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Volume 42(5); May 2011
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Quality Improvement in Digestive Endoscopy
Yu Kyung Cho, M.D.
Korean J Gastrointest Endosc 2010;42(5):25-29.   Published online March 27, 2010
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Obesity and Endoscopic Treatment
Sung Soo Kim, M.D.
Korean J Gastrointest Endosc 2011;42(5):275-282.   Published online May 28, 2011
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Obese patients have been increasing with the development of a social economy. Obesity is a disease with high mortality rates due to associated cardiovascular disease and diabetes. Diet or exercise therapy, medications, bariatric surgery are used for treating obesity. However, although bariatric surgery is safe and effective, it is expensive, and reoperation is a burden if patients fail to lose weight. Operative complications are also a problem. The recent development of endoluminal techniques may permit obesity treatment and many endoscopic procedures have been attempted. The role of endoscopy for treating obesity is treating the postoperative complications of bariatric surgery, for example, a stricture or widening of the anastomosis, fistula, or leaks. Second, endoscopic applications could be used for weight reduction to temporarily bridge surgery for high-risk patients with obesity, and for reducing weight in patients unable to undergo surgery. This article provides a brief overview of bariatric surgery and its complications and introduces several endoscopic applications to treat obesity. (Korean J Gastrointest Endosc 2011;42:275-282)
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Effect of Previous Abdominal or Pelvic Surgery on Colonoscopy
Chang Wook Jeong, M.D., Sang Goon Shim, M.D., Geon Tae Park, M.D., Ji Eun Oh, M.D., Ji Eun Yi, M.D., Jae Gon Woo, M.D., Dae Hyeon Cho, M.D. and Gil Jong Yoo, M.D.
Korean J Gastrointest Endosc 2011;42(5):283-288.   Published online May 28, 2011
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Background/Aims: A number of studies have reported wide variability in the colonoscope insertion time among patients who had prior abdominal surgery. The aim of this study was to investigate the effect of abdominal surgery on colonoscope insertion time.

Methods: The subjects were 192 patients with prior abdominal surgery, among 3,600 patients who underwent a colonoscopy at Samsung Changwon Hospital from May 2008 to May 2010. We collected the following data: insertion time, age, gender, height, weight, BMI, waist circumference, method of abdominal surgery, and the degree of bowel cleanliness. Previous abdominal operations were divided into colectomy, non-colectomy abdominal surgery, pelvic surgery, and laparoscopic surgery groups.

Results: The average colonoscope insertion time in patients with prior abdominal surgery (7.73±5.95 min) was longer than that of the non-surgery group (6.4±3.88 min). Patients in the colectomy groups were older and had a shorter insertion time (5.11±3.32 min) than patients in the other groups.

Conclusions: Insertion of a colonoscope in patients with previous abdominal surgery was more difficult than that in the control group, except the colectomy group. (Korean J Gastrointest Endosc 2011;42:283-288)

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Colonoscopic Perforation During a Diagnostic Colonoscopy
Jeong Ho Kim, M.D., Eun Jung Jeon, M.D., Jun Ho Song, M.D., Sang Hun Lee, M.D., Jin Hwan Jung, M.D., Dae Young Cheung, M.D., Jin Il Kim, M.D., Soo Heon Park, M.D. and Jae Kwang Kim, M.D.
Korean J Gastrointest Endosc 2011;42(5):289-292.   Published online May 28, 2011
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Background/Aims: Colonoscopy is a useful method for detecting colorectal disease, but complications are on the rise due to the increasing number of colonoscopies. The aim of this study was to analyze colon perforations following diagnostic colonoscopies.

Methods: We performed retrospective reviews of all patients with colonoscopic perforations between January 2000 and June 2010.

Results: Of 25,883 diagnostic colonoscopies performed, seven cases of colon perforations were reported. Among those, five cases had an abdominal operation history; the site of perforation was the sigmoid colon in three cases and the rectum in four cases. The manipulation type was forward viewing in three cases and retroflexion in four cases. The time to diagnosis was immediate in six cases and delayed in one case, and treatment was conservative management in three cases and surgical management in four cases.

Conclusions: Special attention is required for patients with a previous abdominal operation and retroflexion. Even after perforations occur, favorable outcomes can be obtained by conservative treatment if the patient's condition is stable, the bowel preparation is proper, and there are no signs of peritonitis. (Korean J Gastrointest Endosc 2011;42:289-292)

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Razor Blade Removal from the Cervical Esophagus Utilizing a Novel Modification of the Overtube
Sang Ryol Ryu, M.D., Seong Hwan Kim, M.D., Choon Sik Seon, M.D., Mi Yeon Chung, M.D., Sang Bong Ahn, M.D., Byoung Kwan Son, M.D., Yun Ju Jo, M.D. and Young Sook Park, M.D.
Korean J Gastrointest Endosc 2011;42(5):293-296.   Published online May 28, 2011
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Foreign bodies in the upper esophagus should be removed as soon as possible to avoid serious complications. These foreign bodies can penetrate the bowel wall and cause severe complications. The peristalsis of the esophagus is not strong enough to prevent it from retaining swallowed objects. Hence, perforation from a foreign body is more likely to occur in the esophagus than in the rest of the gastrointestinal tract. A razor blade is a rare foreign body of the esophagus. Its sharpness and large size make it difficult to remove. A razor blade was very firmly impacted in the esophageal wall in our case, and the razor blade had not moved from the upper esophagus. A standard overtube has limitations to remove a razor blade inside the overtube's lumen. We report here on a case of using a wedge resected overtube made it possible to successfully extract a razor blade and no serious complications occurred after extraction of the razor blade. (Korean J Gastrointest Endosc 2011;42:293-296)
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A Case of Double Pylorus Developed on the Gastric Body
Jeong Bae Park, M.D. and Jin Ho Lee, M.D.*
Korean J Gastrointest Endosc 2011;42(5):297-300.   Published online May 28, 2011
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Double pylorus is a rare disease. It is described by a double communication between the gastric antrum and the duodenal bulb. The cause of double pylorus is either a congenital abnormality or an acquired condition. It is believed to be mostly a complication of peptic ulcer disease. Most reports revealed conditions only for the gastric antrum. However, case reports describing the involvement of the gastric body are extremely rare. Herein, we report a case of a double pylorus that developed on the gastric body and we present a review of the literature. (Korean J Gastrointest Endosc 2011;42:297-300)
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Two Cases of Aspiration Pneumonia after Endoscopic Submucosal Dissection
Ji Young Choi, M.D., Do Hoon Kim, M.D., Ji Yong Ahn, M.D., Hyun Joo Park, M.D., Gui Jun Yun, M.D., Young Saeng Kim, M.D., Hwoon-Yong Jung, M.D. and Jin-Ho Kim, M.D.
Korean J Gastrointest Endosc 2011;42(5):301-305.   Published online May 28, 2011
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The greatest advantage of endoscopic submucosal dissection (ESD) in the stomach is that it can be used to perform en bloc resection of a large gastric neoplasm. However, ESD is more technically difficult and more commonly associated with prolonged procedure time and complications than conventional endoscopic mucosal resection. Until now, only a few reports have considered aspiration pneumonia after ESD, which is rare, but can be fatal. We experienced two cases of aspiration pneumonia after ESD with a gastric neoplasm. One was treated by intensive care with mechanical ventilation, and the other by antibiotics only. Prevention is thought to be important for aspiration pneumonia after ESD; therefore, patients at high risk for aspiration pneumonia are urged to take precautions. We considered various factors contributing to aspiration under endoscopy, such as local pharyngeal anesthesia, procedural time, and bleeding. (Korean J Gastrointest Endosc 2011;42:301-305)
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A Case of Henoch-Schönlein Purpura Involving Colon Mimicking Colon Cancer
Seung Hoon Park, M.D., Jin-Oh Kim, M.D., Hyun Gun Kim, M.D., Tae Hee Lee, M.D., Wan Jung Kim, M.D., Sung Wook Hong, M.D., Sung Gon Jun, M.D. and So Young Jin, M.D.*
Korean J Gastrointest Endosc 2011;42(5):306-310.   Published online May 28, 2011
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Henoch-Schönlein purpura is the most common form of systemic vasculitis in children but occurs rarely in adults. Henoch-Schönlein purpura has characteristic features of a purpuric skin rash, abdominal pain, arthralgia, and abnormal urinary findings. Gastrointestinal tract involvement is characterized by abdominal pain and gastrointestinal bleeding. Recently, we experienced a case of Henoch-Schönlein purpura with gastrointestinal involvement mimicking colon cancer in a 41-year-old female who complained of erythematous macules, arthralgia, and abdominal pain. The initial colonoscopic findings and computed tomographs failed to rule out colon cancer, but serial endoscopic examinations and clinical manifestations revealed colonic involvement of Henoch-Schönlein purpura. (Korean J Gastrointest Endosc 2011;42:306-310)
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A Case of Stercoral Perforation of Sigmoid Colon Diagnosed by Colonoscopy
Won Jang, M.D., Tae Joo Jeon, M.D., Ran Heo, M.D., Hwa Mi Kang, M.D., Tae-Hoon Oh, M.D., Dong Dae Seo, M.D., Won Chang Shin, M.D. and Hyun-Jung Kim, M.D.*
Korean J Gastrointest Endosc 2011;42(5):311-314.   Published online May 28, 2011
AbstractAbstract PDF
Stercoral perforation of the colon is a rare disease. Yet, in recent times, the number of reported cases has increased because of the growing elderly population. Stercoral perforation of the colon usually occurs in the elderly or bedridden patients with chronic constipation. Stercoral perforation may cause a massive hemorrhage or peritonitis. The prognosis of stercoral perforation is poor, as the reported postoperative mortality is 35∼40%. So, early diagnosis and proper treatment are very important for improving survival. However, making an early diagnosis may be difficult because of the nonspecific initial symptoms. We experienced a case of stercoral perforation that was diagnosed by colonoscopy. The defect was in the sigmoid colon, and it was covered with peritoneum. The patient completely recovered after resection and anastomosis of the perforated colon. We report here on this case with a review of the relevant literature. (Korean J Gastrointest Endosc 2011;42:311-314)
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A Case of Transient Small Intestinal Intussusceptions in an Adult
Yeong Geol Jo, M.D., Tae Hee Lee, M.D., Soon Hyo Kwon, M.D., Gang Il Cheon, M.D., Hyun Gun Kim, M.D., Wan Jung Kim, M.D., Jin Oh Kim, M.D. and Joon Seong Lee, M.D.
Korean J Gastrointest Endosc 2011;42(5):315-319.   Published online May 28, 2011
AbstractAbstract PDF
Intussusception occurs when a segment of the bowel invaginates into the lumen of an adjacent distal segment. Intussusception in adults is a rare disease, accounting for only 5% of all cases. Asymptomatic small bowel intussusception in adults without a lead point is usually transient. When the length of the intussusception is less than 3.5 cm, it can be managed conservatively. This case was an asymptomatic small bowel intussusception without a lead point, which was discovered incidentally during an abdominal computed tomography scan. Spontaneous reduction in the intussusception was observed without any complications while maintaining conservative treatment only. (Korean J Gastrointest Endosc 2011; 42:315-319)
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A Case of Biliary Cast Syndrome in a Non-liver Transplatation Patients
Hong Joo Lee, M.D., Jung Il Lee, M.D.*, Ji Young Park, M.D., Jung Kook Wi, M.D., Kyung Hwan Kang, M.D., Hoe Hoon Chung, M.D., Jung Wook Kim, M.D. and Kyung Min Cho, M.D.
Korean J Gastrointest Endosc 2011;42(5):320-322.   Published online May 28, 2011
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The development of total biliary casts is very unusual, and especially in patients who have not undergone liver transplantation. There are only a few reports of total biliary casts in non-liver transplantation patients who have antiphospholipid antibody syndrome, B-cell non-Hodgkin's lymphoma, cholecystectomy or allogenic hematopoietic stem cell transplantation. Here we present the case of a previously well 77-year-old man who developed a total biliary casts without any risk factors and there was no obvious liver insult. The casts were managed endoscopically. (Korean J Gastrointest Endosc 2011;42:320-322)
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A Case of Pancreatic Cancer and Opioid Withdrawal after Endoscopic Ultrasound-guided Celiac Plexus Neurolysis
Soo Hwan Seol, M.D., Hyun Soo Kim, M.D., Byung Sik Hwang, M.D., Dae Myung Oh, M.D., In Yub Baek, M.D., Min Kyu Park, M.D., Hyon Uk Ryu, M.D. and Jong Kyu Kwon, M.D.
Korean J Gastrointest Endosc 2011;42(5):323-326.   Published online May 28, 2011
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Pancreatic cancer is usually unresectable upon diagnosis, and treatment aims to optimize the quality of the patient's life by managing symptoms, and, particularly, by providing adequate pain control. When the pain is refractory to opioids, interventions such as celiac plexus neurolysis (CPN) can be considered. Endoscopic ultrasound (EUS)-guided CPN has been introduced for pancreatic cancer. Reported herein is a case of a 75 year-old man with pancreatic cancer who was treated with opioids due to severe abdominal pain. EUS-guided CPN was performed for pain control, and the opioid administration was discontinued as the pain improved dramatically. However, the patient experienced opioid withdrawal symptoms, including anxiety, insomnia, nausea, and vomiting. Thus, although EUS-guided CPN successfully reduced pain in a patient undergoing such treatment and to whom opioid was administered, opioid administration should not be abruptly discontinued. Rather, the opioid dose should be reduced gradually to avoid drug withdrawal. (Korean J Gastrointest Endosc 2011;42:323-326)
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A Case of Benign Biliary Stricture as a Complication of Photodynamic Therapy for Biliary Papillomatosis
Mun Ki Choi, M.D., Dong Uk Kim, M.D., Gwang Ha Kim, M.D., Geun Am Song, M.D., Hyung Seok Nam, M.D., Yang Seon Yi, M.D., Kang Hee Ahn, M.D. and Jung Seop Eom, M.D.
Korean J Gastrointest Endosc 2011;42(5):327-333.   Published online May 28, 2011
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Biliary papillomatosis is a rare disease with a high risk of recurrence and malignant transformation. Therapeutic options include partial hepatectomy, Whipple's procedure and liver transplantation. If there is no surgical option left due to several reasons, local palliative procedures such as biliary stenting and drainage for the treatment of cholestasis are considered, but tumor growth cannot be influenced. Photodynamic therapy might be a new additional, palliative option for patients with biliary papillomatosis who are not eligible for surgery. Benign biliary stricture is a rare complication of photodynamic therapy. We report here a case of a 63-year-old male who developed benign biliary stricture after photodynamic therapy using the photosensitizer photofrin. (Korean J Gastrointest Endosc 2011;42:327-333)
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Four Cases of Guidewire Induced Periampullary Perforation During Endoscopic Retrograde Cholangiopancreatography
Tae Hoon Lee, M.D., Sang-Heum Park, M.D., Bum Suk Son, M.D., Baek Gyu Jun, M.D., Jun Young Eun, M.D., Jae Yun Kim, M.D., Sae Hwan Lee, M.D. and Sun-Joo Kim, M.D.
Korean J Gastrointest Endosc 2011;42(5):334-340.   Published online May 28, 2011
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Duodenal perforation associated with endoscopic retrograde cholangiopancreatography is very uncommon. However, it usually requires early diagnosis and surgical management. Perforations are commonly caused by endoscopic sphincterotomy, biliary or duodenal stent placement, guidewire-related causes, and endoscopy itself. Perforatioins can follow various clinical courses, and management depends on the cause of the perforation. Among the above causes, guidewire-induced perforation is very rare and related reports and analyses are limited. Herein we describe four cases of guidewire-induced periampullary perforation during endoscopic retrograde cholangiopancreatography, and analyze clinical characteristics and management. (Korean J Gastrointest Endosc 2011;42:334-340)
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