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Inflammatory pseudotumor (IPT) is a rare benign tumor of unknown etiology that can occur in almost any organ system. It has neoplastic features such as local recurrence, invasive growth, and vascular invasion, leading to the possibility of malignant sarcomatous changes. The clinical presentations of colonic IPT may include abdominal pain, anemia, a palpable mass, and intestinal obstruction. A few cases of colonic IPT have been reported, but colonic IPT with pedunculated morphology is very rare. Furthermore, since it can mimic malignant polyps, understanding the endoscopic findings of colonic IPT is important for proper treatment. Herein, we present a case of colonic IPT with pseudosarcomatous changes, presenting as a large polyp, mimicking a malignant polyp in the cecum, along with a literature review.

Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection. (Korean J Med 2020;95:398-403)

Background/Aims: Needle knife fistulotomy (NKF) is a technique to facilitate pancreatic and biliary duct access during ERCP. The double-guidewire technique (DGT) is also used in cases of difficult cannulation, but it can increase the incidence of post-ERCP-pancreatitis (PEP). This study examined the success and complication rates of NKF after unsuccessful standard cannulation or DGT in patients with pancreaticobiliary disease. Methods: The data of 209 patients who received NKF as a rescue procedure between January 2009 and December 2016 were reviewed retrospectively. The cannulation success and complication rates were assessed. Results: The overall cannulation success rate was 90.4%. The success rates of patients who received NKF after standard cannulation or DGT were similar (82.6% [142/172] and 73.0% [27/37], respectively, p=0.179). Furthermore, there was no significant difference in the incidence of procedure-related adverse events between the two groups (10.5% [18/172] and 16.2% [6/37], respectively, p=0.391). Endoscopic retrograde pancreatic drainage (ERPD) insertion decreased the incidence of PEP (0% [0/16] in ERPD and 14.6% [19/130] in non-ERPD, p=0.132) among patients who received PD cannulation. Conclusions: NKF is an effective and safe method that can be considered for rescue management after the initial failure of standard cannulation or DGT. NKF following standard cannulation can be preferred over NKF following DGT because of the higher success rate and the lower rate of pancreatitis, but the difference was not significant. PD stenting in patients at high risk of PEP can be considered to decrease pancreatitis.

Objective: Adequate lymph node harvest (LNH) in colorectal cancer is closely related to survival. This study aimed to evaluate the effect of preoperative colonoscopic tattooing (PCT) with indocyani...

Intramural hematoma of the esophagus is a rare condition that can be spontaneous or secondary to trauma, toxic ingestion, or intervention. If it is the spontaneous type, it usually presents initially with epigastric pain, hematemesis or dysphagia. We present a case of intramural hematoma of the esophagus mimicking acute coronary syndrome. A 63-year-old man presented with severe acute chest pain. He has four coronary stents that were inserted five years ago, from a different hospital, and is on dual antiplatelet agents. Coronary angiography was performed immediately under the suspicion of acute coronary syndrome, and we found that there was no obvious clogging of the coronary arteries. Next, chest computed tomography was performed due to suspected aortic dissection, and the result was also negative. Four days later, endoscopy was performed and intramural hematoma covered with large ulcers was diagnosed.

Endoscopic resection for early gastric cancer (EGC) without lymph node metastasis may be a valuable treatment option. To date, endoscopic resection for undifferentiated EGC is being investigated. We evaluated the risk of lymph node metastasis in undifferentiated EGC by examining the preoperative endoscopic findings and operated pathologic specimen. The medical records of patients who underwent surgical resection because of undifferentiated EGC between November 2008 and December 2015 were reviewed retrospectively. The risk factors associated with lymph node metastasis and the lymph node metastasis rate in the expanded indication of undifferentiated EGC were evaluated. A total of 376 patients with undifferentiated EGC (233 signet ring cell type and 143 poorly differentiated type) were analyzed. Lymph node metastasis was found in 9.8% of the patients. Among the patients who met the expanded criteria (59 patients), only one patient had lymph node metastasis (signet ring cell type without ulceration and 15 mm in size). The risk factors associated with lymph node metastasis were lesion size >20 mm (OR 3.013), scar deformity (OR 2.248), surface depression (OR 2.360), submucosal invasion (OR 3.427), and lymphovascular invasion (OR 6.296). Before endoscopic resection of undifferentiated EGC, careful selection of patients should be considered. The undifferentiated EGC with size ≥15 mm, scar deformity, surface depression, submucosal invasion, and lymphovascular invasion should be considered surgical resection instead of endoscopic resection.

Background Upper gastrointestinal endoscopic examination is a relatively safe procedure; however, all endoscopic procedures are invasive and are associated with a risk of iatrogenic perforation. To evaluate clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation. Factors associated with surgical management or mortality were analyzed. Methods Between November 2008 and November 2018, the medical records of 149,792 upper gastrointestinal endoscopic procedures were evaluated. The mechanisms of perforations were categorized as electrocoagulation-induced or blunt trauma-induced injuries. The incidence and clinical outcomes of iatrogenic perforations based on the types of procedures performed were evaluated. Results Iatrogenic endoscopic perforations occurred in 28 cases (0.019%). Iatrogenic perforation-related mortality occurred in 3 patients. The iatrogenic perforation rate based on the types of procedures performed was as follows: diagnostic endoscopy = 0.002%, duodenal endoscopic mucosal resection = 0.9%, esophageal endoscopic submucosal dissection = 10.7%, gastric endoscopic submucosal dissection = 0.2%, endoscopic self-expandable metal stent insertion for malignant esophageal obstruction = 0.1%, duodenoscope-induced injury = 0.02%, endoscopic sphincterotomy = 0.08%, and ampullectomy = 6.8%. All electrocoagulation-induced perforations (n = 21) were managed successfully (15 cases of endoscopic closure, 5 cases treated conservatively, and 1 case treated surgically). Three patients died among those with blunt trauma-induced perforations (n = 7). The factors associated with surgical management or mortality were old age, poor performance status (Eastern Cooperative Oncology Group score ≥ 1), advanced malignancy, and blunt trauma. Conclusions Most cases of electrocoagulation-induced iatrogenic perforations can be treated using endoscopic clips. If endoscopic closure fails for blunt trauma-induced perforations, prompt surgical management is mandatory.

Hemosuccus pancreaticus is an unusual gastrointestinal hemorrhage through the main pancreatic duct. We report a rare case of hemosuccus pancreaticus due to a simple mucinous cyst of the pancreas. A 52-year-old man who had been followed-up for a suspected branch duct intraductal papillary mucinous neoplasm (IPMN) visited the emergency room due to hematochezia. Endoscopy showed active bleeding from the ampulla. Computed tomography revealed hemorrhage in a 2.0-cm cystic mass in the pancreatic body. The patient was diagnosed with hemosuccus pancreaticus caused by bleeding into the main pancreatic duct from suspected IPMN. Elective laparoscopic distal pancreatectomy was performed. The histopathological diagnosis was a simple mucinous cyst with squamous metaplasia based upon the pathological finding involving the absence of ovarian-type stroma. In conclusion, it should be recognized that a pancreatic cyst including simple mucinous cyst may cause hemosuccus pancreaticus, and these cysts should be viewed as neoplastic and approached similarly as other mucinous pancreatic neoplasms.

Endoscopic submucosal dissection (ESD) has been widely implemented for the treatment of gastric superficial neoplasia. However, the final pathologic diagnosis after ESD may be different from that indicated by the results of endoscopic forceps biopsy. This study identified risk factors for gastric epithelial lesions so that early gastric cancer (EGC) could be diagnosed after ESD. From December 2008 to January 2017, 1541 lesions (1410 patients) diagnosed as initial adenoma or indefinite for neoplasia by endoscopic forceps biopsy were enrolled. The EGC rate and factors predicting upstaged diagnoses were analyzed retrospectively. The diagnostic discrepancy rate was 31.1%. Upstaged and downstaged diagnostic rates after ESD were 23.8% and 7.3%, respectively. The upstaged diagnosis rate for EGC was 18.8%. Gross depression (OR, 16.017) and surface redness (OR, 22.136) were significantly associated with EGC and lesions indefinite for neoplasia during the initial endoscopic forceps biopsy. Central depression (OR, 2.959), nodular surface (OR, 6.581), and surface redness (OR, 6.399) were significantly associated with EGC and lesions with low-grade dysplasia during the initial endoscopic forceps biopsy. Central depression (OR, 1.999), nodular surface (OR, 1.733), surface redness (OR 2.283), lesion location (upper third of the stomach) (OR, 3.989), and tumor size ≥10 mm (OR, 2.200) were significantly associated with EGC and lesions with high-grade dysplasia during the initial endoscopic forceps biopsy. Central depression, nodular surface, surface redness, lesion location, and tumors >10 mm were associated with EGC. Gastric epithelial lesions with these characteristics require attention before ESD.

OBJECTIVE Endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for gastric epithelial neoplasia. Endoscopic characteristics of the primary lesion and post-ESD scars may be informative to predict the possibility of local recurrence. METHODS Between November 2008 and July 2015, a retrospective study was conducted in a single-tertiary referral hospital. Consecutive patients who underwent ESD for early gastric cancer (EGC) or high-grade dysplasia were analyzed to evaluate the incidence of local recurrence and associated endoscopic characteristics. RESULTS A total of 639 lesions were analyzed. The rates of en-bloc and complete resection were 98.1% and 95.5%, respectively. A total of 15 local recurrent lesions were found (2.3%). The endoscopic findings of primary lesions associated with local recurrence were a lesion size ≥20 mm (odds ratio, OR, 4.408; 95% confidence interval, CI, 1.369-14.186, p = .013) and incomplete endoscopic resection (OR 17.059, 95% CI 4.887-59.551, p

Background and aim Endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for early gastric cancer (EGC) without lymph node metastasis. However, additional surgical gastrectomy should be considered after non-curative endoscopic resection. We aimed to evaluate the predictive factors associated with non-curative endoscopic resection. Methods Between November 2008 and June 2015, a retrospective study was conducted in a single, tertiary, referral hospital. A total of 596 EGC lesions resected by ESD were analyzed. Non-curative endoscopic resection was defined as the occurrence of lesions associated with piecemeal resection, positive resection margins, lymphovascular invasion, or lesions that did not meet the expanded indications for ESD. Results The rate of non-curative endoscopic resection was 16.1%. The mean follow-up period was 35.3 ± 25.0 months. Associated predictive factors for non-curative endoscopic resection were female sex (OR, 2.470; p = 0.004), lesion size ≥ 20 mm (OR 3.714; p < 0.001), longer procedure time (OR 2.449, p = 0.002), ulceration (OR 3.538, p = 0.002), nodularity (OR 2.967, p

Background/aims This study evaluated the value of abdominal computed tomography (CT) in preoperative N staging of early gastric cancers (EGCs) within standard and expanded indications of endoscopic resection (ER) and investigated the factors affecting accuracy. Methods Between March 2009 and March 2016, a total of 268 patients with EGC within the standard and expanded indications of ER underwent preoperative abdominal CT and surgical gastrectomy with lymph node (LN) dissection. Preoperative N staging of CT was compared with the pathologic result. Results The accuracy of N staging for EGCs within the standard and expanded indications was 86.1% (235/268). There was no LN metastasis in patients with cN1 in CT staging. LN metastasis was found in 7 patients with EGCs that met the expanded ER indication and cN0 in CT staging. According to the univariate analysis, ulcers, including scars, were associated with the false positive of lymph node metastasis in abdominal CT (odds ratio 3.56; 95% confidence interval 1.56-8.15). Conclusions The present study suggests that the value of abdominal CT is limited for nodal staging of EGCs that meet the ER indication.

The optimal management of precursor lesions such as gastric low-grade dysplasia is crucial in order to improve gastric cancer-related mortality. However, there are no universally accepted management guidelines regarding which lesions should be resected or should be monitored by follow-up visits. We retrospectively analyzed data from 1006 gastric low-grade dysplasia lesions that had been resected via endoscopic submucosal dissection. We also evaluated the endoscopic risk factors associated with upstage diagnosis from low-grade dysplasia to high-grade dysplasia or gastric cancer. The mean age of our patients was 63.7 ± 9.1 years and 70.3% of our study population included men. The predominant location and gross type of lesions was the lower third of the stomach (78.6%) and the elevated type (57.8%), respectively. The rates of pathological concordance, upstage, and downstage diagnosis were 85.3, 12.1, and 2.6%, respectively. Multivariate analysis, after adjusting for age and sex, showed that a lesion size ≥ 10 mm (Odds ratio [OR] 2.231; p = 0.003), erythema (OR 7.315; p

Although fecal calprotectin (Fcal) and the fecal immunochemical test (FIT) have been associated with endoscopic activity in ulcerative colitis (UC), the clinical implications of each marker depending on the mucosal status are not well known. A total of 174 results obtained from 128 patients with UC who simultaneously underwent colonoscopy and fecal tests were retrospectively evaluated from March 2015 to February 2018. The correlation and predictability of fecal markers as a surrogate marker of endoscopic activity, and the sensitivity, specificity, and predictive value of fecal tests for mucosal healing were statistically evaluated. Both fecal tests showed a statistically significant correlation with Mayo Endoscopic Subscore (MES) (Fcal: r = 0.678, P

The timely detection of early gastric cancer (EGC) is important in performing endoscopic submucosal dissection (ESD). We attempted to determine the location characteristics of regions where EGC is frequently detected and analyzed the EGC characteristics associated with that location. We retrospectively reviewed the medical records of patients with EGC treated by ESD between November 2008 and August 2016. We retrospectively investigated and analyzed 647 EGC lesions. The patients’ mean age was 66.7 ± 10.8 years. The patient population was predominantly male (77.1%, 499/647). A well-to-moderately differentiated carcinoma was observed in 97.2% of patients. The common site of carcinoma occurrence was the lower part of the stomach (the antrum and lower third of body, 89.6%). Among the stomach hemispheres, the lesser curvature side was the most frequent site of EGC (43.9%). The posterior side of EGC was more frequent than anterior side of EGC (20.4 vs. 15.6%, respectively). Submucosal invasive EGC was more frequent in the mid-to-upper parts of stomach than lower part of stomach (odds ratio 1.919; confidence interval 1.014–3.623; p = 0.045). Most EGCs that are resectable with ESD were found in the lower part and in the lesser curvature of the stomach. The submucosal invasive EGC was more frequent in the mid-to-upper part of stomach.

Background and study aims Although the Vienna Classification recommends endoscopic resection for gastric high-grade dysplasia (HGD), many resected lesions are diagnosed as gastric cancer after endoscopic resection. This study aims to evaluate the clinical outcomes of gastric HGD identified by endoscopic forceps biopsy (EFB) after endoscopic submucosal dissection (ESD) and factors associated with discrepant results. Patients and methods From December 2008 to July 2015, a total of 427 lesions diagnosed as initial HGD by EFB were enrolled. The rate of early gastric cancer (EGC) and factors predicting diagnosis upgrade were analyzed retrospectively. Results Tumors ranged between 2 and 65 mm in size (median 12.59). En bloc and complete resection rates were 97.4 and 95.3%, respectively. The diagnostic discrepancy rate was 76.3%. Upgrade and downgrade rates of pathological diagnoses were 66.5 and 9.8%, respectively. Central depression (OR 4.151), nodular surface (OR 5.582), surface redness (OR 2.926), lesion location (upper third of the stomach) (OR 3.894), and tumor size ≥10 mm (OR 2.287) were significantly associated with EGC. Nodular surface (OR 2.746), submucosal fibrosis (OR 3.958), lesion location (upper third of the stomach) (OR 6.652), and tumor size ≥10 mm (OR 4.935) significantly predicted invasive submucosal cancer. Conclusions Central depression, nodular surface, surface redness, lesion location, large tumor size, and submucosal fibrosis were associated with EGC or submucosal cancer. Caution must be used in treating lesions with these features with ESD.

Missed polyps are frequently observed in surveillance colonoscopy or referral resection. We evaluated the polyp missing rate and its associated risk factors in patients who were referred to a tertiary hospital for endoscopic resection of advanced colorectal neoplasia. A total of 388 patients with advanced neoplasia who underwent colonoscopy in their referring hospitals and only endoscopic resection without total colonoscopy in Pusan National University Yangsan Hospital from 2009 to 2014 and who underwent surveillance colonoscopy within 6 to 12 months were retrospectively analyzed. The per-patient missing rate for polyps, adenomas, and advanced neoplasia in referring hospital were 58.2% (226 cases), 47.2% (183 cases), and 5.7% (22 cases), respectively. The advanced neoplasia in surveillance colonoscopy comprised the following: ≥1 cm lesions (11 cases, 50%), high-grade dysplasia (4 cases, 18.2%), villous adenoma (4 cases, 18.2%), and invasive cancer (3 cases, 13.6%). Risk factors for missed adenomas in multivariate analysis were ≥60 years (P = .004), male (P

Background/Aims: Benign esophageal stricture after esophagectomy is not an infrequent complication. Anastomotic esophageal stricture requires frequent multiple dilations. We aimed to evaluate the clinical outcomes of dilation therapies using an endoscopic balloon or bougie dilator and analyzed the risk factors associated with refractory stricture. Methods: Between January 2009 and May 2016, the medical records of 21 patients treated with endoscopic balloon dilation or bougie dilation for esophageal anastomotic strictures were retrospectively reviewed. Results: During the study periods, a total of 21 patients were diagnosed with esophageal anastomotic stricture and included for analysis (17 male; mean age, 68.2±7.2 years at the first procedure). The mean stricture length was 6.4±8.1 mm. The refractory stricture was found in 28.6% of patients, and successful relief of dysphagia was achieved in 71.4% of patients. The major complication associated with dilations was absent. Factors associated with refractory stricture were stricture length (> 10 mm, p

AIM To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS). METHODS This was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified. RESULTS Among the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications. CONCLUSION Limited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Brucellosis is a multisystem disease with various clinical symptoms. Neurobrucellosis is a rare but serious manifestation of brucellosis. A 60-year-old man with a previous diagnosis of brucellar spondylitis presented with sudden onset of aphasia and numbness of the right upper extremity. Cerebral angiography showed diffuse narrowing and dilatation on the distal branches of both the anterior cerebral artery (ACA) and the left middle cerebral artery (MCA) which indicated cerebral vasculitis, and the patient's Brucella agglutinin titer was 1:1280. After combined antimicrobial and steroid therapy was started, the patient's condition improved significantly, and he was discharged after 1 month. Antimicrobial therapy was continued for 16 months on an outpatient basis, and the last Brucella agglutinin titer was 1:40. To our knowledge, this is the first case of relapsed neurobrucellosis with vasculitis in Korea to have been treated successfully.

Interventional lung assist (iLA) effectively reduces CO2 retention and allows protective ventilation in cases of life-threatening hypercapnia. Despite the clinical efficacy of iLA, there are a few major limitations associated with the use of this approach, such as bleeding, thrombosis, and catheter-related limb ischemia. We presented two cases in which thrombotic complications developed during iLA. We demonstrated the two possible causes of thrombotic complications during iLA; stasis due to low blood flow and inadequate anticoagulation.

AIM To evaluate the efficacy of quantitative fecal immunochemical test (FIT) as biomarker of disease activity in ulcerative colitis (UC). METHODS Between February 2013 and November 2014, a total of 82 FIT results, obtained in conjunction with colonoscopies, were retrospectivelyevaluated for 63 patients with UC. The efficacy of FIT for evaluation of disease activity was compared to colonoscopic findings. Quantitative fecal blood with automated equipment examined from collected feces. Endoscopic disease severity were assessed using the Mayo endoscopic subscore (MES) classification. The extent of disease were classified by proctitis (E1), left sided colitis (E2), and extensive colitis (E3). Clinical activity were subgrouped by remission or active. RESULTS All of 21 patients with MES 0 had negative FIT (< 7 ng/mL), but 22 patients with MES 2 or 3 had a mean FIT of > 134.89 ng/mL. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of negative FIT about mucosal healing were 73.33%, 81.82%, 91.49%, 51.43% and 73.17%, respectively. The sensitivity, specificity, PPV, NPV and accuracy of predictive value of positive FIT (cutoff value > 100 ng/mL) about active disease status were 45.45%, 93.33%, 71.43%, 82.35% and 26.83%, respectively. Among patients with clinical remission, FIT was negative in 31 (81.6%) of 38 cases, with a mean fecal hemoglobin concentration of 6.12 ng/mL (range, negative to 80.9 ng/mL) for this group of patients. Among patients with clinical active disease, FIT was negative in 16 (36.4%) out of 44 cases, with a mean fecal hemoglobin concentration > 167.4 ng/mL for this group of patients. FIT was positively correlated with endoscopic activity (r = 0.626, P < 0.01) and clinical activity (r = 0.496, P < 0.01). But, FIT did not correlate with the extent of disease (r = -0.047, P = 0.676) CONCLUSION Quantitative FIT can be a non-invasive and effective biomarker for evaluation of clinical and endoscopic activity in UC, but not predict the extent of disease.