Gastroparesis might not be uncommon in patients with diabetes mellitus in a real-world clinical setting: a cohort study.

BACKGROUND: This study investigated the frequency of diabetic gastroparesis and associated risk factors in a real-world clinical setting. METHODS: This retrospective cross-sectional study included patients who underwent assessments of solid gastric emptying time (GET) by technetium-99 m scintigraphy between May 2019 and December 2020. We categorized patients into three groups according to gastric retention of technetium-99 m: rapid (< 65% at 1 h or < 20% at 2 h), normal (≤60% at 2 h and/or ≤ 10% at 4 h), and delayed (> 60% at 2 h and/or > 10% at 4 h). RESULTS: Patients with diabetes mellitus (DM) were more likely to show abnormal GET than those without DM (119 [70.8%] vs. 16 [44.4%]). The mean glycated A1c was 10.3% in DM patients. DM patients with normal GET were significantly younger (57.2 years, P = 0.044) than those with delayed (65.0 years) or rapid GET (60.2 years). Fasting glucose levels were the lowest in the normal GET group and the highest in the rapid GET group (delayed: 176.3 mg/dL, normal: 151.2 mg/dL, rapid: 181.0 mg/dL, P = 0.030). However, glycated A1c was not significantly different among the delayed, normal, and rapid GET groups in patients with DM. Patients with delayed and rapid GET showed a higher frequency of retinopathy (6.0 vs. 15.5%, P = 0.001) and peripheral neuropathy (11.3 vs. 24.4%, P = 0.001) than those with normal GET. In the multinomial logistic regression analysis, retinopathy demonstrated a positive association with delayed GET, while nephropathy showed a significant negative correlation. CONCLUSION: DM gastroparesis in the clinical setting was not uncommon. Abnormal GET, including delayed and rapid GET, was associated with DM retinopathy or peripheral neuropathy.

Rescue technique for self-expandable metallic stent placement using ultrathin endoscope after failure of the conventional method in patients with malignant colon obstruction: a multicenter retrospective study.

BACKGROUND AND AIMS: Self-expandable metallic stents (SEMS) can be used to treat malignant colorectal obstruction (MCO). Guidewire insertion to the proximal site of MCO is the most important step for SEMS placement. However, some patients cannot undergo guidewire insertion because of total obstruction or location at anatomically challenging areas. We report a guidewire insertion technique using an ultrathin endoscope (UTE) in patients with MCO in whom conventional SEMS insertion failed. METHODS: This study was a retrospective cohort study conducted at three academic centers in Korea. The medical records of 956 consecutive patients who underwent SEMS placement during 2012-2021 were analyzed. After failing guidewire insertion using a colonoscope, a UTE was inserted. Guidewire insertion was done through the working channel of the UTE. Following guidewire insertion, the endoscope was removed from the patient. While removing the endoscope, the guidewire was advanced to be located at the originally inserted site. Then, the colonoscope was inserted over the guidewire, and SEMS was replaced. RESULTS: Conventional SEMS insertion failed in 75 patients. Of these, guidewire insertion using a UTE was tried in 59 patients. The rate of technical success was 91.5% (54/59). Considering all patients, the overall technical success rate of SEMS placement was 97.8% (935/956). This technique increased the technical success rate by 5.6% among the total cohort. CONCLUSIONS: The UTE facilitated guidewire insertion and enhanced the overall success rate for SEMS placement. In addition, this technique can be used as a rescue method when guidewire insertion fails using a colonoscope.

Comparison of precutting endoscopic mucosal resection and endoscopic submucosal dissection for large (20-30 mm) flat colorectal lesions.

BACKGROUND AND AIM: The complete and safe removal of large (≥ 20 mm) colorectal lesions is an area of concern. Endoscopic submucosal dissection (ESD) effectively removes these lesions compared with endoscopic mucosal resection (EMR). However, ESD requires advanced techniques, longer procedure time, and high cost. Precutting EMR (EMR-P) is a modified EMR method that overcomes the limitations of EMR. This study aimed to compare the efficacy and safety of EMR-P and ESD in large (20-30 mm) flat colorectal lesions. METHODS: This was a retrospective analysis of cases in which 20- to 30-mm flat colorectal lesions were resected at Seoul St. Mary's Hospital from January 2014 to December 2019. Propensity score matching was performed to control for possible confounders. RESULTS: Two hundred and ninety-nine patients were included in this study. After matching, 90 patients were assigned to each group. There were no significant difference in complete resection rates (92.2% vs 92.2%, P = 1.000), en bloc resection rates (95.6% vs 97.8%, P = 0.682), and mean size of lesions (22.9 ± 3.1 mm vs 23.0 ± 3.1 mm, P = 0.867) between EMR-P and ESD. Procedure time was significantly shorter with EMR-P (11.0 ± 6.5 min vs 37.0 ± 19.3 min, P < 0.001). The adverse events rate was not significantly different between both groups. No local recurrence occurred in both groups. CONCLUSIONS: Precutting EMR was not significantly different to ESD in terms of complete resection rate and en bloc resection rate for 20- to 30-mm flat colorectal lesions without fibrosis. Furthermore, EMR-P has shorter procedure time than ESD. EMR-P could be considered one of standard treatments for large flat colorectal lesions.

Comparison of 2 L Polyethylene Glycol Plus Ascorbic Acid and 4 L Polyethylene Glycol in Elderly Patients Aged 60-79: A Prospective Randomized Study.

BACKGROUND: The bowel-cleansing efficacy and safety of 2 L polyethylene glycol (PEG) with ascorbic acid (2L PEG + Asc) has rarely been studied in the elderly population. In this randomized trial, we compared the bowel cleanliness, safety, and tolerability of 2L PEG + Asc with those of 4 L PEG in an elderly population aged 60-79. METHODS: Study participants were randomized either to 2L PEG + Asc or 4L PEG. The primary endpoint was the success rate of bowel preparation, using the Boston Bowel Preparation Scale. Before colonoscopy, all participants were questioned about adverse events and tolerability regarding purgative ingestion. RESULTS: A total of 347 individuals were enrolled (2L PEG + Asc, 174; 4L PEG, 173). Mean age in the 2L PEG + Asc and the 4L PEG was 69.3 ± 5.6 and 69.3 ± 5.0, respectively (P = 0.917). The rate for successful bowel cleansing was comparable between the 2L PEG + Asc (92%) and the 4L PEG (96%, P = 0.118). Total ingested liquid including purgative and water was lower in the 2L PEG + Asc group (2.9 L) than in the 4L PEG group (4.2 L, P < 0.001). The tolerability of purgative was superior in the 2L PEG + Asc (overall satisfaction, P < 0.001; willingness to reuse, P < 0.001). There were no serious adverse events during the trial. CONCLUSIONS: The bowel-cleansing efficacy of 2L PEG + Asc was comparable to that of 4L PEG. Tolerability was superior in the 2L PEG + Asc group. For older people, 2L PEG + Asc is an efficacious and safe bowel cleanser. (Clinical trial registration number: KCT0004123).

Circumferential submucosal incision prior to endoscopic mucosal resection versus conventional endoscopic mucosal resection for colorectal lesions with endoscopic features of sessile serrated lesions.

BACKGROUND AND AIMS: Sessile serrated lesions (SSLs) are more prone to incomplete resection than conventional adenomas. This study evaluated whether circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) can increase the rate of complete and en bloc resections of colorectal lesions with endoscopic features of SSL. METHODS: Retrospective analyses and propensity score matching were performed for the resection of colorectal lesions ≥ 10 mm with endoscopic features of SSL. RESULTS: After 1:1 ratio matching, 127 lesions in the CSI-EMR group and 127 in the EMR group were selected for analysis. The median size of the lesions was 15 mm (IQR 12-16) in both groups. There was no significant difference in either the complete resection rate or en bloc resection rate between CSI-EMR and EMR groups (96.9% vs. 92.9%, P = 0.155; 92.1% vs. 89.0%, P = 0.391). By contrast, the R0 resection rate was significantly higher in the CSI-EMR group than in the EMR group (89.8% vs. 59.8%, P < 0.001). The median procedure time was significantly longer in the CSI-EMR group than in the EMR group (6.28 min vs. 2.55 min, P < 0.001), whereas there was no significant difference between the two groups in the incidence of adverse events or recurrence rate. Multivariate analysis showed that CSI-EMR was the only factor significantly associated with R0 resection (P < 0.001). CONCLUSIONS: For colorectal lesions with endoscopic features of SSL, CSI-EMR does not increase the complete or en bloc resection rate, but does increase the R0 resection rate. The procedure time is longer for CSI-EMR than EMR. The association of CSI-EMR with R0 resection and non-recurrence should be further evaluated.

Implementation effect of institutional policy of EGD observation time on neoplasm detection.

BACKGROUND AND AIMS: The observation time in EGD is associated with detection rate of premalignant or neoplastic lesions in the upper GI (UGI) tract. The aim of this study was to evaluate an institutional policy of EGD observation time on the detection rate of UGI neoplasms. METHODS: From July 2017 to March 2019, all endoscopists were requested to comply with our institutional policy of spending more than 3 minutes of observation time in every screening EGD. Observation time was defined as the time from when the endoscope reached the duodenum to when it was withdrawn. We obtained a neoplasm detection rate (NDR) during this period and compared it with that of a baseline period from 2009 to 2015. RESULTS: During the study period, 30,506 EGDs were performed. Mean subject age was 49.9 ± 10.5 years, and 56.5% were men. All endoscopists achieved an average EGD observation time of more than 3 minutes during this period. Mean observation time was 3:35 ± 0:50, which was significantly longer than the baseline (2:38 ± 0:21, P < .001). NDR was .33%, which was higher than the baseline (.23%, P < .001). Even after adjusting for subjects' age and gender, smoking history, and endoscopists' biopsy sampling rate, prolonged EGD observation time of more than 3 minutes increased the NDR of UGI neoplasms (odds ratio, 1.51; 95% confidence interval, 1.21-1.75). CONCLUSIONS: This study provides evidence that implementing a protocol of a prolonged observation time could increase NDR. Observation time should be an important quality indicator of the EGD examination.

Increased incidence of metachronous gastric neoplasm after endoscopic resection in patients with synchronous gastric neoplasm.

BACKGROUND: Recurrence risk is a major concern after endoscopic resection (ER) of gastric neoplasms. This study was to compare metachronous risk in patients with and without synchronous neoplasms after complete ER. METHODS: After ER for gastric neoplasms, patients were divided into those with and without synchronous neoplasm. The metachronous risk of gastric neoplasms was compared between the two groups. RESULTS: After ER of 678 cancers and 891 adenomas, synchronous neoplasm was found in 11.8% of cancers and 11.4% of adenomas. In the multiple (n = 182) and the single group (n = 1387), metachronous neoplasms occurred in 18.1 and 8.6%, respectively (HR 2.40; 95% CI, 1.62-3.34). When the pathology of the recurred lesion was limited to cancer, metachronous risk was also significantly higher in the multiple than in the single group (HR, 2.2; 95% CI, 1.17-3.85). In the recurred pathology of the multiple group, cancer development was frequently observed in patients with cancer compared to those with only adenomas in the synchronous lesion (67.0% vs. 13.0%, respectively; P = 0.023). CONCLUSIONS: This study demonstrated that metachronous risk was significantly higher in patients with synchronous gastric neoplasms after ER. Therefore, meticulous examination is important in patients with synchronous neoplasm.

Comparative efficacy of per-oral endoscopic myotomy and Heller myotomy in patients with achalasia: a meta-analysis.

BACKGROUND AND AIMS: Although both per-oral endoscopic myotomy (POEM) and Heller myotomy (HM) have been used for the treatment of achalasia, the comparative efficacy of POEM and HM has yet to be fully evaluated. METHODS: We searched all relevant studies published up to September 2018 examining the comparative efficacy between POEM and HM. Study quality was assessed using the Newcastle-Ottawa scale. Meta-analyses for Eckardt scores, perioperative outcomes, and reflux-related outcomes were performed based on a random-effects model. RESULTS: Fifteen studies with a total of 1213 patients were evaluated. The follow-up duration ranged from 2 to 46.2 months and from 2 to 54.2 months in the POEM and HM groups, respectively. Postoperative Eckardt scores were lower (better) in the POEM group than in the HM group (pooled standardized mean difference [SMD], -0.58; 95% confidence interval [CI], -1.03 to -0.13). Length of myotomy was greater in the POEM group than in the HM group (pooled SMD, 0.63; 95% CI, 0.42-0.84). There was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups (pooled risk ratio [RR], 1.03; 95% CI, 0.61-1.73; and pooled RR, 1.22; 95% CI, 0.67-2.25, respectively). Erosive esophagitis on endoscopy tended to be less common in the HM group (pooled RR, 1.88; 95% CI, 0.98-3.62). CONCLUSION: Although long-term follow-up data are insufficient, the short-term efficacy of POEM was superior to that of HM. Erosive esophagitis tended to be more common in the POEM group; however, there was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups.

The effect of photo-documentation of the ampulla on neoplasm detection rate during esophagogastroduodenoscopy.

BACKGROUND: A few studies have investigated quality indicators of esophagogastroduodenoscopy (EGD) for identifying upper gastrointestinal (GI) malignancy. The current study aimed to evaluate whether the rate of ampulla photo-documentation could be associated with the detection of upper GI neoplasms. METHODS: We used data from 111 962 asymptomatic patients who underwent EGD performed by 14 endoscopists at a health promotion center. The rate of ampulla photo-documentation was calculated by reviewing EGD photos archived during each endoscopist's first year of working at the center. The detection of neoplasms during a 7-year period was investigated. We examined the association between the rate of ampulla photo-documentation and the rate of neoplasm detection. RESULTS: The mean rate of ampulla photo-documentation was 49.0 % (range 13.7 % - 78.1 %) during endoscopists' first year of working at the center. Endoscopists' rates of ampulla photo-documentation significantly correlated with the detection of total neoplasms (R2 = 0.57, P = 0.03) and small neoplasms (R2 = 0.58, P = 0.03). There was a significant difference in the detection rates of upper GI neoplasms between high (n = 7) and low (n = 7) ampulla observers (odds ratio [OR] 1.31, 95 % confidence interval [CI] 1.03 - 1.68; P = 0.03). The ampulla photo-documentation rate of each endoscopist significantly correlated with the examination time for a normal EGD (R2 = 0.55; P = 0.04). In multivariate analysis, high ampulla photo-documentation rate was a predictor of neoplasm detection (OR 1.33, 95 %CI 1.03 - 1.70). CONCLUSIONS: The ampulla photo-documentation rate was significantly associated with the detection rate for both total and small upper GI neoplasms. Ampulla photo-documentation should be considered as a quality indicator of EGD.

Comparison Between an Oral Sulfate Solution and a 2 L of Polyethylene Glycol/Ascorbic Acid as a Split Dose Bowel Preparation for Colonoscopy.

BACKGROUND/AIMS: This study aimed to compare the efficacy and tolerability of an oral sulfate solution (OSS) versus 2 L of polyethylene glycol/ascorbic acid (2L-PEG/Asc) for bowel cleansing before colonoscopy. METHODS: A prospective, single-center, single-blinded, noninferiority, randomized, controlled trial was performed. The primary outcome was the rate of successful bowel cleansing, evaluated using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes were examination time, polyp, and adenoma detection rate (PDR and ADR), tolerability, and safety. Ease of use, palatability, intention to reuse, and satisfaction were evaluated using a questionnaire. RESULTS: A total of 187 participants were randomized to receive either OSS (n=93) or 2L-PEG/Asc (n=94). Successful bowel cleansing was achieved in 86.0% (80/93) of the OSS group, which was noninferior to the 2L-PEG/Asc group (88.3%, 83/94), with a difference of -2.3% by ITT analysis [95% confidence interval (CI) -12.0 to +7.4]. The withdrawal time of the OSS group was significantly shorter than that of the 2L-PEG/Asc group (11.8±5.2 vs. 14.3±8.5; P=0.016). Ease of use, palatability, intention to reuse, and satisfaction were similar between the 2 groups. Adverse events were also similar between the 2 groups. Mucosal erythema (4.3%) and aphthous lesions (2.1%) were found only in the 2L-PEG/Asc group. CONCLUSIONS: OSS was as effective as 2L-PEG/Asc for successful bowel cleansing and had acceptable tolerability. OSS is a promising and safe low-volume preparation alternative for colonoscopy. (Clinical trial registration number: NCT02761213.).

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

BACKGROUND: Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. METHODS: Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6 days (range 1-30 days), and median duration of hospitalization was 13 days (range 3-135 days). At the follow-up (mean 24.6 months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. CONCLUSIONS: Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

An Operable, Portable, and Disposable Ultrathin Endoscope for Evaluation of the Upper Gastrointestinal Tract.

BACKGROUND AND AIMS: A prototype of a disposable endoscope (DE) with easy viewing of the esophagus has been developed. The aim of this study was to develop a new version of DE with improved functionality and to assess the feasibility of DE as a screening tool for upper gastrointestinal diseases compared with conventional endoscopes. METHODS: Diagnostic accuracy and maneuverability of DE were evaluated by comparing endoscopy using DE with conventional endoscopy. Different examiners performed DE endoscopy and conventional endoscopy in a randomized order, blinded to the results. Examiners were asked to respond to a questionnaire about ease of handling and observation using DE in preformed result sheets. Tolerability of DE was also evaluated. Non-sedated participants were asked to respond to a questionnaire about the convenience and satisfaction with DE endoscopy on a nine-point Likert scale. RESULTS: The overall ease of insertion and handling of DE was excellent. The new device enabled observation and evaluation of the entire esophagus with a good agreement between DE endoscopy and conventional endoscopy in terms of endoscopic diagnosis (Kappa value; hiatal hernia; 0.910, reflux esophagitis; 0.949, Barrett's esophagus, 1.000). Participants suggested that they were more comfortable with DE endoscopy than with conventional endoscopy with a lower symptom score (p = 0.030). CONCLUSION: The new DE enabled easy observation of the entire esophagus owing to its improved maneuverability, and its diagnostic ability of esophageal diseases was comparable to that of conventional endoscopes. Non-sedated esophagoscopy with this disposable device potentially has widespread applications in outpatient clinics and areas without endoscopic facilities.

Impact of body fat and muscle distribution on severity of acute pancreatitis.

BACKGROUND/OBJECTIVES: Obesity is a well-established risk factor for severe acute pancreatitis (AP); however, the impact of visceral obesity or sarcopenic obesity on severity of AP has not been well studied. We compared the relationship between severity of AP and various body parameters including body weight, body mass index (BMI), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and visceral fat-to-muscle ratio (VMR). METHODS: We analyzed the data of patients who were diagnosed with AP from 2009 to 2015. Image analysis software program (Aquarius Workstation software) was used to calculate individual VAT, SAT, and skeletal muscle areas from abdominal computed tomography scans at L3 vertebral levels. Revised Atlanta Classification was adopted to define severity of AP. Receiver operating characteristics (ROC) curves were constructed to determine the optimal threshold for predicting the severity. RESULTS: Among 203 patients, 13 (6.4%) patients had severe AP and 62 (30.5%) patients had moderately severe cases. VMR demonstrated the highest area under the ROC curve [0.757, (95% confidence interval: 0.689-0.825)] in predicting moderately severe or severe AP. The optimal threshold of VMR for predicting severity was 1. The prevalence of various local complications and persistent organ failure were higher in patients with VMR over 1. CONCLUSIONS: High visceral fat with low skeletal muscle volume was strongly correlated with AP severity. VMR had a stronger correlation with AP severity than body weight or BMI. This simple grading system would be useful if incorporated into future predictive scoring models.

Esophagogastric junction contractile integral and morphology: Two high-resolution manometry metrics of the anti-reflux barrier.

BACKGROUND AND AIM: We evaluated associations of esophagogastric junction (EGJ) metrics as an anti-reflux barrier with impedance-pH, endoscopic esophagitis, and lower esophageal sphincter (LES) metrics. METHODS: We reviewed high-resolution manometry data from consecutive patients with gastroesophageal reflux disease (GERD) symptoms who underwent impedance-pH and endoscopy, and asymptomatic volunteers. The EGJ contractile integral (CI) was calculated as the mean contractile integral/second during three respiratory cycles. EGJ morphology was classified according to LES-crural diaphragm (CD) separation. RESULTS: In total, 137 patients (65 male, age 55 years) and 23 (9 male, age 33 years) controls were enrolled. Twenty-five patients had erosive reflux disease (ERD), 16 had non-erosive reflux disease (NERD), 5 had reflux hypersensitivity, and 91 were not GERD. EGJ-CI were lower in patients with GERD (22.6 [13.8-29.2] mmHg cm) than non-GERD (50.3 [31-69.9] mmHg cm, P < 0.01) and controls (67 [26.7-78.7] mmHg cm). With an EGJ-CI cut-off value of 30 mmHg cm, the area under the curve was 0.814 (0.762-0.896), with 77.8% sensitivity and 81.7% specificity for the prediction of GERD. LES-CD separation was greatest in patients with ERD, followed the NERD, non-GERD, and controls. EGJ morphology type III was associated with a higher DeMeester score (7.9 [1.6-12.6]) than were type II (3.25 [0.9-5.975]) and I (1.75 [0.8-6.2]; P < 0.01). EGJ-CI values were lower in patients with GERD than in others in each EGJ morphology subgroup. CONCLUSION: Esophagogastric junction contractile integral showed good diagnostic accuracy with high specificity in predicting GERD. LES-CD separation is associated with an increase in acid reflux, but EGJ-CI was associated more strongly with GERD than was EGJ morphology.

The impact of pre-resection endoscopic examination time on the rate of synchronous gastric neoplasms missed during endoscopic treatment.

BACKGROUND AND STUDY AIMS: Synchronous multiple gastric cancers have been reported in up to 14% of patients, but few efforts have been made to optimize techniques for detection of multiple neoplasms. We sought to evaluate whether the length of endoscopic examination before endoscopic resection affected the detection rates of synchronous gastric neoplasms. PATIENTS AND METHODS: Among patients referred for endoscopic treatment of gastric neoplasms (n = 1,017), we enrolled those in whom at least one other synchronous neoplasm was found during pre-resection endoscopy or during the 1-year follow-up examination. Pre-resection endoscopic examination time was compared between those in whom multiple neoplasms were completely diagnosed before resection (complete examination group) and those in whom multiple neoplasms were not fully diagnosed prior to resection but were found during follow-up evaluation (incomplete examination group). RESULTS: Eighty-three patients were included in the study. We found no significant difference in any of the multiplicity, location, gross appearance, size, or resection type of primary lesion between the complete (n  =  46) and incomplete examination (n  = 37) groups. The complete examination group had a significantly longer examination time compared to the incomplete examination group (6.5 ± 2.4 min vs. 3.8 ± 1.8 min, respectively; P < 0.001). The synchronous lesions most commonly presented as the flat type (42/94 lesions, 45%) and were smaller than the primary lesions (10.0 ± 7.4 mm vs. 14.3 ± 9.1 mm, respectively; P = 0.002). CONCLUSIONS: Endoscopists should consider the possibility of synchronous gastric neoplasms and examine the whole stomach, thus allowing adequate time to reduce the risk of missed lesions.

Body Mass Index and Clinical Outcomes from Endoscopic Submucosal Dissection of Gastric Neoplasia.

BACKGROUND AND AIM: Association between obesity and endoscopic resection outcomes has not been investigated. We sought to determine the clinical impact of obesity in patients who underwent endoscopic submucosal dissection (ESD) for gastric neoplasia. METHODS: A total of 1571 consecutive patients with gastric neoplasia who underwent ESD between December 2010 and March 2016 were enrolled in this study. We retrospectively analyzed 1181 cases that were divided into three groups based upon body mass index (BMI, kg/m2) according to the criteria for Asia-Pacific populations: normal (<23, n = 411), overweight (≥23 and <25, n = 312), and obese (≥25, n = 458). Demographics, endoscopic findings, pathologic results, and clinical outcomes were analyzed. RESULTS: No significant differences were observed between the three BMI groups in the following measures: the en-bloc resection rate, the complete resection rate, lymphovascular involvement or submucosal invasion of tumor cells, and adverse events. However, when comparing the obese and overweight groups with the normal group, mean procedure time was longer (P = 0.001) and the percentage of cases requiring more than 30 min, which was the overall mean procedure time, was greater (60.7, 53.2, and 50.1%, respectively; P = 0.006). The significantly associated factors with procedure durations longer than 30 min were obesity, longitudinal and circumferential location, large resection size (≥4 cm), cancer pathology, and submucosal layer invasion. In multivariate analyses, obesity was an independent predictor of long procedure time for gastric ESD. CONCLUSION: Being obese or overweight did not directly affect clinical outcomes in gastric ESD. However, obesity was significantly associated with long procedure time. Our results suggest that gastric ESD can be performed safely and effectively in obese patients.

Bleeding After Endoscopic Procedures in Patients With Chronic Hematologic Thrombocytopenia.

BACKGROUND: Procedure-induced bleeding is a major complication after endoscopic intervention. AIMS: The aim of this study was to investigate the risk of endoscopy-related bleeding in patients with chronic hematologic thrombocytopenia. METHODS: We investigated endoscopy-related bleeding in 175 procedures performed on 108 patients with immune thrombocytopenic purpura or aplastic anemia. The outcomes were compared with those of 350 procedures on age-, sex-, and procedure-matched control subjects. Endoscopic interventions included low-risk procedures such as endoscopic biopsy and high-risk procedures including polypectomy, endoscopic resection, and endoscopic retrograde cholangiopancreatogram with sphincterotomy. RESULTS: Bleeding occurred in 17 (9.7%) procedures among the patients with thrombocytopenia. This rate was significantly higher than that in procedures on controls (3.1%, P = 0.003). About 60% of all bleeding events were observed within 24 h after the endoscopic procedure. Bleeding after endoscopic biopsy developed more frequently in the patient group than in the control group (7.1 vs. 0.7%; P < 0.001). Bleeding occurred after 20% of all high-risk procedures. The incidence of bleeding was significantly elevated in patients with a platelet count less than 50 × 103/µl. Multivariate analysis revealed that high-risk procedures and low platelet count (less than 50 × 103/µl) were significantly related to procedure-related bleeding. All bleeding events stopped spontaneously or were controlled with endoscopic hemostasis. CONCLUSIONS: Endoscopic procedure-related bleeding develops frequently in patients with chronic hematologic thrombocytopenia. Post-procedural bleeding should be observed carefully in these patients, especially when the platelet count is less than 50 × 103/µl or high-risk endoscopic procedures are planned.

Incidence of gastric cancer after endoscopic resection of gastric adenoma.

BACKGROUND AND AIMS: The annual incidence of metachronous cancer after endoscopic resection (ER) of early gastric cancer (EGC) is approximately 3%. However, the incidence of gastric cancer after ER of a gastric adenoma is not known. The aim of this study was to determine whether the incidence of gastric cancer after ER of a gastric adenoma was different compared with that of metachronous cancer after ER of EGC. METHODS: We retrospectively analyzed data from patients who underwent ER for gastric neoplasia from January 2005 to August 2013. Enrolled patients were divided into 2 groups: patients with low-grade dysplasia were included in the adenoma group and patients with high-grade dysplasia or invasive neoplasia were included in the EGC group. The main outcome was the incidence of gastric cancer after ER. RESULTS: At a median follow-up of 28 months, gastric cancer newly developed in 13 adenoma patients (3.6%) and in 30 EGC patients (5.1%). The incidence rate of gastric cancer after ER was 14.4 cases per 1000 person-years in adenoma patients and 18.4 cases per 1000 person-years in EGC patients (P = .309 by the log-rank test). The hazard ratio of metachronous neoplasia in adenoma patients compared with EGC patients was 0.97 (95% confidence interval, 0.62-1.53). Metachronous tumors with invasion beyond the muscularis mucosa were more frequent in adenoma patients than in EGC patients (7/35 [20.0%] vs 3/63 [4.8%], P = .017). CONCLUSION: The incidence of gastric cancer after ER for gastric adenoma was not significantly different from that of EGC. If further prospective studies confirm these findings, careful endoscopic surveillance with the same level of intensity should be considered for both gastric adenoma and EGC patients after ER.

Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery.

BACKGROUND: In patients with unresectable colorectal cancer (CRC) obstruction, choosing whether to perform self-expandable metal stent (SEMS) or palliative surgery is challenging, especially in those with good performance status. We aimed to compare the long-term outcomes of SEMS with those of palliative surgery in patients with unresectable CRC obstruction. METHODS: This retrospective study comprised 114 patients with unresectable CRC obstruction who underwent SEMS placement (n = 73) or palliative surgery (n = 41). The main outcome measurements were success rate, adverse events, patency, and survival duration. RESULTS: Early clinical success rates did not differ between SEMS and surgery. However, the rate of late adverse events was significantly higher in the SEMS group (27.4 vs. 9.8 %; P = .005). Patency duration was shorter after SEMS than after surgery (163 vs. 349 days; P < .001), even after additional intervention (202 vs. 349 days; P < .001). The median survival was significantly shorter after SEMS than after surgery (209 vs. 349 days; P = .005). Survival differed between treatments in patients with Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (P = .016) but not in those with ECOG 2 or 3 (P = .487), and this was confirmed by multivariate analysis, which showed that surgery was a significant favorable predictor of survival for patients with ECOG 0 or 1 (hazard ratio .442; 95 % confidence interval .234-.835; P = .016). CONCLUSIONS: Surgery may be preferable to SEMS for the palliation of unresectable CRC obstruction in patients with good performance status, especially ECOG 0 or 1.

Effect of Helicobacter pylori eradication on metachronous gastric cancer after endoscopic resection of gastric tumors: a meta-analysis.

BACKGROUND: Although endoscopic resection is widely accepted as the curative treatment modality for early gastric cancer, secondary metachronous cancer may subsequently develop in the residual gastric mucosa. The preventive effect of Helicobacter pylori eradication on the development of metachronous gastric cancer in such cases remains controversial. The aim of this study was to determine the effect of H. pylori eradication on the development of metachronous gastric cancer after endoscopic resection of gastric neoplasm by a meta-analysis of all relevant studies. MATERIALS AND METHODS: We performed a systematic literature search of PubMed, EMBASE, Google Scholar, and the Cochrane Library without language restrictions through March 31, 2014. We included all relevant articles, including prospective, observational, and retrospective studies. Pooled estimates (odds ratios with 95% confidence intervals) were obtained using a random effects model. RESULTS: Thirteen studies were considered to be appropriate for this meta-analysis. Compared with the control group, the pooled odds ratio in the eradication group was 0.42 (95% confidence interval, 0.32-0.56), and there was no heterogeneity across the studies (p = .853, I(2) = 0%). Subgroup analysis of three prospective trials also showed a lower incidence of metachronous cancer in the eradication group (odds ratio, 0.39; 95% confidence interval, 0.20-0.75). There was no evidence of publication bias in this meta-analysis. CONCLUSION: Helicobacter pylori eradication reduces the occurrence of metachronous gastric cancer in patients who have undergone endoscopic resection.