A comparative study of rubber band ligation versus BANANA-Clip in grade 1 to 3 internal hemorrhoids

Purpose@#Rubber band ligation (RBL) for grade 1 to 3 internal hemorrhoids is a well-established modality of choice. But RBL is also a kind of surgical treatment; it is not free from complications (e.g., delayed bleeding [DB], rectal stenosis). This study aimed to investigate the results of the comparative treatment of RBL and BANANA-Clip (BC; Endovision). @*Methods@#Study participants were 632 consecutive patients with grade 1 to 3 internal hemorrhoids attended to Department of Colorectal Surgery at Wellness Hospital between January 2010 and May 2019. We retrospectively reviewed the incidence rate of complications, including DB between RBL and BC. @*Results@#There were 304 male and 328 female patients, whose ages ranged from 15 to 84 years, with a mean age of 45.7 years. The common symptom and cause of treatment was prolapse (70.1%). The number of ligated sites was 1.49±0.57 in the RBL group and 1.99±0.77 in the BC group. RBL showed a significantly higher incidence of DB (3.5%) compared to BC (0%) (P=0.001). The 1-year success rate was 95.9% in the RBL group and 99.7% in the BC group (P=0.005). @*Conclusion@#In our study, BC was more reliable in treating grade 1 to 3 internal hemorrhoids with higher success rates and less post-ligation complications, especially DB, compared to RBL.

The Usefulness of Heavy Smoking Index as a Test for Nicotine Dependence

BACKGROUND: The Fagerstrom Test for Nicotine Dependence (FTND) is a widely used six-item questionnaire. Its completion require a few minutes, but such time may be too much for busy clinicians and large epidemiologic surveys. The goals of this study was to compare the sensitivity and the specificity of Heavy Smoking Index (HSI) of high nicotine dependence. METHODS: The FTND was administered to 943 current smokers from a smoking-cessation clinic in Gwangjin-gu, Seoul. The HSI which combines two items of the FTND (the number of cigarettes per day and the time of the first cigarette of the day) was compared to the FTND. We measured cigarette per day, duration of smoking, and age of smoking initiation. RESULTS: A cutoff score equal or greater than 4 on the HSI detected a similar rate of nicotine dependence as a cutoff score equal or greater than 6 on the FTND. The HSI showed a sensitivity of 88.0% and a specificity of 86.5%. The concordance between the two instruments was high (kappa= 0.74). CONCLUSION: The HSI was proven to be very useful. If HSI had a proper validity, the HSI can be a good standard of high nicotine dependence for busy clinician and epidemiologists.

Gene Expression Profiling using Oligonucleotide Microarray in Atrophic Gastritis and Intestinal Metaplasia / 대한소화기학회지

BACKGROUND/AIMS: The atrophic gastritis with intestinal metaplasia of gastric mucosa has been considered to be the major factor of carcinogenesis in the stomach. However, the key molecules are still poorly understood. To elucidate the molecular genetic basis, we report the results of our initial microarray data to analyze the genome pattern in patients with atrophic gastritis and intestinal metaplasia of the stomach. METHODS: We used oligonucleotide microarray technique to evaluate the gene expression profiles in atrophic gastritis with intestinal metaplasia, in comparison with those of normal mucosa. For the identification of differentially expressed genes, Significance Analysis of Microarrays (SAM) package method was used. The results were analyzed using global normalization, intensity dependent normalization, and box plot normalization. RESULTS: Eight genes including FABP, REG, OR6C1, MEP1, SLC6A1, SI, Mucin 1, and RAB23 in mucosa of atrophic gastritis and intestinal metaplasia were up-regulated by more than 10 times as compared with normal gastric mucosa. Only one gene, LOC44119 was down-regulated by more than 10 times of the expression as compared with normal gastric mucosa. In respect to the expression of known genes related to gastric carcinogenesis, 8 genes including FN1, SRMS, TP53, TP53IMP2, TP53I3, FGFR4, TGFB1, and TGFA showed up- and down-regulations more than 2 folds in expression pattern. CONCLUSIONS: We could identify a total genome pattern in patient with atrophic gastritis and intestinal metaplasia using oligonucleotide microarray. We believe that the current results will serve as a fundamental bioinformative basis for clinical applications in diagnosis and treatment of gastric cancer and precancerous lesion in the future.

Factors associated with Receiving Rescreening in High Risk Group Diagnosed by Endoscopic Screening of Stomach Cancer

BACKGROUND: Stomach cancer is the most common cancer in Korea. Lifelong health management program recommends that males over 40 years and women over 50 years should undergo stomach cancer screening by endoscopy or upper gastrointestinal series every two years. The importance of re-screening of stomach cancer in a high risk group is emphasized. METHODS: A telephone questionnaire was done one year after to 123 patients over 40 years old considered as a high risk group with either chronic atropic gastritis, intestinal metaplasia, gastric ulcer, gastric adenoma among 804 subjects who had undergone anendoscopic examination from February 2002 to June 2003 at a university hospital health promotion center. RESULTS: The number of patients who responded were 109. The average recognition rate of high risk group was 53.2%. The rate of recognition of high risk group was lower in good subjective health estimation group and in less educated group, in old age group, and in chronic atrophic gastritis and intestinal metaplasia group. The rate of not receiving re-screening after 1 year was 48 (44.0%). Re-screening rate in patients with intestinal metaplasia (35.3%) and chronic atropic gastritis (39.1%) compared to gastric ulcer (77.8%) and gastric polyp (90.0%), in those not recognizing themselves as high risk group, in low education group, in old age, was lower. CONCLUSION: In patients with chronic atropic gastritis and intestinal metaplasia, in those not recognizing themselves as high risk group, in old age and in good subjective health state. We need to educate the importance for regular screening of stomach cancer more intensively.

A Pilot Study as the Biochip Based Gene Expression Profiling in Patients with Hyperplastic Colonic Polyp

PURPOSE: A microarray-based gene expression analysis may offer a rapid and efficient means for assessing. However, the molecular genetic change in nonneoplastic colonic polyp is still poorly understood. To elucidate the molecular genetic basis, We now report the results of our initial microarray data to analyze the genom pattern in patients with hyperplastic polyps of colon. METHODS: 36 samples (18 pairs of colonic polyps and normal colonic mucosa were) harvested from colonoscopic biopsy. 3 of 18 colonic polyps were pathologically identified as the serrated type of hyperplastic polyp. We used the oligonucleotide microarray technique for analysis of the expression profiles of serrated polyps and normal mucosa. For the identification of differentially expressed genes, SAM (Significance Analysis of Microarray) package method was used. The result was analysed by using global normalization, intensity dependent normalization and block-wise normalization. RESULTS: Polypectomy specimens microscopically showed the pathologically characteristic serration with a saw-teeth like luminal border (branching of the crypts). 8 genes including RHEB (Ras homolog enriched in brain), WASF2 (WAS protein family, member 2), TYRP1 (Tyrosinase-related protein 1), VSX1 (Visual system homeobox 1 homolog), ROS1 (V-ros UR2 sarcoma virus oncogene homolog 1), WEE1 (WEE1 homolog), TEC (Tec protein tyrosine kinase), TNFRSF10A (Tumor necrosis factor receptor superfamily, member 10a) in serrated polyp were up-regulated by more than 10 times as compared with normal colonic mucosa. On the other hand, 6 genes including SIAT7D (Sialyltransferase 7D), DRD1 (Dopamine receptor D1), SIAT1 (Sialyltransferase 1), ITSN1 (Intersectin 1), TNFSF12 (Tumor necrosis factor superfamily, member 12), CHES1 (Checkpoint suppressor 1) were down-regulated by less than a tenth of the expression as compared with normal colonic mucosa. CONCLUSIONS: Serrated polyps as a subset of hyperplastic colonic polyps were analyzed with the oligonucleotide microarray technique. We authors could identify 14 genes (8 up-regulated and 6 down-regulated genes) that showed the significant change of expression as compared with normal colonic mucosa. Specifically, we believe that current study will serve as a fundamental base to offer a bioinformative characteristics of the serrated colonic polyp in future clinical applications.

Solitary Neurofibroma of the Nasal Cavity: Transnasal Endoscopic Excision / 대한이비인후과학회지

Neurofibroma is a neurogenic tumor arising from schwann cells or peripheral tissues of nerve sheaths. It is extremely rare in the sinonasal tract. We report on a case of neurofibroma of the nasal cavity treated by endoscopic surgery. Preoprative computed tomography (CT), magnetic resonance imaging (MRI), and punch biopsy suggested that the tumor was benign neurogenic tumor confined to right nasal cavity. The tumor was removed with endoscopic surgery completely, and confirmed as neurofibroma by histological and immunohistochemical examination. We discuss the clinical and pathological characters of neurofibroma arising in the nasal cavity

Epstein-Barr Virus and p16INK4A Methylation in Squamous Cell Carcinoma and Precancerous Lesions of the Cervix Uteri

Methylation of p16 is an important mechanism in cervical carcinogenesis. However, the relationship between cervical squamous cell carcinoma (SCC) and Epstein-Barr virus (EBV) remains controversial. Here, we explored whether EBV infection and/or p16 gene inactivation would play any role in cervical carcinogenesis. Eighty-two specimens included 41 invasive SCCs, 30 cervical intraepithelial neoplasm (CIN; CIN 1, 11 cases, CIN II, 3 cases, CIN III 16 cases) and 11 nonneoplastic cervices. EBV was detected by polymerase chain reaction (PCR) for EBNA-1 and in situ hybridization for EBER-1. The p16 methylation-status and the expression of p16 protein were studied by methylation-specific PCR and immunohistochemistry, respectively. The materials were divided into four groups: 1) nonneoplastic cervices, 2) CIN I, 3) CIN II-III and 4) invasive SCCs. p16 methylation and p16 immunoexpressions increased in CIN and invasive SCCs than nonneoplastic tissue. p16-methylation and p16-immunoreactivities were higher in the EBV-positive group (p=0.009, p<0.001) than in the EBV-negative group. EBV was detected more frequently in CIN and SCCs than nonneoplastic cervices. In conclusion, a correlation between p16 methylation, p16 immunoreactivity and the detection of EBV strongly suggested that the cooperation of EBV and p16 gene may play a synergic effect on cell cycle deregulation.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests. METHODS: One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography. RESULTS: The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types. CONCLUSIONS: Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Microsatellite Instability and Clinicopathologic Significance in Colon Cancer Patients

PURPOSE: Colon cancer shows various genetic alterations in its development and progression. Recently, microsatellite instability (MSI) has been related to a novel mechanism of carcinogenesis, and might be a useful prognostic factor in several gastrointestinal malignancies. The loss of heterozygosity (LOH) is known to be related with the allelic loss of various tumor suppressor genes, however, MSI, which has been found to result from an erroneous DNA mismatch repair system, has been known to be involved in the carcinogenesis of hereditary non-polyposis colon cancers and some aspects of sporadic colorectal cancers. In this study, the status of MSI was examined in sporadic colon cancers, and its correlation with various clinico-pathological parameters investigated. METHODS: Fifty sporadic colorectal cancers, treated by surgery alone, were analyzed for the presence of MSI using microsatellite markers, and tumor and normal DNA, obtained from formalin-fixed paraffin-embedded archival tissues. MSIs were examined at the BAT25, BAT26, D2S123, D5S346 and D17S250 loci, as recommended in the 1997 NIH International Workshop on Microsatellite Instabilities and RER phenotypes. RESULTS: MSI was detected in 11 cases (22%), and was more frequently detected in the non-metastatic adenocarcinoma and Astler-Coller stages A+B1+C1 groups than in the metastatic and B2+C2+D groups. Also, there were no metastatic cases in the MSI-high group, where more than 3 loci had MSI. LOH was detected in three of the recommended markers, and was observed in 17 cases (34%). LOH was more highly detected in the metastatic and B2+C2+D groups, but there was no correlation with the clinico-pathological parameters. However, no LOH-positive cases were found in the MSI-positive group. CONCLUSION: These results suggest that MSI may be partially involved in colorectal carcinogenesis and the metastasis mechanism. Also, the clinical use of the MSI status may help in determining the prognosis of colorectal cancer patients.

Outcome and Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Non- relaxing Puborectalis Syndrome

PURPOSE: Biofeedback is a major treatment method for constipated patients with non-relaxing puborectalis syndrome. However a significant percent of patients still showed poor outcome, and little has been known about the predictors associated with outcome of biofeedback. The aim of this study was to determine the outcome and identify predictors associated with poor outcome of biofeedback therapy for constipated patients with non- relaxing puborectalis syndrome. METHODS: Fifty-two constipated patients with non-relaxing puborectalis syndrome (median age, 47 years) who had more than one biofeedback session after defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were analyzed. Any differences in demographics, clinical symptoms, and parameters of anorectal physiological study were evaluated between success group (patients felt improvement in symptoms at follow-up) and failure group (patients felt no improvement). RESULTS: Follow up (mean follow-up; 17 months) results were evaluated by an independent observer in 45 patients. At post-biofeedback, 42 (81 percents) patients felt improvement in symptoms, including 7 (13 percents) with complete symptom relief. At follow-up, 25 (56 percents) patients felt improvement in symptoms, including 1 (2 percents) with complete symptom relief. There was a significant reduction in difficult defecation (from 81 to 44, 53 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.005, P<0.01), sensation of incomplete defecation (from 90 to 50, 40 percent; P< 0.00001, P<0.000005), laxative use (from 25 to 10, 11 percent; P<0.05), and enema use (from 13 to 0, 2 percent; P<0.01, P<0.05). Normal spontaneous bowel movement was increased from 42 percent pre-biofeedback to 81 percent post-biofeedback (P<0.0001), 80 percent at follow up (P<0.0005). Pre-biofeedback presence of symptoms of bowel habit change predict poor outcome (15 vs. 0 percent; failure vs. success, P<0.05). High pressure zone in prebiofeedback manometry was longer in failure group than in success group (2.80 vs 2.01 cm, P<0.05). In the success group, 11 (44 percent) had a rectocele, 1 (4 percent) had a rectal intussussception, 18 (72 percent) had a descending perineal syndrome, and 3 (12 percent) had a sigmoidocele. In the failure group, 4 (20 percent) had a rectocele, and 1 (5 percent) had a rectal intussusception, 14 (70 percent) had a descending perineal syndrome, and a sigmoidocele was not accompanied (P<0.05). Accompanied rectocele, rectal intussusception, descending perineal syndrome, and sigmoidocele did not influence outcome. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy. Bowel habit change and long high pressure zone in pre-biofeedback manometry were predictors associated with poor outcome of biofeedback therapy for constipated patients with non-relaxing puborectalis syndrome.

Characteristic Findings and Their Clinical Appraisal of Proctography and Cinedefecography in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: We were assessed the characteristic findings of defecography and cinedefecography in patients with pelvic outlet obstructive disease, and compared the characteristic physiologic findings between proctography and cinedefecography. METHODS: Physiologic findings of 196 patients who were performed at least two items of physiologic tests were retrospectively evaluated. Patients were categorized as rectocele (Group I: n=119), nonrelaxing puborectalis syndrome (Group II: n=58), rectoanal intussusception (Group III: n=16), significant sigmoidocele (Group IV: n=3). The proctographic and cinedefecographic features were analyzed according to disease categories. The sensitivity, specificity, accuracy, false positive rate, false negative rate, diagnostic rate, and reproducibility were calculated, and we analyzed the difference between proctography and cinedefecography according to the disease groups. RESULTS: On the proctographic examinations; 1) 112 patients were confirmed as a clinically significant rectocele (n=128, sensitivity; 94%, specificity; 79%, accuracy; 88%, false positive rate; 21%, false negative rate; 6%, kappa; 0.749). 2) A clinically significant nonrelaxing puborectalis were 36 patients (n=73, sensitivity; 62%, specificity; 73%, accuracy; 70%, false positive rate; 27%, false negative rate; 38%, kappa; 0.328). 3) 12 patients were confirmed as significant rectoanal intussusception (n=31, sensitivity; 75%, specificity; 89%, accuracy; 88%, false positive rate; 11%, false negative rate; 25%, kappa; 0.425). 4) 3 patients were confirmed as clinically significant sigmoidocele (n=15, sensitivity; 100%, specificity; 94%, accuracy; 94%, false positive rate; 6%, false negative rate; 0%, kappa; 0.316). On the combination of proctography and cinedefecography; 1) 117 patients were confirmed as a clinically significant rectocele (n=122, sensitivity; 98%, specificity; 94%, accuracy; 96%, false positive rate; 6%, false negative rate; 2%, kappa; 0.925). 2) A clinically significant nonrelaxing puborectalis were 50 patients (n=64, sensitivity; 86%, specificity; 90%, accuracy; 88%, false positive rate; 10%, false negative rate; 14%, kappa; 0.738). 3) 16 patients were confirmed as significant rectoanal intussusception (n=22, sensitivity; 100%, specificity; 97%, accuracy; 97%, false positive rate; 3%, false negative rate; 0%, kappa; 0.826). 4) 3 patients were confirmed as clinically significant sigmoidocele (n=9, sensitivity; 100%, specificity; 97%, accuracy; 97%, false positive rate; 3%, false negative rate; 0%, kappa; 0.488). As compared with combined study (proctography plus cinedefecography), the proctography show decreased diagnostic rates in the evaluation of rectocele (P<0.05), nonrelaxing puborectalis (P<0.01), and rectoanal intussusception (P<0.05). And, the proctography also show increased false positive rate in the evaluation of rectocele (P<0.01), nonrelaxing puborectalis (P<0.01), and rectoanal intussusception (P<0.05). CONCLUSIONS: In our study, proctography showed a tendency to overdiagnosis. Therefore, the combined study of proctography and cinedefecography should be taken as a diagnostic tools for pelvic outlet obstructive disease. Adhering to these findings, other anorectal physiologic studies should be added for the clinically significant diagnosis.

Measurement of Pancreatic Islet Cell Autoantibodies by ELISA and RIA in Patients with Diabetes Mellitus / 대한임상병리학회지

BACKGROUND: The isoenzyme of glutamate decarboxylase (GAD), islet associated antigen (IA2, IAA) and insulin are known to be the major target antigens of pancreatic islet cell autoantibody as a predictor of type 1 diabetes mellitus (DM). Generally radioimmunoassay (RIA) methods are used for these autoantibodies but inconvenience of dealing with radioisotope have made enzyme-linked immunosorbent assay (ELISA) developed for clinical utilization. But, lack of evaluation or comparison studies of these two methods for autoantibodies make laboratories hesitate to adopt. METHODS: We measured the glutamate decarboxylase autoantibody (GADA), insulin autoantibody (IAA) and pancreatic islet cell autoantibodies (ICA) by a commercial ELISA method in 34 patients with type 1 DM, and 31 patients with type 2 DM, and 32 healthy control group. Conventional RIA was performed concurrently and compared for GADA and IAA. ICA was measured by conventional indirect immunofluorescent assay (IFA). The obtained results were compared and also C-peptide level was measured as a marker for residual function of islet cell of pancreas. RESULTS: Each autoantibody measured by ELISA in type 1 DM showed positive rate of 11.8% and for ICA, 26.5% for GADA, and 35.3% for IAA. The positive rate of the same group of type 1 DM when using RIA were 76.5% for GADA far exceeding that of ELISA method, and 29.4% for IAA. The percentage of positivity in combination of the ELISA methods for ICA and GAD yielded 29.4%, ICA plus IAA showed 38.2%, and GAD plus IAA was 52.9%, respectively. IAA positive rates in two groups divided by the age of 10 showed no significant difference. The presence of the autoantibodies did not influenced the C-peptide level. CONCLUSIONS: Further large scale studies including prediabetic state and autoimmune diabetes are required to establish the accurate diagnostic method of islet cell autoantibodies. But, presently ELISA method was considered that more improvement was needed for reliable and comparable results especially GADA.