Endoscopic Findings of Upper Gastrointestinal Involvement in Primary Vasculitis.

BACKGROUND/AIMS: Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis. METHODS: Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records. RESULTS: Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis. CONCLUSIONS: Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

Endoscopic Resection for Undifferentiated-Type Early Gastric Cancer: Immediate Endoscopic Outcomes and Long-Term Survivals.

BACKGROUND: Endoscopic resection (ER) is considered carefully as a curative treatment option for selected cases of undifferentiated-type early gastric cancer (UEGC). This study investigated immediate endoscopic and long-term survival outcomes of patients with UEGC treated with ER. METHODS: A review of a database of 2483 EGC consecutively enrolled patients who underwent ER between January 2004 and December 2010 identified 101 patients with UEGC who met the expanded indications. Outcomes were investigated in these patients. RESULTS: The rates of R0 en bloc and curative resection were 86 and 70 %, respectively. Of 30 tumors non-curatively resected, 17 were larger than 20 mm in diameter, 12 had positive resection margins, and 13 had submucosal or lymphovascular invasion on resection pathology. ER-related complications occurred in 12 patients (12 %), with all complications treated endoscopically without surgery. The median ER procedure time was 26 min [interquartile range (IQR) 20-39 min]. Only tumor location in the lower part of the stomach was significantly associated with curative ER (P = 0.038). Tumor recurrence was observed in seven patients at a median 17 months (IQR 12-47 months) after ER. During a median follow-up of 60 months (IQR 48-80 months), the 5-year overall mortality rates were 5 % in the curative and 4 % in the non-curative resection groups (P = 0.927). There were no gastric cancer-related deaths. CONCLUSIONS: ER shows acceptable immediate endoscopic and long-term survival outcomes in selected patients with UEGC.

Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms.

BACKGROUND: Bleeding is a major complication following endoscopic resection (ER) of gastric mucosal lesions. We aimed to determine the risk factors for post-ER bleeding and their correlations according to the time elapsed since the procedure. METHODS: We retrospectively enrolled 670 lesions in 610 patients who underwent ER between March 2009 and December 2010. We classified these lesions into three types in accordance with the bleeding time, i.e., immediate bleeding (IB), early delayed bleeding (EDB), and late delayed bleeding (LDB). We analyzed the risk factors for each bleeding type according to baseline patient characteristics, procedure-related factors, and correlations between the occurrence of each bleeding type. RESULTS: There were 408 post-ER bleeding events in our study cohort: 302 IB events, 88 EDB events, and 18 LDB events. In multivariate analysis, a histologic finding of carcinoma and the resection time were significant predictors of IB (p < 0.001). Of the 302 IB events, 13.9% showed EDB. Additionally, LDB occurred in 2.4% of lesions with EDB and 4.6% of lesions without EDB. Similar to the IB group, of 368 lesions without IB, 12.5% showed EDB. In addition, LDB occurred in 2.2% of lesions with EDB and 1.2% of lesions without EDB. IB was associated with a higher risk of EDB (p < 0.001) and LDB (p < 0.001), whereas EDB was not related to an increased risk of LDB (p = 0.997). CONCLUSION: IB significantly increases the risk of EDB and LDB, but EDB does not increase the risk of LDB. Histologically confirmed carcinoma or a prolonged time for resection increases the risk of post-ER IB. We recommend careful follow-up approaches following ER of a gastric mucosal lesion in high-risk patients to prevent a potentially critical occurrence of delayed bleeding.

Clinical Outcomes of Postoperative Upper Gastrointestinal Leakage According to Treatment Modality.

BACKGROUND & AIM: We evaluated the clinical outcomes according to treatment modality for gastrointestinal anastomotic leakage. METHODS: Of the 19,207 patients who underwent gastrectomy for gastric cancer from March 2000 to April 2013, we retrospectively analyzed the 133 cases who developed anastomotic leakage. These patients were treated using endoscopic management, surgery, or conservative management (endoscopic treatment was introduced in 2009). To evaluate the efficacy of endoscopic treatment, we compared the clinical outcomes between the conservative management-only group before 2009 and the conservative or endoscopic management group from 2009; and between the surgical management-only group before 2009 and the surgical or endoscopic management group from 2009. RESULTS: Seventy-three were initially managed conservatively, 35 were treated surgically, and 25 were treated using endoscopic procedures. Chronologically comparing each treatment group as 'before 2009' (n = 54) and 'from 2009' (n = 79), there were differences in the length of hospital stay (median 32 versus 27, p = 0.048) and duration of antibiotic use (median 28 versus 20, p = 0.013). Patients who underwent conservative or endoscopic management from 2009 showed a shorter hospital stay, period of fasting, and duration of antibiotic use than patients who underwent only conservative management before 2009. Patients who received surgery or endoscopic management from 2009 showed a shorter hospital stay and duration of antibiotic use than patients who underwent only surgery before 2009. CONCLUSION: Endoscopic management for selected cases can reduce duration of hospital stay and antibiotic administration in the treatment of anastomotic leakage after gastrectomy.

Use of Endoscopic Ultrasound to Evaluate Large Gastric Folds: Features Predictive of Malignancy.

The aim of this study was to investigate with endoscopic ultrasound (EUS) the features of the gastric wall that can be used to predict malignant disease in patients with large gastric folds. We retrospectively reviewed the EUS findings of 65 patients (26 with benign and 39 with malignant disease) with large gastric folds on endoscopy and EUS and analyzed the predictors of malignant disease (e.g., gastric wall thickness, preservation of five-layered structure, thickened layers). Gastric wall thickness (≥9.8 mm), thickened deep layer, thickened muscularis propria and non-preserved wall layer structures were significantly more prevalent in patients with malignant disease on EUS. Among them, gastric wall thickness (≥9.8 mm) (odds ratio = 6.72, 95% confidence interval = 1.23-36.73, p = 0.028) and thickened muscularis propria (odds ratio = 37.14, 95% confidence interval = 7.02-196.49, p < 0.001) were significantly associated with malignant disease. Our data indicate that EUS is a useful tool for assessing large gastric folds and that gastric wall thickness (≥9.8 mm) and thickened muscularis propria are significant features predictive of malignant disease on EUS.

Delayed Bleeding Rate According to the Forrest Classification in Second-Look Endoscopy After Endoscopic Submucosal Dissection.

BACKGROUND AND AIM: Forrest classification is a valid tool to predict rebleeding rate in peptic ulcer, not in post-endoscopic resection ulcer. We evaluated the delayed bleeding rate in Forrest classification II and III lesions when they were not treated in second-look endoscopy. METHODS: Between July 2011 and February 2012, 706 lesions in 656 consecutive patients who underwent second-look endoscopy performed on the second day after endoscopic submucosal dissection (ESD) were prospectively investigated. Endoscopic findings were described according to Forrest classification, and late delayed bleeding was defined as bleeding from second-look endoscopy to 1 month. We evaluated the rate of late delayed bleeding in untreated Forrest classification II and III lesions during second-look endoscopy. RESULTS: Among the 706 gastric tumors analyzed, late delayed bleeding after ESD occurred in 29 lesions (4.1%). At second-look endoscopy, Forrest I lesions (immediately treated by endoscopic hemostasis) were found in 63 cases [Ia, 8 lesions (1.1%); Ib, 55 lesions (7.8%)]; there was no further bleeding after discharge. Forrest II and III lesions (not treated in second-look endoscopy) were found in 643 cases [IIa, 62 lesions (8.8%); IIb, 119 lesions (16.9%); IIc, 460 lesions (65.2 %); III, 2 lesions (0.3%)]; and there was no significant difference in the late delayed bleeding rate between these groups [IIa, 2/62 (3.2%); IIb, 5/119 (4.2%); IIc and III, 22/462 (4.8%); P = 1.000]. CONCLUSIONS: The rate of late delayed bleeding of post-ESD ulcers with non-bleeding visible vessels was not significantly different from that of ulcers with non-visible vessels ( http://cris.nih.go.kr , identifier KCT0000268).

Risk factors of lymph node metastasis in patients with gastric neuroendocrine tumor with normal serum gastrin level.

BACKGROUND/AIMS: Locoregional gastric carcinoids with normal serum gastrin level have been recommended radical resection regardless of tumor size or depth of invasion. However, there have been some reports which showed small sporadic gastric carcinoids could be treated with local resection. The aim of this study was to elucidate risk factors of lymph node metastasis in patients with gastric carcinoids with normal serum gastrin level and determine the indications for limited resection such as endoscopic treatment. METHODOLOGY: We performed clinicopathologic reviews of thirty gastric carcinoids with normal serum gastrin level from January 1996 to December 2010. RESULTS: One case show distant metastasis and two cases showed lymph node metastasis at the time of diagnosis. For twenty seven cases which showed no regional lymph node or distant metastasis initially no additional lymph node or distant metastasis were diagnosed throughout the follow up period. Large tumor size (>10 mm), proper muscle infiltration, WHO classification grade 2 and lymphovascular invasion was noted risk factor of lymph node metastasis by univariate logistic regression analysis. CONCLUSIONS: Small (≤10 mm) gastric carcinoids with normal serum gastrin level confined to submucosa can be treated with endoscopic or local resection unless lymphovascular invasion.

Yields and Utility of Endoscopic Ultrasonography-Guided 19-Gauge Trucut Biopsy versus 22-Gauge Fine Needle Aspiration for Diagnosing Gastric Subepithelial Tumors.

BACKGROUND/AIMS: To evaluate the yields and utility of 19-gauge (G) Trucut biopsy (TCB) versus 22 G fine needle aspiration (FNA) for diagnosing gastric subepithelial tumors (SETs). METHODS: We retrieved data for 152 patients with a gastric SET larger than 2 cm who had undergone endoscopic ultrasonography (EUS)-guided 19 G TCB (n=90) or 22 G FNA (n=62). Relevant clinical, tumor-specific, and EUS procedural information was reviewed retrospectively. RESULTS: A specific diagnosis was made for 76 gastrointestinal stromal tumors (GISTs) and 51 non-GIST SETs. The diagnostic yield of TCB was greater than that of FNA (77.8% vs. 38.7%, p<0.001). The percentage of non-diagnostic specimens (suspicious and insufficient) was significantly lower in the TCB group (6.7% and 15.5%, respectively) than in the FNA group (22.6% and 38.7%, respectively; both p<0.001). TCB accurately diagnosed 90.9% of GISTs and 81.1% of non-GIST SETs, whereas FNA accurately diagnosed 68.8% of GISTs and 14.3% of non-GIST SETs. There were nine technical failures with TCB, and the rate of adverse events did not differ between the groups (TCB vs. FNA, 3.3% vs. 8.1%; p=0.27). CONCLUSIONS: Nineteen-gauge TCB is safe and highly valuable for diagnosing gastric SETs larger than 2 cm if technical failure can be avoided.

Features of Gastric Carcinoma With Lymphoid Stroma Associated With Epstein-Barr Virus.

BACKGROUND & AIMS: Gastric carcinoma with lymphoid stroma (GCLS) is a distinct histologic subtype of gastric cancer that is characterized by undifferentiated carcinoma mixed with prominent lymphoid infiltration. More than 80% of GCLS cases are associated with Epstein-Barr virus (EBV) infection, but it is unclear if the virus affects disease progression. We investigated how EBV infection affects the clinical and pathologic features of GCLS, as well as patients' outcomes. METHODS: We performed a retrospective analysis of 274 patients (mean age, 56.8 y; 85.4% male) diagnosed with GCLS, based on pathology findings, from March 1998 through December 2012 at the Asan Medical Center in Seoul, South Korea. Their data were compared with those from 822 age- and sex-matched patients who underwent resection for gastric adenocarcinoma. EBV was detected in tumor samples by in situ hybridization. RESULTS: Of the 274 patients with GCLS, 236 had EBV-positive tumors (86.1%) and 38 had EBV-negative tumors (13.9%). EBV-positive GCLS was more prevalent than EBV-negative GCLS in younger patients, tended to be located proximally, and was more frequently of an early stage macroscopic type. The 10-year, disease-specific rates of survival were 89.1% for patients with EBV-positive GCLS and 66.9% for patients with EBV-negative GCLS (P = .009). Patients with EBV-negative GCLS had clinical and pathologic features and survival times similar to those of patients with conventional adenocarcinoma. By multivariate analysis, longer survival time was associated with EBV-positive tumors (P = .007), younger patient age (P = .002), smaller tumor size (P = .046), lower stage (based on American Joint Committee on Cancer classification; P < .001), and lack of lymphovascular invasion (P = .012). The proportion of undifferentiated tumor cells was not associated significantly with patient survival time. CONCLUSIONS: Clinical and pathologic features of GCLS differ based on EBV infection status. EBV-negative GCLS is similar to conventional adenocarcinoma, and patients have similar survival times. EBV status may be more important than the proportion of undifferentiated tumor cells in the diagnosis of GCLS and management of patients.

Clinical outcomes of endoscopic resection for gastric neoplasms in the pylorus.

BACKGROUND: Endoscopic resection for gastric neoplasms in the pylorus is a technically difficult procedure. We investigated clinical outcomes to determine the feasibility and effectiveness of endoscopic resection for gastric neoplasms in the pylorus. METHODS: Subjects who underwent endoscopic resection for gastric neoplasms in the pylorus between January 1997 and February 2012 were eligible. RESULTS: A total of 227 subjects underwent endoscopic resection for 228 gastric adenomas and early cancers in the pylorus. En bloc resection was achieved for 193 lesions (84.6%), including complete resection of 195 lesions (85.5%), and curative resection of 167 lesions (73.2%). Complete resection and curative resection rates were significantly different according to the location (prepyloric, pyloric, and postpyloric, P = 0.002 and P = 0.006). Delayed bleeding and stricture occurred in 5.3 and 3.1%, respectively, and there was no patient with perforation. During a median follow-up period of 79.0 months, local tumor recurrence was detected in 2.6%. CONCLUSIONS: Endoscopic resection appears to be a feasible and effective method for the treatment of pyloric neoplasms, regardless of the location and distribution of tumor. Thorough evaluation of the distal margin of the tumors is necessary when tumors involve or extend beyond the pyloric ring, and the appropriate use of additional techniques may be useful.

Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm.

BACKGROUND/AIMS: Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness. METHODS: Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated. RESULTS: A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively. CONCLUSIONS: ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.

Clinical and Endoscopic Features of Metastatic Tumors in the Stomach.

BACKGROUND/AIMS: Metastasis to the stomach is rare. The aim of this study was to describe and analyze the clinical outcomes of cancers that metastasized to the stomach. METHODS: We reviewed the clinicopathological aspects of patients with gastric metastases from solid organ tumors. Thirty-seven cases were identified, and we evaluated the histology, initial presentation, imaging findings, lesion locations, treatment courses, and overall patient survival. RESULTS: Endoscopic findings indicated that solitary lesions presented more frequently than multiple lesions and submucosal tumor-like tumors were the most common appearance. Malignant melanoma was the tumor that most frequently metastasized to the stomach. Twelve patients received treatments after the diagnosis of gastric metastasis. The median survival period from the diagnosis of gastric metastasis was 3.0 months (interquartile range, 1.0 to 11.0 months). Patients with solitary lesions and patients who received any treatments survived longer after the diagnosis of metastatic cancer than patients with multiple lesions and patients who did not any receive any treatments. CONCLUSIONS: Proper treatment with careful consideration of the primary tumor characteristics can increase the survival period in patients with tumors that metastasize to the stomach, especially in cases with solitary metastatic lesions in endoscopic findings.

Clinical significance of early detection of esophageal cancer in patients with head and neck cancer.

BACKGROUND/AIMS: The efficacy of surveillance for esopha-geal squamous cell neoplasia (ESCN) in patients with head and neck squamous cell carcinoma (HNSCC) remains contro-versial. Our study aimed to provide clinical data concerning the necessity of surveillance for detecting early ESCN in pa-tients with HNSCC. METHODS: We retrospectively reviewed the data from 714 patients who were pathologically confirmed as having HNSCC (n=236 oral cavity cancers, 137 oropha-ryngeal cancers, 87 hypopharyngeal cancers, and 254 la-ryngeal cancers). RESULTS: Of 714 patients, during a median follow-up of 31 months, 48 ESCNs (37 synchronous and 11 metachronous) were detected in 36 patients (5%). Fifteen synchronous lesions (40.3%) were early ESCN, whereas nine metachronous lesions (81.8%) were early ESCN. The 3-year survival rates of HNSCC only and HNSCC combined with ESCN were 71.2% and 48.2%, respectively (p<0.001). Among 36 patients with ESCN, the 3-year survival rates for early and advanced ESCN were 77.7% and 21.7%, respec-tively (p=0.01). In the multivariate analysis, alcohol consump-tion and hypopharyngeal cancer were significant factors associated with the development of ESCN. CONCLUSIONS: HN-SCC patients with early ESCN were similar in prognosis with patients without ESCN, in contrast to patients with advanced ESCN. Therefore, surveillance for the early detection of ESCN in patients with HNSCC, especially in alcohol drinkers and those with hypopharyngeal cancer, is warranted. (Gut Liver, 2015;9159-166).

Identifying predictors of lymph node metastasis after endoscopic resection in patients with minute submucosal cancer of the stomach.

BACKGROUND: The use of endoscopic submucosal dissection (ESD) for the treatment of minute submucosal (SM) invasive cancer that fulfills the current expanded criteria remains controversial. This study investigated the clinicopathological parameters of patients with sm1 gastric cancers to predict lymph node metastasis (LNM) and evaluate the feasibility of ESD as a curative treatment. METHODS: Data from 278 patients who underwent surgical resection of sm1 gastric cancer between 2006 and 2010 were retrospectively collected, and their clinicopathological parameters were analyzed to identify predictive factors of LNM. RESULTS: Of 278 patients, 28 patients (10.1 %) had LNM. Multivariate analysis identified multiple lesions (p = 0.018), lymphovascular invasion (LVI) (p < 0.001), SM invasion depth >500 µm (p = 0.007), undifferentiated histology (p = 0.012), and ulceration (p = 0.024) as factors significantly associated with LNM in patients with sm1 gastric cancer. Additionally, SM invasion width/superficial tumor size ratio >0.04 (p = 0.036) demonstrated a significant association with LNM in patients with sm1 gastric cancer falling within the current expanded criteria for ESD. LNM was not identified among 35 patients who met the absence of ulceration, SM invasion depth ≤ 500 µm, and SM invasion width/superficial tumor size ratio ≤ 0.04 besides the current expanded indications. CONCLUSIONS: Endoscopic resection can be performed on patients with minute SM invasive, differentiated cancers of ≤ 3 cm without LNM on pretreatment examination. In addition, if histological assessment shows the absence of LVI and ulceration, SM invasion depth ≤ 500 µm, and SM invasion width/superficial tumor size ratio ≤ 0.04, the patient can be carefully observed without additional treatment.

Endoscopic resection for synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma in early stage is a possible alternative to surgery.

BACKGROUND/AIMS: We investigated the clinical outcomes according to the method of treatment in synchronous esophageal and gastric cancer. METHODS: Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were diagnosed in 79 patients between 1996 and 2010. We divided the patients into four groups according to treatment; Group 1 received surgical resection for both cancers or surgery for gastric cancer with chemoradiotherapy for esophageal cancer (n=27); Group 2 was treated by endoscopic resection with or without additional treatment (n=14); Group 3 received chemoradiotherapy only (n=18); and Group 4 received supportive care only (n=20). RESULTS: The median survival times in groups 1 and 2 were 86 and 60 months, respectively. The recurrence rate and mortality were 23% and 48%, respectively, in group 1 and 21% and 4%, respectively, in group 2. The median survival time was 12 months in group 3 and 9 months in group 4. Multivariate analysis showed that age (p<0.001) and treatment group (p=0.019) were significantly associated with death. Compared with group 1, treatment in the intensive care unit (p=0.003), loss of body weight (p=0.042), and decrease in hemoglobin (p=0.033) were worse in group 1. CONCLUSIONS: Endoscopic resection for synchronous esophageal and gastric cancer could be considered as a possible alternative to surgery for early-stage cancer.

Endoscopic surveillance can increase the chance of resectability and endoscopic treatment in gastric cancer.

BACKGROUND/AIMS: Little is known about the effects of periodic endoscopic screening before detection of primary gastric cancer. We compared clinical outcomes in patients who did and did not undergo endoscopy before diagnosis. METHODS: Between January 2009 and November 2011, 769 patients were referred to Asan Medical Center after diagnosis of gastric cancer. Clinical outcomes were compared in patients who had (n=512) and had not (n=257) undergone endoscopic screening before diagnosis of gastric cancer. Factors about resectability and possibility of endoscopic resection were analyzed. RESULTS: In the nonexamined group, 225 patients (87.5%) had resectable gastric cancers and were treated surgically (n=151, 67.1%) or by endoscopic resection (n=74, 32.9%). In the examined group, 493 (96.3%) had resectability and were resected surgically (n=243, 49.3%) or endoscopically (n=250, 50.7%). Multivariate analysis showed that symptoms, no endoscopic screening, and lower serum albumin were associated with unresectability. Of the 718 resectable tumors, 394 underwent surgery and 324 underwent endoscopic resection. Multivariate analysis showed that older age, no symptoms, ≤1 year interval endoscopy, and higher serum albumin were associated with endoscopic resection. CONCLUSIONS: Previous endoscopy can increase gastric cancer resectability. Moreover, a ≤1 year interval from endoscopic examination can increase the possibility of endoscopic resection.

Comparison of clinical outcomes associated with pull-type and introducer-type percutaneous endoscopic gastrostomies.

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea. METHODS: We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed. RESULTS: The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population. CONCLUSIONS: PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.

Clinical significance of intensive endoscopic screening for synchronous esophageal neoplasm in patients with head and neck squamous cell carcinoma.

OBJECTIVES: Patients with head and neck squamous cell carcinoma (HNSCC) often develop second primary tumors in the upper aerodigestive tract. Early detection of synchronous esophageal squamous cell neoplasm (ESCN) is important because the prognosis of HNSCC can be affected by the statuses of second primary tumors. METHODS: In a prospective study, 308 patients with HNSCC were screened for synchronous ESCN between May 2010 and April 2012. All patients underwent conventional white-light endoscopic examination with Lugol chromoendoscopy and narrow band image. RESULTS: The median age was 61 years (range, 26-87 years), and the male-to-female ratio was 4.2:1. Two hundred and thirty-four patients (76.0%) were current or ex-smokers, 207 patients (67.2%) had a history of alcohol consumption and 56 patients (18.2%) had previous history of cancer. Synchronous ESCN was detected in 22 patients (7.1%), and most patients were at an early stage. The locations of index HNSCC in these patients were as follows: hypopharynx (n = 12), larynx (n = 6), oropharynx (n = 2) and oral cavity (n = 2). Synchronous ESCN was detected in 25.5% (12/47) of hypopharyngeal cancer and in 27.8% (15/54) of HNSCC involving the pyriform sinus. Multivariate analysis showed that smoking (current smoker vs. never smoker, Odds Ratio [OR] 8.3, p = 0.028), a history of cancer (OR 5.0, p = 0.002) and pyriform sinus involvement (OR 9.2, p < 0.0001) increased the risk of developing synchronous ESCN. CONCLUSIONS: Patients with HNSCC, especially those who are current smokers, have a history of cancer and have pyriform sinus involvement, should undergo intensive endoscopic screening to detect synchronous ESCN.

Pneumonia after endoscopic resection for gastric neoplasm.

BACKGROUND: Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay. AIM: To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm. METHODS: Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects. RESULTS: Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31-82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2-126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077). CONCLUSIONS: Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.