Efficacy and safety of 1 L polyethylene glycol plus ascorbic acid for bowel preparation in elderly: comparison with oral sulfate solution.

BACKGROUND/AIMS: Recently, 1 L of polyethylene glycol (PEG) plus ascorbic acid (Asc) has been introduced in Korea as a colonoscopy preparation agent. Data on its efficacy and safety in older adults have been limited. We aimed to evaluate the safety and efficacy of 1 L PEG/Asc in older adults by comparing it with oral sulfate solution (OSS). METHODS: A prospective multicenter randomized study was conducted with subjects aged ≥ 65 years who underwent colonoscopy. The participants were randomized to receive 1 L PEG/Asc or OSS. The primary endpoint was successful bowel preparation, defined as total Boston Bowel Preparation Scale ≥ 6, and ≥ 2 at each segment. Patient satisfaction, adverse events, and renal function changes were compared between the groups. RESULTS: Among the 106 patients, 104 were finally included in the analysis. Overall, successful bowel preparation was achieved in 96.2% of both 1 L PEG/Asc and OSS groups. The satisfaction scores for taste, total amount ingested, overall feeling, and willingness to repeat the same regimen were not significantly different between the groups. Adverse events of moderate or higher severity occurred in 16 and 10 cases in the 1 L PEG/Asc and OSS group, respectively. There were no significant changes in electrolyte levels or renal function from baseline. CONCLUSION: The successful bowel preparation rate was > 90% in both groups without severe adverse effects and significant changes in renal function. As a new low-dose preparation regimen for colonoscopy in older adults, 1 L PEG/Asc, is as effective and safe as OSS.

Efficacy, safety and tolerability of oral sulphate tablet for bowel preparation in patients with inflammatory bowel disease: A multicentre randomized controlled study.

BACKGROUND AND AIMS: We evaluated the efficacy, safety and tolerability of novel oral sulphate tablets [OSTs] vs 2 L of polyethylene glycol and ascorbate [PEG/Asc] in patients with inflammatory bowel disease [IBD]. PATIENTS AND METHODS: A total of 110 patients with clinically inactive IBD were enrolled in this single-blind multicentre non-inferiority study. Patients were randomly assigned to the OST or 2 L PEG/Asc group and we applied a split-dose regimen. The primary efficacy endpoint was bowel cleansing success rate defined as Harefield Cleansing Scale Grade A or B. The secondary endpoints were perfect preparation rate, the presence of air bubbles, safety as assessed by laboratory abnormalities and self-reported adverse events, or IBD symptom flare-ups. Tolerability was assessed by a pre-procedural visual analog scale [VAS] interview. RESULTS: Both groups showed high cleansing success rates [98.1%] and there was no significant difference in perfect preparation rate. The proportion of a bubble score 0 was significantly higher in the OST group [94.5% vs 50.0%, p < 0.001]. There was no significant intergroup difference in vomiting or bloating. Symptom flare-ups occurred in two OST group patients. No clinically significant blood test abnormalities were noted in either group. Ease of ingestion and taste scores were significantly higher in the OST group. More patients in the OST group [94.5%] wanted to take the same preparation agent for their next colonoscopy. CONCLUSIONS: Both OST and 2 L PEG/Asc demonstrated high successful cleansing and safety in patients with inactive IBD. OST achieved higher satisfaction than 2 L PEG/Asc. Our results suggest that the OST split-dose regimen is effective and safe for patients with inactive IBD.

Low Bone Mineral Density in Young Patients Newly Diagnosed with Inflammatory Bowel Disease.

BACKGROUND: The prevalence and risk factors of low bone mineral density (BMD) in Asian patients newly diagnosed with inflammatory bowel disease (IBD) have not been fully suggested. AIMS: We aimed to examine the prevalence and risk factors of low BMD in young Korean patients newly diagnosed with IBD. METHODS: We prospectively enrolled 132 patients aged less than 50 years and newly diagnosed with IBD from six tertiary referral centers in Korea between November 2014 and April 2017. BMD was measured by dual-energy X-ray absorptiometry, and then the Z-score was determined. We defined low BMD as a Z-score ≤ - 1.0. RESULTS: Of 68 patients with ulcerative colitis (UC), 22 (32.4%) had low BMD. Also, of 64 patients with Crohn's disease (CD), 24 (37.5%) showed low BMD. Results from multivariate regression analysis identified the risk factors for low BMD as a high level of alkaline phosphatase (ALP) (≥ 140 U/L) (P = 0.010) in UC patients, and being underweight (body mass index ≤ 18.5 kg/m2) (P = 0.017) in CD patients. CONCLUSIONS: Our study showed that about one-third of newly diagnosed IBD Asian patients had low BMD. The clinical factors associated with low BMD were a high level of ALP in UC patients, and being underweight, in CD patients. Therefore, measurements of BMD in young patients should be considered at the diagnosis of IBD.

Comparison of different types of covered self-expandable metal stents for malignant colorectal obstruction.

BACKGROUND: Stent migration is one of the main drawbacks of covered self-expandable metal stent (SEMSs), occurring in up to 40% of malignant colorectal obstruction management cases. Various types of covered SEMSs have been developed to reduce this risk. We aimed to compare the effectiveness and complication rates of the flare-type covered SEMS (Flare) with those of the double-layered covered SEMS (ComVi). METHODS: We performed a prospective, randomized study in four tertiary referral centers between July 2016 and April 2018. Patients with malignant colorectal obstruction were eligible for the study. The primary outcome was migration rate as observed within the first month. Rates of technical success, clinical success, and complications within the first month were also assessed. RESULTS: A total of 60 patients were included (mean age, 70.5 ± 12.5 years; male, 31 [51.7%]). Flare and ComVi stents were applied in 30 patients each. The Flare and ComVi groups showed comparable technical success rates (90% [27/30] vs. 96.7% [29/30], p = 0.605) and clinical success rates (85.2% [23/27] vs. 75.9% [22/29], p = 0.589). Migration occurred in three (11.1%) and four (13.8%) cases in the Flare and ComVi groups, respectively, without significant difference (p = 0.99), and the risk of other complications, including perforation and re-obstruction, did not differ between the two groups. CONCLUSIONS: Our study indicates that both flare-shape and double-layered covered SEMSs are equally effective options for the management of malignant colorectal obstruction with low migration rates when compared with previously reported migration risk of covered SEMS.

Fecal calprotectin is more accurate than fecal immunochemical test for predicting mucosal healing in quiescent ulcerative colitis: a prospective multicenter study.

Objective: Non-invasive stool tests, including the fecal immunochemical test (FIT) and fecal calprotectin (FC), are reliable biomarkers for mucosal healing (MH) in ulcerative colitis (UC). However, which fecal test is superior for predicting MH in inactive UC patients requires evaluation. We aimed to compare the accuracy of FIT and FC results for predicting MH in quiescent UC patients.Methods: This prospective, multicenter study was conducted at three tertiary hospitals. UC patients in clinical remission for at least three months underwent colonoscopy and MH was evaluated using the Mayo endoscopic sub-score (MES). The receiver operating characteristic (ROC) curve and cutoff value with the best accuracy for predicting MH were assessed.Results: Among 127 patients, 65 (51.2%) showed MH (MES = 0). The area under the curve (AUC) for predicting MH (MES = 0) was significantly higher for FC than for FIT (AUC 0.858 (95% confidence interval (CI) 0.784-0.913) vs. 0.707 (95% CI 0.620-0.784), p < .001); there was no difference when MH included MES = 1 (MES ≤ 1) (AUC 0.820 (95% CI 0.742-0.883) vs. 0.813 (95% CI 0.734-0.877), p = .891). When the cutoff value was 70 µg/g for FC and 10 ng/mL for FIT, the sensitivity, specificity, positive predictive value and negative predictive value were 89.2, 71, 76.3, and 86.3, respectively, for FC and 92.3, 50, 65.9, and 86.1, respectively, for FIT.Conclusion: FC is more accurate than FIT for predicting MH in quiescent UC patients. The superiority of FC might be related to the distinctive performance of FC in differentiating inflammatory levels, particularly in low-grade mucosal activity.

Impact of Education on School Nurses' Knowledge of Inflammatory Bowel Disease.

Background/Aims: School nurses' knowledge of inflammatory bowel disease (IBD) has not been evaluated. We aimed to investigate school nurses' knowledge of IBD and determine whether education could improve this knowledge. Methods: School nurses were invited to complete self-reported questionnaires on IBD. Then, IBD specialists from tertiary referral hospitals provided a 60-minute lecture with educational brochures on two occasions, with a 3-month interval. Within 6 months after the educational interventions, school nurses were asked to complete the same IBD questionnaire via e-mail. Results: Among 101 school nurses who were invited to participate, 54 nurses (53.5%) who completed two consecutive questionnaires were included in this study (median age, 45 years; range, 25 to 59 years; 100% female); 11.1% and 7.4% of the study participants had no knowledge regarding ulcerative colitis and Crohn's disease, respectively. They had heard of IBD most frequently from doctors (33.3%), followed by internet sources (25.9%). After 6 months, the number of nurses who could explain IBD to students with over 30% confidence increased from 24 (44.5%) to 42 (77.8%) (p＜0.001). Most nurses (81.5%) reported that the educational intervention was helpful for managing students with abdominal pain or diarrhea. The number of students who received IBD-related welfare services from the Daegu Metropolitan Office of Education doubled when compared with the corresponding number during the prior educational year. Conclusions: There is room for improvement in school nurses' knowledge of IBD. A systematic educational program on IBD should be implemented for these nurses.

Nonimmunity against hepatitis B virus infection in patients newly diagnosed with inflammatory bowel disease.

BACKGROUND/AIMS: This study aimed to elucidate the prevalence of hepatitis B virus (HBV) serologic markers in Korean patients newly diagnosed with, but not yet treated for inflammatory bowel disease (IBD). METHODS: We prospectively enrolled 210 patients newly diagnosed with IBD (109 with ulcerative colitis and 101 with Crohn's disease). Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) levels were measured and compared with those of 1,100 sex- and age-matched controls. RESULTS: The prevalence of chronic HBV infection (positive HBsAg, positive anti-HBc, and negative anti-HBs results) and past infection (negative HBsAg, positive anti-HBc, and positive or negative anti-HBs results) were not significantly different between the patients and controls (chronic HBV infection: IBD, 3.8% vs. control, 4.9%, P=0.596; past infection: IBD, 26.2% vs. control, 28.8%, P=0.625). The patients with IBD aged <20 years were at a higher susceptibility risk (nonimmune) for HBV infection than the controls (IBD, 41.5% vs. control, 22.4%; P=0.018). In the multivariate analysis, an age of <20 years (P=0.024) and symptom duration of ≥12 months before diagnosis (P=0.027) were identified as independent risk factors for nonimmunity against HBV infection. CONCLUSIONS: The patients newly diagnosed with IBD were susceptible to HBV infection. The frequency of nonimmunity was high, especially in the patients aged <20 years and those with a longer duration of symptoms before diagnosis. Therefore, it is necessary to screen for HBV serologic markers and generate a detailed vaccination plan for patients newly diagnosed with IBD.

Factors Associated with Rebleeding in Patients with Peptic Ulcer Bleeding: Analysis of the Korean Peptic Ulcer Bleeding (K-PUB) Study.

BACKGROUND/AIMS: Rebleeding is associated with mortality in patients with peptic ulcer bleeding (PUB), and risk stratification is important for the management of these patients. The purpose of our study was to examine the risk factors associated with rebleeding in patients with PUB. METHODS: The Korean Peptic Ulcer Bleeding registry is a large prospectively collected database of patients with PUB who were hospitalized between 2014 and 2015 at 28 medical centers in Korea. We examined the basic characteristics and clinical outcomes of patients in this registry. Univariate and multivariate analyses were performed to identify the factors associated with rebleeding. RESULTS: In total, 904 patients with PUB were registered, and 897 patients were analyzed. Rebleeding occurred in 7.1% of the patients (64), and the 30-day mortality was 1.0% (nine patients). According to the multivariate analysis, the risk factors for rebleeding were the presence of co-morbidities, use of multiple drugs, albumin levels, and hematemesis/hematochezia as initial presentations. CONCLUSIONS: The presence of co-morbidities, use of multiple drugs, albumin levels, and initial presentations with hematemesis/hematochezia can be indicators of rebleeding in patients with PUB. The wide use of proton pump inhibitors and prompt endoscopic interventions may explain the low incidence of rebleeding and low mortality rates in Korea.

Development of a Web-based, self-reporting symptom diary for Crohn's Disease, and its correlation with the Crohn's Disease Activity Index.

BACKGROUND AND AIMS: Crohn's Disease Activity Index (CDAI) is complex, time-consuming, and impractical. The aim of this study was to investigate whether a newly developed, simple, web-based self-reporting Crohn's Disease symptom diary (CDSD) was as effective as CDAI in assessing disease severity. METHODS: CDSD consisted of 5 clinical parameters based on the Harvey-Bradshaw Index (HBI), which could easily be recorded online, by using CDSD website (www.cdsd.or.kr). Images were added to help patients better understand complications. All patients were asked to visit the website and record their symptoms 7 days before their next hospital appointment. CDAI scores were calculated at the subsequent hospital visit. The collected data were analyzed to determine if the CDAI scores correlated with those obtained from CDSD, and to define a cut-off value of CDSD that would be representative of disease remission. RESULTS: Analysis of 171 visits showed a positive correlation between scores from CDSD and CDAI (Spearman correlation coefficient r = 0.720, p < 0.001). Receiver Operating Characteristic curves showed CDSD score ≤5 points as corresponding with CDAI score ≤150 points (clinical remission). Using a cut-off value of 5 points by CDSD, the positive and negative predictive values for clinical remission were 91.7% and 88.5%, respectively. CONCLUSION: This study demonstrates that CDSD correlated well with CDAI. CDSD score of 5 is the cut-off value for clinical remission (CDAI score ≤150). Use of CDSD might permit a simple, patient-friendly assessment of CD activity, which can provide useful early-phase information on patients with CD as part of their long-term clinical assessment.

Characteristics of Intramolecular Charge Transfer by J-Aggregates in Merocyanine Dye LB Films.

In this study, for the development of future molecular electronic devices, we have investigated the characteristics of the aggregates of Langmuir-Blodgett films. The characteristics of intramolecular charge transfer by J-aggregates in merocyanine dye LB films have been studied experimentally by using UV irradiation and heat treatment. In addition to intramolecular charge transfer, we also studied the conjugation and energy changes of the molecules. In case a dye is thinned by LB method, the alkyl chain is often displaced in order to form a mono-molecular film with ease. Since the molecular association form is often made by self-organization of molecules themselves, in case the dye and the alkyl chain are strongly bonded by the covalent bond, it may be said that the properties of the LB film to be built up are almost determined at the time of synthesis of film-forming molecules. Meanwhile, since, in case LB film is fabricated by the diffusion absorption method, the cohesive force between the water-soluble dye and the surface-active mono-molecular film is electrostatic, the dye molecule can move relatively freely on the air/water interface, which may be regarded as a two-dimensional crystal growth process.

[Comparative Study on Bowel Preparation Efficacy of Ascorbic Acid Containing Polyethylene Glycol by Adding Either Simethicone or 1 L of Water in Health Medical Examination Patients: A Prospective Randomized Controlled Study].

BACKGROUND/AIMS: There are no studies that looked into the bubble eliminating efficacy of polyethylene glycol with ascorbic acid (PEGA), which has been one of the shortcomings of polyethylene glycol (PEG). In this study, we compared newly introduced PEGA regimen by adding either simethicone or 1 L of water. METHODS: A prospective randomized controlled study was carried out at Dongguk Universtiy Gyeongju Hospital from July 2014 to September 2014. A total of 90 patients were randomly assigned to 3 groups; PEGA group (n=30) which served as control, simethicone addition group (n=30) to which simethicone 400 mg was additionally prescribed, and water addition group (n=30) to whom additional 1 L of water was given. Cleansing effectiveness, gas elimination efficacy, side effects, and patient satisfaction were compared between the groups. RESULTS: PEGA group demonstrated the highest cleansing effectiveness, but there was no statistically significant difference among the groups. Simethicone addition group showed significantly lesser amount of bubbles than the other groups (2.57±2.05 vs. 1.10±1.83 vs. 2.60±2.84, p=0.017). The rates of side effects in each group were 20.00% vs. 16.77% vs. 53.33%. Water addition group had significantly more side effects than the PEGA group and the simethicone addition group (p=0.003). The patient satisfaction score of each group was 3.37±0.85 vs. 3.73±0.74 vs. 3.20±0.66 with simethicone addition group showing significantly higher satisfaction than water addition group (p=0.020). CONCLUSIONS: PEGA bowel preparation agent showed satisfactory bowel cleansing despite the decrease in dosage, and addition of simethicone resulted in better bubble elimination.

Risk Factors Associated with Rebleeding in Patients with High Risk Peptic Ulcer Bleeding: Focusing on the Role of Second Look Endoscopy.

BACKGROUND: Re-bleeding after initial hemostasis in peptic ulcer bleeding can be life threatening. Identification of factors associated with re-bleeding is important. The aims of this study were to determine incidence of rebleeding in patients with high risk peptic ulcer bleeding and to evaluate factors associated with rebleeding. METHODS: Among patients diagnosed as upper gastrointestinal hemorrhage at seven hospitals in Daegu-Gyeongbuk, and one hospital in Gyeongnam, South Korea, from Feb 2011 to Dec 2013, 699 patients diagnosed as high risk peptic ulcer bleeding with Forrest classification above llb were included. The data were obtained in a prospective manner. RESULTS: Among 699 patients, re-bleeding occurred in 64 (9.2 %) patients. Second look endoscopy was significantly more performed in the non-rebleeding group than the rebleeding group (81.8 vs 62.5 %, p < 0.001). In multivariate analysis, use of non-steroidal anti-inflammatory agents, larger transfusion volume (≥5 units), and non-performance of second look endoscopy were found as risk factors for rebleeding in high risk peptic ulcer bleeding. CONCLUSION: In our study, rebleeding was observed in 9.2 % of patients with high risk peptic ulcer bleeding. Performance of second look endoscopy seems to lower the risk of rebleeding in high risk peptic ulcer bleeding patients and caution should be paid to patients receiving high volume transfusion and on medication with NSAIDs.

Comparison of scoring systems for nonvariceal upper gastrointestinal bleeding: a multicenter prospective cohort study.

BACKGROUND AND AIM: The Glasgow-Blatchford score (GBS) and Rockall score (RS) are widely used to assess risk in patients with upper gastrointestinal bleeding (UGIB). We compared both scoring systems and evaluated their clinical usefulness. METHODS: Between February 2011 and December 2013, 1584 patients with nonvariceal UGIB were included in the study. A prospective study was conducted to compare the performance of the GBS, pre-RS, and full RS. We compared the performance of these scores using receiver operating characteristic curves. RESULTS: For prediction of the need for hospital-based intervention, the GBS was similar to the full RS (area under the receiver operating characteristic curves [AUROC] 0.705 vs 0.727; P = 0.282) and superior to the pre-RS (AUROC 0.705 vs 0.601; P < 0.0001). In predicting death, the full RS was superior to the GBS (AUROC 0.758 vs 0.644; P = 0.0006) and similar to the pre-RS (AUROC 0.758 vs 0.754; P = 0.869). In predicting rebleeding, the full RS was superior to both GBS (AUROC 0.642 vs 0.585; P = 0.031) and pre-RS (AUROC 0.642 vs 0.593; P = 0.0003). Of 1584 patients, 13 (0.8%) scored 0 on the GBS. Therapeutic intervention was not performed in any of these patients. CONCLUSIONS: The GBS is more useful than the pre-RS for predicting the need for hospital-based intervention. A cutoff value of 0 for low-risk patients who might be suitable for outpatient management is useful. The full RS is helpful in predicting death. None of the systems accurately predict rebleeding with a low AUROC. ( CLINICAL TRIAL: cris.nih.go.kr/KCT0000514).

[Comparison on Endoscopic Hemoclip and Hemoclip Combination Therapy in Non-variceal Upper Gastrointestinal Bleeding Patients Based on Clinical Practice Data: Is There Difference between Prospective Cohort Study and Randomized Study?].

BACKGROUND/AIMS: Endoscopic hemoclip application is an effective and safe method of endoscopic hemostasis. We conducted a multicenter retrospective study on hemoclip and hemoclip combination therapy based on prospective cohort database in terms of hemostatic efficacy not in clinical trial but in real clinical practice. METHODS: Data on endoscopic hemostasis for non-variceal upper gastrointestinal bleeding (NVUGIB) were prospectively collected from February 2011 to December 2013. Among 1,584 patients with NVUGIB, 186 patients treated with hemoclip were enrolled in this study. Subjects were divided into three groups: Group 1 (n = 62), hemoclipping only; group 2 (n = 88), hemoclipping plus epinephrine injection; and group 3 (n = 36), hemocliping and epinephrine injection plus other endoscopic hemostatic modalities. Primary outcomes included rebleeding, other therapeutic management, hospitalization period, fasting period and mortality. Secondary outcomes were bleeding associated mortality and overall mortality. RESULTS: Active bleeding and peptic ulcer bleeding were more common in group 3 than in group 1 and in group 2 (p <œ 0.001). However, primary outcomes (rebleeding, other management, morbidity, hospitalization period, fasting period and mortality) and secondary outcomes (bleeding associated mortality and total mortality) were not different among groups. CONCLUSIONS: Combination therapy of epinephrine injection and other modalities with hemoclips did not show advantage over hemoclipping alone in this prospective cohort study. However, there is a tendency to perform combination therapy in active bleeding which resulted in equivalent hemostatic success rate, and this reflects the role of combination therapy in clinical practice.

Significant risk and associated factors of active tuberculosis infection in Korean patients with inflammatory bowel disease using anti-TNF agents.

AIM: To evaluate the incidence and risk factors of Korean tuberculosis (TB) infection in patients with inflammatory bowel disease (IBD) undergoing anti-TNF treatment. METHODS: The data of IBD patients treated with anti-TNFs in 13 tertiary referral hospitals located in the southeastern region of Korea were collected retrospectively. They failed to show response or were intolerant to conventional treatments, including steroids or immunomodulators. Screening measures for latent TB infection (LTBI) and the incidence and risk factors of active TB infection after treatment with anti-TNFs were identified. RESULTS: Overall, 376 IBD patients treated with anti-TNF agents were recruited (male 255, mean age of anti-TNF therapy 32.5 ± 13.0 years); 277 had Crohn's disease, 99 had ulcerative colitis, 294 used infliximab, and 82 used adalimumab. Before anti-TNF treatment, screening tests for LTBI including an interferon gamma release assay or a tuberculin skin test were performed in 82.2% of patients. Thirty patients (8%) had LTBI. Sixteen cases of active TB infection including one TB-related mortality occurred during 801 person-years (PY) follow-up (1997.4 cases per 100000 PY) after anti-TNF treatment. LTBI (OR = 5.76, 95%CI: 1.57-21.20, P = 0.008) and WBC count < 5000 mm(3) (OR = 4.5, 95%CI: 1.51-13.44, P = 0.007) during follow-up were identified as independently associated risk factors. CONCLUSION: Anti-TNFs significantly increase the risk of TB infection in Korean patients with IBD. The considerable burden of TB and marked immunosuppression might be attributed to this risk.

The evolution of bowel preparation and new developments.

Bowel preparation is essential for successful colonoscopy examination, and the most important factor is the bowel preparation agent used. However, selection of a bowel preparation agent invariably involves compromise. Originally, bowel preparation was performed for radiologic and surgical purposes, when the process involved dietary limitations, cathartics, and enemas, which had many side effects. Development of polyethylene glycol (PEG) solution led to substantive advancement of bowel preparation; however, despite its effectiveness and safety, the large volume involved, and its salty taste and unpleasant odor reduce compliance. Accordingly, modified PEG solutions requiring consumption of lower volumes and sulfate-free solutions were developed. Aqueous sodium phosphate is more effective and better tolerated than PEG solutions; however, fatal complications have occurred due to water and electrolyte shifts. Therefore, aqueous sodium phosphate was withdrawn by the US Food and Drug Administration, and currently, only sodium phosphate tablets remain available. In addition, oral sulfate solution and sodium picosulfate/magnesium citrate are also available, and various studies have reported on adjunctive preparations, such as hyperosmolar or stimulant laxatives, antiemetics, and prokinetics, which are now in various stages of development.

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.

Endoscopic experience improves interobserver agreement in the grading of esophagitis by Los Angeles classification: conventional endoscopy and optimal band image system.

BACKGROUND/AIMS: Interobserver variation by experience was documented for the diagnosis of esophagitis using the Los Angeles classification. The aim of this study was to evaluate whether interobserver agreement can be improved by higher levels of endoscopic experience in the diagnosis of erosive esophagitis. METHODS: Endoscopic images of 51 patients with gastroesophageal reflux disease (GERD) symptoms were obtained with conventional endoscopy and optimal band imaging (OBI). Endoscopists were divided into an expert group (16 gastroenterologic endoscopic specialists guaranteed by the Korean Society of Gastrointestinal Endoscopy) and a trainee group (individuals with fellowships, first year of specialty training in gastroenterology). All endoscopists had no or minimal experience with OBI. GERD was diagnosed using the Los Angeles classification with or without OBI. RESULTS: The mean weighted paired κ statistics for interobserver agreement in grading erosive esophagitis by conventional endoscopy in the expert group was better than that in the trainee group (0.51 vs 0.42, p<0.05). The mean weighted paired k statistics in the expert group and in the trainee group based on conventional endoscopy with OBI did not differ (0.42, 0.42). CONCLUSIONS: Interobserver agreement in the expert group using conventional endoscopy was better than that in the trainee group. Endoscopic experience can improve the interobserver agreement in the grading of esophagitis using the Los Angeles classification.

Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: a randomized prospective study.

BACKGROUND: A conformable self-expandable metallic stent was developed to overcome the limitation of previous self-expandable metallic stents. The aim of this study was to evaluate outcomes after placement of conformable covered and uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction. METHODS: A single-blind, randomized, parallel-group, prospective study were conducted in 4 medical centres between March 2009 and July 2012. 134 patients with unresectable malignant gastroduodenal obstruction were assigned to a covered double-layered (n=66) or uncovered unfixed-cell braided (n=68) stent placement group. Primary analysis was performed to compare re-intervention rates between two groups. RESULTS: 120 patients were analysed (59 in the covered group and 61 in the uncovered group). Overall rates of re-intervention were not significantly different between the two groups: 13/59 (22.0%) in the covered group vs. 13/61 (21.3%) in the uncovered group, p=0.999. Stent migration was more frequent in the covered group than in the uncovered group (p=0.003). The tumour ingrowth rate was higher in the uncovered group than in the covered group (p=0.016). CONCLUSIONS: The rates of re-intervention did not significantly differ between the two stents. Conformable covered double-layered and uncovered unfixed-cell braided stents were associated with different patterns of stent malfunction.

Status and literature review of self-expandable metallic stents for malignant colorectal obstruction.

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.