The therapeutic role of endoscopic ultrasound (EUS) has continued to evolve in recent years. EUS-guided biliary drainage (EUS-BD) can be performed as an effective alternative to percutaneous drainage or surgical options when conventional Endoscopic retrograde cholangiopancreatography fails or is not possible. Depending on the access and exit routes of the stent, multiple approaches to EUS-BD have been proposed. Each patient should receive an individualized approach based on the patient's condition, anatomy, and endoscopist's experience, with an appropriate backup prepared. In high-volume centers, the cumulative success rate has been reported to be over 90%. However, the reported overall complication rate remains relatively high at 10-30%. Further studies are necessary to better understand the long-term results and standardize EUS-BD, including appropriate indications and optimal approach.
Biliary Tract ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage* ; Endosonography ; Humans ; Stents ; Ultrasonography

PURPOSE: In response to a growing threat of violence in hospitals, we examined a specific educational effort to reduce emergency department (ED) violence in the shortterm. METHODS: Cross-sectional prospective surveys were conducted at Chosun University Hospital Emergency Center during a baseline period from May 26 to Jul. 9. 2003, and during a post-education period from Aug. 7 to Sep. 20. 2003. Questions addressed the degree of violence, the reason for the violence, demographic information about the perpetrator of the violence, the outbreak time of the violence and the response of emergency personnel. RESULTS: After an education program on violence, the rate of violent events in the ED was decreased by 23.5%. A notable change was that ED workers handled the violence more positively during the post-education period by isolating or restraining the aggressor. Almost all of the violence was caused by males, particularly those in their third or fourth decade. The violence occurred mostly on the night shift. Of the violence, 52.4% was caused by the patient while 34.8% was caused by the patient's guardian. The leading causes of violence were drunkenness and delays in laboratory tests and treatment. Verbal abuse and threats were the most concern forms of violence. CONCLUSION: Violent events are frequent in the ED. Education programs may reduce the number of events at least temporarily.
Alcoholic Intoxication ; Education* ; Emergencies* ; Emergency Service, Hospital* ; Humans ; Male ; Prospective Studies ; Violence*

Purpose: Total femoral replacement (TFR) is an extreme form of limb salvage. Considering the rarity of this procedure, reports have focused on the complications and a proper indication is unclear. This study analyzed 36 patients with TFR who were asked the following: 1) prognostic factors related to survival in patients who underwent TFR with a tumoral cause; 2) overall implant and limb survival; 3) complications, functional outcome, and limb status for patients surviving for more than 3 years. Materials and Methods: According to the causes for TFR, 36 patients were categorized into three groups: extensive primary tumoral involvement (group 1, 15 cases), tumoral contamination by an inadvertent procedure or local recurrence (group 2, 16 cases), and salvage of a failed reconstruction (group 3, 5 cases). The factors that may affect the survival of patients included age, sex, cause of TFR, and tumor volume change after chemotherapy. Results: The overall five-year survival of the 36 patients was 31.5%±16.2%. The five-year survival of 31 patients with tumoral causes was 21.1%±15.6%. The five-year survival of 50.0%±31.0% in patients with a decreased tumor volume after chemotherapy was higher than that of increased tumor volume (p=0.02). The five-year survival of 12 cases with a wide margin was 41.7%±27.9%, whereas that of the marginal margin was 0.0%±0.0% (p=0.03). The ten-year overall implant survival of 36 patients was 85.9%±14.1%. The five-year revisionfree survival was 16.6%±18.2%. At the final follow-up, 12 maintained tumor prosthesis, three underwent amputation (rotationplasty, 2; above knee amputation, 1), and the remaining one had knee fusion. Among 16 patients with a follow-up of more than three years, 14 patients underwent surgical intervention and two patients had conservative management. Complications included infection in 10 cases, local recurrences in two cases, and one case each of hip dislocation, bushing fracture, and femoral artery occlusion. Conclusion Patients showing an increased tumor volume after chemotherapy and having an inadequate surgical margin showed a high chance of early death. In the long-term follow-up, TFR showed a high infection rate and the functional outcome was unsatisfactory. Nevertheless, this procedure is an inevitable option of limb preservation in selected patients.

Purpose: Extraskeletal myxoid chondrosarcoma (EMC) is an extremely rare malignant mesenchymal neoplasm, accounting for less than 3% of soft tissue sarcomas. This sarcoma is usually characterized by its indolent course. This study examined the clinical manifestations and oncologic outcomes of EMC. Materials and Methods: Seventeen patients diagnosed and treated for EMC between January 2008 and December 2018 were enrolled in this study. The cohort was then reviewed regarding age, gender, symptom onset, tumor location, magnetic resonance images, surgical margin, and pathologic diagnosis. The time to local recurrence and metastasis, follow-up duration, and the patients’ final status were analyzed. Results: The patients were comprised of 10 males and seven female patients with a mean age of 54 (range, 31–79). The tumor location was the buttock in five, thigh in four, knee in three, foot in three, shoulder in one, and back in one. The average tumor diameter was 11.5 cm (range, 2.2–23.2 cm). At the time of diagnosis, five patients were American Joint Committee on Cancer stage II; three were IIIA; three were IIIB; six were IV. Local recurrence occurred in 12 cases, and distant metastasis occurred in 15 cases. The five-year overall survival of the patients with EMC was 73%±17%, and two patients died of the disease. Conclusion Despite the high rate of local recurrence and distant metastasis, the long-term survival rate in patients with EMC is quite high because of its indolent characteristics.

The first endoscopic retrograde cholangiopancreatography (ERCP) wad performed in 1968. With tremendous progress in techniques, instruments and devices, ERCP has played an important role in modern medicine for the diagnosis and management of various pancreaticobiliary diseases. ERCP has a potential risk of various complications even in the hands of the experts. The incidence of all ERCP-related complications is known to be about 4–10%, and that of fatal complications to be less than 0.5%. In order to prevent and minimize its side effects, the everyone who performs ERCP needs to fully understand various techniques and also recognize and deal with ERCP-related complications. In this review, we have summarized the must-know points in techniques and complications of ERCP for the beginners.

The first endoscopic retrograde cholangiopancreatography (ERCP) wad performed in 1968. With tremendous progress in techniques, instruments and devices, ERCP has played an important role in modern medicine for the diagnosis and management of various pancreaticobiliary diseases. ERCP has a potential risk of various complications even in the hands of the experts. The incidence of all ERCP-related complications is known to be about 4–10%, and that of fatal complications to be less than 0.5%. In order to prevent and minimize its side effects, the everyone who performs ERCP needs to fully understand various techniques and also recognize and deal with ERCP-related complications. In this review, we have summarized the must-know points in techniques and complications of ERCP for the beginners.

PURPOSE: Dendritic cells (DCs) are the most potent antigen- presenting cells for initiating the T cell immune response in vivo. Recent studies have shown that active immunotherapy with tumor antigen pulsed DC tumor antigen specific cytotoxic T lymphocyte (CTL) response. The aim of this study was to establish clinically compatible procedures for generating human DCs and to determine if the CEA peptide- pulsed DCs can activate the CEA specific CTL responses in vitro. METHODS: DCs were generated from the peripheral blood monocytes (PBMCs) of HLA A2+ healthy donors using GM-CSF and IL-4. Phenotypic analysis was performed using flow cytometry with FITC- or PE-conjugated Abs against CD1a, CD14, CD80, HLA-DR, CD83 and CD86. The immature DCs were pulsed with a CEA peptide (HLA A2 epitope, [YLSGANLNL]) and the tumor lysates isolated from HLA A2+ CEA positive cell line, NCI-H498, and were incubated with the autologous PBMCs in order to generate an antigen specific CTLs in vitro. After three rounds of stimulation, the presence of a CEA-specific CTL response was determined using a CEA positive cell line as the specific targets with the standard 51Cr release assay, the ELISPOT assay, and the flow cytometry using CEA peptide-MHC tetramer. RESULTS: The DCs obtained after 6 days of culture expressed high levels of CD1a, HLA-DR, and CD80, which corresponded to the immature DC phenotype. The 51Cr- release assay showed that DCs pulsed with the CEA peptide or the lysates of the CEA-positive NCI-H498 cell line could stimulate the CEA-specific CTL responses. The CTL response to DCs pulsed with the CEA peptide was also generated using the DCs pulsed with the CEA peptide. In the ELISPOT assay, the number of CEA peptide-specific, INF-gamma-secreting spots were increased in the CTLs generated by DCs pulsed with the CEA pepide and the tumor lysates. In the peptide-MHC tetramer assay, the CD8+ T cells with the receptors specific to CEA-peptide were increased by stimulation with the DCs pulsed with the CEA peptide and the tumor lysates. CONCLUSION: These findings show that the CEA peptide pulsed DCs can generate CEA specific CTL responses and antigen bearing DCs can be used as the target cells for a cytotoxicity assay. This study provides the foundations for DC-based cancer immunotherapy for CEA expressing solid tumors.
Carcinoembryonic Antigen* ; Cell Line ; Dendritic Cells* ; Enzyme-Linked Immunospot Assay ; Flow Cytometry ; Foundations ; Granulocyte-Macrophage Colony-Stimulating Factor ; HLA-DR Antigens ; Humans ; Immunotherapy ; Immunotherapy, Active ; Interleukin-4 ; Lymphocytes ; Monocytes ; Phenotype ; T-Lymphocytes ; T-Lymphocytes, Cytotoxic* ; Tissue Donors

Hepatic duct diverticulum is a rare form of choledochal cyst that does not fit into the most widely used Todani classification system. Because of its rarity, it may be difficult for clinicians to diagnose and treat it. Here, we present a case of left hepatic diverticulum in a 57-year-old woman with epigastric pain. At presentation, there were mild elevations in the liver function tests. Computed tomography and magnetic resonance cholangiopancreatography showed diverticulum-like cystic lesion with sludge ball near the confluence portion of both intrahepatic bile duct, but the origin of the lesion could not be identified. The clinical impression was type II choledochal cyst. Surgical excision was planned due to recurrent abdominal pain. The operative findings revealed diverticulum arising from left hepatic duct. Histopathology confirmed the lesion to be diverticulum lined by biliary epithelium. The patient had no postoperative complication and no further symptoms since the operation.
Abdominal Pain ; Bile Ducts ; Bile Ducts, Intrahepatic ; Cholangiopancreatography, Magnetic Resonance ; Choledochal Cyst ; Classification ; Diverticulum ; Epithelium ; Female ; Hepatic Duct, Common ; Humans ; Liver Function Tests ; Middle Aged ; Postoperative Complications ; Sewage

Near-infrared fluorescent cholangiography (NIRFC) is an emerging technique for easy intraoperative recognition of biliary anatomy. We present a case of cystic duct variation detected by NIRFC which had a potential risk for biliary injury if not detected. A 32-year-old female was admitted to the Seoul St. Mary's Hospital for surgery for an incidental gallbladder polyp. We performed laparoscopic cholecystectomy with NIRFC. In fluorescence mode, a long cystic duct and an accessory short hepatic duct joining to the cystic duct were found and the operation was completed safely. The patient recovered successfully. NIRFC is expected to be a promising procedure that will help minimize biliary injury during laparoscopic cholecystectomy.
Adult ; Cholangiography* ; Cholecystectomy, Laparoscopic* ; Cystic Duct* ; Female ; Fluorescence ; Gallbladder ; Hepatic Duct, Common ; Humans ; Polyps ; Seoul

Hemosuccus pancreaticus is an unusual gastrointestinal hemorrhage through the main pancreatic duct. We report a rare case of hemosuccus pancreaticus due to a simple mucinous cyst of the pancreas. A 52-year-old man who had been followed-up for a suspected branch duct intraductal papillary mucinous neoplasm (IPMN) visited the emergency room due to hematochezia. Endoscopy showed active bleeding from the ampulla. Computed tomography revealed hemorrhage in a 2.0-cm cystic mass in the pancreatic body. The patient was diagnosed with hemosuccus pancreaticus caused by bleeding into the main pancreatic duct from suspected IPMN. Elective laparoscopic distal pancreatectomy was performed. The histopathological diagnosis was a simple mucinous cyst with squamous metaplasia based upon the pathological finding involving the absence of ovarian-type stroma. In conclusion, it should be recognized that a pancreatic cyst including simple mucinous cyst may cause hemosuccus pancreaticus, and these cysts should be viewed as neoplastic and approached similarly as other mucinous pancreatic neoplasms.
Diagnosis ; Emergency Service, Hospital ; Endoscopy ; Gastrointestinal Hemorrhage ; Hemorrhage ; Humans ; Metaplasia ; Middle Aged ; Mucins* ; Pancreas* ; Pancreatectomy ; Pancreatic Cyst ; Pancreatic Ducts ; Pancreatic Neoplasms