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Financing and provision of long-term care is an increasingly important concern for many middle-income countries experiencing rapid population aging. We examine three countries (South Korea, Japan, and Germany) that use social insurance to finance medical care and have developed long-term care insurance (LTCI) systems. These countries have adopted different approaches to LTCI design within the social insurance framework. We contrast their financing systems and draw lessons regarding revenue generation, benefits design, and eligibility. Based on this review, it seems important for middle-income countries to start developing LTCI schemes early, before aging becomes a significant problem and substantial revenues are needed. Early financing also ensures that the service delivery system has time to adapt because most middle-income countries lack the infrastructure for providing long-term care services. One approach is to start with a limited benefit package and strict eligibility rules and expanded the program as the country develops sufficient experience and more providers became available. All three countries use some form of cost-sharing to discourage service overuse, combined with subsidies for poor populations to maintain appropriate access. A major policy choice is between cash benefits or direct provision of services and the approach will have a large impact on the workforce participation of women.

Background and Aim Considering the significant racial and ethnic diversity in genetic variation, it is unclear whether the genome-wide association studies-identified colorectal cancer (CRC)-susceptibility single-nucleotide polymorphisms (SNPs) discovered in European populations are also relevant to the Korean population. However, studies on CRC-susceptibility SNPs in Koreans are limited. Methods To investigate the racial and ethnic diversity of CRC-susceptibility genetic variants, we genotyped for the established European CRC-susceptibility SNPs in 198 CRC cases and 329 controls in Korea. To identify novel genetic variants using genome-wide screening in Korea, Illumina HumanHap 370K/610K BeadChips were performed on 105 CRC patients, and candidate CRC-susceptibility SNPs were selected. Subsequently, genotyping for replication was done in 189 CRC cases and 190 controls. Results Among the European CRC-susceptibility SNPs, rs4939827 in SMAD7 was associated with a significant decreased risk of Korean CRC (age-/gender-adjusted odds ratio [95% confidence interval]: additive model, 0.67 [95% CI, 0.47–0.95]; dominant model, 0.59 [95% CI, 0.39–0.91]). rs4779584 and rs10795668 were associated with CRC risk in females and males, respectively. Among candidate CRC-susceptibility SNPs selected from genome-wide screening, novel SNP, rs17051076, was found to be associated with a significantly increased risk of microsatellite instability-high CRC (age-/gender-adjusted odds ratio [95% confidence interval]: additive model, 4.25 [95% CI, 1.51–11.98]; dominant model, 3.52 [95% CI, 1.13–10.94]) in the replication study. Conclusions rs4939827, rs4779584, and rs10795668 may contribute to the risk of CRC in the Korean population as well as in European populations. Novel rs17051076 could be associated with microsatellite instability-high CRC in Koreans. These associations support the ethnic diversity of CRC-susceptibility SNPs and should be taken into account in large-scale studies.

†Background/Aims: Second-look endoscopy is performed to check for the possibility of post-endoscopic submucosal dissection (ESD) bleeding and to perform prophylactic hemostasis in most hospitals; however, there is little evidence about the efficacy of second-look endoscopy. We investigated whether second-look endoscopy after ESD is useful in the prevention of post-ESD bleeding. Methods: A total of 550 lesions with gastric epithelial neoplasms in 502 patients (372 men and 130 women) were treated with ESD between August 18, 2009 and August 18, 2010. After the exclusion of three lesions of post-ESD bleeding within 24 hours, 547 lesions (335 early gastric cancers and 212 gastric adenomas) were included for the final analysis. Results: The occurrence rate of delayed post-ESD bleeding was not significantly different between the second-look group and the no second-look group (1% vs 2.5%, p>0.05). The only predictor of delayed bleeding was tumor size, regardless of second-look endoscopy after ESD (22.8±9.87 vs 15.1±10.47, p

Background: The incidence of urinary tract calculi is thought to be higher in patients with inflammatory bowel disease (IBD) than that in the general population. However, few data are available about urolithiasis in patients with Crohn's disease (CD). We investigated the incidence of urolithiasis and the risk factors for urolithiasis in patients with CD. Methods: We examined the records of 387 patients with CD followed at Samsung Medical Center from July 2011 to June 2013. Evidence for the presence of calculi was obtained from radiologic findings (plain films, ultrasonography, or computed tomography), urinary colic symptoms, or a treatment history of urolithiasis after diagnosis of CD. Demographic variables, phenotype, concurrent medications, and previous CD-related surgery were analyzed. Results: Urinary tract calculi were found in 18 (4.7%) patients, which developed after the CD diagnosis. The incidence of urolithiasis in CD was 706 per 100,000 patient-years. Cox models with a time-dependent covariate showed that azathioprine (AZA)/6-mercaptopurine (6-MP) treatment (hazard ratio = 0.963; 95% CI: 0.931, 0.996; p = 0.030) was negatively associated with urolithiasis. Conclusions: The annual incidence rate of urolithiasis in patients with CD was 0.7%. AZA/6-MP therapy was associated with a low risk of urolithiasis in these patients.

BACKGROUND/AIMS CpG island methylator phenotype (CIMP)- high colorectal cancers (CRCs) have distinct clinicopathologi-cal features from their CIMP-low/negative CRC counterparts. However, controversy exists regarding the prognosis of CRC according to the CIMP status. Therefore, this study examined the prognosis of Korean patients with colon cancer according to the CIMP status. METHODS Among a previous cohort pop-ulation with CRC, a total of 154 patients with colon cancer who had available tissue for DNA extraction were included in the study. CIMP-high was defined as ≥3/5 methylated mark-ers using the five-marker panel (CACNA1G, IGF2, NEUROG1, RUNX3, and SOCS1). RESULTS CIMP-high and CIMP-low/neg-ative cancers were observed in 27 patients (17.5%) and 127 patients (82.5%), respectively. Multivariate analysis adjust-ing for age, gender, tumor location, tumor stage and CIMP and microsatellite instability (MSI) statuses indicated that CIMP-high colon cancers were associated with a significant increase in colon cancer-specific mortality (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.20 to 8.69; p=0.02). In microsatellite stable cancers, CIMP-high cancer had a poor survival outcome compared to CIMP-low/negative cancer (HR, 2.91; 95% CI, 1.02 to 8.27; p=0.04). CONCLUSIONS Re-gardless of the MSI status, CIMP-high cancers had poor sur-vival outcomes in Korean patients. (Gut Liver, 2015;9202-207).

Long-term clinical outcomes after endoscopic submucosal dissection (ESD) is unclear for differentiated-type-predominant early gastric cancer (EGC) mixed with undifferentiated component (MUC-EGC). Therefore, the role and appropriate indication of ESD for MUC-EGC remain to be evaluated.Between 2007 and 2011, 1,577 differentiated-type EGC lesions [1,408 pure differentiated-type (PuD)-EGCs and 169 MUC-EGCs] in 1,527 consecutive patients were treated by ESD. After ESD, MUC-EGC was managed in the same way as PuD-EGC. The clinicopathological features and long-term outcomes after ESD of MUC-EGC were compared with those of PuD-EGC.En bloc resection and en bloc with R0 resection rates in MUC-EGC cases were 94.1 % and 81.7 %, respectively. MUC-EGC was significantly associated with larger tumor size, more frequent submucosal invasion, and lymphovascular invasion compared to PuD-EGC. Despite these aggressive features of MUC-EGC, no lymph node metastasis or extragastric recurrence occurred during follow-up after ESD if MUC-EGC met the curative endoscopic resection (ER) criteria for tumors of absolute or expanded indications. Four MUC-EGC cases meeting the curative ER criteria underwent additional radical gastrectomy after ESD, and no case showed lymph node metastasis. During a median 48 months of follow-up, overall survival rates for MUC-EGC meeting the curative ER criteria for tumors of absolute or expanded indications (3-year survival rates, 100 % and 100 %) were comparable to those of PuD-EGC.Long-term outcomes after ESD were favorable for MUC-EGCs meeting the curative ER criteria for tumors of absolute or expanded indications. Therefore, ESD may be used as a promising treatment option for these cases.

We present 19 cases in which argon plasma coagulation (APC) was used as curative initial treatment for 5 low-grade esophageal squamous intraepithelial neoplasias (ESINs), 12 high-grade ESINs, and 2 early esophageal squamous cell carcinomas (ESCCs). Complete response was defined as the absence of tumor from any biopsy taken from the ablated lesion. At follow-up endoscopy 2 - 4 months after APC, 94.7 % of patients had achieved complete response in a single treatment session. Only one patient with high-grade ESIN showed local recurrence. This patient underwent additional APC and showed complete response at 12 months after initial APC. At the 12-month follow-up endoscopy, again 94.7 % had a complete response. The exception was one patient with local recurrence, who underwent additional APC. After the 12-month follow-up endoscopy, no patient showed local recurrence during a median follow-up of 22 months. No stricture requiring endoscopic dilation occurred after the procedure. This study suggests that APC is a feasible and effective treatment modality for ESIN and early ESCC.

Summary Background Despite a growing understanding of the clinical effectiveness of endoscopic treatment for small rectal carcinoid tumors, there is still controversy concerning the best endoscopic treatment for resecting rectal carcinoid tumors easily and effectively. Objectives The objective of the present study was to compare the therapeutic efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) with endoscopic submucosal dissection (ESD) for rectal carcinoid tumors. In addition, a conventional snare-based endoscopic mucosal resection (EMR) was included in the study and compared with both ESMR-L and ESD. Methods A retrospective analysis was performed in 115 patients who underwent endoscopic resection of a rectal carcinoid tumor between January 2005 and June 2011. These patients were classified into three groups according to the type of endoscopic procedure: EMR group ( n = 33), ESMR-L group ( n = 40) and ESD group ( n = 44). Results The complete resection rate of the EMR group was significantly lower than those of the ESMR-L and ESD groups (77.4 vs. 100 and 97.7%, P = 0.002 and P = 0.007). Tumor-free vertical margins were significantly greater in the ESMR-L and ESD groups than in the EMR group (ESMR-L and ESD vs. EMR group, P = 0.013 and P = 0.041). The curative resection rate of rectal carcinoid tumors in the EMR group was 77.4%, which was significantly lower than that of the ESMR-L (95%, 38/40) and EDS groups (97.7%, 43/44) (77.4% vs. 95%, P = 0.036 and 77.4% vs. 97.7%, P = 0.007). Conclusions Our results show that ESMR-L and ESD might be superior to conventional EMR for the treatment of small rectal carcinoid tumors.

Background/Aims Plasminogen activator inhibitor-1 (PAI-1) is important for tumor growth, Invasion, and metastasis. In this study, we investigated the relationship between plasma levels of PAI-1 and colorectal adenomas. Methods We reviewed the medical records of 3,136 subjects who underwent colonoscopy as a screening exam. The subjects were classified into a case group with adenomas (n=990) and a control group (n=2,146). Plasma PAI-1 levels were categorized into three groups based on tertile. Results The plasma levels of PAI-1 were significantly higher in adenoma cases than in controls (p=0.023). The prevalence of colorectal adenomas increased significantly with increasing levels of PAI-1 (p=0.038). In the adenoma group, advanced pathologic features, size, and number of adenomas did not differ among the three groups based on tertiles for plasma PAI-1 levels. Using multivariate analysis, we found that plasma level of PAI-1 was not associated with the risk of colorectal adenomas (p=0.675). Adjusted odds ratios for colorectal adenomas according to increasing plasma levels of PAI-1 were 0.980 (95% confidence interval [CI], 0.768 to 1.251) for the second-highest plasma level and 1.091 (95% CI, 0.898 to 1.326) for the highest level, compared with the lowest levels. Conclusions These results suggest that elevated plasma PAI-1 levels are not associated with the risk of colorectal neoplasms.

Lymph node (LN) metastasis is one of the most important risk factors for the prognosis of pancreatic cancer. This study aimed to identify novel LN metastasis-associated markers and therapeutic targets for pancreatic and gallbladder cancers. DNA microarray analysis was carried out to identify genes differentially expressed between 17 pancreatic cancer tissues with LN metastasis and 17 pancreatic cancer tissues without LN metastasis. The expression of LZIC, FXR, SCAMP1, and SULT1E1 is significantly higher in pancreatic cancer tissues with LN metastasis than in pancreatic cancer tissues without LN metastasis. We recently reported that FXR plays an important role in LN metastasis of pancreatic cancer, and in this study, we selected the secretory carrier membrane protein 1 (SCAMP1) gene. To determine that function of the SCAMP1 gene, we examined the effects of SCAMP1 knockdown on pancreatic and gallbladder cancer proliferation, migration, and invasion using SCAMP1 small interfering RNA (siRNA) and the activity of vascular endothelial growth factor (VEGF) was measured by enzyme-linked immunosorbent assay. SCAMP1 overexpression is associated with LN metastasis in pancreatic cancer patients. The siRNA-mediated downregulation of SCAMP1 resulted in a marked reduction in cell migration and invasion, but not proliferation in MIA-PaCa2, PANC-1, TGBC-1, and TGBC-2 cells. In addition, downregulation of SCAMP1 inhibited VEGF levels of conditioned medium from SCAMP1 siRNA-transfected cells. These results suggest that downregulation of SCAMP1 could be a potential therapeutic target for patients with pancreatic and gallbladder cancer.

There is suggestive but sparse evidence that dyslipidemia is associated with colorectal neoplasms. We investigated the association of serum lipid and apolipoprotein concentrations with the prevalence of colorectal adenomas.Cross-sectional study of 19,281 consecutive participants aged 40-79 years undergoing screening colonoscopy at the Center for Health Promotion of the Samsung Medical Center in Korea from January 2006 to June 2009.We identified 5,958 participants with colorectal adenomas (30.9%), including 5,504 (28.5%) with non-advanced adenomas and 454 (2.4%) with advanced adenomas. The adjusted relative prevalence ratios (aRPRs) comparing the fourth with the first quartiles of serum triglycerides were 1.35 (95% confidence interval (CI) 1.20-1.52; P trend0.001) for non-advanced adenomas and 1.45 (95% CI 1.02-2.06; P trend=0.005) for advanced adenomas. Higher levels of high-density lipoprotein (HDL) cholesterol and apolipoprotein A-1 (ApoA-1) were significantly associated with 12% (Q4 vs. Q1 aRPR 1.12; 95% CI 1.00-1.26; P trend=0.049) and 17% (Q4 vs. Q1 aRPR 1.17; 95% CI 1.04-1.31; P trend=0.004) higher prevalence of non-advanced adenoma. There was also a non-significant association between higher levels of low-density lipoprotein (LDL) cholesterol (Q4 vs. Q1 aRPR 1.22; 95% CI 0.91-1.66; P trend= 0.12) and apolipoprotein B (ApoB) (Q4 vs. Q1 aRPR 1.32; 95% CI 0.94-1.83; P trend=0.07) with higher prevalence of advanced adenoma. There was no association between total cholesterol levels with colorectal adenoma.In this large cross-sectional study, higher levels of serum triglycerides were significantly associated with an increasing prevalence of both non-advanced and advanced colorectal adenomas, while higher levels of ApoA-1 and HDL cholesterol were significantly associated with an increasing prevalence of non-advanced adenomas.

Background and Aim It is unclear which mechanisms play a predominant role in the pathogenesis of esophageal non-cardiac chest pain (NCCP). We aimed to examine the features of esophageal proper muscle and esophageal contractility using a high-frequency intraluminal ultrasound (HFIUS) in patients with NCCP. Methods A total of 68 patients with NCCP were classified into two groups according to the results of typical reflux symptoms and/or esophagogastroduodenoscopy and/or 24-h esophageal pH monitoring: gastroesophageal reflux disease (GERD)-positive NCCP (n = 34) and GERD-negative NCCP groups (n = 34). Additionally 16 asymptomatic healthy subjects were included as controls. Using HFIUS, we analyzed the esophageal proper muscle thickness and cross-sectional area (CSA) at 3 cm above lower esophageal sphincter (LES) and 9 cm above LES during baseline rest and peak contraction periods among the control, GERD-positive NCCP and GERD-negative NCCP groups, and examined the completeness of three phases of esophageal action during five wet swallows in the three groups. Results The muscle thickness and CSA tended to be larger in GERD-negative NCCP than in GERD-positive NCCP and in control groups at esophageal body during both periods. All of the controls and patients with GERD-positive NCCP presented the complete peristaltic type. Whereas, 11 of 34 patients with GERD-negative NCCP presented the incomplete peristaltic type. Conclusions Using HFIUS, patients with GERD-negative NCCP had increased muscle thickness and CSA. Some GERD-negative NCCP had the incomplete peristaltic type.

Background/Aims: Limited data exist regarding the natural history of duodenal carcinoid tumors and the efficacy of endoscopic treatment. Methods: A total of 27 patients with duodenal carcinoid tumors were enrolled. All tumors were located outside the periampullary region and were ≤10 mm in size. 11 patients underwent endoscopic mucosal resection (EMR) and argon plasma coagulation (APC). 13 patients did not undergo any specific procedure for tumor removal and were followed clinically. Results: Of 13 patients not undergoing treatment, tumors disappeared in 5 cases during follow-up with diagnostic forceps biopsy. Endoscopically visible lesions remained in the last follow-up endoscopy in 8 patients (61.5%). No lymph node or distant metastases or tumor-related deaths occurred during a median follow-up of 37 months. Of 11 cases treated with EMR, tumor-free resection margins were achieved in 10 cases and no local recurrence occurred after treatment. Two perforations occurred during EMR. Of the 3 cases treated with APC, local recurrence occurred in 1 case. Conclusions: Given the risks associated with EMR and the likely favorable natural history of small duodenal carcinoid tumors, conservative management with close follow-up may represent a viable alternative to endoscopic treatment, especially in patients with a high risk of perioperative complications.

Summary Background/Aims Proximal serrated polyp (SP) is one of potential explanations for the failure of colonoscopy to prevent all interval cancers. The aims of our study were to determine the prevalence of proximal SP in Korea and to investigate clinical factors associated with the proximal SP detection in average-risk people undergoing screening colonoscopy. Methods We re-analyzed the data of the previous prospective study which included asymptomatic, average-risk people over 45 years of age who underwent screening colonoscopy from four tertiary medical centers in South Korea between December 2007 and November 2008 to compare guaiac-based and quantitative immunochemical fecal occult blood tests. SPs included hyperplastic polyps, sessile serrated adenomas, and traditional serrated adenomas. Results A total of 926 subjects were analyzed. Of these, 454 subjects (49.0%) and 356 (38.4%) had a total of 859 polyps and 709 adenomas, respectively. One hundred and ten subjects (11.9%) had a total of 150 SPs and 49 (5.3%) had a total of 60 proximal SPs. In comparison between subjects with and without proximal SP, there were no differences with respect to procedure-related variables including endoscopic training, day of week, time of day, and elapsed time as well as demographic features such as age and sex. Conclusions In average-risk people underwent screening colonoscopy, the prevalence of proximal SP was 5.3% in Korea. There were no significant clinical factors associated with the proximal SP detection.

Extremely well-differentiated tubular adenocar- cinomas (EWDAs) of the stomach are character- ized by surface maturation and their mimicking of intestinal metaplasia. Endoscopically, intramu- cosal EWDAs are frequently ill defined with indis- tinct borders due to the pallor of the neoplastic mucosa and the lack of contrast against the back- ground atrophic and metaplastic mucosa. We evaluated the effectiveness of endoscopic resec- tion for EWDAs after endoscopic submucosal dis- section (ESD). Among 872 patients with early gastric cancer, 17 EWDAs were identified (1.9%). Endoscopically, the flat or depressed type was significantly more common among EWDAs (88.2%) than among early gastric cancers of other histologies (37.8%; P

Summary The aim of this study was to determine the correlation between microsatellite instability (MSI) and young age in patients with advanced colorectal adenomas. We retrospectively analyzed young patients (≤ 40 years of age) with advanced adenomas (n = 84) between January 1996 and December 2006. We randomly selected the control group as patients ≥ 50 years of age with advanced adenomas (n = 84) during the same time period. Of these patients, the MSI test and MLH1 immunohistochemistry were performed in the available tissue samples from patients with advanced adenomas. The number of patients who had the two tests was 52 in the young group and 49 in the old group. The monomorphic nature of the BAT26 panel for MSI analysis was used without comparison of normal tissue. MSI was detected in three young patients (n = 52) and none of the old patients (n = 49). There was no statistical difference between the two groups (P = 0.243). All three young patients with MSI had a strong family history of colorectal cancer. MSI analysis was not a useful method of screening for HNPCC in young patients with advanced colorectal adenoma, at least in cases without a family history of colorectal cancer.

Patients with gallbladder cancer usually have a poor prognosis, and effective standard chemotherapeutic regimens have not been established. The anticancer activities of guggulsterone have been demonstrated in various cancer cells. The aims of the study were to determine the effect of guggulsterone on gallbladder cancer cells and to investigate whether treatment with guggulsterone influences the antitumor activities of gemcitabine. The Dojindo Cell Counting Kit-8 assay was used to determine the inhibition of proliferation by drugs in TGBC1 and TGBC2 cells. Cell migration and invasion were examined using 24-well inserts and Matrigel™-coated invasion chambers. The activities of NF-κB p65, VEGF-C, and MMP-2 were measured by ELISA. Guggulsterone inhibited the proliferation and suppressed migration and invasion of gallbladder cancer cells in a dose-dependent manner. Guggulsterone significantly decreased NF-κB p65, VEGF-C, and MMP-2 activities in the gallbladder cancer cells examined. Gallbladder cancer cells treated with a combination of guggulsterone and gemcitabine demonstrated significant inhibition of cell proliferation and invasion when compared to treatment with gemcitabine alone. In addition, NF-κB p65 activation decreased significantly in cells treated with a combination of guggulsterone and gemcitabine when compared to treatment with gemcitabine alone. Guggulsterone exhibits anticancer activities and enhances the antitumor activities of gemcitabine through the suppression of NF-κB activation in gallbladder cancer cells. These results suggest that guggulsterone could be a potential therapeutic option for patients with gallbladder cancer.

The influence of body mass index (BMI) on the outcome of patients with colorectal cancer (CRC) is largely unknown, particularly in an Asian population. Therefore, we investigated the influence of BMI on survival of patients who underwent surgical treatment for CRC in Korean population. This prospective cohort study included CRC patients who underwent surgery between June 2003 and May 2005. Study participants were divided into two BMI groups: normal weight (

Appropriate surveillance intervals are important to ensure that the benefits of surveillance are not offset by harm. This study aimed to determine the factors associated with nonadherence to recommended colonoscopic surveillance intervals. The study enrolled 296 patients who underwent screening colonoscopy. The colonoscopies were performed by four endoscopists in the first or second year of fellowship. After each procedure, the endoscopists responded to a questionnaire that elicited information on the degree of concern for missed polyps (using a visual analog scale [VAS]), colonoscopic technical factors, and surveillance intervals. Of the 296 patients, 105 (36%) were adherent and 191 (64%) and were nonadherent to the guidelines. There were no differences in insertion time, withdrawal time, or polyp detection rate between the adherence and nonadherence groups. The endoscopy at cecal intubation was longer in the nonadherence group than in the adherence group (P = 0.013). The proportion of patients with poor bowel preparation was higher in the nonadherence group than in the adherence group (P = 0.011). The endoscopist’s concern for missed polyps was greater in the nonadherence group than in the adherence group (P

Summary Background/aim Non-alcoholic fatty liver disease (NAFLD) is associated with multiple adenomatous polyps and advanced neoplasm. This study aims to investigate the influence of NAFLD on the tumor characteristics and prognosis in patients with colorectal cancer (CRC). Methods We analyzed 227 patients who were first diagnosed with CRC and underwent abdominal ultrasonography within six months prior to diagnosis at Samsung Medical Center between 2000 and 2005. Results Of the study population, 26.0% were diagnosed with NAFLD. Upon baseline comparison, CRC patients with NAFLD had higher BMI and ALT values than CRC patients without NAFLD (25.3 ± 2.7 vs. 22.6 ± 3.0, P = 0.000 and 26.6 ± 17.4 vs. 21.2 ± 14.0, P = 0.018, respectively). Additionally, CRC patients with NAFLD were diagnosed earlier than CRC patients without NAFLD (P = 0.004). However, there were no significant differences between two groups with regard to location and differentiation of tumors, CEA or numbers of synchronous adenoma and advanced adenoma. The cumulative 1-, 3-, and 5-year survival rates in CRC patients with NAFLD were 98.3%, 89.8%, and 86.4%, respectively, which were higher but statistically not significant than 90.4%, 79.6%, and 74.8%, respectively, in CRC patients without NAFLD (P = 0.079). During follow-up, freedom from recurrence was similarly observed in CRC patients with and without NAFLD (89.8% and 87.3%, respectively, P = 0.614). Conclusions The results of this study suggest that the presence of NAFLD does not influence on the prognosis in CRC patients, especially with respect to disease recurrence during follow-up.

Background/Aims When undergoing endoscopic submucosal dissection (ESD), patients with liver cirrhosis (LC) may suffer from a high risk of bleeding, bacteremia and tissue vulnerability. There have been few reports evaluating the efficacy and safety of ESD in patients with LC. Methods From January 2004 to March 2010, 23 patients with LC (cirrhosis group) underwent ESD for superficial gastric neoplastic lesions. The number of patients with a liver function in the Child-Pugh classes A and B were 20 and 3, respectively. The clinical outcomes and complications were compared with 69 patients without LC (control group) that were matched for age and sex. Results The en bloc resection, R0 resection and en bloc plus R0 resection rates of the cirrhosis group were 82.6%, 91.3%, and 82.6%, respectively, and did not show significant differences from the rates of the control group. No local recurrence was found in either group during the follow-up period. The procedure length of time (41.0 vs 39.0 minutes), rate of bleeding (4.3% vs 7.2%) and rate of perforation (0.0% vs 1.4%) in the cirrhosis group were also comparable to the results from the control group. Conclusions ESD was safely performed in patients with LC, and satisfactory outcomes were achieved with high en bloc and R0 resection rates for superficial gastric neoplastic lesions.

Our aim was to investigate the incidence of tumor recurrence in cases in which there was a discrepancy in the diagnosis of complete resection by pathologists and colonoscopists, especially in the lateral resection margin.We reviewed 245 patients with colorectal tumors that were treated by endoscopic submucosal dissection (ESD) between March 2006 and June 2011. We evaluated the recurrence rate in cases judged as pathologically incomplete resection despite endoscopically complete resection.Of the 24 cases with tumor cells on the lateral resection margin, the histologies of the colorectal tumors were found to be tubular adenoma (TA) with low-grade dysplasia (n = 19), TA with high-grade dysplasia (n = 3) and differentiated adenocarcinoma (n = 2). No tumor recurrence was observed in 22 patients after ESD. Four patients did not receive surveillance colonoscopy. The median tumor size was 28 mm (12-35) and the median follow-up period was 19 months (5-42).This retrospective analysis was limited by a short follow-up period. However, surveillance colonoscopy could be attempted without additional ESD in those cases in which incomplete resection on the lateral margin was judged pathologically, if endoscopic complete resection was grossly achieved.

Non-technical summary What is known about gastric electrophysiology and used in motility clinics throughout the world is mostly deduced from animal studies and extracellular recordings from human patients. Extracellular recording from gastrointestinal muscles, however, is prone to extensive motion artifact, and it is not clear that animal models can be translated directly to human physiology. Therefore, we have performed a detailed analysis of electrical activity from carefully mapped specimens of gastric muscle removed from humans during surgery for gastric cancers. Our data show several important differences in electrical activity recorded with intracellular microelectrodes and accepted gastric electrophysiological dogma. We observed ongoing electrical slow wave activity in the gastric fundus; we also found no evidence for a slow wave frequency gradient. Muscles from all regions through the thickness of the muscularis demonstrated intrinsic pacemaker activity, and this corresponded with the widespread distribution of pacemaker cells.

Background/Aims Propofol induced sedation with bispectral index (BIS) monitoring has been reported to lead to higher satisfaction in patients and endoscopists during endoscopic submucosal dissection (ESD) procedures. There are no data, however, regarding the efficacy of midazolam and meperidine (M/M) induced sedation with BIS monitoring during ESD. The purpose of this study was to evaluate whether M/M induced sedation with BIS monitoring could improve satisfaction and reduce the dose of M/M required during ESD. Methods Between September 2009 and January 2010, 56 patients were prospectively enrolled and randomly assigned to a BIS group (n=28) and a non-BIS group (n=28). Patient and endoscopist satisfaction scores were assessed using the visual analog scale (0 to 100) following the ESD. Results The mean satisfaction scores did not significantly differ between the BIS and non-BIS groups (92.3±16.3 vs 93.3±15.5, p=0.53) or endoscopists (83.1±15.4 vs 80.0±16.7, p=0.52). Although the mean meperidine dose did not differ (62.5±27.6 vs 51.0±17.3, p=0.18) between the two groups, the mean dose of midazolam in the non-BIS group was lower than in the BIS group (6.8±2.0 vs 5.4±2.1, p=0.01). Conclusions BIS monitoring during ESD did not increase the satisfaction of endoscopists or patients and did not lead to an M/M dose reduction. These results demonstrate that BIS monitoring provides no additional benefit to M/M induced sedation during ESD.

Background/Aims: The aim of this study was to evaluate the usefulness of health screening for early detection and improved prognosis in pancreatic cancer. Methods: Between 1995 and 2008, 176,361 examinees visited the Health Promotion Center (HPC). Twenty patients diagnosed with pancreatic cancer were enrolled. During the same period, 40 patients were randomly selected from 2,202 patients diagnosed with pancreatic cancer at the Out Patient Clinic (OPC) for comparison. Results: Within the HPC group, 10 patients were initially suspected of having pancreatic cancer following abnormal ultrasonographic fi ndings, and 9 patients had suspected cases following the detection of elevated serum CA 19-9. The curative resection rate was higher in the HPC group than in the OPC group (p=0.011). The median survival was longer in the HPC group than in the OPC group (p=0.000). However, there was no significant difference in the 3-year survival rate between the two groups. Asymptomatic patients (n=6/20) in the HPC group showed better curative resection and survival rates than symptomatic patients. However, the difference was not statistically signifi cant. Conclusions: Health screening is somewhat helpful for improving the curative resection rate and median survival of patients with pancreatic cancer detected by screening tests. However, the benefi t of this method in improving long-term survival is limited by how early the cancer is detected. (Gut Liver 2011;5:194199)

The incidence of colorectal adenomas and advanced neoplasia in the transplant population has not been well characterized. The aim of this study was to determine whether or not there was an increased incidence of colorectal adenomas and advanced neoplasia in solid organ transplantation (SOT) recipients compared with an average-risk population. We reviewed 360 patients with solid organ transplants who underwent colonoscopy between February 1995 and July 2008, and 360 age- and gender-matched patients in an average-risk population. The mean duration from transplantation to colonoscopy in the SOT group was 40.4 ± 34.0 months. Ninety-three (25.8%) adenomas were detected in the SOT group, while 98 (27.2%) adenomas were detected in the control group (p = 0.763). There was a statistically significant difference (p < 0.0001) in the number of patients with advanced neoplasia in the SOT group (24 patients [6.7%]) compared with the control group (3 patients [0.8%]). The independent risk factors of advanced neoplasia were old age (odds ratio [OR], 1.067; 95% CI, 1.019-1.118) and transplantation (OR, 6.069; 95% CI, 1.455-25.314). In summary, there was a significant increase in the incidence of advanced colorectal neoplasia in SOT recipients. The reason for this finding is unclear, and studies with a larger number of patients are needed to further evaluate this group.

Background/Aims: Early gastric cancer (EGC) can be treated by endoscopic resection, which results in an excellent prognosis. Optimal screening intervals considering risk factors for gastric cancer have not been established. The aim of this study was to determine the maximum gastric cancer screening interval in terms of long-term survival. Methods: Curative resection was performed in 561 patients with gastric cancer who had completed a questionnaire on their previous history of screening tests and risk factors. The association between EGC detection rate and previous screening history was evaluated, and 5-year disease-free survival rates were compared between various screening intervals. Results: Multivariate analysis showed that intestinal metaplasia [hazard ratio (HR) 9.690, 95% confidence interval (CI) 5.896–15.927] and previous screening history (HR 0.077, 95% CI 0.048–0.125) were independent factors associated with advanced gastric cancer. In patients without intestinal metaplasia, there was no significant difference in the extent of gastric cancer progression and the 5-year disease-free survival rate between groups with screening intervals of less than 3 years. In patients with intestinal metaplasia, the cutoff screening interval for detection of EGC and disease-free survival was 2 years. Conclusion: The optimum screening interval for disease-free survival for gastric cancer in a normal population is 3 years, but a screening interval of 2 years should be used for patients with intestinal metaplasia in Korea.

Background/Aims The incidence of gastroesophageal reflux disease (GERD) is increasing in Korea. The aim of this study was to evaluate the relationship between GERD symptoms and dietary factors in Korea. Methods From January 2007 to April 2008, 162 subjects were enrolled (81 in GERD group and 81 in control group). They were asked to complete the questionnaires about GERD symptoms and dietary habits. The symptom severity score was recorded by visual analogue scale. Results Subjects with overweight or obesity had an increased risk for GERD (OR, 2.52; 95% CI, 1.18-5.39). Irregular dietary intake was one of the risk factors for GERD (OR, 2.33; 95% CI, 1.11-4.89). Acid regurgitation was the most suffering (2.85 ± 2.95 by visual analogue scale) and frequent reflux-related symptom (57.5%) in GERD. Noodles (OR, 1.22; 95% CI, 1.12-1.34), spicy foods (OR, 1.09; 95% CI, 1.02-1.16), fatty meals (OR, 1.20; 95% CI, 1.09-1.33), sweets (OR, 1.42; 95% CI, 1.00-2.02), alcohol (OR, 1.16; 95% CI, 1.03-1.31), breads (OR, 1.17; 95% CI, 1.01-1.34), carbonated drinks (OR, 1.69; 95% CI, 1.04-2.74) and caffeinated drinks (OR,1.41; 95% CI, 1.15-1.73) were associated with symptom aggravation in GERD. Among the investigated noodles, ramen (instant noodle) caused reflux-related symptoms most frequently (52.4%). Conclusions We found that noodles, spicy foods, fatty meals, sweets, alcohol, breads, carbonated drinks and caffeinated drinks were associated with reflux-related symptoms.

The risk factors correlated with the post-operative recurrence of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are not well established. The aim was to determine the risk factors of recurrence.We reviewed retrospectively the differences of clinicopathologic features between the recurrence and nonrecurrence groups of patients with IPMN who underwent surgical resection and analyzed the recurrence-related factors.A total of 103 patients were confirmed to have IPMNs. The mean postoperative follow-up was 3.2 years, and the recurrence rate was 12.6%. Recurrent cases (n=13) had the following pathologic grades: adenoma, 1; and invasive carcinoma, 12. The mean postoperative survival was 17.0 months in the recurrence group and 41.4 months in the nonrecurrence group (P0.001). The independent risk factors of recurrence were invasive carcinoma (P=0.017, hazard ratio=71.79; 95% confidence interval (CI)=2.13-2417.05), elevated carbohydrate antigen 19-9 (P=0.007, hazard ratio=37.97, 95% CI=2.66-542.32), and main location in the pancreatic head (P=0.038, hazard ratio=0.16, 95% CI=0.03-0.90).The risk factors associated with recurrence of IPMNs were invasive pathology, elevated carbohydrate antigen 19-9, and main location in the pancreatic head. A more careful follow-up is needed for such patients.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are classified into the following four histopathologic subtypes: gastric, intestinal, pancreatobiliary, and oncocytic. However, the clinicopatholgic characteristics of IPMN subtypes have not been fully clarified. Recently, a subgroup classification of minimally invasive intraductal papillary mucinous carcinomas (MI-IPMCs) was suggested in contrast to overt invasive carcinoma from IPMCs (IC-IPMCs). The purpose of this study was to determine whether or not the pathologic subtype classification can predict prognosis and to validate the usefulness of the newly proposed diagnostic criteria of MI-IPMCs. We reviewed the clinicopathologic characteristics of 142 surgically resected cases of IPMNs. There were 54, 56, 30, and two cases of the gastric, intestinal, pancreatobiliary, and oncocytic types of IPMNs, respectively. The intestinal and pancreatobiliary types were more likely to have a main duct type. All gastric type tumors were adenomas or moderate dysplasia, whereas greater than one half of the intestinal and pancreatobiliary types were carcinomas in situ or invasive carcinomas. A significant difference in recurrence and death rate was noted for invasive carcinoma between the intestinal and pancreatobiliary types. The majority of MI-IPMCs were the intestinal type, whereas the majority of IC-IPMCs were the pancreatobiliary type. The IC-IPMC group showed a decreased recurrence-free and overall survival with statistically significance (p < 0.001 and p = 0.001, respectively). Our results suggest that the pathologic subtype classification and the newly proposed diagnostic criteria for minimal invasion may also be useful to predict prognosis of IPMNs of the pancreas.

Xanthogranulomatous cholecystitis (XGC) mimics early-stage gallbladder (GB) cancer with wall thickening on computed tomography (CT), both clinically and radiologically. Preoperative differentiation of XGC from early-stage GB cancer is important for selecting the most appropriate surgical management. Therefore, we evaluated the clinical features and multidetector CT (MDCT) findings of XGC to determine whether it can be distinguished from early-stage GB cancer.We retrospectively evaluated 25 patients with XGC and 56 patients with the wall-thickening type of T1- and T2-stage GB cancer, where all of the diagnoses were pathologically confirmed by surgical treatment. All of the patients underwent preoperative MDCT. The clinical symptoms, laboratory findings, and CT findings were compared.Abdominal pain, fever, and jaundice were noted more frequently in the patients with XGC. Serum aspartate aminotransferase and alanine aminotransferase levels were more elevated in patients with XGC, whereas carbohydrate antigen (CA 19-9) was higher in the patients with GB cancer. When the T-category cancer staging of XGC and early-stage GB cancer were compared, diffuse GB wall thickening, intramural hypoattenuated nodule, gallstone, and pericholecystic infiltration were consistent significant findings associated with XGC, regardless of the cancer staging.MDCT findings such as diffuse GB wall thickening, intramural hypoattenuated nodule, gallstone, and pericholecystic infiltration together with the clinical symptoms, can provide clues for physicians to differentiate XGC from early-stage GB cancer with wall thickening on CT.

Background and Aim: Pathological bolus exposure is defined in the present study as cases in which all reflux percentage times are above 1.4% of the total reflux number, as revealed by impedance–pH monitoring. The role of pathological bolus exposure in the pathogenesis of non-cardiac chest pain (NCCP) is poorly known. We aimed to classify and characterize NCCP using combined impedance–pH monitoring. Methods: Seventy-five consecutive patients with NCCP were prospectively enrolled from January 2006 to October 2008. All the patients underwent upper endoscopy, esophageal manometry, and 24-h multichannel intraluminal impedance (MII)–pH metering. Results: Sixteen patients (21.3%) had esophageal erosion upon endoscopy. Upon esophageal manometry, 37 patients (49.3%) had esophageal dysmotility. When the patients were classified based on MII–pH metering, 16 (21.3%) showed pathological acid exposure, and 40 (53.3%) showed pathological bolus exposure. The DeMeester score of patients with pathological acid exposure was higher than that of patients with pathological bolus exposure (P = 0.002). There was no significant difference in age, sex, typical esophageal symptoms, presence of esophageal erosion, esophageal dysmotility, improvement with proton pump inhibitor medication, symptom index ≥50%, percentage of time clearance pH below 4 ≥4%, and all reflux time ≥1.4% in the fasting period between the two groups. When the patients were divided into gastroesophageal reflux disease (GERD)-related NCCP and non-GERD-related NCCP groups based on MII–pH metering and upper endoscopy, there was no difference between the two groups. Conclusions: Combined impedance–pH monitoring improves the detection and characterization of NCCP. This study suggests that pathological bolus exposure plays a major role in eliciting NCCP.

Background/Aims: Many studies have suggested that hyperplastic polyps (HPs) are associated with adenomas and even malignancy. We investigated whether or not HPs are associated with the presence of synchronous advanced colorectal neoplasms as a function of their size and location. Methods: A total of 2,482 asymptomatic patients who underwent screening colonoscopies were classified into the following two groups: cases with advanced neoplasms and controls without advanced neoplasms. The proximal colon was defined as all segments proximal to the splenic flexure. We defined diminutive HPs as Results: The median age of the patients was 51 years. 76.8% (n = 1,909) of the patients were males. 82 patients (3.3%) had at least one advanced neoplasm. Based on multivariate analysis, the independent risk factors for advanced neoplasms were old age (OR = 2.81), male gender (OR = 2.92), non-advanced adenomas (OR = 3.57), and non-diminutive HPs (OR = 4.75, p = 0.000). Having at least one non-diminutive HP in either the proximal or distal colon was associated with an increased risk of advanced neoplasm, with no statistically significant difference (proximal vs. distal colon, OR = 5.95 vs. 5.36). Conclusions: These results suggest that non-diminutive HPs are important markers of advanced colorectal neoplasms regardless of location.

†† † † † , † † ‡ ‡ † ‡ Background/Aims: Endoscopic submucosal dissection (ESD), a new and potentially curative method for treating gastrointestinal neoplasms, may have longer procedure time and the risk of complications when compared to conventional endoscopic mucosal resection. This study evaluated the efficacy and safety of ESD in patients with comorbid diseases. Methods: The outcomes of 337 patients who underwent ESD for early gastric cancer at Samsung Medical Center from April 2003 to December 2006 were analyzed retrospectively. The Charlson comorbidity scale was used to divide the patients into low-risk (no risk factor) and high-risk (at least one risk factor) groups. The outcomes and complications were compared between the high-and low- risk groups. Results: The low- and high-risk groups comprised 240 and 97 patients with mean ages of 61.1 and 64.7 years, respectively (p=0.002). Tumor location, tumor size, depth of invasion, procedure duration, and rates of en bloc resection, complete resection, complication, and recurrence did not differ significantly between the two groups (p＞0.05). Conclusions: ESD may be a safe and effective treatment for early gastric cancer in patients with comorbid diseases. (Gut Liver 2010;4:186191)

Objective. Cytomegalovirus (CMV) aggravates preexisting inflammatory bowel disease (IBD), and there are numerous reports of CMV colitis in IBD patients. However, little attention has been paid to CMV colitis in non-IBD patients. The aim was to determine the clinical manifestations, endoscopic appearance, and clinical course of CMV colitis in non-IBD patients. Material and methods. We reviewed medical records of patients diagnosed with CMV colitis based on immunohistochemical studies of biopsy specimens or surgical specimens between 1998 and 2009. Results. The medical records of 43 patients were reviewed. Subjects included individuals with AIDS, and those undergoing chemotherapy, steroid therapy, or transplantation, as well as individuals with other co-morbidities and individuals with no previous illnesses. Frequent symptoms were non-bloody diarrhea, abdominal pain, fever, and hematochezia. Macroscopically normal rectosigmoid mucosa was observed in eight of 21 patients who underwent full-length colonoscopy. Endoscopic findings were varied, and included macroscopically normal (n = 2), colitis alone (n = 12), ulcer alone (n = 5), and ulcer with colitis (n = 22). The ulcer margin was well-circumscribed in 12 of 21 patients. Thirty-six patients were administered antiviral agents and two patients died. All patients who were not treated with an antiviral agent recovered spontaneously while waiting for their biopsy results. Conclusions. Colonoscopy is preferred to sigmoidoscopy for diagnosis of CMV colitis. Antiviral therapy should not be mandatory for a subset of patients with CMV colitis.

Mammary serine protease inhibitor (maspin, SERPIN-B5) is expressed in normal human mammary epithelial cells and is known to be down-regulated during cancer progression. Aberrant maspin expression has been reported in a number of cancers, including pancreatic and ovarian cancer. Recently, we identified several genes that may be tumor markers for gallbladder (GB) cancer using a DNA microarray method. There are no published data regarding maspin expression in GB cancer. The aims of this study were to determine maspin expression in normal mucosa, adenoma, dysplasia and carcinoma of GB, and to compare the pattern of maspin expression in early and advanced GB cancers. One hundred one patients with primary GB cancer who underwent resection between March 1999 and May 2008 were included. Twenty-five adenomas and 10 normal GB specimens were also included. We performed tissue microarray construction and immunohistochemical staining to evaluate maspin expression. The immunostaining results were estimated semiquantitatively by one pathologist. The positive rate of maspin expression was 59.4% (60/101) in GB cancer, whereas no maspin was expressed in adenomas and normal mucosa of GB. In case of positive maspin expression, it was gradually increased from dysplasia to carcinoma. No significant difference in the positive rate of maspin expression between early and advanced cancer was detected (49% versus 60%; P = 0.731). This result suggests that maspin expression may be involved in dysplasia-carcinoma sequence and the early steps of GB carcinogenesis.

Efficacy and Tolerability of Split-Dose Magnesium Citrate: Low-Volume (2 Liters) Polyethylene Glycol vs. Single- or Split-Dose Polyethylene Glycol Bowel Preparation for Morning Colonoscopy

We investigated the clinical usefulness of HbA1c in screening an average-risk group50 years of age who need colonoscopy for colorectal cancer (CRC) screening.Eight hundred nineteen asymptomatic males who underwent colonoscopy for CRC screening with blood chemistries between January 2006 and December 2006 were enrolled. The ages of the subjects ranged from 40 to 59.Subjects in their 50 s had significantly more adenomatous polyps than subjects in their 40 s (32.7% vs. 26.0%, p0.05). The incidence of adenomatous polyp increased with increasing quartiles of HbA1C as follows: first quartile (19.9%, HbA1c 4.0-5.0), second quartile (27.8%, HbA1c 5.1-5.3), third quartile (32.7%, HbA1c 5.4-5.5), and fourth quartile (34.9%, HbA1c = 5.6-8.8)(p = 0.008). When combining quartile of HbA1c and age (40 s vs. 50 s) according to HbA1C levels, the odds ratio for adenomatous polyp in subjects in their 40 s with HbA1c5.4% was significantly lower than that in subjects in their 50 s. However, the odds ratio for adenomatous polyp in subjects in their 40 s with HbA1cor =5.4% was similar to that in subjects in their 50 s with average risk for CRC.An elevated HbA1c may be useful as a clinical predictor of adenomatous polyps in male subjects50 years of age who have average risk for CRC.

Background and Aim: Patients with achalasia have a thicker muscularis propria compared to normal patients. Because pneumatic balloon dilatation (PD) is an effective treatment for achalasia, the changes in the esophageal muscles after PD may predict treatment outcomes, if muscular change is of primary importance. In the present study, we aimed to observe the changes in esophageal muscle thickness following PD and assessed whether symptom relapse can be predicted on the basis of the esophageal muscle cross-sectional area (CSA), as measured by high-frequency intraluminal ultrasound (HFIUS). Methods: Fifteen patients treated by PD were studied and followed up for a median of 3.6 years. An HFIUS was done before PD and 6 months after PD. The esophageal muscle CSA measured at the lower esophageal sphincter (LES), and 3 and 6 cm above the LES, was used to see whether any association was present between symptom recurrence and the esophageal muscle CSA. Results: A single PD resulted in a 2-year remission rate of 66%. A significance variance in change (−65%–248%) was noticed in the muscle CSA after PD. The predilation muscle CSA, post-dilation muscle CSA, and change in the muscle CSA after PD was not associated with symptom recurrence. Conclusion: Our findings suggest that measuring the muscle CSA does not help to predict treatment outcome. Muscular changes in achalasia might be just reactive changes.

Distal microsatellite instability (MSI)-high colorectal cancers (CRCs) have been investigated by few studies and are generally regarded as having similar features to proximal MSI-high CRCs. In the present study, we aimed to elucidate whether distal sporadic MSI-high CRCs displayed distinguished clinicopathological and molecular features from proximal MSI-high CRCs.All patients who underwent their first surgical resections for stage I-IV sporadic CRCs between August 2003 and August 2006 were initially considered for enrollment, and their MSI data were prospectively collected. Among them, 135 patients with MSI-high CRCs (86 proximal and 49 distal CRCs) were finally identified. The clinicopathological and molecular characteristics, and prognosis of these cases with MSI-high CRCs were reviewed and compared according to tumor site (proximal versus distal).Distal MSI-high CRCs showed significantly more frequent association with younger age, male gender, differentiated histology, small tumor size, distant metastasis, stability in BAT25 and BAT26, and hMLH1 expression on immunohistochemical staining as compared with proximal MSI-high CRCs. In addition, distal MSI-high CRCs demonstrated significantly worse 3-year overall and disease-free survival rates than proximal MSI-high CRCs (87.0% versus 97.4%; 81.6% versus 95.9%). For stage III-IV CRCs, distal MSI-high CRCs also showed significantly worse 3-year overall and disease-free survival rates than proximal MSI-high CRCs (72.2% vs. 90.5%; 58.3% vs. 94.4%).These results indicated that distal sporadic MSI-high CRCs formed a distinct subgroup with distinguished clinicopathological and molecular features from proximal MSI-high CRCs. In addition, this study demonstrated that distal MSI-high CRCs had worse prognosis than proximal MSI-high CRCs.

Colonic spasm, a relatively common problem during colonoscopy, may interfere with intubation and examination. This study was conducted to compare the effect of warm water consumption before unsedated colonoscopy on the incidence of spasm, pain, and technical difficulties. In addition, we studied the associations between attributes of patients and the degree of pain experienced by them during procedures undertaken after warm water consumption.A prospective, randomized, controlled, and investigator-blinded study was conducted in which three groups of patients underwent unsedated colonoscopies. Those randomized to group A (n=64) were instructed to drink 2 l of warm water and 90 ml of sodium phosphate (NaP) solution before colonoscopy. For comparison, those randomized to groups B (n=64) and C (n=64) were instructed to drink 2 l of cold water and 90 ml of NaP solution, or 90 ml of NaP solution without any additional water, respectively. Patient demographics, procedure-related factors, and degree of spasm, pain, and technical difficulty were assessed.Ileal intubation and withdrawal times were significantly shorter for group A than for groups B and C (P0.001 and P0.001, respectively). There was no significant difference between groups in the degree of spasm reported by the endoscopist. The level of pain at the sigmoid colon and splenic flexure during colonoscopy was lower for group A than for groups B and C on both advancement and withdrawal of the colonoscope (P0.001 and P0.001, respectively). The level of discomfort 2 h after the completion of endoscopy was lower for group A than for the other groups. (P=0.001). A subgroup analysis showed that warm water consumption was especially beneficial for patients40 years of age and for those with irritable bowel syndrome. A multivariate analysis showed that warm water consumption before colonoscopy (odds ratio (OR) 0.22; 95% confidence interval (CI): 0.09-0.48 vs. the cold water group and OR 0.34; 95% CI: 0.16-0.73 vs. the no water group) was an independent factor for the reduction of pain during colonoscopy.The intake of warm water before unsedated colonoscopy reduces procedure-related pain and technical difficulty, especially in patients who are young or have irritable bowel syndrome, even though it does not improve the frequency of visible spasmodic events.

Background/Aims Although gastric hyperplastic polyps are usually considered as benign lesions, a low risk of carcinomatous conversion is currently recognized. We aimed to identify the characteristics of hyperplastic polyps undergoing neoplastic transformation. Methods A total of 269 gastric hyperplastic polyps from 216 patients removed by endoscopic polypectomy (EP) or surgical resection were enrolled in this study, and their endoscopic pictures and pathology slides were reviewed. Results Neoplastic transformation was detected on forceps biopsy specimen in 11 cases. However, the pathology findings from the EP or surgical specimen revealed neoplastic transformation in 14 cases (5.2%; 4 with dysplasia and 10 with adenocarcinoma). No significant difference was found between hyperplastic polyps with and without neoplastic transformation in age, sex, location, number of polyps or gross appearance. However, neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm than in polyps ≤1 cm (12 of 143; 8.4% vs. 2 of 126; 1.6%) (p=0.013). Conclusions Neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm. Therefore, EP should be considered for gastric hyperplastic polyps >1 cm for the accurate diagnosis and definitive treatment.

Background The biologic significance of low-level microsatellite instability (MSI) in colorectal cancers (CRCs) remains unclear. This study aimed to elucidate whether sporadic MSI-low CRCs in Korea displayed distinguished clinicopathological characteristics from microsatellite stable (MSS) and MSI-high CRCs. Methods We consecutively enrolled 657 patients who underwent their first surgical resections for stage I–IV sporadic CRCs and compared their clinicopathological features and prognosis after resection according to MSI status (574 MSS, 30 MSI-low and 53 MSI-high CRCs). Results When compared with MSS CRCs, MSI-low CRCs showed significantly more frequent association with poorly differentiated histology, mucinous carcinoma, and large tumour size. In addition, MSI-low CRCs demonstrated significantly less frequent lymph node metastasis and advanced tumour stage than MSS CRCs. When compared with MSI-high CRCs, MSI-low CRCs were significantly more frequently located in distal colon. Three-year overall and disease-free survival rates of MSS, MSI-low and MSI-high CRCs were 83.5%, 90.0% and 91.7% and 82.0%, 89.1% and 87.5%, respectively and neither demonstrated significant difference between three groups. Conclusions These results indicated that sporadic MSI-low CRCs in Korea displayed distinguished clinicopathological features and might form a distinct subgroup especially from MSS CRCs. Further large studies are required to evaluate the impact of MSI-low status on prognosis. J. Surg. Oncol. 2009;99:351–355. © 2009 Wiley-Liss, Inc.

Background 5-Aminosalicylic acid lacks the well-known side effects associated with the long-term use of non-steroidal anti-inflammatory drugs. We investigated anti-carcinogenic mechanisms of 5-aminosalicylic acid on a colon cancer cell line. Methods MTT analysis was performed for various colon cancer cell lines. The expression of NF-κB and metalloproteinases was examined in either HT-29 cells treated with IL-1β and/or 5-aminosalicylic acid. Matrigel assay was used to evaluate invasive potential of HT-29 cells. Analysis of a cDNA microarray containing 8700 genes was performed to identify the alteration of gene expression in response to treatment to 5-aminosalicylic acid. Results The use of MTT analysis showed that 5-aminosalicylic acid suppressed the growth of HT-29 cells. The activity of NF-κB was also decreased by combined-treatment with IL-1β and 5-aminosalicylic acid. The use of an ELISA and zymography demonstrated that MMP-2 and MMP-9 enzyme activity were decreased in HT-29 cells by treatment with various concentration of 5-aminosalicylic acid. A matrigel analysis demonstrated that 5-aminosalicylic acid treatment on HT-29 significantly inhibited the invasiveness of the cells. In cDNA microarray, 163 genes following 5-aminosalicylic acid exposure showed altered expression. Conclusions This study indicated that 5-aminosalicylic acid suppresses the growth of human colon cancer cells and is able to inhibit MMPs expression via NF-κB mediated cell signals and invasiveness.

OBJECTIVES We investigated the clinical and radiological features of focal mass-forming autoimmune pancreatitis (FMF AIP) to help physicians avoid performing unnecessary surgery because of an improper diagnosis. METHODS We evaluated 23 patients with chronic inflammatory pancreatic masses and who underwent pancreatectomy for presumed pancreatic cancer from April 1995 to December 2005. These patients were distinguished into 8 FMF AIP patients and 15 ordinary chronic pancreatitis patients through a histological review, along with considering the immunoglobulin G4 staining. Twenty-six randomly selected pancreatic cancer patients were also evaluated as a control group. RESULTS On the portal venous phase of computed tomography, 6 (85.7%) of 7 FMF AIP patients showed homogeneous enhancement, whereas only 3 chronic pancreatitis patients (25%) and none of the pancreatic cancer patients showed homogeneous enhancement (P < 0.001). None of the FMF AIP patients showed upstream main pancreatic duct dilatation greater than 5 mm or proximal pancreatic atrophy. CONCLUSIONS For patients with a pancreatic mass, if their radiological images show homogeneous enhancement on the portal venous phase, the absence of significant upstream main pancreatic duct dilatation greater than 5 mm, and the absence of proximal pancreatic atrophy, then conducting further evaluations should be considered to avoid performing unnecessary surgery.

Aim This prospective cohort study aimed to evaluate the etiology of elevated CA 19-9 levels and to present appropriate guidelines for the asymptomatic patients. Methods Between January 2004 and March 2007, we enrolled consecutive asymptomatic patients who had elevated CA 19-9 levels >37 U/mL. To evaluate the etiology, the CA 19-9 level was rechecked and further studies were carried out. If the CA 19-9 level decreased to the normal range, or if it showed a decreasing trend, then it was monitored annually. Yet, if the CA 19-9 level showed an increasing trend, then the level was monitored at intervals of 1, 3, and 6 months until no evidence of malignancy was proven. Results Of the 62,976 patients, 501 (0.8%) subjects showed an elevated CA 19-9 level. This prospective analysis was conducted on 353 subjects (70.5%) who were followed up for at least 6 months. Ten patients (2.8%) were diagnosed with malignancies. There were 97 patients (27.5%) with benign diseases and 246 patients (69.7%) were deemed non-specific. Conclusions CA 19-9 should not be used as a screening tool. In the case of a persistently elevated CA 19-9 level, further work-up for determining the etiology should be done.