Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy.

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Impact of Autoimmune Gastritis on Occurrence of Metachronous Gastric Neoplasms after Endoscopic Resection for Gastric Neoplasms.

Gastric cancer is the fifth most common cancer and the third leading cause of cancer-related deaths worldwide. Autoimmune gastritis (AIG) is characterized by antibody production against the gastric parietal cells, reducing the number of functional parietal cells. It is also associated with an increased susceptibility to gastric neuroendocrine tumors and gastric cancer. Endoscopic resection (ER) is an effective treatment for early gastric cancer; however, metachronous gastric neoplasms (MGN) can develop. This study aimed to evaluate the clinical effect of AIG on the occurrence of MGN after ER for gastric neoplasms. We retrospectively analyzed patients who underwent ER for gastric neoplasms. Patients with multiple lesions, recurrent lesions, or a history of partial gastrectomy were excluded. The presence of AIG was determined using anti-parietal cell antibody (APCA) testing. Follow-up endoscopy and metachronous tumor occurrence rates were compared between the AIG and non-AIG groups. Of the 569 patients, 282 underwent APCA testing and 20 (7.1%) were diagnosed with AIG. The incidence of MGN was significantly higher in the AIG group than in the non-AIG group (45.0% vs. 18.3%); however, the MGN occurrence pattern was similar between the two groups. Multivariate analysis revealed that AIG (HR 3.32, 95% CI 1.55-7.10, p = 0.002) and a higher body mass index (HR 1.16, 95% CI 1.06-1.27, p = 0.002) were independent factors significantly associated with the occurrence of MGN. Patients with AIG have a higher risk of metachronous lesion occurrence after ER for gastric neoplasms. Positive results of APCA testing have independent clinical implications for predicting MGN. Proper monitoring and management are essential for early detection and treatment of recurrent lesions in patients with AIG.

Rescue technique for self-expandable metallic stent placement using ultrathin endoscope after failure of the conventional method in patients with malignant colon obstruction: a multicenter retrospective study.

BACKGROUND AND AIMS: Self-expandable metallic stents (SEMS) can be used to treat malignant colorectal obstruction (MCO). Guidewire insertion to the proximal site of MCO is the most important step for SEMS placement. However, some patients cannot undergo guidewire insertion because of total obstruction or location at anatomically challenging areas. We report a guidewire insertion technique using an ultrathin endoscope (UTE) in patients with MCO in whom conventional SEMS insertion failed. METHODS: This study was a retrospective cohort study conducted at three academic centers in Korea. The medical records of 956 consecutive patients who underwent SEMS placement during 2012-2021 were analyzed. After failing guidewire insertion using a colonoscope, a UTE was inserted. Guidewire insertion was done through the working channel of the UTE. Following guidewire insertion, the endoscope was removed from the patient. While removing the endoscope, the guidewire was advanced to be located at the originally inserted site. Then, the colonoscope was inserted over the guidewire, and SEMS was replaced. RESULTS: Conventional SEMS insertion failed in 75 patients. Of these, guidewire insertion using a UTE was tried in 59 patients. The rate of technical success was 91.5% (54/59). Considering all patients, the overall technical success rate of SEMS placement was 97.8% (935/956). This technique increased the technical success rate by 5.6% among the total cohort. CONCLUSIONS: The UTE facilitated guidewire insertion and enhanced the overall success rate for SEMS placement. In addition, this technique can be used as a rescue method when guidewire insertion fails using a colonoscope.

Accuracy of Endoscopic Ultrasonography for Determining the Depth of Invasion in Early Gastric Cancer.

BACKGROUND: Accurate staging for depth of invasion (T stage) of early gastric cancer is critical for determining the treatment modality. Endoscopic ultrasonography is a reliable method for assessing the T stage. However, its diagnostic accuracy varies. The aim of this study is to investigate clinicopathologic factors affecting the diagnostic accuracy of endoscopic ultrasonography in early gastric cancer. METHODS: Patients with early gastric cancer who had undergone endoscopic resection or gastrectomy were included. The diagnostic accuracy of endoscopic ultrasonography was evaluated by comparing the T stage by endoscopic ultrasonography with histopathology of the resected specimen. Subgroup analysis was performed according to the endoscopic resection criteria. RESULTS: A total of 223 early gastric cancer lesions were included. The overall accuracy of endoscopic ultrasonography for T staging was 66.4%. The diagnostic accuracy for lesions ≤2 cm was significantly higher than for those of 2-3 cm (odds ratio 3.59) or those >3 cm (odds ratio 5.47). The diagnostic accuracy was significantly decreased in lesions with ulceration (odds ratio 2.62) or non-flat morphology (odds ratio 2.94). The accuracy of endoscopic ultrasonography for lesions corresponding to the absolute endoscopic resection criteria was significantly higher than for those corresponding to the expanded criteria (97.3% vs 71.9%, P = .002). Of the tumors that were overestimated by endoscopic ultrasonography treated with gastrectomy, 93.3% corresponded to the expanded criteria. CONCLUSION: Endoscopic ultrasonography had poor accuracy in early gastric cancer lesions larger than 2 cm, those with ulceration, and those with non-flat morphology, that is, lesions corresponding to the expanded criteria were more frequently overstaged by endoscopic ultrasonography. Such early gastric cancers should be carefully considered when staging by endoscopic ultrasonography before gastrectomy.

Comparison of 2 L Polyethylene Glycol Plus Ascorbic Acid and 4 L Polyethylene Glycol in Elderly Patients Aged 60-79: A Prospective Randomized Study.

BACKGROUND: The bowel-cleansing efficacy and safety of 2 L polyethylene glycol (PEG) with ascorbic acid (2L PEG + Asc) has rarely been studied in the elderly population. In this randomized trial, we compared the bowel cleanliness, safety, and tolerability of 2L PEG + Asc with those of 4 L PEG in an elderly population aged 60-79. METHODS: Study participants were randomized either to 2L PEG + Asc or 4L PEG. The primary endpoint was the success rate of bowel preparation, using the Boston Bowel Preparation Scale. Before colonoscopy, all participants were questioned about adverse events and tolerability regarding purgative ingestion. RESULTS: A total of 347 individuals were enrolled (2L PEG + Asc, 174; 4L PEG, 173). Mean age in the 2L PEG + Asc and the 4L PEG was 69.3 ± 5.6 and 69.3 ± 5.0, respectively (P = 0.917). The rate for successful bowel cleansing was comparable between the 2L PEG + Asc (92%) and the 4L PEG (96%, P = 0.118). Total ingested liquid including purgative and water was lower in the 2L PEG + Asc group (2.9 L) than in the 4L PEG group (4.2 L, P < 0.001). The tolerability of purgative was superior in the 2L PEG + Asc (overall satisfaction, P < 0.001; willingness to reuse, P < 0.001). There were no serious adverse events during the trial. CONCLUSIONS: The bowel-cleansing efficacy of 2L PEG + Asc was comparable to that of 4L PEG. Tolerability was superior in the 2L PEG + Asc group. For older people, 2L PEG + Asc is an efficacious and safe bowel cleanser. (Clinical trial registration number: KCT0004123).

Circumferential submucosal incision prior to endoscopic mucosal resection versus conventional endoscopic mucosal resection for colorectal lesions with endoscopic features of sessile serrated lesions.

BACKGROUND AND AIMS: Sessile serrated lesions (SSLs) are more prone to incomplete resection than conventional adenomas. This study evaluated whether circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) can increase the rate of complete and en bloc resections of colorectal lesions with endoscopic features of SSL. METHODS: Retrospective analyses and propensity score matching were performed for the resection of colorectal lesions ≥ 10 mm with endoscopic features of SSL. RESULTS: After 1:1 ratio matching, 127 lesions in the CSI-EMR group and 127 in the EMR group were selected for analysis. The median size of the lesions was 15 mm (IQR 12-16) in both groups. There was no significant difference in either the complete resection rate or en bloc resection rate between CSI-EMR and EMR groups (96.9% vs. 92.9%, P = 0.155; 92.1% vs. 89.0%, P = 0.391). By contrast, the R0 resection rate was significantly higher in the CSI-EMR group than in the EMR group (89.8% vs. 59.8%, P < 0.001). The median procedure time was significantly longer in the CSI-EMR group than in the EMR group (6.28 min vs. 2.55 min, P < 0.001), whereas there was no significant difference between the two groups in the incidence of adverse events or recurrence rate. Multivariate analysis showed that CSI-EMR was the only factor significantly associated with R0 resection (P < 0.001). CONCLUSIONS: For colorectal lesions with endoscopic features of SSL, CSI-EMR does not increase the complete or en bloc resection rate, but does increase the R0 resection rate. The procedure time is longer for CSI-EMR than EMR. The association of CSI-EMR with R0 resection and non-recurrence should be further evaluated.

Comparison of precutting endoscopic mucosal resection and endoscopic submucosal dissection for large (20-30 mm) flat colorectal lesions.

BACKGROUND AND AIM: The complete and safe removal of large (≥ 20 mm) colorectal lesions is an area of concern. Endoscopic submucosal dissection (ESD) effectively removes these lesions compared with endoscopic mucosal resection (EMR). However, ESD requires advanced techniques, longer procedure time, and high cost. Precutting EMR (EMR-P) is a modified EMR method that overcomes the limitations of EMR. This study aimed to compare the efficacy and safety of EMR-P and ESD in large (20-30 mm) flat colorectal lesions. METHODS: This was a retrospective analysis of cases in which 20- to 30-mm flat colorectal lesions were resected at Seoul St. Mary's Hospital from January 2014 to December 2019. Propensity score matching was performed to control for possible confounders. RESULTS: Two hundred and ninety-nine patients were included in this study. After matching, 90 patients were assigned to each group. There were no significant difference in complete resection rates (92.2% vs 92.2%, P = 1.000), en bloc resection rates (95.6% vs 97.8%, P = 0.682), and mean size of lesions (22.9 ± 3.1 mm vs 23.0 ± 3.1 mm, P = 0.867) between EMR-P and ESD. Procedure time was significantly shorter with EMR-P (11.0 ± 6.5 min vs 37.0 ± 19.3 min, P < 0.001). The adverse events rate was not significantly different between both groups. No local recurrence occurred in both groups. CONCLUSIONS: Precutting EMR was not significantly different to ESD in terms of complete resection rate and en bloc resection rate for 20- to 30-mm flat colorectal lesions without fibrosis. Furthermore, EMR-P has shorter procedure time than ESD. EMR-P could be considered one of standard treatments for large flat colorectal lesions.

Second-Line Bismuth-Containing Quadruple Therapy for Helicobacterpylori Infection: A 12-Year Study of Annual Eradication Rates.

BACKGROUND: Bismuth-containing quadruple therapy (BQT) consisting of a proton-pump inhibitor (PPI), bismuth, metronidazole and tetracycline is recommended as a second-line treatment for Helicobacter pylori (H. pylori) infection when PPI-based standard triple therapy (STT) consisting of a PPI, amoxicillin and clarithromycin is unsuccessful. The purpose of this study was to analyze the long-term results of BQT as a second-line therapy to determine its effectiveness. METHODS: This study included 643 subjects who failed first-line STT and received 7 or 10-14 days of BQT as a second-line therapy. We retrospectively analyzed the annual H. pylori eradication rates, demographic factors and adverse events. RESULTS: The overall eradication rates by intention-to-treat (ITT) and per-protocol (PP) analyses were 80.7% (519/643) and 93.3% (519/556), respectively. By PP analysis, the eradication rates for 2008-2011, 2012-2015, and 2016-2019 were 93.3%, 91.0%, and 96.4%, respectively (p = 0.145). There were no significant differences between the 7-day group and the 10-14-day group in both the ITT (79.7% vs. 86.0%, p = 0.148) and the PP analyses (92.7% vs. 96.6%, p = 0.187). A multivariate analysis showed that current smoking was associated with eradication failure. Eighty-nine subjects (16.0%) suffered adverse events, mainly gastrointestinal symptoms, but only six cases were severe. CONCLUSIONS: BQT as a second-line therapy is an effective treatment for H. pylori. Treatment for 10-14 days showed a higher eradication rate compared with a 7-day regimen, but not significantly.

Incomplete Removal of an Intrauterine Device Perforating the Sigmoid Colon.

Intrauterine devices (IUDs) are widely used for contraception in South Korea. However, several complications of IUDs have been reported, including inflammation, obstruction, perforation, and fistula. IUD perforation is the rarest of these complications but is also severe. Migrated IUDs can be retrieved through endoscopy, laparoscopy, or laparotomy. Presented below is an atypical case of an IUD perforating the sigmoid colon, which could not be removed endoscopically, and was subsequently incompletely removed through laparoscopic surgery. The present case underlines the importance of appropriate diagnosis and treatment approach in the management of IUD perforation.

Clinical Outcomes of Endoscopic Resection for Low-Grade Dysplasia and High-Grade Dysplasia on Gastric Pretreatment Biopsy: Korea ESD Study Group.

BACKGROUND/AIMS: Some cases of gastric low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on forceps biopsy (FB) are diagnosed as gastric cancer (GC) after endoscopic resection (ER). This study aims to evaluate the clinical outcomes of ER for gastric LGD and HGD on pretreatment FB and to identify the factors that predict pathologic upstaging to GC. METHODS: Patients who underwent ER for LGD and HGD on pretreatment FB from March 2005 to February 2018 in 14 hospitals in South Korea were enrolled, and the patients' medical records were reviewed retrospectively. RESULTS: This study included 2,150 cases of LGD and 1,534 cases of HGD diagnosed by pretreatment FB. In total, 589 of 2,150 LGDs (27.4%) were diagnosed as GC after ER. Helicobacter pylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration significantly predicted GC. A total of 1,115 out of 1,534 HGDs (72.7%) were diagnosed with GC after ER. Previous history of GC, H. pylori infection, smoking history, tumor location in the lower third of the stomach, tumor size >10 mm, depressed lesion, and ulceration were significantly associated with GC. As the number of risk factors predicting GC increased in both LGD and HGD on pretreatment FB, the rate of upstaging to GC after ER increased. CONCLUSIONS: A substantial proportion of LGDs and HGDs on pretreatment FB were diagnosed as GC after ER. Accurate ER procedures such as endoscopic submucosal dissection should be recommended in cases of LGD and HGD with factors predicting pathologic upstaging to GC.

Implementation effect of institutional policy of EGD observation time on neoplasm detection.

BACKGROUND AND AIMS: The observation time in EGD is associated with detection rate of premalignant or neoplastic lesions in the upper GI (UGI) tract. The aim of this study was to evaluate an institutional policy of EGD observation time on the detection rate of UGI neoplasms. METHODS: From July 2017 to March 2019, all endoscopists were requested to comply with our institutional policy of spending more than 3 minutes of observation time in every screening EGD. Observation time was defined as the time from when the endoscope reached the duodenum to when it was withdrawn. We obtained a neoplasm detection rate (NDR) during this period and compared it with that of a baseline period from 2009 to 2015. RESULTS: During the study period, 30,506 EGDs were performed. Mean subject age was 49.9 ± 10.5 years, and 56.5% were men. All endoscopists achieved an average EGD observation time of more than 3 minutes during this period. Mean observation time was 3:35 ± 0:50, which was significantly longer than the baseline (2:38 ± 0:21, P < .001). NDR was .33%, which was higher than the baseline (.23%, P < .001). Even after adjusting for subjects' age and gender, smoking history, and endoscopists' biopsy sampling rate, prolonged EGD observation time of more than 3 minutes increased the NDR of UGI neoplasms (odds ratio, 1.51; 95% confidence interval, 1.21-1.75). CONCLUSIONS: This study provides evidence that implementing a protocol of a prolonged observation time could increase NDR. Observation time should be an important quality indicator of the EGD examination.

Increased incidence of metachronous gastric neoplasm after endoscopic resection in patients with synchronous gastric neoplasm.

BACKGROUND: Recurrence risk is a major concern after endoscopic resection (ER) of gastric neoplasms. This study was to compare metachronous risk in patients with and without synchronous neoplasms after complete ER. METHODS: After ER for gastric neoplasms, patients were divided into those with and without synchronous neoplasm. The metachronous risk of gastric neoplasms was compared between the two groups. RESULTS: After ER of 678 cancers and 891 adenomas, synchronous neoplasm was found in 11.8% of cancers and 11.4% of adenomas. In the multiple (n = 182) and the single group (n = 1387), metachronous neoplasms occurred in 18.1 and 8.6%, respectively (HR 2.40; 95% CI, 1.62-3.34). When the pathology of the recurred lesion was limited to cancer, metachronous risk was also significantly higher in the multiple than in the single group (HR, 2.2; 95% CI, 1.17-3.85). In the recurred pathology of the multiple group, cancer development was frequently observed in patients with cancer compared to those with only adenomas in the synchronous lesion (67.0% vs. 13.0%, respectively; P = 0.023). CONCLUSIONS: This study demonstrated that metachronous risk was significantly higher in patients with synchronous gastric neoplasms after ER. Therefore, meticulous examination is important in patients with synchronous neoplasm.

2019 Seoul Consensus on Esophageal Achalasia Guidelines.

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Mutation Analysis of Colorectal and Gastric Carcinomas Originating from Adenomas: Insights into Genomic Evolution Associated with Malignant Progression.

Small malignant tumor foci arising from benign lesions are rare but offer a unique opportunity to investigate the genomic evolution that occurs during malignant transformation. In this study, we analyzed 11 colorectal and 10 gastric adenoma-carcinoma pairs, each of which represented malignant tumors (carcinomas) embedded in benign lesions (adenomas) found in the same patient. Whole-exome sequencing revealed that mutation abundance was variable across different cases, but comparable between adenoma-carcinoma pairs. When mutations were classified as adenoma-specific, carcinoma-specific, or common, adenoma-specific mutations were more enriched with subclonal mutations than were carcinoma-specific mutations, indicative of a perturbation in mutational subclonal architecture (such as selective sweep) during malignant transformation. Among the recurrent mutations in colorectal cancers, APC and KRAS mutations were common between adenomas and carcinomas, indicative of their early occurrence during genomic evolution. TP53 mutations were often observed as adenoma-specific and therefore likely not associated with the emergence of malignant clones. Clonality-based enrichment analysis revealed that subclonal mutations of extracellular matrix genes in adenomas are more likely to be clonal in carcinomas, indicating potential roles for these genes in malignant transformation. Compared with colorectal cancers, gastric cancers showed more lesion-specific mutations than common mutations and higher levels of discordance in copy number profiles between matched adenomas and carcinomas, which may explain the elevated evolutionary dynamics and heterogeneity of gastric cancers compared to colorectal cancers. Taken together, this study demonstrates that co-existing benign and malignant lesions enable the evolution-based categorization of genomic alterations that may reveal clinically important biomarkers in colorectal and gastric cancers.

Bleeding after Endoscopic Resection in Patients with End-Stage Renal Disease on Dialysis: A Multicenter Propensity Score-Matched Analysis.

BACKGROUND/AIMS: Frequent bleeding after endoscopic resection (ER) has been reported in patients with end-stage renal disease (ESRD). We aimed to evaluate the association and clinical significance of bleeding with ER in ESRD patients on dialysis. METHODS: Between February 2008 and December 2018, 7,571 patients, including 47 ESRD patients on dialysis who underwent ER for gastric neoplasia, were enrolled. A total of 47 ESRDpatients on dialysis were propensity score-matched 1:10 to 470 non-ESRD patients, to adjust for between-group differences in variables such as age, sex, comorbidities, anticoagulation use, tumor characteristics, and ER method. Matching was performed using an optimal matching algorithm. For the matched data, clustered comparisons were performed using the generalized estimating equation method. Medical records were retrospectively reviewed. Frequency and outcomes of post-ER bleeding were evaluated. RESULTS: Bleeding was more frequent in the ESRD with dialysis group than in the non-ESRD group. ESRD with dialysis conferred a significant risk of post-ER bleeding (odds ratio, 6.1; 95% confidence interval, 2.7-13.6; p<0.0001). All post-ER bleeding events were controlled using endoscopic hemostasis except in 1 non-ESRD case that needed surgery. CONCLUSION: ESRD with dialysis confers a bleeding risk after ER. However, all bleeding events could be managed endoscopically without sequelae. Concern about bleeding should not stop endoscopists from performing ER in ESRD patients on dialysis.

Comparative efficacy of per-oral endoscopic myotomy and Heller myotomy in patients with achalasia: a meta-analysis.

BACKGROUND AND AIMS: Although both per-oral endoscopic myotomy (POEM) and Heller myotomy (HM) have been used for the treatment of achalasia, the comparative efficacy of POEM and HM has yet to be fully evaluated. METHODS: We searched all relevant studies published up to September 2018 examining the comparative efficacy between POEM and HM. Study quality was assessed using the Newcastle-Ottawa scale. Meta-analyses for Eckardt scores, perioperative outcomes, and reflux-related outcomes were performed based on a random-effects model. RESULTS: Fifteen studies with a total of 1213 patients were evaluated. The follow-up duration ranged from 2 to 46.2 months and from 2 to 54.2 months in the POEM and HM groups, respectively. Postoperative Eckardt scores were lower (better) in the POEM group than in the HM group (pooled standardized mean difference [SMD], -0.58; 95% confidence interval [CI], -1.03 to -0.13). Length of myotomy was greater in the POEM group than in the HM group (pooled SMD, 0.63; 95% CI, 0.42-0.84). There was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups (pooled risk ratio [RR], 1.03; 95% CI, 0.61-1.73; and pooled RR, 1.22; 95% CI, 0.67-2.25, respectively). Erosive esophagitis on endoscopy tended to be less common in the HM group (pooled RR, 1.88; 95% CI, 0.98-3.62). CONCLUSION: Although long-term follow-up data are insufficient, the short-term efficacy of POEM was superior to that of HM. Erosive esophagitis tended to be more common in the POEM group; however, there was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups.

An Operable, Portable, and Disposable Ultrathin Endoscope for Evaluation of the Upper Gastrointestinal Tract.

BACKGROUND AND AIMS: A prototype of a disposable endoscope (DE) with easy viewing of the esophagus has been developed. The aim of this study was to develop a new version of DE with improved functionality and to assess the feasibility of DE as a screening tool for upper gastrointestinal diseases compared with conventional endoscopes. METHODS: Diagnostic accuracy and maneuverability of DE were evaluated by comparing endoscopy using DE with conventional endoscopy. Different examiners performed DE endoscopy and conventional endoscopy in a randomized order, blinded to the results. Examiners were asked to respond to a questionnaire about ease of handling and observation using DE in preformed result sheets. Tolerability of DE was also evaluated. Non-sedated participants were asked to respond to a questionnaire about the convenience and satisfaction with DE endoscopy on a nine-point Likert scale. RESULTS: The overall ease of insertion and handling of DE was excellent. The new device enabled observation and evaluation of the entire esophagus with a good agreement between DE endoscopy and conventional endoscopy in terms of endoscopic diagnosis (Kappa value; hiatal hernia; 0.910, reflux esophagitis; 0.949, Barrett's esophagus, 1.000). Participants suggested that they were more comfortable with DE endoscopy than with conventional endoscopy with a lower symptom score (p = 0.030). CONCLUSION: The new DE enabled easy observation of the entire esophagus owing to its improved maneuverability, and its diagnostic ability of esophageal diseases was comparable to that of conventional endoscopes. Non-sedated esophagoscopy with this disposable device potentially has widespread applications in outpatient clinics and areas without endoscopic facilities.

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

BACKGROUND: Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. METHODS: Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6 days (range 1-30 days), and median duration of hospitalization was 13 days (range 3-135 days). At the follow-up (mean 24.6 months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. CONCLUSIONS: Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

The effect of photo-documentation of the ampulla on neoplasm detection rate during esophagogastroduodenoscopy.

BACKGROUND: A few studies have investigated quality indicators of esophagogastroduodenoscopy (EGD) for identifying upper gastrointestinal (GI) malignancy. The current study aimed to evaluate whether the rate of ampulla photo-documentation could be associated with the detection of upper GI neoplasms. METHODS: We used data from 111 962 asymptomatic patients who underwent EGD performed by 14 endoscopists at a health promotion center. The rate of ampulla photo-documentation was calculated by reviewing EGD photos archived during each endoscopist's first year of working at the center. The detection of neoplasms during a 7-year period was investigated. We examined the association between the rate of ampulla photo-documentation and the rate of neoplasm detection. RESULTS: The mean rate of ampulla photo-documentation was 49.0 % (range 13.7 % - 78.1 %) during endoscopists' first year of working at the center. Endoscopists' rates of ampulla photo-documentation significantly correlated with the detection of total neoplasms (R2 = 0.57, P = 0.03) and small neoplasms (R2 = 0.58, P = 0.03). There was a significant difference in the detection rates of upper GI neoplasms between high (n = 7) and low (n = 7) ampulla observers (odds ratio [OR] 1.31, 95 % confidence interval [CI] 1.03 - 1.68; P = 0.03). The ampulla photo-documentation rate of each endoscopist significantly correlated with the examination time for a normal EGD (R2 = 0.55; P = 0.04). In multivariate analysis, high ampulla photo-documentation rate was a predictor of neoplasm detection (OR 1.33, 95 %CI 1.03 - 1.70). CONCLUSIONS: The ampulla photo-documentation rate was significantly associated with the detection rate for both total and small upper GI neoplasms. Ampulla photo-documentation should be considered as a quality indicator of EGD.