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.

Remission of diffuse ulcerative duodenitis in a patient with ulcerative colitis after infliximab therapy: a case study and review of the literature.

Although ulcerative colitis (UC) is confined to colonic and rectal mucosa in a continuous fashion, recent studies have also demonstrated the involvement of upper gastrointestinal tract as diagnostic endoscopy becomes more available and technically advanced. The pathogenesis of UC is not well established yet. It might be associated with an inappropriate response of host mucosal immune system to gut microflora. Although continuous and symmetric distribution of mucosal inflammation from rectum to colon is a typical pattern of UC, clinical feature and course of atypically distributed lesions in UC might also help us understand the pathogenesis of UC. Herein, we report a case of duodenal involvement of UC which successfully remitted after infliximab therapy. Endoscopic and pathologic findings before and after administration of anti-tumor necrosis factor suggest that the pathogenesis of upper gastrointestinal involvement of UC may be similar to that of colon involvement.

Endoscopist Fatigue May Contribute to a Decline in the Effectiveness of Screening Colonoscopy.

GOALS: To assess whether endoscopist fatigue adversely affects the adenoma detection rate (ADR) during screening colonoscopy. BACKGROUND: Endoscopist fatigue may affect the ADR during colonoscopy; however, this association has not been directly studied. STUDY: A prospective, multi-center study was performed on screening colonoscopies performed for asymptomatic subjects between March 2012 and December 2012 in Korea. Endoscopist fatigue was defined and measured by Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. The ADR was compared between fatigued endoscopists and nonfatigued endoscopists, and a multivariate regression analysis was performed to identify independent factors related to the detection of colorectal adenoma. RESULTS: During the study period, a total of 457 subjects underwent screening colonoscopy. After excluding 62 subjects, outcomes of 395 subjects were analyzed. The overall ADR of the study population was 39.7%. The mean score of FACIT-F was 36.4±10.8, and a cutoff score of 25 was chosen to define fatigue. The ADR was lower in fatigued endoscopists than nonfatigued endoscopists (25.0% vs. 42.6%, P=0.008). Using multivariate regression analysis, endoscopist fatigue measured with FACIT-F (odds ratio=3.585; 95% confidence interval, 1.663-7.728; P=0.001) was found to be an independent factor for the ADR. CONCLUSIONS: FACIT-F score may be a novel measure for endoscopist fatigue, and ADR was adversely influenced by endoscopist fatigue measured by FACIT-F. Our results suggest that endoscopist fatigue may contribute to a decline in the effectiveness of screening colonoscopy.

Double-balloon enteroscopy in elderly patients: is it safe and useful?

BACKGROUND/AIMS: Providers may be hesitant to perform double-balloon enteroscopy (DBE) in the elderly because the increased number of co-morbidities in this population poses a greater risk of complications resulting from sedation. There are limited data on the use of DBE in the elderly. Here, we assessed the safety and efficacy of DBE in the elderly compared to those in younger patients. METHODS: We retrospectively analyzed the medical records of 158 patients who underwent 218 DBEs. Patients were divided into an elderly group (age ≥65 years; mean 71.4±5.4; n=34; 41 DBEs) and a younger group (age <65 years; mean 39.5±13.5; n=124; 177 DBEs). RESULTS: In both groups, the most common indication for DBE was obscure gastrointestinal bleeding. Mucosal lesions (33.3% vs. 60.9%; P=0.002) were the most common finding in both groups, followed by tumors (30.8% vs. 14.1%; P=0.036). The elderly were more likely to receive interventional therapy (51.3% vs. 23.5%; P=0.001). The diagnostic yield of DBE was slightly higher in the elderly group (92.3% vs. 86.5%; P=0.422), but was not statistically significant. The therapeutic success rate of DBE was 100% in the elderly group compared to 87.5% in the younger group (P=0.536). The overall DBE complication rate was 1.8% overall, and this rate did not differ significantly between the groups (2.6% vs. 1.7%; P=0.548). CONCLUSIONS: DBE is safe and effective in the elderly, and has a high diagnostic yield and high therapeutic success rate.

Inter-observer agreement in the endoscopic classification of colorectal laterally spreading tumors: a multicenter study between experts and trainees.

BACKGROUND AND AIM: The risk of cancer varies with the subtype of colorectal "laterally spreading tumors" (LSTs). However, visual interpretations vary among endoscopists. The aim of this study was to evaluate inter-observer agreement and accuracy in the endoscopic classification of LST subtypes among experts and trainees. METHODS: In total, 40 LST images were collected and reviewed independently by 14 gastroenterology experts and 10 trainees. All investigators recorded their findings as one of the following four categories: homogeneous, nodular mixed, flat-elevated, and pseudo-depressed. Agreement was assessed in terms of the kappa (κ) statistic and AC1 estimate. Accuracy is reported as percentage agreement with the gold standard, based on the gross morphology of the resected specimens. RESULTS: Of the possible 91 pair-wise κ estimates among experts, 41 (45.1%) were >0.75, indicating excellent agreement, while only 2 (4.44%) of the 45 pair-wise κ estimates among trainees were >0.75. Agreements for individual LST subtypes in the trainee group were significantly lower than those in the expert group. The κ and AC1 estimates showed similar values in individual subtypes of LSTs. The overall accuracy of LST was also significantly higher for the experts than the trainees (85.9 vs. 72.5%, P < 0.001). Notably, the flat-elevated subtype showed the lowest agreement and accuracy and was frequently misclassified as the pseudo-depressed subtype by both groups. CONCLUSIONS: Inter-observer agreement and accuracy for LST subtype classification differ significantly between experts and trainees. Implementation of an adequate training system for beginners is necessary to better identify colorectal LSTs.

[Trends in the eradication rates of Helicobacter pylori infection in Daegu and Gyeongsangbuk-do, Korea: multicenter study over 13 years].

BACKGROUND/AIMS: The eradication rates of Helicobacter pylori infection have been reported to have decreased over the years due to antibiotics resistance. The aim of this study is to investigate the trend of eradication rates of first-line triple therapy for H. pylori over the past 13 year period, and to evaluate factors affecting H. pylori eradication in Daegu and Gyeongsangbuk-do, Korea. METHODS: A total of 2,982 patients with H. pylori infection who were treated with either 1 week or 2 weeks first-line therapy (proton pump inhibitor [PPI], amoxicillin, and clarithromycin) from January 1999 through December 2011 were included in this study. Data were collected by retrospectively reviewing the medical records. RESULTS: The overall H. pylori eradication rate was 87.2%. The eradication rates from 1999 to 2011 fluctuated between 78.0% and 95.7%, but no definite evidence of a decreasing tendency was seen over the 13 year period (p=0.113). Furthermore, there was no significant difference in the eradication rate according to the duration of therapy (p=0.592). However, there was a significant difference in the eradication rate among various PPIs (p<0.01). CONCLUSIONS: There was no decreasing trend in the H. pylori eradication rate over the past 13 years in Daegu and Gyeongsangbuk-do, Korea. There also was no difference in the eradication rates depending on duration of therapy. However, a significant difference was noted among various PPIs.

Prevalence of hepatitis-B viral markers in patients with inflammatory bowel disease in a hepatitis-B-endemic area: inadequate protective antibody levels in young patients.

BACKGROUND: There are few data regarding the prevalence of hepatitis-B virus (HBV) markers in inflammatory bowel disease (IBD) patients in Korea, which is a hepatitis-B-endemic area. The aim of this study was to assess the prevalence of HBV markers in IBD patients in comparison with controls. METHODS: We enrolled 513 IBD patients [241 Crohn's disease (CD) and 272 ulcerative colitis (UC)] whose hepatitis-B surface antigen and anti-HBs levels were evaluated. Anti-HBc was assayed in 357 patients. These markers were compared with those of 1020 sex-matched and age-matched controls. RESULTS: Prevalence of hepatitis-B surface antigen in IBD patients was 3.7% and there was no significant difference between groups (CD 4.1%, UC 3.3%, control 4.4%, P=0.713). The frequency of effective vaccination against HBV (positive anti-HBs, without anti-HBc) was lower in IBD patients less than 30 years old compared with the same-aged controls (CD 43.3%, UC 48.5%, control 61.9%, P=0.002), whereas there was no difference between groups in subjects more than 30 years old. One third of IBD patients were at risk of susceptibility to HBV infection (nonimmune), particularly those less than 30 years old, compared with controls of the same age (CD 43.3%, UC 36.4%, control 21%, P<0.001). In IBD patients, multivariate analysis identified that age less than 30 years was an independent risk factor for nonimmune status. CONCLUSIONS: IBD was not a risk factor for HBV infection even in endemic areas. However, many young IBD patients were susceptible to HBV infection. It is crucial to screen for HBV immunity and to implement a meticulous vaccination strategy for young Korean IBD patients.

Herpes simplex virus duodenitis accompanying Crohn's disease.

Herpes simplex virus (HSV) is a recognized cause of gastrointestinal infection in immunodeficient patients. Although a few cases of HSV gastritis and colitis in immunocompromised patients have been reported, there are no reports of HSV duodenitis in patients with Crohn's disease (CD). A 74-year-old female was admitted with general weakness and refractory epigastric pain. She had been diagnosed with CD three years ago. Esophagogastroduodenoscopy (EGD) revealed diffuse edematous and whitish mucosa with multiple erosions in the duodenum. Considering the possibility of viral co-infection, cytomegalovirus (CMV) immunohistochemical staining, PCR, and cultures of duodenal biopsies were performed, all of which were negative with the exception of the isolation of HSV in culture. After administration of intravenous acyclovir for 1 week, follow-up EGD showed almost complete resolution of the lesions and the patient's symptoms improved. In CD patients with refractory gastro-intestinal symptoms, HSV, as well as CMV, should be considered as a possible cause of infection, so that the diagnosis of viral infection is not delayed and the appropriate antiviral treatment can be initiated.

[Advanced neoplasm detection and its associated factors in colonoscopic surveillance of endoscopically resected early colorectal cancer].

BACKGROUND/AIMS: Early colon cancer can be effectively diagnosed and treated by colonoscopy, and surveillance colonoscopy is necessary to detect precursor lesions or new early colon cancer. We analyzed the surveillance results of patients with endoscopically resected early colon cancer to evaluate the detection rate of advanced neoplasia and its associated factors. METHODS: We conducted a retrospective study at Soonchunhyang University Seoul Hospital, from May 2003 to December 2011. Patients who underwent endoscopic resection for early colon cancer, showed mucosal and submucosal invasion on histopathologic examination, and received surveillance colonoscopy at least once were enrolled in the current study. Patients who underwent operation and those who were lost during surveillance period were excluded. RESULTS: Among a total of 305 patients diagnosed with early colon cancer, 211 patients met our inclusion criteria. Of these patients, 15 (7.1%) advanced neoplasias were detected at first colonoscopy. One hundred ninety-eight patients (93.8%) underwent surveillance colonoscopy within one year and 14 (7.0%) advanced neoplasias were detected in this group of patients. When patients with and without advanced neoplasia at first surveillance colonoscopy performed within one year were compared, inadequate bowel preparation (OR, 18.237; 95% CI, 3.741-88.895; p<0.001) and three or more colon polyps (OR, 9.479; 95% CI, 1.103-81.452; p=0.040) were significant risk factors for detecting advanced neoplasia. CONCLUSIONS: Considering the high detection rate of advanced neoplasia at first surveillance colonoscopy in patients with endoscopically resected early colon cancer, surveillance interval should be within one year, especially when the bowel preparation has been inadequate and three or more colon polyps have been detected.

Plasma levels of acylated ghrelin in patients with functional dyspepsia.

AIM: To investigate the relationship between plasma acylated ghrelin levels and the pathophysiology of functional dyspepsia. METHODS: Twenty-two female patients with functional dyspepsia and twelve healthy volunteers were recruited for the study. The functional dyspepsia patients were each diagnosed based on the Rome III criteria. Eligible patients completed a questionnaire concerning the severity of 10 symptoms. Plasma acylated ghrelin levels before and after a meal were determined in the study participants using a commercial human acylated enzyme immunoassay kit; electrogastrograms were performed for 50 min before and after a standardized 10-min meal containing 265 kcal. RESULTS: There were no significant differences in plasma acylated ghrelin levels between healthy volunteers and patients with functional dyspepsia. However, in patients with functional dyspepsia, there was a negative correlation between fasting plasma acylated ghrelin levels and the sum score of epigastric pain (r = -0.427, P = 0.047) and a positive correlation between the postprandial/fasting plasma acylated ghrelin ratio and the sum score of early satiety (r = 0.428, P =0.047). Additionally, there was a negative correlation between fasting acylated ghrelin plasma levels and fasting normogastria (%) (r = -0.522, P = 0.013). Interestingly, two functional dyspepsia patients showed paradoxically elevated plasma acylated ghrelin levels after the meal. CONCLUSION: Abnormal plasma acylated ghrelin levels before or after a meal may be related to several of the dyspeptic symptoms seen in patients with functional dyspepsia.

A case of intrapancreatic accessory spleen mistaken as a pancreatic mass due to different enhancing pattern from normal spleen.

Most cases of accessory spleen show similar features as normal spleen in imaging studies. However, some accessory spleen has unusual scan feature which can be misdiagnosed. We present a case of intrapancreatic accessory spleen that was discovered incidentally during a workup for abdominal pain in a 47-year-old woman. CT and MRI revealed a different enhancing pattern from that of the spleen. Further evaluation with endoscopic ultrasonography failed to identify the pancreatic mass. Therefore, it was surgically removed and diagnosed pathologically as an accessory spleen.

Appropriate indications for endoscopic submucosal dissection of early gastric cancer according to tumor size and histologic type.

BACKGROUND: Endoscopic submucosal dissection (ESD) is increasingly being performed for early gastric cancers (EGCs) that are larger than 2 cm and those that are not intestinal-type (IT) cancers by Lauren's classification. The technical feasibility of ESD for these EGCs has not been fully evaluated. OBJECTIVE: To identify appropriate expanded indications for ESD of EGC. DESIGN AND SETTING: A retrospective analysis of prospectively collected data was performed on consecutive patients who underwent ESD at a single tertiary center. PATIENTS AND METHODS: In total, 487 EGCs in 461 patients treated by ESD were classified by size and histologic type: IT EGCs 2 cm or less (257 lesions in 235 patients), IT EGCs larger than 2 cm (172 lesions in 168 patients), and non-IT EGCs (58 lesions in 58 patients). MAIN OUTCOME MEASUREMENTS: Curative resections were assessed among the 3 groups, and logistic regression analysis was used to analyze factors related to curative resection. RESULTS: The rates of curative resection significantly decreased from IT EGCs 2 cm or less (88.7%) to IT EGCs larger than 2 cm (73.3%) to non-IT EGCs (37.9%). Tumor size (>3 cm), ulceration, histologic type (non-IT), and piecemeal resection were independently unfavorable factors in curative resection. LIMITATIONS: Small sample size and short-term duration of follow-up study. CONCLUSIONS: ESD with curative intent is technically most feasible for nonulcerative and IT EGCs smaller than 3 cm.

A novel device for endoscopic submucosal dissection, the Fork knife.

AIM: To introduce and evaluate the efficacy and technical aspects of endoscopic submucosal dissection (ESD) using a novel device, the Fork knife. METHODS: From March 2004 to April 2008, ESD was performed on 265 gastric lesions using a Fork knife (Endo FS) (group A) and on 72 gastric lesions using a Flexknife (group B) at a single tertiary referral center. We retrospectively compared the endoscopic characteristics of the tumors, pathological findings, and sizes of the resected specimens. We also compared the en bloc resection rate, complete resection rate, complications, and procedure time between the two groups. RESULTS: The mean size of the resected specimens was 4.27 +/- 1.26 cm in group A and 4.29 +/- 1.48 cm in group B. The en bloc resection rate was 95.8% (254/265 lesions) in group A and 93.1% (67/72) in group B. Complete ESD without tumor cell invasion of the resected margin was obtained in 81.1% (215/265) of group A and in 73.6% (53/72) of group B. The perforation rate was 0.8% (2/265) in group A and 1.4% (1/72) in group B. The mean procedure time was 59.63 +/- 56.12 min in group A and 76.65 +/- 70.75 min in group B (P < 0.05). CONCLUSION: The Fork knife (Endo FS) is useful for clinical practice and has the advantage of reducing the procedure time.

[Significance of microsatellite instability in early gastric cancer treated by endoscopic submucosal dissection].

BACKGROUND/AIMS: Microsatellite instability (MSI) is defined as a change of any length due to either insertion or deletion of repeating units, in a microsatellite within a tumor when compared to normal tissue. MSI is closely related with genetic instability, particularly in hereditary nonpolyposis colorectal cancer. MSI is found in 10-50% of all gastric cancers, suggesting that MSI may play an important role in carcinogenesis. The aim of this study was to investigate the relationship between microsatellite instability and clinicopathologic features in early gastric cancers (EGCs) treated by endoscopic submucosal dissection (ESD). METHODS: We analyzed clinicopathological features of 95 specimens of EGCs including MSI, histologic type, mucin phenotype, p53, VEGF, location of cancer, depth of invasion, incidence of synchronous and metachronous cancer, age, and gender derived from 94 patients, treated by ESD during recent 19 months were analyzed in this study. RESULTS: According to microsatellite stability, MSI was observed in 13 (13.7%) cases of 95 specimens. The incidence of MSI was increased in patients with cancer at lower part of stomach and female gender. There was no significant relation between MSI and clinicopathologic features including histologic type, mucin phenotype, p53, VEGF, and depth of invasion. CONCLUSIONS: Our results demonstrate that there is no relationship between MSI and clinicopathologic features except tumor location and gender in ECGs treated by ESD. However, further studies are needed to evaluate the significance of MSI in EGCs.

Comparison of autofluorescence imaging endoscopic findings with pathologic findings after endoscopic submucosal dissection of gastric neoplasms.

BACKGROUND/AIMS: All epithelial cells emit autofluoresce, with tumor cells emitting weaker autofluorescence. We categorized patterns of autofluorescence imaging (AFI) and compared their clinical characteristics and pathology findings after endoscopic submucosal dissection. METHODS: Twenty patients were enrolled, comprising 4 adenomas and 16 early gastric cancers. AFI findings were classified as follows: G0 (well-defined pink lesion on a green background with a clear interface over >/=50% of its area), G1 (pink-green mottled lesion on a green background with a clear interface over <50% of its area), P1 (pink-green mottled lesion on a purple background with a clear interface over <50% of its area), and P2 (vague lesion on a purple background with a clear interface over

Outcome of photodynamic therapy for early esophageal cancer.

BACKGROUND/AIMS: Endoscopic treatment as an alternative to surgery has become increasingly popular for improving the quality of life. Although photodynamic therapy (PDT) has been used for the endoscopic treatment of digestive cancer, its curative efficacy remains unclear. We evaluated the curative efficacy of PDT in superficial esophageal cancer in inoperable patients. METHODS: Ten male patients with histologically proven early esophageal cancer (surgery was contraindicated for age > 80 years, surgery was contraindicated, Karnofsky performance status of at least 30%, or refusal of surgery) were intravenously injected with a hematoporphyrin derivative (2 mg/kg), and PDT was performed 48 h later. The response to treatment was assessed by gastroscopy with biopsies. RESULTS: The mean follow-up period was 27.6 months (range, 9.6-58.7 months). Endoscopic ultrasonography revealed that all ten cases were at tumor stage T1. Complete remission (CR) to initial and subsequent PDT was observed in all patients. For the CR cases, the recurrence rate was 10% (1/10) and the time from initial PDT to recurrence was 9.6 months. CONCLUSIONS: For patients in whom surgery is risky or refused, PDT may represent an acceptable alternative treatment modality, especially for superficial esophageal cancer without lymph node metastasis. However, a study involving long-term follow-up in a large population is needed for confirmation.

Synchronous early gastric cancer resembling submucosal tumor at the fundus.

Concern about detecting gastric carcinoma in its early stages has increased the incidence of detecting multiple synchronous gastric carcinomas. Although gastric carcinomas may present with various gross features, those showing the features of submucosal tumor (SMT) are rare. We report on a case of synchronous gastric carcinomas comprising one lesion with typical features of superficial early gastric carcinoma and the other with atypical features that mimicked SMT. Even though synchronous gastric carcinoma is rare, it may be worthwhile to make a pathological diagnosis of coexisting SMT using endoscopic-ultrasound-guided fine-needle aspiration or endoscopic mucosal resection.

[A case of chronic pouchitis resistant to medical treatment].

Pouchitis, a non-specific acute inflammation occurring in the ileal pouch, is one of the most common complications developed after the restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) performed for the treatment for the patients with ulcerative colitis and familial adenomatous polyposis. The prevalence of pouchitis is known to range from 20% to 50%. One to two percent of the cases are chronic and resistant to the drug therapy. The effective treatment for this chronic resistant pouchitis is to remove the ileal pouch and perform the permanent ileostomy. Hereby, we report one case of chronic pouchitis resistant to multiple drug therapy developed after IPAA performed for the treatment of ulcerative colitis in a patient.