Direct gastric invasion from the liver metastasis of colorectal origin: A case report.

RATIONALE: Colorectal cancer is the third most common cancer diagnosed worldwide. At the time of diagnosis of colorectal cancer, one of the most common metastatic sites is liver. Gastric metastasis from colorectal origin is rare. Moreover, a direct invasion of the stomach, by hepatic metastasis from colorectal cancer, is particularly uncommon. PATIENT CONCERNS: A 56-year-old male patient with hematochezia was referred to our hospital. DIAGNOSIS: The patient was diagnosed with unresectable colorectal cancer because of the presence of >10 metastases involving both lobes of the liver. INTERVENTIONS AND OUTCOMES: After chemotherapy, the metastatic nodules in the liver nearly disappeared, except for a small nodule in segment VI. The patient underwent a radiofrequency ablation for the single lesion in the liver and laparoscopic low-anterior-resection for the primary tumor. Despite receiving various chemotherapy regimens, he experienced 6 recurrences, leading to 5 hepatectomies including a right hemi-hepatectomy, 1 pulmonary wedge resection, and 2 courses of radiation treatments. Lastly, a metastatic lesion in the liver was observed with invasion into the stomach. Subsequently, gastric wedge resection with resection of segments III and IV of the liver was performed. Direct invasion of the liver metastases into the stomach was confirmed histologically. LESSONS: The patient is still alive, with a good quality of life, even after more than 8 years since the initial diagnosis. In the last instance of metastatic recurrence, direct invasion from the liver metastases into the stomach was observed, which is rare, and there are currently no reported cases.

Comparison of the Clinical Outcomes of Esophagectomy and Concurrent Chemoradiotherapy in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma.

Background/Aims: The efficacy of concurrent chemoradiotherapy (CCRT) or esophagectomy for locally advanced esophageal squamous cell carcinoma (ESCC) is unclear. This study compared the survival and recurrence of patients with locally advanced ESCC after definitive CCRT and surgery. Methods: A retrospective study was conducted on patients with locally advanced ESCC who underwent CCRT or esophagectomy at Kosin University Gospel Hospital from January 2010 to December 2016. The patients' baseline characteristics, pathology, recurrence rate, and three-year/five-year overall survival were obtained. Results: This study evaluated ESCC patients with cT1-T2, N+ or cT3-T4, or N, who were treated by definitive CCRT (n=14) or esophagectomy (n=32). No significant difference was noted between the two groups, except for the location of the cancer and performance state. The respective three- and five-year overall survival rates were 30.8% and 23.1% in the CCRT group and 40.2% and 22.5% in the esophagectomy group (p=0.685). In the CCRT group, three patients (21.4%) had a complete response, and two (66.7%) had a recurrence. In the esophagectomy group, an R0 resection was achieved in 28 (87.5%) patients, and a recurrence occurred in 18 (64.3%). The median disease-free survival in the CCRT and esophagectomy groups was 14 and 17 months, respectively (p=0.882). Conclusions: These results showed no significant difference in survival between the definitive CCRT and surgery as the initial treatment. Nevertheless, larger prospective studies will be needed because of the retrospective nature and small number of patients in this study.

Factors associated with gastric and duodenal neuroendocrine tumors: A multicenter case-control study.

BACKGROUND AND AIMS: The incidence of gastric and duodenal neuroendocrine tumors (GNET and DNET, respectively) is increasing, however associated factors of these diseases are not well known. Here, we investigated the factors associated with GNET and DNET. METHODS: Patients with GNET and DNET presenting at eight tertiary referral centers between 2001 and 2020 were included and compared with healthy controls who underwent upper endoscopic screening. Clinical factors and laboratory data were analyzed to determine associated factors of GNET and DNET. RESULTS: Overall, 396 patients with GNET and 193 patients with DNET were included and compared with 1725 healthy controls. Multivariate analysis showed that age (odds ratio [OR] 0.98), diabetes (OR 1.72), hypertension (OR 1.97), low serum high-density lipoprotein cholesterol (HDL-C) levels (OR 2.54), and past/present H. pylori infection (OR 1.46) were significantly associated with GNET. In contrast, DNET was significantly associated with diabetes (OR 1.80), hypertension (OR 1.68), low serum HDL-C levels (OR 2.29), and past/present H. pylori infection (OR 5.42). In the sex-based subgroup analysis in GNET, current smoking was strongly associated in women (OR 9.85), but not in men. CONCLUSIONS: This study identified several common metabolic factors associated with GNET and DNET. Additionally, some factors had sex-specific associations.

Efficacy of direct-to-operating room trauma resuscitation: a systematic review.

BACKGROUND: Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility. METHODS: The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest. RESULTS: We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR. CONCLUSION: Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.

Case of Concomitant Endoscopic Treatment of Achalasia with Superficial Esophageal Cancer.

Achalasia, a rare motility disorder of the esophagus, is generally accepted as a premalignant disorder. This paper presents the case of a 72-year-old male with achalasia and synchronous superficial esophageal cancer who experienced dysphagia symptoms for five years. As achalasia is associated with an increased risk of esophageal cancer, both can be treated simultaneously if detected at the time of diagnosis. Achalasia and synchronous esophageal cancer are rarely detected and treated endoscopically. This paper reports a case of concurrent successful treatment.

Improvement of Severe Colon Stricture after Rituximab Therapy for Concomitant Mucosa-associated Lymphoid Tissue Lymphoma in a Patient with Ulcerative Colitis.

Colorectal strictures are uncommon in patients with ulcerative colitis (UC). An extranodal marginal zone B-cell lymphoma of mucosa- associated lymphoid tissue (MALT) lymphoma is rarely involved in the colon but may be associated with inflammatory bowel diseases. A 41-year-old female with a six-year history of UC presented with a severe stricture of the sigmoid colon that prevented the passage of a colonoscope. A histological examination revealed non-specific inflammation and fibrosis without dysplasia or cancer. Despite conventional treatment, including mesalazine and azathioprine for one year after that visit, the stricture persisted. In addition, diffuse, edematous exudative inflammation and multiple shallow ulcers were observed in the distal rectum, revealing a MALT lymphoma testing positive for CD20, CD43, CD5, and Bcl-2, but negative for CD3, CD10, CD23, and cyclin-D1. Four weekly doses of rituximab were administered. Follow-up colonoscopy performed one month after treatment revealed slight improvement in the rectal lesion without remnant histological evidence of a MALT lymphoma. In addition, the stricture showed marked improvement, and the colonoscope could pass easily through the stricture site. This is the first case report on an improvement of a severe sigmoid colon stricture in a patient with UC after rituximab treatment for a concomitant rectal MALT lymphoma.

Risk Factors and Management of Blunt Inferior Vena Cava Injury: A Retrospective Study.

BACKGROUND: Traumatic inferior vena cava (IVC) injuries are uncommon, but the mortality rate remains high at 38-70%. To date, most studies on traumatic IVC injuries have evaluated blunt rather than penetrating injuries. We aimed to identify the clinical features and risk factors that affect the prognosis of patients with blunt IVC injuries to improve treatment strategies for these patients. METHODS: We retrospectively analyzed patients diagnosed with blunt IVC injury over 8 years at a single trauma center. Clinical and biochemical parameters; transfusion, surgical, and resuscitation methods; associated injuries; intensive care unit stay; and complications data were compared between survival and death groups to identify clinical features and risk factors of blunt IVC injury-related mortality. RESULTS: Twenty-eight patients with blunt IVC injury were included during the study periods. Twenty-five (89%) patients underwent surgical treatment, and the mortality was 54%. The mortality rate according to the IVC injury location was the lowest for supra-hepatic IVC injury (25%, n = 2/8), whereas it was the highest for retrohepatic IVC injury (80%, n = 4/5). In the logistic regression analysis, Glasgow Coma Scale (GCS) (odds ratio [OR] = 0.566, 95% confidence interval [CI] [0.322-0.993], p = 0.047) and red blood cell (RBC) transfusion for 24 h (OR = 1.132, 95% CI [0.996-1.287], p = 0.058) were independent predictors for mortality. CONCLUSIONS: Low GCS score and high-volume packed RBC transfusion requirements for 24 h were significant predictors of mortality in patients with blunt IVC injuries. Unlike IVC injuries caused by penetrating trauma, supra-hepatic IVC injuries caused by blunt trauma have a good prognosis.

When should patients take simethicone orally before colonoscopy for avoiding bubbles: A single-blind, randomized controlled study.

BACKGROUND: Many studies have reported the use of simethicone before colonoscopy removes bubbles. However, guidelines weakly recommend simethicone administration before colonoscopy. The present study aimed to confirm the advantages of taking simethicone and determine the appropriate time for taking simethicone. METHODS: We randomly assigned patients to the following 5 groups according to the administration time: 4 groups were divided based on 2 parameters (the day before and on the day of colonoscopy and before and after bowel cleansing) and the remaining group was the control group. We compared bubble score (BS), number of simethicone solution irrigations when visually obscured, satisfaction score of the endoscopist, insertion time. RESULTS: A total of 204 patients were included in the study. There was a difference in BS according to the timing of simethicone administration (P < .001). The group taking simethicone on the day of the test had a better BS than the group taking simethicone the day before (P < .001). The group taking simethicone on the previous day had a better BS than the control group (P = .001). In the group of taking simethicone on the examination day, the number of irrigations was lower, and satisfaction with the inspector was higher than group of taking simethicone on previous day and control group (both P < .001). The insertion time showed a non-significantly decreasing trend (P = .417). CONCLUSION: Administering simethicone reduced bubbles and facilitated effective colonoscopy, especially when administrating it on the day of examination. It needs to be administered on the day of the examination regardless of bowel preparation.

Trauma system establishment and outcome improvement: a retrospective national cohort study in South Korea.

BACKGROUND: Trauma is a major cause of mortality, disability, and health care costs worldwide. The establishment of a trauma system is known to solve these problems, but few studies have objectively evaluated the impact of a trauma system on outcomes. Since 2012, South Korea has established a national trauma system based on the implementation of 17 regional trauma centers nationwide and the improvement of the prehospital transfer system. This study aimed to measure the changes in performance and outcome according to the established national trauma system. MATERIAL AND METHODS: In this national cohort-based, retrospective follow-up observational study, the authors calculated the preventable trauma death rate (PTDR) by conducting a multipanel review of patients who died in 2015, 2017, and 2019. Furthermore, the authors constructed a risk-adjusted mortality prediction model of 4 767 876 patients between 2015 and 2019 using the extended-International Classification of Disease Injury Severity Scores to compare outcomes. RESULTS: The PTDR was lower in 2019 than in 2015 (15.7 vs. 30.5, P <0.001) and 2017 (15.7 vs. 19.9%, P <0.001) representing 1247 additional lives saved in 2019 compared to that in 2015. In the risk-adjusted model, total trauma mortality was highest in 2015 at 0.56%, followed by that in 2016 and 2017 (0.50%), 2018 (0.51%), and 2019 (0.48%), revealing a significant decrease in mortality over the years ( P <0.001 for trend), representing nearly 800 additional lives saved. The number of deaths for more severe patients with a probability of survival less than 0.25 significantly decreased from 81.50% in 2015 to 66.17% in 2019 ( P <0.001). CONCLUSIONS: The authors observed a significant reduction in the PTDR and risk-adjusted trauma mortality in the 5-year follow-up since 2015 when the national trauma system was established. These findings could serve as a model for low-income and middle-income countries, where trauma systems are not yet established.

Deep-Learning for the Diagnosis of Esophageal Cancers and Precursor Lesions in Endoscopic Images: A Model Establishment and Nationwide Multicenter Performance Verification Study.

BACKGROUND: Suspicion of lesions and prediction of the histology of esophageal cancers or premalignant lesions in endoscopic images are not yet accurate. The local feature selection and optimization functions of the model enabled an accurate analysis of images in deep learning. OBJECTIVES: To establish a deep-learning model to diagnose esophageal cancers, precursor lesions, and non-neoplasms using endoscopic images. Additionally, a nationwide prospective multicenter performance verification was conducted to confirm the possibility of real-clinic application. METHODS: A total of 5162 white-light endoscopic images were used for the training and internal test of the model classifying esophageal cancers, dysplasias, and non-neoplasms. A no-code deep-learning tool was used for the establishment of the deep-learning model. Prospective multicenter external tests using 836 novel images from five hospitals were conducted. The primary performance metric was the external-test accuracy. An attention map was generated and analyzed to gain the explainability. RESULTS: The established model reached 95.6% (95% confidence interval: 94.2-97.0%) internal-test accuracy (precision: 78.0%, recall: 93.9%, F1 score: 85.2%). Regarding the external tests, the accuracy ranged from 90.0% to 95.8% (overall accuracy: 93.9%). There was no statistical difference in the number of correctly identified the region of interest for the external tests between the expert endoscopist and the established model using attention map analysis (P = 0.11). In terms of the dysplasia subgroup, the number of correctly identified regions of interest was higher in the deep-learning model than in the endoscopist group, although statistically insignificant (P = 0.48). CONCLUSIONS: We established a deep-learning model that accurately classifies esophageal cancers, precursor lesions, and non-neoplasms. This model confirmed the potential for generalizability through multicenter external tests and explainability through the attention map analysis.

Can the patient pinpoint where the ingested fish bone is impacted?: A single-center, retrospective study.

Among the plethora of foreign body impactions, fish bones are common examples that patients may struggle to properly disclose in clinical situations. This study investigated whether patients could pinpoint where the ingested fish bone was lodged. In addition, we investigated the differences between fish bone and other foreign bodies, the usefulness of computed tomography (CT), and the related risk factors for hospitalization. The cases of patients who underwent an endoscopic removal of fish bone between April 2008 and April 2020 were retrospectively reviewed. The clinical outcomes, X-ray scan, CT, and complications of each patient were investigated. A total of 96 patients were included in this study. The mean size of the impacted fish bone was 23.78 mm, and most were found in the upper esophagus (n = 38). There was a weak correlation between pain location and the actual lesion location (r = 0.419, P < .001). Compared to those of other foreign bodies, the location of impacted fish bones was different (P < .001), the X-ray detection rate of fish bones was lower (P < .001), and the complication incidence was higher (P = .030). CT (95.89%) showed higher sensitivity than X-ray scanning (11.24%) (P < .001). Foreign body size (P = .004) and door-to-endoscopy time (P = .029) were related to admission. Patients only managed to point out the approximate location of the ingested fish bone. CT detected fish bones well, but scans should include at least the entire esophagus instead of solely the area where pain is felt. Fish bone impaction has different clinical characteristics from other foreign bodies. Endoscopic removal without delay can reduce the admission rates.

Association between the Blautia/Bacteroides Ratio and Altered Body Mass Index after Bariatric Surgery.

BACKGRUOUND: Current evidence support that the gut microbiota plays a potential role in obesity. Bariatric surgery can reduce excess weight and decrease the risk of life-threatening weight-related health problems and may also influence gut microbiota. In this study, we aimed to investigate the changes in gut microbiota before and after bariatric surgery and evaluate the association of the gut microbial shift and altered body mass index (BMI) after bariatric surgery. METHODS: Between January 2019 and July 2020, stools from 58 patients scheduled for bariatric surgery were collected. Six months after bariatric surgery, stools from 22 of these patients were re-collected, and the changes in gut microbiota before and after bariatric surgery were evaluated. In addition, the differences in gut microbiota between patients with severe obesity (BMI >35 kg/m2, n=42) and healthy volunteers with normal BMI (18.8 to 22.8 kg/m2, n=41) were investigated. RESULTS: The gut microbiota of patients who underwent bariatric surgery showed increased α-diversity and differed ß-diversity compared with those before surgery. Interestingly, Blautia was decreased and Bacteriodes was increased at the genus level after bariatric surgery. Further, the Blautia/Bacteroides ratio showed a positive correlation with BMI. To validate these results, we compared the gut microbiota from severely obese patients with high BMI with those from healthy volunteers and demonstrated that the Blautia/Bacteroides ratio correlated positively with BMI. CONCLUSION: In the gut microbial analysis of patients who underwent bariatric surgery, we presented that the Blautia/Bacteroides ratio had changed after bariatric surgery and showed a positive correlation with BMI.

Colonoscopy Insertion in Patients with Gastrectomy: Does Position Impact Cecal Intubation Time?

BACKGROUND: A history of abdominal surgery is associated with difficulty in colonoscopy insertion. Few studies have reported effective colonoscopy insertion for patients who underwent abdominal surgery due to stomach cancer. AIM: We aimed to compare the impact of supine position (SP) and left lateral position (LLP) as the starting position of colonoscopy insertion in patients who underwent abdominal surgery due to stomach cancer. METHODS: This was a prospective, randomized controlled trial. Patients undergoing colonoscopy for screening or post-polypectomy surveillance after gastrectomy due to stomach cancer were enrolled and randomized to the SP or LLP group as the starting position of colonoscopy insertion. All colonoscopic examinations were performed with a transparent cap. The primary outcome was to compare the cecal intubation time between the two groups. RESULTS: A total of 224 patients were enrolled. The mean cecal intubation time was not significantly different between the SP and LLP groups (364.5 s versus 306.9 s; p = 0.105). In patients with a lower body mass index (< 21 kg/m2) or who underwent gastrectomy within three years, the mean cecal intubation time of the LLP group was shorter than the SP group. In the multivariate analysis for the factors affecting to increase in the cecal intubation time (> 5 min), the starting position was not an independent factor. CONCLUSION: Either the SP or LLP could serve as a possible starting position of colonoscopy insertion for patients who underwent abdominal surgery due to stomach cancer.

Improvement of mortality in severe liver injury after trauma center implementation: a propensity score matched study.

PURPOSE: To evaluate changes in the management and outcome of severe liver injury after trauma center implementation. METHODS: Trauma patients with severe liver injury (organ injury scale score ≥ 4) treated between January 2011 and December 2020 were retrospectively reviewed. A trauma center was built in 2016 at our institution, and patients were dichotomized into two groups: before trauma center (BTC) and after trauma center (ATC) group. Treatment methods and outcomes were compared between the groups with 1:1 propensity score matching. RESULTS: We included 50 patients in the BTC group and 104 patients in the ATC group. Patients in the ATC group had frequent utilization of angiography (16% vs 47.1%, p < 0.001), faster transfusion [84 (37-152) min vs 17 (10-79) min, p < 0.001], and less fluid administration within 24 h [8.3 (5.7-13.7) L vs 5.7 (3.1-10.1) L, p = 0.002]. However, mortality rate was not significantly different between the groups (26.0% vs 20.2%, p = 0.416). 1:1 propensity score matching was performed using the variables of age, injury severity score, systolic blood pressure, Glasgow Coma Scale, and initial base excess level. After matching, the mortality rate (26.0% vs 10.0%, p = 0.037) and ventilator application (74.0% vs 54.0%, p = 0.037) significantly improved. CONCLUSION: Severe liver injury management improved after trauma center implementation.

Helicobacter pylori infection and iron deficiency in non-elderly adults participating in a health check-up program.

BACKGROUND/AIMS: Helicobacter pylori infection is presumably associated with iron deficiency and iron deficiency anemia (IDA). This study aimed to evaluate the relationship between H. pylori infection and the decline in iron stores in non-elderly adults during their health check-ups. METHODS: We identified a total of 1,069 subjects who were tested for iron, ferritin, and total iron-binding capacity during their health check-ups, from January 2016 to May 2017. Of these, subjects who underwent endoscopy via rapid urease test and those aged 65 years or below were finally enrolled. RESULTS: Overall, 281 subjects were enrolled, and 187 patients (66.5%) tested positive for H. pylori. The mean age was 36.1 years (range, 22 to 65), and 176 subjects (62.6%) were male. The mean levels of hemoglobin (14.1 ± 1.7 g/dL vs. 14.6 ± 1.4 g/dL, p = 0.019) and ferritin (121.7 ± 106.9 ng/mL vs. 151.8 ± 107.8 ng/mL, p = 0.027) in the H. pylori-positive group were significantly lower than those in the H. pylori-negative group. Iron deficiency (ferritin < 30 ng/mL) was more common in patients with H. pylori infection (p = 0.002). There was no significant difference in anemia (hemoglobin < 13 g/dL in men, < 12 g/dL in women) or IDA (anemia, ferritin < 10 ng/mL, and transferrin saturation < 16%) with H. pylori. Logistic regression analysis demonstrated that female sex (odds ratio, 197.559; 95% confidence interval, 26.461 to 1,475.015) and H. pylori infection (odds ratio, 3.033; 95% confidence interval, 1.216 to 7.567) were factors associated with iron deficiency. CONCLUSION: H. pylori infection is associated with iron deficiency, suggesting a decline in iron stores among infected non-elderly adults.

Localized gastric amyloidosis successfully treated with endoscopic submucosal dissection: A case report.

RATIONALE: Amyloidosis is a general term that refers to the extracellular deposition of amyloid. The amyloid can also be deposited in a single organ. However, cases of localized gastric amyloidosis have rarely been reported. Here, we report a case of localized gastric amyloidosis that was successfully treated with endoscopic submucosal dissection. PATIENT CONCERN: A 60-years-old man underwent esophagogastroduodenoscopy as part of a regular check-up without any comorbidities or symptoms. DIAGNOSTICS: A 12 mm-sized, round, elevated lesion with a central depression, which was covered with normal mucosa, and located on the greater curvature of the lower body of the stomach was discovered during endoscopy. Subsequently, endoscopic ultrasonography was performed, which revealed a 11.7 mm-sized, hypoechoic, heterogeneous lesion located in the muscularis mucosa and submucosa. A biopsy was performed, and amyloid deposition was confirmed. Although other investigations for checking systemic amyloidosis were performed, there were no specific findings. Therefore, the final diagnosis was localized gastric amyloidosis. INTERVENTIONS: Endoscopic submucosal dissection was performed according to the patient's request and the lesion was completely removed. OUTCOMES: The patient was followed-up for 3 years without any recurrence. CONCLUSIONS: Endoscopic submucosal dissection can be good diagnostic and treatment option for localized gastric amyloidosis.

An Evaluation of the Effect of Performance Improvement and Patient Safety Program Implemented in a New Regional Trauma Center of Korea.

BACKGROUND: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. METHODS: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. RESULTS: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). CONCLUSION: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.

Low recurrence rate after endoscopic resection in non-ampullary duodenal lesions: A 16-year single-center retrospective study.

ABSTRACT: Endoscopic resection (ER) for non-ampullary duodenal lesions (NADLs) is technically more difficult than lesions of the stomach. However, endoscopic treatment of duodenal lesions has been increasingly performed in recent years. This study aimed to evaluate the efficacy and safety of ER for NADLs.Patients who underwent ER for NADLs between 2004 and 2019 were retrospectively reviewed. Clinical and pathologic features of the lesions including the clinical outcomes and adverse events were analyzed.The study included 80 patients with NADLs. The mean age of patients was 59.3 years (22-80 years), the mean size of the lesion was 8.8 ±â€Š7.0 mm, and the mean procedure time was 13.2 ±â€Š11.2 min. Half (40/80) of the lesions were in the duodenal bulb including the superior duodenal angle. Final histological data showed 56 adenomas (70.5%), 13 Brunner gland tumors (16.2%), and 4 pyloric gland tumors (5.0%). The final diagnoses of 5 lesions after ER showed higher-grade dysplasia compared to pre-ER biopsy findings. The en bloc resection rate was 93.8% (75/80), and the complete resection rate with clear margins was 90.0% (72/80). Micro-perforation occurred in 2 of 80 patients and was successfully treated with conservative treatment. There were no cases of delayed bleeding. The mean follow-up period was 27.0 months (2-119 months) with no cases of recurrence.ER may be an effective treatment for NADLs with favorable long-term outcomes. However, the possibility of perforation complications should always be considered during ER.