Background/Aims: The use of a self-expandable metal stent (SEMS) is recommended for unresectable malignant biliary obstruction (MBO). Stent-related adverse events might differ according to the position of the stent through the ampulla of Vater (AOV). We retrospectively evaluated SEMS patency and adverse events according to the position of the SEMS. Methods: In total, 280 patients who underwent endoscopic SEMS placement due to malignant distal biliary obstruction were analyzed retrospectively. Suprapapillary and transpapillary SEMS insertions were performed on 51 patients and 229 patients, respectively. Results: Between the suprapapillary group (SPG) and transpapillary group (TPG), the stent patency period was not significantly different (median [95% confidence interval]: 107 days [82.3 to 131.7] vs 120 days [99.3 to 140.7], p=0.559). There was also no significant difference in the rate of adverse events. In subgroup analysis, the stent patency for an MBO located within 2 cm from the AOV was found to be significantly shorter than that for an MBO located more than 2 cm from the AOV in the SPG (64 days [0 to 160.4] vs 127 days [82.0 to 171.9], p<0.001) and TPG (87 days [52.5 to 121.5] vs 130 [97.0 to 162.9], p<0.001). Patients with an MBO located within 2 cm from the AOV in both groups had a higher percentage of duodenal invasion (SPG: 40.0% vs 4.9%, p=0.002; TPG: 28.6% vs 2.9%, p<0.001) than patients with an MBO located more than 2 cm from the AOV. Conclusions The SPG and TPG showed similar results in terms of stent patency and rate of adverse events. However, patients with an MBO located within 2 cm from the AOV had a higher percentage of duodenal invasion with shorter stent patency than those with an MBO located more than 2 cm from the AOV, regardless of stent position.

Background: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI. Methods: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed. Results: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI;additionally, age (65–74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI. Conclusions Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

Purpose: The Korean Renal Cancer Study Group (KRoCS) provides consensus recommendations on the role of cytoreductive nephrectomy (CRN) in patients with metastatic renal cell carcinoma (mRCC). Materials and Methods: A group of mRCC experts from the Korean Urological Oncology Society convened at the 2021 KRoCS meeting on CRN for mRCC. Results: The consensus document was developed to address 4 questions related that were judged to be the most relevant to patient care: (1) Is there a role for CRN in patients planning targeted therapy? (2) Is there a role for CRN in patients planning immuno-oncology agents? (3) When is the optimal time of CRN in patients planning systemic treatment? (4) What is the ideal patient selection for CRN? The panelists have come up with following consensus. For mRCC patients, CRN should be considered only in those with IMDC (International Metastatic Renal Cell Carcinoma Database Consortium) favorable and intermediate risk disease, regardless of the systemic treatment plans. Timing of CRN should consider the risk group as well as the number of risk factors, but is generally recommended for after assessing the degree of response to initial systemic treatment. Patients with good performance status, limited metastatic burden on top of resectable primary tumor are candidates recommended for CRN with or without metastasectomy with priority. Conclusions In conclusion, there is still a role for CRN in the multimodality treatment of mRCC. Careful patient selection is of paramount importance. As the treatment landscape of mRCC continues to change, the role of CRN in the current immuno-oncology era will require more exploration.

BACKGROUND: Hepatitis B virus (HBV) infection leads to hepatic and extrahepatic manifestations including chronic kidney disease (CKD). However, the association between HBV and CKD is not clear. This study investigated the association between chronic HBV infection and CKD in a nationwide multicenter study. METHODS: A total of 265,086 subjects who underwent health-check examinations in 33 hospitals from January 2015 to December 2015 were enrolled. HBV surface antigen (HBsAg) positive cases (n = 10,048), and age- and gender-matched HBsAg negative controls (n = 40,192) were identified. CKD was defined as a glomerular filtration rate (GFR) < 60 mL/min/1.73 m² or proteinuria as at least grade 2+ of urine protein. RESULTS: HBsAg positive cases showed a significantly higher prevalence of GFR < 60 mL/min/1.73 m² (3.3%), and proteinuria (18.9%) than that of the controls (2.6%, P < 0.001, and 14.1%, P < 0.001, respectively). In the multivariate analysis, HBsAg positivity was an independent factor associated with GFR < 60 mL/min/1.73 m² along with age, blood levels of albumin, bilirubin, anemia, and hemoglobin A1c (HbA1c). Likewise, HBsAg positivity was an independent factor for proteinuria along with age, male, blood levels of bilirubin, protein, albumin, and HbA1c. A subgroup analysis showed that HBsAg positive men but not women had a significantly increased risk for GFR < 60 mL/min/1.73 m². CONCLUSION: Chronic HBV infection was significantly associated with a GFR < 60 mL/min/1.73 m² and proteinuria (≥ 2+). Therefore, clinical concern about CKD in chronic HBV infected patients, especially in male, is warranted.
Anemia ; Antigens, Surface ; Bilirubin ; Case-Control Studies* ; Female ; Glomerular Filtration Rate ; Hepatitis B Surface Antigens ; Hepatitis B virus ; Hepatitis B, Chronic* ; Hepatitis, Chronic* ; Humans ; Male ; Multivariate Analysis ; Prevalence ; Proteinuria ; Renal Insufficiency, Chronic*

SUMMARY OF EVENT: An endoscopic retrograde pancreatic duct (ERPD) stent was inserted in a male patient with chronic pancreatitis via endoscopic retrograde cholangiopancreatography (ERCP) to relieve chronic epigastric pain. After the procedure, an abdominal computed tomography scan showed localized peritonitis with a dislocated ERPD stent. The patient underwent an emergency operation, which revealed that the peritonitis was caused by perforation of the pancreatic parenchyma by the ERPD stent. TEACHING POINT: A hydrophilic guide wire can puncture the pancreas during ERPD stent insertion. Therefore, it is necessary to ensure that the guide wire reaches the main pancreatic duct, especially in patients with chronic pancreatitis.
Cholangiopancreatography, Endoscopic Retrograde ; Emergencies ; Humans ; Male ; Pancreas ; Pancreatic Ducts ; Pancreatitis, Chronic* ; Peritonitis ; Punctures ; Stents

We propose a double layered (intradural and epidural patch) duraplasty that utilizes Lyoplant and Duraseal. We examined a 47-year-old woman after decompression for thoracic ossification of posterior longitudinal ligament was performed in another hospital. On postoperative day 7, she complained of weakness in both legs. Postoperative magnetic resonance imaging (MRI) showed cerebrospinal fluid (CSF) collection with cord compression. In the operative field, we found 2 large dural defects on the ventral dura mater. We performed a conventional fat graft with fibrin glue. However, the patient exhibited neurologic deterioration, and a postoperative MRI again showed CSF collection. We performed dorsal midline durotomy and inserted a intradural and epidural Lyoplant patch. She immediately experienced diminishing back pain postoperatively. Her visual analog scale and motor power improved markedly. Postoperative MRIs performed at 2 and 16 months showed no spinal cord compression or CSF leakage to the epidural space. We describe a new technique for double layered duraplasty. Although we do not recommend this technique for all dural repairs, double-layered duraplasty may be useful for repairing large inaccessible dural tears in cases of persistent CSF leakage refractory to conventional management.
Back Pain ; Cerebrospinal Fluid ; Cerebrospinal Fluid Leak ; Decompression ; Dura Mater ; Epidural Space ; Female ; Fibrin Tissue Adhesive ; Humans ; Leg ; Magnetic Resonance Imaging ; Microtomy ; Middle Aged ; Ossification of Posterior Longitudinal Ligament ; Spinal Cord Compression ; Spine* ; Tears ; Transplants ; Visual Analog Scale

Papillary thyroid cancer (PTC) has a good prognosis and a low incidence of distant metastases. It is extremely rare for PTC to metastasize to the pancreas. Only five cases have been previously reported worldwide. Most cases are discovered incidentally by abdominal computed tomography (CT) or positron emission tomography-CT (PET-CT) during follow-up studies after thyroidectomies. Pancreatic metastasis of PTC is usually unidentifiable by a whole-body I131 scan, a common follow-up modality. When a pancreatic mass is found in patients with PTC, it must be differentiated from pancreatic cancer. In previous reports, patients with pancreatic metastases of PTC underwent operations for therapeutic diagnosis or underwent fine needle aspiration biopsies (FNAB). However, it is unclear whether the benefit of an operation outweighs the risk. We experienced a case of PTC with pancreatic metastasis that was found on PET-CT. Contrast-enhanced endoscopic ultrasonography (EUS) was performed to evaluate the characteristics of the pancreatic mass and pathological confirmation was obtained cytologically via EUS-FNA.
Biopsy ; Biopsy, Fine-Needle ; Diagnosis ; Electrons ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Follow-Up Studies ; Humans ; Incidence ; Neoplasm Metastasis* ; Pancreas ; Pancreatic Neoplasms* ; Prognosis ; Thyroid Neoplasms* ; Thyroidectomy

Metastatic carcinoma that causes appendicitis is extremely rare. To our knowledge, metastatic cholangiocarcinoma in the appendix has been reported in only 1 case in the English literature. We report herein the case of an 87-year-old woman who presented with abdominal pain and jaundice. Advanced cholangiocellular carcinoma and a proximal appendiceal mass with appendicitis were detected on contrast-enhanced computed tomography and positron emission tomography/computed tomography. After elective laparoscopic appendectomy and wedge resection of the cecum, pathologic results revealed metastatic adenocarcinoma from extrahepatic cholangiocellular carcinoma in the appendix.
Abdominal Pain ; Adenocarcinoma ; Aged, 80 and over ; Appendectomy ; Appendicitis* ; Appendix ; Cecum ; Cholangiocarcinoma* ; Electrons ; Female ; Humans ; Jaundice ; Neoplasm Metastasis

Ampullary neuroendocrine tumor is rare but requires total resection for treatment. Traditionally, pancreatic duodenal resection has been recommended for treatment of ampullary neuroendocrine tumor. Because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases with low grade, no metastasis, and no invasion of the pancreatic or bile duct. We present a case of an ampullary neuroendocrine tumor which was successfully and completely resected via endoscopic papillectomy. Endoscopic papillectomy can be a viable alternative for the resection of neuroendocrine tumor at the major duodenal papilla in cases with high surgical risks.
Ampulla of Vater ; Bile Ducts ; Carcinoid Tumor ; Endoscopy ; Mortality ; Neoplasm Metastasis ; Neuroendocrine Tumors*

PURPOSE: To evaluate the incidence and clinical features of age-related macular degeneration (AMD) in Korea. METHODS: Web-based (www.armd-nova.or.kr) registration was conducted for AMD patients aged 50 or more who were newly diagnosed by retinal specialists in Korea from August 20, 2005 to August 20, 2006. Patient data including ophthalmologic examination, fundus photography, fluorescein angiogram and/or indocyanin green angiogram (ICG), past medical history, behavioral habit, combined systemic diseases were up-loaded. RESULTS: Among finally enrolled 1,141 newly diagnosed AMD patients, 690 patients (60.5%) were male and 451 patients (39.5%) were female. The average age of AMD patients was 69.7+/-8.0. Early AMD was observed in 190 patients and 951 patients had late AMD. Classic choroidal neovascular membrane (CNVM) was observed in 18.6% of exudative AMD patients and 63.4 % had occult CNVM. Subfoveal CNVM was observed in 80.4% of the patients with CNVM. Among the 580 exudative AMD eyes that performed indocyanin green angiography (ICG), 184 eyes (31.7%) had polypoidal choroidal vasculopathy (PCV) and 36 eyes (6.2%) showed retinal angiomatous proliferation (RAP). Age, male gender, smoking, diabetes and hypertension significantly increased the risk of the AMD among Koreans. CONCLUSIONS: Because of the low rate of participation by retinal specialists, definite incidence of AMD was not obtainable. However, the estimated 1-year AMD incidence in the Pusan area of Korea is at least 0.4%. In contrast to Western people, 31.7% of exudative AMD cases were revealed to be PCV and 6.2% were revealed to be RAP. This discrepancy between ethnic groups should be considered in the diagnosis and treatment modality selection of Korean AMD patients.
Aged ; Angiography ; Choroid ; Ethnic Groups ; Eye ; Female ; Fluorescein ; Humans ; Hypertension ; Incidence ; Korea ; Macular Degeneration ; Male ; Membranes ; Photography ; Retinaldehyde ; Smoke ; Smoking ; Specialization