Usefulness of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for the Management of Intrahepatic Bile Duct Lesions (with Videos)

Lee Won Myung,Moon Jong Ho,Lee Yun Nah,Min Chang Wook,Shin Il Sang,Myeong Jun Ho,Kim Hee Kyung,Yang Jae Kook,Lee Tae Hoon 거트앤리버 소화기연관학회협의회 2024 Gut and Liver Vol.18 No.2

Background/Aims: Peroral cholangioscopy (POC) has been used to assess intrahepatic duct (IHD) lesions but with a limited role. A new multibending (MB) ultraslim endoscope has been designed to improve POC performance. We evaluated the usefulness of POC using the MB ultraslim endoscope for the management of IHD lesions. Methods: Between March 2017 and March 2020, 22 patients underwent direct POC using the MB ultraslim endoscope for IHD lesions documented by previous imaging or cholangiopancreatography. The primary outcome was technical success of POC, and secondary outcomes were technical success of POC-guided interventions, median procedure time, and POC-related adverse events. Results: The technical success rate for POC using the MB ultraslim endoscope for IHD lesions was 95.5% (21/22). Free-hand insertion was successful in 95.2% (20/21). The overall technical success rate for POC-guided intervention was 100% (21/21), including nine diagnostic and 12 therapeutic procedures (eight direct stone removal and four intraductal lithotripsies). The median procedure time was 29 minutes (range, 9 to 79 minutes). There were no procedure-related adverse events. Conclusions: Direct POC using the MB ultraslim endoscope allows direct visualization of IHD lesions and may be useful for diagnosis and therapeutic management in selected patients.

The Korean Society of Gastroenterology & SIDDS 2062 : Slide Session ;K-BP-01 : Pancreatobiliary ; A Newly Modifi ed Access Balloon Catheter for Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope in Patients with Biliary Obstruction

( Yun Nah Lee ),( Jong Ho Moon ),( Hyun Jong Choi ),( Hee Jae Jung ),( Moon Han Choi ),( Tae Hoon Lee ),( Sang Woo Cha ),( Young Deok Cho ),( Sang Heum Park ),( Sun Joo Kim ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Background and Aims: Direct peroral cholangioscopy (DPOC) using an ultra-slim endoscope is one of possible POCs by single operator to provide direct visualization of the bile duct. However, currently available accessory for DPOC is limited for the effective procedure. The aim of this study was to evaluate the feasibility and success rate of intraductal guided DPOC with a novel access balloon catheter for cholangioscopy to maintain access. Patients and Methods: From January 2014 to July 2014, 36 patients with biliary obstruction underwent DPOC. Biliary obstruction on intra-pancreatic segment was excluded. All patients underwent an endoscopic sphincterotomy and/or papillary balloon dilation. Intraductal balloon guided DPOC using modifi ed two lumens 5F access balloon catheter for cholangioscopy (MTW Endoskopie, Wesel, Germany) was performed. The success of cholangioscopy was defi ned as advance of the endoscope into the distal margin of obstruction. Results: The success rate of intraductal balloon guided direct POC using access balloon catheter was 97.2% (35/36 patients). 26 patients were malignant, and 5 patients was benign biliary stricture, 4 patients showed impacted stone. DPOC was failed in one patient with benign stricture. Interventional procedures including forceps biopsy or lithotripsy were performed successfully, if needed. Procedure related complication was not occurred in all patients except one self-limited cholangitis. Conclusions: Modifi ed access balloon catheter for cholangioscopy seems to facilitate performing intraductal balloon guided DPOC for the direct visual examination of bile duct in patients with biliary obstruction.

LC, Acute : O-060 ; The usefulness of transient elastography, acoustic radiation force impulse elastography and real time elastography for the evaluation of liver fibrosis in non alcoholic liver disease

( Yun Nah Lee ),( Young Seok Kim ),( Sang Gyune Kim ),( Jae Pil Han ),( Sae Hwan Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Hong Soo Kim ),( Boo Sung Kim ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.1

Background: Clinical usefulness of noninvasive diagnostic methods for the evaluation of liver fibrosis was not fully documented. We evaluated the accuracy of the FibroScan®, acoustic radiation force impulse (ARFI) and real time elastography (RTE) and the efficacy of the addition of the platelet and P2MS to the elastography for predicting liver fibrosis in nonalcoholic liver disease (NALD). Methods: FibroScan®, ARFI and RTE were performed simultaneously at the same day of liver biopsy in 70 patients with various NALD from October 2010 to March 2011. ARFI was performed with SIEMENS ACUSON S2000 ultrasound system and RTE with HITACHI HI VISION-Preirus and EUP-L52 linear probe (3-7MHz). The median values of 10 measurements in ARFI and RTE were calculated, respectively. We used platelet count and P2/MS [platelet count (109/L)]2/ [monocyte fraction(%)×segmented neutrophil fraction (%)] for predicting more accurately liver fibrosis. We defined Vs as velocity of sheer wave (m/s) in ARFI and Es as elasticity score in RTE. Results: From 70 patients, 10 had METAVIR scoring system F0, 4 had F1, 22 had F2, 12 had F3 and 22 had F4. Positive correlations between each methods and fibrosis were found in FibroScan®, ARFI, RTE, P2MS, Vs/PLT, Vs/P2MS, Es/PLT, and Es/P2MS. In the diagnosis of significanct fibrosis (≥F2), the area under the receiver-operating characteristic curve (AUROC)s by FibroScan, ARFI and RTE are 0.689, 0.687 and 0.554. The AUROCs by Vs/PLT and Es/PLT are 0.860 and 0.769. In addition, the AUROCs by P2MS, Vs/P2MS and Es/P2MS are 0.781, 0.778 and 0.746. Comparing with AUROC of each methods for predicting fibrosis (≥F2), Vs/PLT is superior to ARFI (p=0.0018) and Es/PLT is also superior to RTE (p=0.015). Es/P2MS is superior to RTE (p=0.0316), but Vs/P2MS is not significantly different to ARFI (p=0.1491). Moreover, Vs/ P2MS is not superior to Vs/PLT (p=0.0084) and not significantly different to Es/PLT (p=0.5481). Conclusion: Both FibroScan® and ARFI are useful noninvasive modalities for the assessment of liver fibrosis. Vs/P2MS and Es/P2MS can be more helpful for predicting liver fibrosis in NALD than elastography alone, but are not superior to Vs/PLT and Es/PLT.

LC, Acute : O-060 ; The usefulness of transient elastography, acoustic radiation force impulse elastography and real time elastography for the evaluation of liver fibrosis in non alcoholic liver disease

( Yun Nah Lee ),( Young Seok Kim ),( Sang Gyune Kim ),( Jae Pil Han ),( Sae Hwan Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Hong Soo Kim ),( Boo Sung Kim ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.-

Background: Clinical usefulness of noninvasive diagnostic methods for the evaluation of liver fibrosis was not fully documented. We evaluated the accuracy of the FibroScan®, acoustic radiation force impulse (ARFI) and real time elastography (RTE) and the efficacy of the addition of the platelet and P2MS to the elastography for predicting liver fibrosis in nonalcoholic liver disease (NALD). Methods: FibroScan®, ARFI and RTE were performed simultaneously at the same day of liver biopsy in 70 patients with various NALD from October 2010 to March 2011. ARFI was performed with SIEMENS ACUSON S2000 ultrasound system and RTE with HITACHI HI VISION-Preirus and EUP-L52 linear probe (3-7MHz). The median values of 10 measurements in ARFI and RTE were calculated, respectively. We used platelet count and P2/MS [platelet count (109/L)]2/ [monocyte fraction(%)×segmented neutrophil fraction (%)] for predicting more accurately liver fibrosis. We defined Vs as velocity of sheer wave (m/s) in ARFI and Es as elasticity score in RTE. Results: From 70 patients, 10 had METAVIR scoring system F0, 4 had F1, 22 had F2, 12 had F3 and 22 had F4. Positive correlations between each methods and fibrosis were found in FibroScan®, ARFI, RTE, P2MS, Vs/PLT, Vs/P2MS, Es/PLT, and Es/P2MS. In the diagnosis of significanct fibrosis (≥F2), the area under the receiver-operating characteristic curve (AUROC)s by FibroScan, ARFI and RTE are 0.689, 0.687 and 0.554. The AUROCs by Vs/PLT and Es/PLT are 0.860 and 0.769. In addition, the AUROCs by P2MS, Vs/P2MS and Es/P2MS are 0.781, 0.778 and 0.746. Comparing with AUROC of each methods for predicting fibrosis (≥F2), Vs/PLT is superior to ARFI (p=0.0018) and Es/PLT is also superior to RTE (p=0.015). Es/P2MS is superior to RTE (p=0.0316), but Vs/P2MS is not significantly different to ARFI (p=0.1491). Moreover, Vs/P2MS is not superior to Vs/PLT (p=0.0084) and not significantly different to Es/PLT (p=0.5481). Conclusion: Both FibroScan® and ARFI are useful noninvasive modalities for the assessment of liver fibrosis. Vs/P2MS and Es/P2MS can be more helpful for predicting liver fibrosis in NALD than elastography alone, but are not superior to Vs/PLT and Es/PLT.

National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea

Lee Yoon Suk,Jeon Tae Joo,Paik Woo Hyun,Ahn Dong-Won,Chung Kwang Hyun,Son Byoung Kwan,Song Tae Jun,Moon Sung-Hoon,Lee Eaum Seok,Lee Jae Min,Yoon Seung Bae,Paik Chang Nyol,Lee Yun Nah,Park Jin-Seok,Lee 거트앤리버 소화기연관학회협의회 2023 Gut and Liver Vol.17 No.3

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.

Optimal Predictive Criteria for Common Bile Duct Stones: The Search Continues

Yun Nah Lee,문종호 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.2

Inhibitory Effects of Ginsenoside Metabolites, Compound K and Protopanaxatriol, on $GABA_C$ Receptor-Mediated Ion Currents

Lee, Byung-Hwan,Hwang, Sung-Hee,Choi, Sun-Hye,Kim, Hyeon-Joong,Lee, Joon-Hee,Lee, Sang-Mok,Ahn, Yun Gyong,Nah, Seung-Yeol The Korean Society of Pharmacology 2013 The Korean Journal of Physiology & Pharmacology Vol.17 No.2

Ginsenosides, one of the active ingredients of Panax ginseng, show various pharmacological and physiological effects, and they are converted into compound K (CK) or protopanaxatriol (M4) by intestinal microorganisms. CK is a metabolite derived from protopanaxadiol (PD) ginsenosides, whereas M4 is a metabolite derived from protopanaxatriol (PT) ginsenosides. The ${\gamma}$-aminobutyric acid $receptor_C$ ($GABA_C$) is primarily expressed in retinal bipolar cells and several regions of the brain. However, little is known of the effects of ginsenoside metabolites on $GABA_C$ receptor channel activity. In the present study, we examined the effects of CK and M4 on the activity of human recombinant $GABA_C$ receptor (${\rho}$ 1) channels expressed in Xenopus oocytes by using a 2-electrode voltage clamp technique. In oocytes expressing $GABA_C$ receptor cRNA, we found that CK or M4 alone had no effect in oocytes. However, co-application of either CK or M4 with GABA inhibited the GABA-induced inward peak current ($I_{GABA}$). Interestingly, pre-application of M4 inhibited $I_{GABA}$ more potently than CK in a dose- dependent and reversible manner. The half-inhibitory concentration ($IC_{50}$) values of CK and M4 were $52.1{\pm}2.3$ and $45.7{\pm}3.9{\mu}M$, respectively. Inhibition of $I_{GABA}$ by CK and M4 was voltage-independent and non-competitive. This study implies that ginsenoside metabolites may regulate $GABA_C$ receptor channel activity in the brain, including in the eyes.

LC : Prediction of Liver-Related Events Using Transient Elastography in Patients with Chronic Liver Disease

( Yun Nah Lee ),( Young Seok Kim ),( Sang Gyune Kim ),( Sae Hwan Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Hong Soo Kim ),( Boo Sung Kim ) 대한간학회 2013 춘·추계 학술대회 (KASL) Vol.2013 No.1

Background and Aims: Transient elastography (TE) by Fibroscan is a noninvasive method for the diagnosis of liver fi- brosis, but the effi cacy for prediction of clinical decompensation in patients with chronic liver disease (CLD) is uncertain. The aim of this study was to evaluate the efficacy of TE for predicting development of liver related events (LRE) in patients with chronic liver disease. Methods: Between August 2008 and December 2010, 104 CLD patients who underwent TE and liver biopsy before antiviral therapy or portal pressure modifying treatment were enrolled, retrospectively. Patients were evaluated to develop LRE for at least 2 years or until they experienced LRE. Results: During the median follow-up period [median 33.0 (9.0-60.0) months], total 16 LREs developed in 12 (11.5%) patients. TE [P=0.047; odds ratio (OR), 1.064; 95% confidence interval (CI), 1.001-1.130] and ALT [P=0.024 OR, 1.011; 95% CI, 1.001-1.020] were identified as independent predictor for development of LREs by multivariate analysis. The AUROC of TE for predicting the occurrence of LRE was 0.823 and sensitivity and specificity were 75% and 87%, respectively (P<0.001). When patients were divided in two groups according to optimal TE value below or above 15.6 kPa, probability of remaining free of first LRE was significantly higher in group with below 15.6 kPa (P<0.001). Conclusion: TE is effective tool to predict development of LREs in patients with CLD. Therefore, TE is considered to be a valuable clinical tool to avoid invasive procedures

Role of Image-Enhanced Endoscopy in Pancreatobiliary Diseases

Yun Nah Lee,Jong Ho Moon,Hyun Jong Choi 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.6

Recent advances in cholangiopancreatoscopy technology permit image-enhanced endoscopy (IEE) for pancreatobiliary diseases. Thereare limitations in endoscopy performance and in the study of the clinical role of IEE in bile duct or pancreatic duct diseases. However,currently available IEEs during cholangiopancreatoscopy including traditional dye-aided chromoendoscopy, autofluorescence imaging,narrow-band imaging, and I-SCAN have been evaluated and reported previously. Although the clinical role of IEE in pancreatobiliarydiseases should be verified in future studies, IEE is a useful promising tool in the evaluation of bile duct or pancreatic duct mucosallesions.

소화기 ; 한국인 자가면역성 간염을 진단하기 위한 Simplified Scoring Criteria의 가치 및 유용성

이윤나 ( Yun Nah Lee ),김영석 ( Young Seok Kim ),김상균 ( Sang Gyune Kim ),임재희 ( Jae Hee Lim ),정승원 ( Soung Won Jeong ),장재영 ( Jae Young Jang ),이세환 ( Se Hwan Lee ),김홍수 ( Hong Soo Kim ),김부성 ( Boo Sung Kim ),김희경 ( 대한내과학회 2011 대한내과학회지 Vol.81 No.3

목적: 자가면역성 간염(AIH)을 진단하기 위한 revised original scoring criteria는 지나치게 번거로워 임상에서의 적용이 쉽지 않았다. 이러한 단점을 보안하기 위해 2008년 Hennes 등 [19]에 의해 simplified scoring criteria가 발표되었다. 이에 저자 등은 이 criteria를 한국인에게 적용하였을 경우, 진단적 가치 및 유용성을 평가하고자 연구를 시행하였다. 방법: Original revised scoring criteria에 의해 AIH이 진단된 22예와 자가면역 간염/원발성담즙 간경변증(autoimmune hepatitis/primary biliary cirrhosis, AIH/PBC) 중복증후군을 진단받은 5예, 그리고 대조군으로 독성간염 50예, 비알코올성 지방간(NAFLD) 18예, 원발성담즙 간경변증(PBC) 11예를 후향적으로 분석하였다. 결과: AIH 중 20명(90.9%)과 AIH/PBC 중복 증후군 5명 모두가 simplified scoring criteria에 의해 AIH로 진단되었다. 그리고 PBC 중 3명인 27.3%에서 새로운 진단기준을 적용하였을 경우 위양성을 보였다. AIH 진단에 대한 simplified scoring criteria의 민감도와 특이도는 각각 90.9%와 96.2%였다. 결론: 한국인에게 simplified scoring criteria는 중복증후군을 포함한 자가면역성 간염을 진단하는 데 유용하게 사용될 수 있을 것으로 생각한다. Background/Aims: The diagnostic criteria for autoimmune hepatitis (AIH) were created and revised by the International Autoimmune Hepatitis Group (IAIHG) in 1999. Simplified scoring criteria based on four clinical components were recently proposed. The aim of this study was to assess the diagnostic value and usefulness of these simplified criteria in Korea. Methods: We applied the simplified scoring criteria to 22 AIH patients diagnosed according to the original revised scoring criteria proposed in 1999. Furthermore, in order to compare the predictive power of these two sets of diagnostic criteria, we included 84 patients with liver diseases [toxic hepatitis (n = 50), nonalcoholic fatty liver disease (n = 18), primary biliary cirrhosis (PBC) (n = 11), and PBC/AIH overlap syndrome (n = 5)] other than AIH. Results: Twenty (90.9%) patients with AIH and five (100%) with PBC/AIH overlap syndrome were diagnosed with AIH according to the simplified scoring criteria. Three (27.3%) patients with PBC were false-positive for AIH according to the simplified scoring criteria. Those patients diagnosed according to the simplified scoring criteria showed an increased frequency of ANA and/or SMA of ≥ 1:80 (p = 0.491) and an increased frequency of serum IgG levels at or above the upper normal limit compared to patients with PBC (p = 0.006). The sensitivity and specificity of the simplified scoring criteria for the diagnosis of AIH were 90.9 and 96.2%, respectively. Conclusions: The simplified scoring criteria offer a reliable and simple method for excluding AIH; however, these criteria may have limitations in the diagnosis of patients with atypical features, especially those with low autoantibody and IgG levels. (Korean J Med 2011;81:340-350)