Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique.

AIM: The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum. METHOD: Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events. RESULTS: The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029). CONCLUSION: Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.

A high-resolution anorectal manometry parameter based on integrated pressurized volume: A study based on 204 male patients with constipation and 26 controls.

BACKGROUND: Conventional anorectal manometric parameters based on linear waves cannot properly predict balloon expulsion (BE) time. We aimed to determine the correlation between integrated pressurized volume (IPV) parameters during simulated evacuation (SE) and BE time in healthy individuals and constipated patients and to assess the correlation between each parameter and symptoms. METHODS: A total of 230 male participants (including 26 healthy volunteers and 204 chronically constipated patients) underwent high-resolution anorectal manometry (HRAM) and BE tests. The IPV was calculated by multiplying the amplitude, distance, and time from the HRAM profile. Receiver operating characteristic curve (ROC) analysis and partial least square regression (PLSR) were performed. KEY RESULTS: ROC analysis indicated that the IPV ratio between the upper 1 cm and lower 4 cm of the anal canal was more effective for predicting BE time (area under the curve [AUC]: 0.74, 95% confidence interval [CI]: 0.67-0.80, P < .01) than the conventional anorectal parameters, including defecation index and rectoanal gradient (AUC: 0.60, 95% CI: 0.52-0.67, P = .01). PLSR analysis of a linear combination of IPV parameters yielded an AUC of 0.79. Moreover, the IPV ratio showed a greater clinical correlation with patient symptoms than conventional parameters. CONCLUSIONS AND INFERENCES: The IPV parameters and the combination of IPV parameters via PLSR were more significantly correlated with BE time than the conventional parameters. Thus, this study presents a useful diagnostic tool for the evaluation of pathophysiologic abnormalities in dyssynergic defecation using IPV and BE time.

Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up.

BACKGROUND: The beneficial effect of biofeedback therapy (BFT) over a period of more than 2 years has not been studied in a large group of patients. The aim of this study was to evaluate the long-term efficacy of BFT for dyssynergic defecation (DD). METHODS: We evaluated the results for 347 consecutive constipated patients with DD who underwent BFT for a median of five sessions between 2004 and 2009. Initial responses were assessed immediately after the completion of BFT. A responder was defined as a subject with at least a three-point improvement from before to after BFT on an 11-point global bowel satisfaction (GBS) scale, or a two-point improvement if the baseline GBS was more than six points. The probability of remaining a responder was estimated by non-parametric maximum likelihood estimation. KEY RESULTS: The initial response rate to BFT was 72.3% (n = 251), Parkinson's disease and higher baseline GBS scores were associated with initial non-response. The long-term efficacy of BFT was analyzed in 103 patients who were followed up for more than 6 months; the initial effects of BFT were maintained in 85 of the patients (82.5%) during a median of 44 months of follow-up (IQR = 12-68). The probability of remaining a responder was 60% at 2 years, and 58% at 5 years. CONCLUSIONS & INFERENCES: The efficacy of BFT is maintained for more than 2 years after BFT in a considerable proportion of constipated patients with DD. BFT is effective and durable treatment for managing DD.

Comparison of LTBI treatment regimens for patients receiving anti-tumour necrosis factor therapy.

SETTING: A tertiary referral centre in South Korea. OBJECTIVE: To compare the completion rates and adverse drug reactions of three latent tuberculous infection (LTBI) treatment regimens for patients receiving anti-tumour necrosis factor (anti-TNF) therapy. DESIGN: A total of 408 patients were diagnosed with LTBI before receiving anti-TNF therapy between December 2004 and December 2013. Nine months of isoniazid (9H), 4 months of rifampicin (4H) or 3 months of isoniazid/rifampicin (3HR) were prescribed. The results were analysed retrospectively. RESULTS: The mean age of the 408 study subjects was 44 years; 258 (63.2%) were male. The 9H, 4R and 3HR treatment regimens were given to respectively 61 (15.0%), 139 (34.1%) and 208 (51.0%) patients. A total of 362 (88.7%) patients completed the treatment. The treatment completion rate was highest in patients receiving 3HR (94.2%). Of the 408 patients, 54 (13.2%) had one or more adverse drug reactions; their frequency was similar in the three groups. CONCLUSIONS: In patients receiving anti-TNF therapy, 3HR seems to be the most acceptable treatment regimen for LTBI, given its high completion rate and acceptable rate of adverse drug reactions.

The 'either test positive' strategy for latent tuberculous infection before anti-tumour necrosis factor treatment.

SETTING: A ttertiary referral centre in South Korea. OBJECTIVES: The 'either test positive' strategy, incorporating both the tuberculin skin test (TST) and the T-SPOT(®).TB(T-SPOT) assay, was evaluated as a novel method for diagnosing latent tuberculous infection (LTBI) before treatment with anti-tumour necrosis factor (TNF) in patients with immune-mediated inflammatory diseases. DESIGN: From June 2008 to April 2012, 430 patients received anti-TNF treatment at our institution. TST and T-SPOT were performed simultaneously at baseline. LTBI was defined as a positive TST or a positive T-SPOT result. RESULTS: The positivity rates for the TST and T-SPOT assays were respectively 19.1% (82/430) and 44.2% (190/430), yielding an LTBI-positive rate of 48.6% (209/430). LTBI treatment was initiated in 46.0% (198/430) of patients and was completed by 89.4% (177/198). During follow-up (median 884 days), 0.9% (4/430) of the patients developed active tuberculosis (TB). All four TB patients were TST-negative at baseline, although two received LTBI treatment based on the baseline positive T-SPOT assay results. CONCLUSIONS: The either test positive strategy is a valid method for diagnosing LTBI before anti-TNF treatment, although it is not clear whether it is superior to other strategies.

Normal values for high-resolution anorectal manometry/topography in a healthy Korean population and the effects of gender and body mass index.

BACKGROUND: High-resolution manometry (HRM) based on spatiotemporal plots is increasingly being used. The aim this study was to evaluate, for the first time, the influence of gender, with adjustment for age, body mass index (BMI), and vaginal delivery, on anorectal functions in asymptomatic adults. METHODS: Fifty-four asymptomatic healthy subjects (M : F = 27 : 27; age = 20-67 years) who were matched by age and gender were enrolled prospectively. We evaluated anorectal pressures, rectal sensation using a HRM probe, and balloon expulsion time. Multivariate linear regression analysis was performed to identify the independent effects of each factor. KEY RESULTS: Anal resting pressure (median [IQR]; 32 [18] vs 46 [17] mmHg, p < 0.001), anal squeeze pressure (75 [28] vs 178 [72] mmHg, p < 0.001), rectal pressure (33 [16] vs 53 [46] mmHg, p = 0.009) and anal pressure (16 [17] vs 30 [36] mmHg, p = 0.019) during simulated evacuation with rectal distention, and the threshold for the desire to defecate (60 [20] vs 80 [60] mL, p = 0.020) were significantly lower in women than in men. BMI was positively correlated with anal resting pressure (95% CI: 0.598-2.947) and negatively correlated with the threshold for first sensation (95% CI: -0.099 to -0.015). Vaginal delivery did not affect any of the anorectal HRM parameters. CONCLUSIONS & INFERENCES: HRM parameters may be associated with gender and BMI. Therefore, gender and BMI should be taken into consideration when interpreting HRM results.

Incidence and clinical features of Clostridium difficile infection in Korea: a nationwide study.

The incidence and severity of Clostridium difficile infections (CDI) have increased in Western countries. However, there are limited data regarding the epidemiology of CDI in Eastern countries. This nationwide study was conducted in 17 hospitals to determine temporal trends in CDI incidence (from 2004 to 2008) in South Korea. The total incidence of CDI in Korea was 1·7 cases/1000 adult admissions in 2004, and 2·7/1000 cases in 2008 (P = 0·028). When analysing the clinical features of 1367 CDI patients diagnosed in 2008, oral metronidazole was effective as a first-line treatment for CDI (61·9%). Relapse rate was 8·9% and complicated CDI was only observed in 3·6%. The incidence of CDI increased significantly in Korea from 2004 to 2008. Although the clinical features were milder than in Western countries, the increasing burden of CDI needs ongoing surveillance systems.

Combined use of a TST and the T-SPOT®.TB assay for latent tuberculosis infection diagnosis before anti-TNF-α treatment.

BACKGROUND: Diagnosis of latent tuberculosis infection (LTBI) before anti-tumour-necrosis factor (anti-TNF) treatment is important. However, the tuberculin skin test (TST) has limitations, and the role of interferon-gamma release assays has not yet been determined. OBJECTIVE: To evaluate the combined use of TST and the T-SPOT(®).TB (T-SPOT) assay prior to anti-TNF treatment. METHODS: From July 2004 to March 2008, 281 patients were treated with anti-TNF agents. TST and T-SPOT were performed simultaneously at baseline. LTBI was defined as a positive TST of ≥10 mm induration or as a positive T-SPOT if TST was ≥5 mm but <10 mm. LTBI treatment was initiated, and patients were followed until August 2010. RESULTS: Positivity rates for TST and T-SPOT were respectively 33.6% (94/280) and 69.1% (186/269). LTBI treatment was initiated in 35.9% (101/281) of the patients, and active TB developed in 2.1% (6/281). Among the six TB patients, three were TST-negative at baseline and received no LTBI treatment, whereas all four who underwent T-SPOT showed positive results at baseline. CONCLUSION: In a TB-prevalent country, TST-defined LTBI diagnosis and treatment seem to be limited in preventing the development of TB before anti-TNF treatment. Further studies for T-SPOT alone or the combined use of TST and T-SPOT (either test positive strategy) for detecting LTBI are necessary.

Diagnostic sensitivity of culture and drug resistance patterns in Korean patients with intestinal tuberculosis.

SETTING: It is challenging to differentiate between intestinal tuberculosis (ITB) and Crohn's disease in areas where TB is still prevalent. The use of diagnostic tools and verifying the drug resistance patterns of ITB can be helpful for its correct diagnosis. OBJECTIVE: To determine the diagnostic sensitivity of a culture assay using colonoscopic biopsy specimens and the drug resistance patterns of Mycobacterium tuberculosis isolated from ITB. DESIGN: Data from 400 patients diagnosed with ITB were retrospectively analysed. RESULTS: Of the 400 patients, 170 (42.5%) were males; the median age at diagnosis was 40 years. The sensitivity of culture was 44.1% (145/329). Resistance to at least one anti-tuberculosis drug was identified in 13 (17.6%) and multidrug-resistant TB (MDR-TB) was diagnosed in two (2.7%) of the 74 patients for whom drug susceptibility testing was performed. Including M. tuberculosis isolated from respiratory specimens, the proportion of MDR-TB was 4.4% (5/113); previous anti-tuberculosis treatment was an independent risk factor for MDR-TB (26.7% vs. 1.0%, P < 0.01). CONCLUSION: Culture of colonoscopic biopsy specimens shows substantial diagnostic sensitivity; the frequency of MDR-TB is higher in previously treated cases than in new cases.

Long term follow-up of appendiceal and distal right-sided colonic inflammation.

The aim of this study was to investigate the possibility of appendiceal orifice inflammation (AOI) as a preceding lesion in the development of ulcerative colitis. A total of 20 patients were identified (mean age 41.2 years; 11 males) who had ulcerative colitis-like inflammatory lesions at the appendiceal orifice without concomitant typical features of ulcerative colitis, such as rectal involvement. A total of 19 patients were followed up endoscopically for a mean duration of 18.4 months (range 2 - 84 months). Typical ulcerative colitis developed in five patients (25 %; four proctitis, one pancolitis) in a mean time of 18.4 months (range 2 - 36 months). Negative conversion of all inflammatory lesions occurred in seven patients (35 %) after a mean follow-up of 20 months (range 3 - 84 months). In the remaining seven patients (35 %), initial lesions did not progress to ulcerative colitis and did not go into remission during a mean follow-up of 16.9 months (range 2 - 42 months). These results suggest that, at least in some cases, AOI precedes development of ulcerative colitis.

Omeprazole may be superior to famotidine in the management of iatrogenic ulcer after endoscopic mucosal resection: a prospective randomized controlled trial.

BACKGROUND: Acid suppressing agents are widely used to treat the iatrogenic ulcers following endoscopic mucosal resection for gastric neoplasms. However, the relative merits of proton pump inhibitor or histamine(2)-receptor antagonist for endoscopic mucosal resection-induced ulcers are not known. AIM: To prospectively compare omeprazole and famotidine for the healing of endoscopic mucosal resection-induced ulcers and for bleeding control. METHODS: After endoscopic mucosal resection, patients were randomly assigned to omeprazole (20 mg/day) or to famotidine (40 mg/day) group for a 28-day treatment period. The ulcer sizes and stages, bleeding rates and ulcer-related symptoms were compared. RESULTS: A total of 100 patients were randomized equally to each group. Forty-one patients in each group were finally compared. The two groups were comparable in terms of baseline characteristics. Twenty-eight days after treatment, the two groups were not different with respect to ulcer stage (P = 0.137) or ulcer reduction ratio (P = 0.380). No difference was observed with respect to ulcer-related symptoms (P = 0.437) and no bleeding episode occurred in any of the 82 patients. In subgroup that underwent endoscopic submucosal dissection, fewer patients in the omeprazole group showed active ulcers than those in the famotidine group (P = 0.035). CONCLUSION: Our results demonstrate that omeprazole may be superior to famotidine for iatrogenic ulcers following endoscopic mucosal resection, especially for large ulcers.