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The study investigated the association between Helicobacter pylori treatment and the risk of gastric cancer after endoscopic resection of gastric dysplasia. Patients who received endoscopic resection for gastric dysplasia between 2010 and 2020 from Korean nationwide insurance data were included. We verified the occurrence of new-onset gastric cancer and metachronous gastric neoplasm, which encompasses both cancer and dysplasia, >1 year after the index endoscopic resection. Newly diagnosed gastric cancer ≥3 years and ≥5 years was regarded as late-onset gastric cancer. A multivariable Cox regression model with H pylori treatment status as a time-dependent covariate was used to determine the risk of gastric cancer and metachronous gastric neoplasms. Gastric dysplasia in 69,722 patients was treated with endoscopy, and 49.5% were administered H pylori therapy. During the median 5.6 years of follow-up, gastric cancer developed in 2406 patients and metachronous gastric neoplasms developed in 3342 patients. Receiving H pylori therapy was closely related to lower gastric cancer risk (adjusted hazard ratio [aHR], 0.88; 95% confidence interval [CI], 0.80-0.96). H pylori treatment also significantly decreased metachronous gastric neoplasm development (aHR, 0.76; 95% CI, 0.70-0.82). Furthermore, H pylori therapy showed a prominent protective effect for late-onset gastric cancer development at ≥3 years (aHR, 0.84; 95% CI, 0.75-0.94) and ≥5 years (aHR, 0.80; 95% CI, 0.68-0.95). In this nationwide cohort, H pylori therapy after endoscopic resection of gastric dysplasia was associated with a reduced risk of gastric cancer and metachronous gastric neoplasm occurrence. [Display omitted] This large-scale study found that treating Helicobacter pylori may reduce the risk of developing stomach cancer in patients who have undergone endoscopic removal of gastric dysplasia. [ABSTRACT FROM AUTHOR]

Background The resistance of Helicobacter pylori to antibiotics has increased the need for new empirical, first-line treatments. However, the efficacy of sequential therapy (ST) and concomitant therapy (CT) compared with triple therapy (TT) has not been adequately evaluated. Aim In this study, we evaluated the efficacy of these empirical three regimens. Methods The 517 patients enrolled in the study were prospectively randomized to receive 10 days of TT ( n = 171), ST ( n = 170), and CT ( n = 176) at 5 university-affiliated hospitals from May 2013 to March 2015. The post-treatment H. pylori status was determined using the 13 C-urea breath test. Results The baseline characteristics were similar among the three groups. The intention-to-treat eradication rates were 62.6%, 70.6%, and 77.8% in the TT, ST, and CT groups, respectively ( p < 0.01). The corresponding per-protocol eradication rates were 82.8%, 89.5%, and 94.4%, respectively ( p < 0.01). There were no significant differences in the compliance, side effects, and follow-up loss rates. Conclusion A higher eradication rate was achieved with empirical 10-day ST, and CT than with the TT regimen, with similar rates of compliance and treatment side effects. [ABSTRACT FROM AUTHOR]

Abstract: Background and aims: Because histological examination of gastric lesions by forceps biopsy is of limited accuracy, management on the basis of histological results is occasionally controversial. We examined the characteristics of early gastric cancers that presented as dysplasia resulting from a previous forceps biopsy. Patients and methods: Between April 2007 and December 2010, 341 gastric adenocarcinoma lesions from 330 patients previously diagnosed histologically via endoscopic submucosal dissection were examined. We retrospectively assessed the characteristics of early gastric cancer according to their initial forceps biopsy results. Results: In total, 183 EGCs were diagnosed as dysplasia (53.7%; 89 low-grade and 94 high-grade) and 158 (46.3%) as carcinoma by forceps biopsy before endoscopic submucosal dissection. Significant differences were noted with respect to histologic differentiation of carcinomas, Lauren histologic type, depth of invasion, lymphovascular invasion, and en bloc resection between the dysplastic group and carcinoma group, based on forceps biopsy results. Conclusion: A forceps biopsy result is not fully representative of the entire lesion and, thus, endoscopic submucosal dissection should be considered for lesions diagnosed as dysplasia via forceps biopsy in order to avoid the risk of missed carcinomas. [Copyright &y& Elsevier]

Background: High-quality bowel preparation is a prerequisite for colonoscopy. Few studies have evaluated visual aids as a means of improving the quality of bowel preparation. Objective: To assess the effect of patient education by using cartoon visual aids on the quality of bowel preparation. Design: An endoscopist-blinded, randomized, controlled trial. Setting: Tertiary referral center. Subjects: Patients scheduled for screening colonoscopy in a health examination center. Interventions: Patients were assigned to receive the existing verbal and written instructions (group A) or a new cartoon visual educational instruction (group B) for colonoscopy. Main Outcome Measurements: The primary endpoint was the quality of bowel preparation, assessed by using the Boston Bowel Preparation Scale (BBPS). Secondary endpoints were the quality of bowel preparation assessed by using the Universal Preparation Assessment Scale; insertion, withdrawal, and workup times; and polyp detection rates in the 2 groups. Logistic regression analysis was performed to determine the factors associated with poor bowel preparation according to a BBPS score less than 5. Results: Group B exhibited better bowel preparation than group A according to BBPS scores (mean BBPS score, 6.12 ± 2.19 vs 7.44 ± 1.87, P ≤ .01; median BBPS score, 6.00 ± 0.00 vs 9.00 ± 0.00, P ≤ .01; good bowel preparation for colonoscopy, BBPS score ≥5, 81.6% vs 93.1%, P = .02). Multivariate analysis revealed that older age (odds ratio 1.07, P ≤ .01) and no use of visual aids (odds ratio 3.08, P = .02) were independent factors associated with poor bowel preparation. Limitations: Single-center study. Conclusions: Patient education with cartoons effectively improved bowel preparation for colonoscopy. [Copyright &y& Elsevier]

Background: EUS is useful for diagnosis of GI disease. However, artifacts caused by gastric mucus may worsen visibility during EUS. Objective: To investigate the efficacy of premedication with pronase, the proteolytic enzyme, for improving imaging during EUS. Design: Blinded, randomized, prospective study. Setting: Tertiary-care referral center. Patients: This study involved 183 patients scheduled for EUS. Intervention: Patients were assigned to oral premedication with saline solution (group A), pronase and bicarbonate (group B), or pronase, bicarbonate, and simethicone (group C). Either conventional EUS or high-frequency catheter EUS (HFUS) was selected. Gastric cavity and gastric mucosal surface obscurity grades were assessed by using visibility scores from ultrasonographic images of each patient. Main Outcome Measurements: Means of visibility scores and proportion of images with better visibility scores of the gastric cavity and gastric mucosal surface. Lower scores indicate better visibility of the gastric mucosal surface and fewer artifacts within the gastric cavity on conventional EUS and HFUS. Results: Group B had significantly lower mean gastric cavity and gastric mucosal surface visibility scores than did groups A and C in both conventional EUS and HFUS. Group B also had a high proportion of images that had better gastric cavity and gastric mucosal surface visibility scores than did the other two groups in conventional EUS and HFUS. Limitations: Small number of patients and no assessment of the amount of mucus before oral premedication. Conclusion: Premedication for conventional EUS and HFUS by using a mixture of pronase and bicarbonate seems to decrease the number of gastric wall and lumen hyperechoic artifacts observed in patients given either saline solution or pronase/bicarbonate/simethicone. [Copyright &y& Elsevier]

Background: The cause of pancreatitis is unknown in as many as 30% of cases of recurrent acute pancreatitis, even after ERCP. Objective: To investigate the role of intraductal US (IDUS) for managing idiopathic recurrent pancreatitis (IRP). Design: Prospective study. Setting: Tertiary referral hospital. Patients: Thirty-one patients with suspicious IRP with negative findings on ERCP. Interventions: IDUS during ERCP. Main Outcome Measurements: IDUS findings showing any possible cause of pancreatitis. Results: IDUS revealed small bile duct stones (≤3 mm) in 5 patients (16.1%) and sludge in 3 patients (9.7%). The detection rate for a bile duct stone and sludge was significantly higher in patients with a dilated CBD than a nondilated CBD on ERCP (71.4 vs 12.5%; P < .05). Recurrent pancreatitis did not develop in 7 of 8 patients with biliary stones or sludge after an endoscopic sphincterotomy (EST). Two patients (6.5%) demonstrated a small polypoid lesion on the distal end of the pancreatic duct. One patient underwent surgery for intra-ampullary cancer, and another one underwent EST without another attack of pancreatitis. Three patients (9.7%) showed evidence of chronic pancreatitis with small pancreatic stones and/or calcifications on IDUS. Limitations: Small number of patients. IDUS results were not compared with those of conventional EUS. There was no reference standard for chronic pancreatitis as diagnosed by IDUS. Conclusions: IDUS identified a possible cause of idiopathic recurrent pancreatitis in 42% of patients with negative findings on ERCP. The IDUS-guided approach combined with ERCP and EST may be useful for decreasing recurring attacks of pancreatitis. [Copyright &y& Elsevier]

Background & Aims: Achalasia esophagus is characterized by loss of peristalsis and incomplete esophagogastric junction (EGJ) relaxation. We studied mechanisms of esophageal emptying in patients with achalasia using simultaneous high-resolution manometry, multiple intraluminal impedance, and high-frequency intraluminal ultrasonography image recordings. Methods: Achalasia was categorized into 3 subtypes, based on the esophageal response to swallows: types 1 and 2 were defined by simultaneous pressure waves of <30 mm Hg and >30 mm Hg, respectively, and type 3 was defined by spastic simultaneous esophageal contractions. Results: Based on high-resolution manometry, the predominant achalasia pattern of type 2 was characterized by a unique motor pattern that consisted of upper esophageal sphincter contraction, simultaneous esophageal pressure (pan-esophageal pressurization), and EGJ contraction following swallows. High-frequency intraluminal ultrasonography identified longitudinal muscle contraction of the distal esophagus as the cause of pan-esophageal pressurization in type 2 achalasia. Multiple intraluminal impedance revealed that esophageal emptying occurred intermittently (36% swallows) during periods of pan-esophageal pressurization. Patients with achalasia of types 1 and 3 had no emptying or relatively normal emptying during most swallows, respectively. Conclusions: In achalasia, esophageal emptying results from swallow-induced longitudinal muscle contraction of the distal esophagus, which increases esophageal pressure and allows flow across the nonrelaxed EGJ. [Copyright &y& Elsevier]

Background: Self-expandable metal stents (SEMSs) are an effective palliative treatment for malignant biliary or duodenal strictures, but endoscopic stenting for combined malignant biliary and duodenal obstruction remains technically difficult. Objective: To evaluate the feasibility and clinical success rate of endoscopic double stent-in-stent placement by using a new duodenal metallic stent for the management of malignant biliary and duodenal obstructions. Design: Prospective, observational clinical feasibility study. Setting: Tertiary referral center. Main Outcome Measurement: Technical and clinical success, complications, midterm outcome. Patients and methods: Eight patients with inoperable malignant biliary and duodenal strictures were enrolled. Endoscopic placement of a biliary SEMS was performed through the mesh of the duodenal stent. Results: The duodenal strictures were in the first part of the duodenum in 3 patients (type 1) and in the second part in 5 patients (type 2). Duodenal stents were successfully deployed in all patients. Endoscopic placement of a biliary SEMS through the mesh of the duodenal stent was successful in 7 (87.5%) of 8 patients. In 2 of 3 patients with type 2 duodenal strictures with failed bile duct cannulation, biliary stenting was successful by using the rendezvous procedure. Early complications occurred in 1 patient. The overall median survival after combined stenting was 91 days (range 36–314 days). Limitations: Small number of patients and no comparison with other enteral stents. Conclusions: Biliary stenting through the new duodenal metallic stent is technically feasible and has a high success rate. Combined endoscopic biliary and duodenal stent-in-stent placement is a promising solution for the palliation of malignant biliary and duodenal obstruction. [Copyright &y& Elsevier]

Background: Peroral cholangioscopy (POC) provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother−baby endoscope system is not widely used because of several limitations. Although direct cholangioscopy with an ultraslim upper endoscope with a guidewire has been reported, success is not always guaranteed. Objective: To evaluate the feasibility and success rate of direct POC using an ultraslim endoscope with an intraductal balloon to maintain access compared with the guidewire method. Design: Prospective, observational clinical feasibility study. Setting: Tertiary referral center. Main Outcome Measurements: We compared overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system. Patients and Methods: Twenty-nine patients with biliary disease underwent direct POC. All patients had previously undergone an endoscopic sphincterotomy or papillary balloon dilation with a large balloon. Eleven patients underwent wire-guided direct POC. Intraductal balloon-guided direct POC was performed in 21 patients. The balloon catheter was used to maintain access while an ultraslim upper endoscope was advanced over the balloon catheter, through the ampulla of Vater, and directly into the bile duct. Results: Wire-guided direct POC was successful in 5 of 11 (45.5%) patients. In contrast, the success rate of intraductal balloon-guided direct POC was 95.2% (20/21 patients, P < .05). Forceps biopsies under direct visualization of the intraductal lesion and therapeutic intervention, including laser lithotripsy or electrohydraulic lithotripsy, were performed successfully. Procedure-related complications were not observed. Limitations: A small number of patients and no comparison with conventional cholangioscopy. Conclusions: Intraductal balloon-guided direct POC with an ultraslim upper endoscope allows the direct visual examination and therapeutic intervention of bile ducts in patients with biliary disease. Further development of the endoscopic apparatus and specialized accessories are expected to facilitate this procedure. [Copyright &y& Elsevier]

Background: Benign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation. Objective: Our study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture. Design: A prospective outcome study. Setting: Tertiary-care academic medical centers. Patients: A total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy. Interventions: Under direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip–knife. Main Outcome Measurements: Efficacy, safety, and long-term patency after procedures were evaluated. Results: During 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications. Limitation: Our study included a small number of patients. Therefore, further prospective randomized controlled trials are needed. Conclusions: A modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture. [Copyright &y& Elsevier]

Background: The “mother–baby” endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon–assisted endoscopy, for direct POC. Objective: To evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access. Setting: A single center. Design: Case series. Patients: Twelve patients with biliary disease. Interventions: Direct POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures. Main Outcome Measurements: Success rate of this technique, diagnostic or therapeutic feasibility, and complications. Results: Overtube-balloon–assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred. Limitations: A small number of patients and no comparison with conventional cholangioscopy. Conclusions: The overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC. [Copyright &y& Elsevier]

Background: Selective cannulation in patients with a Billroth II gastrectomy is still challenging. Objective: To evaluate the usefulness of a multibending, forward-viewing endoscope (M-scope) for selective cannulation during diagnostic or therapeutic ERCP in patients with a Billroth II gastrectomy. Design: Case series. Setting: Tertiary center. Patients: Fourteen patients having biliary disease with a Billroth II gastrectomy in whom selective cannulation failed when using a conventional forward-viewing endoscope. Interventions: In all cases, we attempted selective biliary cannulation for ERCP with a single-bending, forward-viewing endoscope for 10 minutes. After failure with the conventional endoscope, we retried selective cannulation with the M-scope for 10 minutes. After cannulation, the diagnostic or therapeutic endoscopic procedures were performed. Main Outcome Measurements: We assessed the success rate of selective cannulation, the possibility of therapeutic approaches, and procedure-related complications. Results: In all cases, we successfully reached the ampulla of Vater with the M-scope. The overall success rate of selective cannulation with the M-scope was 92.9% (13/14). One patient developed mild pancreatitis. Therapeutic procedures such as sphincterotomy, balloon dilatation, stone removal, and biliary drainage were all possible. Limitations: Small number of patients; uncontrolled, single-center study. Conclusions: The M-scope seems to be helpful for selective cannulation during ERCP in patients with a Billroth II gastrectomy. All diagnostic and therapeutic procedures were possible through the M-scope. [Copyright &y& Elsevier]

Background and Aims A previous study reported that cold snare polypectomy (CSP) was superior to cold forceps polypectomy (CFP) for the removal of diminutive colorectal polyps (DCPs) (≤5 mm) when the techniques were assessed for completeness of resection. However, completeness is expected to be greater with CFP when strict investigation of the remnant polyp is performed. The aim of this study was to assess the efficacy of CFP with narrow-band imaging (NBI) evaluation of polypectomy sites for removal of DCPs, compared with CSP. Methods This was a randomized, controlled, noninferiority trial at a tertiary-care referral hospital. Of the 380 patients screened, 146 patients with 231 DCPs were enrolled. CFP was used to resect DCPs until no remnant polyp was visible by NBI endoscopy. The primary noninferiority endpoint was histologic eradication of polyps, with a noninferiority margin of -10%. Results A size of >3 mm was seen in 129 polyps (55.8%). The overall rates of histologic eradication were 90.5% in the CFP group and 93.0% in the CSP group (difference, 2.5%; 95% confidence interval [CI], -9.67 to 4.62). However, when confined to the polyps >3 mm, the histologic eradication rate was 86.8% and 93.4% (95% CI, -17.2 to 3.6), respectively. Polyp size, histology, location, and time taken for polypectomy did not differ between the groups. The failure rate of tissue retrieval was higher in the CSP than in the CFP group (7.8% vs 0.0%, respectively; P =.001). Conclusions In this study, >90% of all DCPs were completely resected by using CFP with NBI evaluation of polypectomy sites, showing noninferiority compared with CSP. However, in polyps measuring >3 mm, CFP failed to show noninferiority versus CSP. CFP appears to be the proper method for resection of DCPs 1 to 3 mm in size if no remnant polyp is visible by NBI endoscopy, but CFP is likely to be insufficient for larger polyps. (Clinical trial registration number: NCT02201147 .) [ABSTRACT FROM AUTHOR]