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Background The endoscopic submucosal dissection (ESD) technique has been gaining popularity, with continued advances in this treatment approach. However, ESD still is associated with potential complications such as severe bleeding and perforation. Methods This study was performed to compare the clinical outcomes for macro- and microperforations with ESD procedures and to determine the short-term prognosis after ESD. A macroperforation was defined as a gross perforation that occurred during an ESD procedure, and a microperforation was defined by free air observed on simple radiography after the procedure. Immediate closure of macroperforations was performed using endoclips. From July 2003 through May 2008, 1,711 patients underwent ESD for gastric lesions such as dysplasia, early cancer, and subepithelial lesions. Results Among 39 perforation cases (2.3%), macroperforations occurred for 26 patients (67%) and microperforations for 13 patients (33%). All the patients except one who underwent emergency surgery because of severe bleeding and perforation during ESD were managed successfully by intravenous antibiotics and no oral intake. The clinical prognosis and endoscopic characteristics of the patients with macroperforations did not differ from those of the patients with microperforations. Conclusions Perforations associated with ESD could be managed safely and successfully by nonsurgical methods. The clinical prognoses for macro- and microperforations were favorable and comparable.

Objectives: The ideal diagnostic criteria of autoimmune pancreatitis (AIP) are still challenging. Therefore, we investigated the clinical features of AIP in Korea and assessed the clinical use of new Korean diagnostic criteria. Methods: We reviewed 67 patients with AIP enrolled in 16 hospitals via a multicenter study. The diagnosis was confirmed according to the Korean diagnostic criteria that included pancreatic imaging, laboratory findings, histopathology, and response to steroid. Results: Mean age of the patients was 56 years, and 73% were men. Obstructive jaundice (52%) was the most common symptom, and 14 patients (21%) had other organ involvement. Fifty-four patients (81%) revealed diffuse swelling of the pancreas. Either immunoglobulin (Ig)G or IgG4 was elevated in 76%. According to the Korean criteria, 65 patients had definite diagnostic criteria, and 2 patients had probable criteria. Fifteen patients were fulfilled with image, serological, and histopathologic criteria, and 4 patients could be diagnosed with image and steroid responsiveness. Ten patients experienced recurrent attacks of AIP during the mean 20-month follow-up. Conclusions: Among 67 cases of AIP, either IgG or IgG4 was elevated in 76% of patients, and 14 patients (21%) had other organ involvement. New Korean diagnostic criteria are useful for diagnosis of AIP.

The aims of the present study were: (1) to assess the prevalence of symptom-based irritable bowel syndrome (IBS) in Korean adults, (2) to assess several organic abnormalities which can be found in IBS patients, and (3) to analyze the risk or associated factors that influence the presence of IBS. Adult health examinees were requested to fill out a questionnaire. The prevalence of IBS was calculated using Rome II criteria. Using several tests, several organic abnormalities were identified in the IBS group. Risk factors were analyzed by comparing the IBS and normal groups. The prevalence value for IBS according to Rome II criteria was 16.8%. Mucosal hyperplasia, lymphocyte aggregation, and increased eosinophil counts were relatively common microscopic findings in IBS group. Female gender, self-consciousness of IBS, and irregular defecation were expressed as significantly independent risk or associated factors for IBS. Several colonic microscopic findings mentioned above may be helpful in accurate diagnosis of IBS. Therefore a more-precise and large population study about these findings is necessary to reach a definitive conclusion.

Pancreatitis is the most common complication of diagnostic and therapeutic ERCP. Almost certainly, the etiology of this pancreatitis is multifactorial.The primary objective of this study was to evaluate the relationship between the extent of pancreatic ductal opacification and the frequency of pancreatitis.Retrospective study.The ERCP database at our institution was searched for prospectively collected data from 1994 to 2005.A total of 14,331 ERCPs were included in the analysis. Patients were divided into 4 groups according to the extent of pancreatic duct opacification: group 1, no attempted opacification or failed cannulation of the pancreatic duct (n = 6739); group 2, opacification of head only (n = 845); group 3, opacification of head and body (n = 2061); and group 4, opacification to the tail (n = 4685). The incidence and severity of pancreatitis was compared between and within each group.The overall pancreatitis rate was 4.0%. There was a progressively higher frequency of pancreatitis with increased extent of opacification to the pancreatic ductal system (P.001). The overall pancreatitis severity was mild in 2.9%, moderate in 0.8%, and severe in 0.3% of cases. There was a significant difference in pancreatitis severity between patients with pancreatogram (regardless of grade of filling) and patients without pancreatogram. (P.001). However, there was no difference in the pancreatitis severity between groups 2 to 4 (patients with pancreatogram). Age (65 years vs65 years), sex, and type of procedure performed (diagnostic and therapeutic) were not significantly different beyond the extent of pancreatic ductal opacification. Multivariate analysis showed that suspected sphincter of Oddi dysfunction with manometry and the extent of pancreatic duct opacification were independent predictors of post-ERCP pancreatitis.Less filling of the pancreatic ductal system was associated with less post-ERCP pancreatitis. Before performing endoscopic retrograde pancreatography, endoscopists should carefully evaluate whether any pancreatogram or what extent of pancreatogram is needed clinically. Greater use of noninvasive pancreatography and less use of endoscopic retrograde pancreatography should decrease post-ERCP pancreatitis.

Supplemental Digital Content is available in the text, Although adequate bowel preparation is a prerequisite for colonoscopy, preparation among inpatients is often suboptimal. This study aimed to evaluate the impact of ward nurse education on the quality of bowel preparation of inpatients. A prospective, double-blinded, non-randomized, controlled study was performed. Expert endoscopists provided enhanced education to nurses who belonged to an “educated ward” followed by training that was repeated every week for 1 month. The primary outcome was the quality of the bowel preparation, which was based on the Ottawa Bowel Preparation Scale (OBPS). Patient compliance and their subjective feelings and the factors affecting inadequate bowel preparation were also analyzed. One hundred three inpatients in the educated ward and 102 patients in the control ward were enrolled. Baseline data were comparable between the 2 wards. The mean values of the total OBPS scores were 4.42 ± 2.23 and 6.15 ± 2.38 in the educated and control wards, respectively (P

High quality bowel preparation is essential for successful colonoscopy. This study aimed to assess the impact of reinforced education by telephone or short message service (SMS) on the quality of bowel preparation.A prospective, endoscopist-blinded, randomized, controlled study was conducted. Reinforced education groups received additional education via reminders by telephone or SMS 2 days before colonoscopy. The primary outcome was the quality of the bowel preparation according to the Boston Bowel Preparation Scale (BBPS). The secondary outcomes included polyp detection rate (PDR), adenoma detection rate (ADR), tolerance, and subjective feelings of patients.A total of 390 patients were included. Total BBPS score was significantly higher in the reinforced education groups than in the control group (mean [SD] telephone vs.7.1 [1.2] vs. 6.3 [1.4], P 0.001; SMS vs.6.8 [1.3] vs. 6.3 [1.4], P = 0.027). Between the two interventions, there was no significant difference in total BBPS score. PDR and ADR were not different among groups. Reinforced education groups showed lower anxiety and better tolerance compared with controls. A preparation-to-colonoscopy time of 6 hours and 80 % of the purgative ingested were independent factors associated with inadequate bowel preparation (BBPS 5), whereas re-education by telephone was inversely related to inadequate bowel preparation.SMS was the optimal education modality, and was as effective as telephone reminders for the quality of bowel preparation. A reinforced educational approach via telephone or SMS should be individualized, depending on the resource availability of each clinical practice.ClinicalTrials.gov (NCT01911052).

Although inflammation induced by endoscopic retrograde cholangiopancreatography (ERCP) may affect laparoscopic cholecystectomy (LC), making the procedure more difficult, clinical impact of ERCP on LC is unclear. The aim of this study was to evaluate the effects of ERCP on LC and to determine appropriate time of LC after ERCP. Six hundred twenty-one patients who underwent LC for gallstone disease were enrolled. These patients were divided into two groups; patients with preoperative ERCP prior to LC (ERCP group) and patients who underwent LC without ERCP (non-ERCP group). Among these patients, patients who had shown acute cholecystitis or cholangitis were excluded. To control for different demographic factors in the two groups, propensity score case matching was used at a 1:1 ratio. Finally, 142 patients were matched with 71 patients of the ERCP group and 71 patients of the non-ERCP group. Intraoperative inflammation degree, technical difficulty, and postoperative outcome were analyzed. In the ERCP group, the degree of inflammation was severe and operations were more difficult than those of the non-ERCP group. The operation time was longer, and rates of open conversion were higher in the ERCP group. On multivariate analysis, preoperative ERCP was significant factor for difficult operations. The difficulty of operation was not different according to the operation timing after ERCP. Preoperative ERCP is a significant factor in difficult LC. Therefore, experienced surgeons should perform LC after preoperative ERCP. Since operation difficulty was similar according to the timing of cholecystectomy after ERCP, there is no reason to delay LC after ERCP.

Adherence to medication during the treatment of inflammatory bowel disease (IBD) is important in terms of maintaining remission. According to studies on adherence to medication in other chronic diseases, non-adherence is associated with negative attitudes to treatment. The aims of this study were to assess adherence rates and IBD patients' beliefs and attitudes regarding medication using a questionnaire based approach.Two hundred and eighty seven patients from three tertiary hospitals were enrolled and completed a questionnaire that addressed adherence (Medication Adherence Report Scale, MARS), beliefs, and attitudes to medication (Beliefs about Medications Questionnaire, BMQ).Using a cutoff score of 16/20 for MARS, 64 (22.3%) patients did not adhere to medication. According to attitude analysis conducted using the BMQ, 41.8% of the 287 study subjects felt high necessity but low concern for the medication ("accepting") and 34.8% felt high necessity and concern ("ambivalent"). Multivariate analysis showed significantly lower adherence to medication among younger patients, patients with experience of adverse effects to medication, patients with demanding jobs, and for those with an "indifferent" or "skeptical" attitude regarding the benefits of medication. On the other hand, IBD patients with "accepting" attitude adhered to medication.Twenty-two percent of IBD patients were non-adherent to medical treatment, and belief of the need for medication was found to significantly enhance adherence. Interventions, such as education about the efficacy and safety of medications, should be considered to facilitate adherence to medical treatment among IBD patients.

This study aimed to validate the equivalence of first-line concomitant and hybrid regimens for Helicobacter pylori infection in an era of increasing antibiotic resistance. The study also aimed to assess regimen compliance.H. pylori-infected patients from six hospitals in Korea were randomly assigned to either concomitant or hybrid regimens. The concomitant regimen consisted of 20 mg of esomeprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg metronidazole, twice daily for 10 days. The hybrid regimen consisted of a 5-day dual therapy (20 mg of esomeprazole and 1 g of amoxicillin, twice daily) followed by a 5-day quadruple therapy (20 mg of esomeprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg of metronidazole, twice daily).Eradication rates for concomitant and hybrid therapy were 78.6% (187/238) and 78.8% (190/241) in the intention-to-treat analysis, and 89.8% (176/196) and 89.6% (181/202) in the per protocol analysis. For both analyses, 95% confidence intervals fell within the ± 8% equivalence margin. Adherence was better in the hybrid group (95.0%) than in the concomitant group (90.1%), a difference that was borderline significant (P = 0.051). Adverse event rates were higher in the concomitant group than in the hybrid group for nausea (15.8% vs 8.8%; P = 0.028) and regurgitation (17.6% vs 10.7%; P = 0.040).As compared with concomitant therapy, hybrid therapy offered similar efficacy, better compliance, and fewer adverse events. Hybrid therapy could be a reasonable first-line treatment option for H. pylori in areas with high antibiotics resistance.

Background : Nonalcoholic fatty liver disease (NAFLD) has been more and more often regarded as a serious disorder, because nonalcoholic steatohepatitis (NASH), a part of NAFLD, may progress to the end stage of liver disease. Though an advanced age, obesity, diabetes mellitus (DM) etc. being not infrequent conditions in Korea, are known to exacerbate the severity of this disease, there are only a few Korean reports on this subject. The purpose of this study is to identify possible factors that might add up to the pathological severity of this disorder in Korean patients. Methods : Of 60 patients with steatosis found at liver biopsy, 43 NAFLD patients were reviewed retrospectively after exclusion of other liver diseases. Results : The cases of steatosis were mild, moderate, and severe in 9, 10, and 24 patients, respectively. The degree of necroinflammatory activity was mild, moderate, and severe in 33, 9, and 1 patients, respectively. There were no established factors directly related to these classes. As to fibrosis, the cases were classified as none, mild, moderate, severe, and cirrhotic in 9, 11, 16, 7, and 0 patients, respectively. The stage of fibrosis correlated with the age (p

To evaluate the incidence and risk factors of Korean tuberculosis (TB) infection in patients with inflammatory bowel disease (IBD) undergoing anti-TNF treatment.The data of IBD patients treated with anti-TNFs in 13 tertiary referral hospitals located in the southeastern region of Korea were collected retrospectively. They failed to show response or were intolerant to conventional treatments, including steroids or immunomodulators. Screening measures for latent TB infection (LTBI) and the incidence and risk factors of active TB infection after treatment with anti-TNFs were identified.Overall, 376 IBD patients treated with anti-TNF agents were recruited (male 255, mean age of anti-TNF therapy 32.5 ± 13.0 years); 277 had Crohn's disease, 99 had ulcerative colitis, 294 used infliximab, and 82 used adalimumab. Before anti-TNF treatment, screening tests for LTBI including an interferon gamma release assay or a tuberculin skin test were performed in 82.2% of patients. Thirty patients (8%) had LTBI. Sixteen cases of active TB infection including one TB-related mortality occurred during 801 person-years (PY) follow-up (1997.4 cases per 100000 PY) after anti-TNF treatment. LTBI (OR = 5.76, 95%CI: 1.57-21.20, P = 0.008) and WBC count5000 mm(3) (OR = 4.5, 95%CI: 1.51-13.44, P = 0.007) during follow-up were identified as independently associated risk factors.Anti-TNFs significantly increase the risk of TB infection in Korean patients with IBD. The considerable burden of TB and marked immunosuppression might be attributed to this risk.

To compare the esophagogastric junction (EGJ) areas observed in sedated and non-sedated patients during esophagogastroduodenoscopy (EGD).Data were collected prospectively from consecutive patients who underwent EGD for various reasons. The patients were divided into three groups according to the sedation used: propofol, midazolam, and control (no sedation). The EGJ was observed during both insertion and withdrawal of the endoscope. The extent of the EGJ territory observed was classified as excellent, good, fair, or poor. In addition, the time the EGJ was observed was estimated.The study included 103 patients (50 males; mean age 58.44 ± 10.3 years). An excellent observation was achieved less often in the propofol and midazolam groups than in the controls (27.3%, 28.6% and 91.4%, respectively, P0.001). There was a significant difference in the time at which EGJ was observed among the groups (propofol 20.7 ± 11.7 s vs midazolam 16.3 ± 7.3 s vs control 11.6 ± 5.8 s, P0.001). Multivariate analysis showed that sedation use was the only independent risk factor for impaired EGJ evaluation (propofol, OR = 24.4, P0.001; midazolam, OR = 25.3, P0.001). Hiccoughing was more frequent in the midazolam group (propofol 9% vs midazolam 25.7% vs control 0%, P = 0.002), while hypoxia (SaO290%) tended to occur more often in the propofol group (propofol 6.1% vs midazolam 0% vs control 0%, P = 0.101).Sedation during EGD has a negative effect on evaluation of the EGJ.

Endoscopic submucosal dissection (ESD) has been widely performed for the treatment of early gastric cancer (EGC). The aim of this study is to examine the effectiveness of ESD in submucosal invasive gastric cancers (SM-GC), with a special focus on patients who underwent non-curative resection. Data for 1,246 patients who underwent ESD for treatment of EGC at six medical centers in Daegu-Gyeongbuk, Korea, between February 2003 and May 2010 were collected. After retrospective analysis of ESD databases, 118 patients were enrolled and classified into three groups: (1) EGC with submucosal invasion less than 500 μm (SM1-GC) that met the expanded criteria (EC) (SM1 EC, n = 42); (2) SM1-GC that did not meet the EC (SM1 non-EC, n = 38); and (3) EGC with submucosal invasion greater than 500 μm (SM2-GC, n = 38). The en bloc and complete resection rates did not differ significantly among the three groups. However, the curative resection rate was significantly better in the SM1 EC group (69.0 %) compared to that in SM1 non-EC and SM2-GC groups (0 % in both cases). Out of a total of 118 patients, 89 (75.4 %) underwent non-curative resection, and cancer recurrence was observed in 9 (9/89, 10.1 %). We analyzed the survival rate in these non-curative patients and the overall survival and disease-free survival did not differ significantly between patients that were treated with additional surgical resection and those that were simply followed up after ESD. Non-curative resection in SM-GC does not always lead to cancer recurrence. Thus, if additional surgery cannot be performed because of the patient’s unsuitable condition or refusal, a close follow-up with endoscopy can be considered as an alternative for carefully selected patients. Moreover, as the ESD technology continues to evolve, it might be possible to expand the criteria for curative ESD in patients with SM-GC.

Background As a result of increased resistance to antibiotics, Helicobacter pylori eradication rates using standard triple therapy have been declining. Aim To validate the efficacy and tolerability of a concomitant regimen as a first-line treatment for H. pylori infection. Methods A total of 348 naive H. pylori-infected patients from six hospitals in Korea were randomly assigned to concomitant therapy and standard triple therapy groups. The concomitant regimen consisted of 30 mg of lansoprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg of metronidazole, twice daily for 10 days. The standard triple regimen consisted of 30 mg of lansoprazole, 1 g of amoxicillin, and 500 mg of clarithromycin, twice daily for 10 days. Results Concomitant and standard eradication rates were 78.7% (137/174) vs. 70.7% (123/174) by intention-to-treat (p = 0.084) and 88.7% (133/150) vs. 78.4% (120/153) by per-protocol (p = 0.016), respectively. The two groups were similar with regard to the incidence of adverse events. Conclusions Although 10-day concomitant therapy was validated as a suboptimal treatment option for the treatment of H. pylori infection, this regimen is expected to be a promising starting point in the development of an optimal treatment regimen for H. pylori infection.

To compare outcomes using the novel portable endoscopy with that of nasogastric (NG) aspiration in patients with gastrointestinal bleeding.Patients who underwent NG aspiration for the evaluation of upper gastrointestinal (UGI) bleeding were eligible for the study. After NG aspiration, we performed the portable endoscopy to identify bleeding evidence in the UGI tract. Then, all patients underwent conventional esophagogastroduodenoscopy as the gold-standard test. The sensitivity, specificity, and accuracy of the portable endoscopy for confirming UGI bleeding were compared with those of NG aspiration.In total, 129 patients who had GI bleeding signs or symptoms were included in the study (age 64.46 ± 13.79, 91 males). The UGI tract (esophagus, stomach, and duodenum) was the most common site of bleeding (81, 62.8%) and the cause of bleeding was not identified in 12 patients (9.3%). Specificity for identifying UGI bleeding was higher with the portable endoscopy than NG aspiration (85.4% vs 68.8%, P = 0.008) while accuracy was comparable. The accuracy of the portable endoscopy was significantly higher than that of NG in the subgroup analysis of patients with esophageal bleeding (88.2% vs 75%, P = 0.004). Food material could be detected more readily by the portable endoscopy than NG tube aspiration (20.9% vs 9.3%, P = 0.014). No serious adverse effect was observed during the portable endoscopy.The portable endoscopy was not superior to NG aspiration for confirming UGI bleeding site. However, this novel portable endoscopy device might provide a benefit over NG aspiration in patients with esophageal bleeding.

BACKGROUND There are few data regarding the prevalence of hepatitis-B virus (HBV) markers in inflammatory bowel disease (IBD) patients in Korea, which is a hepatitis-B-endemic area. The aim of this study was to assess the prevalence of HBV markers in IBD patients in comparison with controls. METHODS We enrolled 513 IBD patients [241 Crohn's disease (CD) and 272 ulcerative colitis (UC)] whose hepatitis-B surface antigen and anti-HBs levels were evaluated. Anti-HBc was assayed in 357 patients. These markers were compared with those of 1020 sex-matched and age-matched controls. RESULTS Prevalence of hepatitis-B surface antigen in IBD patients was 3.7% and there was no significant difference between groups (CD 4.1%, UC 3.3%, control 4.4%, P=0.713). The frequency of effective vaccination against HBV (positive anti-HBs, without anti-HBc) was lower in IBD patients less than 30 years old compared with the same-aged controls (CD 43.3%, UC 48.5%, control 61.9%, P=0.002), whereas there was no difference between groups in subjects more than 30 years old. One third of IBD patients were at risk of susceptibility to HBV infection (nonimmune), particularly those less than 30 years old, compared with controls of the same age (CD 43.3%, UC 36.4%, control 21%, P

Acute pancreatitis is an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems. Acute fluid collections and pseudocyst formation are the most frequent complications of acute pancreatitis.The aims of this study were to evaluate the incidence, risk factors, and clinical course of pancreatic fluid collections and pseudocyst formation following acute pancreatitis.A prospective multicenter study was conducted in five participating centers with 302 patients diagnosed with acute pancreatitis from January 2011 to July 2012.The incidence of pancreatic fluid collections and pseudocyst was 42.7 and 6.3 %, respectively. Patients with fluid collections were significantly younger, compared to those without fluid collections (51.5 ± 15.9 vs. 60.4 ± 16.5 years, P = 0.000). The proportion of alcoholic etiology (54.3 %) in patients with fluid collections was significantly higher compared to other etiologies (P = 0.000). C-reactive protein (CRP) (48 h) was significantly higher in patients with fluid collections, compared to patients without fluid collections (39.2 ± 77.4 vs. 15.1 ± 36.2 mg/dL, P = 0.016). LDH (48 h) was significantly higher in patients with pseudocyst formation, compared to patients with complete resolution (1,317.6 ± 706.4 vs. 478.7 ± 190.5 IU/L, P = 0.000). Pancreatic fluid collections showed spontaneous resolution in 69.8 % (90/129) and 84.2 % of the pseudocysts disappeared or decreased in size during follow up.Age, CRP (48 h), and alcohol etiology are risk factors for pancreatic fluid collections. LDH (48 h) appears to be a risk factor for pseudocyst formation. Most pseudocysts showed a decrease in size or spontaneous resolution with conservative management.

The results of studies that evaluated predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are inconsistent. The aim of this study was to investigate predictive factors for 30-day rebleeding in these patients. A consecutive 312 patients presenting symptoms and signs of gastrointestinal bleeding were enrolled in this prospective, observational study. Clinical and demographic characteristics and endoscopic findings were evaluated for potential factors associated with 30-day rebleeding using logistic regression analysis. Overall, 176 patients were included (male, 80.1%; mean age, 59.7±16.0 yr). Rebleeding within 7 and 30 days occurred in 21 (11.9%) and 27 (15.3%) patients, respectively. We found that chronic kidney disease (CKD) (OR, 10.29; 95% CI, 2.84-37.33; P100 beats/min) during the admission (OR, 3.79; 95% CI, 1.25-11.49; P=0.019), and Forrest classes I, IIa, and IIb (OR, 6.14; 95% CI, 1.36-27.66; P=0.018) were significant independent predictive factors for 30-day rebleeding. However, neither Rockall nor Blatchford scores showed statistically significant relationships with 30-day rebleeding in a multivariate analysis. CKD, hemodynamic instability during hospitalization, and an endoscopic high-risk appearance are significantly independent predictors of 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding. These factors may be useful for clinical management of such patients.

Endoscopic submucosal desection (ESD) is an effective treatment for selected patients with early gastric cancer (EGC). The purpose of this study was to examine the short-term and long-term outcomes of ESD of undifferentiated early gastric cancer. Data for 1,241 patients who underwent ESD for treatment of EGC between February 2003 and May 2010 were collected. We performed a retrospective analysis of the medical records of 74 patients diagnosed with undifferentiated EGC. We divided the enrolled cases into two groups: the expanded-criteria group (EC group) versus the non-EC group, according to lesion size, presence of ulceration, and pathologic review. Of a total of 74 lesions with undifferentiated EGC, as a result of pathologic examination the EC group included 29 cases and the non-EC group included 45 cases. The mean diameter of lesions was 19.86 ± 12.5 mm. The overall rates of en bloc resection and complete resection were 90.5 % (67/74) and 73 % (54/74), respectively. The curative resection rate was low at 31.1 %. If limited to the pathologically diagnosed EC group, the curative resection rate was 79.3 % (23/29). During median follow-up periods of 34 months (range 7–81), local recurrences were observed in 5.5 % (4/74) of patients. All of these were in the non-EC group and all underwent noncurative resection. There was no mortality related to ESD for treatment of EGC during follow-up. ESD may be a feasible treatment for selected patients with undifferentiated EGC; this should be validated by development of new criteria for ESD for treatment of EGC.

The name of the second author was spelled incorrectly. The correct name is: Yu Jin Hah. In addition, the name of the third author was incorrectly represented in the Citation. The correct Citation is: Lee YJ, Hah YJ, Kang YN, Kang KJ, Hwang JS, et al. (2013) The Autophagy-Related Marker LC3 Can Predict Prognosis in Human Hepatocellular Carcinoma. PLoS ONE 8(11): e81540. doi:10.1371/journal.pone.0081540

Background Defects of autophagy and endoplasmic reticulum (ER) stress are related to many diseases and tumors. However, only a few studies have examined hepatocellular carcinoma (HCC) as related to these processes. Therefore, in this study, we investigated the expression and extent of autophagy and ER stress-related markers in HCC and their influence on clinical characteristics and prognosis for each protein. Methodology The expression of autophagy-related markers (LC3 and Beclin-1) and ER stress-related markers (GRP78 and CHOP) was analyzed by immunohistochemistry on tissues from completely resected specimens of 190 HCC patients. Their influence on clinicopathologic features and prognosis were evaluated using the chi-square test and Kaplan-Meier analysis. Correlations of each protein were determined by Spearman's correlation analysis. Principal Findings LC3 expression was not correlated with TNM, BCLC stage, or Edmonson-Steiner grading, whereas it was correlated with longer overall survival (OS) (p = 0.039) and tended to be related with longer time to recurrence (TTR) (p=0.068) although it did not show statistical significance. Multivariate analysis indicated that LC3 expression was a significantly independent prognostic factor of OS (HR, 0.42; 95% CI, 0.22-0.80; p-value=0.009) and TTR (HR, 0.54; 95% CI, 0.33–0.90; p=0.017). Expression of LC3 in advanced stages of TNM (III) (p=0.045) and Edmonson-Steiner Grades (III and IV) (p=0.043) was correlated with longer survival, but not in the early stages. A positive correlation was not observed between the expression of autophagy-related markers and ER stress-related markers. Conclusion Our results suggest that the expression and extent of LC3 might be a strong prognostic factor of HCC, especially in patients with surgical resection.

Situs inversus totalis (SIT) is a rare condition in which there is complete right to left reversal of the abdominal and thoracic organs. SIT generally does not bear any pathophysiological significance, and the survival rate of patients with SIT does not differ from that of healthy individuals. However, patients with SIT require a thorough radiological examination to identify the presence of associated anatomic variations before undergoing invasive procedures such as surgery or hemostasis of gastrointestinal hemorrhage because they may have accompanying abnormalities in anatomical structures along with reversed organs. Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure that is most commonly performed for the enteral feeding of patients with dysphagia and a normal gastrointestinal function. However, the procedure requires extracaution because minor complications may lead to life-threatening situations due to the underlying illnesses. Here, we report the case of a patient with SIT who underwent a PEG procedure without complications, and review the existing literature on this subject.

Preoperative screening for synchronous colorectal neoplasia (CRN) has been recommended in patients with gastric cancer because patients with gastric cancer are at increased risk for synchronous CRN. The aim of this study was to investigate the diagnostic accuracy of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting synchronous advanced CRN in patients with gastric cancer. A total of 256 patients who underwent colonoscopy and 18F-FDG PET/CT for preoperative staging were enrolled in this study. The diagnosis of focal colonic 18F-FDG uptake on 18F-FDG PET/CT image was made based on histopathologic results from the colonoscopic biopsy. The 18F-FDG PET/CT result was considered as true positive for advanced CRN when focal 18F-FDG uptake matched colorectal carcinoma or adenoma with high-grade dysplasia in the same location on colonoscopy. Synchronous advanced CRN was detected in 21 of the 256 patients (4.7%). Sensitivity, specificity, and accuracy of 18F-FDG PET/CT were 76.2%, 96.2%, and 94.5%. The size of CRN with a true positive result was significantly larger than that with a false negative result. 18F-FDG PET/CT demonstrated high diagnostic accuracy for detecting synchronous advanced CRN in patients with gastric cancer. Colonoscopy is recommended as the next diagnostic step for further evaluation of a positive 18F-FDG PET/CT result in patients with gastric cancer.

To avoid missing events associated with clinical activity, the authors previously developed a novel, web-based, self-reporting Crohn disease (CD) symptom diary. However, although this diary provided a means of self-checking based on responses to set questions based on Harvey–Bradshaw index scores, it was limited in terms of describing other specific symptoms. Thus, the authors added a space to the questionnaire, which allows patients to send clinicians questions or a description of unpredictable events. The aim of the present study was to assess the clinical usefulness of this messaging system by analyzing patients’ messages. The messaging system between patients and their doctors was included in a webpage created for recording patients’ symptom diaries (www.cdsd.or.kr). Using this system, patients can send messages easily at any time and doctors can read and respond to these messages immediately using a smart phone or computer. In the present study, the authors retrospectively reviewed 686 messages sent by 152 patients from July 2012 to July 2014 and patient medical records. Mean patient age was 29.0 ± 11.6 years and the male-to-female ratio was 99:53. Most messages regarded symptoms (381 messages, 55.5%), which was followed by self-reports about general condition (195 messages, 28.4%) and questions about treatment (71 messages, 10.3%). With respect to symptoms, abdominal pain was most common (145 cases, 21.1%) followed by hematochezia (36 cases, 5.2%). Problems about medication were the most frequently associated with treatment (65, 91.5%). Patients above 40 years showed a greater tendency to focus on symptoms and treatment (P = 0.025). The doctor answer rate was 56.3% (n = 386), and based on these responses, an early visit was needed in 28 cases (7.3%). Using this web-based messaging system, patients were able to obtain proper advice from their physicians without visiting clinics or searching the Internet, and in addition, 7.3% of messages prompted an early visit. Although longer follow-up is required, this study shows that the devised messaging system provides a clinically relevant communication tool for patients and physicians.

AIM To investigate histologic abnormalities in the gastric smooth muscle of patients with diabetes mellitus (DM). METHODS Full-thickness gastric specimens were obtained from patients undergoing surgery for gastric cancer. H&E stain and Masson’s Trichrome stain were performed to assess the degree of fibrosis. Immunohistochemical staining using various antibodies was also performed [antibodies against protein gene product 9.5 (PGP9.5), neuronal nitric oxide synthase (nNOS), vasoactive intestinal peptide (VIP), neurokinin-1 (NK1) receptor, c-Kit, and platelet-derived growth factor receptor-alpha, (PDGFRα)]. Immunofluorescent staining and evaluation with confocal microscopy were also conducted. RESULTS Twenty-six controls and 35 diabetic patients (21 short-duration patients and 14 long-duration patients) were included. There were no significant differences in basic demographics between the two groups except in mean body mass index (BMI) (higher in the DM group). Proportions of moderate-to-severe intercellular fibrosis in the muscle layer were significantly higher in the DM group than in the control group (P < 0.01). On immunohistochemical staining, c-Kit- and PDGFRα-positive immunoreactivity were significantly decreased in the DM group compared with the control group (P < 0.05). There were no statistically significant differences in PGP9.5, nNOS, VIP, and neurokinin 1 expression. On immunofluorescent staining, cellularity of interstitial cells of Cajal (ICC) was observed to decrease with increasing duration of DM. CONCLUSION Our study suggests that increased intercellular fibrosis, loss of ICC, and loss of fibroblast-like cells are found in the smooth muscle of DM patients. These abnormalities may contribute to changes in gastric motor activity in patients with DM.

Few data are available on response failure and hospital mortality. This study aimed to evaluate the association between response failure to the treatment of CDI and 30-day mortality.Medical records of patients diagnosed with CDI between March 2005 and March 2010 were reviewed. CDI diagnosis was considered in patients with diarrhea when the stool toxins assay was positive or pseudomembranous colitis (PMC) was confirmed by endoscopy. If there were no symptomatic improvements during 10 days of treatment, the case was regarded as response failure. Patients were stratified into a mild or severe disease group based on clinical criteria.Among 536 subjects (age 64±14.12, mild 266, severe 270), 26 (4.9%) showed response failure, which occurred more frequently in the severe disease than mild disease group. Forty-eight (9%) patients died within 1 month and mortality rate in the failure group was higher than in the response group (42.3% vs. 7.3%, p0.001). Malignancy, albumin2.5 mg/dL, WBC15,000 cells/mm3, ICU admission and response failure were independent risk factors associated with 30-day mortality after CDI.Response failure to the treatment negatively affects a patients’ survival within 30 days after CDI.

Endoscopic treatments of colorectal neoplasms have yet to be standardized. This study aimed to compare efficacy and tolerability of different endoscopic resection methods for colorectal epithelial tumors. Patients with non-pedunculated colorectal tumors undergoing endoscopic treatments were consecutively enrolled, and their medical records were reviewed retrospectively. The resection methods were classified into three groups: endoscopic mucosal resection with circumferential precutting (EMR-P), endoscopic submucosal dissection with snaring (ESD-S), and endoscopic submucosal dissection alone (ESD). We compared en bloc resection, pathological complete resection, and complications associated with these methods. Overall, 206 lesions from 203 patients were included in the study (mean size 25.2 ± 10.1 mm). The number of lesions treated with EMR-P, ESD-S, and ESD was 91 (44.2 %), 57 (27.7 %), and 58 (28.2 %), respectively. There was a significant difference in both the en bloc resection rates (EMR-P, 61.5 %; ESD-S, 64.9 %; ESD, 96.6 %; p = 0.001) and complete resection rates (EMR-P, 51.6 %; ESD–S, 54.4 %; ESD, 75.9 %; p = 0.009). Bleeding and perforation were less frequently observed in the EMR-P group. In the subgroup-analysis of lesions less than 20 mm, however, these differences were not observed. All endoscopic resection methods, including EMR-P, ESD-S, and ESD, were effective and safe for the treatment of colorectal neoplasms. Technically demanding ESD with high en bloc and complete resection rate should be reserved for the suspicious cancer lesion, which requires the precise histological evaluation. EMR-P with good feasibility can be considered an alternative to ESD for the lesions less than 20 mm.

BACKGROUNDS/AIMS: In spite of several case reports about gastrointestinal stromal tumor (GIST) complicated with hemorrhage, study regarding the risk factors of bleeding in this tumor is scanty. Therefore, we analyzed the clinical characteristics of bled GISTs and tried to find risk factors of bleeding by comparing with non-bled cases. METHODOLOGY: Medical records of 49 bled GIST cases from 5 university hospitals in Korea between year 2001 to 2010 were compared with 96 non-bled cases. Whole pathological slides were reviewed by an experienced pathologist. RESULTS: Female predominance (58.6%) was noted and the mean age of the included patients was 58.4±13.1 years. In univariate analysis, location of jejunum, prolonged prothrombin time, presence of surface dimpling in CT, cellular pleomorphism and positivity of S100 was significantly dominant in the bled cases. Multivariate analysis showed significant differences in the location of jejunum (p=0.004, OR=3.533), prolonged prothrombin time (p=0003, OR=19.643), presence of surface dimpling (p=0.026, OR=6.250) in CT, and positivity of S100 (p=0.001, OR=12.941). CONCLUSIONS: Location of jejunum, prolonged prothrombin time, presence of surface dimpling in CT, and positivity of S100 are independent risk factors associated with bleeding in GI GIST patients.

The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications. Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy. A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100 % and the clinical success rate 94.1 %. Overall complications were observed in 49 patients (32.2 %) during the follow-up period (median, 98 days; interquartile range, 19–302 days). Obstruction (17.1 %), migration (7.9 %), perforation (5.2 %), bleeding (1.3 %), and tenesmus (0.7 %) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan–Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group. Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.

Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD. Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedure-related variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors. The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation (p = 0.01/0.047 and p = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319–5.267; p = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056–6.656; p = 0.038) were significant predictive factors for perforation. The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD.

A 44-year-old woman was transferred to KeimyungUniversity Dongsan Hospital, Daegu, Korea in January2010 due to skin rash and itching sensation. Whileshe was suffering from the above symptoms, herhusband had been diagnosed with an eosinophilicliver abscess, so she visited her local hospital to workup her symptoms. Subsequently, peripheral bloodeosinophilia, positive skin test for dog allergen and ahepatic abscess on abdominal computed tomography(CT) were incidentally found. On admission to ourhospital she was afebrile and a physical examinationyielded no specific findings. Routine blood testrevealed a white blood cell count of 7.65 ¥ 10

BACKGROUND/AIMS Dysfunction of the gastrointestinal tract occurs in about 76% of patients who are diabetic for more than 10 years. Although diabetes-related dysfunctions of the stomach such as gastroparesis have been extensively studied over the recent years, studies about the mechanism underlying colonic symptoms in long-term diabetes models are rare. Therefore, the goal of our study was to clarify the nature of colonic dysfunction in a long-term diabetic rat model. METHODS The characteristics of colonic smooth muscle were investigated in Otsuka Long-Evans Tokushima Fatty (OLETF) rats, an animal model of type 2 diabetes. These results were compared to those obtained from Long-Evans Tokushima Otsuka (LETO) control rats. RESULTS Spontaneous contractility of the proximal colon was significantly decreased in the diabetic rats compared to the controls, while the spontaneous contractility of the distal colon was not. The number of interstitial cells of Cajal networks in the proximal colon was greatly decreased in diabetic rats compared to the controls. Contractility of the proximal colon in response to carbachol, an acetylcholine receptor agonist, was significantly weaker in the diabetic rats. In addition, the degree of relaxation in response to nitric oxide in the proximal colon of diabetic rats also appeared to be attenuated. CONCLUSIONS The results from our study suggest that the decrease of interstitial cells of Cajal network, cholinergic receptors, and neuronal nitric oxide synthase in the proximal colon plays important roles in diabetes-related dysfunction of colon.

The increasing use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) calls for greater consideration of radiation exposure risk to endoscopists and assistants, and emphasizes the proper system of radiation protection. This study was designed to assess the effect of a newly developed, self-designed, protective lead shield.A curtain-shaped protective shield composed of seven movable lead plates was developed, each with the following dimensions: depth, 0.1 cm; width, 15 cm; length, 70 cm. The curtain-shaped protective shield was designed to be located between the patient and the endoscopist. Twenty-nine patients (11 men and 18 women) undergoing ERCP between January 2010 and March 2010 were selected for this study. The dose of radiation exposure was recorded with or without the protective lead shield at the level of the head, chest, and pelvis. The measurement was made at 50 cm and 150 cm from the radiation source.The mean patient age was 64 years. The mean patient height and weight was 161.7+/-6.9 cm and 58.9+/-9.9 kg, respectively. The mean body mass index (BMI) was 22.5+/-3.0 kg/m2. Endoscopists received 1522.2+/-537.0 mR/hr without the protective lead shield. At the same distance, radiation exposure was significantly reduced to 68.8+/-88.0 mR/hr with the protective lead shield (p-value0.0001). The radiation exposure to endoscopists and assistants was significantly reduced by the use of a protective lead shield (p value0.0001). The amount of radiation exposure during ERCP was related to the patient's BMI (r=0.749, p=0.001).This self-designed, protective lead shield is effective in protecting endoscopists and assistants from radiation exposure.

Endoscopic submucosal dissection (ESD) is an useful therapeutic technique for large gastrointestinal epithelial tumors that it provides an en bloc resection. Although there is some controversy about the role of ESD for colorectal lesions, for large lesions in the distal rectum, ESD has the advantage of preserving anal function. However, the large amount of insufflating gas used during the procedure can cause severe abdominal pain and discomfort. Moreover, high intra-luminal pressure caused by a by large amount of gas can cause a micro-perforation. There is no consensus as to whether ESD is the optimal treatment for synchronous large colorectal laterally spreading tumors (LSTs) that cannot be removed en-bloc by conventional endoscopic mucosal resection. Here, a case with two neighboring synchronous large LSTs, one located in the rectum and the other in the distal sigmoid colon, were sequentially removed by separate ESD procedures performed on two consecutive days in a patient who could not tolerate a long procedure.