Effect of Preceding Biopsy on the Results of Endoscopic Submucosal Dissection for Colorectal Laterally Spreading Tumor.

BACKGROUND: Forceps biopsies are usually performed before endoscopic submucosal dissection (ESD) for colonic laterally spreading tumors (LSTs). However, preceding biopsy is commonly believed to possibly inhibit complete tumor resection by causing blurring of tumor borders and tissue fibrosis. AIMS: The aims were to investigate whether the preceding biopsy of colorectal LST affects the complete endoscopic tumor resection and increases the risk of complications. METHODS: We retrospectively reviewed the medical records of patients with colorectal LSTs who underwent ESD at our center during an 8-year period. Patients were divided into two groups according to whether they underwent biopsy of the tumor before ESD. In addition, the characteristics of patients and tumors, including the completeness of tumor resection, were investigated. RESULTS: Of 288 patients (174 men) enrolled in this study, 194 (67.4%, preceding biopsy group) underwent biopsies before ESD, whereas 94 (32.6%, no biopsy group) did not. There were no significant differences in age, sex, comorbidity, medication history, tumor location, and final pathologic result between both groups. Tumor size was larger (p = 0.002) and LST-G tumor was more common (p = 0.003) in the preceding biopsy group than in the no biopsy group. No significant difference was seen in ESD outcomes, including procedure time, hospitalization period, incidence of complications, en bloc resection rate, resection margin status, and incidence of surgical operation, between both groups. CONCLUSIONS: Biopsy of LST is commonly performed before endoscopic resection. Contrary to popular belief, it does not increase the incomplete tumor resection rate and incidence of complications. TRIAL REGISTRATION: KCT0002321.

Aggressive intravenous hydration with lactated Ringer's solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial.

BACKGROUND AND STUDY AIMS : The present study aimed to determine the type of intravenous hydration that is best suited to reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. PATIENTS AND METHODS: In a prospective randomized multicenter trial, average-to-high risk patients who underwent first-time ERCP were randomly assigned to three groups (1:1:1) who received: aggressive intravenous hydration (3 mL/kg/h during ERCP, a 20-mL/kg bolus and 3 mL/kg/h for 8 hours after ERCP) with either lactated Ringer's solution (LRS) or normal saline solution (NSS), or standard intravenous hydration with LRS (1.5 mL/kg/h during and for 8 hours after ERCP). The primary end point was post-ERCP pancreatitis (PEP). RESULTS: 395 patients were enrolled, and 385 completed the protocols. The three groups showed no significant differences in demographic characteristics. There was a significant difference in the intention-to-treat (ITT) PEP rate between the aggressive LRS group (3.0 %, 95 % confidence interval [CI] 0.1 % - 5.9 %; 4 /132), the aggressive NSS group (6.7 %, 95 %CI 2.5 % - 10.9 %; 9 /134) and the standard LRS group (11.6 %, 95 %CI 6.1 % - 17.2 %; 15 /129; P = 0.03). In the two-group comparisons, the ITT PEP rate was significantly lower for the aggressive LRS group than for the standard LRS group (relative risk [RR] 0.26, 95 %CI 0.08 - 0.76; P = 0.008). There was no significant difference in the ITT PEP rate between the aggressive NSS group and the standard LRS group (RR 0.57, 95 %CI 0.26 - 1.27; P = 0.17). CONCLUSION: Aggressive hydration with LRS is the best approach to intravenous hydration for the prevention of PEP in average-to-high risk patients.

The histologic detection of Helicobacter pylori in seropositive subjects is affected by pathology and secretory ability of the stomach.

BACKGROUND: Helicobacter pylori is unevenly distributed in hypochlorhydric environments. The study aim was to elucidate the risk factors for a negative Giemsa staining finding in seropositive subjects by measuring the secretory ability of the stomach. METHODS: Subjects aged over 18 years were included consecutively after endoscopic biopsy at gastric lesions with color or structural changes. Blood was sampled for the serum pepsinogen (PG) assay and H. pylori serology test. After excluding the subjects with past H. pylori eradication, the risk factors for a negative Giemsa staining finding in seropositive subjects were analyzed. RESULTS: Among 872 included subjects, a discrepancy between the serum anti-H. pylori IgG and Giemsa staining findings was found in 158 (18.1%) subjects, including 145 Giemsa-negative, seropositive subjects. Gastric adenocarcinoma/adenoma (OR = 11.090, 95% CI = 3.490-35.236) and low serum PG II level (OR = 0.931, 95% CI = 0.899-0.963) were the independent risk factors for a negative Giemsa staining finding in seropositive subjects. The cutoff value of serum PG II level was 7.45 ng/mL (area under curve [AUC] = 0.904, 95% CI = 0.881-0.927). Follow-up studies of Giemsa staining at different sites of the stomach revealed that 75% of the Giemsa-negative seropositive subjects with adenocarcinoma are positive, whereas none of those with low serum PG II level of <7.45 ng/mL revealed positive findings. CONCLUSIONS: The risk of a negative Giemsa staining finding in seropositive subjects is increased in gastric adenocarcinoma/adenoma specimens and in subjects with a diminished gastric secretory ability with low serum PG II level of <7.45 ng/mL. A false-negative Giemsa staining finding is common in subjects with adenocarcinoma, and therefore, additional biopsies at different sites should be performed in these subjects.

Endoscopic Submucosal Dissection of Early Gastric Cancer in Patients with Liver Cirrhosis.

BACKGROUND AND OBJECTIVES: Endoscopic submucosal dissection (ESD) has become widely accepted method for treating early gastric cancer (EGC), but little is known about its role in patients with liver cirrhosis (LC). The aims of this study were to evaluate the outcomes of ESD in treating EGC in patients with LC. METHODS: The multicenter retrospective study identified 43 patients with chronic hepatitis B (CHB)-related cirrhosis undergoing ESD for treating EGC. The patients (LC group) were subdivided into two groups based on their Child-Pugh classification (CP-class): 32 with CP-class A (LC-A) and 11 with CP-class B (LC-B). The patients were compared to 47 non-cirrhotic CHB patients who underwent ESD (CHB group). Eight patients had a past history of hepatocellular carcinoma (HCC) prior to ESD, but no patients had viable HCC when ESD was performed. RESULTS: Procedural outcomes (en bloc, lateral/basal margins resection) and post-procedural complications (bleeding or perforation) did not differ significantly between the LC and CHB groups or between the LC-A and LC-B groups. No patients experienced worsening of the Child-Pugh score 1 month after ESD compared with the baseline score. During a median observation period of 66 months, the recurrence rates of gastric cancers were similar between the LC and CHB groups (5-year recurrence rates: 2.4 vs. 2.3%, p = 0.925), and all recurrent gastric cancers were completely resected by additional ESD. The overall mortality rate was increased in the LC group (5-year mortality rates: 17.9 vs. 5.7%, p = 0.034), and 8 of 10 deaths were attributed to liver-related diseases (such as HCC, complications of portal hypertension, hepatic failure). CONCLUSIONS: ESD is feasible in patients with EGC and comorbid LC, even those with CP-class B cirrhosis. Their prognosis depends on LC-related diseases and not recurrent EGC.

Impact of endoscopic papillary large-balloon dilation on sphincter of Oddi function: a prospective randomized study.

BACKGROUND AND AIMS: Endoscopic papillary balloon dilation (≤8 mm in diameter) preserves sphincter of Oddi (SO) function. However, it is still unknown whether papillary function is preserved after endoscopic papillary large-balloon dilation (EPLBD, ≥12 mm in diameter). We investigated SO function after EPLBD with or without endoscopic sphincterotomy (EST) by endoscopic manometry, up to 1 year after the procedure. METHODS: This was a prospective randomized study involving patients with bile duct stones ≥12 mm. Eighty-six patients who met the inclusion criteria were assigned randomly to either EPLBD alone or EST with EPLBD, and endoscopic manometric studies were performed. The primary outcome was comparison of the manometric data between the 2 groups and within each group both 1 week and 1 year after the procedure. RESULTS: One week after EPLBD alone and EST with EPLBD, the basal pressure of SO dropped from 30.4 (8.2) to 6.4 (8.4) mm Hg (P < .001) and 29.5 (18.9) to 2.9 (3.6) mm Hg (P < .001), respectively. SO function was not recovered at 1 year; the manometric measurements were similar to those taken at the 1-week time point in both groups. Similar outcomes were obtained in patients with EPLBD alone compared with those with EST and EPLBD, including the initial stone clearance rate (95.2% vs 97.7%, P = .612), the frequency of mechanical lithotripsy (21.4% vs 13.6%), and overall adverse events (11.9% vs 13.6%, P = 1.0) including the rate of pancreatitis after the procedure (7.1% vs 11.4%, P = .714). During an overall median follow-up of 17.8 months, the recurrence rate of bile duct stones was 16.7% in patients who underwent EPLBD alone and 15.9% in patients who underwent EST with EPLBD (P = .924). CONCLUSIONS: Both EPLBD alone and EST + EPLBD resulted in persistent and comparable loss of SO function after 1 year. EPLBD alone has similar efficacy and safety to those of EST with EPLBD with respect to removal of large stones.

A randomized controlled trial of prophylactic antibiotics in the prevention of electrocoagulation syndrome after colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is currently commonly performed, but colorectal ESD has a substantial risk of adverse events, including post-ESD electrocoagulation syndrome (PEECS). We investigated whether the use of prophylactic antibiotics can reduce the occurrence of PEECS. METHODS: Patients who underwent colorectal ESD were randomly assigned to 1 of 2 treatment regimens. Ampicillin and/or sulbactam mixed with normal saline solution was administered 1 hour before ESD in group 1 then additionally injected every 8 hours twice more. In group 2, normal saline solution without antibiotics was administered following the same schedule. We investigated the characteristics of the patients and tumors, the incidence of PEECS, laboratory findings, and the visual analog scale (VAS) score for abdominal pain measured on the morning after ESD. RESULTS: A total of 100 cases (50 per group) were finally analyzed, and 97 tumors were successfully resected en bloc. The number of patients having C-reactive protein (CRP) levels ≥1 mg/dL and the number of patients having VAS scores for abdominal pain ≥1 were greater in group 2 than in group 1 (P = .008 and .023, respectively). The incidence of PEECS in group 2 also was higher than that in group 1 (1 and 8 in groups 1 and 2, respectively; P = .031). CONCLUSIONS: The prophylactic use of ampicillin and/or sulbactam in colorectal ESD is associated with reduced risk of PEECS, decreased CRP levels, and decreased abdominal pain. The use of prophylactic antibiotics in colorectal ESD may be an effective tool for reducing the risk of PEECS. (Clinical trial registration number: KCT0001102.).

Factors Related to Upper Gastrointestinal Symptom Generation in 2275 Helicobacter pylori Seroprevalent Adults.

BACKGROUND AND AIM: Upper gastrointestinal (UGI) symptoms are common; however, the role of Helicobacter pylori and gastric corpus atrophy in the generation of these symptoms is controversial. The aim of this study was to determine the risk factors for UGI symptoms in adults in an endemic area of H. pylori infection. METHODS: Korean adults who completed questionnaires on the day of serum anti-H. pylori IgG and pepsinogen (PG) assays before UGI endoscopy were included. Gastric corpus atrophy was based on the criteria of a serum PG I/II ratio <3.0 and a PG I <70 ng/ml. RESULTS: Of the 2275 included subjects, 723 (31.8%) had at least one UGI symptom. A total of 374 (16.4%) subjects had multiple symptoms without significant correlations between the symptoms (λ < 0.2). The H. pylori serology assay was positive in 1382 (60.7%) subjects, and gastric corpus atrophy was present in 291 (12.8%). Neither H. pylori seropositivity (p = 0.077) nor gastric corpus atrophy (p = 0.138) was related to the presence of UGI symptoms. Female gender and smoking were independent risk factors for heartburn and upper abdominal pain (all p < 0.001). Furthermore, female gender was the only independent risk factor for multiple UGI symptoms (p < 0.001), globus sensation (p < 0.001), early satiety (p < 0.001), epigastric soreness (p = 0.001), and chest discomfort (p = 0.003). CONCLUSIONS: In an H. pylori seroprevalent population, female gender is the most common risk factor followed by smoking for UGI symptom generation. Neither H. pylori seropositivity nor gastric corpus atrophy is an independent risk factor for UGI symptom generation.

Link between Serum Pepsinogen Concentrations and Upper Gastrointestinal Endoscopic Findings.

The serum pepsinogen (PG) assay findings are correlated with the status of Helicobacter pylori infection, but there are controversies on the link with upper gastrointestinal (UGI) endoscopic findings. The aim of this study was to determine the significance of a serum PG assay for correlating with endoscopic findings in H. pylori-seroprevalent adult population. Korean adults who visited for a health check-up were included consecutively. Subjects after gastrectomy or H. pylori eradication were excluded. After completing the serum PG assay and anti-H. pylori immunoglobulin G (IgG) titer on the same day of UGI endoscopy, subjects with equivocal serology test finding or gastric neoplasm were excluded. Of the 4,830 included subjects, 3,116 (64.5%) were seropositive for H. pylori. Seropositive finding was related to high serum PG I (P < 0.001) and PG II (P < 0.001) concentrations, low PG I/II ratio (P < 0.001), old age (P < 0.001), and male gender (P = 0.006). After adjusting age and gender, the serum PG I and II concentrations were positively correlated with the presence of nodular gastritis (NG) (all P = 0.003). The serum PG I was positively correlated with gastric ulcer (P = 0.003), and it was correlated with duodenal ulcer in seropositive subjects (P = 0.008). The PG I/II ratio was positively correlated with erosive esophagitis, while it was inversely related to chronic atrophic gastritis and metaplastic gastritis (all P < 0.001). Our findings suggest that the serum PG assay finding correlates well with the UGI endoscopic finding. A higher serum PG concentration in subjects with NG and peptic ulcer disease suggests that endoscopic findings reflect gastric secreting ability.

Magnetic-assisted capsule endoscopy in the upper GI tract by using a novel navigation system (with video).

BACKGROUND AND AIMS: Capsule endoscopy for visualization of the upper GI tract has thus far been experimental and potentially expensive. Our aim was to demonstrate the maneuverability and evaluate the ability to completely visualize and maintain views in the upper GI tract by using a simple magnetic-assisted capsule endoscopy (MACE) system. METHODS: Twenty-six volunteers were recruited. The hand-held magnet was placed at strategic points on the body surface and rotated to hold and maneuver the capsule. The ability to view the upper GI tract landmarks was noted: esophagogastric junction (EGJ), cardia, fundus, body, incisura, antrum, and pylorus. Control was assessed by the ability to hold the capsule for 1 minute at 5 positions: the lower esophagus and 4 designated positions in the proximal and distal stomach and also traversing the stomach and through the pylorus. Volunteers subsequently underwent a standard gastroscopy. RESULTS: The median data are as follows: age, 38 years (range 26-45 years); BMI, 24 (range 19-38); and procedure time, 24 minutes (range 12-39 minutes). Successful visualization of each landmark was EGJ, 92%; cardia, 88%; fundus, 96%; body, 100%; incisura, 96%; antrum, 96%; and pylorus, 100%; with fewer clear views of the EGJ and fundus. The capsule could be held in 88% of designated positions for 1 minute, moved from the fundus to the antrum in all cases, and traversed the pylorus in 50% (n = 13). An age of 40 years and older was associated with successful pyloric traversing (P = .04). There was positive concordance for 8 of 9 minor pathological findings on standard gastroscopy. CONCLUSION: MACE in the upper GI tract is feasible. There is a high degree of visualization and control, with some improvement required for optimizing proximal gastric views and traversing the pylorus.

Endoscopic wire-guided papillectomy versus conventional papillectomy for ampullary tumors: A prospective comparative pilot study.

BACKGROUND AND AIM: A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures. METHODS: This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice. RESULTS: Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032). CONCLUSIONS: The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

The Clinical Features and Predisposing Factors of Asymptomatic Erosive Esophagitis.

BACKGROUND: Asymptomatic erosive esophagitis (AEE) is considered an erosive esophagitis without the typical reflux symptoms, but the clinical course and significance of AEE is still unclear. AIM: We investigated the prevalence and predisposing factors of AEE, and tried to determine its clinical features and significance. METHODS: Subjects, who had at least two health inspections (upper endoscopy, self-reporting questionnaire, and serum Helicobacter pylori IgG antibody test) at our center, were enrolled. The questionnaire included typical reflux symptoms, previous medical history, underlying disease, smoking, alcohol intake, and medication history. Based on the results of follow-up study, the changes in endoscopic findings and reflux symptoms were also investigated. RESULTS: Of the 2961 patients visiting our clinic, 568 (19.2 %) were diagnosed with AEE. Age over 50 years, male sex, a body mass index over 25, current smoking, heavy drinking, negativity for H. pylori infection, and hiatal hernia were independent predisposing factors for AEE (p = 0.020, p < 0.001, p < 0.001, p = 0.013, p = 0.003, p < 0.001, p = 0.038, respectively). Within the follow-up period (mean 25 ± 9.5 months), reflux symptoms developed in 30 subjects (7.9 %), and current smoking was the only risk factor for the development of AEE symptoms (p = 0.015). On the follow-up endoscopy, erosive esophagitis disappeared in nearly half of the subjects with AEE (174, 45.6 %). CONCLUSIONS: AEE is common, but many cases of AEE may be spontaneously cured without treatment. Although symptom development is rare, quitting smoking may be helpful as a prevention strategy. CLINICAL TRIAL REGISTRATION NUMBER: KCT0001716.

Does 2 L Polyethylene Glycol Plus Ascorbic Acid Increase the Risk of Renal Impairment Compared to 4 L Polyethylene Glycol?

BACKGROUND: The use of polyethylene glycol (PEG)-based solutions is the gold standard for bowel preparation. However, PEG use might be associated with the risk of acute kidney injury. AIMS: We aimed to compare the safety of 2 L PEG plus ascorbic acid (AA) versus 4 L PEG. METHODS: Health examinees that underwent colonoscopy and blood tests on the same day at our center were included in this retrospective study. All subjects were prescribed either 2 L PEG plus AA or 4 L PEG for the bowel preparation prior to the colonoscopy. The incidences of electrolyte imbalance and renal impairment after colonic preparation were investigated. Renal impairment was determined if the subject's estimated glomerular filtration rate was measured less than 60 mL/min/1.73 m2. RESULTS: Of the 29,789 cases, 14,790 received 2 L PEG plus AA (group A) and 14,999 received 4 L PEG (group B) for colonic preparation. Renal impairment occurred more commonly in group A (n = 467, 3.2 %) than in group B (n = 189, 1.3 %). Electrolyte changes such as hypernatremia and hyperkalemia were more common in group A than group B, whereas hyponatremia, hypokalemia, and hypophosphatemia were more common in group B than group A. Old age, male sex, and the use of 2 L PEG plus AA were independent risk factors for renal impairment. CONCLUSIONS: The evidence strongly suggests that acute kidney injury is more likely to occur when 2 L PEG plus AA is used for the bowel preparation than when 4 L PEG is used. CLINICAL TRIAL REGISTRATION NUMBER: KCT0001703.

Correlation between Helicobacter pylori infection, IgE hypersensitivity, and allergic disease in Korean adults.

BACKGROUND: The correlation between allergic disease and Helicobacter pylori infection is still controversial in endemic areas. The aim of this study was to determine whether H. pylori infection is related to allergic disease and/or immunoglobulin E (IgE) hypersensitivity in Korean adults. MATERIALS AND METHODS: Consecutive Korean adults who visited our center for a routine checkup were enrolled. All subjects completed a questionnaire that was designed to ascertain their medical history pertaining to physician-diagnosed allergic disease, allergy treatments, and H. pylori eradication therapy. Blood was sampled for serum anti-H. pylori IgG antibody. IgE hypersensitivity was measured using a commercially available ImmunoCAP(®) Phadiatop (Phadia AB, Uppsala, Sweden). RESULTS: Of the 3376 Korean adults who were enrolled, 62 did not answer to the questionnaires adequately and were thus excluded. The proportion of noninfected subjects (p < .001) and the prevalence of IgE-related allergic disease (p < .001) were both highest among those aged <40 years, while the prevalence of non-IgE-related allergic disease was highest among those aged ≥70 years (p < .001). Logistic regression analysis revealed that being younger than 40 years was significantly related to the absence of H. pylori infection (OR = 2.507, 95% CI = 1.621-3.878, p < .001). CONCLUSIONS: The statuses of H. pylori infection, IgE hypersensitivity, and allergic diseases differ with age group, there being a higher prevalence of IgE-related allergic disease and a lower H. pylori infection rate among young adults. The hygiene hypothesis might explain these findings in young Koreans, due to the rapid development and improvements in sanitation in Korea.

The clinical course of asymptomatic esophageal candidiasis incidentally diagnosed in general health inspection.

OBJECTIVE: Esophageal candidiasis mostly occurs in the immunocompromised host. However, it may also affect healthy people and is frequently asymptomatic. The clinical significance of asymptomatic esophageal candidiasis (AEC) is still unclear. The aims of the study were to investigate the prevalence of AEC during health inspection and to identify its predisposing factors and clinical significance. MATERIALS AND METHODS: A total of 49,497 subjects who underwent a health inspection that included upper endoscopy were enrolled. We retrospectively reviewed the subject's self-reporting questionnaires, medical records and endoscopic findings. We considered "long-term" follow-up to be >6 months with at least one more follow-up endoscopy. RESULTS: One hundred and seventy (0.4%) subjects were endoscopically diagnosed as esophageal candidiasis and 141 subjects were AEC. Multivariate analysis revealed that old age (≥60 years) was an independent risk factor for AEC (OR, 1.862, p = 0.005). The number of subjects with long-term follow-up was 79 (195.3 person-years). Among these, AEC of 64 subjects (81.0%) had disappeared on the follow-up endoscopy and was not recurrent. The other 15 subjects had AEC diagnosed more than once on the follow-up endoscopy, and 5 of them were spontaneously healed during the follow-up period. The remaining 10 subjects whose candidiasis was sustained up to the last endoscopy did not complain of symptoms during the follow-up period, and their endoscopic findings did not worsen. CONCLUSIONS: AEC is rare and old age is the only risk factor. AEC does not require medical care because it is a self-limited disease.

Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: pathologic review of 173 cases.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is now commonly performed as a treatment for colorectal tumors. However, little is known about the relationship between submucosal fibrosis and the outcome of the colonic ESD procedure. The aims of this study were to investigate the relationship between the degree of submucosal fibrosis in colorectal tumors and the outcomes of ESD for these tumors and to evaluate the risk factors for submucosal fibrosis. METHODS: We retrospectively reviewed the records of patients with colorectal adenoma or carcinoma who had undergone an ESD, during a four-year period from January 2010 to December 2013. The resected specimens were histologically examined after Masson's trichrome staining, and the severity of the submucosal fibrosis was classified as no fibrosis (F0), mild fibrosis (F1), or severe fibrosis (F2). RESULTS: Among a total of 173 cases (106 male, mean age 65.0 ± 10.2 years; F0 33, F1 78, F2 62) enrolled, 46 incidences of complications (perforation 19, post-coagulation syndrome 21, bleeding 6) had developed. Multivariate analysis revealed that F2 fibrosis was significantly associated with the development of complications. Submucosal invasion and large tumor size (≥ 30 mm) were identified as independent predictors of F2 fibrosis. CONCLUSION: Severe fibrosis is the most powerful risk factor for complications and can interfere with en bloc resections. The possibility of submucosal fibrosis should be considered, and the procedure should be cautiously performed in cases where the tumor diameter is greater than 30 mm and when submucosal cancer is suspected.

Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms.

BACKGROUND AND OBJECTIVES: There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD. METHODS: There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS. RESULTS: There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics. CONCLUSIONS: The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

Orange juice intake reduces patient discomfort and is effective for bowel cleansing with polyethylene glycol during bowel preparation.

BACKGROUND: Many patients report discomfort because of the unpleasant taste of bowel preparation solutions. OBJECTIVE: This study aimed to determine whether adding orange juice to 2 L of polyethylene glycol plus ascorbic acid is effective for reducing patient discomfort and improving palatability during bowel preparation. DESIGN: This was a single-blinded, randomized controlled trial. SETTINGS: The study was conducted at a tertiary referral hospital and a generalized hospital. PATIENTS: Consecutive outpatients and inpatients were randomly allocated to drink 2 L of polyethylene glycol-ascorbic acid or 2 L of polyethylene glycol-ascorbic acid with orange juice in a single dose or a split dose. MAIN OUTCOME MEASURES: Tolerability, palatability score, willingness, and related adverse events were investigated by questionnaires. Bowel cleansing was rated using the Aronchick scale. Each score was graded on a 5-point scale. RESULTS: A total of 107 patients, 53 in the orange juice group and 54 in the polyethylene glycol-ascorbic acid group who underwent elective colonoscopy were enrolled. The palatability score (mean ± SD) was higher in the orange juice group than in the control group (2.36 ± 0.76 vs 1.78 ± 0.88; p = 0.005). Nausea was less frequent in the orange juice group (26.4% vs 59.3%; p = 0.001). Total amount of bowel preparation ingested was not significantly different between the groups (p = 0.44). The bowel preparation score (mean ± SD) was not significantly different (1.49 ± 0.80 vs 1.43 ± 0.77; p = 0.94). Willingness to repeat the same process was higher in the orange juice group (90.4% vs 66.7%; p = 0.003). LIMITATIONS: This study is limited because only ambulatory patients were enrolled. CONCLUSIONS: Orange juice intake before drinking 2 L of polyethylene glycol-ascorbic acid for colonoscopy can reduce patient discomfort, resulting in improved acceptability and patient compliance. This method is as effective for bowel cleansing as polyethylene glycol.

Recurrence of gastroesophageal reflux disease correlated with a short dinner-to-bedtime interval.

BACKGROUND AND AIM: Gastroesophageal reflux disease (GERD) can be classified into erosive reflux disease (ERD) and nonerosive gastroesophageal reflux disease (NERD). We aimed to compare the recurrence rates of ERD and NERD and determine the risk factors related to the recurrence. METHODS: This prospective study comprised 337 consecutive adults who completed questionnaires on their GERD symptoms, height, weight, sleeping position, dinner time, and bedtime. During upper gastrointestinal endoscopy, the presence of a hiatal hernia and mucosal breaks in the low esophagus, esophageal length (the distance between the Z-line and the incisors), and the esophageal length-to-height ratio were recorded. Recurrence was diagnosed when the patient required additional proton pump inhibitor medication after initial recovery with 4-8 weeks of treatment. RESULTS: Recurrence was experienced by 47 (26.0%) of 181 GERD patients. The recurrence rate did not differ between the 48 ERD (27.1%) and 133 NERD (25.6%) patients (P = 0.849). Of the various factors studied, recurrence was found to be correlated with a dinner-to-bedtime interval of less than 3 h (P = 0.002), globus sensation (P = 0.031), and old age (P = 0.047). Logistic regression analysis revealed that a short interval between dinner and bedtime was the only factor significantly related to the recurrence (P = 0.002). CONCLUSION: Both ERD and NERD patients who sleep within 3 h after eating have a higher risk of GERD recurrence. Our findings highlight the impact of a short dinner-to-bedtime interval on the recurrence of GERD (ClinicalTrials.gov ID: KCT0000134).

Low prevalence of microsatellite instability in interval gastric cancers.

BACKGROUND AND AIM: Esophagogastroduodenoscopy (EGD) is recommended at 2-year intervals in countries with a high prevalence of gastric cancer. The aim of this study was to determine whether interval gastric cancers that develop within 2 years of a previous complete screening are associated with microsatellite instability (MSI). METHODS: Newly diagnosed gastric cancer patients who had undergone gastrectomy were included. Of these 459 patients, 177 were classified as interval gastric cancer since they were diagnosed within 2 years of a previous EGD. Noninterval gastric cancer patients were subclassified into 65 patients who underwent previous EGD between the past 2 and 10 years and 217 patients without EGD during the last 10 years. Analysis for MSI was conducted using two mononucleotide and three dinucleotide markers. RESULTS: MSI was found more frequently in noninterval gastric cancers than in interval gastric cancers (p = 0.009). Interval gastric cancers were associated with a higher prevalence of early gastric cancer (p = 0.006), smaller size (p < 0.001), and lower TNM stages (p = 0.006). On logistic regression analysis, noninterval gastric cancers were related to MSI (p = 0.010) and larger size (≥4 cm) (p = 0.009). Subjects with interval gastric cancer showed better survival than those with noninterval gastric cancer (p = 0.006). CONCLUSIONS: During a 2-year screening interval, noninterval gastric cancers tend to be larger, more advanced, and associated with MSI. Biannual EGD screening is effective for detecting small gastric cancers at an early stage, but is not useful in detecting gastric cancers with MSI.

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease.

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.