At least 90% of stones are extracted after conventional endoscopic retrograde cholangiopancreatography. However, some cases are still difficult to manage completely. We describe some methods of removing difficult common bile duct stones through a single-operator cholangioscopy using SpyGlass system, direct peroral cholangioscopy, and temporary biliary stenting.

Approximately 3-15% of patients who have undergone removal of bile duct stones with endoscopic sphincterotomy have recurrence of stones which often presents as acute cholangitis. Despite better understanding on the factors and mechanisms underlying the recurrence of bile duct stones achieved during the past few decades, endoscopic removal still remains the mainstay of management for recurrent bile duct stones. Recently investigated and suggested management of recurrent bile duct stones are highlighted in this review.
Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis/pathology ; Gallstones/surgery/*therapy ; Humans ; Recurrence ; Risk Factors ; Sphincterotomy, Endoscopic ; Ursodeoxycholic Acid/administration & dosage

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Gallbladder cancer is the most common cause of hilar biliary obstruction; however, it rarely causes combined biliary, duodenal, and colon triple obstruction. In this case, the quality of life for a patient with recurrent gallbladder cancer with combined duodenal, colonic, and biliary obstruction was improved by endoscopic and endosonographic palliation, despite its technical difficulty and complexity. Seven metal stents were implanted one by one using only endoscopic methods. Successful stent-in-stent placement and endoscopic ultrasound-guided stenting after failed ERCP improved the patient’s quality of life to the extent that there was no need for any external drainage.

We previoulsy reported the successful performances of the BRW stereotactic biopsy and aspiration of supratentorial and brain stem lesions. The BRW system has disadvantage of less accessibility to the cerebellar lesions by suboccipital approach. To overcome this disadvantage, we have tried to treat four patients having a cerebellar lesions, a case of hemangioblastoma, two cerebellar hemorrhages and acoustic neuroma, by transtentorial BRW stereotactic approach. This approach has been used successfully under the local anesthesia with satisfactory postoperative neurological results. We present a detailed technique of this approach.
Anesthesia, Local ; Biopsy ; Brain Stem ; Hemangioblastoma ; Hemorrhage ; Humans ; Neuroma, Acoustic

Recently we experienced stereotaxic endoscopic biopsy and resection of intracranial tumors using the Brown-Robert-Wells system. Surgical exploration was undertaken under the local anesthesia:1 germinoma in pineal region, 1 arachnoid cyst in basal cistern. The method is described, and the its potential clinical applications is discussed.
Arachnoid ; Biopsy ; Endoscopy* ; Germinoma

In spontaneous brain stem hemorrhage, efforts are being made to treat the hemorrhage by means of active medical treatment of intricate suboccipital craniectomy. But these efforts are still unsatisfactory in decreasing the high mortality and morbidity. Our recent efforts have got good results in the 11 cases of brain stem hemorrhage by removing the hemorrhage through the application of R.R.W. stereotactic system and gradual urokinase irrigation. The residual hemorrhage following the initial aspiration was completely evacuated by gradual urokinase irrigation through stereotactically placed catheter. Also this catheter was used for monitoring of intrahematomal intracranial pressure for an early stoppage of the increased intracranial pressure or early detecting of rebleeding. This kind of stereotactic evacuation and gradual irrigation with urokinase could remove the brain stem hemorrhage accurately and easily in a short time under the local anesthesia. Mean-while the normal brain tissue is subjected to less surgical trauma by this procedure, which can be interpreted as having a wide indication, a definite advantage, with a low mortality of 27.3%.
Anesthesia, Local ; Brain Stem* ; Brain* ; Catheters ; Electric Impedance ; Hemorrhage* ; Intracranial Pressure ; Mortality ; Urokinase-Type Plasminogen Activator*

BACKGROUND: Multiple allergosorbent test chemiluminescent assay (MAST CLA) is a simple method for in vitro measurement of allergen-specific IgE antibodies. In the present study, the diagnostic performance of MAST CLA was evaluated from the data of Asan Medical Center. METHODS: With the test results of Korea IgE Panel, Korean Food Panel and Korean Inhalant Panel, we evaluated the next following. First, the change of the positive rates of allergen-specific IgE antibodies after the Korea IgE panel was divided into each Food Panel and Inhalant Panel; Second, the diagnostic performance of total IgE determined by MAST CLA in comparison with those determined by RIA; Third, the discrepancy of reactive intensity in Food and Inhalant Panels tested with the same specimens; Fourth, the diagnostic performance of MAST CLA compared with RAST, in detecting the IgE antibodies to three most common allergens. RESULTS: Overall positive rate was 33.9% (548/1,617); 39.3% for Korea IgE Panel, 22.9% for Food Panel, 34.6% for Inhalant Panel. Positive rate was increased only 0.5% for Food Panel and only 0.3% for Inhalant Panel by the new allergens added. The sensitivity, specificity, and concordance rate of total IgE levels determined by MAST CLA in comparison with those determined by RIA was 68.4%, 64.9%, 66.8% in Food Panel, and, 87.6%, 44.4%, 68.5% in Inhalant Panel. Five of the eighteen specimens tested by Food and Inhalant Panels simultaneously showed discrepant reactivity with the extent of class 1. The sensitivity, specificity, and concordance rate of MAST CLA compared with RAST were 36.1%, 100.0%, 67.1% for D. farinae, 30.8%, 96.8%, 60.6% for D. pteronyssinus, and 21.4%, 96.2%, 70.0% for housedust. CONCLUSIONS: The allergens newly added to Food and Inhalant Panels were not contributable to the detection of allergen-specific IgE. The specificity of total IgE was so low that positive total IgE result without specific IgE should be interpreted as false positive. The sensitivity to common allergens was also too low. So, MAST CLA needs further improvement to be used as a primary screening test for allergy.
Allergens ; Antibodies ; Chungcheongnam-do* ; Dust ; Hypersensitivity ; Immunoglobulin E ; Korea ; Luminescent Measurements* ; Mass Screening ; Sensitivity and Specificity