Kwi Sook Choi

Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas.

Although endoscopic submucosal dissection (ESD) is increasingly utilized to treat early neoplasms of the gastrointestinal tract, its use for duodenal neoplasms is limited by the thin wall and narrow lumen of the duodenum. We have reviewed cases where ESD was used to treat sessile, nonampullary duodenal neoplasms. To do this, we retrospectively reviewed the medical records of patients treated with ESD for adenomas of the duodenum from January 2001 to December 2010, assessing the curative outcomes and complication rates. A total of 14 cases were reviewed. Mean patient age was 56.4 years. The mean size of tumors and mean size of the specimens were 17.1 mm and 26.4 mm, respectively. The en bloc resection rate with ESD was 78.6%, and the complete (R0) resection rate was 85.7%. No patient in the study experienced major bleeding. However, second-look endoscopy revealed minor bleeding requiring endoscopic homeostasis in one case (7.1%). Perforations were observed in five cases (35.7%). Two of the five patients with perforation underwent surgery. The ESD methods yielded acceptable curative resection rates for duodenal adenomas, although ESD was associated with a higher rate of perforation. Therefore, duodenal ESD should be performed with care and only in selected patients to avoid serious complications.

Unchanging trend of esophagogastric junction adenocarcinoma in Korea: experience at a single institution based on Siewert's classification

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing in Western countries. It is unclear, however, whether similar changes are occurring in Asia. We therefore investigated the incidence of AEG in Korea, and assessed the clinical characteristics of three types of AEG based on Siewerts classification. We retrospectively reviewed the medical records of 16 811 patients diagnosed with esophageal squamous cell carcinoma (ESC, n= 1450) or gastric noncardiac adenocarcinoma (GNCA, n= 14 751) between 1992 and 2006. The patients were divided into three 5-year cohorts (cohort A [1992-1996], n= 2734, cohort B [1997-2001], n= 5727, and cohort C [2002-2006], n= 8350), and the ratios of AEG (n= 610) to non-AEG (ESC and GNCA) in each cohort were compared. Using Siewerts classification, the tumors were categorized into one of three types, and patient demographic features and 5-year survival rates were compared. The ratio of AEG to non-AEG cases did not change over time (0.037, 0.034, and 0.039 for cohorts A, B, and C, respectively; P= 0.40). Of the 610 patients with AEG, 23 (3.7%) had type 1 tumors, 47 (7.7%) had type 2, and 540 (88.5%) had type 3. The 5-year survival rate of patients with type 1 AEG was much lower (4.8 +/- 4.7%) than that of those with type 2 (47.9 +/- 7.8%) and type 3 (47.4 +/- 2.5%) tumors. Unlike in Western countries, the ratio of AEG to non-AEG cases has not increased over time in Korea. Type 1 AEG was rarer and associated with a more unfavorable prognosis in Korea than in Western countries.

Meta-Analysis of First-Line Triple Therapy for Helicobacter pylori Eradication in Korea: Is It Time to Change?

Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea. Graphical Abstract

Clinical Significance of Early Detection of Esophageal Cancer in Patients with Head and Neck Cancer

Background/Aims The efficacy of surveillance for esophageal squamous cell neoplasia (ESCN) in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Our study aimed to provide clinical data concerning the necessity of surveillance for detecting early ESCN in patients with HNSCC. Methods We retrospectively reviewed the data from 714 patients who were pathologically confirmed as having HNSCC (n=236 oral cavity cancers, 137 oropharyngeal cancers, 87 hypopharyngeal cancers, and 254 laryngeal 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%, respectively (p=0.01). In the multivariate analysis, alcohol consumption 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.

Natural course of noncurative endoscopic resection of differentiated early gastric cancer.

BACKGROUND AND STUDY AIMS Following noncurative endoscopic resection of early gastric cancer (EGC), the patient should be observed when the underlying disease is severe, the patient is elderly, or the patient refuses further treatment. The aim of this study was to analyze the clinical outcomes of patients with differentiated EGC who underwent noncurative endoscopic resection without additional treatment. PATIENTS AND METHODS Included patients underwent noncurative endoscopic resection for differentiated EGC without additional treatment at the Asan Medical Center between July 1994 and January 2009. Clinical and oncological outcomes were analyzed. RESULTS A total of 159 patients were included in the analysis. The median follow-up period was 33 months (interquartile range [IQR] 22 - 52 months). In total, 40 patients died (25.2 %) - 3 due to stomach cancer, 34 due to other causes, and 3 from unknown causes; the median survival time after endoscopic treatment for these patients was 27.5 months (IQR 13.8 - 48.3 months). Multivariate analysis showed that the rates of underlying disease (P < 0.001) and lymphovascular invasion (P = 0.005) were higher among the 40 patients who died than among the 119 survivors. The overall 3-  and 5-year survival rates were 82.9 % and 77.1 %, respectively; the rates of the patients with lymphovascular invasion were 61.9 % and 42.4 %, respectively, and the rates of patients without lymphovascular invasion were 86.1 % and 81.8 %, respectively (P < 0.001). CONCLUSIONS Additional treatment provides fewer benefits to patients who do not have long life expectancies. Additional surgery can be considered for patients with lymphovascular invasion because of its high mortality rate; however, the benefits and risks of surgery should be considered carefully.

Transnasal endoscope-assisted endoscopic submucosal dissection for gastric adenoma and early gastric cancer in the pyloric area: a case series.

Endoscopic submucosal dissection (ESD) is an important therapeutic option for gastric adenoma and early gastric cancer (EGC). However, ESD is technically difficult when lesions are located in the pyloric area. Our aim was to introduce the transnasal endoscope-assisted ESD method, which provides for excellent cutting-line visualization through control of submucosal traction. A total of eight patients with gastric adenoma or EGC located in the pyloric area were consecutively enrolled. A primary operating endoscope was used to perform marking, incision, submucosal dissection, and hemostasis, while a thinner, transnasal endoscope operated by a second endoscopist was used to retract connective submucosal tissue to provide cutting-line visualization using V-shaped grasping forceps. En bloc resection was achieved in all eight cases, as was complete resection. The median longest lesion diameter was 19 mm (range: 12-25 mm), and the median procedure time was 37.5 minutes (range: 29-59 minutes). There were no incidents of significant bleeding or perforation. Transnasal endoscope-assisted ESD was useful for treating gastric neoplasms in the pyloric area. The procedure was relatively easy and safe, provided excellent visualization through tissue retraction, and allowed for complete en bloc resection.

Solitary Synchronous Metastatic Gastric Cancer Arising from T1b Renal Cell Carcinoma: A Case Report and Systematic Review

Metastasis to the stomach from renal cell carcinoma (RCC) is extremely rare. Usually, gastric metastasis seems to be a late event in patients with RCC and is accompanied by disseminated tumor spread to other organs. Solitary synchronous gastric metastasis from small, localized RCC has rarely been reported. We report a case of 79-year-old man with synchronous gastric metastasis presenting with a single erosive lesion from pT1 RCC. The patient underwent radical nephrectomy and endoscopic resection for metastatic gastric cancer. The resected specimen showed an ill-defined tumor, approximately 0.6 cm long, with a clear resection margin. The morphologic features of the tumor cells were consistent with those of metastatic RCC of the clear cell type. At 6 monthss follow-up, the patient did not show local recurrence or additional metastasis on upper endoscopy and computed tomography scan.

Benign bronchoesophageal fistula in adults: endoscopic closure as primary treatment.

BACKGROUND/AIMS Benign bronchoesophageal fistula (BEF) is a rare condition that is usually treated surgically; however, less invasive endoscopy procedures have been attempted to overcome the disadvantages of surgery. The aim of this study was thus to determine the results of endoscopic management as a primary treatment in patients with BEF. METHODS We retrospectively analyzed data from 368 patients with BEF who were treated at a tertiary care, academic medical center between January 2000 and August 2009. RESULTS Benign causes were found for only 18 of the 368 patients. Of these, seven were treated endoscopically and the others by surgery or other methods. The first endoscopy procedures failed in all seven patients, with second trials of endoscopy performed in four patients at a median of 8 days (range, 3 to 11 days) after the first procedure. The second endoscopic procedure was successful in two out of four patients; one patient showed no recurrence of the fistula, whereas the second patient experienced a recurrence after 24 months. All patients underwent successful surgical procedures after the failure of endoscopic treatment, with no further recurrences. CONCLUSIONS Although we observed a low rate of success for primary endoscopic treatment of benign BEF, the invasive nature of surgery suggests the need for a prospective study with a large number of patients to evaluate the efficacy of less invasive procedures such as endoscopic treatment.

Routine endoscopic screening for synchronous esophageal neoplasm in patients with head and neck squamous cell carcinoma: a prospective study

Early detection of synchronous esophageal squamous cell neoplasm (ESCN) in head and neck squamous cell carcinoma (HNSCC) patients can significantly affect their prognosis. We investigated the prevalence of synchronous ESCN and the risk factors for developing ESCN in patients with HNSCC, and evaluated the effect of routine endoscopic screening in these patients. Subjects who were diagnosed as HNSCC from May 2010 to January 2014 were eligible. All patients underwent conventional white light endoscopic examinations with narrow band imaging and Lugol chromoendoscopy. Among 458 subjects screened, 28 synchronous ESCN were detected in 24 patients (5.2%). The prevalence of ESCN was greatest in patients with hypopharyngeal cancer (20.9%). In multivariate analysis, pyriform sinus involvement was independent risk factor for developing synchronous ESCN (odds ratio 171.2, P < 0.001). During the follow-up period (median, 24 months), the 3-year overall survival rates was significantly lower in patients with ESCN than in patients without ESCN (54.2% vs. 78.3%, P = 0.0013). Routine endoscopic screening for detecting synchronous ESCN should be recommended for patients with HNSCC, especially those with pyriform sinus involvement.

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.