Incidence and risk of pancreatic cancer in patients with acute or chronic pancreatitis: a population-based cohort study.

We aimed to evaluate the incidence and risk of pancreatic cancer (PC) in pancreatitis. We identified patients with acute pancreatitis (AP) (n = 225,811, 50.0%) and chronic pancreatitis (CP) (n = 225,685, 50.0%) from Korean population-based data and matched them with age- and sex-matched controls (n = 4,514,960). We analyzed the incidence and adjusted hazard ratios (aHRs) of PC among patients followed for more than 2 years or 5 years, and assessed risk changes over time in single episode of AP (SAP), recurrent AP (RAP), CP with AP, and CP without AP groups. We also performed subgroup analysis for both sexes. The incidences (per 104 person-years) and risks (aHR) of PC were higher in the RAP (12.69, 5.00) or CP with AP (12.12, 5.74) groups compared to the SAP (2.31, 1.32) or CP without AP (2.28, 1.57) groups. The risks of PC decreased over time, however, the risk of PC remained elevated in the RAP and CP with AP groups for more than 8 years. Females with RAP, SAP, and CP with AP had higher risks of PC than males. The risk of PC is higher and persists for longer duration in patients with RAP and CP with AP compared to those with SAP or CP without AP.

Comparative Study of Intestinal Microbiome in Patients with Ulcerative Colitis and Healthy Controls in Korea.

Ulcerative colitis (UC) poses a contemporary medical challenge, with its exact cause still eluding researchers. This is due to various factors, such as the rising incidence, diagnostic complexities, and difficulties associated with its management. We compared the intestinal microbiome of patients with UC to that of healthy controls to determine the qualitative and quantitative changes associated with UC that occur in the intestinal microbiota. The intestinal bacterial abundance in 40 Korean patients with UC and 25 healthy controls was assayed using via next-generation sequencing. There were five major phyla in both groups: Firmicutes (UC patients: 51.12%; healthy controls: 46.90%), Bacteroidota (UC patients: 37.04%; healthy controls: 40.34%), Proteobacteria (UC patients: 6.01%; healthy controls: 11.05%), Actinobacteriota (UC patients: 5.71%; healthy controls: 1.56%), and Desulfobacteriota (UC patients: 0.13%; healthy controls: 0.14%). Firmicutes was more prevalent in patients with UC (51.12%) compared to that of healthy controls (46.90%). Otherwise, Bacteroidota was more prevalent in healthy controls (40.34%) compared to patients with UC (37.04%). Although there was no significant difference, our results showed a substantially lower gut microbiome diversity in patients with UC (mean: 16.5; 95% confidence interval (CI) = 14.956-18.044) than in healthy controls (mean: 17.84; 95% CI = 15.989-19.691), the beta diversity and the flora structure of the microbiome in patients with UC differed from those in healthy controls. This will be helpful for the development of new treatment options and lay the groundwork for future research on UC. To understand the disease mechanism, it is essential to define the different types of microbes in the guts of patients with UC.

On-demand Versus Continuous Maintenance Treatment With a Proton Pump Inhibitor for Mild Gastroesophageal Reflux Disease: A Prospective Randomized Multicenter Study.

Background/Aims: It remains unclear which maintenance treatment modality is most appropriate for mild gastroesophageal reflux disease (GERD). We aimed to compare on-demand treatment with continuous treatment using a proton pump inhibitor (PPI) in the maintenance treatment for patients with non-erosive GERD or mild erosive esophagitis. Methods: Patients whose GERD symptoms improved after 4 weeks of standard dose PPI treatment were prospectively enrolled at 25 hospitals. Subsequently, the enrolled patients were randomly assigned to either an on-demand or a continuous maintenance treatment group, and followed in an 8-week interval for up to 24 weeks. Results: A total of 304 patients were randomized to maintenance treatment (continuous, n = 151 vs on-demand, n = 153). The primary outcome, the overall proportion of unwillingness to continue the assigned maintenance treatment modality, failed to confirm the non-inferiority of on-demand treatment (45.9%) compared to continuous treatment (36.1%). Compared with the on-demand group, the GERD symptom and health-related quality of life scores significantly more improved and the overall satisfaction score was significantly higher in the continuous treatment group, particularly at week 8 and week 16 of maintenance treatment. Work impairment scores were not different in the 2 groups, but the prescription cost was less in the on-demand group. Serum gastrin levels significantly elevated in the continuous treatment group, but not in the on-demand group. Conclusions: Continuous treatment seems to be more appropriate for the initial maintenance treatment of non-erosive GERD or mild erosive esophagitis than on-demand treatment. Stepping down to on-demand treatment needs to be considered after a sufficient period of continuous treatment.

Intrahepatic Cholangiocarcinoma Arising from Biliary Hamartomas in Patients with Recurrent Acute Cholangitis: A Case Report and Literature Review.

Biliary hamartomas are tumor-like malformations of the liver. Biliary hamartomas are a type of fibrocystic disorder originating from ductal plate malformation and are typically considered benign, but with the risk of malignant transformation. In this case report, we present a rare occurrence of intrahepatic cholangiocarcinoma (ICC) that developed from biliary hamartomas, along with a literature review. A 76-year-old man with a diagnosis of biliary hamartomas had a history of recurrent cholangitis for 12 years, necessitating cholecystectomy, ERCP, and repeated antibiotic treatments. During his last episode, imaging studies revealed a hypervascular infiltrative mass in the right posterior liver segment. A liver biopsy confirmed adenocarcinoma and subsequent surgical pathology revealed ICC originating from biliary hamartomas. Chronic inflammation in the bile duct associated with biliary hamartomas may serve as a potential trigger for malignant transformation, as observed in this case. Therefore, close surveillance is essential for patients with biliary hamartomas presenting with infectious complications.

The Awareness and Experience About Endoscopic Adverse Events Among South Korean Endoscopists.

BACKGROUND/AIMS: The number of endoscopic procedures and related adverse events is increasing. We investigated South Korean endoscopists' awareness and experience of endoscopic adverse events. MATERIALS AND METHODS: We used Google Forms to conduct an online questionnaire survey among South Korean endoscopists from December 11 to 29, 2020. The survey comprised 30 questions developed by members of the Quality Management Committee of the Korean Society of Gastrointestinal Endoscopy. RESULTS: In total, 475 endoscopists participated in the survey. Of these, 454 (95.6%) were board-certified gastroenterologists and 255 (53.7%) had >10 years of endoscopy experience. Most participants had experienced serious adverse events requiring hospitalization (80.4%, 382/475); however, only 100 (21.1%) were aware of programs for the prevention and management of adverse endoscopic events in their affiliated endoscopy centers. Most participants (98.5%, 468/475) agreed with the need for education on medical accidents for healthcare workers. Responses were inconsistent regarding the definition of adverse events formulated by the 2010 American Society for Gastrointestinal Endoscopy Workshop. Most participants were not aware of the minimal standard terminology (76.6%, 364/475) and had not used it when writing endoscopy reports (88.8%, 422/475). Responses were inconsistent regarding which events to record in endoscopy records. CONCLUSION: Further discussion on the nationwide adverse-event reporting system and education program for adverse events related to endoscopy is needed to ensure the safety of patients and endoscopists.

Clinical Outcome of Endoscopic Submucosal Dissection for Papillary Type Early Gastric Cancer: A Multicenter Study.

Background/Aims: Papillary adenocarcinoma is classified to differentiated-type gastric cancer and is indicated for endoscopic submucosal dissection. However, due to its rare nature, there are limited studies on it. The purpose of this study was to determine the outcome of endoscopic submucosal dissection in patients with papillary-type early gastric cancer and to find the risk factors of lymph node metastasis. Methods: Patients diagnosed with papillary-type early gastric cancer at eight medical centers, who underwent endoscopic submucosal dissection or surgical treatment, were retrospectively reviewed. The clinical results and long-term outcomes of post-endoscopic submucosal dissection were evaluated, and the risk factors of lymph node metastasis in the surgery group were analyzed. Results: One-hundred and seventy-six patients with papillary-type early gastric cancer were enrolled: 44.9% (n=79) in the surgery group and 55.1% (n=97) in the endoscopic submucosal dissection group. As a result of endoscopic submucosal dissection, the en bloc resection and curative resection rates were 91.8% and 86.6%, respectively. The procedure-related complication rate was 4.1%, and local recurrence occurred in 3.1% of patients. Submucosal invasion (odds ratio, 3.735; 95% confidence interval, 1.026 to 12.177; p=0.047) and lymphovascular invasion (odds ratio, 7.636; 95% confidence interval, 1.730 to 22.857; p=0.004) were the risk factors of lymph node metastasis in papillary-type early gastric cancer patients. Conclusions: The clinical results of endoscopic submucosal dissection in papillary-type early gastric cancer were relatively favorable, and endoscopic submucosal dissection is considered safe if appropriate indications are confirmed by considering the risk of lymph node metastasis.

Survey-Based Analysis of the Clinical Treatment Status of Irritable Bowel Syndrome in Korea.

BACKGROUND: The quality-of-life of patients with irritable bowel syndrome is low; incorrect diagnosis/treatment causes economic burden and inappropriate consumption of medical resources. This survey-based study aimed to analyze the current status of irritable bowel syndrome treatment to examine differences in doctors' perceptions of the disease, and treatment patterns. METHODS: From October 2019 to February 2020, the irritable bowel syndrome and Intestinal Function Research Study Group of the Korean Society of Neurogastroenterology and Motility conducted a survey on doctors working in primary, secondary, and tertiary healthcare institutions. The questionnaire included 37 items and was completed anonymously using the NAVER platform (a web-based platform), e-mails, and written forms. RESULTS: A total of 272 doctors responded; respondents reported using the Rome IV diagnostic criteria (amended in 2016) for diagnosing and treating irritable bowel syndrome. Several differences were noted between the primary, secondary, and tertiary physicians' groups. The rate of colonoscopy was high in tertiary healthcare institutions. During a colonoscopy, the necessity of random biopsy was higher among physicians who worked at tertiary institutions. 'The patient did not adhere to the diet' as a reason for ineffectiveness using low-fermentable oligo-, di-, and mono-saccharides, and polyols diet treatment was higher among physicians in primary/secondary institutions, and 'There are individual differences in terms of effectiveness' was higher among physicians in tertiary institutions. In irritable bowel syndrome constipation predominant subtype, the use of serotonin type 3 receptor antagonist (ramosetron) and probiotics was higher in primary/secondary institutions, while serotonin type 4 receptor agonist was used more in tertiary institutions. In irritable bowel syndrome diarrhea predominant subtype, the use of antispasmodics was higher in primary/secondary institutions, while the use of serotonin type 3 receptor antagonist (ramosetron) was higher in tertiary institutions. CONCLUSION: Notable differences were observed between physicians in primary/secondary and tertiary institiutions regarding the rate of colonoscopy, necessity of random biopsy, the reason for the ineffectiveness of low-fermentable oligo-, di-, and mono-saccharides, and polyols diet, and use of drug therapy in irritable bowel syndrome. In South Korea, irritable bowel syndrome is diagnosed and treated according to the Rome IV diagnostic criteria, revised in 2016.

Efficacy and Safety of Fexuprazan in Patients with Acute or Chronic Gastritis.

Background/Aims: Fexuprazan is a novel potassium-competitive acid blocker that could be of benefit to patients with gastric mucosal injury. The aim of this study was to assess the 2-week efficacy and safety of fexuprazan in patients with acute or chronic gastritis. Methods: In this study, 327 patients with acute or chronic gastritis who had one or more gastric erosions on endoscopy and subjective symptoms were randomized into three groups receiving fexuprazan 20 mg once a day (q.d.), fexuprazan 10 mg twice a day (b.i.d.), or placebo for 2 weeks. The posttreatment assessments were the primary endpoint (erosion improvement rate), secondary endpoints (cure rates of erosion and edema and improvement rates of redness, hemorrhage, and subjective symptoms), and drug-related adverse events. Results: Among the patients, 57.8% (59/102), 65.7% (67/102), and 40.6% (39/96) showed erosion improvement 2 weeks after receiving fexuprazan 20 mg q.d., fexuprazan 10 mg b.i.d., and placebo, respectively. Both fexuprazan 20 mg q.d. and 10 mg b.i.d. showed superior efficacy to the placebo (p=0.017 and p<0.001, respectively). Likewise, both fexuprazan 20 mg q.d. and 10 mg b.i.d. also showed higher erosion healing rates than the placebo (p=0.033 and p=0.010, respectively). No difference was noted in the edema healing rate and the improvement rates for redness, hemorrhage, and subjective symptoms between the fexuprazan and placebo groups. No significant difference was noted in the incidence of adverse drug reactions. Conclusions: Fexuprazan 20 mg q.d. and 10 mg b.i.d. for 2 weeks showed therapeutic efficacy superior to that of placebo in patients with acute or chronic gastritis (ClinicalTrials.gov identifier NCT04341454).

Randomized controlled trial to evaluate the efficacy and safety of fexuprazan compared with esomeprazole in erosive esophagitis.

BACKGROUND: Fexuprazan, a novel potassium-competitive acid blocker, reversibly suppresses the K+/H+-ATPase enzyme in proton pumps within gastric parietal cells. Fexuprazan's suppression of gastric acid was maintained in healthy individuals for 24 h in a dose-dependent manner. AIM: To compare fexuprazan to esomeprazole and establish its efficacy and safety in patients with erosive esophagitis (EE). METHODS: Korean adult patients with endoscopically confirmed EE were randomized 1:1 to receive fexuprazan 40 mg or esomeprazole 40 mg once daily for eight weeks. The primary endpoint was the proportion of patients with healed EE confirmed by endoscopy at week 8. The secondary endpoints included the healing rate of EE at week 4, symptom response, and quality of life assessment. Safety profiles and serum gastrin levels were compared between the groups. RESULTS: Of the 263 randomized, 218 completed the study per protocol (fexuprazan 40 mg, n = 107; esomeprazole 40 mg, n = 111). Fexuprazan was non-inferior to esomeprazole regarding the healing rate at week 8 [99.1% (106/107) vs 99.1% (110/111)]. There were no between-group differences in the EE healing rate at week 4 [90.3% (93/103) vs 88.5% (92/104)], symptom responses, and quality of life assessments. Additionally, serum gastrin levels at weeks 4 and 8 and drug-related side effects did not significantly differ between the groups. CONCLUSION: Fexuprazan 40 mg is non-inferior to esomeprazole 40 mg in EE healing at week 8. We suggest that fexuprazan is an alternative promising treatment option to PPIs for patients with EE.

Clinical significance of the number of retrieved lymph nodes in early gastric cancer with submucosal invasion.

The prognosis of early gastric cancer (EGC) with submucosal invasion is favorable; however, several cases of recurrence have been reported even after curative gastrectomy. This study aimed to investigate risk factors and evaluate the clinical significance of the number of retrieved lymph nodes (LNs) in EGC with submucosal invasion. We retrospectively analyzed the data of 443 patients with gastric cancer with submucosal invasion after curative gastrectomy for recurrent risk factors. Recurrence was observed in 22 of the 443 gastric cancer patients with submucosal invasion. In the univariate analysis, the risk factors for recurrence were the number of retrieved LNs ≤ 25 and node metastasis. In the multivariate analysis, retrieved LNs ≤ 25 (hazard ratio [HR] = 5.754, P-value = .001) and node metastasis (HR = 3.031, P-value = .029) were independent risk factors for recurrence after curative gastrectomy. Body mass index was related to retrieved LNs ≤ 25 in univariate and multivariate analyses (HR = .510, P = .002). The number of retrieved LNs and node metastases were independent risk factors for EGC with submucosal invasion. For EGC with submucosal invasion, retrieved LNs > 25 are necessary for appropriate diagnosis and treatment.

[Aortoesophageal Fistula Induced by an Indwelling Nasogastric Tube: A Case Report].

A 91-year-old woman who presented with melena and hypovolemic shock visited the emergency room. She received enteral nutrition by nasogastric tube in a bedridden state due to hip surgery. Gastroscopy initially suggested a simple ulcer that occurred after a nasogastric tube was placed for a long time, but the ulcer was deep, and the amount of instantaneous bleeding was considerable. Therefore, an aortoesophageal fistula was suspected. Angiography was performed instead of endoscopic hemostasis, followed by thoracic endovascular aortic repair (TEVAR). After the TEVAR procedure, the patient recovered without further gastrointestinal bleeding. Prompt judgment and communication between the endoscopist and the interventional physician are important for successful hemostasis in an aortoenteric fistula patient.

Vitamin D and Colorectal Cancer: Current Perspectives and Future Directions.

Vitamin D is considered to be the main mediator of the beneficial effects of sun exposure. In humans, highest expression of Vitamin D receptors is found in the intestinal tract. In addition, 1α,25-dihydroxyvitamin D3 (or calcitriol), the most active Vitamin D metabolite, plays important homeostatic roles in the intestine, particularly calcium absorption. Vitamin D deficiency is defined as a serum 25-hydroxyvitamin D [25(OH)D] level of < 20 ng/mL. Previous studies show that higher circulating 25(OH)D levels are associated with reduced risk of colorectal cancer (CRC) and improved survival. Most research to date has been conducted in animals, specifically mice. Although human studies have a limited number of participants, one study recruiting a large cohort of patients with advanced or metastatic CRC revealed that higher plasma 25(OH)D levels are associated with improved overall and progression-free survival. However, the effects of Vitamin D supplementation on incidence and mortality of CRC remain inconclusive. Although Vitamin D may help to prevent cancer, there is a paucity of research demonstrating conclusively that Vitamin D alters prognosis after chemotherapy. Here, we review the mechanisms by which Vitamin D affects CRC, as well as the results of clinical, epidemiological, and human intervention studies. We also discuss current perspectives and future directions regarding Vitamin D and CRC.

Efficacy of a Restrictive Diet in Irritable Bowel Syndrome: A Systematic Review and Network Meta-analysis.

Background/Aims: Dietary factors can aggravate the symptoms of irritable bowel syndrome (IBS). Many IBS patients try restrictive diets to relieve their symptoms, but the types of diets with an exacerbating factor are unknown. Therefore, this paper reports the results of a systematic review and network meta-analysis of randomized-controlled trials (RCTs) reviewing the efficacy of food restriction diets in IBS. Methods: The MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases were searched until July 21, 2021, to retrieve RCTs assessing the efficacy of restriction diets in adults with IBS. Two independent reviewers performed the eligibility assessment and data abstraction. RCTs that evaluated a restriction diet versus a control diet and assessed the improvement in global IBS symptoms were included. These trials reported a dichotomous assessment of the overall response to therapy. Results: A total of 1,949 citations were identified. After full-text screening, 14 RCTs were considered eligible for the systematic review and network meta-analysis. A starch- and sucrose-reduced diet and a diet with low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) showed significantly better results than a usual diet. Symptom flare-ups in patients on a gluten- free diet were also significantly lower than in those on high-gluten diets. Conclusions: These findings showed that the starch- and sucrose-reduced, low FODMAP, and gluten-free diets had superior effects in reducing IBS symptoms. Further studies, including head-to-head trials will be needed to establish the effectiveness of dietary restrictions on IBS symptoms.

Efficacy of a comprehensive binary classification model using a deep convolutional neural network for wireless capsule endoscopy.

The manual reading of capsule endoscopy (CE) videos in small bowel disease diagnosis is time-intensive. Algorithms introduced to automate this process are premature for real clinical applications, and multi-diagnosis using these methods has not been sufficiently validated. Therefore, we developed a practical binary classification model, which selectively identifies clinically meaningful images including inflamed mucosa, atypical vascularity or bleeding, and tested it with unseen cases. Four hundred thousand CE images were randomly selected from 84 cases in which 240,000 images were used to train the algorithm to categorize images binarily. The remaining images were utilized for validation and internal testing. The algorithm was externally tested with 256,591 unseen images. The diagnostic accuracy of the trained model applied to the validation set was 98.067%. In contrast, the accuracy of the model when applied to a dataset provided by an independent hospital that did not participate during training was 85.470%. The area under the curve (AUC) was 0.922. Our model showed excellent internal test results, and the misreadings were slightly increased when the model was tested in unseen external cases while the classified 'insignificant' images contain ambiguous substances. Once this limitation is solved, the proposed CNN-based binary classification will be a promising candidate for developing clinically-ready computer-aided reading methods.

Spontaneous heterotopic mesenteric ossification around the pancreas causing duodenal stenosis: A case report with literature review.

INTRODUCTION AND IMPORTANCE: Heterotopic mesenteric ossification (HMO) is a rare condition that can be hereditary or nonhereditary. It can lead to small bowel obstruction, which may require corrective surgery. Most affected patients have a history of abdominal surgery or trauma. Spontaneously occurring HMO is even rarer, with only 7 cases reported till date. There has been no previous report of spontaneous peripancreatic HMO. CASE PRESENTATION: A 60-year-old man presented with complaints of recurrent nausea and vomiting for 2 months. Esophagogastroduodenoscopy revealed luminal stenosis and edematous changes involving the second and third parts of the duodenum but not its complete obstruction. Abdominopelvic computed tomography showed faintly enhanced thickening of the involved duodenal walls along with mild dilatation of the common bile duct. Considering the possibility of periampullary cancer, we performed a pylorus-preserving pancreaticoduodenectomy. Histopathological examination confirmed the diagnosis of HMO with extensive fibrosis involving the peripancreatic soft tissue. CLINICAL DISCUSSION: The peripancreatic HMO with severe fibrosis can occur duodenal stenosis, and it is mimicking periampullary cancer. However, the preoperative diagnosis of spontaneous HMO is difficult, and a diagnosis confirmed after surgery. CONCLUSION: Herein, we described our experience of managing a rare case of duodenal stenosis due to spontaneous HMO involving peripancreatic tissue.

Primary Aortoduodenal Fistula Causes Massive Melena: A Case Report.

A primary aortoenteric fistula is defined as the spontaneous development of communication between the gastrointestinal tract and the native aorta. This is unlike a secondary aortoenteric fistula that occurs after surgery, such as a vascular graft. A primary aortoenteric fistula is an extremely rare cause of upper gastrointestinal bleeding. The condition is often overlooked because of its extremely low incidence. This paper reports a case of a 75-year-old man who presented with massive melena. Esophagogastroduodenoscopy revealed an ulcer measuring approximately 1.3 cm with a huge pulsating vessel in the third portion of the duodenum. Later, the diagnosis of primary aortoduodenal fistula was confirmed. The patient died in the preoperative stage due to massive bleeding. The findings of this case suggest that the endoscopists should recognize aortoenteric fistula as a potential cause of gastrointestinal bleeding.

Development of a deep learning-based software for calculating cleansing score in small bowel capsule endoscopy.

A standardized small bowel (SB) cleansing scale is currently not available. The aim of this study was to develop an automated calculation software for SB cleansing score using deep learning. Consecutively performed capsule endoscopy cases were enrolled from three hospitals. A 5-step scoring system based on mucosal visibility was trained for deep learning in the training set. Performance of the trained software was evaluated in the validation set. Average cleansing score (1.0 to 5.0) by deep learning was compared to clinical grading (A to C) reviewed by clinicians. Cleansing scores decreased as clinical grading worsened (scores of 4.1, 3.5, and 2.9 for grades A, B, and C, respectively, P < 0.001). Adequate preparation was achieved for 91.7% of validation cases. The average cleansing score was significantly different between adequate and inadequate group (4.0 vs. 2.9, P < 0.001). ROC curve analysis revealed that a cut-off value of cleansing score at 3.25 had an AUC of 0.977. Diagnostic yields for small, hard-to-find lesions were associated with high cleansing scores (4.3 vs. 3.8, P < 0.001). We developed a novel scoring software which calculates objective, automated cleansing scores for SB preparation. The cut-off value we suggested provides a standard criterion for adequate bowel preparation as a quality indicator.

Consistency of Helicobacter pylori eradication rates of first-line concomitant and sequential therapies in Korea: A nationwide multicenter retrospective study for the last 10 years.

BACKGROUND: Eradication rate of standard triple therapy for H. pylori has declined to unacceptable level, and alternative regimens such as concomitant and sequential therapy have been introduced. We aimed to assess the consistency of eradication rates of concomitant and sequential therapies as for the first-line H. pylori eradication in Korea. METHODS: A nationwide multicenter retrospective study was conducted including 18 medical centers from January 2008 to December 2017. We included 3,800 adults who had test to confirm H. pylori eradication within 1 year after concomitant or sequential therapy. RESULTS: Concomitant and sequential therapy were prescribed for 2508 and 1292 patients, respectively. The overall eradication rate of concomitant therapy was significantly higher than that of sequential therapy (91.8% vs. 86.1%, p < .001). In time trend analysis, the eradication rates of concomitant therapy were 90.2%, 88.2%, 92.1%, 94.3%, 91.1%, and 93.4% for each year from 2012 to 2017 with an increasing trend (p = .0146), while those of ST showed no significant trend (p = .0873). Among 263 patients with second-line therapy, bismuth quadruple therapy showed significantly higher eradication rate than quinolone-based triple therapy (73.9% vs. 51.5% in ITT analysis, p = .001; 82.7% vs. 63.0% in PP analysis, p = .002). CONCLUSION: Concomitant therapy is the best regimen for the first-line H. pylori eradication showing consistently higher eradication rate with an increasing trend for the last 10 years in Korea. Bismuth quadruple therapy should be considered for second-line therapy after eradication failure using non-bismuth quadruple therapy.

Optimal procedure-related hospitalization using clinical pathway protocols following gastric endoscopic submucosal dissection.

BACKGROUND: The clinical pathway (CP) protocols simplified a systematic process from hospitalization to discharge, and were conducted to achieve standardization of the treatment process as well as improve outcomes. Thus, we investigated the optimal procedure-related hospitalization period following gastric endoscopic submucosal dissection (ESD) by comparing the rate of delayed bleeding (DB) and perforation according to CP protocols. METHODS: We retrospectively enrolled 630 patients who underwent ESD for gastric dysplasia or early gastric cancer (EGC); Group A (368 patients) followed Protocol A for a hospital stay of a single night; Group B (262 patients) followed Protocol B for a hospital stay of two nights. RESULTS: The patient characteristics were comparable between the two groups, except for pathologic diagnosis (42.1% in Group A vs. 32.1% in Group B for EGC). DB occurred in 21 patients, and there was no significant difference in the overall DB rates between Group A (12/368 = 3.3%) and Group B (9/262 = 3.4%) (P = 0.904). The DB rates were 2.5% (8/315) and 7.5% (4/53) in Group A, and 2.7% (6/223) and 7.7% (3/39) in Group B, without and with the use of antiplatelets, respectively, and 33.3% (1/3) in Group A and 50.0% (1/2) in Group B with the use of dual antiplatelets. DB developed at various intervals post-discharge from 2 to 17 days, and was successfully controlled by endoscopic hemostasis in most cases. There were no deaths or surgeries required as a result of uncontrolled DB and no postoperative delayed perforation occurred. CONCLUSIONS: The CP protocols with a one-night hospitalization following gastric ESD decreased the hospital stay and did not influence postoperative complications compared to those with two-night hospitalizations.

Esophageal Stricture Caused by the Ingestion of Undissolved Picosulfate Powder.

Picosulfate solution is widely used as a small volume bowel cleansing agent and is considered to be effective and relatively safe. A case of a 75-year-old woman ingested picosulfate powder and drank a small volume of water, subsequently experienced severe burning pain in the chest. Endoscopy was performed and showed a submucosal hemorrhage and exudative ulcers at the mid to lower esophagus. At 2 weeks, her symptoms improved with conservative treatment. However, liquid food dysphagia developed 11 weeks after ingestion. A follow-up endoscopy revealed multiple esophageal strictures, which were treated with a fully covered metal stent and esophageal balloon dilation. Consequently, the esophageal strictures improved after one year. As this case demonstrates, detailed information about picosulfate powder ingestion after dissolving it in more than 200 mL of water should be presented to patients to avoid esophageal injury.