Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis

BACKGROUND/AIMS: A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG. METHODS: Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0. RESULTS: Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted. CONCLUSIONS: The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.

Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis

BACKGROUND/AIMS: A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG. METHODS: Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0. RESULTS: Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted. CONCLUSIONS: The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.

Effect of Helicobacter pylori Eradication According to the IL-8-251 Polymorphism in Koreans

Previous studies suggested that polymorphisms of proinflammatory cytokine genes are important host genetic factors in Helicobacter pylori infection. The present study evaluated whether IL-8-251 polymorphism affected H. pylori eradication rate and to investigate the effect of H. pylori eradication on angiogenesis and the inflammatory process according to the IL-8-251 polymorphism. A total of 250 H. pylori-positive patients treated by endoscopic resection of the gastric neoplasm were classified into 3 groups (134 H. pylori-eradicated group, 19 H. pylori-eradication failure group, and 97 H. pylori-infected group). H. pylori status, histology, and angiogenic factor levels were evaluated at baseline, 6 months, and 18 months. H. pylori eradication rate was 92.9% in AA genotype, 85.7% in AT genotype and 88.4% in TT genotype (P value = 0.731). Elevated IL-8 and matrix metalloproteinase-9 concentrations in H. pylori-infected gastric mucosa were reversible by successful eradication of H. pylori, independent of the IL-8-251 polymorphism. It is suggested that elevated IL-8 and MMP-9 concentrations in H. pylori-infected gastric mucosa are altered significantly after successful eradication and these conditions continue for 18 months. However, IL-8-251 polymorphism does not affect H. pylori eradication rate and the sequential changes of related angiogenic factors after H. pylori eradication in Koreans.

Effect of Helicobacter pylori Eradication on High Density Lipoprotein Cholesterol and Prevalence of Metabolic Syndrome

BACKGROUND/AIMS: Helicobacter pylori causes extragastric manifestations, including dyslipidemia and metabolic syndrome. However the effects of eradication of H. pylori infection on dyslipidemia and metabolic syndrome have shown conflicting results. We aimed to investigate the effect of eradication therapy on parameters of dyslipidemia and metabolic syndrome and prevalence of metabolic syndrome. MATERIALS AND METHODS: Subjects who received eradication therapy between August 2004 and June 2010 and who underwent health checkup one year after eradication were enrolled in this study. Parameters of dyslipidemia and metabolic syndrome before and after eradication were collected and tested for significant changes. Prevalence of metabolic syndrome before eradication was also compared with that after treatment. RESULTS: Of the 452 subjects enrolled, 324 subjects were males. In male, HDL cholesterol was significantly elevated after eradication treatment in both young (50) age group. Other metabolic parameters such as waist circumference, body mass index, total cholesterol, triglyceride, LDL cholesterol, fasting glucose, systolic and diastolic blood pressure, and c-reactive protein were not significantly different after eradication in both age group. In female, triglyceride increased significantly and HDL cholesterol decreased after eradication in the old age group. But in the young age female group all the metabolic parameters showed no changes. There were no significant changes in prevalence of metabolic syndrome after eradication treatment in both genders. CONCLUSIONS: Helicobacter eradication caused elevation of HDL cholesterol in males. Eradication therapy showed no effect on prevalence of metabolic syndrome.

Effect of After-hours Emergency Endoscopy on the Outcome of Acute Upper Gastrointestinal Bleeding / 대한소화기학회지

BACKGROUND/AIMS: Gastrointestinal endoscopy is imperative for acute upper gastrointestinal bleeding (AUGIB) to find bleeding focus and stop bleeding. This study was designed to assess the necessity of emergency endoscopy and determine screening criteria for the patients who presented to emergency room (ER) with after-hours AUGIB. METHODS: The medical records of 383 patents with AUGIB who presented to ER at after-hours were reviewed. Patients were divided into 2 groups: emergency endoscopy (EE) group (<12 hours after arrival) or delayed endoscopy (DE) group (12-24 hours after arrival). We compared the severity, hemostatic procedures, rebleeding rate, length of hospitalization and 30-day mortality between the two groups. RESULTS: Ninety-eight patients in EE group and 137 patients in DE group were evaluated among patients with non-variceal upper gastrointestinal bleeding. No significant differences in clinical severity, finding the bleeding focus, hemostasis, 30-day mortality, hospital stay, and rebleeding rate were observed between the two groups. Among 148 patients with variceal upper gastrointestinal bleeding, 65 patients were in EE group and 83 patients in DE group. Most clinical severity index were not different between the groups. In EE group, the rate of finding bleeding foci was lower (p=0.043), and 30-day mortality was higher than in DE group (p=0.023). CONCLUSIONS: Emergency endoscopy within 12 hours after arrival at after-hours do not lead to better prognosis in AUGIB.

Management Strategies for Gallbladder Polyps: Is It Possible to Predict Malignant Gallbladder Polyps?

BACKGROUND/AIMS: Gallbladder (GB) polyps are commonly encountered in clinical practice, and are found more frequently as the number of medical screening examinations increases. The aim of this study was to determine optimal practice guideline for surgical treatment and follow-up of GB polyps. METHODS: Data from healthy subjects of Seoul National University Hospital (SNUH) Health Care System of Gangnam Center were used to investigate the true prevalence of GB polyps. We also enrolled 689 patients with GB polyps diagnosed at SNUH from May 1st, 1988 to April 30th, 2006. RESULTS: The GB polyp prevalence was 6.1% (7.1% in males and 4.8% in females). The median follow-up duration in the 689 study patients was 60 months, and 139 (20%) of them had polyps > or =10 mm in size. Twenty-five of the 180 patients who underwent cholecystectomy had adenocarcinomas. The chi-square test was used to identify which of the following were risk factors of malignancy: age, sex, symptoms, size, rate of growth, multiplicity, accompanying stones, and shape. Age (> or =57 years), presence of symptoms, size (> or =10 mm), and shape (sessile) were found to be statistically significant risk factors by univariate analysis. However, multivariate analysis identified only age (> or =57 years) and size (> or =10 mm) as independent predictors of malignancy. CONCLUSIONS: The present study shows that GB polyps > or =10 mm in size in patients aged > or =57 years are the independent factors predicting malignancy of the GB.

Endoscopic Ultrasonography-guided Tru-Cut Biopsy for Differential Diagnosis in the Gastrointestinal Mesenchymal Neoplasm / 대한소화기내시경학회지

BACKGROUND/AIMS: Risk assessment by mitotic count in the gastrointestinal stromal tumor (GIST), the most common mesenchymal neoplasm, is important. EUS-guided fine- needle aspiration cannot obtain sufficient tissue for determination of mitotic count, but An EUS-guided Tru-Cut biopsy (EUS-TCB) can. The aim of this study was to evaluate clinical role of EUS-TCB in differential diagnosis of mesenchymal neoplasm and risk assessment of GIST. METHODS: We prospectively enrolled 18 patients who were diagnosed with submucosal hypoechoic tumors, 2~5 cm, in the muscular layer by EUS in Seoul National University Hospital from November, 2005, to July, 2007. The rates of adequate biopsy and possibility of risk assessment were evaluated. RESULTS: EUS-TCB was performed in 16 patients. The median tumor size was 2.7 cm, and adequate diagnosis was possible in 8 patients. Tumor size in the adequate specimen group was larger than in the inadequate group (p=0.021). The number of needle passes was higher in the adequate specimen group (p=0.012). Risk assessment by mitotic count was possible in only one case. CONCLUSIONS: EUS-TCB in the diagnosis and risk assessment of GIST was inadequate, in part because of insufficient operator experience and small tumors. Development of a new instrument is needed to obtain sufficient tissue.

Risk Factors for Upper Gastrointestinal Rebleeding in Critically Ill Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: To determine the incidence and risk factors associated with rebleeding after upper gastrointestinal bleeding (UGIB) in critically ill patients. METHODS: This study retrospectively reviewed the medical records of 60 patients undergoing bedside esophagogastroduodenoscopy between April 2000 and February 2004 for UGIB that developed whilst in the intensive care unit (ICU). RESULTS: Eight out of 60 patients died within 7 days, and an additional 7 patients died within 30 days after the initial bleeding. Two of these 15 patients (13.3%), died from GI bleeding. The 7-day and 30-day rebleeding rates were 34.6% (18/52 patients), and 51.1% (23/45 patients), respectively. Multiple logistic regression using the significant variables revealed, anemia (Hb or =3 units) to be significant independent risk factor for 30-day rebleeding. CONCLUSIONS: The rebleeding rates in the ICU setting were as high as 34.6% at 7 days and 51.1% at 30 days. This suggests that the underlying conditions of the critically ill patients affect the rebleeding rate more than the endoscopic features. Therefore, adequate general ICU care including the prevention and correction of hypoxia, anemia, and hypoalbuminemia, and minimizing blood loss can reduce the risk of rebleeding after UGIB in an ICU setting.

The Diagnostic Accuracy of Endoscopic Ultrasonography for the Preoperative Staging of Gastric Cancer: the Risk of Overstaging and Understaging / 대한소화기내시경학회지

BACKGROUND/AIMS: The preoperative staging of gastric cancer facilitates the planning of therapy. Preoperative endoscopic ultrasonography is a useful procedure for the staging of gastric cancer, but sometimes there can be problems with overstaging and understaging. METHODS: Endoscopic ultrasonography was performed preoperatively on 171 patients with gastric cancer. The results of endoscopic ultrasonography were compared with the postoperative histological staging. RESULTS: The overall accuracy of endoscopic ultrasonography for the determination of the T stage was 65.5%, the overall accuracy was 74.4%, 51.7% and 38.9% for determining the T1, T2 and T3 staging, respectively. Endoscopic ultrasonography had an accuracy of 67.3% for determining the absence of lymph node metastasis. In univariate analysis, the diagnostic accuracy was lower for infiltrative type and gastric cancer with microinvasion significantly. Multivariate analysis showed overstaging occurred for gastric cancers with concomitant ulcer, inflammation or submucosal fibrosis (p=0.004) and that understaging occurred for gastric cancers with infiltrative type or microinvasion (p=0.029, p<0.001). CONCLUSIONS: Endoscopic ultrasonography is a valuable diagnostic tool for most gastric cancers with some exceptions due to the overstaging and understaging. Gastric cancers with concomitant ulcer, inflammation or submucosal fibrosis may contribute to overstaging. By contrast, gastric cancers with infiltrative type or microinvasion may result in understaging.

A Case of Exophytic Squamous Cell Carcinoma of the Stomach / 대한소화기내시경학회지

Squamous cell carcinoma of the stomach has been reported to occur at a younger age and have a worse prognosis than gastric adenocarcinoma. Even though squamous cell carcinoma of the stomach has several different clinical characteristics, it is difficult to distinguish it from gastric adenocarcinoma by radiological or endoscopical methods without a histopathological confirmation. Primary squamous cell carcinoma of the stomach is a rare type of cancer. To date, only six cases have been reported in Korea. Gastric cancer seldom grows exophytically and there are no reports of squamous cell carcinoma of the stomach with exophytic growth in Korea. We report a case of pure squamous cell gastric cancer with exophytic growth with a brief review of the relevant literature.