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Background/Aims: This study aimed to review the indications, methods, cooperation, complications, and outcomes of percutaneous endoscopic gastrostomy (PEG). Methods: Questionnaires were sent to 200 hospitals, of which 62 returned their questionnaires, with a response rate of approximately 30%. Descriptive statistics were calculated to analyze the responses to the questionnaires. Results: In 2019, a total of 1,052 PEGs were performed in 1,017 patients at 62 hospitals. The main group who underwent PEG was older adult patients with brain disease, particularly stroke. Nutritional supply was an important purpose of the PEG procedure. “The pull method” was the most commonly used for initial PEG insertion. The complications related to PEG were mostly mild, with leakage being the most common. Patients who underwent PEG procedures were primarily educated regarding the post-procedure management and complications related to PEG. Preoperative meetings were skipped at >50% of the institutions. Regarding the cooperation between the nutrition support team (NST) and the physician performing PEG, few endoscopists answered that they cooperated with NST before and after PEG. Moreover, the rate of NST certification obtained by physicians performing PEG and the frequency of attendance at NST-related conferences were relatively low. Conclusions: This study shows a similar trend to that found in the previous PEG guidelines. However, it covers new aspects, including team-based work for PEG procedure, nutrition support, and education for patients and guardians. Therefore, each medical institution needs to select an appropriate method considering the medical environment and doctor’s abilities.

Introduction: Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically lymph node negative early breast cancer, reducing the need for axillary lymph node dissection (ALND) and its associated risks. Intra-operative frozen section is a method of rapid pathological assessment of the sentinel node to identify the presence of metastatic disease and potentially avoid the need for a second operation in patient who will require an axillary lymph node dissection. Methods: A retrospective review of a prospectively collected breast cancer database was performed. All patients with breast cancer who underwent SLNB and/or ALND at our institution, between May 1st 2017 to June 1st 2022 were identified. There were 565 patients who were included in the study. Results: Intra-operative frozen section was able to accurately identify 71% of patients who had macrometastasis in their sentinel lymph node, thus allowing them to immediately proceed to ALND and avoid a second operation. In patient who had a false negative frozen section result, only 6.5% required ALND. The majority of false negative results were due to isolated tumour cells or micrometastasis, and therefore would not have required further intervention. Conclusion: Intra-operative frozen section of sentinel lymph node biopsy in breast cancer is useful in reducing the need for a second operation, allowing staging of the axilla to occur more efficiently and with high diagnostic accuracy.

Background/Aims: Few studies have investigated the long-term outcomes of endoscopic resection for early gastric cancer (EGC) in very elderly patients. The aim of this study was to determine the appropriate treatment strategy and identify the risk factors for mortality in these patients. Methods: Patients with EGC who underwent endoscopic resection from 2006 to 2017 were identified using National Health Insurance Data and divided into three age groups: very elderly (≥85 years), elderly (65 to 84 years), and non-elderly (≤64 years). Their long- and short-term outcomes were compared in the three age groups, and the survival in the groups was compared with that in the control group, matched by age and sex. We also evaluated the risk factors for long- and short-term outcomes. Results: A total of 8,426 patients were included in our study: 118 very elderly, 4,583 elderly, and 3,725 non-elderly. The overall survival and cancer-specific survival rates were significantly lower in the very elderly group than in the elderly and the non-elderly groups. Congestive heart failure was negatively associated with cancer-specific survival. A significantly decreased risk for mortality was observed in all groups (p

Abstract The aim of this study was to address the issue of differentiating between Mayo endoscopic subscore (MES) 0 and MES 1 using a deep learning model. A dataset of 492 ulcerative colitis (UC) patients who demonstrated MES improvement between January 2018 and December 2019 at Samsung Medical Center was utilized. Specifically, two representative images of the colon and rectum were selected from each patient, resulting in a total of 984 images for analysis. The deep learning model utilized in this study consisted of a convolutional neural network (CNN)-based encoder, with two auxiliary classifiers for the colon and rectum, as well as a final MES classifier that combined image features from both inputs. In the internal test, the model achieved an F1-score of 0.92, surpassing the performance of seven novice classifiers by an average margin of 0.11, and outperforming their consensus by 0.02. The area under the receiver operating characteristic curve (AUROC) was calculated to be 0.97 when considering MES 1 as positive, with an area under the precision-recall curve (AUPRC) of 0.98. In the external test using the Hyperkvasir dataset, the model achieved an F1-score of 0.89, AUROC of 0.86, and AUPRC of 0.97. The results demonstrate that the proposed CNN-based model, which integrates image features from both the colon and rectum, exhibits superior performance in accurately discriminating between MES 0 and MES 1 in patients with UC.

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Chronic kidney disease (CKD) is a leading cause of global mortality. While recent reports suggest potential connections between CKD and chronic rhinosinusitis (CRS), further research is needed to elucidate the direct association between CKD and CRS. This study investigated the association between CKD and CRS using data from the Korean National Health Insurance Service Health Screening Cohort. Participants were recruited according to medical claim codes, and individuals with CKD were matched in a 1:4 ratio with the control group. Covariates, such as demographics, health-related data, and medical history were used. The incidence rates and hazard ratio of CRS were analyzed. A further analysis was performed based on the presence of nasal polyps. Among the 514,866 participants, 16,644 patients with CKD and 66,576 matched controls were included in the analysis. The CKD group demonstrated a higher incidence of CRS than the controls: 18.30 versus 13.10 per 10,000 person-years. The CKD group demonstrated a higher risk of CRS than the control group (1.28 adjusted hazard ratio). In additional analyses, the CKD group did not exhibit a statistically significant correlation for the development of CRS with nasal polyps. This study suggests that CKD is associated with an increased risk for CRS.

Background: The high-flow nasal cannula (HFNC) is a relatively recent method that provides high-flow, heated, humidified gas delivery. Objectives: We compared HFNC (group HF) and conventional nasal cannula (NC) (group CO) during deep sedation with propofol and remifentanil for endoscopic submucosal dissection (ESD). Design: Single-center, retrospective observational cohort study. Methods: In this study, a total of 159 cases were analyzed (group CO, 71 and group HF, 88). We collected the data from electronic medical records from September 2020 to June 2021. The lowest oxygen saturation (SpO 2 ), incidence of hypoxia (SpO 2

Background/Aims Changing trends in the Helicobacter pylori (H. pylori) eradication protocol have not been investigated after the publication of the third-revised Korean guideline in 2013. We aimed to analyze the clinical characteristics of H. pylori-infected patients alongside their treatment protocols using a common data model (CDM). Materials and Methods A 16-year electronic health record (of 1,689,604 patients from 2004 to 2019) was converted into a CDM in Kangdong Sacred Heart Hospital. We extracted records of patients who underwent the rapid urease test or serum anti-H. pylori IgG assay. The treatment protocols were visualized using a sunburst plot. We investigated the clinical characteristics and medication history of patients who underwent a urea breath test after clarithromycin-based eradication therapy. Results Out of 29,458 patients tested for H. pylori infection, 7,647 received a treatment protocol. Among them, 72.5% received a 7~14 days protocol comprising a proton pump inhibitor (PPI), amoxicillin, and clarithromycin. The proportion of patients treated with the first-line protocol (PPI, bismuth, tetracycline, and metronidazole) slightly increased from 1.9% (before 2014) to 3.3% (after 2014) (P

Background/Aims Previous studies have reported an association between Helicobacter pylori (H. pylori) infection and nonalcoholic fatty liver disease (NAFLD). Our study examined whether eradication for H. pylori infection reduces the risk of incident NAFLD. Materials and Methods This retrospective cohort study examined 3,780 adults who had no NAFLD at baseline but were infected with H. pylori. The study population was followed from January 1995 until January 2020. H. pylori infection was determined by an H. pylori-specific IgG antibody test. Fatty liver was diagnosed by ultrasound. Results During a median follow-up of 7.9 years, 1,294 participants developed NAFLD. In a multivariable model adjusted for age, sex, BMI, smoking status, alcohol intake, and metabolic variables, the uneradicated (for H. pylori) group exhibited a higher risk of incident NAFLD than the eradicated group (hazard ratio [HR], 1.36; 95% CI, 1.18~1.56). The multivariable analysis also demonstrated that higher BMI, current smoking and several metabolic abnormalities were significant risk factors for NAFLD. Subgroup analyses revealed that persistent H. pylori infection correlated with an increased risk of NAFLD. H. pylori eradication was associated with a decreased risk of NAFLD development. Conclusions H. pylori infection may have a pathophysiological role in NAFLD development. Hence, successful eradication of H. pylori decreases the risk of incident NAFLD.

Even though the conventional treatment for T1 esophageal cancer is surgery, ESD is becoming the primary treatment. Currently, it is unknown whether secondary esophagectomy after endoscopic submucosal dissection (ESD) is comparable to primary esophagectomy when considering outcomes in patients with T1 esophageal cancer. We compared short- and long-term clinical outcomes between the two groups. Primary surgery (esophagectomy) was performed in 191 patients between 2003 and 2014, and 62 patients underwent secondary surgery (esophagectomy) after ESD for T1 esophageal cancer between 2007 and 2019. Propensity matching was performed for age, sex, Charlson Comorbidity Index (CCI), location, pathology, degree of differentiation, tumor size, and invasion depth. Lymph node metastasis (LNM), overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and post-operative complications were compared between groups. Sixty-eight patients were included after propensity score matching; LNM, OS, DSS, and RFS were comparable between the two groups. Comparing primary and secondary surgery, the respective LNM rates were 23.5% and 26.5%, 6-year OS 78.0% and 89.7%, p = 0.15; DSS were 80.4% and 96.8%, p = 0.057; and RFS were 80.8% and 89.7%, p = 0.069. Comparing the adverse events between the two groups, there was no significant difference in the overall adverse events. However, more early complications were observed in the primary surgery group than in the secondary surgery group (50% vs. 20.6%, p = 0.021). Secondary surgery did not increase the risk of LNM. The long-term outcomes were comparable. Therefore, attempts to perform upfront ESD for superficial esophageal squamous cell cancers are justified.

Abstract Background/Aims Although several chemopreventive drugs against gastric cancer have been proposed, their effects have not been fully evaluated. We examined the impacts of aspirin, metformin, and statin use on gastric cancer development in a population‐based cohort in Korea. Methods We analyzed the association between potential chemopreventive drugs—aspirin, metformin, and statin—and gastric cancer through the Observational Medical Outcomes Partnership Common Data Model‐based Korean nationwide cohort. Use of aspirin, metformin, and statin was defined by ≥365 days of prescriptions for each drug in the general population. To summarize the current evidence, we further performed a systematic review and meta‐analysis of the impact of aspirin, metformin, and statin on gastric cancer development. Results After propensity score matching, 31,839, 6764, and 10,251 subjects were observed for medians of 4.7, 4.2, and 4.2 years for aspirin, metformin, and statin analysis, respectively. Use of aspirin or statin was associated with lower risks of gastric cancer compared to their non‐use, respectively (hazard ratio [HR] [95% confidence interval [CI]]: aspirin, 0.72 [0.60–0.85], p

Background/Aims Endoscopic submucosal dissection (ESD) of gastric tumors in the mid-to-upper stomach is a technically challenging procedure. This study compared the therapeutic outcomes and adverse events of ESD of tumors in the mid-to-upper stomach performed under general anesthesia (GA) or monitored anesthesia care (MAC). Methods Between 2012 and 2018, 674 patients underwent ESD for gastric tumors in the midbody, high body, fundus, or cardia (100 patients received GA; 574 received MAC). The outcomes of the propensity score (PS)-matched (1:1) patients receiving either GA or MAC were analyzed. Results The PS matching identified 94 patients who received GA and 94 patients who received MAC. Both groups showed high rates ofen bloc resection (GA, 95.7%; MAC, 97.9%; p=0.68) and complete resection (GA, 81.9%; MAC, 84.0%; p=0.14). There were no significant differences between the rates of adverse events (GA, 16.0%; MAC, 8.5%; p=0.18) in the anesthetic groups. Logistic regression analysis indicated that the method of anesthesia did not affect the rates of complete resection or adverse events. Conclusions ESD of tumors in the mid-to-upper stomach at our high-volume center had good outcomes, regardless of the method of anesthesia. Our results demonstrate no differences between the efficacies and safety of ESD performed under MAC and GA.

Helicobacter pylori (H. pylori) eradication can reduce the risk of gastric diseases such as gastritis, gastric ulcer, and gastric adenocarcinoma. Since H. pylori was discovered more than 30 years ago, many studies have reported associations between H. pylori infection and extragastric diseases such as immune thrombocytopenia and iron-deficiency anemia. Thus, recent guidelines recommended H. pylori eradication in patients with those diseases. In contrast, although the role of H. pylori eradication in other extragastric diseases remains controversial, there is growing evidence of its benefit on them, especially cardiovascular (ischemic heart disease and stroke), metabolic (dyslipidemia, diabetes mellitus, and non-alcoholic fatty liver disease), neurodegenerative (Parkinson’s disease and Alzheimer’s disease), autoimmune (Graves’ disease, Hashimoto’s thyroiditis, Raynaud’s syndrome, rosacea, and chronic urticaria), and other (cap polyposis, colorectal mucosa-associated lymphoid tissue lymphoma, periodontal disease, hyperemesis gravidarum, and osteoporosis) conditions. A recent prospective randomized study reported that H. pylori eradication improved insulin resistance and dyslipidemia. These findings were consistent with the results of a recent meta-analysis. Therefore, well-designed prospective interventional studies are needed to examine the effects of H. pylori eradication on various extragastric diseases.

Background: Several studies have suggested an association between inflammatory bowel disease (IBD) and the risk of prostate cancer development. However, these findings are inconsistent, and studies based on Asian populations are limited. Objectives: We compared the risk of prostate cancer according to IBD status using the Korean National Health Insurance Service database. Design: A population-based retrospective cohort of age-matched 59,044 non-IBD patients and 14,761 IBD patients between January 2009 and December 2011 was analyzed up to December 2017. Methods: The risk of prostate cancer was compared between patients with IBD and controls using the Cox proportional hazards regression model and Kaplan-Meier survival analysis. Results: During a median follow-up of 6 years, the incidence rate of prostate cancer was 264 per 100,000 person-years in non-IBD patients and 242 per 100,000 person-years in patients with IBD. IBD status was not associated with the risk of prostate cancer compared to non-IBD [adjusted hazard ratio (aHR) 0.93, 95% confidence interval (CI): 0.80–1.08, p = 0.32). The cumulative incidence of prostate cancer did not differ by IBD status (non-IBD patients versus IBD patients: log-rank p = 0.27; non-IBD patients versus ulcerative colitis versus Crohn’s disease: log-rank p = 0.42). In multivariate analysis, age was an independent risk factor for the development of prostate cancer (HR 1.03, 95% CI: 1.02–1.03, p

Background/Aims: The treatment goal of ulcerative colitis (UC) has been changed to achieve endoscopic remission (ER). However, there is insufficient clinical evidence to determine whether a step-up treatment should be performed to achieve ER in clinical remission (CR) without ER, and there are inadequate data on the need to consider the distribution and severity of residual inflammation. This retrospective study aimed to evaluate the prognostic significance of the distribution and severity of residual inflammation in UC patients in CR. Methods: A total of 131 UC patients in CR who underwent endoscopic evaluation for more than three times between January 2000 and December 2018 were reviewed. The patients were allocated by the endoscopic healing state and the distribution of inflammation to ER (n=31, 23.7%), residual nonrectal inflammation with patchy distribution (NRI) (n=17, 13.0%) or residual rectal involvement with continuous or patchy distribution (RI) (n=83, 63.3%) groups. We reviewed clinical characteristics, endoscopic findings, and factors associated with poor outcome-free survival (PFS). Results: In UC patients in CR, PFS was significantly higher in the ER and NRI groups than in the RI group (p=0.003). Patients in the ER and NRI groups had similar PFS (p=0.647). Cox proportional hazard model showed only RI (hazard ratio, 5.76; p=0.027) was associated with a higher risk of poor outcome. Conclusions: We suggest that escalation of treatment modalities may be selectively performed in consideration of the residual mucosal inflammation pattern, even if ER has not been achieved, in UC patients with CR.

Most thickness measurement techniques using X-ray radiation are unsuitable in field processes involving fast-moving organic films. Herein, we propose a Compton scattering X-ray radiation method, which probes the light elements in organic materials, and a new simple, non-destructive, and non-contact calibration-free real-time film thickness measurement technique by setting up a bench-top X-ray thickness measurement system simulating a field process dealing with thin flexible organic films. The use of X-ray fluorescence and Compton scattering X-ray radiation reflectance signals from films in close contact with a roller produced accurate thickness measurements. In a high-thickness range, the contribution of X-ray fluorescence is negligible, whereas that of Compton scattering is negligible in a low-thickness range. X-ray fluorescence and Compton scattering show good correlations with the organic film thickness (R2 = 0.997 and 0.999 for X-ray fluorescence and Compton scattering, respectively, in the thickness range 0–0.5 mm). Although the sensitivity of X-ray fluorescence is approximately 4.6 times higher than that of Compton scattering, Compton scattering signals are useful for thick films (e.g., thicker than ca. 1–5 mm under our present experiment conditions). Thus, successful calibration-free thickness monitoring is possible for fast-moving films, as demonstrated in our experiments.

Abstract Routine prophylaxis for venous thromboembolism (VTE) in Asian IBD patients has been controversial. We aimed to estimate the risk of VTE of Asian patients at different phases of IBD by incorporating patient-specific risk factors. In this cohort study, we analyzed the National Health Insurance claims data between 2012 and 2016 for the entire Korean population. We calculated incidence rates and hazard ratios for VTE. The overall VTE risk was higher in patients with IBD [adjusted hazard ratio (aHR), 2.06; 95% confidence interval (CI), 1.66–2.55], than in controls. When we compare the risk of VTE by different disease phases, the risk of VTE was the highest during post-operation period after IBD-related bowel surgery (aHR, 39.7; 95% CI 9.87–159.3), followed by during hospitalized periods with flare (aHR, 27.2; 95% CI 14.9–49.65) and during hospitalized periods with non-flare (aHR, 16.23; 95% CI 10.71–24.58). The incidence rate (per 1000 person-years) was 15.26 during hospitalized periods with a flare and 9.83 during hospitalized periods with non-flare. According to age groups, the incidence rate (per 1000 person-years) during hospitalized periods with flare was 14.53 in young patients (20–39 years) and 34.58 in older patients (60–80 years). During hospitalized periods with non-flare, the incidence rate was 3.55 in young patients and 23.61 in older patients. The prophylaxis of VTE for Asian patients with IBD should be recommended in older patients admitted to hospital and be considered in young patients who are hospitalized with a flare.

Proton pump inhibitors (PPIs) are commonly used for the treatment of gastric acid-related disorders, and are generally well tolerated. However, by reducing the secretion of gastric acid in the long term, PPI can increase the risk of inducing an imbalance in the gut microbiome composition. Moreover, gastric hypochlorhydria that is caused by PPIs favors the survival and migration of oral bacteria in the lower part of the gastrointestinal tract, with a possible induction of pro-inflammatory microenvironment. Therefore, gut dysbiosis that is associated with the use of PPI has been found to cause adverse infectious and inflammatory diseases. In this regard, adverse effects of the PPI-related gut dysbiosis have been reported in different observational studies, but their clinical relevance remains unclear. Therefore, the aim of this review was to explore the available data on the PPI-related gut dysbiosis in order to better understand its clinical significance.

BackgroundExacerbation of inflammatory bowel disease (IBD) is common. Identification of the exacerbating factors could facilitate interventions for forecastable environmental factors through adjustment of the patient's daily routine. We assessed the effect of natural environmental factors on the exacerbation of IBD.MethodsIn this systematic review and meta-analysis, studies published from January 1, 1992 to November 3th, 2022 were searched in the MEDLINE, Embase, CINAHL Complete and Cochrane Library databases. We extracted data related to the impact of environmental variations on IBD exacerbation, and performed a meta-analysis of the individual studies' correlation coefficient χ2 converted into Cramér's V (φc) with 95% confidence intervals (CI).ResultsA total of 7,346 publications were searched, and 20 studies (sample size 248-84,000 cases) were selected. A meta-analysis with seven studies was performed, and the pooled estimate of the correlation (φc) between the seasonal variations and IBD exacerbations among 4806 cases of IBD exacerbation was 0.11 (95% CI 0.07-0.14; I2 = 39%; p = 0.13). When divided into subtypes of IBD, the pooled estimate of φc in ulcerative colitis (six studies, n = 2649) was 0.07 (95% CI 0.03-0.11; I2 = 3%; p = 0.40) and in Crohn's disease (three studies, n = 1597) was 0.12 (95% CI 0.07-0.18; I2 = 18%; p = 0.30).ConclusionThere was a significant correlation between IBD exacerbation and seasonal variations, however, it was difficult to synthesize pooled results of other environmental indicators due to the small number of studies and the various types of reported outcome measures. For clinical implications, additional evidence through well-designed follow-up studies is needed.Protocol registration number (prospero)CRD42022304916.

Background/Aims: An association between obesity and erosive esophagitis has been reported, but the effects of sarcopenia and obesity on erosive esophagitis are unknown. This study examined the relationship between obesity, sarcopenia, sarcopenic obesity, and erosive esophagitis in a large population of asymptomatic men and women. Methods: This study analyzed 32,762 subjects who underwent a comprehensive health check-up, which included upper gastrointestinal endoscopy, from August 2006 to December 2011 by a cross-sectional study. Sarcopenia was defined as a decrease in the appendicular skeletal muscle mass (ASM)/body weight value of two SD or more below the normal means for a younger reference group. Results: The study was carried out on four groups according to obesity and sarcopenic status: normal, obesity, sarcopenic, and sarcopenic obese group. In a multivariable model, the risk of erosive esophagitis was higher in the obese (adjusted OR [aOR] 1.35, 95% CI 1.22-1.49), sarcopenic (aOR 2.12, 95% CI 1.40-3.19), and sarcopenic obese groups (aOR 1.54, 95% CI 1.27-1.87) than in the normal group. The risk of erosive esophagitis was higher in the sarcopenic and sarcopenic obese groups than the obese group; the ORs were 1.63 (95% CI 1.08-2.47) and 1.22 (95% CI 1.01-1.46), respectively. In dose-response analysis, increasing sarcopenia severity showed a positive and graded relationship with the overall, Los Angeles (LA)-B or higher grade, and LA-C erosive esophagitis. Conclusions: This study suggests that sarcopenia is strongly and progressively associated with erosive esophagitis.

Background: Treatment of Helicobacter pylori (HP) has been shown to reduce the risk of gastric cancer (GC) development. However, previous studies have focused on patients at high risk of GC. This study aimed to assess the effect of HP treatment on the incidence of GC in the general population. Materials and Methods: Medical records were obtained from the Common Data Model-converted sample Cohort of the National Health Insurance Service of Korea (NHIS-CDM). The target cohort included those who had been prescribed HP treatment and the comparator cohort included those who had not. The association between HP treatment and the risk of GC development was assessed using the Cox proportional hazard model. The incidences of GC according to the period after HP treatment in different age groups were analyzed using proportional trend tests. Results: After large-scale 1:4 propensity score matching, 2735 and 5328 individuals were included in the target and comparator cohorts, respectively. During the median follow-up of 6.5 years, the GC incidence was lower in the HP treatment cohort than in the comparator cohort, but this was statistically insignificant (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.50–1.13; p-value = 0.19). This trend was also observed among the older age (≥65 years, HR: 0.87; 95% CI: 0.44–1.68; p-value = 0.69) and male cohorts (HR: 0.82; 95% CI: 0.51–1.27; p-value = 0.38). Among 58,684 individuals who were treated for HP from the whole NHIS-CDM cohort, the incidence of GC consistently decreased over time and showed a marked decrease with increasing age (p for trend < 0.05). Conclusions: In all age groups of the general population, HP treatment could be recommended to reduce the risk of GC.

Background/Aims The quality of bowel preparation is important for optimal colonoscopy. It is influenced by medical and personal factors. We aimed to evaluate the effect of bowel habit on the quality of bowel preparation and to identify predictors of inadequate bowel preparation among bowel habit factors. Methods : From June 2017 to September 2017, 90 volunteers were enrolled in this study. Each participant answered a questionnaire consisting of multiple questions about personal bowel habits, including stool form, frequency of bowel movements per week, duration, and degree of straining for bowel movement. Then, all volunteers underwent colonoscopic exam. Eleven endoscopists performed colonoscopies and used the Boston Bowel Preparation Scale (BBPS) as the index for bowel preparation. Two expert endoscopists simultaneously reviewed all colonoscopic images to confirm the final BBPS. Univariate and multivariate logistic regression analyses were performed to verify the correlation between bowel preparation adequacy and bowel habit. Results : Among the 90 participants, 20 (22.2%) had inadequate bowel preparation (total BBPS ≤6 or any segmental BBPS ≤1). In univariate analysis, infrequent bowel movement (0-2/week) (odds ratio [OR], 12.60; 95% confidence interval [CI], 1.22 to 129, p=0.03) and moderate straining (more than 1/4 of defecations) (OR, 4.40; 95% CI, 1.44 to 13.39; p=0.01) were significantly associated with inadequate bowel preparation. However, only moderate straining was significantly associated with inadequate bowel preparation in multivariate analysis (OR, 3.99; 95% CI, 1.26 to 12.65; p=0.02). Conclusion : s Straining is a significant predictor for inadequate bowel preparation. For patients with straining during bowel movements, an intensified preparation regimen should be considered.

Background and aims: Previous studies have reported that metformin use in patients with diabetes mellitus may reduce the risk of colorectal cancer (CRC) incidence and prognosis; however, the evidence is not definite. This population-based cohort study aimed to investigate whether metformin reduces the risk of CRC incidence and prognosis in patients with diabetes mellitus using a common data model of the Korean National Health Insurance Service database from 2002 to 2013. Methods: Patients who used metformin for at least 6 months were defined as metformin users. The primary outcome was CRC incidence, and the secondary outcomes were the all-cause and CRC-specific mortality. Cox proportional hazard model was performed and large-scaled propensity score matching was used to control for potential confounding factors. Results: During the follow-up period of 81,738 person-years, the incidence rates (per 1000 person-years) of CRC were 5.18 and 8.12 in metformin users and non-users, respectively (p = 0.001). In the propensity score matched cohort, the risk of CRC incidence in metformin users was significantly lower than in non-users (hazard ratio (HR), 0.58; 95% CI (confidence interval), 0.47–0.71). In the sensitivity analysis, the lag period extending to 1 year showed similar results (HR: 0.63, 95% CI: 0.51–0.79). The all-cause mortality was significantly lower in metformin users than in non-users (HR: 0.71, 95% CI: 0.64–0.78); CRC-related mortality was also lower among metformin users. However, there was no significant difference (HR: 0.55, 95% CI: 0.26–1.08). Conclusions: Metformin use was associated with a reduced risk of CRC incidence and improved overall survival.

Introduction: Helicobacter pylori (H. pylori) eradication can prevent metachronous gastric cancer (MGC) after the performance of an endoscopic resection for early gastric cancer (EGC). However, 50% of infections persist after eradication, and the identification of MGC protective factors is important. The anti-tumor activity of aspirin has been demonstrated, but its efficacy in preventing MGC remains controversial. We evaluated the effect of aspirin on metachronous recurrence in H. pylori-negative patients. Methods: A total of 4351 patients were evaluated between January 2007 and December 2016, and 2151 patients who met the inclusion criteria were analyzed. The primary outcome was the cumulative incidence of MGC after an endoscopic resection for EGC. Results: During a 5-year median follow-up (interquartile range, 3.5–6.2), MGC developed in 176 (7.7%) patients, with a cumulative incidence of 89.4% in aspirin users and 92.7% in non-users; this difference was not statistically significant (p = 0.64). The duration of aspirin uses and the occurrence of MGC in both groups were not significantly different. There was no significant difference between groups when the duration of aspirin use was categorized into ≤1 year (hazard ratio (HR), 0.64; 0.20–2.01, p = 0.45), 1–4 years (HR, 1.35; 0.66–2.76, p = 0.41), and >4 years (HR, 1.17; 0.67–2.03, p = 0.58). Conclusions: Aspirin use was not associated with a lower risk of MGC in H. pylori-negative patients. Further prospective studies are needed.

Background/Aims: Helicobacter pylori (H. pylori) infection has been known to cause various extra-gastric diseases, which may be mediated by an increase in systemic inflammation. Thus, we examined the association between H. pylori infection and various markers of systemic inflammation in a large sample of asymptomatic adults. Methods: Cross-sectional data were obtained from 17,028 adults who completed routine health check-ups. H. pylori infection status was determined using a serum immunoglobulin G test, and systemic inflammation was assessed using the C-reactive protein (CRP) levels, neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR). Results: Multiple linear regression model-adjusted for potential confounders-revealed that H. pylori infection was not associated with CRP levels (coefficient: -0.012, 95% confidence interval [CI]: -0.037, 0.012, p=0.319), NLR (coefficient: 0.055, 95% CI: -0.027, 0.138, p=0.192), or PLR (coefficient: 1.798, 95% CI: -1.979, 5.574, p=0.351). In a multivariable logistic regression model, H. pylori infection was not associated with the risk of CRP levels being elevated to ≥0.1 mg/dL (odds ratio: 0.96, 95% CI: 0.81, 1.08) or ≥0.3 mg/dL(odds ratio: 1.02, 95% CI: 0.84, 1.19). In the multivariable model, CRP levels elevated to ≥0.1 mg/dL were significantly associated with body mass index, current smoking status, hypertension, and diabetes mellitus. Regular exercise and high-density lipoprotein cholesterol were factors that minimized the elevation of CRP levels. Conclusions: Chronic infection with H. pylori was not associated with various inflammatory markers. Further investigation is needed to clarify the interaction between H. pylori infection, systemic inflammation, and extra-gastric disease.

Background /Aims: Epidemiologic and clinical data indicate that allergies may be associated with reduced risks for several cancers; however, to date, only a few studies have examined the associations between allergies and gastric cancer. This study aimed to examine the associations between allergies and gastric cancer using a large population-based dataset. Methods : This cross-sectional study obtained data from the Korea National Health and Nutrition Examination Survey between 2010 and 2014, involving a total of 24,089 participants. The associations between allergies and gastric cancer were analyzed using univariable and multivariable logistic regression analyses with complex sampling, while adjusting for confounding factors that included age, sex, body mass index, smoking status, alcohol intake, and level of education. Results : Multivariable logistic regression analyses that were adjusted for the potential confounders determined that a history of allergic diseases tended to be associated with reduced risk of gastric cancer; however, this relationship was not statistically significant (any allergy: odds ratio [OR], 0.62; 95% confidence interval [CI], 0.34-1.12; atopic dermatitis: OR, 0.34; 95% CI, 0.50-1.72; allergic rhinitis: OR, 0.71; 95% CI, 0.34-1.46; asthma: OR, 0.44; 95% CI, 0.15-1.29). Multivariable analysis showed that a history of atopic dermatitis was associated with reduced risk of gastric cancer in men (OR, 0.16; 95% CI, 0.03-0.75). Conclusions: This findings of this study suggest that individuals with allergies tend to have a reduced risk of gastric cancer, without a statistically significant association. Furthermore, atopic dermatitis was associated with reduced risk of gastric cancer, particularly in men.

Postoperative gastrointestinal bleeding (PGIB) is a serious complication with expensive medical costs and a high mortality rate. This study aims to analyze the incidence of PGIB and its associated factors, including its relationship with postoperative analgesic use. Patients aged ≥20 years who received various kinds of surgery from 2013 to 2017 were included (n = 1,319,807). PGIB was defined by admission with ICD-10 codes of gastrointestinal bleeding plus transfusion within 2 months after surgery. A total of 3505 (0.27%) subjects had PGIB, and the incidence was much higher for those who underwent major gastrointestinal and major cardiovascular surgery (1.9% for both), followed by major head and neck (0.7%), major genitourinary (0.5%), and orthopedic surgery (0.45%). On multivariate analysis, older age, male sex, lower income, comorbidities, peptic ulcer disease, and congestive heart failure were associated with a higher risk of gastrointestinal bleeding. Among analgesics, steroid use was associated with increased postoperative bleeding risk (adjusted OR: 1.36, 95% CI: 1.25–1.48). Acetaminophen/nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, anticonvulsants, antidepressants, and opioids were not associated with increased risk. PGIB is considerable for major surgeries, and its risk should be considered, especially for patients with older age and comorbidities and use of steroids.

Background/Aims: Levofloxacin resistance is increasing rapidly, and widely limits its application in Helicobacter pylori eradication. This study aimed to evaluate the efficacy of a clarithromycin- versus gemifloxacin-containing triple therapy regimen in first-line eradication of H. pylori infection. Materials and Methods: This was an open-label, prospective, non-randomized two-armed pilot study in which treatment-naïve subjects with active H. pylori infection received a seven-day triple therapy with rabeprazole 20 mg bid (twice daily), gemifloxacin 320 mg qd (once daily), and amoxicillin 500 mg bid (n=70) or seven-day triple therapy with rabeprazole 20 mg bid (twice daily), clarithromycin 500 mg bid (twice daily), and amoxicillin 500 mg bid (n=83). H. pylori infection status was checked in all patients at enrollment and at least 8 weeks after the end of therapy by the urea breath test. Results: Intention-to-treat eradication rates were 71.1% and 74.3% for clarithromycin-containing triple therapy and gemifloxacin-containing triple therapy, respectively (P=0.398). The corresponding per-protocol eradication rates were 76.6% and 76.1% (P=0.624). The gemifloxacin-containing triple therapy was associated with a lower incidence of adverse events (2.9% vs. 18.5%, P=0.003). Conclusions: Although the seven-day gemifloxacin-containing triple therapy regimen showed a more favorable safety profile, there was no significant difference in eradication rates between the gemifloxacin-containing and clarithromycin-containing triple regimens, and both regimens had eradication rates slightly lower than acceptable efficacy for the Korean population. Therefore, the gemifloxacin-containing regimen might be useful as an alternative regimen for patients showing severe side effects of clarithromycin due to poor tolerance. Further studies on the efficacy of gemifloxacin in the Korean population are warranted.

Previous studies have shown that statins reduce the risk of gastric cancer; however, their role has not been adequately studied in patients without Helicobacterpylori infection. We aimed to investigate whether statins reduced the risk of metachronous gastric cancer (GC) in H. pylori-negative patients who underwent endoscopic resection for early gastric cancer (EGC). Retrospective data of 2153 patients recruited between January 2007 and December 2016, with no H. pylori infection at baseline, who underwent resection for EGC, were analyzed. Metachronous GC was defined as a newly developed GC at least 1 year after endoscopic resection. Patients who used statins for at least 28 days during the follow-up period were considered as statin users. During a median follow-up of 5 years (interquartile range, 3.5–6.2), metachronous GC developed in 165 (7.6%) patients. In the multivariate Cox regression analysis, statin use was an independent factor associated with GC recurrence (adjusted hazard ratio (HR), 0.46; 95% confidence interval (CI), 0.26–0.82). Moreover, the risk of GC reduced with increasing duration (p trend = 0.011) and the dose of statin (cumulative defined daily dose (cDDD) < 500: HR 0.45, 95% CI 0.16–1.28; cDDD ≥ 500: HR 0.19, 95% CI 0.04–0.80; p trend = 0.008) in the propensity score-matched cohort. Statin use was associated with a lower risk of GC recurrence in H. pylori-negative patients with resected EGC in a dose-response relationship.

Although computed tomography (CT) scans are very useful for identification or surveillance of malignancy, they are also associated with the risk of cancer caused by ionizing radiation. We investigated the risk of second primary malignancies (SPMs) after frequent abdominopelvic CT scans in a cohort of Korean patients with early gastric cancer (EGC). We performed a cohort study of 11,072 patients who underwent resection for EGC at Samsung Medical Center and validated the results using data from 7908 patients in a Korean National Health Insurance Service cohort. Cox proportional hazards regression model was used to estimate hazard ratios (HRs) for intra-abdominal SPM. During 43,766.5 person-years of the follow-up at our center, 322 patients developed intra-abdominal SPMs. Patients who underwent receiving >8 abdominopelvic CT scans had a significantly greater risk of developing SPM (HR, 2.73; 95% CI, 1.66–4.50; p < 0.001) than those who had with ≤8 scans. For each additional abdominopelvic CT scan, the adjusted HR for SPM was 1.09 (95% confidence interval (CI), 1.03–1.14). Similar results were observed in the Korean National Health Insurance Service cohort (adjusted HR, 1.14; 95% CI, 1.07–1.22). Significantly elevated risk of SPM was still observed when considering a 2-year latency period (adjusted HR, 2.43; 95% CI, 1.37–4.48) and a 3-year latency period (adjusted HR, 2.17; 95% CI, 1.06–4.47). Frequent abdominopelvic CT scans are associated with an elevated risk of SPMs after the treatment of EGC. Thus, physicians need to weigh carefully the clinical benefits of CT examinations against the potential risks of radiation exposure.

Abstract Obesity is a well-known risk factor for colorectal neoplasia. Yet, the associations of both metabolic and obesity status with metachronous colorectal neoplasia remain unclear. We conducted a cohort study of 9,331 adults who underwent screening colonoscopy and surveillance colonoscopy. Participants were classified as metabolically healthy if they had no metabolic syndrome component. Participants were categorized into four groups according to body mass index and metabolic status: metabolically healthy non-obese (MHNO; n = 2,745), metabolically abnormal non-obese (MANO; n = 3,267), metabolically healthy obese (MHO; n = 707), and metabolically abnormal obese (MAO; n = 2,612). MAO individuals [n = 159 advanced colorectal neoplasia (AN) cases, 6.1%] and MANO individuals (n = 167 AN cases, 5.1%) had a higher incidence of AN compared with MHNO individuals (n = 79 AN cases, 2.9%). In a multivariable model, the risk of metachronous AN was higher in MANO (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.12–1.84) and MAO (HR 1.52, 95% CI 1.18–1.96) than in MHNO. In contrast, the risk of metachronous AN was not significantly elevated in MHO. In subgroup analyses, with or without adenoma at baseline, MAO was a risk group for metachronous AN, and MHO was not. Our findings suggest that metabolic unhealthiness is a significant predictor for metachronous AN.

Background/AimsStudies concerning the efficacy and safety of single-balloon enteroscopy (SBE) compared with that of double-balloon enteroscopy (DBE) often appear to be conflicting. However, previous studies were performed by endoscopists who were less experienced in SBE compared with DBE.Methods : We performed a retrospective analysis of SBE and DBE data performed by a single enteroscopist, with expertise in SBE, using a prospective balloon-assisted enteroscopy registry from 2013 to 2015. Furthermore, we performed a comprehensive literature search and meta-analysis of available studies, including the current study, to clarify the efficacy and safety of SBE versus DBE.Results : A total of 65 procedures in 44 patients with SBE and 74 procedures in 69 patients with DBE were analyzed. There were no significant differences in diagnostic yield (61.1% vs 77.3%, respectively, p=0.397), therapeutic yield (39.1% vs 31.8%, respectively, p=0.548), and complication rate (4.4% vs 2.3%, p=1.000). In the meta-analysis, which included four randomized controlled trials and three observational studies, there were no significant differences in the pooled relative risk and odds ratio for diagnostic and therapeutic yield and complications of SBE compared with those of DBE.Conclusion : sThe performance of SBE appears to be similar to that of DBE in terms of diagnostic and therapeutic yield and complications.

Background/Aims: The indications for colorectal endoscopic submucosal dissection (ESD) vary in clinical practice. To establish colorectal ESD as a standard treatment, standard indications are essential. For establishing standard indications for colorectal ESD, we surveyed the preferences and criteria of endoscopists for colorectal ESD in their practices.Methods: A multiple-choice questionnaire was sent to 27 members of the Korean Society of Gastrointestinal Endoscopy/ESD group. The indications of endoscopists for selecting ESD as a treatment for colorectal tumors ≥2 cm in diameter were surveyed.Results: On the basis of the preprocedural assessment of histology, adenoma with high-grade dysplasia, mucosal cancer, and shallow submucosa invasive cancer were included in the indication for ESD. Based on gross morphology, laterally spreading tumor (LST) granular nodular mixed type, LST-nongranular (LST-NG) flat elevated type, and LST-NG pseudodepressed type were included. On the basis of the pit pattern by Kudo classification, types III, IV, and V-I were included. Based on the narrow band imaging pattern by Sano classification, types II and III-a were included. Other lesions, such as sporadic localized tumors in chronic inflammation and local residual early carcinoma after endoscopic resection, were also included in the indication for ESD.Conclusions: The indications of Korean endoscopists for colorectal ESD are broader than those in recent guidelines, and tend to include more benign-looking tumors. To find the appropriate indications for colorectal ESD, systematic data collection and analysis are required to reach a consensus in a timely manner.

IntroductionOver the past decades, obesity stigma has become a substantial public health issue as studies have highlighted its negative consequences for mental and physical health. However, comparative studies are scarce. In this cross-national study, we focus on the following research questions: (1) Are there differences in the magnitude of public obesity stigma between Germany and the United States (US), and (2) are there differences in the associations of sociodemographic as well as experience (i.e. former obesity experience) and contact-related (i.e. contact to a person with obesity) factors with public obesity stigma between these two countries?Material and methodsNational telephone surveys in Germany and the United States were conducted (total sample = 2,802) by using vignettes for the description of a person with obesity. Fat Phobia Scale, negative reactions, and desire for social distance were assessed as components of public obesity stigma. All three stigma components were examined with multilevel linear regression analyses.ResultsOverall, results show that public obesity stigma is significantly more pronounced in the US than in Germany. Relationships between obesity stigma and sociodemographic as well as experience and contact-related factors remain rather inconclusive, though, in general, stronger associations are shown in the US.ConclusionsContrary to the normalization hypothesis, findings indicate that a comparatively high prevalence of obesity like in the US is associated with a higher level of obesity stigma.

The association between the 6-thioguanine nucleotide (6-TGN) level and clinical remission in Crohn's disease (CD) remains controversial. Thiopurine-induced leukopenia is a life-threatening complication of CD in Asians that was recently shown to strongly correlate with NUDT15 genetic variants. This study aimed to determine the relationship between thiopurine metabolite levels and therapeutic response, and to investigate the association of NUDT15, TPMT, and thiopurine metabolites with leukopenia in patients with CD. We enrolled 165 adult patients with CD undergoing thiopurine treatment. Clinical evaluation and laboratory examinations were carried out every 2-3 months. We measured thiopurine metabolites levels and genotyped NUDT15 and TPMT. During the median 12-month observational period, 95 (67.9%) patients exhibited clinical response and 45 (32.1%) did not respond to the treatment. The median 6-TGN level was significantly higher in responders than in non-responders (P < 0.001). The odds ratio of patients with a 6-TGN level ≥230 pmol/8 × 108 red blood cells for showing a clinical response was 4.63 (95% CI 1.62-11.9). NUDT15 variant types were strongly associated with developing leukopenia. Patients with NUDT15 homozygous variant genotype developed severe early leukopenia with an average reduction of 88.2% (range, 84-94%) from the baseline white blood cell count at 4 weeks. Our findings support the role of therapeutic drug monitoring in thiopurine maintenance treatment to optimize thiopurine therapy, especially, for non-responding CD patients. Thiopurine treatment should not be recommended to patients with NUDT15 homozygous variant genotype due to severe early leukopenia.

The association between obesity and peptic ulcer disease (PUD) is inconclusive. To evaluate the association of obesity and metabolically healthy obesity (MHO) with PUD risk, we performed a retrospective cohort study of 32,472 subjects without PUD at baseline who underwent repeated health examinations. Participants were stratified by body mass index (BMI) and metabolically healthy state. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazard modelling. During the follow-up period, 1940 PUD cases occurred. PUD, particularly gastric ulcer (GU), had significantly higher cumulative incidence in obese subjects compared to non-obese subjects (p value < 0.001). The HR for developing GU was 1.32 (95% CI, 1.16−1.49; p value Helicobacter pylori status), the association was no more significant (p value = 0.789). For duodenal ulcer (DU), cumulative incidence between obese and non-obese groups was not significantly different (p value = 0.464). The risk of developing DU in the obese group was not significantly different from the non-obese group (HR 0.95; 95% CI, 0.83−1.09; p value = 0.469) and consistently showed no association after adjusting for metabolic parameters (p value = 0.199). Furthermore, MHO subjects had no increase in GU or DU risks. In this large cohort study, PUD risk was not associated with obesity or MHO.

Purpose: The original eCura system was designed to stratify the risk of lymph node metastasis (LNM) after endoscopic resection (ER) in patients with early gastric cancer (EGC). We assessed the effectiveness of a modified eCura system for reflecting the characteristics of undifferentiated-type (UD)-EGC. Materials and Methods: Six hundred thirty-four patients who underwent non-curative ER for UD-EGC and received either additional surgery (radical surgery group; n=270) or no further treatment (no additional treatment group; n=364) from 18 institutions between 2005 and 2015 were retrospectively included in this study. The eCuraU system assigned 1 point each for tumors >20 mm in size, ulceration, positive vertical margin, and submucosal invasion <500 µm; 2 points for submucosal invasion ≥500 µm; and 3 points for lymphovascular invasion. Results: LNM rates in the radical surgery group were 1.1%, 5.4%, and 13.3% for the low- (0-1 point), intermediate- (2-3 points), and high-risk (4-8 points), respectively (P-fortrend<0.001). The eCuraU system showed a significantly higher probability of identifying patients with LNM as high-risk than the eCura system (66.7% vs. 22.2%; McNemar P<0.001). In the no additional treatment group, overall survival (93.4%, 87.2%, and 67.6% at 5 years) and cancer-specific survival (99.6%, 98.9%, and 92.9% at 5 years) differed significantly among the low-, intermediate-, and high-risk categories, respectively (both P<0.001). In the high-risk category, surgery outperformed no treatment in terms of overall mortality (hazard ratio, 3.26; P=0.015). Conclusions: The eCuraU system stratified the risk of LNM in patients with UD-EGC after ER. It is strongly recommended that high-risk patients undergo additional surgery. [ABSTRACT FROM AUTHOR]