Endoscopic Resection for Undifferentiated-Type Early Gastric Cancer: Immediate Endoscopic Outcomes and Long-Term Survivals.

BACKGROUND: Endoscopic resection (ER) is considered carefully as a curative treatment option for selected cases of undifferentiated-type early gastric cancer (UEGC). This study investigated immediate endoscopic and long-term survival outcomes of patients with UEGC treated with ER. METHODS: A review of a database of 2483 EGC consecutively enrolled patients who underwent ER between January 2004 and December 2010 identified 101 patients with UEGC who met the expanded indications. Outcomes were investigated in these patients. RESULTS: The rates of R0 en bloc and curative resection were 86 and 70 %, respectively. Of 30 tumors non-curatively resected, 17 were larger than 20 mm in diameter, 12 had positive resection margins, and 13 had submucosal or lymphovascular invasion on resection pathology. ER-related complications occurred in 12 patients (12 %), with all complications treated endoscopically without surgery. The median ER procedure time was 26 min [interquartile range (IQR) 20-39 min]. Only tumor location in the lower part of the stomach was significantly associated with curative ER (P = 0.038). Tumor recurrence was observed in seven patients at a median 17 months (IQR 12-47 months) after ER. During a median follow-up of 60 months (IQR 48-80 months), the 5-year overall mortality rates were 5 % in the curative and 4 % in the non-curative resection groups (P = 0.927). There were no gastric cancer-related deaths. CONCLUSIONS: ER shows acceptable immediate endoscopic and long-term survival outcomes in selected patients with UEGC.

Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms.

BACKGROUND: Bleeding is a major complication following endoscopic resection (ER) of gastric mucosal lesions. We aimed to determine the risk factors for post-ER bleeding and their correlations according to the time elapsed since the procedure. METHODS: We retrospectively enrolled 670 lesions in 610 patients who underwent ER between March 2009 and December 2010. We classified these lesions into three types in accordance with the bleeding time, i.e., immediate bleeding (IB), early delayed bleeding (EDB), and late delayed bleeding (LDB). We analyzed the risk factors for each bleeding type according to baseline patient characteristics, procedure-related factors, and correlations between the occurrence of each bleeding type. RESULTS: There were 408 post-ER bleeding events in our study cohort: 302 IB events, 88 EDB events, and 18 LDB events. In multivariate analysis, a histologic finding of carcinoma and the resection time were significant predictors of IB (p < 0.001). Of the 302 IB events, 13.9% showed EDB. Additionally, LDB occurred in 2.4% of lesions with EDB and 4.6% of lesions without EDB. Similar to the IB group, of 368 lesions without IB, 12.5% showed EDB. In addition, LDB occurred in 2.2% of lesions with EDB and 1.2% of lesions without EDB. IB was associated with a higher risk of EDB (p < 0.001) and LDB (p < 0.001), whereas EDB was not related to an increased risk of LDB (p = 0.997). CONCLUSION: IB significantly increases the risk of EDB and LDB, but EDB does not increase the risk of LDB. Histologically confirmed carcinoma or a prolonged time for resection increases the risk of post-ER IB. We recommend careful follow-up approaches following ER of a gastric mucosal lesion in high-risk patients to prevent a potentially critical occurrence of delayed bleeding.

Clinical Outcomes of Postoperative Upper Gastrointestinal Leakage According to Treatment Modality.

BACKGROUND & AIM: We evaluated the clinical outcomes according to treatment modality for gastrointestinal anastomotic leakage. METHODS: Of the 19,207 patients who underwent gastrectomy for gastric cancer from March 2000 to April 2013, we retrospectively analyzed the 133 cases who developed anastomotic leakage. These patients were treated using endoscopic management, surgery, or conservative management (endoscopic treatment was introduced in 2009). To evaluate the efficacy of endoscopic treatment, we compared the clinical outcomes between the conservative management-only group before 2009 and the conservative or endoscopic management group from 2009; and between the surgical management-only group before 2009 and the surgical or endoscopic management group from 2009. RESULTS: Seventy-three were initially managed conservatively, 35 were treated surgically, and 25 were treated using endoscopic procedures. Chronologically comparing each treatment group as 'before 2009' (n = 54) and 'from 2009' (n = 79), there were differences in the length of hospital stay (median 32 versus 27, p = 0.048) and duration of antibiotic use (median 28 versus 20, p = 0.013). Patients who underwent conservative or endoscopic management from 2009 showed a shorter hospital stay, period of fasting, and duration of antibiotic use than patients who underwent only conservative management before 2009. Patients who received surgery or endoscopic management from 2009 showed a shorter hospital stay and duration of antibiotic use than patients who underwent only surgery before 2009. CONCLUSION: Endoscopic management for selected cases can reduce duration of hospital stay and antibiotic administration in the treatment of anastomotic leakage after gastrectomy.

Features of Gastric Carcinoma With Lymphoid Stroma Associated With Epstein-Barr Virus.

BACKGROUND & AIMS: Gastric carcinoma with lymphoid stroma (GCLS) is a distinct histologic subtype of gastric cancer that is characterized by undifferentiated carcinoma mixed with prominent lymphoid infiltration. More than 80% of GCLS cases are associated with Epstein-Barr virus (EBV) infection, but it is unclear if the virus affects disease progression. We investigated how EBV infection affects the clinical and pathologic features of GCLS, as well as patients' outcomes. METHODS: We performed a retrospective analysis of 274 patients (mean age, 56.8 y; 85.4% male) diagnosed with GCLS, based on pathology findings, from March 1998 through December 2012 at the Asan Medical Center in Seoul, South Korea. Their data were compared with those from 822 age- and sex-matched patients who underwent resection for gastric adenocarcinoma. EBV was detected in tumor samples by in situ hybridization. RESULTS: Of the 274 patients with GCLS, 236 had EBV-positive tumors (86.1%) and 38 had EBV-negative tumors (13.9%). EBV-positive GCLS was more prevalent than EBV-negative GCLS in younger patients, tended to be located proximally, and was more frequently of an early stage macroscopic type. The 10-year, disease-specific rates of survival were 89.1% for patients with EBV-positive GCLS and 66.9% for patients with EBV-negative GCLS (P = .009). Patients with EBV-negative GCLS had clinical and pathologic features and survival times similar to those of patients with conventional adenocarcinoma. By multivariate analysis, longer survival time was associated with EBV-positive tumors (P = .007), younger patient age (P = .002), smaller tumor size (P = .046), lower stage (based on American Joint Committee on Cancer classification; P < .001), and lack of lymphovascular invasion (P = .012). The proportion of undifferentiated tumor cells was not associated significantly with patient survival time. CONCLUSIONS: Clinical and pathologic features of GCLS differ based on EBV infection status. EBV-negative GCLS is similar to conventional adenocarcinoma, and patients have similar survival times. EBV status may be more important than the proportion of undifferentiated tumor cells in the diagnosis of GCLS and management of patients.

Identifying predictors of lymph node metastasis after endoscopic resection in patients with minute submucosal cancer of the stomach.

BACKGROUND: The use of endoscopic submucosal dissection (ESD) for the treatment of minute submucosal (SM) invasive cancer that fulfills the current expanded criteria remains controversial. This study investigated the clinicopathological parameters of patients with sm1 gastric cancers to predict lymph node metastasis (LNM) and evaluate the feasibility of ESD as a curative treatment. METHODS: Data from 278 patients who underwent surgical resection of sm1 gastric cancer between 2006 and 2010 were retrospectively collected, and their clinicopathological parameters were analyzed to identify predictive factors of LNM. RESULTS: Of 278 patients, 28 patients (10.1 %) had LNM. Multivariate analysis identified multiple lesions (p = 0.018), lymphovascular invasion (LVI) (p < 0.001), SM invasion depth >500 µm (p = 0.007), undifferentiated histology (p = 0.012), and ulceration (p = 0.024) as factors significantly associated with LNM in patients with sm1 gastric cancer. Additionally, SM invasion width/superficial tumor size ratio >0.04 (p = 0.036) demonstrated a significant association with LNM in patients with sm1 gastric cancer falling within the current expanded criteria for ESD. LNM was not identified among 35 patients who met the absence of ulceration, SM invasion depth ≤ 500 µm, and SM invasion width/superficial tumor size ratio ≤ 0.04 besides the current expanded indications. CONCLUSIONS: Endoscopic resection can be performed on patients with minute SM invasive, differentiated cancers of ≤ 3 cm without LNM on pretreatment examination. In addition, if histological assessment shows the absence of LVI and ulceration, SM invasion depth ≤ 500 µm, and SM invasion width/superficial tumor size ratio ≤ 0.04, the patient can be carefully observed without additional treatment.

Delayed Bleeding Rate According to the Forrest Classification in Second-Look Endoscopy After Endoscopic Submucosal Dissection.

BACKGROUND AND AIM: Forrest classification is a valid tool to predict rebleeding rate in peptic ulcer, not in post-endoscopic resection ulcer. We evaluated the delayed bleeding rate in Forrest classification II and III lesions when they were not treated in second-look endoscopy. METHODS: Between July 2011 and February 2012, 706 lesions in 656 consecutive patients who underwent second-look endoscopy performed on the second day after endoscopic submucosal dissection (ESD) were prospectively investigated. Endoscopic findings were described according to Forrest classification, and late delayed bleeding was defined as bleeding from second-look endoscopy to 1 month. We evaluated the rate of late delayed bleeding in untreated Forrest classification II and III lesions during second-look endoscopy. RESULTS: Among the 706 gastric tumors analyzed, late delayed bleeding after ESD occurred in 29 lesions (4.1%). At second-look endoscopy, Forrest I lesions (immediately treated by endoscopic hemostasis) were found in 63 cases [Ia, 8 lesions (1.1%); Ib, 55 lesions (7.8%)]; there was no further bleeding after discharge. Forrest II and III lesions (not treated in second-look endoscopy) were found in 643 cases [IIa, 62 lesions (8.8%); IIb, 119 lesions (16.9%); IIc, 460 lesions (65.2 %); III, 2 lesions (0.3%)]; and there was no significant difference in the late delayed bleeding rate between these groups [IIa, 2/62 (3.2%); IIb, 5/119 (4.2%); IIc and III, 22/462 (4.8%); P = 1.000]. CONCLUSIONS: The rate of late delayed bleeding of post-ESD ulcers with non-bleeding visible vessels was not significantly different from that of ulcers with non-visible vessels ( http://cris.nih.go.kr , identifier KCT0000268).

Clinical outcomes of endoscopic resection for gastric neoplasms in the pylorus.

BACKGROUND: Endoscopic resection for gastric neoplasms in the pylorus is a technically difficult procedure. We investigated clinical outcomes to determine the feasibility and effectiveness of endoscopic resection for gastric neoplasms in the pylorus. METHODS: Subjects who underwent endoscopic resection for gastric neoplasms in the pylorus between January 1997 and February 2012 were eligible. RESULTS: A total of 227 subjects underwent endoscopic resection for 228 gastric adenomas and early cancers in the pylorus. En bloc resection was achieved for 193 lesions (84.6%), including complete resection of 195 lesions (85.5%), and curative resection of 167 lesions (73.2%). Complete resection and curative resection rates were significantly different according to the location (prepyloric, pyloric, and postpyloric, P = 0.002 and P = 0.006). Delayed bleeding and stricture occurred in 5.3 and 3.1%, respectively, and there was no patient with perforation. During a median follow-up period of 79.0 months, local tumor recurrence was detected in 2.6%. CONCLUSIONS: Endoscopic resection appears to be a feasible and effective method for the treatment of pyloric neoplasms, regardless of the location and distribution of tumor. Thorough evaluation of the distal margin of the tumors is necessary when tumors involve or extend beyond the pyloric ring, and the appropriate use of additional techniques may be useful.

Risk factors of lymph node metastasis in patients with gastric neuroendocrine tumor with normal serum gastrin level.

BACKGROUND/AIMS: Locoregional gastric carcinoids with normal serum gastrin level have been recommended radical resection regardless of tumor size or depth of invasion. However, there have been some reports which showed small sporadic gastric carcinoids could be treated with local resection. The aim of this study was to elucidate risk factors of lymph node metastasis in patients with gastric carcinoids with normal serum gastrin level and determine the indications for limited resection such as endoscopic treatment. METHODOLOGY: We performed clinicopathologic reviews of thirty gastric carcinoids with normal serum gastrin level from January 1996 to December 2010. RESULTS: One case show distant metastasis and two cases showed lymph node metastasis at the time of diagnosis. For twenty seven cases which showed no regional lymph node or distant metastasis initially no additional lymph node or distant metastasis were diagnosed throughout the follow up period. Large tumor size (>10 mm), proper muscle infiltration, WHO classification grade 2 and lymphovascular invasion was noted risk factor of lymph node metastasis by univariate logistic regression analysis. CONCLUSIONS: Small (≤10 mm) gastric carcinoids with normal serum gastrin level confined to submucosa can be treated with endoscopic or local resection unless lymphovascular invasion.

Effect of Helicobacter pylori eradication on metachronous recurrence after endoscopic resection of gastric neoplasm.

OBJECTIVES: Although many epidemiologic studies have shown that Helicobacter pylori (H. pylori) eradication has prophylactic effects on gastric cancer, their results are less clear in high-risk populations. We conducted this study to examine whether H. pylori eradication would affect the occurrence of metachronous gastric cancer after endoscopic resection in patients with early gastric cancer. METHODS: We retrospectively analyzed 2,089 adults who underwent endoscopic resection of gastric low-grade neoplasia, high-grade neoplasia, or differentiated invasive neoplasia from 2004 to 2008 at Asan Medical Center. Of these, a total of 1,007 patients with early gastric cancer were enrolled in this study. We evaluated the demographic data, the pathology, and the incidence of metachronous recurrence by dividing them into three groups: those without active H. pylori infection (Hp negative group, n=340), those who successfully underwent H. pylori eradication (eradicated group, n=485), and those who failed or did not undergo H. pylori eradication (noneradicated group, n=182). RESULTS: Metachronous recurrence was diagnosed in 75 patients, including 17 in the Hp, 34 in the eradicated, and 24 in the noneradicated groups. Median time to metachronous recurrence was 18 months (range, 7-75 months). The incidence of metachronous gastric cancer was 10.9 cases per 1,000 person-years in the Hp negative group, 14.7 cases per 1,000 person-years in the eradicated group, and 29.7 cases per 1,000 person-years in the noneradicated group. The hazard ratios in the noneradicated group compared with the Hp negative and eradicated groups were 2.5 (P<0.01) and 1.9 (P=0.02), respectively. H. pylori eradication reduced metachronous recurrence of gastric neoplasm, which was also shown in the secondary analysis of 1,487 patients with low-grade neoplasia and early gastric cancer. CONCLUSIONS: Successful H. pylori eradication may reduce the occurrence of metachronous gastric cancer after endoscopic resection in patients with early gastric cancer.

Neoplasms arising in large gastric hyperplastic polyps: endoscopic and pathologic features.

BACKGROUND: Little is known about gastric neoplasms arising from hyperplastic polyps (HPs). OBJECTIVE: To investigate the risk factors associated with neoplasms within HPs and to evaluate the role of alterations of the p16-cyclin D1-pRb pathway in the malignant transformation of HPs. DESIGN: Retrospective, case-control study. SETTING: Tertiary-care center. PATIENTS: Between May 1995 and January 2011, a total of 809 HPs >1 cm were investigated. Associated neoplasms were present in 30 HPs (case group); 30 HPs without neoplasms were selected as a control group. INTERVENTIONS: Gastric polypectomy. MAIN OUTCOME MEASUREMENTS: The risk factors associated with neoplasms within HPs and immunohistochemical expression of p16, cyclin D1, p53, and Ki-67 between case and control groups. RESULTS: Of the 809 HPs, 15 had associated dysplasia, and 15 had carcinoma. Multivariate analysis showed that neoplasm was associated with patient age (odds ratio [OR] 1.159; 95% confidence interval [CI], 1.243-2.044; P < .001), polyp size (OR 1.103; 95% CI, 1.055-1.152; P < .001), and polyp lobulation (OR 4.549; 95% CI, 1.759-11.0766; P < .001) but not with location, multiplicity, intestinal metaplasia, growth pattern, or Helicobacter pylori infection. Loss of p16 expression and high Ki-67 expression were observed in dysplastic areas of HPs compared with the control group (p16 = 14.3% vs 60%; P = .001, Ki-67 = 60.7% vs 36.7%; P < .001). However, no significant differences were found in nondysplastic areas in both groups. LIMITATIONS: Single-center, retrospective study. CONCLUSION: HPs >1 cm may indicate the presence of neoplasms. Loss of p16 and high Ki-67 expression may be markers of HP-associated dysplasia.

Clinical significance of intensive endoscopic screening for synchronous esophageal neoplasm in patients with head and neck squamous cell carcinoma.

OBJECTIVES: Patients with head and neck squamous cell carcinoma (HNSCC) often develop second primary tumors in the upper aerodigestive tract. Early detection of synchronous esophageal squamous cell neoplasm (ESCN) is important because the prognosis of HNSCC can be affected by the statuses of second primary tumors. METHODS: In a prospective study, 308 patients with HNSCC were screened for synchronous ESCN between May 2010 and April 2012. All patients underwent conventional white-light endoscopic examination with Lugol chromoendoscopy and narrow band image. RESULTS: The median age was 61 years (range, 26-87 years), and the male-to-female ratio was 4.2:1. Two hundred and thirty-four patients (76.0%) were current or ex-smokers, 207 patients (67.2%) had a history of alcohol consumption and 56 patients (18.2%) had previous history of cancer. Synchronous ESCN was detected in 22 patients (7.1%), and most patients were at an early stage. The locations of index HNSCC in these patients were as follows: hypopharynx (n = 12), larynx (n = 6), oropharynx (n = 2) and oral cavity (n = 2). Synchronous ESCN was detected in 25.5% (12/47) of hypopharyngeal cancer and in 27.8% (15/54) of HNSCC involving the pyriform sinus. Multivariate analysis showed that smoking (current smoker vs. never smoker, Odds Ratio [OR] 8.3, p = 0.028), a history of cancer (OR 5.0, p = 0.002) and pyriform sinus involvement (OR 9.2, p < 0.0001) increased the risk of developing synchronous ESCN. CONCLUSIONS: Patients with HNSCC, especially those who are current smokers, have a history of cancer and have pyriform sinus involvement, should undergo intensive endoscopic screening to detect synchronous ESCN.

Clinical characteristics and outcomes for gastric cancer patients aged 18-30 years.

BACKGROUND: There is little known about the clinicopathological features and the predictors of survival in extremely young adult patients aged 18-30 years. The aim of this study was to identify clinicopathological features and clinical outcomes for the overall population and for a resectable subgroup of gastric cancer patients aged 18-30 years. METHODS: From January 2004 to December 2010, 207 patients aged between 18 and 30 years old were diagnosed with gastric cancer and treated at the Asan Medical Center. Clinical findings, histopathological parameters and outcomes were reviewed retrospectively. Patients were further divided into 2 groups according to tumor resectability and then clinicopathological factors that affect tumor resectability and clinical outcomes were analyzed. RESULTS: Clinicopathological characteristics of study population showed a predominance of females, undifferentiated tumors, diffuse-type cancers, and advanced gastric cancer. The overall resectability rate was 70.0 % and the median follow-up period was significantly longer in the resectable tumor group (P < 0.001). Significant prognostic predictors for overall survival in overall patients were higher CEA levels (P = 0.016), larger tumor size (P < 0.001), unresectability (P = 0.006), and presence of lymphovascular invasion (P = 0.012) in a multivariate analysis. Significant prognostic factors for overall survival in patients with resectable disease included larger tumor size (>4 cm), lymphovascular invasion and higher CEA level in the multivariate analysis. CONCLUSIONS: Gastric adenocarcinomas in young adult patients aged 18-30 years have unique clinicopathological features. Early detection in a resectable state and subsequent complete resection could increase survival period in young patients with gastric cancer.

Risk factors and clinical outcomes of gastric cancer identified by screening endoscopy: a case-control study.

BACKGROUND AND AIM: A customized screening program for gastric cancer would optimize the benefits of screening endoscopy. This study investigated the risk factors for gastric cancer detected during screening and factors affecting clinical outcomes. METHODS: From April 2000 to December 2010, subjects who underwent screening endoscopy at Asan Medical Center were included. To investigate risk factors, age- and sex-matched control group was selected. The clinical outcomes of gastric cancer identified during screening (screening group) were compared with age, sex, and date of diagnosis-matched subjects who were diagnosed with gastric cancer in the outpatient clinic (outpatient group). RESULTS: Of 109 530 subjects, 327 were diagnosed with gastric cancer. The median age of the screening group was 63.6 years (interquartile range 56-71 years), and the male-to-female ratio was 2.4:1. When comparing with the control group, Helicobacter pylori seropositivity (odds ratio [OR] 2.933, P < 0.001), carcinoembryonic antigen (OR 8.633, P = 0.004), family history of gastric cancer (OR 2.254, P = 0.007), and drinking (OR 3.312, P < 0.001) were independent positive risk factors, and the use of aspirin a negative risk factor for gastric cancer (OR 0.445, P = 0.012) in multivariate analysis. Low-density lipoprotein cholesterol (hazard ratio [HR] 0.987, P = 0.005), cancer antigen 19-9 (HR 21.713, P < 0.001), resectability (HR 59.833, P < 0.001), and family history (HR 0.308, P = 0.009) were independent risk factors for death. The 5-year survival rate was significantly higher in the screening group than in the outpatient group (P < 0.001). CONCLUSIONS: Early detection of gastric cancer by screening endoscopy while asymptomatic enhances patient outcomes, especially in high-risk groups.

Pneumonia after endoscopic resection for gastric neoplasm.

BACKGROUND: Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay. AIM: To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm. METHODS: Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects. RESULTS: Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31-82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2-126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077). CONCLUSIONS: Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.

Discrepancy between endoscopic forceps biopsy and endoscopic resection in gastric epithelial neoplasia.

BACKGROUND: Endoscopic forceps biopsy (EFB) is a major diagnostic procedure for gastric epithelial neoplasia (GEN). However, discrepancy between the result of EFB and endoscopic resection (ER) is not uncommon. Thus, there is controversy over whether specimens obtained by EFB are optimal for diagnosis of GEN. We investigated the discrepancy between EFB and ER in the diagnosis of GEN. METHODS: A total of 1,850 GEN cases were histologically diagnosed with EFB, including 954 low-grade dysplasias (LGDs), 315 high-grade dysplasias (HGDs), and 581 carcinomas. Following diagnosis with EFB, all patients were treated with ER. We retrospectively reviewed the pathologic findings and patient characteristics and analyzed predictors for the discrepancy between the two procedures (largest diameter, number of biopsy fragments, number of biopsy fragments/largest diameter, location, macroscopic type, color, surface unevenness, and erosion). RESULTS: The overall discrepancy rate between EFB and ER was 31.7 % (587/1,850). Among the discordant group, 440 (23.9 %) cases showed a higher grade of disease after ER; 229 of the 954 LGDs (24.0 %) were diagnosed as HGD or carcinoma, 166 of the 315 HGDs (52.7 %) as carcinoma, and 45 of the 581 differentiated carcinomas (7.7 %) as undifferentiated carcinoma. In the LGD group with EFB, the largest diameter (≥1.8 cm; P < 0.001), surface unevenness (P = 0.014), and depressed macroscopic type (P < 0.001) were factors associated with discrepancy. In the carcinoma group with EFB, flat macroscopic type (P = 0.043) was the only significant factor. In the HGD group with EFB, there were no significant factors for discrepancy. CONCLUSIONS: EFB can be insufficient for diagnosing GENs, and ER can be considered not only as treatment but also as a diagnostic modality in GEN. It is especially pertinent to all cases of HGD regardless of their endoscopic features and to cases of LGDs with the largest lesion diameter ≥1.8 cm, surface unevenness, or a depressed macroscopic type.

Endoscopic surveillance can increase the chance of resectability and endoscopic treatment in gastric cancer.

BACKGROUND/AIMS: Little is known about the effects of periodic endoscopic screening before detection of primary gastric cancer. We compared clinical outcomes in patients who did and did not undergo endoscopy before diagnosis. METHODS: Between January 2009 and November 2011, 769 patients were referred to Asan Medical Center after diagnosis of gastric cancer. Clinical outcomes were compared in patients who had (n=512) and had not (n=257) undergone endoscopic screening before diagnosis of gastric cancer. Factors about resectability and possibility of endoscopic resection were analyzed. RESULTS: In the nonexamined group, 225 patients (87.5%) had resectable gastric cancers and were treated surgically (n=151, 67.1%) or by endoscopic resection (n=74, 32.9%). In the examined group, 493 (96.3%) had resectability and were resected surgically (n=243, 49.3%) or endoscopically (n=250, 50.7%). Multivariate analysis showed that symptoms, no endoscopic screening, and lower serum albumin were associated with unresectability. Of the 718 resectable tumors, 394 underwent surgery and 324 underwent endoscopic resection. Multivariate analysis showed that older age, no symptoms, ≤1 year interval endoscopy, and higher serum albumin were associated with endoscopic resection. CONCLUSIONS: Previous endoscopy can increase gastric cancer resectability. Moreover, a ≤1 year interval from endoscopic examination can increase the possibility of endoscopic resection.

Meta-analysis of first-line triple therapy for helicobacter pylori eradication in Korea: is it time to change?

Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea.

Seroconversion rates of Helicobacter pylori infection in Korean adults.

BACKGROUND: Studies on seroconversion and its reversion rate in Korean adults with Helicobacter pylori infection are very rare. The purpose of this study was to evaluate the overall seroprevalence, seroconversion rate, and seroreversion rate of H. pylori infection in an adult population. MATERIALS AND METHODS: We performed this retrospective cohort study on healthy adults who had visited our health screening center at Asan Medical Center more than twice between January 2000 and December 2010. We reviewed the anti- H. pylori Ab IgG profiles of the enrolled people and their family members and the results of esophagogastroduodenoscopies and a self-reported questionnaire. RESULTS: A total of 67,212 people were enrolled in this study. The mean follow-up duration was 4.6 years, and each participant visited the center for a mean of 3.8 visits. The overall proportions of participants demonstrating persistent seropositivity, persistent seronegativity, seroconversion, and seroreversion were 53.1%, 32.5%, 4.3%, and 10.1%, respectively. The annual seroconversion rate was 2.79%. The annual crude and spontaneous seroreversion rates of the entire study population were 3.64% and 2.42%, respectively. According to multivariate logistic regression, old age (HR = 1.015), smoking (HR = 1.216), alcohol consumption more than four times per week (HR = 1.263), marriage (HR = 2.735), and living with H. pylori-infected family members (HR = 1.525) were identified as statistically significant risk factors associated with seroconversion. CONCLUSION: The annual seroconversion rate was 2.79% in our study population. Marriage and living with H. pylori-infected family members were important risk factors affecting seroconversion in our adult population.

Is transnasal endoscope-assisted endoscopic submucosal dissection for gastric neoplasm useful in training beginners? A prospective randomized trial.

BACKGROUND: The main problem in performing endoscopic submucosal dissection (ESD) of gastric neoplasms is that it is technically difficult, especially for beginners. METHODS: A total of 51 patients were randomly assigned to undergo transnasal endoscope-assisted or routine ESD performed by two endoscopists inexperienced in ESD while supervised by one expert. RESULTS: Total procedure time (p = 0.330), complete resection rate (p = 0.977), and complication rate (p = 0.157) were similar for the patients who underwent transnasal endoscope-assisted and routine ESD, but bleeding control time was significantly longer in the transnasal endoscope-assisted ESD group (p = 0.002). Three and six patients in the transnasal endoscope-assisted and routine ESD groups, respectively, were "dropped out" during the procedures (p = 0.291). The endoscopists tended to regard the traction with the transnasal endoscope as more useful for large tumors (p = 0.062). Bleeding control in patients who underwent the transnasal endoscope-assisted ESD was significantly longer for patients with tumors located in the anterior wall, posterior wall, and lesser curvature of the stomach (p = 0.001). CONCLUSION: Transnasal endoscope-assisted ESD does not result in improved outcomes when performed by beginners, except for some large tumors. The traction method used by beginners was not superior to proper supervision and advice by an expert during ESD and allowing the expert to perform the procedure when the risk of complications is high or the procedure is delayed.

Clinical outcomes of argon plasma coagulation for the treatment of gastric neoplasm.

BACKGROUND: There are insufficient reports on the outcomes and local recurrence rates for gastric neoplasms treated using argon plasma coagulation (APC). The purpose of this study was to analyze the clinical outcomes in early gastric cancer or gastric adenoma patients following APC treatment. METHODS: Seventy-one patients were enrolled and all underwent APC at the Asan Medical Center between July 2007 and August 2011. Clinical and oncological outcomes were analyzed. RESULTS: The median follow-up period was 20 months (interquartile range 13-29 months). Among the 71 patients we evaluated, nonlifting after submucosal saline injection was found in 35 patients and 15 patients (21.2%) experienced local recurrence with a median period of 10 months (IQR 5-13 months). The rate of local recurrence was higher in the nonlifting group and the 40-W group than in the lifting group and the 60- or 80-W groups (31.4 vs. 11.1%, p = 0.045 and 31.7 vs. 6.7%, p = 0.017, respectively). Multivariate analysis showed that the power setting with the 40-W and nonlifting groups after submucosal injection was associated with local recurrence. CONCLUSIONS: APC therapy after submucosal saline injection using high power (60 or 80 W) appears to be an effective alternative in the management of gastric neoplasm.