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.

Purpose: The use of gallium-68 prostate-specific membrane antigen-11 positron emission tomography/computed tomography (Ga-68 PSMA-11 PET/CT) is becoming increasingly common among men with prostate cancer (PCa). However, it remains uncertain which patients will derive the most benefit, and there is a scarcity of real-world data regarding its impact on altering treatment plans. This study investigated which patients would most benefit from Ga-68 PSMA-11 PET/CT, focusing on detection rates and changes in treatment strategies, drawing from a single-center experience. Materials and Methods: In total, 230 men with PCa who underwent Ga-68 PSMA-11 PET/CT between November 2021 and August 2022 were included in this retrospective study. The patients were classified into 5 groups based on their disease status: group 1, further work-up for high-risk localized PCa; group 2, de novo metastatic PCa; group 3, biochemical recurrence after definitive treatment; group 4, castration-resistant PCa; group 5, others. The positivity rate, positive lesions, predictive value of lymph node metastases, comparison with conventional images, and treatment changes after Ga-68 PSMA-11 PET/CT were analyzed in each group. Results: Of the 230 patients, 40 (17.4%), 20 (8.7%), 77 (33.5%), 76 (33.0%), and 17 (7.4%) were classified into groups 1–5, respectively. Ga-68 PSMA-11 PET/CT showed lesions in 74.8% of patients, and the optimal cutoff value for PSA was 1.99 ng/mL. Lesions not observed on conventional imaging were found in 62 patients (33.2%). In 38 patients (13.5%), treatment was changed due to Ga-68 PSMA-11 PET/CT. Conclusions These real-world data suggest that Ga-68 PSMA-11 PET/CT may be clinically useful for various disease conditions, as substantial stage migration and subsequent treatment changes occur in men with PCa. However, the prognostic impact of this modality remains unclear; thus, a well-designed prospective study is needed to address this issue.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Pancreatobiliary Association has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five preprocedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs.

Background: Programmed death ligand 1 (PD-L1) expression cannot currently be predicted through radiological findings. This study aimed to develop a prediction model capable of differentiating between positive and negative PD-L1 expression through a radiomics-based investigation of computed tomography (CT) images in patients with urothelial carcinoma. Methods: Sixty-four patients with urothelial carcinoma who underwent immunohistochemical testing for PD-L1 were retrospectively reviewed. The number of patients in the positive and negative PD-L1 groups (PD-L1 expression >5%) was 14 and 50, respectively. CT images obtained 90 seconds after contrast medium administration were selected for radiomic extraction. For all tumors, 1,691 radiomic features were extracted from CT using a manually segmented three-dimensional volume of interest. Univariate and multivariate logistic regression analyses were performed to identify radiomic features that were significant predictors of PD-L1 expression. For the radiomics-based model, a receiver operating characteristic (ROC) analysis was performed. Results: Among 64 patients, 14 were included in the PD-L1 positive group. Logistic regression analysis found that the following radiomic features significantly predicted PD-L1 expression: wavelet-low-pass, low-pass, and high-pass filters (LLH)_gray-level size-zone matrix (GLSZM)_SmallAreaEmphasis, wavelet-LLH_firstorder_Energy, log-sigma-0-5-mm-3D_GLSZM_SmallAreaHighGrayLevelEmphasis, original_shape_Maximum2DDiameterColumn, wavelet-low-pass, low-pass, and low-pass filters (LLL)_gray-level run-length matrix (GLRLM)_ShortRunEmphasis, and exponential_firstorder_Kurtosis. The radiomics signature was –4.0934+21.6224 (wavelet-LLH_GLSZM_SmallAreaEmphasis)+0.0044 (wavelet-LLH_firstorder_Energy)–4.7389 (log-sigma-0-5-mm-3D_GLSZM_SmallAreaHighGrayLevelEmphasis)+0.0573 (original_shape_Maximum2DDiameterColumn)–29.5892 (wavelet-LLL_GLRLM_ShortRunEmphasis)–0.4324 (exponential_firstorder_Kurtosis). The area under the ROC curve model representing the radiomics signature for differentiating cases that were deemed PD-L1 positive based on immunohistochemistry was 0.96. Conclusions This preliminary radiomics model derived from contrast-enhanced CT predicted PD-L1 positivity in patients with urothelial cancer.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Society of Pancreatobiliary Endoscopy has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five pre-procedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs.

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.

Purpose: This study aimed to compare the intraoperative and postoperative outcomes between robotic and laparoscopic transperitoneal adrenalectomies. Methods: In this retrospective study, 93 patients underwent adrenalectomy using 2 surgical modalities: 45 patients underwent adrenalectomy using the da Vinci Xi system (robotic group), and 48 patients using laparoscopic devices (laparoscopic group). We compared the operation time, intraoperative bleeding, and hospital stay according to the surgical modality and tumor characteristics. Results: There were no significant differences in the operative time (P = 0.827), hospital stay (P = 0.177), and intraoperative bleeding (P = 0.174) between the groups. However, the robotic group showed a lower coefficient of variation in total operative time than that of the laparoscopic group (100.6 ± 23.3 minutes vs. 101.9±32.7 minutes, 0.230 vs. 0.321). When divided into 2 subgroups based on the tumor size (<3 cm and ≥3 cm), the robotic group with a tumor sized >3 cm had a shorter operative time than that of the laparoscopic group (P = 0.032). The robotic group also had fewer cases of intraoperative bleeding (P = 0.034). Conclusions Compared to the laparoscopic transperitoneal adrenalectomy, the robotic one achieved a lower deviation in total operative time and showed less bleeding and a shorter operative time, especially for tumors sized >3 cm.

Purpose: Outcome analysis of urachal cancer (UraC) is limited due to the scarcity of cases and different staging methods compared to urothelial bladder cancer (UroBC). We attempted to assess survival outcomes of UraC and compare to UroBC after stage-matched analyses. Materials and Methods: Total 203 UraC patients from a multicenter database and 373 UroBC patients in single institution from 2000 to 2018 were enrolled (median follow-up, 32 months). Sheldon stage conversion to corresponding TNM staging for UraC was conducted for head-to-head comparison to UroBC. Perioperative clinical variables and pathological results were recorded. Stage-matched analyses for survival by stage were conducted. Results: UraC patients were younger (mean age, 54 vs. 67 years; p < 0.001), with 163 patients (80.3%) receiving partial cystectomy and 23 patients (11.3%) radical cystectomy. UraC was more likely to harbor ≥ pT3a tumors (78.8% vs. 41.8%). While 5-year recurrence-free survival, cancer-specific survival (CSS) and overall survival were comparable between two groups (63.4%, 67%, and 62.1% in UraC and 61.5%, 75.9%, and 67.8% in UroBC, respectively), generally favorable prognosis for UraC in lower stages (pT1-2) but unfavorable outcomes in higher stages (pT4) compared to UroBC was observed, although only 5-year CSS in ≥ pT4 showed statistical significance (p=0.028). Body mass index (hazard ratio [HR], 0.929), diabetes mellitus (HR, 1.921), pathologic T category (HR, 3.846), and lymphovascular invasion (HR, 1.993) were predictors of CSS for all patients. Conclusion Despite differing histology, UraC has comparable prognosis to UroBC with relatively favorable outcome in low stages but worse prognosis in higher stages. The presented system may be useful for future grading and risk stratification of UraC.

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.

Background: and Purpose While excessive daytime sleepiness can predate Parkinson’s disease in late-life, its association with parkinsonian-like (P-L) symptoms in middle age are unknown. Since neurodegeneration can appear decades before a diagnosis of Parkinson’s disease, identifying clinical features associated with this early progression is important. The purpose of this study was to determine the association of daytime sleepiness with P-L symptoms in a population-based sample of middle-aged Korean adults. Methods: During 2013 and 2014, daytime sleepiness and P-L symptoms were assessed in 2,063 males and females aged 50–64 years who were participating in the Korean Genome and Epidemiology Study. The severity of daytime sleepiness was quantified by the score on the Epworth Sleepiness Scale (ESS). Self-reported P-L symptoms included nine motor disorders commonly associated with Parkinson’s disease. Participants with parkinsonism and related conditions are excluded. Results: The prevalence of excessive daytime sleepiness (ESS score >10) was 7.0%. The frequencies of P-L symptoms ranged from 0.5% (for “trouble buttoning buttons”) to 18.4% (for “handwriting smaller than it once was”). After adjustment for covariates and multiple testing, the relative odds of P-L symptoms comparing the 80th and 20th percentiles of ESS scores was 1.6 (p=0.001) for “voice is softer than it once was,” 2.1 (p<0.001) for “balance when walking is poor,” and 1.5 (p=0.002) for “loss of facial expression.” The prevalence of excessive daytime sleepiness increased from 6.3% to 19.8% when the number of symptoms increased from zero to three (p=0.004). Conclusions In Korean adults aged 50–64 years, daytime sleepiness is significantly associated with P-L symptoms. Whether coexisting daytime sleepiness and P-L symptoms predate extrapyramidal and other impairments in later life warrants further investigation.