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Surgical resection is one of the most widely used modalities for the treatment of hepatocellular carcinoma (HCC). Early extrahepatic recurrence (EHR) of HCC after surgical resection is considered to be closely associated with poor prognosis. However, data regarding risk factors and survival outcomes of early EHR after surgical resection remain scarce.To investigate the clinical features and risk factors of early EHR and elucidate its association with survival outcomes.From January 2004 to December 2019, we enrolled treatment-naïve patients who were ≥ 18 years and underwent surgical resection for HCC in two tertiary academic centers. After excluding patients with tumor types other than HCC and/or ineligible data, this retrospective study finally included 779 patients. Surgical resection of HCC was performed according to the physicians' decisions and the EHR was diagnosed based on contrast-enhanced computed tomography or magnetic resonance imaging, and pathologic confirmation was performed in selected patients. Multivariate Cox regression analysis was performed to identify the variables associated with EHR.Early EHR within 2 years after surgery was diagnosed in 9.5% of patients during a median follow-up period of 4.4 years. The recurrence-free survival period was 5.2 mo, and the median time to EHR was 8.8 mo in patients with early EHR. In 52.7% of patients with early EHR, EHR occurred as the first recurrence of HCC after surgical resection. On multivariate analysis, serum albumin4.0 g/dL, serum alkaline phosphatase100 U/L, surgical margin involvement, venous and/or lymphatic involvement, satellite nodules, tumor necrosis detected by pathology, tumor size ≥ 7 cm, and macrovascular invasion were determined as risk factors associated with early EHR. After sub-categorizing the patients according to the number of risk factors, the rates of both EHR and survival showed a significant correlation with the risk of early EHR. Furthermore, multivariate analysis revealed that early EHR was associated with substantially worse survival outcomes (Hazard ratio, 6.77; 95% confidence interval, 4.81-9.52;Early EHR significantly deteriorates the survival of patients with HCC, and our identified risk factors may predict the clinical outcomes and aid in postoperative strategies for improving survival.

BACKGROUND Cytomegalovirus (CMV) colitis is usually seen in immunocompromised patients with risk factors such as human immunodeficiency virus infection, solid organ transplant, inflammatory bowel disease, or malignancy. Therefore, many clinicians usually do not consider the possibility of CMV colitis in immunocompetent patients. We reported a rare case of segmental colonic hypoganglionosis associated with CMV colitis in an immunocompetent patient. CASE SUMMARY A 48-year-old woman with no underlying disease was admitted to our hospital for severe abdominal pain and constipation. Computed tomography of the abdomen showed diffuse dilatation of the small intestine and the entire colon. Initial sigmoidoscopic findings and result of polymerase chain reaction (PCR) for CMV revealed the compatible findings of CMV colitis, the patient was treated with intravenous ganciclovir. After treatment, sigmoidoscopic findings and CMV PCR results improved. However the patient continued to suffered from constipation. Eight months after the initial admission, patient visited the emergency department with severe abdominal pain and imaging revealed aggravation of fecal impaction and bowel dilatation. We performed subtotal colectomy to control patient’s symptom. Histological examination of the resected specimen showed significantly reduced number of mature ganglion cells in the sigmoid colon compared to that in the proximal colon. CONCLUSION Our case demonstrates that CMV colitis can develop even in patients with no other underlying disease, and that CMV colitis can be one of the causes for developing colonic hypoganglionosis.

Extrahepatic recurrence (EHR) after curative hepatectomy for hepatocellular carcinoma (HCC) is associated with a poor prognosis. We investigated the features of EHR and identified its predictive factors. This retrospective study included 398 treatment-naive patients who underwent curative hepatectomy for HCC at two tertiary hospitals. Multivariate Cox-regression analysis was performed to identify the variables associated with EHR. EHR was diagnosed in 94 patients (23.6%) over a median follow-up period of 5.92 years, most commonly in the lungs (42.6%). The 5-/10-year cumulative rates of HCC recurrence and EHR were 63.0%/75.6% and 18.1%/35.0%, respectively. The median time to EHR was 2.06 years. Intrahepatic HCC recurrence was not observed in 38.3% of patients on EHR diagnosis. On multivariate analysis, pathologic modified Union for International Cancer Control stage (III, IVa), surgical margin involvement, tumor necrosis, sum of tumor size > 7 cm, and macrovascular invasion were predictive factors of EHR. Four risk levels and their respective EHR rates were defined as follows: very low risk, 1-/5-year, 3.1%/11.6%; low risk, 1-/5-year, 12.0%/27.7%; intermediate risk, 1-/5-year, 36.3%/60.9%; and high risk, 1-year, 100.0%. Our predictive model clarifies the clinical course of EHR and could improve the follow-up strategy to improve outcomes.

BACKGROUND Primary endoscopic closure of a perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are very few studies on the efficacy of endoscopic management of delayed traumatic gastric perforation. Herein, we report a novel case of a patient who was successfully treated for delayed traumatic stomach perforation using an alternative endoscopic modality. CASE SUMMARY A 39-year-old woman presented with multiple penetrating traumas in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suturing of the lacerated lung was performed; however, delayed free perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for the primary repair of the gastric wall, re-perforation was noted 15 d postoperatively. The high risk associated with re-surgery prompted an endoscopic intervention using 2 endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications. CONCLUSION Endoscopic closure with endoloops and clips can be a useful therapeutic alternative to re-surgery for delayed traumatic gastric perforation.

BACKGROUND Tumors located in the pylorus are technically more complex to resect by endoscopic resection, as the anatomical characteristics of this region can affect the adequate assessment of margins and performance of the procedure. We reported the results of underwater endoscopic mucosal resection (UEMR) of benign mucosal neoplasms located in the pyloric ring. CASE SUMMARY This case series describes 4 patients with 4 mucosal neoplasms located in the pyloric ring. The diameter of each neoplasm was less than 15 mm. We performed UEMR for the lesions. Water immersion enabled slight floating of the lesions, resulting in easy identification. We achieved en bloc resection with a snare and electrosurgical unit. All procedure were performed within 3 min without adverse events. Pathologic examination showed low-grade dysplasia with clear resection margins in one case and hyperplastic polyps in three cases. CONCLUSION UEMR can be an effective and safe treatment method for neoplasms in the gastric pyloric ring.

Backgrounds/aims Distinguishing gastric ectopic pancreas (GEP) from malignant tumors is relatively difficult. This study evaluated the endosonography findings of pathologically proven GEP. Methods Thirty-one patients diagnosed with GEP based on a histopathological analysis from January 2004 to July 2018 were enrolled in this study. All patients underwent EUS and an endoscopic resection. Results Seventeen patients were female, and the median age was 41.1 years (range, 14-74). The lesions were localized most commonly in the antrum. The mean size of the GEP was 10.6 mm (range, 7-15). Superficial type lesions, lesions with heterogeneous echogenicity, mixed pattern lesions, and lesions with indistinct borders were commonly observed on EUS. Calcification, anechoic duct-like structures, and thickening of the muscularis propria were observed in some patients. Endoscopic mucosal resection (41.9%) and endoscopic submucosal dissection (58.1%) were performed. The mean procedure time was 22.5 minutes. Complete resection was achieved for 71% of patients. No statistically significant results between the endosonography findings and complete resection rates were obtained. The mean follow-up esophagogastroduodenoscopy duration was 4.5 months. None of the patients presented with residual lesions on subsequent endoscopy. Conclusions EUS can help identify the features of GEP. Careful observations of the EUS findings can avoid unnecessary removal of GEP.

이 연구는 초등학교 교사를 대상으로 통합교육의 효율성에 영향을 미치는 사회적 정향 및 교사가치 정향의 구조 관계를 알아보기 위한 조사연구로 수행되었다. 설문지는 사회적 정향 15문항, 교사가치 정향 16문항, 그리고 통합교육 효율성 15문항으로 구성되었다. 이 연구를 위하여 전국의 초등학교 교사 316명의 자료를 분석하였다. 탐색적 요인분석에 기초하여 확인적 요인분석을 적용하였다. 측정모형, 수정모형, 수정된 측정모형 타당성 평가, 그리고 가설적 구조모형 및 구조모형을 결정하는 과정으로 구조방정식 모형을 검정하였다. 구조방정식 모형의 검정 과정에서 밝혀진 연구의 결과는 다음과 같다. 첫째, 초등학교 교사의 사회적 정향은 교사가치 정향에 영향을 미친다. 둘째, 초등학교 교사의 사회적 정향은 통합교육 효율성에 영향을 미친다. 셋째, 초등학교 교사의 사회적 정향이 통합교육 효율성에 영향을 미칠 때, 교사가치 정향의 매개 효과는 나타나지 않는다. 넷째, 초등학교 교사의 사회적 정향이 교사가치 정향과 통합교육 효율성에 미치는 영향은 직접 효과로만 설명된다. 결론적으로 초등학교 교사의 사회적 정향은 교사가치 정향 및 통합교육 효율성에 영향을 미치는 구조이며, 특히 초등학교 교사의 통합교육 효율성에 영향을 미치는 요인은 사회적 정향에 의해 직접적으로 설명되는 구조임을 이 연구에서는 제안하고 있다.

Background/Aims: Colonic diverticular bleeding (CDB) is a common cause of acute lower gastrointestinal bleeding. Patients with CDB are at increased risk for recurrence. Here, we aimed to evaluate the clinical course of patients with CDB and identify risk factors, including the Charlson comorbidity index (CCI), for recurrent CDB (rCDB).Methods: We retrospectively included patients who were hospitalized at the Chonnam National University Hospital for management of CDB between January 2005 and March 2020, and data on the underlying disease, drug history, treatment method, post-discharge rCDB, and death were checked.Results: Among 221 investigated patients (mean age, 68.1 years; 56 females), 56 and 165 had definite and presumptive CDB, respectively, 122 (55.2%) had a right-sided CDB, and 51 (23.3%) experienced rCDB throughout a median period of 339 days (range, 3–4817 days). The most common comorbidities were hypertension (62.4%) and diabetes (33.5%). The median length of hospitalization was 5 days (range, 2–119 days). The CDB-related morality rate was 0.9% at first admission. The cumulative incidence rates of rCDB after 1, 6, 12, 24 months were 4.6%, 9.1%, 12.3%, and 16.9%, respectively. In Cox regression analysis, rCDB more frequently occurred in patients with CCI ≥ 4 than in patients with CCI < 4 (adjusted hazard ratio, 2.76; 95% confidence interval, 1.30–5.88; p < 0.01).Conclusions: rCDB occurred frequently at any time in patients with previous CDB. High CCI scores were associated with rCDB. Clinicians need to consider possible rCDB for patients with high CCIs.

ObjectivesAmiodarone is widely used to treat arrhythmia. However, amiodarone is known for its severe toxicity to the liver, lungs, and thyroid. Amiodarone causes liver damage ranging from asymptomatic serum aminotransferase elevation to hepatic failure requiring liver transplantation. Although amiodarone toxicity has been reported, its simultaneous multi-organ toxicity is not well-known. Here, we introduce a novel case of multi-systemic amiodarone toxicity involving the liver, lungs, thyroid, and eyes.Case PresentationA 61-year-old woman visited the emergency room due to general weakness, nausea, visual disturbance, heat intolerance, and a non-productive cough. The patient had been using clopidogrel and amiodarone due to underlying atrial fibrillation. The total level of bilirubin was 0.71 mg/dL, aspartate aminotransferase was 358 U/L, alanine aminotransferase was 177 U/L, and prothrombin time was 27.1 s. Computed tomography showed diffuse increased liver intensity and scattered hyperattenuated nodular consolidations in both lungs. Transthoracic needle lung biopsy revealed fibrinoid interstitial inflammation with atypical change of type II pneumocytes and intra-alveolar foamy macrophages. In addition, the thyroid-stimulating hormone level was ConclusionsThis case implies the possibility of multi-systemic amiodarone toxicity. Thus, the toxicity of amiodarone to multiple organs must be monitored. Prompt cessation of the drug should be considered upon diagnosis.

Background/Aims Patients with Hansen’s disease are the most vulnerable to hepatitis C. However, no data on the treatment efficacy of direct-acting antiviral agents (DAAs) are available in this group. Therefore, we elucidated the prevalence and clinical outcomes of hepatitis C in persons affected by leprosy in Sorokdo, Jeollanam-do, Korea. Methods We retrospectively included 50 leprosy patients with positive hepatitis C virus (HCV) RNA test results (group A) hospitalized at the Sorokdo National Hospital from May 2016 to March 2018 and 73 patients with chronic hepatitis C who were treated with DAAs at the Chonnam National University Hospital (group B) from May 2016 to December 2017. Results Overall, at the Sorokdo National Hospital, positive HCV antibody and HCV RNA rates were 18.4% and 11.0%, respectively. The mean participant age was 76.5±7 years, and 58% of participants were men. The genotypes were type 1b in 44% (22 out of 50) and type 2 in 56% (28 out of 50). Sustained virologic response was achieved at a rate of 95.5% (21/22) in genotype 1b and 92.9% (26/28) in genotype 2 patients. Ribavirin-induced hemolytic anemia occurred in 57.1% (16/28) of patients with genotype 2. Among these, 28.5% (8/28) received blood transfusions. Conclusions Treatment efficacy was not different between the leprosy-affected population and the general population. However, severe ribavirin-induced hemolytic anemia requiring transfusion was present in 28.5% of genotype 2 patients. Therefore, we suggest ribavirin-free DAAs for the treatment of genotype 2 hepatitis C in leprosy-affected persons in the future.

Background/Aims Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms. Methods Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T½) and incidence of cardiovascular events following GES. Results The mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE (P = 0.015). Univariate analysis showed that GE T½ was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12-2.69; P = 0.014). In a multivariate model, association between GE T½ and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21-3.12; P = 0.006). Conclusion A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms. (J Neurogastroenterol Motil 2019;25:387-393)

Recent studies report a significant age-specific increase in hepatocellular carcinoma (HCC) development among persons over 75 years old. Therefore, there is an urgent need to determine the optimal treatment strategy in elderly patients with HCC. This systemic review examines the clinical characteristics, efficacy, and safety of first-line treatment modalities. The literature was searched regarding epidemiology and clinical outcomes in elderly patients (age ≥75 years) undergoing first-line treatment for HCC. Causative or comorbid conditions of HCC in elderly patients differed from those in younger patients. Radiofrequency ablation may be effective and safe in early stages. Surgical resection may also be feasible in the early stages for selected patients. Transarterial chemoembolization may be safe and effective for intermediate HCC, and sorafenib may be feasible in elderly patients with advanced HCC. Prospective randomized trials are needed to establish the treatment strategy for elderly patients with HCC.

Background Extrahepatic recurrence (EHR) after curative hepatectomy for hepatocellular carcinoma (HCC) is associated with a poor prognosis. We investigated the features of EHR and identified its predictive factors. Methods This retrospective study included 398 treatment-naive patients who underwent curative hepatectomy for HCC at two tertiary hospitals. Multivariate analysis via Cox-regression was performed to identify the variables associated with EHR. Results EHR was diagnosed in 94 patients (23.6%) over a median follow-up period of 5.92 years, most commonly in the lungs (42.6%). The 5-/10-year cumulative rates of HCC recurrence and EHR were 63.0%/75.6% and 18.1%/35.0%, respectively.. The median time to EHR was 2.06 years. Intrahepatic HCC recurrence was not observed in 38.3% of patients on EHR diagnosis. On multivariate analysis, bile duct invasion, tumor necrosis, sum of tumor size > 7 cm, macrovascular invasion, first recurrence free survival 400 IU/mL during recurrence were predictive of EHR. Four risk levels and their respective EHR were defined: very low risk, 2-/5-year, 0.7%/14.2%; low risk, 2-/5-year, 6.4%/31.0%; intermediate risk, 2-/5-year, 21.9%/73.1%; and high risk, 2-/3-year, 70.8%/100.0%. Conclusion Our predictive model clarifies the clinical course of EHR and could improve the follow-up strategy to improve outcomes.

Background Silibinin is a flavonoid with antihepatotoxic properties, and exhibits pleiotropic anticancer effects. However, the molecular mechanisms responsible for its anticancer actions in pancreatic cancer cells, and the effects on such cells and normal pancreatic cells, remain unclear. The objective of this study was to determine the effect of silibinin on human pancreatic cancer cells and normal ductal cells.Methods Human pancreatic cancer cells (MIA PaCa-2 and PANC-1) and normal ductal cells (hTERT-HPNE) were cultured with 0–400 μM silibinin for 48 h. Thereafter, the proliferation, invasion, apoptosis, and signaling pathways of the pancreatic cells were evaluated.Results Silibinin significantly inhibited the proliferation, invasion, and spheroid formation of human pancreatic cancer cells in vitro in a dose-dependent manner (p < 0.05). It also induced apoptosis in a dose-dependent manner. Western blot analysis showed that silibinin downregulated extracellular signaling-regulated kinase (ERK) and serine/threonine protein kinase (AKT) in human pancreatic cancer cells. It also upregulated microtubule associated protein 1 light chain 3 β (LC3B) and cleaved caspase-3 via c-Jun N-terminal kinases (JNK) signaling. On the other hand, silibinin increased the mRNA and protein levels of c-Jun, Twist-related protein 1, and Snail. It also decreased exogenous p53 levels, but increased endogenous c-Jun protein levels in human pancreatic cancer cells. However, silibinin did not affect cell viability and endogenous c-Jun levels in pancreatic normal ductal cells. It increased exogenous p53 levels, but decreased stemness-related gene expression in pancreatic normal ductal cells. Silibinin increased Ki-67 levels in pancreatic cancer cells, but decreased them in pancreatic normal ductal cells.Conclusion Silibinin not only exerted anticancer effects by inhibiting AKT–ERK and JNK signaling, but also upregulated cancer stemness–related genes in human pancreatic cancer cells. These results suggest that silibinin should be used as a therapeutic agent for human pancreatic cancer with caution.

Background Primary endoscopic closure of perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are only few studies on the efficacy of endoscopic management in traumatic delayed gastric perforation. Case presentation: Here, we report the case of a 39-year-old woman who presented with multiple penetrating trauma in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suture of the lacerated lung was performed; however, delayed free-perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for primary repair of the gastric wall, re-perforation was noted 15 d post-operatively. The high re-operation risk prompted an endoscopic intervention using two endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications. Conclusions Endoscopic closure with this novel technique involving endoloops and endoscopic clips can be a useful therapeutic alternative to re-operation for delayed gastric perforation caused by penetrating trauma.

Background Although endoscopic resection is safe and effective for gastric epithelial neoplasms, information is limited on its efficacy and safety in extremely elderly patients who have various comorbidities. Further, the relationship between comorbidities and complications of endoscopic resection is not well established. Therefore, we aimed to evaluate the efficacy and safety of endoscopic resection of gastric epithelial neoplasms in extremely elderly patients. Methods From October 2008 to December 2017, 4475 consecutive patients underwent endoscopic resection of gastric epithelial neoplasms. Among them, 242 were 75 years or older. We assessed Charlson comorbidity index (CCI) scores, procedural outcomes, and procedure- and sedation-related complications related to endoscopic resection. Results Mean patient age was 78.7 ± 3.2 years. Of the 242 patients, 124 (51.2%) had low-grade dysplasia and 112 (46.3%) had adenocarcinoma. The most common comorbidity was hypertension (55.4%), followed by diabetes (23.1%). The mean CCI score was 1.67 ± 1.43. Sixty patients (24.8%) had a CCI score ≥ 3. During the procedure, 10 (4.1%) patients had desaturation that recovered by flumazenil use with mask (n = 2) or Ambu bag (n = 3) ventilation. During subsequent admission, atelectasis or pneumonia occurred in 45 (18.6%) patients, post-procedural bleeding in 12 (5.0%), and perforation in 3 (1.2%). Respiratory complications were more common in patients with a CCI score ≥ 3 (20/60, 33.3%) than in those with a CCI score P = 0.002). Conclusions CCI score is related to respiratory complications of endoscopic resection in extremely elderly patients. Endoscopic resection must be performed cautiously, particularly in elderly patients with a high CCI score, to prevent respiratory complications.

Background : Although previous studies have suggested a high salt intake as a risk factor for precancerous and cancerous lesions of stomach, the evidence is not sufficient to draw a conclusion yet. We aimed to evaluate the association between ‘estimated 24-hour urinary sodium excretion’ and prevalence of synchronous gastric epithelial neoplasm. Methods: Among 2017 patients with gastric epithelial neoplasms, who had test results for estimated 24-hour urinary sodium excretion, 1310 were enrolled. Results: There were 545 (41.6%) patients with high-grade dysplasia and early gastric cancer. The mean age was 64.5 years; 853 (65.1%) were men and 244 (18.6%) were smokers. The rate of Helicobacter pylori infection was 71.0% (797/1123). The incidence of synchronous gastric epithelial neoplasm was 10.6% (139/1310). Significant interactions were seen between estimated 24-hour urine sodium’ and sex ( P -interaction =0.003), with the association largely limited to women; ‘estimated 24-hour urine sodium’ (aOR, 1.26; 95% CI, 1.05 to 1.51, P = 0.012) was an independent risk factor for synchronous gastric neoplasm in women. Conclusions: High ‘estimated 24-hour urinary sodium excretion’ was associated with synchronous gastric epithelial neoplasm in women.

Background/aims The success rate of endoscopic variceal ligation (EVL) is about 85-94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment. Methods Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion. Results Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-butyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group. Conclusions The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.