High Visceral-To-Subcutaneous Fat Ratio Is Associated with an Increased Risk of Gastroesophageal Reflux Disease in Nonobese Adults.

INTRODUCTION: Abdominal obesity increases the risk of gastroesophageal reflux disease (GERD). This study aimed to determine the association between GERD and abdominal fat area quantified by computed tomography (CT). METHODS: We analyzed the effect of abdominal fat area on gastroesophageal reflux symptoms and erosive esophagitis using logistic regression models in 5,338 participants who underwent abdominal fat measurement CT and screening esophagogastroduodenoscopy. RESULTS: Participants with reflux symptoms and erosive esophagitis were diagnosed in 1,168 (21.9%) and 671 (12.5%), respectively. Multivariate analysis showed that subcutaneous and visceral fat areas were significantly associated with reflux symptoms and erosive esophagitis. The adjusted odds ratio (OR) in the fourth quartile of visceral fat area compared with that in the lowest quartile was 1.98 (95% confidence interval (CI) 1.63-2.39) for reflux symptoms and 2.33 (95% CI 1.80-3.01) for erosive esophagitis. Visceral fat area had a stronger effect in the younger age-group. In the group <50 years, the adjusted OR in fourth quartile of visceral fat area was 2.70 (95% CI 1.86-3.94) for reflux symptoms and 3.59 (95% CI 2.22-5.80) for erosive esophagitis. High visceral-to-subcutaneous fat ratio (VSR) increased the risk of reflux symptoms and erosive esophagitis in participants with body mass index <25 kg/m2 and normal waist circumference. CONCLUSION: Subcutaneous and visceral fat areas were associated with an increased risk of reflux symptoms and erosive esophagitis. High VSR increased the risk of reflux symptoms and erosive esophagitis in participants with normal body weight and waist circumference.

Real-time detection of colon polyps during colonoscopy using deep learning: systematic validation with four independent datasets.

We developed and validated a deep-learning algorithm for polyp detection. We used a YOLOv2 to develop the algorithm for automatic polyp detection on 8,075 images (503 polyps). We validated the algorithm using three datasets: A: 1,338 images with 1,349 polyps; B: an open, public CVC-clinic database with 612 polyp images; and C: 7 colonoscopy videos with 26 polyps. To reduce the number of false positives in the video analysis, median filtering was applied. We tested the algorithm performance using 15 unaltered colonoscopy videos (dataset D). For datasets A and B, the per-image polyp detection sensitivity was 96.7% and 90.2%, respectively. For video study (dataset C), the per-image polyp detection sensitivity was 87.7%. False positive rates were 12.5% without a median filter and 6.3% with a median filter with a window size of 13. For dataset D, the sensitivity and false positive rate were 89.3% and 8.3%, respectively. The algorithm detected all 38 polyps that the endoscopists detected and 7 additional polyps. The operation speed was 67.16 frames per second. The automatic polyp detection algorithm exhibited good performance, as evidenced by the high detection sensitivity and rapid processing. Our algorithm may help endoscopists improve polyp detection.

Entecavir-resistant hepatitis B virus decreases surface antigenicity: A full genome and functional characterization.

BACKGROUND AND AIM: Since polymerase and surface genes overlap in hepatitis B virus (HBV), an antiviral-induced mutation in the polymerase gene may alter the surface antigenicity in patients with chronic hepatitis B (CHB), but this possibility has not been clearly confirmed. This study aimed to determine the drug susceptibility and surface antigenicity of the patient-derived mutants. PATIENTS AND METHODS: Full-length HBV genomes isolated from four entecavir-resistant CHB patients were cloned and sequenced. Around 10 clones of full-length HBV obtained from each patient were analysed and registered in the NCBI GenBank. Representative clones were further characterized by in vitro drug susceptibility and surface antigenicity assays. RESULTS: The rtL180M + rtM204V mutations were common among all the clones analysed. Additionally, the ETV resistance mutations rtT184A/L, rtS202G and rtM250V were found among three patients. Most of the ETV-resistant mutants had amino acid alterations within the known epitopes recognized by T- and B-cells in the HBV surface and core antigens. The in vitro drug susceptibility assay showed that all tested clones were resistant to ETV treatment. However, they were all susceptible to ADV and TDF. More importantly, the rtI169T mutation in the RT domain, led to the sF161L mutation in the overlapping S gene, which decreased in surface antigenicity. CONCLUSIONS: The ETV resistance mutations can affect the antigenicity of the HBsAg proteins due to changes in the overlapping sequence of this surface antigen. Thus, the apparent decline or disappearance of HBsAg needs to be interpreted cautiously in patients with previous or current antiviral resistance mutations.

Progression of pancreatic cystic lesions without any risk features is associated with initial cyst size and obesity.

BACKGROUND AND AIM: The clinical significance of incidental pancreatic cystic lesions (PCLs) remains unclear in those that are not accompanied by worrisome features or high-risk stigmata. We aimed to investigate the natural course of PCLs without any risk features and examine the clinical factors associated with their progression. METHODS: We conducted a retrospective cohort study of 427 patients with PCLs, which were incidentally detected by computed tomography between January 2003 and December 2012. Progression of PCLs without any risk features and the clinical factors associated with their progression were investigated. The length of time to significant growth was also evaluated. RESULTS: Ninety-four (22.0%) of the 427 patients had asymptomatic PCLs that showed significant growth after a median surveillance period of 5.3 years; approximately 27.7% of the patients showed significant size changes in the first 5 years, while the remaining 72.3% showed significant changes after 5 years. The cumulative rate of patients with significant growth was associated with initial cyst size and high body mass index. In the growth group, additional treatments were required for 12 patients, one of whom developed malignancy. Four patients in the stable group underwent additional treatment and showed no malignant change. CONCLUSIONS: One-fifth of the asymptomatic PCLs significantly increased in size after a long-term follow-up period, which was associated with initial cyst size and obesity. The size of PCLs mostly increased after 5 years; although the malignancy risk of PCLs was low, it was still a concern.

Risk factors of traditional serrated adenoma and clinicopathologic characteristics of synchronous conventional adenoma.

BACKGROUND AND AIMS: Traditional serrated adenoma (TSA) is rare and known to have a malignant potential. We aimed to investigate the prevalence and risk factors of TSA and compare the characteristics of synchronous conventional adenoma (AD) in patients with TSA with those of AD in patients with AD only. METHODS: We reviewed medical records of 31,932 healthy subjects who underwent screening colonoscopy at a single hospital between 2012 and 2017. RESULTS: TSA was observed in 116 patients (.4%). Among them, 47 patients (40.5%) had TSA only and 69 patients (59.5%) had synchronous AD. Multivariable analysis showed independent risk factors for TSA to include age ≥50 years (odds ratio [OR], 3.34; 95% confidence interval [CI], 1.72-6.49; P < .001), hypertension (OR, 2.07; 95% CI, 1.09-3.92; P = .026), and current smoking (OR, 2.58; 95% CI, 1.28-5.23; P = .008). There were significantly more ADs (2.5 ± 2.0 vs 1.8 ± 1.6, P = .009) and ADs were of larger size (6.7 ± 5.0 vs 5.3 ± 3.6 mm, P = .027) in TSA patients than in AD-only patients. Furthermore, advanced adenoma and high-risk adenoma were more frequently observed in TSA patients than in AD-only patients (24.2% vs 11.2%, P = .002; 43.5% vs 23.6%, P < .001). CONCLUSIONS: The prevalence of TSA in healthy adults was .4%. Age ≥50 years, hypertension, and current smoking may be risk factors of TSA. Synchronous AD is often observed with TSA and may show more advanced features than those in AD-only patients.

Prevalence and risk factors of advanced colorectal neoplasms in asymptomatic Korean people between 40 and 49 years of age.

BACKGROUND AND AIM: Current guidelines recommend colon cancer screening for persons aged over 50 years. However, there are few data on colorectal cancer screening in 40- to 49-year-olds. This study assessed the prevalence and risk factors of colorectal neoplasms in 40- to 49-year-old Koreans. METHODS: We analyzed the results of screening colonoscopies of 6680 persons 40-59 years of age (2206 aged 40-49 and 4474 aged 50-59 years). RESULTS: The prevalence of overall and advanced neoplasms in the 40- to 49-year age group was lower than in the 50- to 59-year age group (26.7% and 2.4% vs 37.8% and 3.5%, respectively). However, the prevalence of overall and advanced neoplasms increased to 39.1% and 5.4%, respectively, in 45- to 49-year-old individuals with metabolic syndrome. In the 40- to 49-year age group, age, current smoking, and metabolic syndrome were associated with an increased risk of advanced neoplasms (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.04-1.30; OR 3.12, 95% CI 1.20-8.12; and OR 2.00, 95% CI 1.09-3.67, respectively). CONCLUSIONS: Individuals aged 40-49 years had a lower prevalence of colorectal neoplasms than those aged 50-59 years, but some 40- to 49-year-olds showed a similar prevalence to those aged 50-59 years. Age, current smoking habits, and metabolic syndrome are associated with an increased risk of advanced neoplasms in subjects aged 40-49 years. Further studies are needed to stratify the risks of colon cancer and guide targeted screening in persons younger than 50 years old.

Helicobacter pylori Infection with Atrophic Gastritis Is an Independent Risk Factor for Advanced Colonic Neoplasm.

BACKGROUND/AIMS: Helicobacter pylori is a major risk factor for atrophic gastritis (AG) and gastric cancer. The correlation between H. pylori, AG and colorectal neoplasm (CRN) has only been examined in a limited number of studies, and findings have been inconclusive. We aimed to investigate the association between H. pylori infection status, AG and advanced CRN. METHODS: This cross-sectional study investigated the relationship between the presence of serum anti-H. pylori IgG antibodies, AG, and advanced CRN in 6,351 consecutive asymptomatic subjects who underwent a screening colonoscopy. RESULTS: A total of 316 participants (5.0%) had advanced CRN. H. pylori seropositivity was 61.3%. In a univariate analysis, the presence of H. pylori infection was associated with advanced CRN (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.17 to 1.91; p=0.001). H. pylori infection was associated with an increased risk of advanced CRN after adjusting for clinically relevant confounders (OR, 1.34; 95% CI, 1.04 to 1.72; p=0.023). H. pylori-related AG was significantly associated with the risk of advanced CRN (OR, 1.40; 95% CI, 1.03 to 1.91; p=0.030), whereas H. pylori infection without AG was not. CONCLUSIONS: H. pylori infection increased the risk of advanced CRN, especially when it was combined with AG. Strict colonoscopy screening and surveillance may be warranted in those with H. pylori-positive AG.

EUS-Guided Multitransgastric Endoscopic Necrosectomy for Infected Pancreatic Necrosis with Noncontagious Retroperitoneal and Peritoneal Extension.

Endoscopic necrosectomy was introduced as a safe and effective treatment modality for infected pancreatic necrosis. Although there have been many reports of endoscopic drainage of retroperitoneal pancreatic necrosis, the optimal endoscopic management of pancreatic necrosis extending to the noncontagious retroperitoneal and peritoneal spaces has yet to be established. We report herein a patient with infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension who was treated successfully by endoscopic ultrasound (EUS)-guided multiple cystogastrostomy and endoscopic necrosectomy. EUS-guided multitransgastric necrosectomy may be technically feasible and effective for the management of infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension that demonstrates suitable anatomy. Further studies to assess the efficacy and safety of this technique are needed before its routine clinical use can be recommended.

Combination of transarterial chemoembolization and three-dimensional conformal radiotherapy for hepatocellular carcinoma with inferior vena cava tumor thrombus.

PURPOSE: To evaluate the effects of transarterial chemoembolization (TACE) and three-dimensional conformal radiotherapy (CRT) in patients with hepatocellular carcinoma (HCC) and inferior vena cava tumor thrombus (IVCTT). METHODS AND MATERIALS: A total of 42 consecutive patients who underwent TACE and CRT (TACE+CRT group) for the treatment of HCC with IVCTT were prospectively enrolled from July 2004 to October 2006. As historical controls, 29 HCC patients with IVCTT who received TACE alone (TACE group) between July 2003 and June 2004 were included. CRT was designed to target only the IVCTT and to deliver a median total dose of 45 Gy (range, 28-50 Gy). RESULTS: Most baseline characteristics of the two groups were similar (p > 0.05). The response and progression-free rates of IVCTT were significantly higher in the TACE+CRT group than in the TACE group (42.9% and 71.4% vs. 13.8% and 37.9%, respectively; p < 0.01 for both rates). Overall, patient survival was significantly higher in the TACE+CRT group than in the TACE group (p < 0.01), with a median survival time of 11.7 months and 4.7 months, respectively. Treatment with TACE+CRT (hazard ratio [HR] = 0.38; 95% confidence interval [CI], 0.20-0.71), progression of IVCTT (HR = 4.05; 95% CI, 2.00-8.21), Child-Pugh class B (HR = 3.44; 95% CI, 1.79-6.61), and portal vein invasion (HR = 2.31; 95% CI, 1.19-4.50) were identified as independent predictors of mortality by multivariable analysis. CONCLUSIONS: The combination of TACE and CRT is more effective in the control of IVCTT associated with HCC and improves patient survival compared with TACE alone.

EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study.

OBJECTIVES: Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) with plastic stents has been introduced as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. Although self-expandable metallic stents with a larger diameter might offer long-lasting patency compared with plastic stents, to date, EUSBD with one-step placement of a fully covered self-expandable metal stent (FCSEMS) has not been evaluated. We conducted this study to determine the feasibility and usefulness of EUSBD with one-step placement of FCSEMS. METHODS: A prospective feasibility study on EUSBD with one-step placement of FCSEMS was carried out in 14 patients with malignant biliary obstruction who were candidates for alternative techniques for biliary decompression because of unsuccessful ERCP. RESULTS: The technical and functional success rate was 100% (14/14). Nine patients were treated using the intrahepatic approach. The remaining five patients were treated using the extrahepatic approach. With the intrahepatic approach, two patients showed self-limited pneumoperitoneum. With the extrahepatic approach, no patients had pneumoperitoneum. No bile peritonitis or cholangitis was observed after the procedure in any of the patients treated using the intra- or extrahepatic approach. During follow-up periods (median 6 months), one case of re-intervention (7%, 1/14) necessitated by distal stent migration was observed. CONCLUSIONS: EUSBD with one-step placement of an FCSEMS may be feasible, safe, and effective as an alternative to PTBD in cases of malignant biliary obstruction when ERCP is unsuccessful. Prospective randomized trials of EUSBD with plastic stent vs. EUSBD with FCSEMS may be needed.

Poor outcomes for IgD multiple myeloma patients following high-dose melphalan and autologous stem cell transplantation: a single center experience.

Immunoglobulin (Ig) D multiple myeloma (MM) accounts for 2% of all MM cases and has been reported to be associated with poor prognosis compared with other MM subtypes. The aim of the present study was to compare the effects of high-dose melphalan treatment and autologous stem cell transplantation (ASCT) on the survival of patients with IgD MM and patients with other MM subtypes. Between November 1998 and January 2005, a total of 77 patients with MM who underwent ASCT at the Asan Medical Center were enrolled in this study. High-dose melphalan (total 200 mg/m2) was used as high-dose chemotherapy. The study population was divided into two groups based on MM subtype: those with IgD MM; and those with other MM subtypes. A total of 8 patients with IgD MM were identified, accounting for about 10% of the study population. Thirty-six patients (47%) had IgG MM, 17 patients (22%) had IgA MM, and 16 patients (20%) had free light-chain MM. The two groups were similar in baseline characteristics. The median follow-up was 17 months and the median overall survival (OS) was 39 months. In the IgD MM group, median eventfree survival (EFS) and OS were 6.9 and 12 months, respectively. In the patients with other MM subtypes, median EFS and OS were 11.5 and 55.5 months (p=0.01, p<0.01), respectively. Multivariate analysis of all patients identified IgD subtype (p=0.002) and Southwest Oncology Group (SWOG) stage 2 or greater at the time of ASCT (p=0.01) as adverse prognostic factors for survival. In this small study at a single center in Korea, patients with IgD MM had poorer outcomes after ASCT than did patients with other MM subtypes.

Hepatic myelopathy as a presenting neurological complication in patients with cirrhosis and spontaneous splenorenal shunt.

Hepatic myelopathy is a rare complication of chronic liver disease that is associated with extensive portosystemic shunts. The main clinical feature of hepatic myelopathy is progressive spastic paraparesis in the absence of sensory or sphincter impairment. Early and accurate diagnosis of hepatic myelopathy is important because patients with early stages of the disease can fully recover following liver transplantation. Motor-evoked potential studies may be suitable for the early diagnosis of hepatic myelopathy, even in patients with preclinical stages of the disease. Here we describe two patients who presented with spastic paraparesis associated with a spontaneous splenorenal shunt and without any previous episode of hepatic encephalopathy. One patient experienced improved neurologic symptoms after liver transplantation, whereas the other patient only received medical treatment, which did not prevent the progression of spastic paraparesis.

BEAC or BEAM high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: comparative analysis of efficacy and toxicity.

The treatment of choice for relapsed/refractory non-Hodgkin's lymphoma (NHL) consists of high-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT). Little is known, however, regarding the comparative toxicity and efficacy of various HDC regimens applied in NHL. We have retrospectively evaluated the clinical aspects of the BCNU, etoposide, cytarabine, and cyclophosphamide (BEAC) and BCNU, etoposide, cytarabine, and melphalan (BEAM) regimens for ASCT. Between April 1994 and February 2005, 97 NHL patients underwent HDC with BEAC (N = 69) or BEAM (N = 28), followed by ASCT, at the Asan Medical Center. We matched each BEAM patient with two BEAC patients having the same International Prognostic Index. Thus, 84 patients (56 BEAC and 28 BEAM) were analyzed. Median age was 40.5 years, and baseline characteristics were well balanced between the two groups. The median time to neutrophil engraftment (>500/mm(3)) was significantly longer with BEAC than with BEAM (12 vs 11 days, P = 0.001), as was the total amount of red blood cell transfusion (6.5 vs 3.7U, P = 0.037), but the median time to platelet engraftment (>20,000/mm(3)) and the total amount of platelet transfusion did not differ between the two groups. BEAM patients had significantly more frequent World Health Organization grade greater than or equal to 2 diarrhea than BEAC patients (46.4 vs 19.6%, P = 0.010), but the incidence of mucositis, nausea/vomiting, and bleeding and the number of episodes of febrile neutropenia and septicemia did not differ between the two groups. Median follow-up for survivors was 33 months in the BEAM group and 89 months in the BEAC group. Median overall survival and median event-free survival were not reached in the BEAM group and were 7.9 (95% confidence interval [CI], 1-14.8 months, P = 0.003) and 3.7 months (95% CI, 0.1-7.2 months, P = 0.001), respectively, in the BEAC group. BEAM appeared to be superior to BEAC for survival. Regimen-related toxicities were similar, except that BEAM was associated with more frequent but acceptable diarrhea.

ESHAP salvage therapy for refractory and relapsed non-Hodgkin's lymphoma: a single center experience.

BACKGROUND: The ESHAP chemotherapy regimen, that is, the combination of the etoposide, methylprednisolone, high-dose cytarabine and cisplatin, has been shown to be active against relapsing or refractory non-Hodgkin's lymphoma (NHL) in previous therapeutic trials. We attempted to determine whether ESHAP therapy would be effective and well-tolerated in Korean patients. METHODS: Twenty two patients with refractory or relapsed NHLs (all aggressive types) were enrolled in this study. We retrospectively evaluated the treatment response, the survival rate and the time to progression. RESULTS: Six patients (27.3%) attained complete remission and eight patients (36.4%) attained partial remission. The overall response rate was 63.6%. The median survival duration was 15.5 months (95% confidence interval; 10.7 to 20.3 months), and the median duration of the time to progression was 8.3 months (95% confidence interval; 0.3 to 16.3 months). Myelosuppression was the major toxicity, but severe neutropenia or thrombocytopenia was rare, and renal toxicity was also infrequent. CONCLUSIONS: ESHAP regimen is effective in Korean patients suffering with relapsed or refractory NHLs, but a more effective salvage modality is needed because of the short duration of remission and the insignificant impact on long-term survival.