Kwangbum Cho

Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors

BACKGROUND AND AIM Although perforation of the colon is known as one of the main complications of endoscopic submucosal dissection (ESD) for colorectal tumor management, factors predictive of perforation have not been fully evaluated. This study aimed to determine the factors associated with perforation during colorectal ESD. METHODS Patients with colorectal tumors undergoing ESD were enrolled and their records were reviewed retrospectively. Age, sex, co-morbidity, medication history, procedure time, resection method, tumor size, location, gross morphology, the presence of fibrosis, and histologic findings were included as possible risk factors. In the cases where perforation had occurred, factors associated with the duration of hospitalization were analyzed. RESULTS One hundred eight lesions in 108 patients were eligible for inclusion in the study (68 patients were male; mean patient age was 63.01 ± 10.71 years). Mean tumor size was 27.59 ± 10.10 mm (range: 8 - 53 mm). Laterally spreading tumor was the most common type (75 %), followed by the protruding type (25 %). Procedure time was 61.95 ± 41.90 minutes (range: 5 - 198 minutes). Complete en bloc resection was achieved for 85 lesions (78.7 %). Perforation occurred in 22 patients (20.4 %). Multivariate analysis confirmed that tumor size [odds ratio (OR): 1.084; 95 % confidence interval (CI): 1.015 - 1.158; P = 0.017] and the presence of fibrosis (OR: 4.551; 95 %CI: 1.092 - 18.960; P = 0.037) were independent risk factors for perforation. All cases of perforation were managed with nonsurgical treatment. Younger age and abdominal pain appeared to be related to prolonged hospitalization. CONCLUSION Tumor size and fibrosis are important factors related to complications during colorectal ESD. Younger age and development of abdominal pain can predict the hospital course in patients with perforation after ESD.

Predictors of Malignancy in “Pure” Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study

Background/Aims Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in “pure” BD-IPMNs without enhanced mural nodules on CT. Methods This retrospective study included 180 patients with surgically confirmed “pure” BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. Results BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in “pure” BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. Conclusions In patients with “pure” BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.

788 Clinical Differences and Outcomes of Non-Ulcer Bleeding Compared With Ulcer Bleeding in Non-Variceal Upper Gastrointestinal Bleeding: Multicenter Database Study

Background: The existing literature regarding smoking and alcohol consumption and risk of gastrointestinal bleeding (GIB) is sparse and conflicting. In an attempt to study modifiable risk factors of GIB, we assessed the risk of GIB associated with smoking and alcohol consumption in a large prospective cohort of men. Methods: We studied 51,529 men in the Health Professional follow-up Study (HPFS) who were aged 40-75 years at baseline in 1986. We identified men with GIB requiring hospitalization and/or blood transfusion based on their responses to biennial questionnaires from 2006-2012 and reviewed medical records to validate self-report. Information about smoking and alcohol consumption was updated every two and four years, respectively. We used Cox proportional hazards regression to calculate the relative risks (RR) and 95% confidence intervals (CI) adjusting for age, study year, body mass index, physical activity, regular aspirin and nonsteroidal anti-inflammatory drug use, and alcohol/smoking. Results: We documented 311 episodes of GIB during a 26-year follow up period. After adjustments for other potential risk factors, individuals who consumed >15 g/day of alcohol had a multivariate RR of 1.65 (95% CI, 1.10-2.47; p for linear trend 0.004) when compared with men who did not consume alcohol. Intake of > 15 g/day of alcohol appeared to be primarily related to upper GIB (multivariable RR 1.74; 95% CI, 0.98-3.08; p for linear trend 0.007). Risk of GIB increased linearly with amount of liquor consumed (p for linear trend 15 g/day of alcohol was significantly associated with peptic ulcer disease (multivariable RR 1.85; 95% CI, 0.97-3.54; p for linear trend 0.02), but not esophagitis/gastritis/duodentitis, or diverticular bleeding. There were few cases of bleeding due to portal hypertension (n=4). Current and past smokers did not appear to have increased risk of GIB when compared to those who never smoked (multivariable RR 0.89; 95% CI, 0.45-1.76 and 1.12, 95% CI 0.88-1.41, respectively). We also did not find a significant association between pack years of smoking and risk of GIB (multivariable RR 1.01; 95% CI, 0.63-1.62 when comparing men with at least 45 pack-years of exposure to never smokers). Conclusions: In this large prospective study, alcohol consumption, but not smoking, was associated with an increased risk of GIB. Associations were most notable for upper GI bleeding associated with intake of liquor.

Mo1165 Prediction for Mortality in Patients With Non-Variceal Upper Gastrointestinal Bleeding: Novel DGSG Score

Background: Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency resulting in significant morbidity, mortality and cost of care. Whilst red blood cell (RBC) transfusion may be life-saving in massive UGIB, recent controlled trials suggest that a liberal transfusion practice is associated with increased re-bleeding rates and reduced survival after UGIB. 1 Aim: To determine the association between transfusion and rebleeding, mortality at 30 days and at one year after acute non-variceal UGIB. Methods: A retrospective, cohort study of patients who underwent endoscopy at three Western Australian tertiary hospitals for a suspected acute non-variceal UGIB in the period 2008-2010. A detailed chart review and linkage to hospital morbidity, emergency department, death registration and patient blood management data was performed. Logistic regression models were used to investigate factors associated with odds of an early rebleed. Cox models were used to identify factors associated with mortality outcomes. Results: There were 2,238 individuals with a total of 2,370 UGIB admission records. The median age at presentation for first UGIB was 70 years (range 19 to 99 years) and 63% of the cohort was male. Increasing volumes of early RBC transfusion was associated with increased odds of an early rebleed in a dose response trend but only in patients who presented with an Hb >90g/dl (OR 1.5; 95% CI 1.3-1.8; p=0.001). 30-day mortality was 4.9% (n=109). An increased rate of 30 day mortality was observed with increasing number of units of FFP (HR 2.3; 95% CI 1.1-4.6; p=0.02) and platelets (HR 3.7; 95% CI 1.8-7.7; p=0.001) transfused during the UGIB admission after adjusting for other patient and treatment related covariates. There were a further 200 deaths (9%) that occurred after 30 days but within one year of UGIB admission. Transfusion of greater than five units of FFP during the UGIB admission was associated with increased one year mortality (HR 6.7; 95% CI 3.3-13.4; p=0.001) but only for patients who had an INR 150,000 and after adjusting for other covariates. RBC transfusion was not associated with mortality outcomes. Conclusion: In this large, multicentre study, early RBC transfusion was associated with increased rebleeding in patients who presented with Hb > 90g/dl. FFP transfusion and not RBC transfusion was associated with increased mortality outcomes for patients, particularly those with a normal coagulation profile. Reference: 1. Villanueva et al, NEJM 2013; 368: 11-21.

S1925 A Multi-Center, Randomized, Comparative Study to Determine the Appropriate Dose of Lansoprazole for the Diagnostic Test in Korean Patients with Gastroesophageal Reflux Disease

Introduction: An empiric trial of acid suppression with a proton pump inhibitor (PPI) is widely used as a diagnostic test for gastroesophageal reflux disease (GERD). However, the report about diagnostic value of a short trial with standard dose PPI is rare. The aim of this study was to determine the onset of symptom relief with standard or double dose of lansoprazole in Korean patients with erosive esophagitis or nonerosive reflux disease (NERD). Methods: This multi-center randomized study enrolled 93 patients with erosive esophagitis (n=30) or NERD (n=63) to receive lansoprazole treatment using 30 mg or 60 mg once daily for 14 days. Between two clinical visits (at enrolment and 14 days), patients were asked to keep a diary in which they recorded severity of GERD symptoms daily. Substantial symptom relief was defined as a more than 50% reduction in total symptom score. Results: In total patients, substantial symptom relief was achieved by the end of the first week (day 6). There were no significant differences of total symptom score reductions between standard and double dose groups of patients with erosive esophagitis. But onset of substantial symptom relief was faster in the double dose group (day 2) than the standard dose group (day 6). In patients with NERD, there were no significant differences of total symptom score reductions between standard and double dose group. Onset of substantial symptom relief was same in the standard and double dose groups of patients with NERD (day 8). Conclusions: In this multi-center, randomized study of Korean patients, standard-dose lansoprazole was as effective as double-dose lansoprazole in relieving symptoms by day 14 of treatment. Onset of substantial symptom relief was slower in the patients with non-erosive reflux disease than those with erosive esophagitis.

Nonsurgical Treatment of Gastric Perforation Complicated By Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Background/Aims: Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) are novel techniques used for the treatment of early gastric cancer and precancerous lesions of the stomach. However, complications such as bleeding and perforation may occur during the procedure, and these complications may raise the morbidity and mortality rates. EMR/ESD-induced perforations can be treated with conservative medical or non-surgical methods. Furthermore, an increasing number of reports have addressed conservative management of EMR/ESD-induced perforations. We evaluated the effectiveness and safety of implementing conservative treatment for perforations associated with EMR and ESD. Methods: We reviewed 482 patients with 507 lesions who underwent EMR or ESD due to early gastric cancers or gastric adenomas between February 2003 and December 2007. We identified 14 perforations occurring as complications of EMR/ESD and investigated their clinical outcomes. Results: Fourteen perforations (14/507 [2.8%]) occurred, 11 of which were immediately clipped during the procedure, and 3 of which were diagnosed after the procedure when free air was visualized on the radiograph. All patients were managed conservatively with fluid resuscitation and antibiotics (mean, 5.8 days). They recovered without surgery and were discharged in stable condition at a mean of 7.2 days post-procedure. Conclusions: Endoscopic clip application might be an effective and safe option for conservative management of EMR/ESD-induced perforations. (Korean J Gastrointest Endosc 2008;37:97-104)