and apomucin-immunohistochemistly well correlated with its tumor prognosis. Co-expressing of gastric apomucin MUC5AC and MUC6 correlated with prognosis at O-typeampullary carcinomas.Table

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Growth Rate of Gallbladder Polyp As Predictor to Neoplastic PolypSu Rin Shin, Jong Kyun Lee, Kyu Taek Lee, Kee Taek Jang, Seong Hyun Kim, Jong ChulRhee

BACKGROUND: Gallbladder (GB) polyps larger than 10mm are well known to be highlysuggested neoplastic polyp and cholecystectomy has been indicated. On the other hand,there has been not acceptable consensus for GB polyp less than 10mm especially when itincreases. Some reported rapid growth of GB polyp could be important feature to predictneoplastic polyp but large trials have been yet published. The aim of present study was toevaluate significance of growth rate as predictive factor for neoplastic polyp. PATIENTSAND METHODS: From August 1994 to august 2007, a total of 169 patients who had GBpolyp and underwent cholecystectomy were reviewed retrospectively. All patients werefollowed up by two consecutive abdominal ultrasonographies with more than three monthsinterval. Demographic and laboratory findings were investigated. Of the ultrasonographicfindings, size and number of GB polyp, presence of stone and degree of the fatty liver werereview. The growth rate was defined as difference of maximum diameters between latterand former exam divided into follow up interval (months). On the basis of the pathologicreports GB polyps were classified into non-neoplastic and neoplastic polyp including adenomaand carcinoma. REULSTS: 148 non-neoplastic polyps and 21 neoplastic polyps consistedof 16 adenomas and 5 carcinomas were enrolled. Median age of patients was 47.2 (range25-74) in non-neoplastic polyp group and 55.3 (range 35-75) in neoplastic polyp group.With univariate analysis, old age more than 60, hypertension, fasting glucose, solitary polyp,large size more than 10mm and rapid growth rate more than 0.6mm/month were significantlyattributed with neoplastic polyp. But multivariate analysis resulted that old age (≥60, OR5.05 p=0.009), solitary polyp (OR 0.295, p=0.030) and size (≥10mm, OR 3.946, p=0.032)were attributable factors for neoplastic polyp but growth rate was not. Even in polyp lessthan 10mm, growth rate could not correlate frequency of neoplastic polyp. CONCLUSION:Most of all, old age more than 60, solitary polyp and large size more than 10mm were riskfactors for neoplastic polyp. The growth rate of GB polyp was not significant predictivefactor. Therefore it would not demand to operate with GB polyp less than 10mm in diameter,only because it increased.

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Liver Elasticity in Patients with Pancreatobiliary DiseaseYoko Yashima, Ryota Masuzaki, Toshihiko Arizumi, Osamu Togawa, Saburo Matsubara,Yousuke Nakai, Ryosuke Tateishi, Kenji Hirano, Naoki Sasahira, Takeshi Tsujino,Hiroyuki Isayama, Minoru Tada, Haruhiko Yoshida, Takao Kawabe, Masao Omata

Objective: The liver elasticity measured noninvasively by Fibroscan (Echosens, Paris) hasbeen reported to correlate with the extent of hepatic fibrosis in the cases with chronic liverdiseases. Chronic cholestasis also showed to have elevated Liver stiffness Measurement (LSM)due to hepatic fibrosis. However, there has been no report on LSM in patients with short-term cholestasis due to mechanical obstruction. Method: We examined 139 patients withbiliary and pancreatic disorders (malignacy and nonmalignancy) with or without cholestasis.In these, all the preexisting chronic liver diseases were excluded. This study was prospectivelyconducted from April 2007 to November 2007 at our hospital with ethic committee approval.The cohorts were consisted of 3 groups; 75 patients in Non-C group (non cholestasis), 15in Long-Term C group (long-term cholestasis) and 36 in Short-Term C group (short-termobstructive jaundice ). Result: The mean LSM was 22.6 Kpa, 14.8 and 7.2 in Long-TermC , in Short-Term C and in Non-C group,respectively. LSM of the former two were signific-antly higher than that of Non-C group (p<0.01). Among several clinical features and disorders,we found that hilar obstruction had higher FSV than non-hilar obruction (p<0.05). Inaddition, biliary drainage resulted in the decline of LSM in non-hilar, but not hilar typejaundice. Conclusion: Cholestasis may affect the liver 'elasticity' in bilio-pancreatic diseasesnot only in long-term but also in short-term cholestasis. It is conceivable that the formeris insidious progression of hepatic fibrosis, ant the latter is reversible , closely related tomechanical obstructive process.

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Endoscopic Papillary Large Balloon Dilatation After EndoscopicSphincterotomy for Bile Duct Stones in Difficult SphincterotomyYoung Hwangbo, Seok Ho Dong, Jae Young Jang, Hyo Jong Kim, Byung-Ho Kim, YoungWoon Chang, Rin Chang

Background : Endoscopic sphincterotomy (ES) followed by endoscopic papillary large balloondilatation (EPLBD) can be used for bile duct stones especially in patient with large stonesor difficult to perform full-ES. The aim of this retrospective study was to evaluate theusefullness and safty of ES plus EPLBD for bile duct stones difficult to extract, and whichclinical indications needed additional EPLBD after ES. Methods : Thirty-seven patients inwhom endoscopic sphincterotomy only were not efficient in the removal of bile duct stonesunderwent dilation with a 8- to 20-mm diameter (CRE, controlled radial expansion) balloon.Results : The mean age of patients was 69.4±9.38 years. The average maximum stonediameter was 15.9±8.64 mm. The clinical reasons of additional EPBD after ES were large(>15

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mm) stone 17 patients (45.9%), bleeding tendency 15 patients (40.5%), periampullary large-diverticulum 16 patients (43.2%), subtotal gastrectomy with Billroth-II anastomosis 4 patients(10.8%), revision of old EST site 10 patients (27.0%), and technically difficult full-EST 3patients (8.1%). Complete stone removal was accomplished in 35 patients (94.6%). Noprocedure-related perforation or mortality was observed. Post-ERCP pancreatitis wasoccurred in only one patient (2.7%), who recovered easily by medical management.Transientelevation of amylase and lipase after the procedure was observed in 7 patients (18.9%).Minor bleeding was encountered in 7 patients (18.9%), and was easily controlled by anballoon tamponade and endoscopic epinephrine injection. Conclusions : Endoscopic papil-lary large balloon dilatation after endoscopic sphincterotomy would be a simple, safe,and effective method for removing large bile duct stones, and also for various difficultsphincterotomy states.

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Benefits of Temporal Endoscopic Gallbladder Stenting (EGS) FollowedLaparoscopic Transcystic Removal in CholecystitisMaki Sugimoto, Hideki Yasuda, Keiji Koda, Masato Suzuki, Masato Yamazaki, TohruTezuka, Chihiro Kosugi, Ryota Higuchi, Yohsuke Yagawa

METHODS: Between Jan 2004 and Dec 2007, we performed 164 laparoscopic cholecystec-tomy (LC) for cholecystitis. Preoperative endoscopic gallbladder drainage was used in 71patients (43%), 60 patients (36.7%) who accepted ENGBD and 11 patients (6.7%) whounderwent transpapillary EGS placement were subjected in this retrospective study. ENGBDwas inserted as a single-pigtail polyethylene naso-biliary tube. EGS entailed placement of asingle-pigtail polyethylene stent between the gallbladder and the duodenum. During surgery,transcystic duct extraction of EGS was carried out. The advantages and techniques oftemporally EGS followed LC were described. RESULTS: Benefits of GB cannulation couldbe the disimpaction of gallstones and the drainage of obstructed gallbladder. Drainage isexpected to achieve after being pushed back the obstructing stone into the gallbladder. Noprocedure-associated morbidity or mortality was found in both procedure. These resultedeffective bile drainage and resolution of their symptoms immediately in all patients. DuringLC, GB tube enabled to clarify inflamed cystic duct, thereby made operative dissectioneasier. There were no bile duct injuries or mortalities. No intraoperative or postoperativecomplications occurred. In particular, EGS could decrease physical restriction and adjustedadequate preoperative period by tube-free situation. The deviations were none in EGS (0%),but 5 in ENGBD (8.3%). During surgery, transcystic duct extraction of EGS was successfullycarried out in all patients without biliary injuries. CONCLUSION: EGS is a beneficialprocedure to perform safer laparoscopic cholecystectomy for cholecystitis. This approach isminimal invasive, safe, and effective in preventing tube deviation from the gallbladder,potential morbidity and mortality. Transcystic removal of EGS is feasible for lapaloscopicsurgery in cholecystitis.

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Outcome of Biliary Dyskinesia in Pediatrics and a New Definition ofGallbladder Ejection Fraction for DiagnosisYamen Smadi, Anur Praveen, Abdelkader Hawasli, Hernando Lyons

Background: The increasing incidence of biliary dyskinesia (BD) as a cause of chronicabdominal pain in children has led to a parallel increase in the number of cholecystecomiesin this population. In children, BD as an indication for cholecystectomy varies from 14%to 58%. Gallbladder ejection fraction (GBEF) for diagnosis of BD (extrapolated from adultstudies) varies from 15% to 50%. Rate of symptom resolution also differs from 15% to 98%.Most pediatric studies have been small samples (5-30 patients). Objectives: To study theprevalence of BD as an indication for cholecystectomy; to study the clinical outcomes aftersurgery; and to determine the CCK stimulated GBEF which leads to the highest resolutionof symptoms after cholecystectomy. Methods: We retrospectively reviewed the medicalrecords of patients (0-21years) who underwent cholecystectomy (n=212) at our hospitalfrom August 1998 to November 2006. The reason for cholecystectomy was recorded. Patientswith BD were followed for short postoperation-outcome by reviewing their records forresolution of symptoms, and for long postoperation-outcome by phone questionnaire. Out-comes were compared with preoperation GBEF. GBEF was divided into 2 categories: < 11%,and 12-31%. Symptom resolution was categorized as resolved or not resolved. Chi Squareanalysis determined procedure effectiveness. Results: Laparoscopic cholecystectomy (LPC)was performed in 212 patients; 37 (17.5%) had BD, and 175 ( 82.6%) had cholelithiasis.Of the 37 patients with BD who had LPC, 32 were female (86.5%) and 5 male (13.5%).Mean age was 16±3 years (range: 11-21 years). All 37 patients had delayed GBEF (meanGBEF=15%, range: 3-31%). Presenting symptoms included RUQ abdominal pain (n=23,62%), unspecific abdominal pain (n=14, 38%), fatty food intolerance (n=5, 13.5%), fatigue(n=4, 11%), and flatulence (n=3, 8%). The 37 patients were divided into two groups; groupI with GBEF ≤11(n=13, 35.1%) and group II with GBEF>11 (n=24, 64.9%). In group I,9 patients (69.2%) had short term improvement, compared to 14 (58.3%) in group II; P=0.72. We were able to follow the long term improvement in 30 patients, 9 in group I(GBEF≤11), and 21 in group II (GBEF >11). 7 patients in group I (77.8%) had long termimprovement , compared to 6 (28.6%) in group II, P= 0.02. Conclusion: Cholelithiasis wasthe most common indication for cholecystectomy in our pediatric population. Patients withGBEF ≤ 11 had better long term improvement after cholecystectomy than patients withGBEF>11, and for that reason we recommend surgery only for those with GBEF ≤ 11.

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