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Background and Aims Data are limited regarding the impact of age and sedation on cardiocerebrovascular disease (CCD) adverse events after GI endoscopy. We investigated the incidence of and risk factors for CCD adverse events after diagnostic GI endoscopy and the impact of age and sedation on these unfavorable outcomes. Methods In this nationwide population-based study, the incidence of and risk factors for newly diagnosed CCD within 14 days after diagnostic endoscopy were analyzed using Health Insurance Review and Assessment Service data from January to December 2015. Results Among 1,943,150 subjects, CCD adverse events occurred in approximately 2.23% within 14 days after endoscopy. According to the performance of sedation during endoscopy (60.1% nonsedation vs 39.9% sedation, midazolam alone [96.4%]), the incidence rates of CCD adverse events (per 10,000 persons) were 275.8 versus 302.8 for EGD, 116.9 versus 143.8 for colonoscopy, and 230.4 versus 243.2 for EGD + colonoscopy, respectively. On multivariate analysis, older age (70-99 years) and sedation were independent risk factors for CCD adverse events. Regarding CCD risk stratified by age and sedation, older age had a significant impact on CCD adverse events in individuals who underwent EGD only or EGD + colonoscopy, but sedation did not. However, both older age and sedation had considerable influence on CCD adverse events in individuals who underwent colonoscopy only. Sedation during endoscopy was significantly associated with minor but not major CCD adverse events. CCD adverse events were significantly higher for inpatients. Conclusion CCD adverse events after diagnostic endoscopy were significantly frequent in individuals with older age (70-99 years) and/or sedation during endoscopy. Stratification by age and sedation shows that the impact of these 2 factors on CCD adverse events differs according to endoscopy type.

Background and Aims Endoscopy is performed with air insufflation and is usually associated with abdominal pain. It is well recognized that carbon dioxide (CO 2 ) is absorbed more quickly into the body than air; however, to date, few studies have investigated the use of CO 2 insufflation during consecutive EGD and colonoscopy (CEC). Thus, this study evaluated the efficacy of CO 2 insufflation compared with air insufflation in CEC. Methods From March 2014 to April 2016, a total of 215 consecutive patients were randomly assigned to receive CO 2 insufflation (CO 2 group, n = 108) or air insufflation (air group, n = 107). Abdominal pain after CEC was recorded on a visual analogue scale (VAS). The amount of sedatives administered, use of analgesics, polyp detection rate (PDR), adenoma detection rate (ADR), abdominal circumference, and adverse events were also analyzed. Results Baseline patient characteristics were not significantly different between the groups. Abdominal pain on the VAS in the CO 2 group and air group 1 hour after CEC was, respectively, 13.8 and 20.1 ( P = .010), 3 hours after CEC was 8.3 and 12.5 ( P = .056), 6 hours after CEC was 3.5 and 5.3 ( P = .246), and 1 day after CEC was 1.8 and 3.4 ( P = .192). The dose of sedative administered, analgesic usage, PDR, ADR, and adverse events were not statistically different between the groups. However, the increase in abdominal circumference was significantly higher in the air group than in the CO 2 group. Conclusions CO 2 insufflation was superior to air insufflation with regard to the pain score on the VAS in the hour after CEC. (Clinical trial registration number: KCT0001491.)

Background and Aims Endoscopic resection has been performed for treatment of GI stromal tumors (GISTs) in the upper GI tract. However, the therapeutic roles of the endoscopic procedure remain debatable. We aimed in this retrospective study to evaluate the feasibility and long-term follow-up results of endoscopic resection of GISTs in the upper GI tract, compared with surgery. Methods Between March 2005 and August 2014, 130 cases of GIST in the upper GI tract were resected. We compared baseline characteristics and clinical outcomes including R0 resection rate and recurrence rate between the endoscopy group (n = 90) and surgery group (n = 40). Results The most common location of GIST was the stomach body in the endoscopy group, whereas it was the duodenum in the surgery group ( P = .001). Tumor size was significantly smaller (2.3 vs 5.1 cm; P P P P = .001), and 50.0% of resected tumors belonged to a very low–risk group in the endoscopy group, whereas 35.0% and 30.0% belonged to low-risk and high-risk in the surgery group ( P = .001). However, during 45.5 months of follow-up, the recurrence rate was not significantly different between the 2 groups (2.2% vs 5.0%; P = .586). Conclusions Endoscopic resection might be an alternative therapeutic modality for GISTs in the upper GI tract in selective cases.

Background and Aims Although colonic perforation is a dreadful adverse event associated with stent placement, data on this topic are sparse. We aimed to investigate the clinical outcomes of colonic perforation and factors related to its occurrence in patients who received self-expandable metal stents (SEMSs) for malignant colorectal obstruction. Methods We retrospectively reviewed the data of 474 patients with malignant colorectal obstruction who received endoscopic SEMS insertion from April 2004 to May 2011 in Severance Hospital and Gangnam Severance Hospital. Early perforation, defined as perforation occurring within 2 weeks, was assessed in bridge-to-surgery (n = 164) and palliative stent placement patient groups (n = 310). Delayed perforation was analyzed using data from the palliative stent placement group alone. Results The technical and clinical success rates were 90.5% and 81.0%, respectively. Early and delayed perforations occurred in 2.7% (13/474) and 2.7% (8/301) of patients, respectively. Among 21 patients with perforation, 14 (66.7%) received emergency surgery and 5 (23.8%) died within 30 days after perforation. Regarding the perforation-related factors, age ≥70 years (odds ratio, 3.276; 95% confidence interval [CI], 1.041-10.309) and sigmoid colonic location (odds ratio, 7.706; 95% CI, 1.681-35.317) were independently associated with occurrence of early perforation. Stent location in the flexure (hazard ratio, 17.573; 95% CI, 2.004-154.093) and absence of peritoneal carcinomatosis (hazard ratio, 6.139; 95% CI, 1.150-32.776) were significantly associated with delayed perforation. Conclusions The perforation-related 30-day mortality rate was 23.8%. Older age and sigmoid colonic location were significantly associated with occurrence of early perforation, whereas flexure location and absence of peritoneal carcinomatosis were related to delayed perforation.

Background and Aims The effects of chemotherapeutic agents on the development of colorectal adenomas in patients with previous colorectal cancer (CRC) are not defined. Therefore, we evaluated the potential effect of adjuvant chemotherapy on the incidence of colorectal adenomas in patients with previous CRC. Methods We selected patients with low-risk stage II CRC with or without postoperative 5-fluorouracil–based adjuvant chemotherapy to reduce selection bias. Among 1808 patients with stage II CRC who underwent colonoscopic surveillance after curative resection of CRC between 2006 and 2013, 192 patients were retrospectively enrolled in this study after matching for age and sex. The patients were divided into 96 patients receiving and 96 patients not receiving 5-fluorouracil–based chemotherapy. Results Forty patients (41.7%) exhibited colorectal adenomas among 96 patients who received adjuvant chemotherapy, compared with 50 patients (52.1%) with colorectal adenomas among 96 patients who received surgery only. The incidence rate of advanced adenoma was significantly lower in the chemotherapy group than in the nonchemotherapy group (3.1% vs 10.4%, P = .044). After adjustment for clinically relevant factors such as body mass index, aspirin use, metformin use, number of follow-up colonoscopies, and operation type, adjuvant chemotherapy was found to be associated with a decreased incidence of advanced adenoma (odds ratio, .151; 95% confidence interval, .035-.653; P = .011) in patients with stage II CRC. Conclusions The results showed that chemotherapy in patients with CRC may be associated with a lower risk of colorectal advanced adenoma development.

Background Only 30% to 40% of patients with advanced proximal neoplasms (APN) have distal colon neoplasms. Objective To develop a risk score model for APN and propose an individualized screening protocol for colorectal cancer. Design Retrospective cohort study. Setting Tertiary-care center. Patients Derivation cohort (6200 adults) and validation cohort (1389 adults). Intervention Screening colonoscopy. Main Outcome Measurements An APN risk score model was developed from the derivation cohort (6200 adults) and was tested in the validation cohort (1389 adults), who underwent screening colonoscopy. Results Age, male sex, and smoking were clinical risk factors for APN. The presence of a distal neoplasm was a sigmoidoscopic risk factor for APN. We calculated APN risk scores (0-8) based on these variables and classified patients as low risk (0-2) or high risk (3-8). In the validation cohort, the relative risk of APN was 3.5-fold higher in the high-risk group than in the low-risk group. Our model suggests that colonoscopy should be performed as an initial screening test in patients with a high clinical risk for APN. Sigmoidoscopy should be performed initially in patients with low clinical risk for APN followed by supplementary colonoscopy in those with high APN risk scores based on both clinical and sigmoidoscopic risk factors. This protocol detected APN in 22 of 34 APN+ patients (64.7%) with little increase in the endoscopy burden, whereas only 16 of 34 APN+ patients (47.1%) would be identified by initial sigmoidoscopy followed by colonoscopy only in cases with distal neoplasms. Limitations Retrospective design. Conclusion Our APN risk score model provides an algorithm for efficient screening of colorectal cancer by sigmoidoscopy and colonoscopy.

Background There has been no consensus regarding the optimal treatment durations and drug regimens in patients with endoscopic submucosal dissection (ESD)–induced ulcers. Objective To assess the efficacy of proton pump inhibitor (PPI) and rebamipide combination therapy compared with PPI monotherapy for ESD-induced ulcer healing. Design Randomized, prospective, controlled study; clinical trial. Setting Five hospitals in a University Medical Center group in Korea. Patients This study involved 290 adults (309 lesions) who underwent ESD for gastric adenoma or early gastric cancer. Intervention PPI and rebamipide combination therapy. Main Outcome Measurements The ulcer healing rate at 4 weeks after ESD. Results The ulcer healing rates at 4 weeks after ESD in the PPI and rebamipide combination therapy group were significantly higher than those in the PPI alone group, both in the full analysis (94.9% vs 89.9%; P P = .020). This combination therapy was an independent predictive factor for a high ulcer healing rate (adjusted odds ratio [OR] 5.572; 95% confidence interval [CI], 2.615-11.876; P = .014). Additionally, the combination therapy group exhibited a higher quality of ulcer healing than the PPI monotherapy group (reviewer 1: P = .027; OR 1.949; 95% CI, 1.077-3.527; reviewer 2: P = .027; OR 1.933; 95% CI, 1.074-3.481). Limitations Open-label study. Conclusion PPI and rebamipide combination therapy had a superior 4-week ESD-induced ulcer healing rate and quality of ulcer healing compared with PPI monotherapy. (Clinical trial registration number: NCT01167101.)

Background EMR has emerged as an alternative therapeutic option for selected cases of early colorectal cancer (ECC). However, the factors associated with resectability and curability of EMR for ECC remain unknown. Objective To investigate clinical outcomes and factors related to resectability and curability in ECC cases treated with EMR. Design Retrospective study. Setting Tertiary-care academic medical center. Patients This study involved all patients in whom EMR was performed for ECC at Severance Hospital between March 1997 and August 2007. A total of 236 cases of ECC occurring in 231 patients (66.2% men) were enrolled. Intervention EMR. Curative surgical resection and lymph node dissection were used in cases that were incompletely cured by EMR. Main Outcome Measurements Resectability, curability, and recurrence. Results Complete cure was achieved for 162 lesions (68.6%). Of the remaining 74 cases (31.4%), 69 (29.2%) were incompletely cured, and the other 5 (2.1%) had an undetermined resection status and ultimately required supplementary surgical resection for curative treatment. Location on the right side of the colon, piecemeal resection, and submucosal carcinoma were independently associated with incomplete resection, whereas depressed tumor type was independently related to incomplete cure. Among the ECC cases completely cured by EMR and followed for more than a year (n = 118), local recurrence was observed in one case (0.8%) during the median follow-up period of 39.4 months (range 12.4-123.1 months). Limitations Single-center, retrospective study. Conclusion Our data show that EMR is feasible and could be an effective option for treatment of ECC if the technique is applied with the appropriate indications.

Background Preoperative pathologic diagnosis of a gastric subepithelial tumor (SET) may improve clinical decision making. However, the clinical impact of EUS-guided Trucut biopsy (EUS-TCB) data on decision making in patients with a gastric SET has not been assessed. Objective To evaluate the impact of EUS-TCB information on the clinical management of patients with a gastric SET. Design Retrospective review of prospectively collected data. Setting Tertiary referral center. Patients Sixty-five patients with gastric SETs 2 cm or larger in diameter. Intervention EUS-TCB. Main Outcome Measurements The number of patients for whom treatment plans were changed because of EUS-TCB results. Results Nine SETs were not punctured by the TCB needle because of technical problems, and we were unable to obtain adequate subepithelial tissue from 19 SETs. Treatment plans were changed for 18 of 65 patients (27.7%). The changes were avoiding unnecessary resection (7 benign SETs ≥3 cm in diameter), scheduling for definitive treatment (6 GI stromal tumors and 1 carcinoid tumor), and modifying the surgical field (3 large GI stromal tumors and 1 carcinoma). When we assessed treatment plans relative to tumor location, we found that avoiding unnecessary resection was associated with the presence of cardiac SETs. Limitations Retrospective study with a small number of patients. Conclusions EUS-TCB changed or influenced management decisions in 18 of 65 patients (27.7%) with gastric SETs. Patients could receive proper and tailored surgery, medical treatment, or surveillance according to size and location of SETs with EUS-TCB.

Background Current guidelines for endoscopic management such as EMR and endoscopic submucosal dissection (ESD) in early gastric cancer (EGC) are in evolution, with broader indication criteria. Objective To determine the clinical outcomes of endoscopic treatment, based on absolute indication and extended indication criteria and endoscopic methods. Design Retrospective study. Setting Tertiary-care, academic medical center. Patients EMR or ESD was performed on 1627 cases of EGC in 1447 patients from July 1994 to January 2009. Intervention EMR and ESD. Main Outcome Measurements Clinical outcomes of EGC after EMR or ESD, based on the indication criteria. Results Although the complete resection rate was higher (95.9% vs 88.4%; P P = .054) in the absolute than in the extended indication group, there was no between-group difference in the local recurrence rate (0.9% vs 1.1%; P = .783) at a median follow-up period of 32 months (interquartile range 22-48 months). In the extended indication group, ESD resulted in a significantly higher complete resection rate than EMR (83.0% vs 91.1%; P = .006). Limitations Retrospective study. Conclusion ESD in the extended indication group showed acceptable clinical outcomes with a relatively high complete resection rate and a low local recurrence rate.

Although endoscopic resection for early gastric cancer (EGC) is increasingly available, it has not been determined whether indications for endoscopic resection are equally acceptable for multiple EGCs.To compare the various clinicopathologic factors and risk of lymph node (LN) metastasis between multiple and solitary EGCs.Case-control study.University hospital.This study involved 1717 patients with 156 multiple and 1561 solitary EGCs.Gastrectomy with LN dissection.Incidence of LN metastasis.In multiple EGCs, main lesions had larger tumor size and deeper invasion depth than the accessory lesions (P.001). The clinicopathologic features of multiple EGCs were similar to those of solitary EGCs with respect to tumor size, depth of invasion, lymphovascular invasion, and incidence of LN metastasis. Importantly, the risk of LN metastasis in multiple EGCs that met the indication criteria for endoscopic resection was not significantly different from that in solitary EGCs. Tumors meeting conventional indications for endoscopic resection had no risk of LN metastasis, whereas tumors meeting expanded indications showed a similar risk of LN metastasis in the two groups. In multiple EGCs, tumor size ≥3 cm and lymphovascular invasion were independent risk factors of LN metastasis.Small number of patients with multiple EGCs studied.Multiple EGCs had clinicopathologic characteristics and risk of LN metastasis similar to those of solitary EGCs. Endoscopic resection may be adopted as curative treatment for multiple EGCs that meet indications for endoscopic resection. Further studies are needed to verify the present study results.

Background Endoscopic submucosal dissection (ESD) is curative treatment for patients with early gastric cancer (EGC). Because of the technical difficulties, however, these procedures may take a long time, which can increase the rate of procedure-related complications. Objective To investigate the procedure time of ESD performed by 4 experts according to the location and size of the EGC. Design Retrospectively analyzed study of prospectively collected data. Setting Tertiary care, academic medical center. Patients Complete ESDs were performed by 4 experts, primarily using an insulated-tip knife, for 916 EGCs. Intervention ESD. Main Outcome Measurement Procedure time relative to the location and size of tumors was analyzed along with other predictive factors. Results ESD procedure time was increased as tumor size increased and for tumors in the middle and lower thirds of the stomach. Univariate analysis showed that tumor size, location, depth, submucosal fibrosis, and perforation during the procedure were significant predictors of procedure time. Multivariate analysis showed that proximal location, tumor size greater than 20 mm, submucosal fibrosis, and perforation during the procedure were independent predictors of a longer procedure time. Limitation Single-center, retrospective study design. Conclusions Procedure time became longer as tumor location became higher and as tumor size increased, except for tumors in the upper third of the stomach. These findings suggest that tumor size and location may be useful in predicting the time required to perform ESD.

Background Secondary endoscopic treatment for remnant lesions of rectal carcinoid tumors after primary EMR or polypectomy is technically difficult because of fibrosis of residual tissues. EMR by using a cap (EMR-C), a method to resect the submucosal layer by suction by using a transparent cap, may be feasible as a salvage treatment. Objective To assess the feasibility of salvage EMR-C. Design Retrospective analysis. Setting Tertiary academic health care system. Patients Thirty-one patients who were referred for salvage treatment of a failed en bloc excision of rectal carcinoid tumors after primary EMR or polypectomy between January 2007 and December 2009. Interventions Salvage EMR-C for remnant carcinoid tumors in the rectum. Main Outcome Measurements Rate of complete resection, complications, length of procedure, and recurrence rate. Results The mean age of the patients was 52.0 ± 11.8 years (range 30–78 years). The mean tumor size was 8.9 ± 3.2 mm (range 5.0–13.0 mm). The mean procedure time was 9.1 ± 3.7 minutes, and clear resection margins were pathologically confirmed in all 31 patients. The most common complication of salvage EMR-C was bleeding (7 patients, 22.6%), which was successfully treated by hemoclipping in all cases. The 1-year follow-up colonoscopy and CT results for all patients were negative for recurrence. Limitations Retrospective design and limited cases at a single center. Conclusions EMR-C is a feasible salvage therapeutic option for failed en bloc excision after primary endoscopic treatment of rectal carcinoid tumors.

Background Colonoscopic insertion of a self-expandable metallic stent (SEMS) has been widely performed for the treatment of malignant colorectal obstruction. Different types of stents could influence the efficacy and complication rate of stent use. Objective To compare the efficacy and complication rates between two SEMSs, the uncovered WallFlex stent and the covered Comvi stent. Design A prospective, randomized study. Setting Tertiary-care academic medical center. Patients Between 2007 and 2009, a total of 151 patients with malignant colorectal obstruction were enrolled. Intervention Two types of colorectal SEMSs (the uncovered WallFlex stent by Boston Scientific Corp and the newly developed covered Comvi stent by Taewoong Medical Co) were inserted. Main Outcome Measurements Technical success, clinical success, stent patency, and complication rate according to stent type. Results Technical failure occurred in 2 patients (1.3%); one was in the WallFlex group and the other in the Comvi group. Clinical failure developed in 9 patients (6.0%): 6 patients from the WallFlex group and 3 from the Comvi group. Complications because of cancer infiltration occurred more frequently in the WallFlex group (14.5% vs 3.8%). However, the rate of stent migration was higher in the Comvi group (21.1% vs 1.8%). The mean patency of the stent did not differ between the two groups ( P = .50). Limitations This was a single-center study. Conclusion Both uncovered WallFlex and covered Comvi stents were suitable for relieving malignant colorectal obstruction. Tumor ingrowth was more common in the WallFlex group, but stent migration was more common in the Comvi group.

Background EUS-guided FNA (EUS-FNA) or trucut biopsy (TCB) is indispensible in the diagnosis of mediastinal malignancies. Less is known, however, about the usefulness of EUS-guided sampling for nonmalignant, mediastinal tuberculosis (TB), despite the increase in the incidence of TB. Objective To assess the diagnostic yields of EUS-FNA/TCB in patients with mediastinal TB. Design Retrospective study. Setting Tertiary-care referral hospital in a geographic region with an intermediate TB burden. Patients This study involved 24 consecutive patients with mediastinal TB, who underwent EUS-FNA/TCB from July 2005 to September 2008. Intervention EUS-FNA/TCB. Main Outcome Measurements Technical success and diagnostic yields of EUS-FNA/TCB. Results Mediastinal lesions (mean diameter, 28.6 mm; range 17.0-49.5 mm) were targeted by using 22-gauge-needle FNA in 10 patients and 19-gauge-needle TCB in 14 patients. Before EUS, only 10 of the 24 patients had a presumptive diagnosis of mediastinal TB, whereas 11 patients were suspected of having malignancies. Six patients showed mass-like lung parenchymal lesions mimicking lung cancer, and 7 patients had a history of malignancy. Pathologic examination showed granulomatous inflammation in 16 patients (66.7%), including 10 patients with caseating granulomas. Positive microbiologic results were obtained in 10 patients (41.7%): 3 by Ziehl-Neelsen staining, 5 by Mycobacterium tuberculosis culture, and 5 by TB polymerase chain reaction (PCR) assay. EUS-FNA/TCB confirmed mediastinal TB in 20 of the 24 patients and directed 11 patients clinically suspected of having malignancies to anti-TB treatment. The diagnostic yields of FNA and TCB were similar (90.0% vs 78.6%). Limitations Retrospective design in a tertiary-care referral hospital. Conclusion EUS-FNA/TCB is sufficiently useful to confirm mediastinal TB and can exclude suspected malignancies in TB patients.

Background Capsule endoscopy (CE) is now widely accepted as a first-line diagnostic modality for obscure GI bleeding (OGIB). However, the clinical implications of negative results of CE studies remain unclear. Objective To investigate long-term (>1 year) outcomes for patients undergoing CE for OGIB and to identify risk factors associated with rebleeding. Design and Setting Retrospective study in a tertiary care hospital. Methods A total of 57 consecutive patients who had undergone CE for OGIB were enrolled and their pre- and post-CE clinical data were collected. Specific treatments were defined as treatments directly aimed at presumed bleeding causes including hemostasis and disease-specific medical therapy, whereas nonspecific treatments were defined as symptomatic treatments for anemia. Results Of the 57 patients, the indication for CE was obscure-overt bleeding in 46 patients and obscure-occult bleeding in 11 patients. Among 51 patients for whom long-term data were available, significant (P2) lesions were found in 23 (45.1%) patients. The overall rebleeding rate was 35.3% during a median follow-up duration of 31.7 months (range 12.8-58.0 months). There was no statistically significant difference in the cumulative rebleeding rate between patients with positive and negative CE results (34.8% vs 35.7%, respectively; P = .989). However, specific treatments after CE (hazard ratio, 0.111; 95% CI, 0.013-0.980; P = .043) significantly decreased rebleeding. Limitations Small number of patients, retrospective study design. Conclusions The rebleeding rate for patients with OGIB and negative CE results was substantial, indicating that these patients should be closely observed. However, specific treatment after CE significantly reduced the incidence of recurrent bleeding.

Background and Aims In individuals with either no or 1 to 2 nonadvanced adenomas, future risks of advanced colorectal neoplasia (AN) vary according to clinical risk factors. However, little is known about the association between the adenoma detection rate (ADR) and the risk for metachronous AN in patients with low-risk adenomas. Methods We identified 7171 participants with no or 1 to 2 nonadvanced adenomas at first-time screening colonoscopy. The risk of metachronous AN was investigated at surveillance colonoscopy, according to clinical characteristics and the ADR. Results In multivariate analysis the risk for metachronous AN was strongly associated with increasing age, male sex, increasing number of adenomas, and the ADR of the endoscopist. With the ADR modeled as a continuous variable, each 1.0% increase in the rate of ADR predicted a 3.0% decrease in the risk of metachronous AN (adjusted odds ratio [OR], .97; 95% confidence interval [CI], .95-.99). With the ADR modeled using a binary cut-off (32%), the risk of metachronous AN was reduced in patients of endoscopists with an ADR ≥32% (adjusted OR, .53; 95% CI, .35-.83). Moreover, the risk of metachronous AN was reduced (adjusted OR, .66; 95% CI, .46-.95) in patients of endoscopists with an ADR in the highest tertile, compared with patients of endoscopists with ADRs in the lowest tertile. The impact of ADR on metachronous AN was significant for patients with low-risk adenomas rather than patients with no adenoma. Conclusions In patients with low-risk adenomas, the ADR of the endoscopist was inversely associated with the risk of metachronous AN.

Verrucous carcinoma is a slow-growing, well–differentiated variant of squamous carcinoma, with a propensity for local invasion into surrounding tissue. It is found most commonly in the oropharynx, genitalia, and the soles of the feet. Verrucous carcinoma of the esophagus (VCE) are very rare and are typically associated with chronic mucosal irritation or a long-term local disease process. We report a patient with VCE who had a long history of bile-reflux esophagitis after total gastrectomy.

Background During an EMR or endoscopic submucosal dissection (ESD) for colorectal tumors, an injection needle catheter is passed through the contaminated endoscopic channel and may directly inoculate bacteria into the blood stream during submucosal injection. In addition, extensively exposed submucosa, especially with an ESD, directly contacts colonic luminal bacteria after the procedure, which may increase the risk of bacteremia. However, the incidence of bacteremia after an EMR or ESD for colorectal tumors has not been reported. Objective To evaluate the frequency of bacteremia associated with an EMR or ESD for colon lesions. Design A prospective study. Patients A total of 40 patients who underwent a conventional EMR (n = 30), an EMR after circumferential pre-cutting (n = 3), or ESD (n = 7) for colorectal tumors. Interventions and Main Outcome Measurements Blood cultures were obtained immediately before, 5 minutes after, and 30 minutes after the procedure. Patients were closely monitored for 24 hours after the procedure to detect the development of infectious complications. Results Blood cultures at baseline and 5 minutes after the procedure were all negative. However, a blood culture at 30 minutes after the procedure showed a positive result in 1 of 40 patients (2.5%). This patient underwent a conventional EMR, and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant. None of the 40 patients showed any signs or symptoms associated with infection. Limitation The small sample size. Conclusions An EMR, or even an ESD, for colon lesions may be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics.

Background Various training programs in colonoscopy recommend that trainees should perform at least 100 to 200 procedures to be considered technically competent at diagnostic colonoscopy. Objective Our purpose was to determine the adequate level of training for technical competence in screening and diagnostic colonoscopy. Design A prospective multicenter trial. Setting Fifteen tertiary care academic medical centers. Patients Over 8 months we prospectively evaluated the procedures of 24 first-year GI fellows in 15 tertiary care academic medical centers. A total of 4351 colonoscopies were assessed prospectively with variable clinical factors. Intervention Cecal intubation was documented by photographing the identified cecal landmarks, including the appendiceal orifice and the ileocecal valve. Main Outcome Measurements Acquisition of competence (success rate) was evaluated for colonoscopic training on the basis of 2 objective criteria: (1) adjusted completion rate (>90%) and (2) cecal intubation time ( Results The overall success rate was 83.5% (3635/4351). The mean cecal intubation time was 9.23 ± 4.63 minutes. The success rate significantly improved and reached the requisite standard of competence after 150 procedures (71.5%, 82.6%, 91.3%, 94.4%, 98.4%, and 98.7%, respectively, for every 50 consecutive blocks). The polyp detection rate did not improve significantly during the 8 months and was not correlated with the learning curve. In addition, mean time to cecal intubation decreased significantly, from 11.16 to 8.39 minutes, after 150 procedures. Logistic regression analysis found that prolonged cecal intubation was caused by the following factors: elderly patients, female sex, low body mass index, poor bowel preparation, poor American Society of Anesthesiologists status, abdominal pain as an indication, instructor's supervision, and low case volume. Limitations We did not record final pathologic reports of detected polyps and withdrawal time. Conclusions Competence in technically efficient screening and diagnostic colonoscopy generally requires experience with more than 150 cases. Also, factors associated with prolonged cecal intubation for typical trainees did not differ from those for experienced colonoscopists.

Background Colorectal neoplasm is rapidly increasing in Asia, but a guideline for screening is not available. Objective To evaluate the characteristics of colorectal neoplasm in asymptomatic Asian subjects. Design Prospective cohort study. Setting Multinational multicenters, including both primary and referral centers in Asia. Patients A total of 860 consecutive asymptomatic adults undergoing screening colonoscopy in 11 Asian cities from July 2004 to December 2004. Patients under 16 years old; those patients with a colorectal resection history, colonoscopies, or barium enema within 5 years; symptoms suggestive of colorectal diseases; and those who had undergone surveillance colonoscopy were excluded. Main Outcome Measurements The incidence and distribution of colorectal neoplasm and advanced neoplasm. Results The mean age (±SD) was 54.4 ± 11.6 years; 471 were men (54.8%). The prevalence of colorectal neoplasm and advanced neoplasm was 18.5% and 4.5%, respectively. Male sex, advancing age, and a family history of colorectal cancer were risk factors for advanced neoplasm. Of the 168 patients with colorectal neoplasm, 76 had distal neoplasm only (45.2%), 66 had proximal neoplasm only (39.3%), and 26 had both proximal and distal neoplasms (15.5%). Although the presence of distal advanced neoplasm was a significant risk factor for proximal advanced neoplasm, 14 of the 758 subjects without distal neoplasm had proximal advanced neoplasm (1.8%). Limitations The small number of enrolled subjects, especially from certain ethnic groups. Conclusions The overall prevalence of advanced colorectal neoplasm in asymptomatic Asians is comparable with the West. Male sex, advancing age, and a family history of colorectal cancer were associated with a higher risk of advanced neoplasm.

Background: Acute appendicitis is one of the most common causes of acute abdomen. Despite recent advances in radiologic imaging, the diagnosis of acute appendicitis may be difficult on occasion. The aims of this study were to describe the colonoscopic features of appendicitis and to determine whether colonoscopy can be used as an adjunct for the diagnosis of appendicitis in patients with atypical presentations. Methods: The colonoscopic findings in 21 patients (14 men, 7 women; average age 55 years) with a colonoscopic or histopathologic diagnosis of appendicitis were analyzed retrospectively. Colonoscopy was performed because diagnoses suggested by CT were other than acute appendicitis (11 patients), and/or the presenting clinical features were atypical for acute appendicitis with the duration of symptoms being 10 days or longer (17 patients). Results: The colonoscopic diagnosis was acute appendicitis for all 21 patients. Seventeen underwent appendectomy, the diagnosis being verified in all cases. Of the 4 patients whose symptoms improved without appendectomy, 3 were considered to have acute appendicitis because pus was seen to drain from the appendiceal orifice at colonoscopy. A definite diagnosis could not be made in the remaining 1 patient. Therefore, the diagnosis of appendicitis was considered confirmed in 20 of 21 patients. Colonoscopic findings in these 20 patients included hyperemia (15) and bulging (18) at the appendiceal orifice area with surrounding mucosal edema (19), and drainage of pus from the appendiceal orifice (7). Conclusion: Colonoscopy may be useful in the diagnosis of appendicitis when the clinical presentation is atypical for appendicitis and/or imaging studies are nondiagnostic. (Gastrointest Endosc 2002;56:343-8.)

glands may contribute to the pathogenesis of EIPD. In the normal esophagus, secretory products of the submucosal glands are continuously excreted on the mucosal surface by an active contractile movement of myoepithelial cells. In EIPD, this excretory mechanism is disturbed by some underlying cause, which most likely includes congenital abnormality, motor dysfunction of the esophageal wall, GERD, and infection. As a consequence, the ductal portion of the glands is considered to become dilated, forming pseudodiverticular pouches. The present observations, however, suggested that even in the dilated ducts in EIPD, continuous excretory movement is still preserved to some degree. This is probably one of the reasons many patients with EIPD remain asymptomatic for a long time. In conclusion, although EIPD has been considered a static condition similar to diverticulosis, seen, for example, in the large intestine, our observations suggest that EIPD is not a static pathological condition but rather an active, continuously mobile process by which mucinous material within the submucosal pouches is repeatedly discharged onto the mucosal surface.

c f m r t a m p c o s a p F d Gallstone ileus is an infrequent cause of intestinal obstruction and is responsible for 1% to 4% of all mechanical intestinal obstructions.1 Gallstones usually enter the bowel via a holecystoenteric fistula resulting from recurrent attacks of holecystitis.2 However, gallstone ileus may arise in the absence of a gallbladder, especially in patients with previous surgeries, including biliary-enteric anastomosis.3 Surgical intervention has been the primary treatment of gallstone ileus.4 Here, we report a case of a gallstone ileus that was nonsurgically treated with endoscopic fragmentation by using double-balloon endoscopy (DBE).

Little is known about gastric neoplasms arising from hyperplastic polyps (HPs).To investigate the risk factors associated with neoplasms within HPs and to evaluate the role of alterations of the p16-cyclin D1-pRb pathway in the malignant transformation of HPs.Retrospective, case-control study.Tertiary-care center.Between May 1995 and January 2011, a total of 809 HPs1 cm were investigated. Associated neoplasms were present in 30 HPs (case group); 30 HPs without neoplasms were selected as a control group.Gastric polypectomy.The risk factors associated with neoplasms within HPs and immunohistochemical expression of p16, cyclin D1, p53, and Ki-67 between case and control groups.Of the 809 HPs, 15 had associated dysplasia, and 15 had carcinoma. Multivariate analysis showed that neoplasm was associated with patient age (odds ratio [OR] 1.159; 95% confidence interval [CI], 1.243-2.044; P.001), polyp size (OR 1.103; 95% CI, 1.055-1.152; P.001), and polyp lobulation (OR 4.549; 95% CI, 1.759-11.0766; P.001) but not with location, multiplicity, intestinal metaplasia, growth pattern, or Helicobacter pylori infection. Loss of p16 expression and high Ki-67 expression were observed in dysplastic areas of HPs compared with the control group (p16 = 14.3% vs 60%; P = .001, Ki-67 = 60.7% vs 36.7%; P.001). However, no significant differences were found in nondysplastic areas in both groups.Single-center, retrospective study.HPs1 cm may indicate the presence of neoplasms. Loss of p16 and high Ki-67 expression may be markers of HP-associated dysplasia.

Background: Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. The aim of this prospective study was to determine whether certain variables are associated with insertion time and patient discomfort during colonoscopy. Methods: Nine hundred nine consecutive colonoscopic examinations performed by a single endoscopist in patients without obstructive disease of the colorectum were analyzed. Four liters of Colonlyte (Taejun, Seoul, Korea) were used for bowel cleansing, and meperidine (25 mg) was administered intramuscularly 10 minutes before the procedure. The degree of patient discomfort was assessed using a 5-level Likert scale. Results: Among 909 study patients, colonoscopy was completed to the cecum in 876 patients (96.4%). The adjusted completion rate was 98% and mean insertion time for complete colonoscopy was 6.9 ± 4.2 minutes. Colonoscopy caused less patient discomfort than barium enema or esophagogastroduodenoscopy. Multivariate logistic regression analysis demonstrated that inadequate bowel cleansing, advanced age, and constipation as an indication are independent factors associated with prolonged insertion time (> 10 minutes). Female gender was the only independent factor associated with significant discomfort (≥ level 4) during colonoscopy. Conclusions: Among the factors affecting insertion time and patient discomfort during colonoscopy, unsatisfactory bowel preparation was the only correctable factor. (Gastrointest Endosc 2000;52:600-5.)

c p s Since the first description of cap polyposis as a particular type of colorectal polyp with an inflammatory “cap,” many patients with this condition have been described. These caps are characterized by fibrinopurulent exudates covering the surface of the polyp on colonoscopic examination. Clinically, these caps cause mucoid diarrhea and are histologically associated with inflammatory granulation tissue covering the top of the polyp. Despite the clear endoscopic and histologic features of cap polyposis, its pathogenesis is still obscure, and effective treatment modalities have not been established. Various treatment modalities have been tried, including avoidance of straining at defecation,2 treatment with metronidazole,3-6 antibiotcs,3,7 5-aminosalicylic acid (5-ASA),2-7 steroids,3-8 Helicobacter pylori eradication therapy,2,4,8 infliximab,3,6,7 and ndoscopic6 or surgical resection;5,6 but the results have een inconsistent. Also, little is known about the longerm outcome of patients with cap polyposis. Here, we escribe our experience with 7 patients diagnosed with ap polyposis, including 5 who were treated with steroids.