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Background/Aims Intrahepatic cholangiocarcinoma (ICC) is the second-most common primary liver malignancy, arising from the peripheral intrahepatic bile duct epithelium. Hepatitis B virus (HBV) or hepatitis C virus (HCV) may be involved in the development of ICC. We explored the prognostic value of hepatitis virus infection, as well as other prognostic factors affecting survival in patients with ICC. Methods A retrospective chart review was performed for patients diagnosed with ICC between August 2005 and December 2018 at Konkuk University Medical Center. We identified a total of 131 patients with ICC. Overall survival rates of patients with and without hepatitis were determined. Univariate and multivariate analyses were used to estimate factors influencing survival outcomes. Results A total of 17.6% (23/131) of patients were positive for HBV or HCV. Hepatitis B positive ICC patients were significantly younger with higher albumin and higher α-fetoprotein than those without hepatitis viral infections. The median survival of hepatitis-positive and hepatitis-negative groups was 280 and 213 days, respectively. Survival rates were not significantly different between the two groups (p = 0.279). Multivariate analyses indicated that lower serum carbohydrate antigen 19-9 (CA 19-9) (p < 0.001), lower T stage (p = 0.042), the absence of lymph-node metastasis (p = 0.043), and receiving curative surgery (p = 0.033) were independent predictors of better outcomes. Conclusions While hepatitis influenced a number of clinical features in ICC patients, it did not affect survival rate. Prognostic factors influencing survival outcomes with ICC were CA 19-9 level, T stage, the presence of lymph node metastasis, and curative surgery.

Forceps biopsies are usually performed before endoscopic submucosal dissection (ESD) for colonic laterally spreading tumors (LSTs). However, preceding biopsy is commonly believed to possibly inhibit complete tumor resection by causing blurring of tumor borders and tissue fibrosis. The aims were to investigate whether the preceding biopsy of colorectal LST affects the complete endoscopic tumor resection and increases the risk of complications. We retrospectively reviewed the medical records of patients with colorectal LSTs who underwent ESD at our center during an 8-year period. Patients were divided into two groups according to whether they underwent biopsy of the tumor before ESD. In addition, the characteristics of patients and tumors, including the completeness of tumor resection, were investigated. Of 288 patients (174 men) enrolled in this study, 194 (67.4%, preceding biopsy group) underwent biopsies before ESD, whereas 94 (32.6%, no biopsy group) did not. There were no significant differences in age, sex, comorbidity, medication history, tumor location, and final pathologic result between both groups. Tumor size was larger (p = 0.002) and LST-G tumor was more common (p = 0.003) in the preceding biopsy group than in the no biopsy group. No significant difference was seen in ESD outcomes, including procedure time, hospitalization period, incidence of complications, en bloc resection rate, resection margin status, and incidence of surgical operation, between both groups. Biopsy of LST is commonly performed before endoscopic resection. Contrary to popular belief, it does not increase the incomplete tumor resection rate and incidence of complications. KCT0002321

배경목적: 내시경 초음파 유도하 췌장 저류액 배액은 효과적인 시술이나 이 시술에 특화된 맞춤형 부속기구는 부족한 실정이다. 이 연구의 목적은 내시경 초음파 유도하 경위장관 배액술 전용으로 새로 고안된 양측 플랜지가 있는 완전피막형 금속 스텐트의 유용성을 평가하고자 하였다. 방법: 동물연구는 한 마리의 개를 대상으로 하였고 임상연구는 췌장 저류액을 가진 5명의 환자 (5명은 췌장가성낭종, 1명은 벽 형성 췌장괴사)를 대상으로 하여 내시경 초음파 유도하 배액술을 시행하였다. 연구의 성과는 기술적, 임상적 성공여부, 합병증, 스텐트 제거 가능 여부로 판단하였다. 결과: 동물연구에서 스텐트는 내시경 초음파 유도하 경십 이지장 접근으로 합병증 없이 성공적으로 유치되었다. 시술 직후 시행한 부검에서 담낭-십이지장 연결은 온전하였다. 6명의 환자에서 모두 스텐트는 성공적으로 유치되었다. 모든 환자에서 시술후 합병증과 스텐트 이탈은 없었다. 결론: 새로 고안된 양측 플랜지가 있는 완전피막형 금속스텐트를 사용한 췌장저류액의 내시경 초음파 유도하 경위장관 배액술은 기술적으로 가능하였고 심각한 합병증은 없었다. 스텐트 선단부의 맞춤형 플랜지 형상은 시술의 효과를 배가시켰다.

목적: 헬리코박터 파일로리 균에 대한 혈청전환의 위험성은 감염된 가족과 거주하거나 상부위장관 내시경 검사를 받으면 상승한다. 우리나라에서는 음주가 혈청전환의 위험요인으로 알려져 있으나, 외국에서는 이와 상반된 연관성을 보인다. 이에 본 연구에서는 한국인에서 혈청전환을 유발하는 위험 요인을 분석하고, 음주량이 혈청전환에 미치는 영향력을 조사하였다. 방법: 혈청 항헬리코박터 파일로리 항체 검사에서 음성을 보인 한국인 성인 중 매년 혈청항체에 대한 추적 검사를 하면서 혈청 펩시노겐 검사와 상부위장관 내시경 검사를 함께 받은 사람을 대상으로 하였다. 위 절제술이나 제균 치료를 받은 사람은 대상에서 제외하였다. 심한 음주자는 일주일에 15잔 이상을 마시는 남자와 8잔 이상을 마시는 여자로 정의하였다. 결과: 항체 음성자 267명 중 26명(9.7%)이 혈청전환을 보였으며, 평균 추적 기간은 39.0 ± 19.1개월이었다. 혈청전환율은 음주량(p = 0.001), 비스테로이드성항염증제 복용력(p =0.015), 높은 체질량지수(p = 0.033), 긴 추적 기간(p = 0.038), 많은 추적 검사 횟수(p = 0.004)와 비례해서 증가하였다. 이중에서 심한 음주자(OR 6.754, 95% CI 1.892-24.102, p = 0.003)와 보통 음주자(OR 4.360, 95% CI 1.130-16.826, p = 0.033)만이 혈청전환의 독립적인 위험 인자로 밝혀졌다. 추적 검사시의 혈청 펩시노겐 II 수치는 혈청전환자(12.0 ± 7.8 ng/mL)가 대조군(9.1 ± 5.3 ng/mL)에 비해서 높았다(p = 0.038). 결론: 한국인에서 음주는 혈청전환과 연관된 주요 위험인자이다. 이는 음주를 줄이고 비위생적 음주 습관을 개선하는 것이 한국인 성인들 사이에서 헬리코박터 파일로리균의 전염을 예방하는데 도움이 될 수 있다는 것을 시사한다.

Background/Aims: Nodular gastritis (NG) is a well-known endoscopic finding observed in patients with a Helicobacter pylori infection, which may lead to invasive gastric cancer. Lymphofollicular gastritis consists of lymphoid follicles or lymphoid cell aggregates, and is common in children. The aim of this study was to identify patients with NG from those in whom gastric biopsied specimens showed lymphoid follicles and lymphoid cell aggregates. Methods: Subjects, whose gastric biopsy specimens showed lymphoid follicles or lymphoid cell aggregates, were included in this study. The inclusion criterion was that they underwent a serum pepsinogen assay on the day of upper gastrointestinal endoscopy. NG was diagnosed if the endoscopy findings revealed regular-sized, multiple, colorless subepithelial nodules. Results : Among 108 subjects who showed lymphoid follicles or lymphoid cell aggregates, 13 (12.0%) revealed NG on endoscopy, and all these subjects showed positive Giemsa staining. Patients diagnosed with NG were younger (p=0.012) and showed a female predominance (p=0.001) compared to those without NG. The mean serum pepsinogen levels were higher (p=0.001) and lymphoid follicle-dominant subjects were more common (p＜0.001) in the NG subjects than in those without NG. Logistic regression analysis revealed a younger age (p=0.041) and female gender (p=0.002) to be significant independent risk factors for NG. Conclusions: NG should be distinguished from lymphofollicular gastritis because only 12% of patients showing gastric biopsy findings of lymphoid follicles and lymphoid cell aggregates demonstrated NG on endoscopy. NG is an endoscopic finding that is more common in women and in the younger population, irrespective of the biopsy findings and gastric secretory ability.

Objective Midazolam sedation during elective endoscopy is widely performed and flumazenil is frequently administered after endoscopy to reverse sedation in clinical practice. This study aimed to investigate the safety and efficacy of flumazenil injections after elective endoscopy under midazolam sedation. Methods Participants who underwent an upper endoscopy under midazolam sedation were randomly divided into two groups. In group I, flumazenil was administered i.v. 10 min after the patient's transfer to the recovery room, and no antidote was injected in group II. The time of stay in the recovery room and adverse events were reviewed through the nursing records. We asked the patients about their pain and degree of satisfaction according to a visual analogue scale (VAS), their memory of the procedure, mental status and the presence of uncomfortable symptoms on the day of the procedure and the day afterwards. Results The length of stay in recovery was significantly shorter in group I than in group II. No significant differences were found in the number of patients with pain (VAS ≥1), adverse events and discomfort between the two groups. Additionally, there were no differences in the patients' memory of the procedure, satisfaction with sedation, willingness to repeat the endoscopy and mental status. Conclusions The time in the recovery room after flumazenil administration was significantly shortened, and the use of the drug did not increase the risk of adverse events or discomfort. The use of flumazenil for reversing midazolam sedation seems to be safe and effective.

Endoscopic submucosal dissection (ESD) has become widely accepted method for treating early gastric cancer (EGC), but little is known about its role in patients with liver cirrhosis (LC). The aims of this study were to evaluate the outcomes of ESD in treating EGC in patients with LC. The multicenter retrospective study identified 43 patients with chronic hepatitis B (CHB)-related cirrhosis undergoing ESD for treating EGC. The patients (LC group) were subdivided into two groups based on their Child–Pugh classification (CP-class): 32 with CP-class A (LC-A) and 11 with CP-class B (LC-B). The patients were compared to 47 non-cirrhotic CHB patients who underwent ESD (CHB group). Eight patients had a past history of hepatocellular carcinoma (HCC) prior to ESD, but no patients had viable HCC when ESD was performed. Procedural outcomes (en bloc, lateral/basal margins resection) and post-procedural complications (bleeding or perforation) did not differ significantly between the LC and CHB groups or between the LC-A and LC-B groups. No patients experienced worsening of the Child–Pugh score 1 month after ESD compared with the baseline score. During a median observation period of 66 months, the recurrence rates of gastric cancers were similar between the LC and CHB groups (5-year recurrence rates: 2.4 vs. 2.3%, p = 0.925), and all recurrent gastric cancers were completely resected by additional ESD. The overall mortality rate was increased in the LC group (5-year mortality rates: 17.9 vs. 5.7%, p = 0.034), and 8 of 10 deaths were attributed to liver-related diseases (such as HCC, complications of portal hypertension, hepatic failure). ESD is feasible in patients with EGC and comorbid LC, even those with CP-class B cirrhosis. Their prognosis depends on LC-related diseases and not recurrent EGC.

Background/Aims Some people have difficulty tolerating upper endoscopy. The cause of and risk factors for this are not well known. The aim of this study was to investigate the factors involved in poor cooperation during screening upper endoscopy. Methods A total of 4,422 subjects who underwent a health inspection with upper endoscopy carried out by a single experienced endoscopist were included. We retrospectively investigated subjects’ self-reporting questionnaires and medical records, including endoscopic and histologic findings. The examinees’ cooperation and the completeness of endoscopic examination were evaluated based on the operator’s subjective judgment. Results Examinee cooperation during the endoscopic procedure was poor in 358 out of 4,422 subjects (8.1%). Of the subjects with poor cooperation, the endoscopic examination was incomplete in 36 subjects (10.1%). Multivariate analysis revealed that young age (< 40 years), female sex, high body mass index (≥ 25), hiatal hernia, and procedural sedation using midazolam were independent risk factors for poor cooperation. Conclusions Cooperation during screening upper endoscopy was poor in a considerable number of examinees. Endoscopists must keep in mind that examinee cooperation is more likely to be poor in the young, obese people, women, patients with hiatal hernias, and those who receive procedural sedation.

Background/Aims The presence of invasion is a diagnostic criterion of early gastric cancer (EGC) in Korea, whereas diagnosis in Japan is based on enlarged nuclei and prominent nucleoli. Moreover, the depth of invasion is the location of cancer cell infiltration in Korea, whereas it is the location of lymphovascular invasion (LVI) or cancer cell infiltration in Japan. We evaluated the characteristics of EGC with LVI to uncover the effects of different diagnostic criteria. Methods Consecutive T1-stage EGC patients who underwent complete resection were included after endoscopic or surgical resection. The presence of LVI was evaluated. Results LVI was present in 112 of 1,089 T1-stage EGC patients. LVI was associated with depth of invasion (p

Background/Aims: Despite improvements in surgical techniques and postopera tive patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. Methods: The medical records of 20 patients who underwent endoscopic retro grade cholangiopancreatography because of bile leakage after hepatobiliary sur gery from August 2009 to September 2014 were reviewed retrospectively. Endo scopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. Results: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liv er beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modal ities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincter -otomy. Conclusions: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Background/aims Peptic ulcer disease (PUD) is a common condition, but is difficult to detect in asymptomatic individuals. We aimed to investigate the prevalence of symptomatic and asymptomatic PUD during screening endoscopy and to identify risk factors for the presence of symptoms in patients with PUD. Methods We investigated subjects who underwent a health inspection, including endoscopy of the upper gastrointestinal (GI) tract and a serum anti-Helicobacter pylori IgG assay, and who completed a self-report questionnaire about their symptoms. Results Of the 12,852 subjects included in the study, 124 (1.0%) had symptomatic PUD and 309 (2.4%) had asymptomatic PUD. Old age, current smoking, and H. pylori infection were independent risk factors for symptomatic and asymptomatic PUD. Use of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent risk factor only for symptomatic PUD (p=0.040). Compared to subjects with asymptomatic PUD, subjects with symptomatic PUD were more likely to have active-stage ulcers (p=0.002) and to drink more heavily (p=0.005). Conclusions Use of NSAIDs is a risk factor for symptomatic PUD, but not for asymptomatic PUD. Excessive alcohol consumption and active-stage ulcers in patients with PUD are related to the presence of gastroduodenal symptoms.

Recent studies have shown that endoscopic sphincterotomy (EST) followed by large balloon dilation or large balloon dilation only for the removal of common bile duct (CBD) stones has good efficacy and acceptable adverse event rates. Theoretically, endoscopic papillary large-balloon dilation (EPLBD) without EST is easier to manipulate than the combined method and is also more suitable for patients with concomitant large stones and bleeding tendency. A retrospective cohort study that compared stone clearance between EPLBD without and with EST showed similar outcomes in overall successful stone removal (96.8% vs 95.7%; p = .738) and complete stone removal without endoscopic mechanical lithotripsy (80.6% vs 73.9%; p = .360). In a systematic review of 32 EPLBD studies, the initial success rate of EPLBD without EST was significantly lower than that of EPLBD with EST (76.2% vs 84.0%; p

We evaluated the value of fluorine-18 fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) as a complementary imaging modality to endoscopy to predict the curability of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). The institutional review board approved this retrospective study with a waiver of informed consent. The records of patients who underwent FDG PET/CT for initial routine staging of gastric cancer from January 2012 to October 2017 were reviewed retrospectively. Among them, the patients who had EGC with well or moderately differentiated adenocarcinoma were included in this study. A total of 210 EGCs in 199 patients (mean age ± SD, 67 ± 10 years) were selected for this study. For the analysis of FDG PET/CT image, the radiotracer uptake by the primary tumor was compared with the background gastric uptake. Each case was classified as curable by ESD (no discrete radioactivity) and not curable by ESD (discrete radioactivity). The detection rate of EGC by FDG PET/CT was 37.1% (78 discrete radioactivity in 210 EGCs). However, for the detection of EGC that is not curable by ESD, the sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve with 95% confidence intervals were 79% (67–87%), 91% (85–95%), 81% (71–88%), 89% (84–93%), and 0.85 (0.79–0.89), respectively. FDG PET/CT may be a useful complementary imaging modality to endoscopy to predict the curability of ESD for EGC.

Background and Aim: A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures. Methods: This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice. Results: Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032). Conclusions: The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.

In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. Recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.

Afferent loop syndrome is a rare complication of pancreaticoduodenectomy, and the endoscopic approach is difficult due to the surgically altered anatomy. Herein, we report a case of afferent loop obstruction treated by endoscopic metal stent insertion using two endoscopes. A 57-year-old male who had undergone the Whipple operation 7 months prior for pancreatic head cancer presented with abdominal pain and jaundice. Abdominal computed tomography showed afferent loop obstruction due to recurrent metastatic pancreatic cancer. First, we attempted to insert the stent using percutaneous transhepatic approaches following percutaneous transhepatic biliary drainage, but these failed. We therefore accessed the obstruction site using a relatively thin endoscope and then exchanged this endoscope for another with a large working channel, through which the self-expandable metal stent was passed. The stent was inserted successfully. This method will increase the success rate of endoscopic treatment. (Korean J Med 2015;89:428-432)

Background/Aims: In the ABC classification system, group A consists of seronegative subjects without gastric corpus atrophy. This study aimed to determine the prevalence and characteristics of pseudo group A subjects. Methods: Group A subjects were identified among consecutive Korean adults who underwent a serum anti-Helicobacter pylori immunoglobulin G (IgG) test and pepsinogen (PG) assay on the day of endoscopy. Past infection was defined as the presence of either eradication history or endoscopic findings suggesting past infection (i.e., gastric xanthoma, metaplastic gastritis, or advanced atrophy >closed-type 1). Results: Among 2,620 group A subjects, 448 (17.1%) had eradication history, and 133 (5.1%) showed endoscopic findings suggesting past infection. Older age (odds ratio [OR], 1.148; 95% confidence interval [CI], 1.067 to 1.236) and earlier year of birth (OR, 1.086; 95% CI, 1.009 to 1.168) were independent risk factors for classification into pseudo group A, with cutoff points at 50.5 years and birth year of 1959.5, respectively. Positive H. pylori test findings were found in 22 subjects (3.1%) among the 715 subjects who underwent the urea breath test or Giemsa staining on the same day. Current infection was positively correlated with PG I and PG II levels (p

Background Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker whose level is elevated in many types of cancers and other benign conditions. CA 19-9 levels are frequently found to be elevated in individuals during general health examinations. This study aimed to investigate the clinical characteristics of such individuals and to determine the need for medical follow-up. Methods We investigated individuals who underwent a health inspection, including a serum CA 19-9 test, at our center. Their CA 19-9 levels, age, sex, body mass index (BMI), and personal and past histories were investigated. Additionally, subgroup analyses were performed for those who underwent follow-up study for the elevated CA 19-9 levels. Results Of 58,498 subjects, 581 (1.0%) had elevated CA 19-9 levels. Multivariate analyses revealed that older age, female sex, lower BMI, and diabetes were independent predisposing factors for elevated CA 19-9 level. A subgroup analysis revealed that the causative conditions were identified in 129 of 351 subjects (36.8%). Among them, the causative conditions in 31 subjects (8.8%, including four cases of cancer and 15 of benign tumors) were not detected at the initial check-up and were found during the follow-up period. Conclusion The use of CA 19-9 as a marker for cancer in healthy individuals is inappropriate. However, medical follow-up in individuals with elevated CA 19-9 levels may be useful because some causative diseases may be detected during follow-up.

Background and study aims The present study aimed to determine the type of intravenous hydration that is best suited to reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Patients and methods In a prospective randomized multicenter trial, average-to-high risk patients who underwent first-time ERCP were randomly assigned to three groups (1:1:1) who received: aggressive intravenous hydration (3 mL/kg/h during ERCP, a 20-mL/kg bolus and 3 mL/kg/h for 8 hours after ERCP) with either lactated Ringer’s solution (LRS) or normal saline solution (NSS), or standard intravenous hydration with LRS (1.5 mL/kg/h during and for 8 hours after ERCP). The primary end point was post-ERCP pancreatitis (PEP). Results 395 patients were enrolled, and 385 completed the protocols. The three groups showed no significant differences in demographic characteristics. There was a significant difference in the intention-to-treat (ITT) PEP rate between the aggressive LRS group (3.0 %, 95 % confidence interval [CI] 0.1 % – 5.9 %; 4 /132), the aggressive NSS group (6.7 %, 95 %CI 2.5 % – 10.9 %; 9 /134) and the standard LRS group (11.6 %, 95 %CI 6.1 % – 17.2 %; 15 /129; P = 0.03). In the two-group comparisons, the ITT PEP rate was significantly lower for the aggressive LRS group than for the standard LRS group (relative risk [RR] 0.26, 95 %CI 0.08 – 0.76; P = 0.008). There was no significant difference in the ITT PEP rate between the aggressive NSS group and the standard LRS group (RR 0.57, 95 %CI 0.26 – 1.27; P = 0.17). Conclusion Aggressive hydration with LRS is the best approach to intravenous hydration for the prevention of PEP in average-to-high risk patients.

Background/aims The serum anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG) and serum pepsinogen (PG) assays are widely used to screen for gastric cancer. An equivocal serology test finding indicates IgG titer between the positive and negative test findings. This study aims to evaluate the long-term follow-up result after an equivocal test finding on the serum anti-H. pylori IgG assay. Methods Koreans aged 18 years or older with an equivocal serum anti-H. pylori IgG assay finding were included. Subjects were excluded if they did not undergo H. pylori serology test, serum PG assay, and upper gastrointestinal (UGI) endoscopy on the same day at our center. The annual test findings were followed-up using the same methods. Results Of the 7,178 subjects who underwent the serum assays and UGI endoscopy on the same day, 274 (3.8%) subjects showed an equivocal H. pylori serology test finding. Of the 98 subjects who were followed-up, 58 (59.2%) showed seropositive finding at the mean follow-up period of 30.6±12.4 months. Subjects with seroconversion showed a higher initial serum PG I (p=0.023) and PG II (p=0.036) levels than those without seroconversion. Conclusions An equivocal H. pylori serology test finding was not rare (3.8%) in Korean adults, and 60% of equivocal subjects showed seroconversion within 3 years. Higher seroconversion rates in subjects with high PG I and PG II levels suggest that intact gastric secreting ability plays a role in the survival of H. pylori. Therefore, equivocal subjects with increased serum PG levels should be considered as potential seropositive subjects.

Objective Endoscopic submucosal dissection (ESD) is commonly performed as a treatment for gastric neoplasms. However, sedation with midazolam (MDZ) often does not reach satisfactory sedation levels during the procedure and the drug may suppress respiration and blood pressure. This study aimed to investigate the safety and efficacy of dexmedetomidine (DEX) with on-demand MDZ (the DEX group) in comparison with MDZ alone (the MDZ group) as a sedative during ESD of gastric neoplasms. Methods Eighty patients undergoing ESD for gastric tumor were randomly assigned to one of two treatment regimens (40 patients in each). We investigated the depth of sedation by using a Modified Observers Assessment Alertness/Sedation score, the number of patients' reactions interfering with the procedure, sedation related-adverse events and the degree of satisfaction of patients and doctors. Results There was no statistically significant difference between the two groups regarding their age, gender, body mass index, American Society of Anesthesiologists physical status classification and the characteristics of the tumor. Appropriate sedation rate and the degree of satisfaction of the doctors were significantly higher in the DEX group than in the MDZ group. Patients' reactions interfering with the procedure were more numerous in the MDZ group than in the DEX group. There was no significant difference in adverse events between the two groups. Conclusions DEX with on-demand MDZ for sedation during gastric ESD is as safe as MDZ alone and the sedation effect of DEX with MDZ is superior to that of MDZ alone.

Background and Aims Endoscopic submucosal dissection (ESD) is now commonly performed as a treatment for colorectal tumors. However, little is known about the relationship between submucosal fibrosis and the outcome of the colonic ESD procedure. The aims of this study were to investigate the relationship between the degree of submucosal fibrosis in colorectal tumors and the outcomes of ESD for these tumors and to evaluate the risk factors for submucosal fibrosis. Methods We retrospectively reviewed the records of patients with colorectal adenoma or carcinoma who had undergone an ESD, during a four-year period from January 2010 to December 2013. The resected specimens were histologically examined after Masson's trichrome staining, and the severity of the submucosal fibrosis was classified as no fibrosis (F0), mild fibrosis (F1), or severe fibrosis (F2). Results Among a total of 173 cases (106 male, mean age 65.0 ± 10.2 years; F0 33, F1 78, F2 62) enrolled, 46 incidences of complications (perforation 19, post-coagulation syndrome 21, bleeding 6) had developed. Multivariate analysis revealed that F2 fibrosis was significantly associated with the development of complications. Submucosal invasion and large tumor size (≥ 30 mm) were identified as independent predictors of F2 fibrosis. Conclusion Severe fibrosis is the most powerful risk factor for complications and can interfere with en bloc resections. The possibility of submucosal fibrosis should be considered, and the procedure should be cautiously performed in cases where the tumor diameter is greater than 30 mm and when submucosal cancer is suspected.

Mallory-Weiss tears (MWTs) are mucosal lacerations caused by forceful retching and are typically located at the gastroesophageal junction. Reported cases of MWT with serious complications seen in esophagogastroduodenoscopy are limited. We report MWT in an 81-year-old woman who presented with gastric perforation by esophagogastroduodenoscopy. We discuss and indicate that hiatal hernia, atrophic gastritis and old age may be associated with the gastric perforation in comparison to typical tears occurring at the gastroesophageal junction.

Background/Aims Epidemiological data indicate that emotional stress and depression might influence the development of gastrointestianl disorders and cancers, but the relationship between the two is still unclear. The aim was to investigate the effect of stress/depression on the prevalence of digestive diseases. In addition, we tried to identify whether stress and depression are risk factors for these diseases. Methods A total of 23 698 subjects who underwent a medical check-up including upper and lower endoscopy were enrolled. By review -ing the subject’s self-reporting questionnaire and endoscopic findings, we investigated the digestive diseases, including functional dyspepsia (FD), irritable bowel syndrome (IBS), reflux esophagitis, peptic ulcer disease, and adenoma and carcinoma of the stomach and colon. Stress and depression scores were measured by the Brief Encounter Psychosocial Instrument and Beck’s Depression Inventory, respectively (Korean version). Results Stress and depression were related to FD, IBS, and reflux esophagitis. Depression was also linked to peptic ulcer disease and adenoma/carcinoma of the colon and stomach. Multivariate analysis revealed that stress and depression were independent risk factors for FD (OR, 1.713 and 1.984; P < 0.001) and IBS (OR, 1.730 and 3.508; P < 0.001). In addition, depression was an independent risk factor for gastric adenoma/carcinoma (OR, 4.543; P < 0.001). Conclusions Stress and depression are related to various digestive diseases, and they may be predisposing factors for FD and IBS. Depression may also be a cause of gastric cancer. Psychological evaluation of gastroenterology patients may be necessary, but more study is needed.

There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD. There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS. There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (−) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics. The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

BACKGROUND Many patients report discomfort because of the unpleasant taste of bowel preparation solutions. OBJECTIVE This study aimed to determine whether adding orange juice to 2 L of polyethylene glycol plus ascorbic acid is effective for reducing patient discomfort and improving palatability during bowel preparation. DESIGN This was a single-blinded, randomized controlled trial. SETTINGS The study was conducted at a tertiary referral hospital and a generalized hospital. PATIENTS Consecutive outpatients and inpatients were randomly allocated to drink 2 L of polyethylene glycol-ascorbic acid or 2 L of polyethylene glycol-ascorbic acid with orange juice in a single dose or a split dose. MAIN OUTCOME MEASURES Tolerability, palatability score, willingness, and related adverse events were investigated by questionnaires. Bowel cleansing was rated using the Aronchick scale. Each score was graded on a 5-point scale. RESULTS A total of 107 patients, 53 in the orange juice group and 54 in the polyethylene glycol-ascorbic acid group who underwent elective colonoscopy were enrolled. The palatability score (mean ± SD) was higher in the orange juice group than in the control group (2.36 ± 0.76 vs 1.78 ± 0.88; p = 0.005). Nausea was less frequent in the orange juice group (26.4% vs 59.3%; p = 0.001). Total amount of bowel preparation ingested was not significantly different between the groups (p = 0.44). The bowel preparation score (mean ± SD) was not significantly different (1.49 ± 0.80 vs 1.43 ± 0.77; p = 0.94). Willingness to repeat the same process was higher in the orange juice group (90.4% vs 66.7%; p = 0.003). LIMITATIONS This study is limited because only ambulatory patients were enrolled. CONCLUSIONS Orange juice intake before drinking 2 L of polyethylene glycol-ascorbic acid for colonoscopy can reduce patient discomfort, resulting in improved acceptability and patient compliance. This method is as effective for bowel cleansing as polyethylene glycol.

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P

Midazolam sedation during elective endoscopy is widely performed and flumazenil is frequently administered after endoscopy to reverse sedation in clinical practice. This study aimed to investigate the safety and efficacy of flumazenil injections after elective endoscopy under midazolam sedation.Participants who underwent an upper endoscopy under midazolam sedation were randomly divided into two groups. In group I, flumazenil was administered i.v. 10 min after the patient's transfer to the recovery room, and no antidote was injected in group II. The time of stay in the recovery room and adverse events were reviewed through the nursing records. We asked the patients about their pain and degree of satisfaction according to a visual analogue scale (VAS), their memory of the procedure, mental status and the presence of uncomfortable symptoms on the day of the procedure and the day afterwards.The length of stay in recovery was significantly shorter in group I than in group II. No significant differences were found in the number of patients with pain (VAS ≥1), adverse events and discomfort between the two groups. Additionally, there were no differences in the patients' memory of the procedure, satisfaction with sedation, willingness to repeat the endoscopy and mental status.The time in the recovery room after flumazenil administration was significantly shortened, and the use of the drug did not increase the risk of adverse events or discomfort. The use of flumazenil for reversing midazolam sedation seems to be safe and effective.

Background The correlation between allergic disease and Helicobacter pylori infection is still controversial in endemic areas. The aim of this study was to determine whether H. pylori infection is related to allergic disease and/or immunoglobulin E (IgE) hypersensitivity in Korean adults. Materials and Methods Consecutive Korean adults who visited our center for a routine checkup were enrolled. All subjects completed a questionnaire that was designed to ascertain their medical history pertaining to physician-diagnosed allergic disease, allergy treatments, and H. pylori eradication therapy. Blood was sampled for serum anti-H. pylori IgG antibody. IgE hypersensitivity was measured using a commercially available ImmunoCAP® Phadiatop (Phadia AB, Uppsala, Sweden). Results Of the 3376 Korean adults who were enrolled, 62 did not answer to the questionnaires adequately and were thus excluded. The proportion of noninfected subjects (p

Background/Aims: Patients with cholangiocarcinoma usually present at an advanced stage, and more than 50% of cases are not resectable at the time of diagnosis. Recently, photodynamic therapy (PDT) has been proposed as a palliative and neoadjuvant modality. We evaluated whether combination of PDT and chemotherapy is more effective than PDT alone. Methods: In total, 161 patients with cholangiocarcinoma diagnosed between February 1999 and September 2009 were evaluated. Sixteen patients were treated with PDT and chemotherapy (group A), and 58 were treated with PDT (group B). Results: The median survival was 538 days (95% confidence interval [CI], 475.3 to 600.7) in group A and 334 days (95% CI, 252.5 to 415.5) in group B (p=0.05). Lymph node metastasis status, serum bilirubin of pretreatment, tumor node metastasis stage, treatment method (PDT with chemotherapy vs PDT alone), time to PDT and the number of PDT sessions were prognostic factors with statistical significance in the univariate analysis. A multivariate analysis showed that PDT with chemo therapy and more than two sessions of PDT were significant independent predictors of longer survival in advanced cholangiocarcinoma (hazard ratio [HR], 2.23; 95% CI, 1.18 to 4.20; p=0.013 vs HR, 1.79; 95% CI, 1.044 to 3.083; p=0.034). Conclusions: PDT with chemotherapy results in longer survival than PDT alone. (Gut Liver 2014;8:318-323)

Background/Aims A link between G protein β3 (GNB3) polymorphism and functional dyspepsia (FD) has been suggested. The aim of this study was to determine the role of GNB3 polymorphism in the long-term prognosis of FD in Koreans. Methods FD patients and normal healthy controls were recruited from patients who visited our center between December 2006 and June 2007. All of the subjects completed Rome III questionnaires before undergoing upper gastrointestinal endoscopy and colonoscopy. Genomic DNA was extracted for GNB3 genotyping. After 5 years, the subjects were reevaluated using the same questionnaires. Results GNB3 825T carrier status was significantly related to FD in Koreans (p=0.04). After 5 years, 61.0% of the initial FD patients and 12.2% of the initial normal subjects were diagnosed with FD (odds ratio [OR], 11.7; 95% confidence interval [CI], 4.3 to 31.1; p

Objective To determine whether the combination test of serum pepsinogen (PG) levels and Helicobacter pylori (H. pylori) antibody was effective for predicting the incidence and histology of gastric neoplasms. Methods This study included asymptomatic Korean adults who underwent esophagogastroduodenoscopy with blood tests for PG levels and H. pylori immunoglobulin G antibody test on the same day. Participants with extragastric malignancy, history of H. pylori eradication or gastric neoplasms, or recent antacid medication were excluded. Gastric atrophy was defined as a serum PG I/II ratio ≤3.0 and PG I ≤70 ng/mL. The participants were classified into four groups according to the presence (+) or absence (−) of gastric atrophy and H. pylori infection. Results Of the 3328 included participants, 17 were incidentally diagnosed as having either gastric adenoma or carcinoma. The incidence of gastric neoplasm was highest in the gastric atrophy (+)/H. pylori (−) group (4.17%; OR 25.8, P = 0.009), but the neoplasm exhibited the least advanced histology. The gastric atrophy (−)/H. pylori (−) group exhibited the lowest incidence of gastric neoplasm (0.17%) but the most advanced histology. Conclusion A combination of serum PG levels and H. pylori antibody test is useful for detecting gastric neoplasms based on the slow gastric carcinogenesis pathway progressing from gastric adenoma to Lauren's intestinal-type gastric cancer, but not for those with advanced histology such as Lauren's diffuse-type gastric cancer.