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Tailored therapy based on dual priming oligonucleotide-based polymerase chain reaction (DPO-PCR) can be considered an alternative to overcome the low eradication rate in high clarithromycin-resistance areas. The triple therapy (TT) duration of the tailored approach in most studies was 7 days for patients without point mutation. However, recent western guidelines have recommended a treatment duration of 14 days. The aim of this study was to compare the success rate of 7 and 14 days of TT for eradicating Helicobacter pylori without point mutation, as determined by DPO-PCR. Between Feb 2016 and Feb 2019, medical records of patients who underwent DPO-PCR were reviewed. Patients without point mutation as determined by DPO-PCR were enrolled in this study. The eradication success rate and adverse events were evaluated. A total of 366 patients without A2142G and A2143G point mutation were enrolled. The success rates of 7-day and 14-day TT were 88.4% (168/190) and 85.9% (151/176) by intention to treat analysis (P = .453) and 90.8% (168/185) and 90.4% (151/167) by per-protocol analysis (P = .900), respectively. The adverse event rates showed no significant difference between the 2 groups. In patients without point mutation based on DPO-PCR results, 7-day TT is as effective as 14-day TT. Therefore, 7 days may be considered as a cost-effective treatment duration in Korea.

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.

The management plan for gastric indefinite for neoplasia is undetermined, and endoscopic forceps biopsy might be inconclusive in ascertaining whether a resection is required. This study aimed to evaluate the clinical outcomes of endoscopic submucosal dissection (ESD) for gastric indefinite for neoplasia and to identify the factors highly predictive of true neoplasia. This retrospective study was conducted in a single, tertiary, referral hospital between November 2008 and December 2015. A total of 109 gastric indefinite for neoplasia lesions from endoscopic forceps biopsy that were resected by ESD were included in the study. The clinical outcomes and endoscopic factors for prediction of true neoplasia were analyzed. A total of 99 patients (90.8%) were diagnosed with definite neoplasia after ESD and were classified as category 3 (n = 42), category 4 (n = 50), and category 5 (n = 7) according to the revised Vienna classification. The mean age of the patients was 65.8 ± 9.8 years. The mean lesion size was 10.7 ± 6.1 mm. The patient population predominantly consisted of male patients (70.6%). The en bloc and complete endoscopic resection rates were 98.2% and 94.5%, respectively. Factors associated with true neoplastic lesions were male sex (odds ratio [OR] 8.596, p = 0.008) and lesion size ≥ 5 mm (OR 11.355, p = 0.003). Factors associated with category 4–5 were male sex (OR 3.165, p = 0.021) and erosive change (OR 2.841, p = 0.031). Endoscopic resection for indefinite for neoplasia with larger lesions size and erosive changes, especially in males, should be considered when possible.

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

Tumors located on the proximal stomach are associated with a longer procedure time and lower en-block resection of endoscopic submucosal dissection (ESD). Additionally, it is more difficult to perform ESD for lesions after distal gastrectomy because of the narrow inner space. We aimed to evaluate the therapeutic outcomes of ESD for lesions on the remnant stomach compared with those on the upper third of the entire stomach. A total of 135 patients with a neoplasm located on the proximal stomach who received ESD between Aug 2008 and Dec 2016 were enrolled. We retrospectively reviewed en-bloc resection rate, complete resection rate, and complication rate according to whether distal gastrectomy was performed. Clinical outcomes were compared among the 1:2 propensity-matched groups. Between the remnant stomach and entire stomach, the en-bloc [92% (23/25) and 92.0% (46/50), respectively; P = 1.000] and complete resection [84% (21/25) and 88.0 (44/50), respectively; P = 0.723] rates were not significantly different. In patients with lesions that indicated ESD, there was no significant difference in en-bloc and complete resection rates. In a multivariable analysis, submucosal fibrosis [odds ratio (OR) 5.9, 95% confidence interval (CI) 1.1–30.7] and submucosa invasive cancer (OR 10.1, 95% CI 1.4–74.3) were independent risk factors for incomplete resection. ESD is a feasible therapeutic option for lesions located on the proximal stomach regardless the operation history of distal gastrectomy. However, the complete resection rate decreases for lesions with submucosal fibrosis or the submucosa invasion.

Endoscopic submucosal dissection (ESD) enables the complete removal of gastric lesions regardless of tumor size. ESD is typically performed using one of several available electrocautery knives and endoscopic mucosal resection (EMR) is performed using a diathermic snare. We aimed to investigate the clinical outcomes and complications in patients in whom a snare tip was used for ESD.We retrospectively evaluated the medical records of 30 patients who underwent removal of a gastric lesion using a snare tip by ESD or hybrid ESD (ESD with snaring). For hybrid ESD, snaring was performed after an adequate submucosal dissection. The clinical outcomes according to the endoscopic procedure performed were evaluated.ESD was performed in 12 patients and hybrid ESD was performed in 26 patients. Overall en-bloc and complete resection rates were both 97.4%. There was one case where piece-meal resection was performed in the hybrid ESD group. There were no procedure related complications such as perforation or bleeding. The mean specimen size was 2.8 ± 0.6 cm in the ESD group and 2.3 ± 0.5 cm in the hybrid ESD group (p = .031). The mean procedure time did not differ between the two methods (12.8 min in ESD and 9.7 min in hybrid ESD, p = .060).The snare tip can be used as an electrocautery knife to incise the mucosa and dissect the submucosa during removal of a gastric lesion.

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.

To successfully resect early gastric cancer (EGC), prediction of lymph node metastasis is essential. Beyond endoscopic submucosal dissection (ESD) indication or lymphovascular invasion (LVI) are known risk factors associated with lymph node metastasis. However, accurate prediction of tumor invasion depth or LVI is impossible before endoscopic resection even when endoscopic ultrasound is used. The aim of this study was to identify the predictive factors associated with beyond ESD indication or LVI after ESD for EGC. Between Jan 2011 and Feb 2015, 532 lesions from 506 patients who received ESD for EGCs were included. We reviewed the data of patients diagnosed as EGCs without ulceration or those smaller than 3 cm with ulceration. The incidence of EGCs found to be beyond expanded ESD indications or present of LVI after ESD was 11.1% (59/532). On multivariable analysis, endoscopic features of SM invasion, surface color changes, and elevated lesions were associated with beyond ESD indication or LVI. In particular, submucosal (SM) invasive features such as SM tumor-like marginal elevation [odds ratio (OR) 17.2; 95% confidence interval (CI) 2.0–146.7], fusion of convergent folds (OR 12.9; 95% CI 3.9–42.1), irregular surface (OR 17.8; 95% CI 5.6–56.8), and discoloration of the tumor surface (OR 16.1; 95% CI 2.4–105.9) were significant risk factors for beyond ESD indication or LVI. The decision to proceed with endoscopic resection for EGCs with endoscopic features of SM invasion, surface color changes, or elevated forms must be made cautiously.

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.

Background. Endoscopic ultrasound- (EUS-) guided drainage is generally performed under fluoroscopic guidance. However, improvements in endoscopic and EUS techniques and experience have led to questions regarding the usefulness of fluoroscopy. This study aimed to retrospectively evaluate the safety and efficacy of EUS-guided drainage of extraluminal complicated cysts without fluoroscopic guidance.Methods. Patients who had undergone nonfluoroscopic EUS-guided drainage of extraluminal complicated cysts were enrolled. Drainage was performed via a transgastric, transduodenal, or transrectal approach. Single or double 7 Fr double pigtail stents were inserted.Results. Seventeen procedures were performed in 15 patients in peripancreatic fluid collections (n=13) and pelvic abscesses (n=4). The median lesion size was 7.1 cm (range: 2.8–13.0 cm), and the mean time spent per procedure was26.2±9.8minutes (range: 16–50 minutes). Endoscopic drainage was successful in 16 of 17 (94.1%) procedures. There were no complications. All patients experienced symptomatic improvement and revealed partial to complete resolution according to follow-up computed tomography findings. Two patients developed recurrent cysts that were drained during repeat procedures, with eventual complete resolution.Conclusion. EUS-guided drainage without fluoroscopic guidance is a technically feasible, safe, and effective procedure for the treatment of extraluminal complicated cysts.

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.