions: The CBD diameter recovers rapidly after the extraction of CBD stones. An initial large CBD diameter before stone extraction is associated with the long-term dilatation of CBD.
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http://dx.doi.org/10.1111/1751-2980.12100DOI Listing
January 2014

Gastroprotective Effects of Grape Seed Proanthocyanidin Extracts against Nonsteroid Anti-Inflammatory Drug-Induced Gastric Injury in Rats.

Gut Liver 2013 May 9;7(3):282-9. Epub 2013 Apr 9.

Department of Internal Medicine, Catholic Research Institute of Medical Sciences, The Catholic University of Korea College of Medicine, Seoul, Korea.

Background/aims: To investigate the gastroprotective effects of grape seed proanthocyanidin extracts (GSPEs) against nonsteroid anti-inflammatory drug (NSAID)-induced gastric mucosal injury in rats.

Methods: Sprague-Dawley rats were randomly allocated to the normal control, indomethacin, low-dose GSPE, high-dose GSPE and misoprostol groups. All groups except the normal control group received pretreatment drugs for 6 consecutive days. On the 5th and 6th day, indomethacin was administered orally to all groups except for normal control group. The microscopic features of injury were analyzed. The levels of gastric mucosal glutathione, gastric mucosal prostaglandin E2 (PGE2), and proinflammatory cytokines were investigated.

Results: The total areas of ulceration in the GSPE and misoprostol groups were significantly decreased compared with the indomethacin group (p<0.05). However, a difference in ulcer formation among the drug treatment groups was not observed. Meanwhile, the glutathione levels in the high-dose GSPE group were higher than those of both the indomethacin and misoprostol groups (p<0.05) and were similar to those of the normal control group. Additionally, there was no difference among the groups in the levels of gastric mucosal PGE2 and proinflammatory cytokines.

Conclusions: High-dose GSPE has a strong protective effect against NSAID-induced gastric mucosal injury, which may be associated with the antioxidant effects of GSPE.
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http://dx.doi.org/10.5009/gnl.2013.7.3.282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3661959PMC
May 2013

Common bile duct stones on multidetector computed tomography: attenuation patterns and detectability.

World J Gastroenterol 2013 Mar;19(11):1788-96

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 505 Banpo-Dong, Seocho-Gu, Seoul 137-701, South Korea.

Aim: To investigate the attenuation patterns and detectability of common bile duct (CBD) stones by multidetector computed tomography (MDCT).

Methods: Between March 2010 and February 2012, 191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography (ERCP) were enrolled and reviewed retrospectively. The attenuation patterns of CBD stones on MDCT were classified as heavily calcified, radiopaque, less radiopaque, or undetectable. The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol, mixed cholesterol, brown pigment, and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated.

Results: MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity. The attenuation patterns of CBD stones on MDCT were heavily calcified 34 (26%), radiopaque 31 (24%), less radiopaque 46 (35%), and undetectable 19 (15%). The radiopacity of CBD stones differed significantly according to stone type (P < 0.001). From the receiver operating characteristic curve, stone size was useful for the determination of CBD stone by MDCT (area under curve 0.779, P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm. The factors related to detectability of CBD stones on MDCT were age, stone type, and stone size on multivariate analysis (P < 0.05).

Conclusion: The radiopacity of CBD stones on MDCT differed according to stone type. Stone type and stone size were related to the detectability by MDCT, and appropriate cut-off stone size was 5 mm.
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http://dx.doi.org/10.3748/wjg.v19.i11.1788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607755PMC
March 2013

Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones.

J Gastroenterol Hepatol 2013 May;28(5):893-8

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Background And Aim: Periampullary diverticula (PAD) are not uncommon findings during endoscopic retrograde cholangiopancreatography, but its clinical significance had not been established. To investigate the clinical characteristics associated with PAD and their relationships with the type and size of PAD in patients with common bile duct (CBD) stones was aimed.

Methods: Three hundred seventy patients undergoing endoscopic retrograde cholangiopancreatography between March 2010 and July 2012 were consecutively enrolled, and their demographics, laboratory data, and CBD stone-related characteristics according to PAD type and PAD size were analyzed.

Results: Mean age, mean size of CBD stones, prevalence of systemic inflammatory response syndrome, and serum C-reactive protein level differed in patients with CBD stones according to the presence or absence of PAD. The presence of PAD and positive blood culture were correlated with systemic inflammatory response syndrome (P = 0.033 and P < 0.001, respectively). The recurrence of CBD stones was more frequent, and the diameter of CBD was larger in patients with PAD type I than in those with PAD type III. Mean age and CBD diameter were lower in patients with PAD size < 15 mm than those with PAD size ≥ 15 mm. Multivariate analyses indicated that CBD diameter was related to PAD size (P = 0.002) and the recurrence of CBD stones was related to PAD type (P = 0.001).

Conclusions: PAD are associated with larger CBD stones and severe cholangitis with CBD stones. CBD diameter is related to PAD size, and the recurrence of CBD stones is related to PAD type.
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http://dx.doi.org/10.1111/jgh.12184DOI Listing
May 2013

Newly developed autoimmune cholangitis without relapse of autoimmune pancreatitis after discontinuing prednisolone.

World J Gastroenterol 2012 Nov;18(41):5990-3

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.

A 57-year-old man presented with a 2-wk history of painless jaundice and weight loss. He had a large ill-defined enhancing mass-like lesion in the uncinate process of the pancreas with stricture of the distal common bile duct. Aspiration cytology of the pancreatic mass demonstrated inflammatory cells without evidence of malignancy. Total serum immunoglobulin G level was slightly elevated, but IgG4 level was normal. After the 2-wk 40 mg prednisolone trial, the patient's symptoms and bilirubin level improved significantly. A follow-up computed tomography (CT) scan showed a dramatic resolution of the pancreatic lesion. A low dose steroid was continued. After six months he self-discontinued prednisolone for 3 wk, and was presented with jaundice again. A CT scan showed newly developed intrahepatic biliary dilatation and marked concentric wall thickening of the common hepatic duct and the proximal common bile duct without pancreatic aggravation. The patient's IgG4 level was elevated to 2.51 g/L. Prednisolone was started again, after which his serum bilirubin level became normal and the thickening of the bile duct was resolved. This case suggests that autoimmune pancreatitis can progress to other organs that are not involved at the initial diagnosis, even with sustained pancreatic remission.
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http://dx.doi.org/10.3748/wjg.v18.i41.5990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491610PMC
November 2012

Comparative study of rendezvous techniques in post-liver transplant biliary stricture.

World J Gastroenterol 2012 Nov;18(41):5957-64

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.

Aim: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures.

Methods: The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively.

Results: The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group.

Conclusion: The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.
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http://dx.doi.org/10.3748/wjg.v18.i41.5957DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491604PMC
November 2012

Duodenal obstruction following acute pancreatitis caused by a large duodenal diverticular bezoar.

World J Gastroenterol 2012 Oct;18(38):5485-8

Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.

Bezoars are concretions of indigestible materials in the gastrointestinal tract. It generally develops in patients with previous gastric surgery or patients with delayed gastric emptying. Cases of periampullary duodenal divericular bezoar are rare. Clinical manifestations by a bezoar vary from no symptom to acute abdominal syndrome depending on the location of the bezoar. Biliary obstruction or acute pancreatitis caused by a bezoar has been rarely reported. Small bowel obstruction by a bezoar is also rare, but it is a complication that requires surgery. This is a case of acute pancreatitis and subsequent duodenal obstruction caused by a large duodenal bezoar migrating from a periampullary diverticulum to the duodenal lumen, which mimicked pancreatic abscess or microperforation on abdominal computerized tomography. The patient underwent surgical removal of the bezoar and recovered completely.
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http://dx.doi.org/10.3748/wjg.v18.i38.5485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3471120PMC
October 2012

Ectopic pancreas bleeding in the jejunum revealed by capsule endoscopy.

Clin Endosc 2012 Sep 22;45(3):194-7. Epub 2012 Aug 22.

Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea.

Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evident when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas located in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.
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http://dx.doi.org/10.5946/ce.2012.45.3.194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429734PMC
September 2012

Role of magnetic resonance cholangiopancreatography for choledocholithiasis: analysis of patients with negative MRCP.

Scand J Gastroenterol 2012 Feb 8;47(2):217-24. Epub 2011 Dec 8.

Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea.

Objective: To investigate the negative predictive value of magnetic resonance cholangiopancreatography (MRCP) for common bile duct (CBD) stones and the prognosis of patients suspected to have choledocholithiasis in whom the MRCP was negative for CBD stones.

Methods: We enrolled the patients suspected to have choledocholithiasis in whom the MRCP was negative for the CBD stones between January 2008 and March 2011 and retrospectively analyzed the outcomes of 115 patients.

Results: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 27 patients (23%, group 1), and none had CBD stones. The negative predictive value of MRCP was 100%. During a median follow-up of 18.3 months, acute cholangitis with newly developed CBD stones occurred in two patients. Eighty-eight patients (77%, group 2) did not undergo ERCP and all recovered from acute cholangitis without CBD surgery. During a median follow-up of 18.7 months, acute cholangitis, acute cholecystitis, gallstone pancreatitis, and pancreatico-biliary cancers occurred in four (4.6%), three (3.5%), one (1.2%), and three (3.5%) patients, respectively. New CBD stones were found in only two patients among four patients with recurrent acute cholangitis. No patient had recurrent cholangitis caused by MRCP-missed CBD stones. The rates of recurrent cholangitis and cholangitis-free survival did not differ between groups 1 and 2.

Conclusion: The negative predictive value of MRCP was very high. ERCP can be reserved for patients who are MRCP negative for choledocholithiasis, but close follow-up is needed because of recurrent cholangitis or pancreatico-biliary cancer.
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http://dx.doi.org/10.3109/00365521.2011.638394DOI Listing
February 2012
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