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Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea. [ABSTRACT FROM AUTHOR]

Background/Aims: Peroral cholangioscopy (POC) has been used to assess intrahepatic duct (IHD) lesions but with a limited role. A new multibending (MB) ultraslim endoscope has been designed to improve POC performance. We evaluated the usefulness of POC using the MB ultraslim endoscope for the management of IHD lesions. Methods: Between March 2017 and March 2020, 22 patients underwent direct POC using the MB ultraslim endoscope for IHD lesions documented by previous imaging or cholangiopancreatography. The primary outcome was technical success of POC, and secondary outcomes were technical success of POC-guided interventions, median procedure time, and POC-related adverse events. Results: The technical success rate for POC using the MB ultraslim endoscope for IHD lesions was 95.5% (21/22). Free-hand insertion was successful in 95.2% (20/21). The overall technical success rate for POC-guided intervention was 100% (21/21), including nine diagnostic and 12 therapeutic procedures (eight direct stone removal and four intraductal lithotripsies). The median procedure time was 29 minutes (range, 9 to 79 minutes). There were no procedure-related adverse events. Conclusions: Direct POC using the MB ultraslim endoscope allows direct visualization of IHD lesions and may be useful for diagnosis and therapeutic management in selected patients. [ABSTRACT FROM AUTHOR]

Background/Aims: This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea. Methods: The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021. Results: The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively. Conclusions: Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones. [ABSTRACT FROM AUTHOR]

Background/Aims: Although endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) are widely used for tissue acquisition of pancreatic solid mass, the optimal strategy of this procedure has not been established yet. The aim of this nationwide study was to investigate the current practice patterns of EUS-FNA/FNB for pancreatic solid mass in Korea. Methods: The Policy-Quality Management of the Korean Pancreatobiliary Association (KPBA) developed a questionnaire containing 22 questions. An electronic survey consisting of the questionnaire was distributed by e-mail to members registered to the KPBA. Results: A total of 101 respondents completed the survey. Eighty respondents (79.2%) performed preoperative EUS-FNA/FNB for operable pancreatic solid mass. Acquire needles (60.4%) were used the most, followed by ProCore needles (47.5%). In terms of need size, most respondents (>80%) preferred 22-gauge needles regardless of the location of the mass. Negative suction with a 10-mL syringe (71.3%) as sampling technique was followed by stylet slow-pull (41.6%). More than three needle passes for EUS-FNA/FNB was performed by most respondents (>80%). The frequency of requiring repeated procedure was significantly higher in respondents with a low individual volume (<5 per month, p=0.001). Prophylactic antibiotics were routinely used in 39 respondents (38.6%); rapid on-site pathologic evaluation was used in 6.1%. Conclusions: According to this survey, practices of EUS-FNA/FNB for pancreatic solid mass varied substantially, some of which differed considerably from the recommendations present in existing guidelines. These results suggest that the development of evidence-based quality guidelines fitting Korean clinical practice is needed to establish the optimal strategy for this procedure. [ABSTRACT FROM AUTHOR]

Background/Aims Although early detection of intraductal neoplasms of the bile duct (IN-B) is crucial for the curative treatment of cholangiocarcinoma (CCA), current diagnostic modalities remain suboptimal. We aimed to evaluate whether disposable digital single-operator cholangioscopy (D-SOC) could be an effective tool for screening intraductal neoplasms of the bile duct in patients with bile duct stones. Methods Consecutive 181 patients who underwent D-SOC after endoscopic bile duct stone removal were enrolled. The primary outcome was the detection rate of intraductal neoplasms of the bile duct, and secondary outcomes were the technical success rates of D-SOC and D-SOC guided forceps biopsy, the diagnostic accuracy of D-SOC findings, adverse events, and the number of patients needed to screen to identify a single intraductal neoplasm. Results D-SOC was successfully performed in all patients, and 23 (13.5%) showed abnormal intraductal superficial lesions of the bile duct. The technical success rate of D-SOC guided forceps biopsy was 91.3% (21/23 patients). Pathological evaluation identified IN-Bs in 9 patients (42.9%) and benign lesions in 12 patients (57.1%); patients with IN-Bs were diagnosed with CCAs (n=2), intraductal papillary neoplasms of the bile duct (n=6), and adenomas with dysplasia (n=1). D-SOC findings afforded 87.5% sensitivity, 91.4% specificity, and 91.3% accuracy, respectively. Curative surgical resection was performed on 2 patients. Mild cholangitis occurred in 3 patients (1.7%) and was managed conservatively. The number of patients who needed to screen to detect a neoplastic bile duct lesion was calculated to be 20.1. Conclusion D-SOC can be a valuable tool for screening intraductal neoplasms of the bile duct, including CCAs, in patients with bile duct stones (NCT05600803). [ABSTRACT FROM AUTHOR]

Background/Aims Newly developed image-enhanced endoscopies such as texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) can improve the assessment of obscure ampullary lesions. We aimed to explore the usefulness of TXI and RDI compared to narrow-band imaging (NBI) in differentiating ampullary lesions. Methods Consecutive patients with suspected ampullary lesions underwent sequential endoscopic observation using white-light imaging, NBI, TXI-1, TXI-2, and RDI-3. After the detection and characterization of the ampullary lesions, the final diagnosis was confirmed through histologic findings from forceps biopsy, endoscopic papillectomy, and/or surgery. The evaluated outcomes included the detection rate of endoscopic features suggesting neoplasms and diagnostic accuracy. Results Among the 31 ampullary lesions, 4 (12.9%) were adenocarcinomas, 7 (22.6%) were adenomas, and 20 (64.5%) were benign. TXI-1 demonstrated superior capability compared to NBI in detecting discoloration (41.9% vs. 9.7%, p=0.023), dotted microvessels (35.5% vs. 6.5%, p=0.032), and irregularly dilated and tortuous vessels (38.7% vs. 9.7%, p=0.048). Although the intergroup difference was not significant, RDI-3 showed a trend toward superiority over NBI in evaluating irregular villous arrangements (38.7% vs. 22.6%, p=0.812). NBI outperformed both TXI-1 and RDI-3 in distinguishing the demarcation with normal villi (NBI vs. TXI-1, 45.2% vs. 12.9%, p=0.032; NBI vs. RDI-3, 45.2% vs. 9.7%, p=0.011). In the receiver operating characteristic curve analysis, the combined use of TXI and RDI showed significantly higher accuracy (0.91) than NBI alone (0.74, p=0.021). Conclusion TXI and RDI can enhance the characterization of ampullary lesions, providing a more accurate diagnosis when used in conjunction with NBI. [ABSTRACT FROM AUTHOR]

Background/Aims Although a long self-expandable metal stent (SEMS) with a sufficient intragastric portion is preferred for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), it can complicate endoscopic re-intervention for recurrent biliary obstruction (RBO). We evaluated the efficacy and safety of endoscopic re-intervention for RBO through the stent after EUS-HGS using a novel partially covered SEMS with an anchoring flange. Methods The covered SEMS featured a proximal uncovered portion measuring 1.5 cm in length and a resilient fold-back wide distal anchoring flange with a 2.0 cm diameter. Endoscopic re-interventions were performed through the stent lumen while the stent was in situ. The evaluated outcomes were the technical and clinical success of the endoscopic re-intervention, procedure time, and adverse events. Results In total, 35 re-interventions for RBO were performed in 19 patients. The overall technical and clinical success rates were 91.4% (32/35) and 85.7% (30/35). The re-intervention methods included stent cleaning (18.2%), additional HGS stent placement (33.3%), and antegrade stent placement (48.5%). Mild cholangitis occurred in 5.7% (2/35) of patients and was managed conservatively. Conclusion Various types of endoscopic re-interventions for RBO can be effectively and safely performed through the lumen of a new partially covered SEMS with an anchoring flange. [ABSTRACT FROM AUTHOR]

Background/Aims: Treatment options for difficult bile duct stones are limited. Direct peroral cholangioscopy (POC)-guided lithotripsy may be an option. A newly developed multibending (MB) ultraslim endoscope has several structural features optimized for direct POC. We evaluated the utility of direct POC using an MB ultraslim endoscope for lithotripsy in patients with difficult bile duct stones. Methods: Twenty patients with difficult bile duct stones, in whom stone removal using conventional endoscopic methods, including mechanical lithotripsy, had failed were enrolled from March 2018 to August 2019. Direct POC-guided lithotripsy was performed by electrohydraulic lithotripsy or laser lithotripsy. The primary outcome was complete ductal clearance, defined as the retrieval of all bile duct stones after lithotripsy confirmed by balloon-occluded cholangiography and/or direct POC. Results: The technical success rate of direct POC was 100% (20/20), and the free-hand insertion rate was 95% (19/20). Direct POC-guided lithotripsy, attempted by electrohydraulic lithotripsy in nine patients (45%) and laser lithotripsy in 11 patients (55%), was successful in 95% (19/20) of the patients. Complete ductal clearance after direct POC-guided lithotripsy was achieved in 95% (19/20) of patients. Patients required a median of 2 (range, 1–3) endoscopic retrograde cholangiopancreatography sessions for complete stone removal. Adverse event was observed in one patient (5%) with hemobilia and was treated conservatively. Conclusions: Direct POC using an MB ultraslim endoscope was safe and effective for lithotripsy in patients with difficult bile duct stones. [ABSTRACT FROM AUTHOR]

Background/Aims: The endoscopic step-up approach is accepted as the preferred treatment for complicated or symptomatic walled-off necrosis (WON). Direct endoscopic necrosectomy (DEN) is an effective therapeutic option, but few reports describe long-term follow-up in this patient population. Thus, we aim to assess the long-term outcomes of DEN following severe necrotizing pancreatitis. Methods: The data of all acute pancreatitis patients who underwent DEN following endoscopic transmural drainage from six referral centers between 2007 and 2017 were retrospectively collected. Results: Sixty patients (76.7% male, mean age 48.3 years) underwent a median of 4 sessions of DEN starting at a median of 45.5 days after the onset of acute pancreatitis. Clinical success was achieved in 51 patients (85%), with a 35% complication rate and a 5% mortality rate. Using multivariate analysis, the risk factor associated with DEN failure or major DEN complications requiring intervention or surgery was an identified bacterial/fungal WON infection (odds ratio, 19.3; 95% confidence interval, 1.5 to 261.7). During the median follow-up period of 27 months, complicated WON recurrence was observed in 5.3% of patients, and long-term complications occurred in 24.6% of patients (four exocrine insufficiency, nine newly developed diabetes mellitus, one recurrent small bowel obstruction, one chylous ascites). Conclusions: Considering that long-term complications are similar to those observed after pancreatectomy, DEN should be performed meticulously while minimizing damage to the viable pancreatic parenchyma with adequate antibiotic escalation. [ABSTRACT FROM AUTHOR]

Background/Aims: The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea. Methods: The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP. Results: Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%. Conclusions: Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea. [ABSTRACT FROM AUTHOR]

Background/Aims: Needle-knife precut fistulotomy (NK-F) is a well-known freehand technique for difficult biliary cannulation (DBC). Another approach involves the use of Iso-Tome®, a modified precutting device with an insulated needle tip to prevent direct thermal injury. This comparative study aimed to evaluate the efficacy of the Iso-Tome® precut (IT-P) compared to that of NK-F for DBC. Methods: Patients with a naïve papilla who underwent early IT-P or NK-F for DBC were enrolled. DBC was defined as failure to achieve selective biliary access by wire-guided cannulation despite 5 minutes of attempted cannulation, ≥5 papillary contacts, or a hooknose- shaped papilla. The primary endpoint was the primary technical success rate, which was based on a noninferiority model. Results: A total of 239 DBC cases were enrolled. The primary technical success rates were 74.7% (89/119) in the IT-P group and 91.6% (110/120) in the NK-F group (lower limit of 90% confidence interval, -0.23; p=0.927 for a noninferiority margin of 10%). The total technical success rates were 87.4% and 95.0%, respectively (p=0.038). The mean precutting times for successful biliary access were 11.2 minutes for IT-P and 7.3 minutes for NK-F (p<0.01). The procedure-related adverse event rates were 9.2% for IT-P and 5.8% for NK-F (p=0.318). The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis were 4.2% and 2.5%, respectively (p=0.499). Conclusions: IT-P failed to exhibit noninferiority compared with NK-F regarding the primary technical success rate of DBC, but there was no difference in the frequency of adverse events. [ABSTRACT FROM AUTHOR]

Background/Aims: In suspected malignant biliary strictures (MBSs), the diagnostic yield of endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling is limited. Transpapillary forceps biopsy (TPB) under intraductal ultrasonography (IDUS) guidance is expected to improve the diagnostic accuracy in patients with indeterminate biliary strictures. We evaluated the usefulness of IDUS-guided TPB in patients with suspected MBS. Methods: Consecutive patients with suspected MBS were prospectively enrolled in the study. ERCP with IDUS was performed in all patients. Both conventional TPB and IDUS-guided TPB on fluoroscopy were performed in each patient. The primary outcome was the diagnostic accuracy of conventional TPB and IDUS-guided TPB. Results: The technical success rate of IDUS-guided TPB was 97.0% (65/67 patients). Of these 65 patients, the final diagnosis was malignancy in 61 patients (93.8%). On IDUS, the most common finding of IDUS was an intraductal infiltrating lesion in 29 patients (47.5%). The overall diagnostic accuracy was significantly higher using IDUS-guided TPB than that using conventional TPB (90.8% vs 76.9%, p=0.027). According to the subgroup analysis based on the tumor morphology, IDUS-guided TPB had a significantly higher cancer detection rate than conventional TPB for intraductal infiltrating lesions (89.6% vs 65.5%, p=0.028). Conclusions: IDUS-guided TPB appears to improve the accuracy of histological diagnosis in patients with MBS. [ABSTRACT FROM AUTHOR]

Background/Aims: Controversy still exists regarding the benefits of covered self-expandable metal stents (SEMSs) compared to uncovered SEMSs. We aimed to compare the patency and stent-related adverse events of partially covered SEMSs (PC-SEMSs) and uncovered SEMSs in unresectable malignant distal biliary obstruction. Methods: A total of 134 patients who received a PC-SEMS or uncovered SEMS for palliation of unresectable malignant distal biliary obstruction were reviewed retrospectively. The main outcome measures were stent patency, stent-related adverse events, and overall survival. Results: The median stent patency was 118 days (range, 3 to 802 days) with PC-SEMSs and 105 days (range, 2 to 485 days) with uncovered SEMSs (p=0.718). The overall endoscopic revision rate due to stent dysfunction was 36.6% (26/71) with PC-SEMSs and 36.5% (23/63) with uncovered SEMSs (p=0.589). Tumor ingrowth was more frequent with uncovered SEMSs (4.2% vs 19.1%, p=0.013), but migration was more frequent with PC-SEMSs (11.2% vs 1.5%, p=0.04). The incidence of stent-related adverse events was 2.8% (2/71) with PC-SEMSs and 9.5% (6/63) with uncovered SEMSs (p=0.224). The median overall survival was 166 days with PC-SEMSs and 168 days with uncovered SEMSs (p=0.189). Conclusions: Compared to uncovered SEMSs, PC-SEMSs did not prolong stent patency in unresectable malignant distal biliary obstruction. Stent migration was more frequent with PC-SEMSs. However, tumor ingrowth was less frequent with PC-SEMSs compared to uncovered SEMSs. [ABSTRACT FROM AUTHOR]

Background/Aims: Treatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS). Methods: EBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events. Results: Among 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days). Conclusions: EBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS. [ABSTRACT FROM AUTHOR]

Cases of pancreatic ductal adenocarcinoma with multiple masses accompanying underlying pancreatic diseases, such as intraductal papillary mucinous neoplasm, have been reported. However, synchronous invasion without underlying pancreatic disease is very rare. A 61-year-old female with abdominal discomfort and jaundice was admitted to our hospital. Abdominal computed tomography (CT) revealed cancer of the pancreatic head with direct invasion of the duodenal loop and common bile duct. However, positron emission tomography-CT showed an increased standardized uptake value (SUV) in the pancreatic head and tail. We performed endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for the histopathologic diagnosis of the pancreatic head and the evaluation of the increased SUV in the tail portion of the pancreas, as the characteristics of these lesions could affect the extent of surgery. As a result, pancreatic ductal adenocarcinomas were confirmed by both cytologic and histologic analyses. In addition, immunohistochemical analysis of the biopsy specimens was positive for carcinoembryonic antigen and p53 in both masses. The two masses were ultimately diagnosed as pancreatic ductal adenocarcinoma, stage IIB, based on EUS-FNB and imaging studies. In conclusion, the entire pancreas must be evaluated in a patient with a pancreatic mass to detect the rare but possible presence of synchronous pancreatic ductal adenocarcinoma. Additionally, EUS-FNB can provide pathologic confirmation in a single procedure. [ABSTRACT FROM AUTHOR]

Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate. [ABSTRACT FROM AUTHOR]

Background/Aims: This study aimed to compare the outcomes of endoscopic submucosal dissection (ESD) and gastrectomy based on the two sets of indications for ESD, namely guideline criteria (GC) and expanded criteria (EC). Methods: Between January 2004 and July 2007, 213 early gastric cancer (EGC) patients were enrolled in this study. Of these patients, 142 underwent ESD, and 71 underwent gastrectomy. We evaluated the clinical outcomes of these patients according to the criteria. Results: The complication rates in the ESD and gastrectomy groups were 8.5% and 28.2%, respectively. The duration of hospital stay was significantly shorter in the ESD group than the gastrectomy group according to the GC and EC (p<0.001 and p<0.001, respectively). There was no recurrence in the ESD and gastrectomy groups according to the GC, and the recurrence rates in the ESD and gastrectomy groups were 4.7% and 0.0% according to the EC, respectively (p=0.279). The occurrence rates of metachronous cancer in the ESD and gastrectomy groups were 5.7% and 5.0% according to the GC (p=1.000) and 7.5% and 0.0% according to the EC (p=0.055), respectively. Conclusions: Based on safety, duration of hospital stay, and long-term outcomes, ESD may be an effective and safe firstline treatment for EGC according to the EC and GC. [ABSTRACT FROM AUTHOR]

Background/Aims Intraductal papillary neoplasm of bile duct (IPNB) is a precursor of invasive carcinoma. However, it can be miss or underdiagnosed by cross-sectional imaging studies and/or cholangiography. Recently, as single operator peroral cholangioscopy (SO-POC) which is easy to maneuver in high image quality has been developed, SO-POC are emerging as one of the diagnostic methods of bile duct diseases. In this study, we evaluated the usefulness of SO-POC for diagnosis and management of IPNB. Methods Data from consecutive patients undergoing SO-POC and diagnosed as IPNB were analyzed. SO-POC was performed with direct POC using an ultra-slim endoscope and/or SpyGlass direct visualization system. All POC findings were reviewed by two experienced investigators. All of IPNB cases were diagnosed as IPNB according to the criteria of World Health Organization 2010 by one expert pathologist. Results A total of 30 patients with IPNB diagnosed by POCs was analyzed. In 16 patients (53.3%), IPNB was not observed in computed tomography and SO-POC was performed for the evaluation of dilated bile duct (n=7) and management of stones (n=7). In 17 patients (56.7%), direct POC with narrow band image and/or I-SCAN was used for evaluation of IPNB. Irregular tortuous and dilated vessels (p=0.012) was found to be significantly associated with invasiveness. POC-guided target biopsy was performed technically successful in all patient. In 11 patients (36.7%), management plan was changed after confirmation of IPNB extent by POC.Background/Aims Intraductal papillary neoplasm of bile duct (IPNB) is a precursor of invasive carcinoma. However, it can be miss or underdiagnosed by cross-sectional imaging studies and/or cholangiography. Recently, as single operator peroral cholangioscopy (SO-POC) which is easy to maneuver in high image quality has been developed, SO-POC are emerging as one of the diagnostic methods of bile duct diseases. In this study, we evaluated the usefulness of SO-POC for diagnosis and management of IPNB. Methods Data from consecutive patients undergoing SO-POC and diagnosed as IPNB were analyzed. SO-POC was performed with direct POC using an ultra-slim endoscope and/or SpyGlass direct visualization system. All POC findings were reviewed by two experienced investigators. All of IPNB cases were diagnosed as IPNB according to the criteria of World Health Organization 2010 by one expert pathologist. Results A total of 30 patients with IPNB diagnosed by POCs was analyzed. In 16 patients (53.3%), IPNB was not observed in computed tomography and SO-POC was performed for the evaluation of dilated bile duct (n=7) and management of stones (n=7). In 17 patients (56.7%), direct POC with narrow band image and/or I-SCAN was used for evaluation of IPNB. Irregular tortuous and dilated vessels (p=0.012) was found to be significantly associated with invasiveness. POC-guided target biopsy was performed technically successful in all patient. In 11 patients (36.7%), management plan was changed after confirmation of IPNB extent by POC. Conclusions SO-POC is useful to detect the IPNB which was not observed by cross-sectional imaging studies and decide the management plan of IPNB. [ABSTRACT FROM AUTHOR]

Background/Aims In a recent, the endobiliary radiofrequency ablation (RFA) has been showed clinical efficacies in a palliative management of extrahepatic distal malignant biliary stricture. In this study, we evaluated the efficacy and safety of endoscopic stenting after the endobiliary RFA compared with stenting alone in a patients with inoperable hilar cholangiocarcinoma. Methods Total 42 patients diagnosed with inoperable hilar cholangiocarcinoma were enrolled prospectively. Twenty-one patients underwent endobiliary RFA using an automatically temperature controlled RFA catheter (ELRA, STARmed) before endobiliary stenting with plastic or metallic stents (RFA group). The primary outcome was stent patency duration. Results The clinical success rates were not statistically significantly different between the RFA and non-RFA groups (95.2% vs 90.5%, p=1.000). After 3 months, stent patency rates was significantly higher in RFA group than that of non-RFA group (95.2% vs 71.4%, p=0.047). The reintervention due to recurrent biliary obstruction in RFA and non-RFA groups was performed in 12 patients (57.1%) and 18 patients (85.7%), respectively (p=0.043). The median cumulative stent patency duration in RFA group was 8.0 months which was significantly longer than 4.0 months of non-RFA group (log-rank test, p=0.01). In a multivariate analysis, RFA was a favorable independent factor (adjusted hazard ratio, 0.416; 95% confidence interval, 0.198 to 0.876; p=0.021) for stent patency. Survival probability and adverse events were not different between the two groups. Conclusions The endobiliary RFA before endoscopic stenting is considered to be effective for improvement of stent patency in patients with inoperable hilar cholangiocarcinoma. Further randomized controlled trials using a large numbers of subjects are required to confirm the benefit and safety of the endobiliary RFA. [ABSTRACT FROM AUTHOR]

Background/Aims Direct peroral cholangioscopy (DPOC) using a conventional ultra-slim endoscope has been limited because of its low and inconsistent success rate in spite of several advantages such as high-quality endoscopic imaging with image-enhanced technology, and the relatively larger working channel. To overcome the technical difficulties of DPOC, a prototype multibending (MB) ultra-slim endoscope has been developed as a dedicated cholangioscope. In this study, we evaluated the clinical usefulness of the DPOC using a MB ultra-slim endoscope with a free-hand insertion of an endoscope into the bile duct. Methods A total of 145 patients with biliary diseases requiring diagnostic and/or therapeutic DPOC were enrolled prospectively. Initially, DPOC using a MB ultra-slim endoscope was tried without device assistance ("free-hand") in all patients up to 15 minutes. The primary outcome was the technical success of free-hand insertion of the MB endoscope during DPOC. Results Free-hand biliary insertion of the MB endoscope for DPOC was technically successful in 133 of 145 patients (91.7%). The procedure time (mean±standard deviation) of DPOC using a free-hand biliary insertion was 2.7±1.6 minutes. DPOC-guided target biopsy was performed in 38 patients (28.6%) and showed technical success in 36 patients (94.7%). Among 110 patients who had no stricture and/or suspicious malignant biliary lesions on previous radiological images, malignant lesion was diagnosed incidentally by DPOC-guided target biopsy in two patients (1.8 %). During the DPOC, total 69 therapeutic interventions were performed and technically successful in 65 patients (94.2%). Adverse events was observed in six patients (4.1%) and treated conservatively in all patients. Conclusions Free-hand biliary insertion of the MB ultra-slim endoscope showed a high technical success rate without severe adverse events. Therefore, the MB endoscope is considered to facilitate broadening the indications for DPOC in various biliary diseases. [ABSTRACT FROM AUTHOR]

Background/Aims The quality management in endoscopic retrograde cholangiopancreatography (ERCP) is an important issue. Although the overall procedure of ERCP is usually similar, the details of basic technique may differ for each ERCPist. The aim of this study is to assess the current status of ERCP in Korea and to evaluate the trend of basic technique in ERCP. Methods In order to obtain information on the basic technique of ERCP in Korea, the Korean Pancreatobiliary Association (KPA) conducted a national survey in 2019. A survey- based study was designed with papered questionnaire in KPA conference. The survey was composed of 32 questions. Main topics were: environments for performing ERCP, preparation before ERCP, favorite techniques/devices in ERCP and management after ERCP. Results Completed questionnaires were returned from 84 ERCPist of KPA members. Among them, 71% had total experience of ERCP above 1,000 cases and experience over 5 years. Main results were as follows: presence of fluoroscopy room for only ERCP procedure, 57 out of 84 (68%); use of opioid for preparation, 80 out of 84 (95%); use of prophylactic anti-spastic agent, 67 out of 84 (80%); use of restraining device, 43 out of 84 (51%). Preferred procedural sedations were balanced-propofol sedation (50%) and midazolam- only sedation (47%). Endoscopic retrograde biliary drainage was more preferred than endoscopic nasobiliary drainage (60% vs 22%). The initial method for opening of orifice was that endoscopic sphincterotomy in 60%, combination of balloon dilatation and sphincterotomy in 17%. There was some variability of basic cannulation technique, type of preferred guidewire, model of mechanical lithotripter and first salvage technique. Conclusions Data from this survey involving a large number of ERCP experts reveal some variability of basic techniques of ERCP in Korea. A future nationwide survey is necessary to evaluate the standard basic techniques for ERCP. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic management of complicated bile duct stones in patients with benign biliary stricture (BBS) is very challenging. Recently developed modified short length of fully covered self-expandable metallic stent (FCSEMS) can be inserted intraductally and easily removed by long lasso. Our aim was to evaluate the usefulness of short intraductal FCSEMS for endoscopic removal of complicated bile duct stones after relieving of biliary stricture. Methods Twenty-six patients (11 women; median age, 61.5 years [range, 23 to 84 years]) having retained bile duct stones with biliary stricture failed by conventional endoscopic removal included this study. Non-flared short FCSEMS (BONASTENT M-Intraductal) having 7 or 10 cm of lasso was intraductally inserted on stricture. After FCSEMS removal at 6months stenting period, endoscopic stone removal was tried. Primary outcome was complete stone clearance rate. Secondary outcomes were success rate of stent insertion and removal, relieving of biliary stricture rate, and procedure-related adverse events. Results Intraductal placement of FCSEMS was successful in all cases. There were three cases (11.5 %) of stent migration during follow-up. Intended stent removal was successful in other 23 patients. Improvement of biliary stricture revealed in all 23 patients. Complete stone clearance was achieved 22 of 26 patients (84.6%). There were no significant adverse event related to procedures. No stent-induced ductal change was observed in all patients. Conclusions Temporary intraductal placement of unflared FCSEMS may be an effective in endoscopic management of complicated bile duct stones in patients with biliary stricture minimizing stent induced adverse events. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic post-papillectomy bleeding occurs in 3% to 20% of cases and delayed bleeding within 1 week is also problematic. However, there was no definite guideline or consensus for prevention or reduction of delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed post-papillectomy bleeding and reduce the recurrence or persistence of residual tumors. Methods A prospective randomized pilot trial was performed at six tertiary referral centers. Patients with ampulla of Vater adenoma were enrolled from January 2016 to April 2018 and were randomized to either the prophylactic APC or non-APC group. The prophylactic APC group underwent APC on the resection margin. On the day after papillectomy, all patients underwent follow-up duodenoscopy to identify post-papillectomy bleeding and followed up with duodenoscopy at 1, 3, 6, and 12 months. The main outcome measurements were delayed (>24 hours) post-papillectomy bleeding rate and tumor persistent rate between the two groups. Results In total, 54 patients randomized into both group. Delayed bleeding rates in the prophylactic APC and non-APC groups were 30.8% (8/26) and 21.4% (6/28), respectively (p=0.434). Post-procedure pancreatitis rates were 23.1% (6/26) in the prophylactic APC and 35.7% (10/28) in the non-APC groups, respectively (p=0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, p=0.656), 3 months (4.2% vs 3.7%, p=1.00), 6 months (8.3% vs 3.7%, p=0.595), 12 months (0% vs 3.7%, p=1.00) (Table 1). Conclusions The prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding, and might not have an additive role on remnant tumor ablation effect immediately after papillectomy or during follow-up. [ABSTRACT FROM AUTHOR]