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Endoscopic resection of early gastric cancer is a well-established standard therapy in Japan and Korea, and is increasingly used in other countries. Endoscopic resection should be curative for patients, and safe, easy and effective not only for patients, but also for endoscopists. Endoscopic submucosal dissection (ESD) is superior to standard endoscopic mucosal resection (EMR) as it is designed to provide en bloc R0 resection regardless of size and/or location. Correct pathological assessment of en bloc resected specimens is crucial for accurate diagnosis and patient stratification for the risk of metastasis. Outcome studies in Japan and Korea, countries with the highest incidence of gastric cancer, have shown that ESD is efficacious in leading to a good long-term outcome; however, ESD requires an experienced endoscopist with a high skill level. Expanded indications for endoscopic resection have been proposed, especially after large en bloc resection have been accomplished using ESD. The use of ESD could be of huge benefit for the management of gastrointestinal superficial neoplasms. However, for ESD to become a viable therapeutic option, it requires close and supportive working relationships between endoscopists, pathologists and surgeons. [ABSTRACT FROM AUTHOR]

Objectives: The increasing levels of bacterial antibiotic resistance have increased the need to evaluate the second-line treatments for Helicobacter pylori. Bismuth-based quadruple therapy is recommended as a second-line treatment, but the optimal duration of this treatment is still debatable. We prospectively analyzed the eradication rate of H. pylori according to the duration of the second-line bismuth-based quadruple therapy. Methods: One hundred and ninety-nine patients who failed at H. pylori eradication were prospectively randomized to receive pantoprazole 40 mg twice daily, metronidazole 500 mg thrice daily, and bismuth subcitrate 300 mg and tetracycline 500 mg four times daily for 7 days (PBMT7) or for 14 days (PBMT14). The post-treatment H. pylori status was determined by the 13C-urea breath test. The eradication rates, drug compliance, and side effects of each group were evaluated. Results: The intention-to-treat (ITT) eradication rates were 81.6% (95% CI 73.9-89.3%, 80 / 98) in the PBMT7 arm and 85.1% (95% CI 78.2-92.0%, 86 / 101) in the PBMT14 arm (p = .028, noninferiority test), while the per-protocol (PP) eradication rates were 89.6% (95% CI 83.2-96.0%, 78 / 87) and 96.2% (95% CI 92.0-100.0% 77 / 80) (p = .015, noninferiority test), respectively. The compliance was 88.8% (87 / 98) and 79.2% (80 / 101) in the PBMT7 and PBMT14 groups, respectively. (p = .066) The number of patients having severe side effects was 15.3% (15 / 98) and 21.8% (22 / 101) in the PBMT7 and PBMT14 groups, respectively, which was similar between both groups. (p = .243). Conclusions: Although PBMT7 was not inferior to PBMT14 statistically, PBMT could not demonstrate enough ITT / PP eradication rate. Therefore, it could be better to extend the duration of treatment for 2 weeks for the second-line treatment of H. pylori in Korea. [ABSTRACT FROM AUTHOR]

Endoscopic resection (ER) has become an important therapeutic option for early gastric cancer (EGC). Some investigators have suggested that this indication should be extended. We aimed to compare the extended indication of ER for intramucosal EGC based on data from a large, single-center study. We assessed lymph node metastasis (LNM) status in 1721 intramucosal EGC patients who underwent surgery to evaluate the potential of extension of the ER. We investigated LNM according to Japanese extended criteria; differentiated mucosal cancers irrespective of ulcer less than 30 mm (Criteria I); differentiated mucosal cancers without ulceration irrespective of tumor size (Criteria II), undifferentiated less than 20 mm without ulceration (Criteria III). We also tried to find the groups which have no and minimal risk of lymph node metastasis. The rate of LNM of mucosal cancer was 2.6% (45/1721). There was minimal lymph nodal metastasis risk for criteria I (0.28%, 2/726, 95% Confidence Interval [CI], 0-0.66%), and criteria II (0.23%, 2/882, 95% CI, 0-0.54%). For criteria III, there was significant lymph node metastasis risk (1.15%, 3/261, 95% CI, 0-2.44%). There was no lymph node metastasis in differentiated mucosal cancer less than 20 mm irrespective of ulcer (0%, 0/501, 95% CI 0-0.73%). The differentiated mucosal cancer group irrespective of ulcer and tumor size have a minimal risk of metastasis (0.43%, 4/941, 95% CI, 0-0.84%) Our data support extension of the ER indication for the differentiated mucosal EGC. However, undifferentiated lesions without ulceration and smaller than 20 mm were associated with significant metastasis. [ABSTRACT FROM AUTHOR]

Eradication of Helicobacter pylori with antibiotics is the established initial treatment of patients with localized gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, there are few reports on follow-up modalities to identify sustained remission in patients who achieve complete remission (CR). We therefore investigated the role of abdominal computed tomography (CT) as follow-up after CR with H. pylori eradication. We retrospectively analyzed 122 patients with H. pylori-positive stage I gastric MALT lymphoma who achieved CR with successful H. pylori eradication. The median follow-up after CR was 35 months (range 3-140months). At a median of 17 months (range 12-21 months) after CR, 7 of 122 patients (5.7%) experienced lymphoma recurrence, all cases of which were confined to the gastric mucosa and were detectable only by endoscopy with multiple biopsies. At the time of recurrence, four of seven patients showed re-infection by H. pylori. Eradication therapy was successful in these patients, resulting in both bacterial eradication and tumor regression. Three patients who experienced histologic recurrence without H. pylori re-infection were observed by a watch and wait strategy and again achieved CR. None of the patients with H. pylori-positive stage I gastric MALT lymphoma who experienced tumor recurrence after CR with successful H. pylori eradication showed recurrence at extragastric sites, including lymph nodes without gastric mucosal lesion. These findings indicate that endoscopic biopsies without abdominal CT scans are sufficient to detect recurrence in these patients. [ABSTRACT FROM AUTHOR]

The author reflects on the benefits of endoscopic ultrasonography (EUS) in endoscopic submucosal dissection (ESD). The author stresses that EUS is a useful diagnostic modality in different parts of the gastrointestinal tract and other neighboring organs. An overview on an article that introduces EUS to the field of ESD is also presented.

Background and Aim: Controversy continues as to whether nutcracker esophagus (NE) is a ‘real’ manometric disease due to its poor correlation with clinical symptoms such as chest pain or dysphagia. While new NE criteria were proposed in a recent study, that study included NE patients both with and without gastroesophageal reflux disease (GERD). We aimed to analyze both general NE (with or without GERD) and pure NE (without GERD) patients in terms of distal esophageal amplitude (DEA) and its correlation with symptoms. Methods: Using previously known normal DEA values (mean and SD), patients were stratified into three different groups: group A (DEA 180 to 220 mmHg, 2 to 3 SD), B (DEA 220 to 260 mmHg, 3 to 4 SD), and C (DEA > 260 mmHg, > 4 SD). Results: A total of 72 patients who simultaneously underwent esophageal manometry and 24-h pH monitoring were diagnosed with NE. They were separated into groups A ( n = 43), B ( n = 18), and C ( n = 11). Although the proportion of general NE patients with symptoms appeared to be greater in group A (65.6%) than in group C (90.9%), statistical analysis showed that this was not a significant correlation ( P = 0.07). Pure NE patients were defined as those returning negative findings after 24-h pH monitoring. These patients were separated into three groups based on the same DEA criteria as above: group A-1 ( n = 33), B-1 ( n = 11), C-1 ( n = 8). The proportion of patients with symptoms increased from 54.5% in group A-1 to 87.5% in group C-1, and this correlation was found to be significant ( P < 0.05). Conclusions: There exists in the general NE population a subset with pure NE. DEA values correlated with symptoms in this subset. [ABSTRACT FROM AUTHOR]

Background: Reflux symptom assessment had reliable accuracy in the diagnosis of gastroesophageal reflux disease (GERD). However, patients may recognize heartburn or regurgitation as dyspepsia because of inaccurate understanding or atypical presentation. The aim of the present study was to estimate endoscopic reflux esophagitis in patients with upper abdominal pain as a predominant symptom in the absence of heartburn or regurgitation. Methods: Two hundred and sixty-three consecutive patients presenting dyspepsia without heartburn or regurgitation were enrolled. Patients with heartburn or regurgitation were excluded using the symptom interviewer method. Dyspepsia was categorized into pain-predominant or dysmotility-predominant groups according to the Rome II proposal. Endoscopic reflux esophagitis was graded using the Los Angeles classification. Results: One hundred and five patients were included in the pain-predominant group and 119 in the dysmotility-predominant group. Reflux esophagitis was found in 18.8% (42/224) of all dyspeptic patients. Grade A esophagitis was noted in 27.6% (29/105) of the pain-predominant group and in 7.6% (9/119) of the dysmotility-predominant group. Grade B was noted in two patients in each group. A total of 29.5% (31/105) and 9.3% (11/119) had reflux esophagitis, respectively ( P < 0.001). Comparing patients with or without reflux esophagitis, there was no difference in body mass index, smoking habit, alcohol consumption, or Helicobacter pylori infection status. Conclusions: A significant proportion of patients presenting dyspepsia, especially pain-predominant dyspepsia, have endoscopic reflux esophagitis. In view of GERD, pain-predominant dyspepsia should be investigated and managed differently from dysmotility-predominant dyspepsia. [ABSTRACT FROM AUTHOR]

Background and Aims: Although the incidence of colorectal cancer is rising in Asian countries, there are no guidelines for its screening in this region due in part to the lack of epidemiological data regarding colorectal neoplasms. This study aimed to evaluate the prevalence of colorectal neoplasms in average-risk Koreans and to assess the effectiveness of screening colonoscopy in Korea. Methods: The prevalence of colorectal neoplasms was assessed by primary screening colonoscopy in 5086 consecutive asymptomatic adults (males 70.5%; age 20–84 years) with no risk factors for colorectal cancer. Results: The overall prevalence of colorectal neoplasms in the 5086 subjects was 21.9% and this increased linearly with age. Among the 2435 subjects aged ≥50 years (males 66.7%; mean age 57.7 years), the prevalence of all colorectal neoplasms was 30.2% (males 35.9% vs females 18.7%; P < 0.001), while advanced neoplasms accounted for only 4.1% (males 5.1% vs females 2.0%; P < 0.001). The prevalence of advanced neoplasms in Korean men of a specific age group was similar to that of Korean women in the 10-years older age group. Also, Koreans in a specific age group showed a prevalence of advanced neoplasms similar to that of Westerners in the 10-years younger age group. Conclusions: Colonoscopy is a useful modality for colorectal cancer screening in Korea, as established in Western countries. However, the screening colonoscopy may begin at an older age for Koreans than for Westerners. Similarly, the optimal starting age for screening in Korean women may be higher than that in men by 10 years. [ABSTRACT FROM AUTHOR]

Background: Primary gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is known to be successfully treated with anti- Helicobacter pylori ( H. pylori) therapy alone. However, there are few reports on long-term results after eradication therapy. The aims of this study were to analyze the rate and the interval to reach complete remission (CR), and to assess the rate and the factors affecting recurrence of MALT lymphoma. Materials and Methods: Between 1996 and 2003, a total of 90  H. pylori-infected patients with low-grade MALT lymphoma were included in this study. For initial staging, endoscopic ultrasonography, chest–abdomen–pelvis CT scans, and bone marrow examination were taken. All patients were made to take anti- H. pylori therapy for 14 days. Tumoral response was assessed by endoscopy every 3 months till CR and every 6 months after achieving CR. Results: Among 90 treated patients, 85 (94.4%) reached CR. The median interval to CR was 3 months (range, 1–24). Seventy-nine (92.9%) patients were in CR at 12 months. Median follow-up period after CR was 45 months (range 15–109). Among 77 patients who were followed-up after CR, 8 (10.4%) patients were proved with recurrence of MALT lymphoma. Cumulative recurrence rate was 2.7, 11.5, and 12.2% at 1, 2, and 3 years. The presence of H. pylori was only a significant risk factor affecting recurrence. Conclusions: The status of H. pylori is the most important risk factor affecting recurrence. Therefore, adequate eradication regimen and accurate regular evaluation for H. pylori status are needed during follow up of primary gastric low-grade B-cell MALT lymphoma. [ABSTRACT FROM AUTHOR]

A 40-year-old male patient with liver cirrhosis developed hematochezia resulting in hepatic encephalopathy. Colonoscopic examination revealed a large, approximately 4.0 cm-sized villous adenoma in the sigmoid colon which showed diffuse blood oozing. We succeeded in the control of bleeding from the lesion only with a detachable snare. The patient recovered from hepatic encephalopathy and may have an opportunity for liver transplantation. Fortunately, the patient regained normal liver function after a successful liver transplantation. [ABSTRACT FROM AUTHOR]