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Endoscopic submucosal dissection is recommended as an alternative therapy for early esophageal cancer. However, achieving curative resection in this procedure remains controversial since precise prediction of lymph node metastasis can be difficult. Here, we present the preliminary results of endoscopic submucosal dissection followed by concurrent chemoradiotherapy for early esophageal cancer with a high risk of lymph node metastasis. From May 2006 to January 2014, six patients underwent concurrent chemoradiotherapy after endoscopic submucosal dissection with a median follow-up period of 63 months. No complications were encountered during concurrent chemoradiotherapy. Although local recurrence did not occur in all patients, two patients were diagnosed with metachronous cancer. Overall, the survival rate was 100%. Thus, endoscopic submucosal dissection followed by concurrent chemoradiotherapy may be a feasible treatment for early esophageal cancer in patients with a high risk of lymph node metastasis. Future prospective large-scale studies are warranted to confirm our results.

Submucosal tumors (SMTs) originate from tissues that constitute the submucosal layer and muscularis propria, and are covered by normal mucosa. Esophageal SMTs are rare, accounting for

Trucut biopsy (TCB) has been proposed to overcome the limitations of endoscopic ultrasonography (EUS)-guided fine-needle aspiration for the pathologic diagnosis of upper gastrointestinal (GI) subepithelial tumor (SET); however, it can be difficult to perform because the Trucut biopsy needle is very stiff. Although technical failures have been reported with the use of TCB, recently the forward-viewing echoendoscope showed a high diagnostic accuracy. We hypothesized that TCB under a conventional forward-viewing endoscope can be applied with higher yield of tissue diagnosis.To evaluate the feasibility of TCB under a forward-looking endoscopy without cumbersome EUS guidance, we introduced a 19-gauge TCB needle into the working channel of a conventional upper endoscope in 27 patients with GI SET to make tissue diagnosis. Prospectively collected data were analyzed, including technical success rate, pathologic result, and adverse events.Twenty-seven patients with GI SET (18 esophageal tumors and nine gastric tumors) underwent TCB under a forward-looking endoscope. All procedures were performed safely without any TCB-related complications. Subsequently, histopathology examination revealed gastrointestinal stromal tumors (GISTs) in three cases and leiomyomas in 21 cases. Histologic assessment was completed in 24 out of 27 patients (88.9 %) because tissue obtained from three patients, whose tumors were located in the stomach, was not sufficient for the pathologic diagnosis.TCB using a conventional forward-viewing endoscope without EUS guidance provided an excellent pathologic diagnosis of upper GI SET.

With the accumulation of clinical trials demonstrating its efficacy and safety, peroral endoscopic myotomy (POEM) has emerged as a less invasive treatment option for esophageal achalasia compared with laparoscopic Heller myotomy. However, the difficulty in determining the exact extent of myotomy, a critical factor associated with the success and safety of the procedure, remains a limitation. Although the various endoscopic landmarks and ancillary techniques have been applied, none of these has been proven sufficient. As a solution for this limitation, the double-scope POEM technique with a second endoscope to assure the exact length of the submucosal tunnel has been applied since 2014. Before double-scope POEM was introduced, the second endoscope was applied only to confirm the accuracy of the procedure. In the present study, we performed double-scope POEM in the treatment of esophageal achalasia through a novel procedure of simultaneous application of the second endoscope to assist in the conventional POEM procedure.

BACKGROUND AND AIM To evaluate the feasibility of a tailored endoscopic cap created using 3D-printing technology that is customized according to esophagogastric lesions of each patient. METHODS Tailored endoscopic caps, which were designed and fabricated with a 3D printer, were inserted in 35 patients. The types of cap were side-hole cap made for cap-assisted endoscopic mucosal resection (EMRC), oblique-head cap designed for endoscopic submucosal dissection (ESD), wide-head cap used for Trucut biopsy (TCB), and narrow-tip cap to facilitate peroral endoscopic myotomy (POEM). RESULTS EMRC in the esophagus and gastroesophageal junction was carried out using a side-hole cap in seven patients. Median total procedure time for successful removal of lesions was 14 min (range 8-50 min). Gastric ESD was carried out using with an oblique-head cap in 16 patients, for which the median total procedure time was 53 min. TCB in the esophagus was done using a wide-head cap in eight patients. While carrying out POEM for tunneling, a narrow-tip cap was used in four patients with achalasia. CONCLUSION Based on the current proof-of-concept study, we anticipate that creating a tailored endoscopic cap is feasible for therapeutic endoscopy.

Esophageal duplication (ED) is rarely diagnosed in adults and is usually asymptomatic. Especially, ED that is connected to the esophagus through a tubular communication and combined with bronchoesophageal fistula (BEF) is extremely rare and has never been reported in the English literature. This condition is very difficult to diagnose. Although some combinations of several modalities, such as upper gastrointestinal endoscopy, esophagography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, can be used for the diagnosis, the results might be inconclusive. Here, we report on a patient with communicating tubular ED that was incidentally diagnosed on the basis of endoscopy and esophagography during the postoperational evaluation of BEF.

Does the timing of adjuvant chemotherapy for gastric cancer influence patient outcome?

Polyvinyl chloride (PVC) is a widely used chemical for production of plastics. However occupational asthma (OA) caused by PVC has been reported only rarely. We report a 34-yr-old male wallpaper factory worker with OA due to PVC and nickel (Ni) whose job was mixing PVC with plasticizers. He visited the emergency room due to an asthma attack with moderate airflow obstruction and markedly increased sputum eosinophil numbers. A methacholine challenge test was positive (PC20 2.5 mg/mL). Bronchoprovocation tests with both PVC and Ni showed early and late asthmatic responses, respectively. Moreover, the fractional concentration of exhaled nitric oxide (FeNO) was increased after challenge with PVC. To our knowledge, this is the first case of OA in Korea induced by exposure to both PVC and Ni. We suggest that eosinophilic inflammation may be involved in the pathogenesis of PVC-induced OA and that FeNO monitoring can be used for its diagnosis.

The differential diagnosis between inactive carrier and active hepatitis is important in patients with chronic hepatitis B (CHB) virus infection. Serum cytokeratin (CK)-18 fragments (M30-antigen) are proposed as biomarkers of apoptosis.We investigated whether serum M30-antigen levels might help to characterize the various phases of CHB and predict the state of significant inflammation in patients with CHB.A total of 339 CHB patients who underwent liver biopsy, were included. Serum M30-antigen levels were compared between inactive carriers (n=21), patients with HBeAg-negative hepatitis (n=95), HBeAg-positive hepatitis (n=141) and liver cirrhosis (n=82).Serum M30-antigen levels were correlated significantly not only with AST (r=0.544, p0.001) and ALT (r=0.315, p0.001) and but also inflammatory grading score on liver biopsy (r=0.240, p0.001). Serum M30-antigen level in HBeAg-negative CHB was significantly higher than that of inactive HBV carrier (399.78 U/L vs 148.90 U/L, p0.001). Multivariate analysis showed that AST (p0.001), albumin (p=0.009) and M30-antigen (p=0.020) were the independent predictors of significant inflammation. Combined serum M30-antigen level (344 U/L) and AST (78 IU/L) measurement provided the most accurate identification of significant inflammation, showing 38.2% sensitivity, 96.1% specificity, 91.0% positive predictive value and 56.1% negative predictive value.Serum M30-antigen can be a predictive marker for distinguishing between inactive carrier and HBeAg-negative CHB. Serum M30 levels are associated with the presence of significant inflammation, especially in patients with normal or minimally elevated ALT in CHB patients.

Endoscopic resection (ER) of early gastric cancer (EGC) has been an optimal treatment for selected patients. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Moreover, a new microscopic imaging for precise endoscopic diagnosis of EGC is introduced. This review covers the current status and new approaches of ER of EGC.

Objectives The aim of this study was to determine the serum markers that predict significant inflammation in patients with chronic hepatitis B (CHB). Design and methods Between October 2005 and June 2009, 384 subjects with CHB were enrolled. Results Multiple logistic regression analysis identified the ALT, hyaluronic acid (HA) and procollagen III N-terminal peptide (PIIINP) as independent predictors of significant inflammation (grade ≥ 3). We constructed a formula for predicting significant inflammation. A significant inflammation (SI) score = 1.773 × ALT score + 1.599 × PIIINP score + 0.677 × HA score − 1.962. The area under receiver operating characteristic curve of the SI score was 0.831. The sensitivity, specificity, positive predictive value and negative predictive value of the SI score were 79.5%, 70.8%, 76.8% and 74.3%, respectively. Conclusions A simple scoring system including ALT, PIIINP and HA is an accurate non-invasive predictor of significant inflammatory activities in patients with CHB.

275 Outcome Over 5 Years of Minimally Invasive Treatment of Early Gastric Cancer Beyond Endoscopic Submucosal Dissection Ga Won Song*, Suk Pyo Shin, Weon-Jin Ko, Jun Hwan Yoo, Duk Hwan Kim, Kim Wonhee, Kwang Hyun Ko, Joo Young Cho, Ki Baik Hahm, Sung-Pyo Hong, Pil Won Park, Jun-Hyung Cho Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background/Aims: The aim of this study was to evaluate the long term outcomes of combined endoscopic submucosal dissection (ESD) with laparoscopic lymph node dissection (LLND) and endoscopic full-thickness resection (EFTGR) with laparoscopic regional lymph node dissection (hybrid natural orifice transluminal endoscopic surgery, hybrid NOTES) for early gastric cancer (EGC). Methods: This is a retrospective analysis at a single tertiary referral center. A total of 23 patients with EGC underwent combined ESD with LLND and hybrid NOTES for early gastric cancer beyond endoscopic submucosal dissection between February 2007 and August 2009. Then the patients received periodic endoscopic follow-up and metastatic surveys over 5 years. The main outcome measures were curability (curative or non-curative), recurrent rate, and survival rates. Results: The curative resection rate of all cases was 95.7% (ESD with LLND 90.0% vs. hybrid NOTES 100%, respectively). Incomplete resection was shown in 1 (tumor-positive vertical margin). Histologically, 11 cases were mucosal cancers, and 12 were submucosal cancers. And there were 12 undifferentiated cancers. The median tumor size was 3.4 cm (range, 1.25.7cm) in long diameter. The lymphovascular invasion was found in 3 cases with 1 lymph node metastasis. 5 patients underwent additional gastrectomy because of tumor-positive margins or treatment-related complications. During over 5 year follow-up periods, none showed local recurrence or lymph node metastasis. The 5 year overall survival rates and disease free survival of the patients was100% in both. Conclusion: Combined ESD with LLND and hybrid NOTES showed favorable long term clinical outcomes. They could be utilized as a bridge between ESD and gastrectomy in selected patients with a risk of lymph node metastasis. 276 Incidence and Risk Factors of Metachronous Gastric Cancer After Endoscopic Resection and Successful Helicobacter pylori Eradication: Results From a Large-Scale, Multicenter Cohort Study in Japan Genki Mori*, Takeshi Nakajima, Ichiro Oda, Kiyoshi Asada, Taichi Shimazu, Nobutake Yamamichi, Takao Maekita, Chizu Yokoi, Mitsuhiro Fujishiro, Takuji Gotoda, Masao Ichinose, Toshikazu Ushijima Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan; Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan; Department of Gastroenterology, University of Tokyo, Tokyo, Japan; Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medice, Tokyo, Japan; Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan Introduction: A previous multicenter prospective randomized study from Japan showed that Helicobacter pylori (HP) eradication reduced the development of metachronous gastric cancer (MGC) after endoscopic resection (ER) for early gastric cancer (GC) from 40.5 to 14.1 cases per 1000 person-years. MGC is, however, still detected in a certain rate even after successful HP eradication, few studies have evaluated the incidence and risk factors of MGC. Aims: To clarify the incidence and risk factors of MGC in the cases after ER for early GC with successful HP eradication. Methods: Participants comprised 594 patients (485 men, 109 women; median age, 66 years; range, 36-79 years) who underwent ER for early GC and successful HP eradication in one of three institutions (National Cancer Center Hospital, The University of Tokyo Hospital and Wakayama Medical University Hospital) between 1999 and 2010. Annual endoscopic surveillance was performed after ER. HP infection was diagnosed using the C urea breath test, serology and culture of biopsy samples. Positive results in at least one of these three tests were considered as evidence of HP infection. The status of baseline gastric mucosal atrophy at the time of successful HP eradication was assessed endoscopically according to the Kimura-Takemoto classification. MGC was defined as a GC newly detected at least 1 year after successful HP www.giejournal.org Vol eradication. Results: Median follow-up period after successful HP eradication was 4.5 years (range, 1.0-11.4 years). During the follow-up period, 93 MGCs were detected in 79 patients. Kaplan-Meier analysis showed a linear increase in the cumulative incidence of MGC; the incidence of MGC was 29.9 cases per 1000 person-years (Fig. 1). Multivariate analysis by using Cox proportional hazard modeling revealed that male sex, open-type gastric mucosal atrophy, and multiple GCs before HP eradication were independent risk factors for MGC (Table 1). Conclusion: Careful and continuous surveillance endoscopy for MGC is required even after successful HP eradication, particularly in male patients, those with extensive gastric mucosal atrophy, and multiple GCs before HP eradication. Multivariate analysis for the risk of MGC ume 81, No. 5S : 2015 GASTROINTE Number STINAL E Hazard Ratio

Sclerosing angiomatoid nodular transformation (SANT) is a rare, benign vascular neoplasm. Most patients have no clinical symptoms, and the tumors are usually discovered incidentally on abdominal computed tomography or ultrasonography. Some studies have reported the clinical features and imaging findings of SANT, but the diagnosis is based on histopathologic examination of a tissue specimen obtained at splenectomy. We report herein an incidentally discovered case of SANT and review the related literature. (Korean J Med 2014;86:357-361)

It is known that rheumatoid arthritis (RA) patients show increased incidence of multiple myeloma (MM), despite its rarity. Only one case of MM with seronegative RA was reported in Korea, thus far. We report a case of MM with seropositive RA. The patient was a 66 year old female who had been diagnosed with seropositive RA 4 years ago. Over the last 1 month, the patient experienced general weakness and weight loss of 10 kg. It was found that her serum creatinine had increased and her urine analysis showed proteinuria. To evaluate renal failure and proteinuria, renal biopsy, bone marrow biopsy and electrophoresis were carried out. A diagnosis of myeloma cast nephropathy was made. We report this rare case of MM represented as acute renal failure during the treatment for RA, and include a review of the literature.

Background/Aims: The treatment for steroid-refractory acute graft versus host disease (GVHD) after allogeneic stem cell transplantation (allo-SCT) needs to be standardized. We report our clinical experience with etanercept for steroid-refractory acute GVHD. Methods: Eighteen patients who underwent allo-SCT and presented with steroid-refractory acute GVHD at Ajou University Hospital were studied retrospectively. They were given 25 mg of etanercept subcutaneously twice weekly for 4 weeks. The clinical responses were evaluated with regard to the severity of acute GVHD. Results: The median patient age was 43.5 years. Using nonparametric tests, etanercept had a down-grading effect on acute GVHD ( p = 0.005), although no patient experienced complete remission. Partial responses were seen in 80%, 17%, and 57% of grade II to IV patients, respectively. Skin and gut GVHD were well controlled with etanercept, whereas hepatic GVHD was not. Four patients died of fatal infections. No factors affecting the clinical outcome of etanercept were identified. Conclusions: Etanercept has a modest effect on steroid-refractory acute GVHD af ter allo-SCT, with tolerable side effects.