Jeong Seon Ji

An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve

BACKGROUNDnVarious training programs in colonoscopy recommend that trainees should perform at least 100 to 200 procedures to be considered technically competent at diagnostic colonoscopy.nnnOBJECTIVEnOur purpose was to determine the adequate level of training for technical competence in screening and diagnostic colonoscopy.nnnDESIGNnA prospective multicenter trial.nnnSETTINGnFifteen tertiary care academic medical centers.nnnPATIENTSnOver 8 months we prospectively evaluated the procedures of 24 first-year GI fellows in 15 tertiary care academic medical centers. A total of 4351 colonoscopies were assessed prospectively with variable clinical factors.nnnINTERVENTIONnCecal intubation was documented by photographing the identified cecal landmarks, including the appendiceal orifice and the ileocecal valve.nnnMAIN OUTCOME MEASUREMENTSnAcquisition of competence (success rate) was evaluated for colonoscopic training on the basis of 2 objective criteria: (1) adjusted completion rate (>90%) and (2) cecal intubation time (<20 minutes).nnnRESULTSnThe overall success rate was 83.5% (3635/4351). The mean cecal intubation time was 9.23 +/- 4.63 minutes. The success rate significantly improved and reached the requisite standard of competence after 150 procedures (71.5%, 82.6%, 91.3%, 94.4%, 98.4%, and 98.7%, respectively, for every 50 consecutive blocks). The polyp detection rate did not improve significantly during the 8 months and was not correlated with the learning curve. In addition, mean time to cecal intubation decreased significantly, from 11.16 to 8.39 minutes, after 150 procedures. Logistic regression analysis found that prolonged cecal intubation was caused by the following factors: elderly patients, female sex, low body mass index, poor bowel preparation, poor American Society of Anesthesiologists status, abdominal pain as an indication, instructors supervision, and low case volume.nnnLIMITATIONSnWe did not record final pathologic reports of detected polyps and withdrawal time.nnnCONCLUSIONSnCompetence in technically efficient screening and diagnostic colonoscopy generally requires experience with more than 150 cases. Also, factors associated with prolonged cecal intubation for typical trainees did not differ from those for experienced colonoscopists.

Sequential Therapy for Helicobacter pylori Infection in Korea: Systematic Review and Meta-Analysis

Background/Aims Sequential therapy (ST) for Helicobacter pylori infection in countries other than Korea has shown higher eradication rates than triple therapy (TT). The aim of this study was to evaluate the efficacy of ST in Korea by performing a meta-analysis. Methods We performed a comprehensive literature search on the efficacy of ST as a first-line therapy. The odds ratios (ORs) of eradicating H. pylori infection after ST compared with TT were pooled. Pooled estimates of the eradication rates of ST and TT were also calculated. Results A total of six studies provided data on 1,759 adult patients. The ORs for the intention to treat (ITT) and the per-protocol (PP) eradication rate were 1.761 (95% confidence interval [CI], 1.403 to 2.209) and 1.966 (95% CI, 1.489 to 2.595). Pooled estimates of the ITT and PP eradication rate were 79.4% (95% CI, 76.3% to 82.2%) and 86.4% (95% CI, 83.5% to 88.8%), respectively, for the ST group, and 68.2% (95% CI, 62.1% to 73.8%) and 78.9% (95% CI, 68.9% to 81.7%), respectively, for the TT group. Conclusions Although ST presented a higher eradication rate than TT in Korea, the pooled eradication rates were lower than expected. Further studies are needed to validate ST as a first-line treatment for H. pylori in Korea.

Myxedema Ascites: Case Report and Literature Review

Myxedema ascites caused by hypothyroidism is rare, so its diagnosis is often delayed and patients frequently receive unnecessary procedures such as liver biopsies and exploratory laparotomies. We report a 71-yr-old man with clinical ascites that was the first manifestation of hypothyroidism, and which resolved completely in response to thyroid hormone replacement therapy. To our knowledge, this is the first report of myxedema ascites in Korea. A review of the literature revealed 51 well-documented cases of myxedema ascites. Analyses of ascites from patients in this condition usually show high protein (>2.5 g/dL) and low white blood cell counts, with a high proportion of lymphocytes. A consistent feature is the good response to thyroid hormone replacement therapy, which has always led to resolution of the ascites. Myxedema ascites is thus rare but easy to treat; it should be borne in mind, especially if the ascites fluid has a high protein content.

The temporary placement of covered self-expandable metal stents to seal various gastrointestinal leaks after surgery.

Gastrointestinal leakage is one of the most serious post surgical complications and is a major source of mortality and morbidity. The insertion of a covered self-expandable metal stent could be a treatment option in selected cases. However, it is unclear how long the stent should be retained to achieve complete sealing, and membrane-covered stents have the problem of a high migration rate. We observed four cases of postsurgical leakage following the primary closure of a duodenal perforation, esophagojejunostomy, and esophagogastrostomy, each of which was successfully managed by the temporary placement of covered stents. In all cases, the optimal time of stent removal could be estimated by the markedly decreased amount of drainage, the lack of leakage observed on radiocontrast images, and the endoscopic findings. In this case series, all of the stents could be removed within 7 weeks. For those cases with a high risk of migration, stents with temporary fixations to earlobes and/or partially uncovered proximal flanges were used. These results suggest that the application of a covered stent could be a treatment option for various gastrointestinal leaks after surgery, particularly when the defect cannot be sealed by conservative care and the leakage has good external drainage.

Routine Mucosal Closure with a Detachable Snare and Clips after Endoscopic Submucosal Dissection for Gastric Epithelial Neoplasms: A Randomized Controlled Trial

Background/Aims The aim of this study was to determine whether the routine closure of mucosal defects after endoscopic submucosal dissection (ESD) can enhance mucosal healing and reduce ESD-associated bleeding. Methods Patients with gastric epithelial neoplasias and no obvious submucosal invasion were prospectively enrolled. Mucosal defects were left untreated in the control group. In the study group, mucosal closure was attempted with a 2-channel endoscope, a detachable snare, and clips. All participants received a second-look endoscopy the day after ESD, and coagulation therapy was administered to patients with visible vessels and active bleeding points. Results Fifty-two patients were enrolled in the study, and 26 patients were assigned to each group. Complete mucosal defect closure occurred in 16 patients (61%) in the study group; incomplete closure occurred in 8 patients (31%) in the study group, and failed closure occurred in 2 patients (8%). Coagulation therapy at the second-look endoscopy was performed more often in the control group than in the study group (31% vs 4%, p=0.024). There were no significant differences in the incidence of immediate or delayed bleeding or in the two-week decrease in hemoglobin between the groups. The prevalence of open ulcers after 8 weeks was significantly lower in the study group than in the control group (18% vs 43%, p=0.012). Conclusions Routine mucosal closure after ESD supports earlier healing of artificial ulcers. A larger-scale trial is necessary to determine whether mucosal closure can reduce ESD-associated bleeding.

Diagnostic accuracy and interobserver agreement in predicting the submucosal invasion of colorectal tumors using gross findings, pit patterns, and microvasculatures.

Background/Aims Depth of invasion is one of the most important factors for establishing treatment strategy for colorectal tumors. Methods Three blinded experts reviewed electronic photos and video clips of 33 early colorectal cancer-like lesions. They estimated the depth of invasion based on conventional white light endoscopy (CWE), magnifying chromoendoscopy (MCE), and magnifying narrow band imaging endoscopy (MNE). Results The lesions included nine mucosal low-grade neoplasias, 16 mucosal high grade neoplasias, and eight carcinomas with invasion to the submucosal layer or beyond. The diagnostic accuracy for submucosal invasion by CWE ranged from 67% to 82%, while those by MCE and MNE ranged from 85% to 88% and 85% to 88%, respectively. The diagnostic accuracy significantly differed between CWE and MCE (p=0.034) and between CWE and MNE (p=0.039). The kappa values for CWE, MCE, and MNE among the endoscopists were 0.564, 0.673, and 0.673, respectively. Conclusions The estimation of submucosal invasion for early colorectal cancer-like lesions based on MCE or MNE is more accurate than CWE. MCE and MNE were demonstrated to have substantial agreement for predicting submucosal invasion.

A Case of Disseminated Intra-abdominal Gastrointestinal Stromal Tumor Managed with Low Dose Imatinib.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Imatinib mesylate is recommended as adjuvant therapy for GIST after surgical resection. However, drug-related adverse events are common. A 74-year-old female with metastatic GIST who was managed with imatinib experienced severe adverse events, including skin rashes, tremor, and alopecia, etc. The imatinib dose was reduced and the size of the metastatic GIST continued to decrease and adverse events showed significant improvement.

Crohn's Disease Initially Accompanied by Deep Vein Thrombosis and Ulnar Neuropathy without Metronidazole Exposure.

Extraintestinal manifestations are not uncommon in Crohns disease, and a thromboembolic event is a disastrous potential complication. Deep vein thrombosis is the most common manifestation of a thromboembolic event and typically occurs in association with active inflammatory disease. Peripheral neuropathy in Crohns disease has rarely been reported and is considered an adverse effect of metronidazole therapy. Here, we describe a patient who was initially diagnosed with Crohns disease complicated with deep vein thrombosis and ulnar neuropathy without metronidazole exposure. The simultaneous occurrence of these complications in the early stage of Crohns disease has never been reported in the English literature.

Three-year colonoscopy surveillance after polypectomy in Korea: a Korean Association for the Study of Intestinal Diseases (KASID) multicenter prospective study

Background/Aims Colonoscopic surveillance is currently recommended after polypectomy owing to the risk of newly developed colonic neoplasia. However, few studies have investigated colonoscopy surveillance in Asia. This multicenter and prospective study was undertaken to assess the incidence of advanced adenoma based on baseline adenoma findings at 3 years after colonoscopic polypectomy. Methods A total of 1,323 patients undergoing colonoscopic polypectomy were prospectively assigned to 3-year colonoscopy surveillance at 11 tertiary endoscopic centers. Relative risks for advanced adenoma after 3 years were calculated according to baseline adenoma characteristics. Results Among 1,323 patients enrolled, 387 patients (29.3%) were followed up, and the mean follow-up interval was 31.0±9.8 months. The percentage of patients with advanced adenoma on baseline colonoscopy was higher in the surveillance group compared to the non-surveillance group (34.4% vs. 25.7%). Advanced adenoma recurrence was observed in 17 patients (4.4%) at follow-up. The risk of advanced adenoma recurrence was 2 times greater in patients with baseline advanced adenoma than in those with baseline non-advanced adenoma, though the difference was not statistically significant (6.8% [9/133] vs. 3.1% [8/254], P=0.09). Advanced adenoma recurrence was observed only in males and in subjects aged ≥50 years. In contrast, adenoma recurrence was observed in 187 patients (48.3%) at follow-up. Male sex, older age (≥50 years), and multiple adenomas (≥3) at baseline were independent risk factors for adenoma recurrence. Conclusions A colonoscopy surveillance interval of 3 years in patients with baseline advanced adenoma can be considered appropriate.

Risk Factors for Additional Surgery after Iatrogenic Perforations due to Endoscopic Submucosal Dissection

Objectives. Endoscopic resection (ER) is commonly performed to treat gastric epithelial neoplasms and subepithelial tumors. The aim of this study was to predict the risk factors for surgery after ER-induced perforation. Methods. We retrospectively reviewed the data on patients who received gastric endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) between January 2010 and March 2015. Patients who were confirmed to have perforation were classified into surgery and nonsurgery groups. We aimed to determine the risk factors for surgery in patients who developed iatrogenic gastric perforations. Results. A total of 1183 patients underwent ER. Perforation occurred in 69 (5.8%) patients, and 9 patients (0.8%) required surgery to manage the perforation. In univariate analysis, anterior location of the lesion, a subepithelial lesion, two or more postprocedure pain killers within 24u2009hrs, and increased heart rate within 24u2009hrs after the procedure were the factors related to surgery. In logistic regression analysis, the location of the lesion at the anterior wall and using two or more postprocedure pain killers within 24u2009hrs were risk factors for surgery. Conclusion. Most cases of perforations after ER can be managed conservatively. When a patient requires two or more postprocedure pain killers within 24u2009hrs and the lesion is located on the anterior wall, early surgery should be considered instead of conservative management.