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1.  Endoscopic papillary large balloon dilation for the removal of bile duct stones 
Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.
PMCID: PMC3870503  PMID: 24379575
Balloon dilation; Endoscopic sphincterotomy; Common bile duct gallstones; Lithotripsy; Complications; Assessment; Patient outcomes
2.  Robotic cholecystectomy with new port sites 
AIM: To introduce robotic cholecystectomy (RC) using new port sites on the low abdominal area.
METHODS: From June 2010 to June 2011, a total of 178 RCs were performed at Ajou University Medical Center. We prospectively collected the set-up time (working time and docking time) and console time in all robotic procedures.
RESULTS: Eighty-three patients were male and 95 female; the age ranged from 18 to 72 years of age (mean 54.6 ± 15.0 years). All robotic procedures were successfully completed. The mean operation time was 52.4 ± 17.1 min. The set-up time and console time were 11.9 ± 5.4 min (5-43 min) and 15.1 ± 8.0 min (4-50 min), respectively. The conversion rate to laparoscopic or open procedures was zero. The complication rate was 0.6% (n = 1, bleeding). There was no bile duct injury or mortality. The mean hospital stay was 1.4 ± 1.1 d. There was a significant correlation between the console time and white blood cell count (r = 0.033, P = 0.015). In addition, the higher the white blood cell count (more than 10000), the longer the console time.
CONCLUSION: Robotic cholecystectomy using new port sites on the low abdominal area can be safely and efficiently performed, with sufficient patient satisfaction.
PMCID: PMC3662947  PMID: 23716987
Robotic cholecystectomy; Port sites; Operation time; Abdominal area; Gallbladder disease
3.  Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones 
BMC Gastroenterology  2013;13:15.
Endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) has been proposed as an alternative to manage large bile duct stones. However, recent reports indicate that LBD without EST may be safe and effective in this setting.
One hundred thirty-one patients with large common bile duct (CBD) stones 12 mm in size or larger underwent LBD alone (n = 62) or EST plus LBD (n = 69) for lithotripsy. The therapeutic outcome and complications were reviewed and compared.
There were no differences between the two groups with regard to age, size and number of stones, or bile duct diameter. The LBD alone group (mean age, 70.4 years) and the EST plus LBD group (mean age, 68.2 years) had similar outcomes in terms of overall successful stone removal (96.8% vs. 95.7%, P = 0.738) and complete stone removal without the need for mechanical lithotripsy (80.6% vs. 73.9%, P = 0.360). Complications in the LBD alone and EST plus LBD groups were as follows: pancreatitis (6.5% vs. 4.3%, P = 0.593), impaction of basket and stone (0% vs. 1.4%, P = 0.341), and perforation (0% vs. 1.4%, P = 0.341).
LBD alone may be a simple, safe, and effective alternative to EST plus LBD in relatively aged patients with large CBD stones, and it can simplify the procedure compared with EST plus LBD.
PMCID: PMC3556067  PMID: 23324454
Common bile duct stones; Endoscopic sphincterotomy; Large-balloon dilation
4.  A Comparative Study on the Efficacy of Covered Metal Stent and Plastic Stent in Unresectable Malignant Biliary Obstruction 
Clinical Endoscopy  2012;45(1):78-83.
The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent.
We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate.
There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182).
The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.
PMCID: PMC3363115  PMID: 22741136
Malignant biliary obstruction; Self-expandable metal stent; Plastic stent
5.  One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy 
Gut and Liver  2012;6(1):113-117.
Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.
Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.
Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.
Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.
PMCID: PMC3286728  PMID: 22375180
Endoscopic balloon dilation; Common bile duct; Stone; Billroth II gastrectomy; Cap-fitted endoscopy
6.  Temporary Placement of a Newly Designed, Fully Covered, Self-Expandable Metal Stent for Refractory Bile Leaks 
Gut and Liver  2011;5(1):96-99.
Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.
PMCID: PMC3065102  PMID: 21461081
Bile leak; Self-expandable metal stent; Duct of Luschka; Laparoscopic cholecystectomy

Results 1-6 (6)