Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm?

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<0.05). There was no difference between the prophylactic hemostasis and nonprophylactic hemostasis groups, including the occurrence rate of delayed bleeding. In the second-look group with prophylactic hemostasis, the hospital stay was more prolonged than in the second-look group without prophylactic hemostasis, but there was no significant difference (p=0.08). CONCLUSIONS: Second-look endoscopy to prevent delayed bleeding after ESD provides no significant medical benefits.

Corrosive Esophagitis Caused by Ingestion of Picosulfate

Corrosive esophagitis is characterized by caustic injury due to the ingestion of chemical agents, mainly alkaline substances such as detergents. Esophageal bleeding, perforation, or stricture can be worsened by high-degree corrosive esophagitis. Picosulfate is a commonly used laxative frequently administered for bowel preparation before colonoscopy or colon surgery. Picosulfate powder should be completely dissolved in water before ingestion because the powder itself may cause chemical burning of the esophagus and stomach. Here, we report a case of corrosive esophagitis due to the ingestion of picosulfate powder that was not completely dissolved in water.

Establishment of a Daily E-mail Learning Program Using Intranet and It's Initial Evaluation

BACKGROUND/AIMS: We started a daily web-based E-mail learning program about gastrointestinal (GI) endoscopy. We surveyed the opinion of the E-mail recipients about the usefulness of the daily E-mail learning program. MATERIALS AND METHODS: Using the intranet system, PDF-file based education materials about interesting endoscopic cases were sent to 144 members of Samsung Medical Center every day. It included every resident of the Department of Medicine, and every fellow of the Division of Gastroenterology. They were invited to answer the questionnaires using E-mail. RESULTS: A total of 92 subjects replied the questionnaire (response rate: 64%). About half of the members (47%) answered that they read the education material in the morning. They answered that they read about more than 75% of the material (48%). It took less than 5 minutes to read a daily material (87%). However, only 13 percent answered that they have sent questions to the editor of the program via E-mail. The members wanted more information about GI pharmacologic treatment (54%). Also, they wanted more cases of benign and malignant upper GI diseases (54%). CONCLUSIONS: In our endoscopy unit, we have successfully established a daily E-mail learning program. It seems to be very useful for teaching and learning interesting cases during busy working hours.

The Role of the CpG Island Methylator Phenotype on Survival Outcome in Colon Cancer

BACKGROUND/AIMS: CpG island methylator phenotype (CIMP)- high colorectal cancers (CRCs) have distinct clinicopathological 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 population 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 markers using the five-marker panel (CACNA1G, IGF2, NEUROG1, RUNX3, and SOCS1). RESULTS: CIMP-high and CIMP-low/negative cancers were observed in 27 patients (17.5%) and 127 patients (82.5%), respectively. Multivariate analysis adjusting 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: Regardless of the MSI status, CIMP-high cancers had poor survival outcomes in Korean patients.

The Role of the CpG Island Methylator Phenotype on Survival Outcome in Colon Cancer

BACKGROUND/AIMS: CpG island methylator phenotype (CIMP)- high colorectal cancers (CRCs) have distinct clinicopathological 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 population 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 markers using the five-marker panel (CACNA1G, IGF2, NEUROG1, RUNX3, and SOCS1). RESULTS: CIMP-high and CIMP-low/negative cancers were observed in 27 patients (17.5%) and 127 patients (82.5%), respectively. Multivariate analysis adjusting 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: Regardless of the MSI status, CIMP-high cancers had poor survival outcomes in Korean patients.

The Feasibility and Safety of the Endoscopic Submucosal Dissection of Superficial Gastric Neoplastic Lesions in Patients with Compensated Liver Cirrhosis: A Retrospective Study

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.

Endoscopic Submucosal Dissection of Early Gastric Cancer

Gastric cancer is the most common cancer worldwide. The proportion of early gastric cancer (EGC) cases at diagnosis has increased because of the use of mass screening endoscopy in older adults. Endoscopic mucosal resection has become the standard treatment for EGC in cases with standard indications because of its low risk of lymph node metastasis. A new endoscopic method, endoscopic submucosal dissection, has recently become available. This method allows en bloc resection without limitation of the size of the lesion. The goal of this article is to review the history and methods of endoscopic treatment with EGC, the conventional and extended indications, the therapeutic outcomes, and the complication rates.

Efficacy of Bispectral Index Monitoring for Midazolam and Meperidine Induced Sedation during Endoscopic Submucosal Dissection: A Prospective, Randomized Controlled Study

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.

Characteristics of Gastric Cancer in Korea - with an Emphasis on the Increase of the Early Gastric Cancer (EGC)

Gastric cancer is the most common malignancy and the second leading cause of cancer-related death in Korea. Age-adjusted annual incidence of gastric cancer per 100,000 persons is 62.8 for male and 25.7 for female. The proportion of early gastric cancer among surgically treated gastric cancer patients was 28.6% in 1995, 32.8% in 1999, and 47.4% in 2004. Screening upper endoscopy is quite commonly performed in Korea, and the proportion of early gastric cancer in the screened population is almost 75%. Gastric adenoma is considered to be a very important precancerous lesion. Gastric adenomas are actively treated in Korea, and at least 1/3 of the gastric adenomas with high grade dysplasia show cancerous focus when endoscopically resected. The prevalence of Helicobacter pylori is decreasing in Korean population, which may lead to the decreased incidence of gastric cancer in the near future. Paradigms of the diagnosis and treatment of gastric cancer are rapidly changing in Korea. Efforts to establish robust scientific data for new approaches are strongly required. The proportion of early gastric cancer among all gastric cancers has been and will be more increased in Korea.

Treatment of upper gastrointestinal bleeding: with emphasis on peptic ulcer bleeding / 대한내과학회지

No abstract available.

A Case of Carcinosarcoma in the Liver / 대한소화기학회지

Primary hepatic carcinosarcoma which has comprised of a mixture of both carcinomatous and sarcomatous elements is very rare. This tumor has been variously called as carcinosarcoma, pleomorphic large cell carcinoma, giant cell carcinoma, or undifferentiated carcinoma. Only less than 20 cases of carcinosarcoma of the liver have been reported sporadically up to now worldwide. Herein, we present a case of carcinosarcoma of the liver along with a review of the literatures.

An Evaluation of Web-based Information about Barrett's Esophagus in Korea / 대한소화기학회지

BACKGROUND/AIMS: Internet has become an important source of medical information not only for doctors but also patients. However, information available in the Internet may provide wrong or even harmful knowledge to the public. The aim of this study was to evaluate the quality of Internet-based medical information about Barrett's esophagus in Korea. METHODS: The first 50 Internet links were retrieved from the Google using the key word 'Barrett's esophagus'. The quality of information from a total of 49 websites was evaluated using a checklist. RESULTS: Among total 49 sites related to 'Barrett's esophagus', only 4 sites (8.2%) were made by hospitals or clinics, and 11 sites (22.4%) were for patients. Of the 49 sites, only one web site (2.0%) had all HON CODE principles (authority, complementarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, honesty in advertising and editorial policy). Sixteen Internet links (32.0%) had fair contents for the definition, and 24 links (48.0%) for the diagnosis, and 15 links (30.0%) for the treatment. CONCLUSIONS: Information about Barrett's esophagus was incomplete in the majority of medical web sites. It will bring about confusion in patients who want to get information about Barrett's esophagus from the Internet. There is a need for better evidence-based information about Barrett's esophagus on the web.

A Case of Gastritis Cystica Profunda Associated with High Grade Tubular Adenoma / 대한소화기학회지

Gastritis cystica profunda is usually characterized by hyperplastic and cystic dilatation of pseudopyloric gland with submucosal invasion. These lesions possess malignant histologic features as metaplastic and even dysplastic alteration can be observed, however they usually exhibit benign behavior. Macroscopically, gastritis cystica profunda may present as a submucosal tumor or as a polyp. In rare case, however, it can be found as a giant mucosal fold. The proposed pathogenesis of lesion relates to ischemia, chronic inflammation, and the presence of foreign body. Herein, we report a case of gastritis cystica profunda associated with high grade tubular adenoma in a patient without antecedent surgery.

The evaluation and treatment of patients with dyspepsia and Helicobacter pylori infection in Korean primary care physician / 대한내과학회지

BACKGROUND: Although Helicobacter pylori infection is now known to be the most common cause of various gastrointestinal diseases and progress in our knowledge about H. pylori is remarkable, whether this knowledge is transferred to general community of practicing physicians is questionable. We wished to investigate the clinical practice and prescribing patterns for dyspepsia and H. pylori infection in primary care in Korea. METHODS: We obtained information about the patterns of practice from reply to questionnaire by mail to physician. We restricted our study to the primary care physicians registered on the Korean Association of Internal Medicine Practitioners. The questionnaire was made of three compartments, which were diagnostic evaluation of dyspepsia, indication and methods of diagnosis and management in H. pylori infection. RESULTS: In case with initial visit of dyspeptic patient, 64.1% of physicians prescribe prokinetics (85.7%), antacid (61.5%), histamine-2-receptor blockers (59.4%), initially. The indications of H. pylori test were as follows; 91.6% in gastric ulcer including scar, 85.3% in duodenal ulcer, 59% in patient-want cases, 51.9% in gastric cancer, 42.7% in gastritis, and 22.8% in gastro-oesophageal reflux disease. And the indications of H. pylori eradication were as follows; 90.6% in gastric ulcer, 88.7% in duodenal ulcer, 35% in gastric cancer, 30.7% in gastritis, 23.5% in patient-want cases, and 24.8% in gastro-oesophageal reflux disease. In addition, 79.7% of physicians prescribe triple therapy including clarithromycin and amoxicillin for H. pylori eradication. CONCLUSION: From this study, we obtained more information about the clinical practice and prescribing patterns about dyspepsia and H. pylori related diseases. More studies are needed to prepare the guidelines for H. pylori under close cooperation between primary care physicians and tertiary hospitals.

A Case of Minimal Change Nephrotic Syndrome Associated with Kimura Disease / 대한신장학회잡지

Kimura disease (KD) is a chronic angiolymphoid proliferative disorder of soft tissue with eosinophilia and elevated IgE levels, with predilection for head and neck in young oriental men. Renal disease is often associated with it. We describe a 16-year-old male with KD and steroid-responsive minimal change nephrotic syndrome. After surgical resection of cervical tumor and steroid therapy, complete remission of nephrotic syndrome and KD was achieved and there has been no relapse of tumor and nephrotic syndrome with normal IgE levels over 12 months.

The Impact of Gene Polymorphisms of Interleukin-10 and Interferon-gamma on the Clinical Courses of Renal Transplant Patients in Korea / 대한신장학회잡지

BACKGROUND: The single nucleotide polymorphism (SNP) of interleukin-10 and the variable number of tandem repeat (VNTR) of CA dinucleotide of Interferon-gamma are reported to have an influence on the production of IL-10 and IFN-gamma respectively. The aims of this study are to investigate the gene polymorphisms of IL-10 and IFN-gamma in Korean renal transplant patients and to assess their impacts on the clinical courses of renal allografts. METHODS: The one hundred eighty-five patients who received renal allografts and were followed for more than 5 months from 1991 to May 2000 in Kangdong Sacred Heart Hospital, and ninety-eight normal healty controls were investigated. Three SNPs in promoter region of IL-10 gene were assayed by PCR-RFLP. The (CA) dinucleotide repeat polymorphism of IFN-gamma were assessed by evaluation of size of PCR products. RESULTS: Allele*2 and allele*3 were major alleles of IFN-gamma in our study and there was no significant difference of alleleic and genotypic distribution between recipient and control group. The -592*A and -592*C in the IL-10 promotor region were tightly linked to -819*T and -819*C, respectively. The frequency of -1082*G/*A genotype of recipent group was 7.0% and smaller than that of control group (17.3%, p=0.02). The *G/*G genotype (IL-10 high producer) was absent in all our study subjects, which was quite different from Western studies. IFN-gamma and IL-10 gene polymorphisms had no impact on the incidence and severity of acute rejection, and long term graft fucntion after transplantation. CONCLUSION: Unlike IFN-gamma the SNPs of IL-10 promoter were quite different from those in Western patients. The frequency of -1,082*G/*A genotype of IL-10 was smaller in recipient group. In conclusion, the polymorphisms of IL-10 and IFN-gamma had no impact on the clinical courses of renal allografts under the current therapeutic strategies.