A randomized trial to determine the diagnostic accuracy of conventional vs. jumbo forceps biopsy of gastric epithelial neoplasias before endoscopic submucosal dissection; open-label study.

BACKGROUND AND AIMS: Larger biopsy specimens or increasing the number of biopsies may improve the diagnostic accuracy of gastric epithelial neoplasia (GEN). The aims of this study was to compare the diagnostic accuracies between conventional and jumbo forceps biopsy of GEN before endoscopic submucosal dissection (ESD) and to confirm that increasing the number of biopsies is useful for the diagnosis of GEN. RESULTS: The concordance rate between EFB and ESD specimens was not significantly different between the two groups [83.1 % (54/65) in JG vs. 79.1 % (53/67) in CG]. On multivariate analyses, two or four EFBs significantly increased the cumulating concordance rate [coefficients; twice: 5.1 (P = 0.01), four times: 5.9 (P = 0.02)]. But, the concordance rate was decreased in high grade dysplasia (coefficient -40.32, P = 0.006). PATIENTS AND METHODS: One hundred and sixty GENs from 148 patients were randomized into two groups and finally 67 GENs in 61 patients and 65 GENs in 63 patients were allocated to the conventional group (CG) or jumbo group (JG), respectively. Four endoscopic forceps biopsy (EFB) specimens were obtained from each lesion with conventional (6.8 mm) forceps or jumbo (8 mm) forceps. The histological concordance rate between 4 EFB specimens and ESD specimens was investigated in the two groups. CONCLUSIONS: Before ESD, the diagnostic accuracy of GENs was significantly increased not by the use of jumbo forceps biopsy but by increasing the number of biopsies.

Second-look endoscopy is not associated with better clinical outcomes after gastric endoscopic submucosal dissection: a prospective, randomized, clinical trial analyzed on an as-treated basis.

BACKGROUND: The efficacy of routine second-look endoscopy (SLE) to detect or prevent bleeding after gastric endoscopic submucosal dissection (ESD) has not yet been validated. OBJECTIVE: The aim of this study was to determine whether SLE affects clinical outcomes including bleeding and morbidity after gastric ESD. DESIGN: A prospective, randomized, controlled study with consecutive data analyzed on an as-treated basis. SETTING: A single, tertiary-care referral center. PATIENTS: A total of 182 patients. INTERVENTION: Gastric ESD and SLE. MAIN OUTCOME MEASUREMENTS: Incidence of and risk factors related to bleeding after ESD and outcomes by univariate or multivariate analysis. RESULTS: Among 182 patients enrolled, 74 and 81 patients were assigned to the SLE and no-SLE groups, respectively. Two groups were observed closely for 4 weeks. Bleeding occurred after ESD in 21 patients (13.5%). Hemoglobin loss (≥2.0 g/dL) was observed in 20 patients, and melena developed in 1 patient after ESD. However, only 1 patient needed a transfusion. Twelve patients (16.2%) in the SLE group and 9 in the no-SLE group (11.1%) experienced bleeding after ESD. The frequency of bleeding after ESD was not significantly different between the 2 groups (P = .66). There were no risk factors related to bleeding after ESD. LIMITATIONS: Single-center analysis. CONCLUSION: SLE is not routinely necessary because it does not affect clinical outcomes, including bleeding and morbidity after ESD. ( CLINICAL TRIAL REGISTRATION NUMBER: KCT0000146.).

Increasing incidence of inflammatory bowel disease among young men in Korea between 2003 and 2008.

BACKGROUND AND AIMS: Temporal trends in incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) can provide valuable clues about etiology. Korea has a draft system, and every male must fulfill his military service. However, according to military rules, patients with CD and UC are not conscripted into the army, and when the disease is diagnosed during military service, patients are relieved from military duties. Such policies provide a unique opportunity to determine the incidence of CD and UC among young men in Korea. We studied the incidence of CD and UC over time in Korea, a rapidly developing country. METHODS: The Armed Forces Medical Command of the Republic of Korea Army provided lists of members who were relieved from military duties due to diagnoses of CD and UC between 2003 and 2008. RESULTS: During this 6-year period, there were 96 incident cases of CD and 104 incident cases of UC. For the 6-year period, the adjusted mean annual incidence rates of CD and UC per 100,000 persons were 3.2 and 3.5, respectively. When analyzed by 2-year intervals, the mean annual incidence of CD and UC increased, from 1.8 and 1.7 per 100,000 persons in 2003-2004, to 2.7 and 3.3 per 100,000 persons in 2005-2006, and to 5.1 and 5.4 per 100,000 persons in 2007-2008, respectively. CONCLUSIONS: Incidence of CD and UC among young men is rapidly increasing in Korea, which strongly suggests an environmental contribution to the disease.

Bupivacaine induced cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction.

Bupivacaine is widely used as a local anesthetic. Central nervous system (CNS) and cardiovascular toxicity are well known side effects. However, there has been no report of bupivacaine-induced myocardial injury. We present a case of bupivacaine cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction, which was eventually diagnosed as bupivacaine-induced cardiac toxicity without CNS toxicity. As soon as a healthy young woman at a private clinic was given a spinal anesthesia of 6mg bupivacaine for hemorrhoidectomy, she developed arrhythmia and hypotension. She was transferred to our emergency room. There was an accelerated idioventricular rhythm with ST segment depression on electrocardiogram, coarse breathing sounds with rales on whole lung field and a butterfly sign on the chest radiograph. 2D transthoracic echocardiography (TTE) revealed reduced left ventricle systolic ejection fraction (approximately 27%). There was regional wall motion abnormality of the left ventricle on 2D TTE and the cardiac marker was increased. We diagnosed the patient as having acute non-ST segment elevation myocardial infarction but her impaired cardiac function improved gradually. On the seventh day from admission, there was a complete spontaneous recovery of cardiac function, and coronary angiography revealed a normal coronary artery. Therefore, we firmly believe that bupivacaine directly injures the cardiac cell.

Is microsatellite instability (MSI) associated with multiplicity in early stage gastric neoplasias?

BACKGROUND/AIMS: The aim of this study was to investigate the relationship between microsatellite instability (MSI) and clinicopathologic features including multiplicity in early stage gastric neoplasias (ESGN). METHODS: From November 2004 until September 2009, 372 patients with consecutive resected gastric neoplasias were retrospectively enrolled. The gastric neoplasias were composed of 117 advanced gastric cancers (AGCs) and 255 ESGNs including 31 gastric dysplasias (including low and high grade dysplasia) and 224 early gastric cancers (EGCs). RESULTS: Based on microsatellite markers, high MSI (MSI-H) was observed in 61 cases (16.4%) and low MSI (MSI-L) in 14 cases (3.8%) of 372 cases. There was a positive correlation between the presence of MSI-H and progression of gastric adenoma to gastric tumor. We compared ESGNs with microsatellite stable (MSS; 223 cases, 87.5%) and ESGNs with MSI-H (24 cases, 9.4%). The ESGNs with MSI-H were only associated with older age and female gender. There were no association with Helicobacter pylori infection, intestinal metaplasia, and distal location in contrast with EGCs with MSI-H. Furthermore, multiplicity of ESGNs was not associated with MSI status. CONCLUSIONS: The clinicopatholgic features of MSI-H phenotype were different according to the progression of gastric neoplasias from ESGNs to AGCs. ESGNs with MSI-H were only associated with old age, female sex. In addition ESGNs with MSI-H were not associated with an increased risk of multifocal tumors.