Prognostic impact of hepatitis B or C on intrahepatic cholangiocarcinoma.

BACKGROUND/AIMS: Intrahepatic cholangiocarcinoma (ICC) is the second-most common primary liver malignancy, arising from the peripheral intrahepatic bile duct epithelium. Hepatitis B virus (HBV) or hepatitis C virus (HCV) may be involved in the development of ICC. We explored the prognostic value of hepatitis virus infection, as well as other prognostic factors affecting survival in patients with ICC. METHODS: A retrospective chart review was performed for patients diagnosed with ICC between August 2005 and December 2018 at Konkuk University Medical Center. We identified a total of 131 patients with ICC. Overall survival rates of patients with and without hepatitis were determined. Univariate and multivariate analyses were used to estimate factors influencing survival outcomes. RESULTS: A total of 17.6% (23/131) of patients were positive for HBV or HCV. Hepatitis B positive ICC patients were significantly younger with higher albumin and higher α-fetoprotein than those without hepatitis viral infections. The median survival of hepatitis-positive and hepatitis-negative groups was 280 and 213 days, respectively. Survival rates were not significantly different between the two groups (p = 0.279). Multivariate analyses indicated that lower serum carbohydrate antigen 19-9 (CA 19-9) (p < 0.001), lower T stage (p = 0.042), the absence of lymph-node metastasis (p = 0.043), and receiving curative surgery (p = 0.033) were independent predictors of better outcomes. CONCLUSION: While hepatitis influenced a number of clinical features in ICC patients, it did not affect survival rate. Prognostic factors influencing survival outcomes with ICC were CA 19-9 level, T stage, the presence of lymph node metastasis, and curative surgery.

Effect of Preceding Biopsy on the Results of Endoscopic Submucosal Dissection for Colorectal Laterally Spreading Tumor.

BACKGROUND: Forceps biopsies are usually performed before endoscopic submucosal dissection (ESD) for colonic laterally spreading tumors (LSTs). However, preceding biopsy is commonly believed to possibly inhibit complete tumor resection by causing blurring of tumor borders and tissue fibrosis. AIMS: The aims were to investigate whether the preceding biopsy of colorectal LST affects the complete endoscopic tumor resection and increases the risk of complications. METHODS: We retrospectively reviewed the medical records of patients with colorectal LSTs who underwent ESD at our center during an 8-year period. Patients were divided into two groups according to whether they underwent biopsy of the tumor before ESD. In addition, the characteristics of patients and tumors, including the completeness of tumor resection, were investigated. RESULTS: Of 288 patients (174 men) enrolled in this study, 194 (67.4%, preceding biopsy group) underwent biopsies before ESD, whereas 94 (32.6%, no biopsy group) did not. There were no significant differences in age, sex, comorbidity, medication history, tumor location, and final pathologic result between both groups. Tumor size was larger (p = 0.002) and LST-G tumor was more common (p = 0.003) in the preceding biopsy group than in the no biopsy group. No significant difference was seen in ESD outcomes, including procedure time, hospitalization period, incidence of complications, en bloc resection rate, resection margin status, and incidence of surgical operation, between both groups. CONCLUSIONS: Biopsy of LST is commonly performed before endoscopic resection. Contrary to popular belief, it does not increase the incomplete tumor resection rate and incidence of complications. TRIAL REGISTRATION: KCT0002321.

ABC Classification Is Less Useful for Older Koreans Born before 1960.

Background/Aims: In the ABC classification system, group A consists of seronegative subjects without gastric corpus atrophy. This study aimed to determine the prevalence and characteristics of pseudo group A subjects. Methods: Group A subjects were identified among consecutive Korean adults who underwent a serum anti-Helicobacter pylori immunoglobulin G (IgG) test and pepsinogen (PG) assay on the day of endoscopy. Past infection was defined as the presence of either eradication history or endoscopic findings suggesting past infection (i.e., gastric xanthoma, metaplastic gastritis, or advanced atrophy >closed-type 1). Results: Among 2,620 group A subjects, 448 (17.1%) had eradication history, and 133 (5.1%) showed endoscopic findings suggesting past infection. Older age (odds ratio [OR], 1.148; 95% confidence interval [CI], 1.067 to 1.236) and earlier year of birth (OR, 1.086; 95% CI, 1.009 to 1.168) were independent risk factors for classification into pseudo group A, with cutoff points at 50.5 years and birth year of 1959.5, respectively. Positive H. pylori test findings were found in 22 subjects (3.1%) among the 715 subjects who underwent the urea breath test or Giemsa staining on the same day. Current infection was positively correlated with PG I and PG II levels (p<0.001) but not with age, anti-H. pylori IgG titer, or classification into pseudo group A. Conclusions: Among the group A subjects, 22.2% had past infection. The risk was higher in subjects older than 50 years, especially those born before 1960. Furthermore, current infection was found in 3.1% of the subjects and was correlated with increased gastric secretory ability.

Usefulness of Carbohydrate Antigen 19-9 Test in Healthy People and Necessity of Medical Follow-up in Individuals with Elevated Carbohydrate Antigen 19-9 Level.

BACKGROUND: Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker whose level is elevated in many types of cancers and other benign conditions. CA 19-9 levels are frequently found to be elevated in individuals during general health examinations. This study aimed to investigate the clinical characteristics of such individuals and to determine the need for medical follow-up. METHODS: We investigated individuals who underwent a health inspection, including a serum CA 19-9 test, at our center. Their CA 19-9 levels, age, sex, body mass index (BMI), and personal and past histories were investigated. Additionally, subgroup analyses were performed for those who underwent follow-up study for the elevated CA 19-9 levels. RESULTS: Of 58,498 subjects, 581 (1.0%) had elevated CA 19-9 levels. Multivariate analyses revealed that older age, female sex, lower BMI, and diabetes were independent predisposing factors for elevated CA 19-9 level. A subgroup analysis revealed that the causative conditions were identified in 129 of 351 subjects (36.8%). Among them, the causative conditions in 31 subjects (8.8%, including four cases of cancer and 15 of benign tumors) were not detected at the initial check-up and were found during the follow-up period. CONCLUSION: The use of CA 19-9 as a marker for cancer in healthy individuals is inappropriate. However, medical follow-up in individuals with elevated CA 19-9 levels may be useful because some causative diseases may be detected during follow-up.

FDG PET/CT to predict the curability of endoscopic resection for early gastric cancer.

PURPOSE: We evaluated the value of fluorine-18 fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) as a complementary imaging modality to endoscopy to predict the curability of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). METHODS: The institutional review board approved this retrospective study with a waiver of informed consent. The records of patients who underwent FDG PET/CT for initial routine staging of gastric cancer from January 2012 to October 2017 were reviewed retrospectively. Among them, the patients who had EGC with well or moderately differentiated adenocarcinoma were included in this study. A total of 210 EGCs in 199 patients (mean age ± SD, 67 ± 10 years) were selected for this study. For the analysis of FDG PET/CT image, the radiotracer uptake by the primary tumor was compared with the background gastric uptake. Each case was classified as curable by ESD (no discrete radioactivity) and not curable by ESD (discrete radioactivity). RESULTS: The detection rate of EGC by FDG PET/CT was 37.1% (78 discrete radioactivity in 210 EGCs). However, for the detection of EGC that is not curable by ESD, the sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve with 95% confidence intervals were 79% (67-87%), 91% (85-95%), 81% (71-88%), 89% (84-93%), and 0.85 (0.79-0.89), respectively. CONCLUSION: FDG PET/CT may be a useful complementary imaging modality to endoscopy to predict the curability of ESD for EGC.

[Identification of Nodular Gastritis among Patients Diagnosed with Lymphofollicular Gastritis on a Gastric Biopsied Specimen].

Background/Aims: Nodular gastritis (NG) is a well-known endoscopic finding observed in patients with a Helicobacter pylori infection, which may lead to invasive gastric cancer. Lymphofollicular gastritis consists of lymphoid follicles or lymphoid cell aggregates, and is common in children. The aim of this study was to identify patients with NG from those in whom gastric biopsied specimens showed lymphoid follicles and lymphoid cell aggregates. Methods: Subjects, whose gastric biopsy specimens showed lymphoid follicles or lymphoid cell aggregates, were included in this study. The inclusion criterion was that they underwent a serum pepsinogen assay on the day of upper gastrointestinal endoscopy. NG was diagnosed if the endoscopy findings revealed regular-sized, multiple, colorless subepithelial nodules. Results: Among 108 subjects who showed lymphoid follicles or lymphoid cell aggregates, 13 (12.0%) revealed NG on endoscopy, and all these subjects showed positive Giemsa staining. Patients diagnosed with NG were younger (p=0.012) and showed a female predominance (p=0.001) compared to those without NG. The mean serum pepsinogen levels were higher (p=0.001) and lymphoid follicle-dominant subjects were more common (p<0.001) in the NG subjects than in those without NG. Logistic regression analysis revealed a younger age (p=0.041) and female gender (p=0.002) to be significant independent risk factors for NG. Conclusions: NG should be distinguished from lymphofollicular gastritis because only 12% of patients showing gastric biopsy findings of lymphoid follicles and lymphoid cell aggregates demonstrated NG on endoscopy. NG is an endoscopic finding that is more common in women and in the younger population, irrespective of the biopsy findings and gastric secretory ability.

The histologic detection of Helicobacter pylori in seropositive subjects is affected by pathology and secretory ability of the stomach.

BACKGROUND: Helicobacter pylori is unevenly distributed in hypochlorhydric environments. The study aim was to elucidate the risk factors for a negative Giemsa staining finding in seropositive subjects by measuring the secretory ability of the stomach. METHODS: Subjects aged over 18 years were included consecutively after endoscopic biopsy at gastric lesions with color or structural changes. Blood was sampled for the serum pepsinogen (PG) assay and H. pylori serology test. After excluding the subjects with past H. pylori eradication, the risk factors for a negative Giemsa staining finding in seropositive subjects were analyzed. RESULTS: Among 872 included subjects, a discrepancy between the serum anti-H. pylori IgG and Giemsa staining findings was found in 158 (18.1%) subjects, including 145 Giemsa-negative, seropositive subjects. Gastric adenocarcinoma/adenoma (OR = 11.090, 95% CI = 3.490-35.236) and low serum PG II level (OR = 0.931, 95% CI = 0.899-0.963) were the independent risk factors for a negative Giemsa staining finding in seropositive subjects. The cutoff value of serum PG II level was 7.45 ng/mL (area under curve [AUC] = 0.904, 95% CI = 0.881-0.927). Follow-up studies of Giemsa staining at different sites of the stomach revealed that 75% of the Giemsa-negative seropositive subjects with adenocarcinoma are positive, whereas none of those with low serum PG II level of <7.45 ng/mL revealed positive findings. CONCLUSIONS: The risk of a negative Giemsa staining finding in seropositive subjects is increased in gastric adenocarcinoma/adenoma specimens and in subjects with a diminished gastric secretory ability with low serum PG II level of <7.45 ng/mL. A false-negative Giemsa staining finding is common in subjects with adenocarcinoma, and therefore, additional biopsies at different sites should be performed in these subjects.

Efficacy and safety of flumazenil injection for the reversal of midazolam sedation after elective outpatient endoscopy.

OBJECTIVE: Midazolam sedation during elective endoscopy is widely performed and flumazenil is frequently administered after endoscopy to reverse sedation in clinical practice. This study aimed to investigate the safety and efficacy of flumazenil injections after elective endoscopy under midazolam sedation. METHODS: Participants who underwent an upper endoscopy under midazolam sedation were randomly divided into two groups. In group I, flumazenil was administered i.v. 10 min after the patient's transfer to the recovery room, and no antidote was injected in group II. The time of stay in the recovery room and adverse events were reviewed through the nursing records. We asked the patients about their pain and degree of satisfaction according to a visual analogue scale (VAS), their memory of the procedure, mental status and the presence of uncomfortable symptoms on the day of the procedure and the day afterwards. RESULTS: The length of stay in recovery was significantly shorter in group I than in group II. No significant differences were found in the number of patients with pain (VAS ≥1), adverse events and discomfort between the two groups. Additionally, there were no differences in the patients' memory of the procedure, satisfaction with sedation, willingness to repeat the endoscopy and mental status. CONCLUSIONS: The time in the recovery room after flumazenil administration was significantly shortened, and the use of the drug did not increase the risk of adverse events or discomfort. The use of flumazenil for reversing midazolam sedation seems to be safe and effective.

Aggressive intravenous hydration with lactated Ringer's solution for prevention of post-ERCP pancreatitis: a prospective randomized multicenter clinical trial.

BACKGROUND AND STUDY AIMS : The present study aimed to determine the type of intravenous hydration that is best suited to reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. PATIENTS AND METHODS: In a prospective randomized multicenter trial, average-to-high risk patients who underwent first-time ERCP were randomly assigned to three groups (1:1:1) who received: aggressive intravenous hydration (3 mL/kg/h during ERCP, a 20-mL/kg bolus and 3 mL/kg/h for 8 hours after ERCP) with either lactated Ringer's solution (LRS) or normal saline solution (NSS), or standard intravenous hydration with LRS (1.5 mL/kg/h during and for 8 hours after ERCP). The primary end point was post-ERCP pancreatitis (PEP). RESULTS: 395 patients were enrolled, and 385 completed the protocols. The three groups showed no significant differences in demographic characteristics. There was a significant difference in the intention-to-treat (ITT) PEP rate between the aggressive LRS group (3.0 %, 95 % confidence interval [CI] 0.1 % - 5.9 %; 4 /132), the aggressive NSS group (6.7 %, 95 %CI 2.5 % - 10.9 %; 9 /134) and the standard LRS group (11.6 %, 95 %CI 6.1 % - 17.2 %; 15 /129; P = 0.03). In the two-group comparisons, the ITT PEP rate was significantly lower for the aggressive LRS group than for the standard LRS group (relative risk [RR] 0.26, 95 %CI 0.08 - 0.76; P = 0.008). There was no significant difference in the ITT PEP rate between the aggressive NSS group and the standard LRS group (RR 0.57, 95 %CI 0.26 - 1.27; P = 0.17). CONCLUSION: Aggressive hydration with LRS is the best approach to intravenous hydration for the prevention of PEP in average-to-high risk patients.

Endoscopic Submucosal Dissection of Early Gastric Cancer in Patients with Liver Cirrhosis.

BACKGROUND AND OBJECTIVES: Endoscopic submucosal dissection (ESD) has become widely accepted method for treating early gastric cancer (EGC), but little is known about its role in patients with liver cirrhosis (LC). The aims of this study were to evaluate the outcomes of ESD in treating EGC in patients with LC. METHODS: The multicenter retrospective study identified 43 patients with chronic hepatitis B (CHB)-related cirrhosis undergoing ESD for treating EGC. The patients (LC group) were subdivided into two groups based on their Child-Pugh classification (CP-class): 32 with CP-class A (LC-A) and 11 with CP-class B (LC-B). The patients were compared to 47 non-cirrhotic CHB patients who underwent ESD (CHB group). Eight patients had a past history of hepatocellular carcinoma (HCC) prior to ESD, but no patients had viable HCC when ESD was performed. RESULTS: Procedural outcomes (en bloc, lateral/basal margins resection) and post-procedural complications (bleeding or perforation) did not differ significantly between the LC and CHB groups or between the LC-A and LC-B groups. No patients experienced worsening of the Child-Pugh score 1 month after ESD compared with the baseline score. During a median observation period of 66 months, the recurrence rates of gastric cancers were similar between the LC and CHB groups (5-year recurrence rates: 2.4 vs. 2.3%, p = 0.925), and all recurrent gastric cancers were completely resected by additional ESD. The overall mortality rate was increased in the LC group (5-year mortality rates: 17.9 vs. 5.7%, p = 0.034), and 8 of 10 deaths were attributed to liver-related diseases (such as HCC, complications of portal hypertension, hepatic failure). CONCLUSIONS: ESD is feasible in patients with EGC and comorbid LC, even those with CP-class B cirrhosis. Their prognosis depends on LC-related diseases and not recurrent EGC.

[Serological Changes after Equivocal Helicobacter pylori-serology Test Findings Dependent on Gastric Secreting Ability].

BACKGROUND/AIMS: The serum anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG) and serum pepsinogen (PG) assays are widely used to screen for gastric cancer. An equivocal serology test finding indicates IgG titer between the positive and negative test findings. This study aims to evaluate the long-term follow-up result after an equivocal test finding on the serum anti-H. pylori IgG assay. METHODS: Koreans aged 18 years or older with an equivocal serum anti-H. pylori IgG assay finding were included. Subjects were excluded if they did not undergo H. pylori serology test, serum PG assay, and upper gastrointestinal (UGI) endoscopy on the same day at our center. The annual test findings were followed-up using the same methods. RESULTS: Of the 7,178 subjects who underwent the serum assays and UGI endoscopy on the same day, 274 (3.8%) subjects showed an equivocal H. pylori serology test finding. Of the 98 subjects who were followed-up, 58 (59.2%) showed seropositive finding at the mean follow-up period of 30.6±12.4 months. Subjects with seroconversion showed a higher initial serum PG I (p=0.023) and PG II (p=0.036) levels than those without seroconversion. CONCLUSIONS: An equivocal H. pylori serology test finding was not rare (3.8%) in Korean adults, and 60% of equivocal subjects showed seroconversion within 3 years. Higher seroconversion rates in subjects with high PG I and PG II levels suggest that intact gastric secreting ability plays a role in the survival of H. pylori. Therefore, equivocal subjects with increased serum PG levels should be considered as potential seropositive subjects.

Factors impacting patient cooperation during elective gastroscopy.

BACKGROUND/AIMS: Some people have difficulty tolerating upper endoscopy. The cause of and risk factors for this are not well known. The aim of this study was to investigate the factors involved in poor cooperation during screening upper endoscopy. METHODS: A total of 4,422 subjects who underwent a health inspection with upper endoscopy carried out by a single experienced endoscopist were included. We retrospectively investigated subjects' self-reporting questionnaires and medical records, including endoscopic and histologic findings. The examinees' cooperation and the completeness of endoscopic examination were evaluated based on the operator's subjective judgment. RESULTS: Examinee cooperation during the endoscopic procedure was poor in 358 out of 4,422 subjects (8.1%). Of the subjects with poor cooperation, the endoscopic examination was incomplete in 36 subjects (10.1%). Multivariate analysis revealed that young age (< 40 years), female sex, high body mass index (≥ 25), hiatal hernia, and procedural sedation using midazolam were independent risk factors for poor cooperation. CONCLUSIONS: Cooperation during screening upper endoscopy was poor in a considerable number of examinees. Endoscopists must keep in mind that examinee cooperation is more likely to be poor in the young, obese people, women, patients with hiatal hernias, and those who receive procedural sedation.

Link between Serum Pepsinogen Concentrations and Upper Gastrointestinal Endoscopic Findings.

The serum pepsinogen (PG) assay findings are correlated with the status of Helicobacter pylori infection, but there are controversies on the link with upper gastrointestinal (UGI) endoscopic findings. The aim of this study was to determine the significance of a serum PG assay for correlating with endoscopic findings in H. pylori-seroprevalent adult population. Korean adults who visited for a health check-up were included consecutively. Subjects after gastrectomy or H. pylori eradication were excluded. After completing the serum PG assay and anti-H. pylori immunoglobulin G (IgG) titer on the same day of UGI endoscopy, subjects with equivocal serology test finding or gastric neoplasm were excluded. Of the 4,830 included subjects, 3,116 (64.5%) were seropositive for H. pylori. Seropositive finding was related to high serum PG I (P < 0.001) and PG II (P < 0.001) concentrations, low PG I/II ratio (P < 0.001), old age (P < 0.001), and male gender (P = 0.006). After adjusting age and gender, the serum PG I and II concentrations were positively correlated with the presence of nodular gastritis (NG) (all P = 0.003). The serum PG I was positively correlated with gastric ulcer (P = 0.003), and it was correlated with duodenal ulcer in seropositive subjects (P = 0.008). The PG I/II ratio was positively correlated with erosive esophagitis, while it was inversely related to chronic atrophic gastritis and metaplastic gastritis (all P < 0.001). Our findings suggest that the serum PG assay finding correlates well with the UGI endoscopic finding. A higher serum PG concentration in subjects with NG and peptic ulcer disease suggests that endoscopic findings reflect gastric secreting ability.

Factors Related to Upper Gastrointestinal Symptom Generation in 2275 Helicobacter pylori Seroprevalent Adults.

BACKGROUND AND AIM: Upper gastrointestinal (UGI) symptoms are common; however, the role of Helicobacter pylori and gastric corpus atrophy in the generation of these symptoms is controversial. The aim of this study was to determine the risk factors for UGI symptoms in adults in an endemic area of H. pylori infection. METHODS: Korean adults who completed questionnaires on the day of serum anti-H. pylori IgG and pepsinogen (PG) assays before UGI endoscopy were included. Gastric corpus atrophy was based on the criteria of a serum PG I/II ratio <3.0 and a PG I <70 ng/ml. RESULTS: Of the 2275 included subjects, 723 (31.8%) had at least one UGI symptom. A total of 374 (16.4%) subjects had multiple symptoms without significant correlations between the symptoms (λ < 0.2). The H. pylori serology assay was positive in 1382 (60.7%) subjects, and gastric corpus atrophy was present in 291 (12.8%). Neither H. pylori seropositivity (p = 0.077) nor gastric corpus atrophy (p = 0.138) was related to the presence of UGI symptoms. Female gender and smoking were independent risk factors for heartburn and upper abdominal pain (all p < 0.001). Furthermore, female gender was the only independent risk factor for multiple UGI symptoms (p < 0.001), globus sensation (p < 0.001), early satiety (p < 0.001), epigastric soreness (p = 0.001), and chest discomfort (p = 0.003). CONCLUSIONS: In an H. pylori seroprevalent population, female gender is the most common risk factor followed by smoking for UGI symptom generation. Neither H. pylori seropositivity nor gastric corpus atrophy is an independent risk factor for UGI symptom generation.

Differences in Prevalence of Lymphovascular Invasion among Early Gastric Cancers between Korea and Japan.

BACKGROUND/AIMS: The presence of invasion is a diagnostic criterion of early gastric cancer (EGC) in Korea, whereas diagnosis in Japan is based on enlarged nuclei and prominent nucleoli. Moreover, the depth of invasion is the location of cancer cell infiltration in Korea, whereas it is the location of lymphovascular invasion (LVI) or cancer cell infiltration in Japan. We evaluated the characteristics of EGC with LVI to uncover the effects of different diagnostic criteria. METHODS: Consecutive T1-stage EGC patients who underwent complete resection were included after endoscopic or surgical resection. The presence of LVI was evaluated. RESULTS: LVI was present in 112 of 1,089 T1-stage EGC patients. LVI was associated with depth of invasion (p<0.001) and age (p=0.017). The prevalence of LVI in mucosal cancer was significantly higher in Korea (p<0.001), whereas that of submucosal cancer was higher in Japan (p=0.024). For mucosal EGC types, LVI was positively correlated with diagnostic criteria applied in Korea (p=0.017). For submucosal EGC types, LVI was positively correlated with Japanese criteria (p=0.001) and old age (p=0.045). CONCLUSIONS: The higher prevalence of LVI for mucosal EGC in Korea and for submucosal EGC in Japan indicates that different diagnostic criteria should be considered when reading publications from other countries.

The outcome of endoscopic management of bile leakage after hepatobiliary surgery.

BACKGROUND/AIMS: Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. METHODS: The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. RESULTS: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy. CONCLUSIONS: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

A randomized controlled trial of prophylactic antibiotics in the prevention of electrocoagulation syndrome after colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is currently commonly performed, but colorectal ESD has a substantial risk of adverse events, including post-ESD electrocoagulation syndrome (PEECS). We investigated whether the use of prophylactic antibiotics can reduce the occurrence of PEECS. METHODS: Patients who underwent colorectal ESD were randomly assigned to 1 of 2 treatment regimens. Ampicillin and/or sulbactam mixed with normal saline solution was administered 1 hour before ESD in group 1 then additionally injected every 8 hours twice more. In group 2, normal saline solution without antibiotics was administered following the same schedule. We investigated the characteristics of the patients and tumors, the incidence of PEECS, laboratory findings, and the visual analog scale (VAS) score for abdominal pain measured on the morning after ESD. RESULTS: A total of 100 cases (50 per group) were finally analyzed, and 97 tumors were successfully resected en bloc. The number of patients having C-reactive protein (CRP) levels ≥1 mg/dL and the number of patients having VAS scores for abdominal pain ≥1 were greater in group 2 than in group 1 (P = .008 and .023, respectively). The incidence of PEECS in group 2 also was higher than that in group 1 (1 and 8 in groups 1 and 2, respectively; P = .031). CONCLUSIONS: The prophylactic use of ampicillin and/or sulbactam in colorectal ESD is associated with reduced risk of PEECS, decreased CRP levels, and decreased abdominal pain. The use of prophylactic antibiotics in colorectal ESD may be an effective tool for reducing the risk of PEECS. (Clinical trial registration number: KCT0001102.).

Impact of endoscopic papillary large-balloon dilation on sphincter of Oddi function: a prospective randomized study.

BACKGROUND AND AIMS: Endoscopic papillary balloon dilation (≤8 mm in diameter) preserves sphincter of Oddi (SO) function. However, it is still unknown whether papillary function is preserved after endoscopic papillary large-balloon dilation (EPLBD, ≥12 mm in diameter). We investigated SO function after EPLBD with or without endoscopic sphincterotomy (EST) by endoscopic manometry, up to 1 year after the procedure. METHODS: This was a prospective randomized study involving patients with bile duct stones ≥12 mm. Eighty-six patients who met the inclusion criteria were assigned randomly to either EPLBD alone or EST with EPLBD, and endoscopic manometric studies were performed. The primary outcome was comparison of the manometric data between the 2 groups and within each group both 1 week and 1 year after the procedure. RESULTS: One week after EPLBD alone and EST with EPLBD, the basal pressure of SO dropped from 30.4 (8.2) to 6.4 (8.4) mm Hg (P < .001) and 29.5 (18.9) to 2.9 (3.6) mm Hg (P < .001), respectively. SO function was not recovered at 1 year; the manometric measurements were similar to those taken at the 1-week time point in both groups. Similar outcomes were obtained in patients with EPLBD alone compared with those with EST and EPLBD, including the initial stone clearance rate (95.2% vs 97.7%, P = .612), the frequency of mechanical lithotripsy (21.4% vs 13.6%), and overall adverse events (11.9% vs 13.6%, P = 1.0) including the rate of pancreatitis after the procedure (7.1% vs 11.4%, P = .714). During an overall median follow-up of 17.8 months, the recurrence rate of bile duct stones was 16.7% in patients who underwent EPLBD alone and 15.9% in patients who underwent EST with EPLBD (P = .924). CONCLUSIONS: Both EPLBD alone and EST + EPLBD resulted in persistent and comparable loss of SO function after 1 year. EPLBD alone has similar efficacy and safety to those of EST with EPLBD with respect to removal of large stones.

Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease.

BACKGROUND/AIMS: Peptic ulcer disease (PUD) is a common condition, but is difficult to detect in asymptomatic individuals. We aimed to investigate the prevalence of symptomatic and asymptomatic PUD during screening endoscopy and to identify risk factors for the presence of symptoms in patients with PUD. METHODS: We investigated subjects who underwent a health inspection, including endoscopy of the upper gastrointestinal (GI) tract and a serum anti-Helicobacter pylori IgG assay, and who completed a self-report questionnaire about their symptoms. RESULTS: Of the 12,852 subjects included in the study, 124 (1.0%) had symptomatic PUD and 309 (2.4%) had asymptomatic PUD. Old age, current smoking, and H. pylori infection were independent risk factors for symptomatic and asymptomatic PUD. Use of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent risk factor only for symptomatic PUD (p=0.040). Compared to subjects with asymptomatic PUD, subjects with symptomatic PUD were more likely to have active-stage ulcers (p=0.002) and to drink more heavily (p=0.005). CONCLUSIONS: Use of NSAIDs is a risk factor for symptomatic PUD, but not for asymptomatic PUD. Excessive alcohol consumption and active-stage ulcers in patients with PUD are related to the presence of gastroduodenal symptoms.

The Clinical Features and Predisposing Factors of Asymptomatic Erosive Esophagitis.

BACKGROUND: Asymptomatic erosive esophagitis (AEE) is considered an erosive esophagitis without the typical reflux symptoms, but the clinical course and significance of AEE is still unclear. AIM: We investigated the prevalence and predisposing factors of AEE, and tried to determine its clinical features and significance. METHODS: Subjects, who had at least two health inspections (upper endoscopy, self-reporting questionnaire, and serum Helicobacter pylori IgG antibody test) at our center, were enrolled. The questionnaire included typical reflux symptoms, previous medical history, underlying disease, smoking, alcohol intake, and medication history. Based on the results of follow-up study, the changes in endoscopic findings and reflux symptoms were also investigated. RESULTS: Of the 2961 patients visiting our clinic, 568 (19.2 %) were diagnosed with AEE. Age over 50 years, male sex, a body mass index over 25, current smoking, heavy drinking, negativity for H. pylori infection, and hiatal hernia were independent predisposing factors for AEE (p = 0.020, p < 0.001, p < 0.001, p = 0.013, p = 0.003, p < 0.001, p = 0.038, respectively). Within the follow-up period (mean 25 ± 9.5 months), reflux symptoms developed in 30 subjects (7.9 %), and current smoking was the only risk factor for the development of AEE symptoms (p = 0.015). On the follow-up endoscopy, erosive esophagitis disappeared in nearly half of the subjects with AEE (174, 45.6 %). CONCLUSIONS: AEE is common, but many cases of AEE may be spontaneously cured without treatment. Although symptom development is rare, quitting smoking may be helpful as a prevention strategy. CLINICAL TRIAL REGISTRATION NUMBER: KCT0001716.