Changes in Causative Pathogens of Acute Cholangitis Proved after Biliary Drainage and Their Antimicrobial Susceptibility over a Period of 6 Years

Transcription

1 PBS-1 Changes in Causative Pathogens of Acute Cholangitis Proved after Biliary Drainage and Their Antimicrobial Susceptibility over a Period of 6 Years Jeong Seok Kwon, Jimin Han, Jung Nam Cho, Kyung Ho Ha, Tae Won Kim, Dae Young Yun, Hyun Hee Kwon, Jin Tae Jung, Joong Goo Kwon, Eun Young Kim, Ho Gak Kim Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea Background/Aims: We evaluated changes of bacteria from bile and blood cultures and antimicrobial susceptibility over six years at our institution. Patients/Methods: From August 2006 to August 2012, medical records of patients with acute cholangitis who received biliary drainage were retrospectively reviewed. Acute cholangitis was diagnosed when one or more of the followings were present: 1) purulent bile in gross appearance 2) leukocytes in bile 50/HPF 3) positive growth in bile culture. Total of 1596 cases were included. Cases were divided into community-acquired cholangitis (n=199, 12.5%) and hospital-acquired cholangitis (n=1,397, 87.5%). The cases were also divided according to time period: Group A (August December 2008, and their antimicrobial susceptibility was evaluated in each group. Results: Mean age of the patients was 68.0 ± 13.8 years. There were 908 male patients (56.9%). Of 1596 cases of bile culture, growth was detected in 1520 cases (95.2%). Gram-negative bacteria were isolated in 1428 cases (94%). Most frequently isolated Gram-negative bacteria were ESBL-producing Escherichia coli (E. coli) (n=485, 34%), E. coli (n=211, 14.8%), Citrobacter freundii (n=110, 7.7%), Klebsiella pneumoniae (K. pneumoniae) (n=99, 6.9%), and ESBL-producing K. pneumoniae (n=91, 6.4%). In hospital-acquired cholangitis group, prevalence of ESBL-producing E. coli and Citrobacter freundii was higher (52.1 vs. 31.5%, p=0.00; 13.7 vs. 6.8%, p=0.001). In Group B, prevalence of E. coli has decreased significantly (p=0.017). Antimicrobial agents with high susceptibility were as follows: amikacin (85.2%), piperacillin-tazobactam (70.2%), cefotetan (77.5%), and imipenem (95.8%). In Group B, susceptibility to piperacillin-tazobactam has decreased significantly (59 vs. 71.9%, p=0.001). Conclusions: Prevalence of ESBL-producing E. coli and K. pneumoniae in cholangitis has increased over 6 years. In hospital-acquired cholangitis, prevalence of ESBL-producing E. coli and Citrobacter freundii is higher. Susceptibility to piperacillin-tazobactam has decreased over recent years. Key Words: Acute cholangitis, Bile culture, Antimicrobial susceptibility, Antimicrobial resistance, Biliary drainage PBS-2 The Safety of Pre-Stenting Biliary Sphinterotomy in Malignant Biliary Obstruction Soo Yong Lee, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan National University School of Medicine pusan National University Yangsan Hospital, Yangsan, Korea Objectives: Pre-stenting biliary sphinterotomy is known to facilitate complex stenting procedure, but still controversial on safety concerns. The aim of this study was to evaluate the safety of endoscopic sphincterotomy (EST) before endoscopic biliary drainage (EBD) Patients and Methods 203 patients were tried to perform EST before EBD for malignant biliary obstruction between November 2008 and August 2012 in a single tertiary-care medical center. After exclusion of 33 patients(7 failed, 18 previous EST, 8 non-est), 170 patients were eligible. Acute procedure complications were defined as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, bleeding, stent migration, sepsis and perforation according to Cotton s criteria. Results: The etiologies of malignant biliary obstruction were bile duct cancer (99/170, 58.2%), pancreatic cancer (43/170, 25.3%), ampullary cancer (10/170, 5.9%), metastatic cancer (8/170, 4.7%), gallbladder cancer (7/170, 4.1%) and other type cancer (HCC, lymphoma, 3/170, 1.8%). The methods of EBD were self-expanding metal stent (SEMS)-uncovered (47/170, 27.6%), SEMS-covered (4/170, 2.4%), single plastic stent (63/170, 37.1%), dual plastic stents (47/170, 27.6%) and nasobiliary drainage (9/170, 5.3%). The acute complication developed in 4.7%(9/170) of patients, 2 were pancreatitis (1.2%), 3 were bleeding(1.8%), 2 were sepsis(1.2%) and 1 was stent migration(0.6%). Conclusion: EST before EBD in malignant biliary obstructions seems to be done safely. Keywords: retrograde cholangiopancreatography, endoscopic biliary drainage, endoscopic sphincterotomy, pancreatobiliary malignancy Key Words: ERCP, EBD, EST PBS-3 Systemic Chemotherapy May Prolong the Biliary Metal Stents Patency in Pancreatic Cancer with Distal Biliary Obstruction Joon Hyuk Choi, Do Hyun Park, Seung Uk Jeong, Byung Uk Lee, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim Department of Gastroenterology, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Objective: The placement of self-expandable metal stent 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S121

2 (SEMS) has been widely used for pancreatic cancer with distal biliary obstruction. Although the recent improvement in chemotherapeutic agents has prolonged survival in patients with pancreatic cancer, little is known about the role of systemic chemotherapy influencing SEMS patency in pancreatic cancer. We had investigated the role of systemic chemotherapy as a predictive factor for malfunction of SEMS in pancreatic cancer with distal biliary obstruction. Materials and Methods: Patients with pancreatic cancer who received distal biliary stents between April 2008 and May 2012 were reviewed. Time to malfunction was defined as the period between stent placement and malfunction or death if stent malfunction was not observed until death. Follow-up data were obtained until August Various prognostic factors including systemic chemotherapy were analyzed. Only patients receiving palliative or neoadjuvant chemotherapy after stent placement were categorized as chemotherapy group. Stent malfunction was defined as stent occlusion, migration, and non-occlusion cholangitis. Table 1. Factors Associated with Stent Malfunction in Univariate and Multivariate Analysis Univariate Multivariate OR [95%CI] P value OR [95%CI] P value Sex (male) ( ) Age > ( ) ( ) Tumor size > 34 mm ( ) ( ) Stricture length > mm ( ) Stent diameter ( mm) ( ) Liver metastasis 2.12 < <0.001 ( ) ( ) Ascites ( ) ( ) Duodenal invasion ( ) Covered stent ( ) Systemic 0.39 < <0.001 chemotherapy ( ) ( ) Total bilirubin > mg/dl ( ) Cholangitis 1.62 ( ) Results: A total of 200 patients with pancreatic cancer were enrolled. The 137 patients of total 200 participants were comprised in the time to malfunction group. Food impaction in the stent (11%, 15 of 137) and stent migration (11%, 15 of 137) were most frequent causes of stent malfunction except death. Tumor size more than 34mm, liver metastasis and non-chemotherapy after stent placement were independent risk factors in multivariate analysis. And patients who received chemotherapy after stent placement (68 of 200) were less complicated by stent malfunction (odds ratio 0.40; 95% CI, ; p<0.001). The median time to malfunction was 94 days in non-chemotherapy group and 190 days in chemotherapy group(p<0.001). Conclusions: Systemic chemotherapy after stent placement may prolong SEMS patency in pancreatic cancer with distal biliary obstruction. Key Words: Pancreatic cancer, Self expandable metal stents, Chemotherapy, Obstrucive jaundice, Stent patency PBS-4 Development of a Swine Benign Biliary Strictrure Model Using Endobiliary Radiofrequency Ablation Seong Hyun Kim¹, Seok Jeong¹, Don Haeng Lee¹, Joon Mee Kim², Se Chul Lee³, Sung-Gwon Kang³ ¹Department of Internal Medicine,²Department of Pathology, Inha University School of Medicine, Incheon, ³Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea Objective: To develop a porcine benign biliary stricture (BBS) model using endobiliary radiofrequency ablation (RFA). Animals and Methods: 14-month-old, female mini pigs (Sus scrofa), each approximately 30 kg, were used. Endoscopic retrograde cholangiography (ERC) was performed in 12 swine. The animals were allocated to three groups (100 W, 80 W, and 60 W) according to the electrical power level. Endobiliary RFA was applied to the distal common bile duct for 60 seconds using by RFA probe which could be endoscopically inserted. ERC was repeated two and four weeks respectively after the RFA to identify BBS. After the strictures were identified, the animals were sacrificed and bile duct samples were achieved to evaluate the pathologic finding. Results: BBS were verified in all animals. Cholangitis were detected on endoscopic findings of day 14 in all the animals of 3 groups, but not significant. Bile duct perforations occurred in 1 swine (n= 1, 100%) for 100 W group, and 1 swine (n=7, 14.3%) for 80 W group. There was no major complication (n=4, 0%) in 60 W group. All benign strictures were proven pathologically. The pathologic findings looked like BBS in human. Conclusion: The application of endobiliary RFA resulted in a safe and reproducible swine model of BBS. Key Words: Radiofrequency Catheter Ablation, Benign Biliary Stricture S nd Congress of the Korean Society of Gastrointestinal Endoscopy

3 PBS-5 Bilateral Drainage, More Effective Approach for Klatskin Tumor Jin Hyun Park, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan University School of Medicine, Busan, Korea Background/Aim: Biliary drainage is one of the most important treatment in palliation with Klatskin tumor. There is still uncertainty about optimal choice of either unilateral or bilateral drainage with hilar biliary obstruction. The aim of this study was to compare clinical outcomes of bilateral drainage with unilateral drainage in hilar biliary obstruction. Method: We retrospectively reviewed 72 patients with unresectable Klatskin tumor who underwent metal stent between January 2009 to September All cases were beyond Bismuth type II. 41 patients were drained bilaterally,whereas 31 patients were performed unilateral stent. Results: Bilateral drainage had superiority over unilateral drainage in median survival time (256 ± 154 days vs 196 ± 80 days, p<0.05) and median stent patency time ( 230 ± 139 days vs 165 ± 68 days, p<0.05). Cholangitis occurred more frequently after unilateral drainage ( 6/31, 19% vs 1/41, 2.4% ). Conclusion: Bilateral drainage seems to more effective method for palliation in hilar biliary obstruction, although its technical difficulty. Key Words: Klatskin tumor, Stent, Bilateral, Unilateral PBS-6 Cross Wired Metallic Stents for Triple Branched Stent in Stent Placement in High-Grade Malignant Hilar Biliar Stricture Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea Background and Aims: Endoscopic triple branched stent-instent placement of metallic stents (MS) is technically demanding procedure. However, triple placement with MS is needed for the effective biliary drainage in selected patients with high-grade malignant hilar biliary stricture (MHBS). Cross wired metalic stent (CWMS, BONA-M Hilar, Standard Sci.Tech) can facilitate contralateral second stenting and allow multiple stenting with stent in stent fashion. The aim of this study was to evaluate the efficacy and safety of endoscopic triple branched stent-in-stent placement of CWMS for the patients with high-grade MHBS. Patients and Methods: A total of 18 patients with MHBS with type IIIa or IV of Bismuth s classification were enrolled. All patients had histologically proven inoperable biliary tract cancer. Third CWMS was inserted on Rt. IHD using a stent-in-stent deployment method after bilateral stent-in-stent placement in 11 patients as a primary drainage. Third stenting was performed as a revisionary drainage after occlusion of bilateral stent-in-stent placement in 7 patients. Results: The technical and functional success rates of endoscopic triple branched stent-in-stent placement of MS was 88.9% (16/18), and 77.8% (14/18). Functional success rate was 81.8% in patients with primary drainage, and 71.4% in patients with a revisionary drainage. Significant complications were not observed during procedures. Median stent patency was 196 days. Cholecystitis was developed in two patients during follow-up. Stent dysfunction occurred in 35.7% of patients with functionally successful stent placement. Conclusions: Endoscopic triple branched stent-in-stent placement using of cross wired metallic stents was technically feasible and safe in selected patients with high-grade malignant hilar biliary strictures. Further study is needed to confirm the clinical effectiveness. Key Words: Klatskin tumor, Metallic stent, Hilar biliary stricture PBS-7 Comparison of Outcomes between Internal Stent Placement and PTBD in Patients with Planned CRT for Perihilar Cholangioca Seung Woo Yi 1, Jae Hee Cho 2, JeongYoup Park 1, Jae bock Chung 1, Seung Woo Park 1, Seungmin Bang 1, Si Yong Song 1 1 Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, 2 Division of Gastroenterology, Department of Internal Medicine, Myongji Hospital, Goyang, Korea Background: The optimal biliary decompression method in resectable perihilar-cholangiocarcinoma has been authorized as percutaneous transhepatic biliary drainage (PTBD). In case of locally advanced perihilar-cholangiocarcinoma, malignant biliary obstruction is judged to have palliation of jaundice by placement of an internal stents or PTBD. We aimed to investigate the efficacy of internal placement of biliary stent compared with PTBD for patients planned CRT in locally advanced perihilar-cholangiocarcinoma. Patients and Methods: The patients who are histologically proven locally advanced perihilar-cholangiocarcinoma between Jan and Dec at single tertiary medical center in Korea, retrospectively analyzed. The perihilar cholangiocarcinoma was defined as disease occurring above the junction of the cyst- 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S123

4 ic duct up to the secondary branches of the hepatic duct. Results Among one hundred seventy six locally advanced perihilar-cholangiocarcinoma patients, CRT was performed in 79 patients; endoscopic biliary decompression was forty six patients (26.14%), and PTBD was thirty three patients (18.75%). The mean period of internal stent indwelling is 152 days whereas 222 days in PTBD group (p=0.675). The R0 operative rate after the CRT was 23.9% in endoscopic stenting group, and 12.1% in PTBD group (p=0.174). The median overall survivals were 463days at endoscopic stenting group and 439days in PTBD group, respectively (p=0.874). Repeated biliary decompression procedure was performed at endoscopic decompression group 26 patients (56.5%), 12 patients in PTBD group (36.4%) (p = 0.077). In the subgroup analysis of endoscopic stenting group, there were 25 cases of SEMS, and 21 cases of biliary drainage using the plastic stent. The stent dysfunction was found 20 patients (80.0%) in plastic stent whereas 6 patients (28.6%) in SEMS group (p=0.001). Median stent patency time was 111 days and 402 days in the plastic stent and SEMS, respectively (p=0.002). Post-operative major complications were not seen in both cases. Conclusions: The endoscopic placement of internal stent might be useful method for biliary decompression in patients with planed CRT for locally advanced perihilar-cholangiocarcinoma, compared to PTBD. In case of biliary endoscopic drainage, the pre-crt SEMS had lower rate for repeated endoscopic procedure than plastic stent in perihilar-cholangiocarcinoma. Key Words: Self-expanding metal stents, Plastic sten, PTBD, Chemoradiotherapy PBS-8 Risk Factors for Cholecystitis after Bilateral Biliary Stent Placement in Patients with Klatskin tumor Young Mi Hong, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park Department of Internal Medicine, Pusan University School of Medicine, Busan, Korea Background/Aims: Endoscopic bilateral metal stenting is a rapidly evolving technique which allows the palliative treatment of malignant hilar obstruction including Klatskin tumor. But cholecystitis in patients with Klatskin tumor is bothersome event to patients and physicians. Biliary stent may be associated with cholecystitis for several reasons. The aim of this study to evaluate the prevalence and risk factors of cholecystitis after bilateral matal stent placement, especially in Klatskin tumor. Patients/Methods: August 2005 to June 2012, 102 patients treated with a metal stent for Klatskin tumor were enrolled. The incidence and characteristics of patients with cholecystitis were evaluated and compared with those of patients without cholecystitis. We retrospectively reviewed following variables : sex, age, Bismuth type, gallbladder filling by contrast medium during endoscoic retrograde cholangiopancreatography (ERCP), cholangitis before ERCP, cystic duct involvement of tumor mass on computed tomography (CT), presence of gallbladder stones. Results: There were 28(27.5%) patients diagnosed with cholecystitis after bilateral metal stent insertion.in cholecystitis, days were, on average, taken (ranging from 1 to 310 days) since metal stent placement to the onset of cholecystitis. We found that cystic duct involvement of tumor mass on CT was associated with cholecystitis (p=0.015) and others were not related with development of cholecystitis. Conclusions: This study suggested that cholecystitis after bilateral metal stent insertion in klatskin tumor is associated with cystic duct involvement of the tumor. To prevent or manage cholecystitis, effective modalities should be sought. Key Words: Klatskin tumor, Bilateral metal stent, Complication, Cholecystitis PBS PL-9 DGT vs Precut Papillotomy with Pancreatic Stent in Initial Pd Cannulation by Chance; Prospective Randomize Muti-Center Eun Taek ParK¹, Sang-Woo Cha², Kyo-Sang Yoo³ ¹Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, ²Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University School of Medicine, Seoul, 3 Department of Internal Medicine, Hanyang University School of Medicine, Kuri Hospital, Kuri, Korea Background/Aim: Successful cannulation of the common bile duct (CBD) is an important benchmark of ERCP. Repeated cannulation for CBD is one of the main risk factors for post-ercp pancreatitis. Recently, pancreatic duct guidewire assisting bile duct cannulation (double guidewire technique, DGT group) or precut papillotomy with a incision over a pancreatic stent (PP-PS group) have been considered a promising alternative approach in difficult cannulation situations. The aim of this study was to compare the performance of DGT with the PP-PS in the patients in whom pancreatic duct cannulation was performed initially. Patients/Methods: When guidewire was placed in the pancreatic duct by chance, the patients were then randomized into DGT or PP-PS groups. After this, bile duct cannulation was retried using DGT or PP-PS. Main outcome measurements were frequency of successful CBD cannulation and post-procedure related complications. S nd Congress of the Korean Society of Gastrointestinal Endoscopy

5 Results: The groups were similar with regard to patient demographics. A total of 70 patients were enrolled. 31 patients were assigned to the DGT group and 39 to the PP-PS group. Successful CBD cannulation was achieved in 22 (70.9%) of 31 patients in the DGT group and 37 (94.8%) of 39 patients in the PP-PS group. The mean cannulation time was 18.4 minutes in the DGT group and 11 minutes in the PP-PS group (p<0.005). There was significant difference in the successful CBD cannulation rate or mean cannulation time after p-duct cannulation between two groups (p< 0.05). Post-procedure hyperamylasemia was significantly higher in DGT group (p<0.001). The overall incidence of post-procedure pancreatitis was 15.4% (6/31) in the DGT group, and 6.6% (2/30) in the PP-PS group (p <0.005). Conclusion: In patients with pancreatic duct cannulation initially by chance, compare to DGT group, PP-PS group facilitate biliary cannulation and the success rates. The incidence of post-procedure hyperamylasemia and post-procedure pancreatitis were also higher in the DGT group. Key Words: ERCP, Pancreatitis, Double Guidewire, Precut Papillotomy, Pancreatic Stent study period (from April 2008 to August 2012). Four patients refused PDT. Twelve patients refused the participation of this clinical trial and enrolled open-label group. Finally, 36 patients were randomized to PDT with TS1 (group A, n=17) or PDT alone (group B, n=19). PDT with TS-1 group resulted in the prolongation of overall survival compared with PDT alone group (mean overall survival time, 17.4 months vs. 8.4 months, p=0.008 by Kaplan-Meier curve, Fig.-1). In open label group, the overall survival was similar to that of PDT with TS-1 (15 months vs months). Group A had a tendency towards longer progression-free survival compared with group B (8.3± 8.9 months vs. 5.3 ± 8.9 months, p=.054). PBS PL-10 Photodynamic Therapy (PDT) with Ts-1 vs. PDT for Unresectable Cholangiocarcinoma: Preliminary Results of Randomized Trial So-Eun Park¹, Do Hyun Park², Sang Soo Lee², Dong-Wan Seo², Sung Koo Lee² and Myung-Hwan Kim² ¹Division of Gastroenterology, Asan Medical Center, ²Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea Backgroud/Aims: In patients with unresectable hilar cholangiocarcinoma (UHC), photodynamic therapy (PDT) with biliary stent has been known for palliation of jaundice and improving survival. Recently orally available chemotherapeutic agent, TS-1 was reported as effective in patients with advanced biliary tract cancer. The aims of this study was to evaluate the combined effect of photodynamic therapy and TS-1. Methods: In patients with histologically confirmed UHC, endoscopic or percutaneous stenting was performed. Patients fulfilling inclusion criteria were randomized to group A (biliary stenting and subsequent PDT with TS-1) and group B (biliary stenting and subsequent PDT). For the refusal to participation in this clinical trial, patients were enrolled to open-label group (biliary stenting and PDT with systemic chemotherapy except TS-1). The primary outcome parameter was the overall survival. Secondary outcome parameter was the progression-free survival. Results: A total of 52 patients with UHC were screened during Conclusions: In this prospective randomized trial, PDT with TS-1 improved overall survival in patients with UHC compared with PDT alone. PDT with systemic chemotherapy may be warranted for the palliative treatment of patients with UHC. Key Words: Photodynamic therapy, Cholangiocarcinoma, Systemic chemotherapy PBS PL-11 Prospective Randomized Trial Comparing Covered Metal Stent Placed Above and Across the Sphincter of Oddi in Malignant Biliary Obstruction: A Multi-Nation, Multi-Center Study Jung Nam Cho¹, Jimin Han¹, Ho Gak Kim¹, Im Hee Shin², Sang Heum Park³, Jong Ho Moon³, Jin Hong Kim⁴, Don Haeng Lee 5, Iruru Maetani 6, Hiroyuki Maguchi 7, Keiji Hanada 8, Ichiro Yasuda 9, Hiroyuki Isayama 10, Dong Ki Lee 11 Department of ¹Internal Medicine, ²Medical Statistics, Catholic University of Daegu School of Medicine, Daegu, ³Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Choenan, 4 Department of Gastroenterology, Ajou University School of Medicine, Suwon, 5 Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea, 6 Department of Gastroenterology, Toho University Medical Center Ohashi Hospital, Tokyo, 7 Department of Gastroenterology, Teine-Keijinkai Hospital, Sapporo, 8 Department of Gastroendoscopy, Onomichi General Hospital, Onomichi, 9 Department of Internal Medicine, Gifu University, Gifu, 10 Department of Gastroenterology, The University of Tokyo, Tokyo, Japan, 11 Department of Internal Medicine, Yonsei University College of Medicine Kangnam Severance Hospital, Seoul, Korea 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S125

6 Aims: To compare stent patency and overall survival of patients with malignant biliary obstruction inserted covered self-expandable metallic stent (C-SEMS) between placement above the sphincter of Oddi (SOD) without sphincterotomy (Group A) and across the SOD after sphinterotomy (Group B). Patients and Methods: From February 2010 to September 2012, this study was conducted in 6 centers from Korea and 5 centers from Japan. Total of 83 patients with unresectable malignant biliary obstruction were randomized into either Group A or B. Biliary obstruction was defined as bile duct obstruction located at least 2.0 cm distal from hilar bifurcation and 0.5 cm proximal to the ampulla. Results: There were 1 case of common hepatic bile duct cancer, 27 common bile duct cancer, 11 gallbladder cancer, 41 pancreatic cancer and 4 of extrinsic compression from metastatic lymph node. There were 40 patients in Group A and 43 in Group B. Technical success was 100% in both groups and functional failure occurred in 1 and 2 cases in Group A and B. Median follow-up period was and days. Mean stent patent period were and days (p=0.835), and mean period of overall survival was and days (p=0.873) in Group A and B. Stent occlusion was recognized in 15(39.5%) and 14(37.8%) in group A and B. During follow-up, occlusion-free survival rates per year were 40.2% and 22.2% in Group A and B. Cholangitis without stent occlusion occurred 1 and 2 cases in Group A and B. There were no significant differences in complications after procedure in both groups. Distal migration occurred in three cases in only Group B. Conclusion: Theoretically, placement of C-SEMS above the SOD may reduce duodenobiliary reflux and result in longer stent patency, and reduced rate of cholangitis without occlusions. However, in this study, there was no significant difference in stent patency and cholangitis between C-SEMS placement above and across the SOD. Key Words: Malignant biliary obstruction, Metal stent, Stent patency, Survival PBS PL-12 Optimal Duration of Placement of a Fully Covered Self-Expandable Metal Stent for Common Bile Duct: A Canine Study Tae Jun Song¹, Sang Soo Lee², Do Hyun Park², Dong Wan Seo², Sung Koo Lee², Myung-Hwan Kim² ¹Department of Internal Medicine, Inje University Ilsan Paik hospital, Koyang, ²Department of Internal Medicine, University of Ulsan College of medicine, Asan Medical Center, Seoul, Korea fully covered self-expandable metal stent (FCSEMS) has been used for the treatment not only of malignant biliary obstruction but also benign biliary stricture. However, since there are few studies on the histopathological changes of a bile duct due to FCSEMS placed inside a bile duct over the long term, it is difficult to determine the optimal stenting duration of how long stents should be placed inside a bile duct. The purpose of this study is to identify the histopathological changes of a bile duct resulting from long-term placement of an FCSEMS. Methods: In May of 2010, FCSEMSs were inserted into the common bile ducts of 12 canines. Post euthanasia, necropsy was performed to examine histopathological changes of the bile ducts after one month (n = 3), three months (n = 3), six months (n = 3), and nine months (n = 3) respectively. A single blinded pathologist examined histopathological changes of the normal bile duct in which a stent was not inserted, and the proximal portion, the middle portion, and the distal portion of the stented bile duct. Results: FCSEMSs could be successfully inserted in all animals. The results of liver function tests, which were performed before necropsy, were within the normal range in all animals. The results of necropsy showed that the covered membranes of FCSEMSs were intact and FCSEMSs were easily removed from the bile ducts in all animals except one. Severe epithelial hyperplasia of the stented bile duct occurred in one animal in which an FCSEMS was placed for three months, and as a result, a disruption of the covered membrane and epithelial ingrowth into the stent were observed. In this animal, the removal of the FCSEMS was very difficult, and the most severe inflammatory change of the stented bile duct was found on histopathological examination. On histopathological examinations, when compared with the non-stented bile ducts, mild inflammatory changes were observed in the stented bile ducts, and there was no significant difference between the animals inserting an FCSEMS for one month, three months, six months, and nine months. Among the 12 animals, de novo stricture was found in 5 animals. Conclusion: It was found that an FCSEMS might be inserted into the bile duct without severe histopathological changes of the stented bile duct until 9 months after the insertion. Key Words: Stents, Common Bile Duct, Cholangiopancreatography Endoscopic Retrograde, Dogs Background and Aim: Recently, endoscopic placement of a S nd Congress of the Korean Society of Gastrointestinal Endoscopy

7 PBS PL-13 The Role of EUS-FNA after Negative Transpapillary Forceps Biopsy in Patients with Malignant Biliary Strictures Dong Choon Kim¹, Jong Ho Moon¹, Hyun Jong Choi¹, Hee Kyung Kim², Yoon La Young¹, Tae Hoon Lee¹, Sang Woo Cha¹, Young Deok Cho¹, Sang Heum Park¹, Sun Joo Kim¹ Digestive Disease Center, ¹Department of Internal Medicine, ²Department of Pathology Soon Chun Hyang University College of Medicine, Korea Background/Aim: Transpapillary forceps biopsy (TFB) on ERCP is a usual tissue sampling technique for the histopathological diagnosis of malignant biliary strictures (MBS). However, the detection rate of this method has been unsatisfactory. The aim of this study was to retrospectively evaluate the diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in patients with MBS who had negative results of TFB. Methods: 75 consecutive patients with MBS underwent endoscopic TFB during ERCP. EUS-FNA was performed in patients with negative results for histopathological reports. The gold standard of malignancy was histopathologic results by tissue sampling or operation. We investigated the EUS-FNA results, level of stricture lesions and influence of the EUS-FNA results on treatment modalities. Results: In 75 patients, 42 patients had distal bile duct (BD) strictures and the others were proximal BD strictures. Malignancy was confirmed on endoscopic TFB in 59 of 75 patients (78.6%). 56 patients were adenocarcinoma, and 3 patients were neuroendocrine carcinoma. EUS-FNA was performed in 16 patients with negative results by endoscopic TFB. Of 16 patients, 11 patients had distal BD strictures and 5 patients had proximal BD strictures. FNA specimens were successfully obtained in all patients, and the histopathological results confirmed malignancy in 15 cases (14 cases: adenocarcinoma, 1 case: neuroendocrine carcinoma) and the other 1 case was negative for malignancy. Of 15 patients, 8 patients were treated by chemotherapy, 4 patients were supportive care, 2 patients were operation, and 1 patient was photodynamic therapy. In case with negative result by EUS-FNA, was confirmed malignancy (adenocarcinoma) as a result of surgery. Conclusions: In patients with MBS who had negative results by endoscopic TFB, EUS-FNA is useful for the histopathologic confirmation. Key Words: EUS-FNA, Malignant Biliary Strictures, Transpapillary forceps biopsy PBS PL-14 Differential Diagnosis of Pancreatic Cysts Using Proteomics Hwan sic Yun¹, Woo Ik Change¹, Kwang Hyuck Lee¹, Kyu Taek Lee¹, Soo Youn Lee², Poong-Lyul Rhee¹, Jong Kyun Lee¹ ¹Department of Internal Medicine, Sungkyunkwan University School of Medicine, ²Department of Laboratory Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea Objectives: Pancreatic cysts display a wide spectrum of histology. However, differential diagnosis of pancreatic cysts is still challenging. This study was aimed to evaluate and validate cyst fluid CEA and proteomics markers in differentiating 1) pancreatic pseudocyst, 2) benign non-mucinous pancreatic cyst, 3) benign or malignant mucinous pancreatic cyst. Methods: From February 2008 to March 2012, we collected 57 patients who had pancreatic cysts. We analyzed endoscopic ultrasound (EUS) findings, cystic fluid tumor markers (CEA, CA 19-9) and proteomics markers that could help differentiating non-mucinous cysts and mucinous cysts. Results: Fifty seven patients (17 pseudocysts, 22 benign non-mucinous cysts, 18 benign or malignant mucinous cysts) were enrolled. Mean age was 52.1 (20-76). All of them underwent endoscopic ultrasound (EUS) and nineteen (33.3%) patients got surgery. One patient (1.8%) had complication of pancreatitis after EUS guided fine needle aspiration (EUS-FNA). Both CEA and CA 19-9 showed statistical significance in differentiating non-mucinous cysts and mucinous cysts (p<0.001, p=0.009). Diagnostic sensitivity and specificity of CEA in differentiating mucinous cysts was 100% and 87% in 6.3 ng/ml cut-off value. And CA19-9 showed 72.2% sensitivity and 69.2% specificity in ng/ml cut-off value. Among proteomics markers, twenty four markers showed statistical significance in differentiating between non-mucinous cysts and mucinous cysts. Assuming the cut-off value of CEA that differentiates non-mucinous and mucinous was 192 ng/ml, as previous reports, the diagnostic accuracy became very low (50% sensitivity, 100% specificity). However joining with proteomics marker polymeric immunoglobulin receptor A1, the sensitivity and specificity became 94.4% and 86.4% in respectively. Also joining with proteomics marker polymeric immunoglobulin receptor A3, the sensitivity and specificity were 88.9% and 83.4%. Conclusions: In this study, cystic CEA showed very high sensitivity and specificity in differentiating non-mucinous and mucinous cysts. However cut-off value was 6.3 ng/ml, in which was very low compared to the previous reports. Assuming the cut-off value as 192 ng/ml as previous study, proteomics mark- 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S127

8 ers could be very helpful for differentiating between non-mucinous and mucinous cysts. Key Words: Pancreatic Cyst, Mucinous Cyst, Proteomics PBS-15 EPLBD for the Removal of Common Bile Duct Stones Does Not Increase the Risk of Post-ERCP Pancreatitis Yoon Jeong Nam, Tae Nyeun Kim, Jun Suk Park, Min Geun Gu, Jae Young Lee, Kook Hyun Kim, Kyung Ok Kim, Si Hyung Lee, Byung Ik Jang Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Background and Aims: Endoscopic sphicterectomy (ES) and endoscopic papillary large balloon dilation (EPLBD) are frequently used procedures for the treatment of common duct stones. EPLBD is known to increase the risk of post-ercp pancreatitis in some studies. The aims of this study were to evaluate whether EPLBD increases the risk of post-ercp pancreatitis and to find the risk factors influencing post-ercp pancreatitis. Methods: A total of 434 patients who underwent ERCP for the treatment of common duct stones larger than 1cm in diameter from January 2006 to December 2011 were reviewed retrospectively. Patients were divided into 4 groups; ES group (n=190), EPLBD combined with limited ES group (n=129), EPLBD without ES group (n=85), and EPLBD with previous history of ES group (n=30). Post-ERCP pancreatitis was defined as the development of abdominal pain with more than 3 times elevation of serum amylase or lipase. Results: Of the total 434 patients, post-ercp pancreatitis was developed in 12 patients (2.8%). Endoscopic biliary stenting was an independent risk factor of pancreatitis by univariate (p=0.004) and multivariate analysis (p=0.004, OR 5.713, 95% Cl, 1.770~18.469). Age, sex, BMI, history of cholecystectomy, stone size, mechanical lithotripsy, CBD and P-duct diameter, balloon size and duration of balloon dilation were not significantly related with post-ercp pancreatitis. Incidence of post-ercp pancreatitis was 1.6%, 3.1%, 5.9%, 0% in ES group, EPLBD combined with limited ES group, EPLBD without ES group, EPLBD with previous history of ES group, respectively. There was no significant difference in the incidence of post-ercp pancreatitis among 4 groups (p=0.218). Conclusion: Endoscopic papillary large balloon dilation does not increase the risk of post-ercp pancreatitis compared to endoscopic sphicterectomy. Endoscopic biliary stenting seems to be an independent risk factor of post-ercp pancreatitis. Key Words: EPLBD, ERCP, Pancreatitis PBS-16 Percutaneous Papillary Large Balloon Dilation For Treatment of Large Bile-Duct Stones: A Feasibility Study Jee Young Han, Seok Jeong, Don Haeng Lee, Byoung Wook Bang, Jung Il Lee, Jin-Woo Lee, Kye Sook Kwon, Hyung Gil Kim, Yong Woon Shin, Young Soo Kim Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Background: When the access to major duodenal papilla or endoscopic retrograde cholangiopancreatography (ERCP) is failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful to remove common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) performed during PTCS-L for the removal of large CBD stones, is not established yet. The aim of this study was to investigate the safety and efficacy of PPLBD for the treatment of large CBD stones. Methods: Eleven patients with large CBD stones in whom the access to major papilla or ERCP had failed in a tertiary referral center between September 2011 and August 2012 were enrolled prospectively. Papillary dilation using large-bored (12-20 mm) balloon dilation catheter was performed through the percutaneous transhepatic route. We analyzed the efficacy of the stone retrieval and post-procedure complications after the procedure. Results: The success rate for the complete duct clearance was 100%. There was no patient who needs use of basket to remove the stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 minutes. There was no complications occurred after PPLBD. Asymptomatic hyperamylasemia did not occur in all patients. Conclusion: The current data suggested that PPLBD is safe and effective for removal of large CBD stones. Key Words: Balloon Dilation, Choledocholithiasis PBS-17 Endoscopic Papillary Balloon Dilation and Endoscopic Sphincterotomy for Removal of Bile Duct Stones in Young Patients Yu Ri Seo, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang-Woo Cha, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea Objectives: Endoscopic biliary sphincterotomy (EBS) is the standard treatment for bile duct (BD) stones. However, EBS S nd Congress of the Korean Society of Gastrointestinal Endoscopy

9 can cause permanent loss of sphincter function that long-term complications are still unknown. Younger patients having longer life expectancy are risky for developing late complications. Endoscopic papillary balloon dilation (EPBD) is an alternative procedure preserving the sphincter function, although it is generally known has a higher risk of pancreatitis than EBS. We conducted a prospective study to compare safety and outcomes of EPBD with EBS for removal of BD stones in patients younger than 40 years of age. Methods: Total 132 patients were enrolled in this study, 62 patients who underwent EPBD (EPBD group, mean age: 31.1 years) and 70 patients who underwent EBS (EBS group, mean age: 35.2 years) for extraction of BD. Inclusion criteria was 1) Age < 41 at first ERCP performed 2) CBD stones were confirmed by ERCP 3) stone maximum diameter <13 mm. Resuts: 1) EPBD and EBS were successfully performed in all patients. 2) Complete endoscopic clearance of the bile duct was achieved in all patients. 3) Complete stone removal at a single endoscopic session was achieved in 59 (95.2%) EPBD group and in 61 (87.1%) EBS group. 4) Mechanical lithotripsy was needed to fragment stones in 5 (8.1%) EPBD group and in 9 (12.9%) EBS group. 5) Early complication rate was 9.7% (6 pancreatitis ; mid 5, moderate 1) in EPBD group and 11.4% (6 pancreatitis ; mid 5, moderate 1, 1 bleeding, 1 perforation) in EBS group. 6) Late complication rate was 1.6% (1 recurred stone with cholangitis) in EPBD group and 5.7% (4 recurred stone with 3 cholangitis) in EBS group. Conclusions: Endoscopic papillary balloon dilation is a safe and effective procedure for the removal of BD stones in young patients expecting longer survival. Key Words: EPBD, Endoscopic biliary sphincterotomy PBS-18 Long-Term Results after Treatment of Hepatolithiasis and Predictive Factors for Cholangiocarcinoma Kwang Duck Ryu¹, Dong Uk Kim¹, Seong Oh Park¹, Hye Kyung Jeon¹, Gwang Ha Kim¹, Jeong Heo¹, Geun Am Song¹ Departemtn of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Aims: Hepatolithiasis is one of risk factors of cholangiocarcinoma and is usually treated with operative and non-operative procedure (Percutaneous transhepatic cholangioscopic lithotomy, PTCSL). We examined the long-term results of patients with hepatolithiasis treated by operation or PTCSL and predictive factors for cholangiocarcinoma associated hepatolithiasis. Methods: We performed a retrospective study of medical records of patients with hepatolithiasis in Pusan national university hospital from April 1988 to July Of 363 patients with hepatolithiasis, 78 underwent operative procedure, 113 underwent PTCSL, and 172 underwent medical treatment or observation. The median follow-up period was 22.2months (range,1-257months). Results: Female (62.3%) was dominant in patients with hepatolithiasis. We observed cholangiocarcinoma in 8.3% (30/363), secondary biliary cirrhosis in 8.8% (32/363), stricture in 16.5% (60/363) and secondary sclerosing cholangitis in 0.5% (2/363) as the complications associated hepatolithiasis. Complete stone clearance was achieved in 84.6% (66/78) of operation and in 70.8% (80/113) of PTCSL. During follow-up period after treatment, recurrent rate of stones was 16.4%; 18.6% (12/66) of operation and 15.0% (12/80) of PTCSL and late development rate of cholangiocarcinoma was 3.1%; 1.2% (1/78) of operation and 4.4% (5/113) of PTCSL. In multivate analysis, liver atrophy is only significantly associated with cholangiocarcinoma (p=0.006; Odds ratio, 2.01; 95% CI, ). Conclusion: Operation had a superior trend than PTCSL in complete stone clearance and recurrence rate of hepatolithiasis was similar in both operation and PTCSL. Liver atrophy with hepatolithiasis might be a predictive factor of development of cholangiocarcinoma. Key Words: Hepatolithiasis, Cholangiocarcinoma, Operation, PTCSL PBS-19 Therapeutic Saline Irrigation of the Bile Duct after the Endoscopic Removal of Common Bile Duct Stones Sang Eon Jang¹, Sang Hyub Lee², Ban Seok Lee³, Dong-Won Ahn⁴, Jin-Hyeok Hwang² ¹Department of Internal Medicine, Cheongju St. Mary s Hospital, Cheongju, ²Department of Internal Medicine, Seoul National University Bundang Hospital, Sungnam, ³Ddepartment of Internal Medicine, Cheju Halla Hospital, Cheju, 4 Department of Internal Medicine, Boramae Medical Center, Seoul, Korea Background: Small stone fragments after an endoscopic stone extraction for choledocholithiasis may act as the nidus for recurrent choledocholithiasis. Therefore, efforts to eliminate the nidus might reduce the recurrence of choledocholithiasis and cholangitis related to choledocholithiasis. Aim: To determine whether an additional therapeutic saline irrigation of the bile duct (TSIB) after the endoscopic removal of common bile duct (CBD) stones would decrease residual CBD stones and the recurrence of cholangitis. Methods: A retrospective analysis was performed for the con- 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S129

10 secutively collected data about the patients who underwent the complete endoscopic treatment for CBD stone. Results: Among 99 patients, 45 patients underwent TSIB. Residual CBD stones were detected in 18 patients (18.2%). The incidences of residual CBD stones were 8.9% (4 or 45 patients) in the irrigation group and 25.9% (14 of 54 patients) in the non-irrigation group (p=0.037). In multivariate analysis, TSIB was found to be the only significant factors for the decrease of residual CBD stones (HR=0.258, p=0.039). When analyzing the occurrence of recurrent cholangitis and the procedure related to complications, there were no significant differences according to the performance of TSIB. Conclusion: TSIB could reduce the residual CBD stones without complications. Key Words: Therapeutic Irrigation, Common Bile Duct Stone, Cholangitis PBS-20 The Role of IDUS for the Management of Acute Biliary Pancreatitis with No Evidence of Choledocholithiasis on ERCP La Young Yoon, Jong Ho Moon, Hyun Jong Choi, Dong Choon Kim, Tae Hoon Lee, Sang Woo Cha, Young Deok Cho, Sang-Heum Park, Sun Joo Kim Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea Background and Aim: ERCP has been considered the standard for the evaluation and management of acute biliary pancreatitis (ABP). Identifying a bile duct (BD) stone in patients with ABP is important for the management and prevention of recurrent attack of pancreatitis. But, small BD stones may not be detected on ERCP. The aim of this study was to prospectively evaluate the usefulness of intraductal US (IDUS) in patients with suspicious ABP having no evidence of choledocholithiasis on ERCP. Patients and Methods: A total 92 patients suspected with ABP without evidence of BD stones on imaging studies including ERCP were enrolled. Wire guided IDUS was performed during ERCP in all patients. Stones or sludge detected by IDUS were confirmed after endoscopic sphincterotomy (EST) and extraction. Results: IDUS successfully performed in all patients. Among the 92 patients, IDUS revealed BD stones in 33 (35.8%) and biliary sludge in 26 (28.2%) patients. The results of IDUS were consistent with those of EST and stone extraction. During the mean follow-up of 24 months, recurrent pancreatitis did not occur in 54 (91.5%) of 59 patients with BD stone or biliary sludge on IDUS after endoscopic therapy. Conclusion: IDUS improves diagnostic accuracy for the detection of occult BD stones in patients suspicious ABP. IDUS guided endoscopic treatment can help prevent recurrent pancreatitis. Key Words: Choledocholithiasis, Acute biliary pancreatitis, Intraductal US PBS-21 Safety and Efficacy of Extracorporeal Shockwave Lithotripsy with Endotherapy for the Treatment of Pancreatic Duct Stones Byung Uk Lee, Myung-Hwan Kim, Seung Uk Jung, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Aim: A retrospective analysis was performed to evaluate the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) as a treatment of pancreatic stones. Method: Between March 2008 and July 2012, 77 patients with pancreatic stone presenting with pain and large pancreatic duct stone not amenable to extraction with an endoscopic retrograde cholangio pancreatography (ERCP) were selected for ESWL. The ESWL was performed with an electroconductive lithotripter (Sonolith VISION, EDAP-TMS) equipped with both fluoroscopic and ultrasound target system. Analgesia (pethidine) was administrated intravenously to control the pain during ESWL. Fragmented calculi were cleared by followed endotherapy. The success rates, complications and pre-, during- and post-eswl pain scale (visual analogue scale, VAS) were evaluated. Result: A mean pancreatic stone size was 14.2mm and a mean of 4.6 ESWL (range: 1~10) session was performed for each patient with mean of 3,025 shocks (range: 2,500~4,750) at a power setting of 12.8 kv (range: 11.8~13.5) were employed. Fragmentation of the stones were achieved in 74/77 (96.1%) patients, and overall clearance of the stones were 72/77 (93.5%) patients. Complete clearance of the main pancreatic duct was achieved in 52 patients (67.5%) and partial clearance in 20 patients (25.9%). Three patients (3.9%) developed acute pancreatitis. Complete relief of pain without pancreatic stenting achieved in 63/74 (85.1%) patients. The mean pre-, during- and post- ESWL VAS score was 5.75, 2.03, 0.45 (p<0.01). Three patients were undergoing pancreatic surgery due to persistent pain with remnant stone. A mean dose of pethidine used during ESWL was 56.2mg (range: 25~100) per session. Conclusion: Without general or epidural anesthesia, large pan- S nd Congress of the Korean Society of Gastrointestinal Endoscopy

11 creatic stone can be managed safely and effectively by the combination of ESWL and endotherapy. Key Words: Pancreatic Stone, ESWL(extracorporeal Shockwave Lithotripsy) PBS-22 Comparison Outcomes for Unresectable Hilar Cholangiocarcinoma Treated with Definitive Photodynamic Therapy (PDT) Combined with Gemcitabine-Based Chemotherapy Eun Taek Park, Sang Uk Lee, Byung Hoon Han, Byung Cheol Yun Department of Internal Medicine, Kosin University School of Medicine, Gospel Hospital, Busan, Korea Background/ Aims: Hilar cholangiocarcinoma (CC) has an extremely poor prognosis with less than 5% of patients surviving 5 years. Preliminary clinical studies have suggested that PDT maybe beneficial for palliation of hilar CC. PDT for hilar CC revealed that the tumoricidal depth of PDT using porfimer sodium (Photofrin ; Axan Pharma Inc., Canada) is limited to 4- to 4.5-mm of tissue penetration, which cannot eradicate a primary tumor when invasion extends to a depth of over 6mm. The aim of this study to assess the efficacy that the percutanous transhepatic cholangioscopy (PTCS) guided compelling dilatation of malignant stricture before PDT for improving the depth of tissue penetration (definitive PDT) and then retrospectively analyzed the outcome of possible treatment modality with definitive photodynamic therapy (PDT) combined with gemcitabine-based chemotherapy and conservative treatment in hilar CC. Material And Methods: Forty-seven patients with unresectable hilar CC were included in this study. 24 patients underwent conservative treatment alone (Group A) including drainage procedure, 23 patients treated with definitive PTD with chemotherapy including drainage procedure (Group B) were analyzed retrospectively. Before PDT, group B patients were performed PTCS guided compelling dilatation with balloon catheter or bouginator on malignant stricture site and immediate insertion of 18Fr plastic catheter. PDT was performed after 7 days. And then drainage procedure (including uncovered metal stent) performed after 1 session of PDT and gemcitabine-based chemotherapy was done for 6 cycles. Results: The Group A and B were comparable due to age, gender, performance status, pretreatment bilirubin level and hilar CC stage. Overall survival rate of Group A and B were 63% and 94% at 1 year, respectively (p<0.001). The mean survival period of patients with of Group A and B was 8.2 months and 16.3 months, respectively (p<0.001). The metal stent patency of Group A and B was 167 days and 283 days, respectively (p=0.003). Definitive PDT related complications were observed in 2 patients related to balloon dilatation including 1 hemobilia and 1 bile duct leakage. But no patient developed acute serious complication. Conclusion: Compelling dilatation of malignant stricture site before PDT (definitive PDT) with chemotherapy is significantly improved the survival rate and metal stent patency due to tissue penetrating and increased tumoricidal depth in hilar CC. The side effects secondary to compelling dilatation with PDT are very rare and clinically insignificant in this study. We concluded that this procedure seemed to be more effective and safe than conservative treatment alone in unresectable hilat CC. Key Words: Photodynamic Therapy, Unresectable Klatskin Tumor, Gemcitabine PBS-23 Longterm Outcome of PDT with Chemotherapy Compared with PDT Alone and ERND Only in Patients with Cholangiocarcinoma Mi Jin Hong, Young Koog Cheon, Cho I Lee, Eung Jun Lee, Tae Yoon Lee, Chan Sup Shim Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea Aims: Cholangiocarcinoma (CC) is the primary cancer of bile duct. Patients usually present at an advanced stage, with more than 50% of cases being unresectable at the time of diagnosis. As a result, a large proportion of patients are beyond the scope of curative treatment upon diagnosis. Recently photodynamic therapy (PDT) has been evaluated as a palliative and neoadjuvant modality. However, it is not known that combination with photodynamic therapy and chemotherapy is promising activity, most notably gemcitabine-based combinations. Materials and Methods: A total of 232 atients with hilar cholangiocarcinoma diagnosed between Feburuary 1999 and September 2009 were evaluated. 16 were treated with PDT and gemcitabine or/and another (Group A), 58 were treated with PDT only (Group B) and 71 patients were treated with endoscopic biliary drainage alone (Group C). These data were collected prospectively and analysed retrospectively. Results: Median survival was 538 days (95% CI, ) in group A, 334 days (95% CI, ) in group B, and 220 days (95% CI, ,3) (p = 0.001). There was no statistically significant difference between group A and B. Whether of lymph node metastasis (p=0.037), serum bilirubin level ofpretreatment (p=0.040), TNM stage (p=0.048), treatment methods (PDT with chemotherapy, PDT alone, vs. ERBD 62 nd Congress of the Korean Society of Gastrointestinal Endoscopy S131