Kyoungwon Jung

Prognostic significance of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in patients with stage III and IV colorectal cancer

AIM To evaluate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in patients with colorectal cancer (CRC). METHODS Between April 1996 and December 2010, medical records from a total of 1868 patients with CRC were retrospectively reviewed. The values of simple inflammatory markers including NLR and PLR in predicting the long-term outcomes of these patients were evaluated using Kaplan-Meier curves and Cox regression models. RESULTS The median follow-up duration was 46 mo (interquartile range, 22-73). The estimation of NLR and PLR was based on the time of diagnosis. In multivariate Cox regression analysis, high NLR (≥ 3.0) and high PLR (≥ 160) were independent risk factors predicting poor long-term outcomes in patients with stage III and IV CRC. However, high NLR and high PLR were not prognostic factors in patients with stage I and II CRC. CONCLUSION In this study, we identified that high NLR (≥ 3.0) and high PLR (≥ 160) are useful prognostic factors to predict long-term outcomes in patients with stage III and IV CRC.

Borrmann Type 4 Advanced Gastric Cancer: Focus on the Development of Scirrhous Gastric Cancer

Early diagnosis of Borrmann type 4 advanced gastric cancer (AGC) is very important for improving the prognosis of AGC patients. Because there is no definite mass in most cases of Borrmann type 4 AGC, its accurate diagnosis via endoscopy requires an understanding of its pathogenesis and developmental process. Moreover, many people confuse linitis plastica (LP) type gastric cancer (GC), scirrhous GC, and Borrmann type 4 AGC. To distinguish each of these cancers, knowledge of their endoscopic and pathological differences is necessary, especially for LP type GCs in the developmental stage. In conclusion, diagnosis of pre-stage or latent LP type GC before progression to typical LP type GC requires the detection of IIc-like lesions in the fundic gland area. It is also crucial to identify any abnormalities such as sclerosis of the gastric wall and hypertrophy of the mucosal folds during endoscopy.

Second-line bismuth-containing quadruple therapy for Helicobacter pylori eradication and impact of diabetes.

AIM To investigate Helicobacter pylori (H. pylori) eradication rates using second-line bismuth-containing quadruple therapy and to identify predictors of eradication failure. METHODS This study included 636 patients who failed first-line triple therapy and received 7 d of bismuth-containing quadruple therapy between January 2005 and December 2015. We retrospectively demonstrated H. pylori eradication rates with respect to the year of therapy as well as demographic and clinical factors. H. pylori eradication was confirmed by a 13C-urea breath test or a rapid urease test at least 4 wk after the completion of bismuth-based quadruple therapy: proton pump inhibitor, metronidazole, bismuth, and tetracycline. RESULTS The overall eradication rates by intention-to-treat analysis and per-protocol analysis were 73.9% (95%CI: 70.1%-77.4%) and 94.5% (95%CI: 92.4%-96.5%), respectively. Annual eradication rates from 2005 to 2015 were 100.0%, 92.9%, 100.0%, 100.0%, 100.0%, 97.4%, 100.0%, 93.8%, 84.4%, 98.9%, and 92.5%, respectively, by per-protocol analysis. A multivariate analysis showed that diabetes mellitus (OR = 3.99, 95%CI: 1.56-10.20, P = 0.004) was associated with H. pylori eradication therapy failure. CONCLUSION The second-line bismuth-containing quadruple therapy for H. pylori infection is still effective in Korea, and diabetes mellitus is suggested to be a risk factor for eradication failure.

Gastric Cancer Caused by Adenoma: Predictive Factors Associated with Lesions Other Than the Expanded Indications

Background/Aims We aimed to investigate whether the current indications for curative endoscopic resection (ER) of gastric cancer (GC) can be applied to GC caused by adenoma. Additionally, we attempted to identify factors predictive of lesions subsequently found in addition to the expanded indications for ER. Methods We retrospectively analyzed 342 patients diagnosed with GC caused by adenoma who underwent ER at a single tertiary center between February 2011 and December 2014. The gross whole tumor size was measured using the endoscopically resected specimen. The microscopic whole tumor size was measured using mapping paper. The estimated cancer size was calculated using the microscopic whole tumor size and the square root of the carcinoma component. Results A gross whole tumor size ≥3 cm, carcinoma component ≥35%, and gross ulceration were predictive of lesions other than the expanded indications for ER. The overall rate of lymph node metastasis was 0.3% (1/327), which only occurred in one patient with a lesion other than the expanded indications (4.5%, 1/22). Conclusions The current indications for curative ER in GC can be applied to GC caused by adenoma. In cases suspected of having lesions other than the expanded indications, patients should be cautiously selected for ER to reduce the risk of an inappropriate procedure.

A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings

Purpose Precise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography. Materials and Methods A retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1–2 cm selectively above the tumors upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line. Results Negative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients. Conclusions Our tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

Diagnostic Value of Carcinoembryonic Antigen in Ascites for Colorectal Cancer with Peritoneal Carcinomatosis

Background/Aims Diagnostic tests for carcinoembryonic antigen (CEA) in ascites have been performed in various malignant cases, but there is only few data on the applicability of CEA for colorectal cancer (CRC) patients with peritoneal carcinomatosis. We aimed to determine the usefulness of CEA in ascites (aCEA) as a diagnostic parameter for CRC with peritoneal carcinomatosis. Methods Between January 2000 and May 2013, the medical records of 259 patients who underwent paracentesis for the evaluation of ascites were retrospectively reviewed. CRC patients with ascites (n=82) and patients with non-malignant ascites (n=177) were evaluated. Patients who had other malignancies, including gastric or ovarian cancer, with ascites were excluded. The optimal diagnostic cut-off value of aCEA for CRC with peritoneal carcinomatosis was determined using receiver operating characteristic curve analysis. The value of aCEA for predicting the occurrence of peritoneal carcinomatosis was evaluated using a logistic regression model. Results The optimal cut-off value of aCEA to diagnose CRC with peritoneal carcinomatosis was 3.89 ng/mL, and the area under the curve for aCEA was 0.996 (sensitivity 96.3%, specificity 100%, positive predictive value 100%, negative predictive value 98.3%). Multivariate logistic regression analysis showed that aCEA was an independent factor predicting the occurrence of peritoneal carcinomatosis. Conclusions In this study, we showed that aCEA may be a useful parameter for diagnosing CRC with peritoneal carcinomatosis, and we propose an optimal aCEA cut-off value of 3.89 ng/mL. Further study that includes patients with other malignant ascites may be necessary to validate these findings.

Can Esophageal Baseline Impedance Predict Proton Pump Inhibitor Response in Gastroesophageal Reflux Disease

c 2018 The Korean Society of Neurogastroenterology and Motility J Neurogastroenterol Motil, Vol. 24 No. 1 January, 2018 www.jnmjournal.org Gastroesophageal reflux disease (GERD) is characterized by reflux of stomach contents and causes unpleasant symptoms and complications. Proton pump inhibitors (PPIs) are widely used to treat GERD and significantly reduce gastric acid secretion. However, despite PPI therapy, up to 40% of patients report persistent GERD symptoms. Some studies have attempted to predict which patients will have a poor response to PPI treatment. A recently published review article reported that poor response to PPI treatment is related to a PPI-metabolizer genotype, CYP, and requires combined adjunctive therapy. Adjusting treatment in patients with the PPI-metabolizer genotype or switching to a CYP2C19-independent PPI is a simple way to increase the PPI response. In addition, the use of adjunctive agents may be considered when the physiological mechanism of PPI nonresponse is suspected. For such patients, recent research focused on whether the diagnosis is truly correct and the degree of treatment response can be predicted. According to the recent implementation of a pH monitoring method combined with baseline impedance (BI), and depending on the degree of acid exposure and esophageal hypersensitivity highlighted in the Rome IV criteria for functional esophageal disorders, patients with suspected GERD with typical chest pain and regurgitation are divided into 4 subtypes: erosive esophagitis, non-erosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn (FH). Especially when using mean nocturnal BI in the distal esophagus for patients with heartburn, several studies showed that the value of BI and degree of reflux showed a negative correlation and the mean BI level was statistically significantly lower in the PPI-responsive group than in the non-responsive group. Therefore, esophageal BI is used to predict the therapeutic effect of PPI related to severity of acid exposure. However, there is still insufficient evidence to standardize this strategy. Along with the BI, the concept of intercellular space diameter (ISD) has recently been studied. Histologically, dilated intercellular space (DIS) is frequently observed in GERD patients. In addition, JNM J Neurogastroenterol Motil, Vol. 24 No. 1 January, 2018 pISSN: 2093-0879 eISSN: 2093-0887 https://doi.org/10.5056/jnm17138 Editorial Journal of Neurogastroenterology and Motility

Assessment of colon polyp morphology: Is education effective?

AIM To determine the inter-observer variability for colon polyp morphology and to identify whether education can improve agreement among observers. METHODS For purposes of the tests, we recorded colonoscopy video clips that included scenes visualizing the polyps. A total of 15 endoscopists and 15 nurses participated in the study. Participants watched 60 video clips of the polyp morphology scenes and then estimated polyp morphology (pre-test). After education for 20 min, participants performed a second test in which the order of 60 video clips was changed (post-test). To determine if the effectiveness of education was sustained, four months later, a third, follow-up test was performed with the same participants. RESULTS The overall Fleiss’ kappa value of the inter-observer agreement was 0.510 in the pre-test, 0.618 in the post-test, and 0.580 in the follow-up test. The overall diagnostic accuracy of the estimation for polyp morphology in the pre-, post-, and follow-up tests was 0.662, 0.797, and 0.761, respectively. After education, the inter-observer agreement and diagnostic accuracy of all participants improved. However, after four months, the inter-observer agreement and diagnostic accuracy of expert groups were markedly decreased, and those of beginner and nurse groups remained similar to pre-test levels. CONCLUSION The education program used in this study can improve inter-observer agreement and diagnostic accuracy in assessing the morphology of colon polyps; it is especially effective when first learning endoscopy.

A Case of Tuberculous Peritonitis Presenting as Small Bowel Obstruction

The peritoneum is one of the common extrapulmonary sites of tuberculosis infection. Patients with underlying end-stage renal or liver disease are frequently complicated by tuberculous peritonitis; however, the diagnosis of the tuberculous peritonitis is difficult due to its insidious nature, well as its variability in presentation and limitation of available diagnostic tests. Once diagnosed, the preferred treatment is usually antituberculous therapy in uncomplicated cases. However, surgical treatment may also be required for complicated cases, such as small bowel obstruction or perforation. An 85-year-old woman was referred our hospital for abdominal pain with ileus. Despite medical therapy, prolonged ileus and progression to sepsis were shown, she underwent surgery to confirm the diagnosis and relief of mechanical ileus. Intraoperative peritoneal biopsy and macroscopic findings confirmed tuberculous peritonitis. Therefore, physicians should consider the possibility of tuberculous peritonitis in patients with unexplained small bowel obstruction.

Recurrent Abdominal Pain after Laparoscopic Appendectomy

Laparoscopic surgical approaches, compared with open surgical approaches, provide comparable clinical outcomes, but lower complications. Unfortunately, a rare complication-portomesenteric vein thrombosis-had been reported after laparoscopic surgery. A 42-year-old woman was referred our hospital for recurrent abdominal pain after laparoscopic appendectomy from acute appendicitis. It was determined that abdominal pain was due to postoperative superior mesenteric vein thrombus. A six-month anticoagulation therapy is an excellent treatment for superior mesenteric vein thrombus . Therefore, physicians should be aware of portomesenteric vein thrombosis in patients with newly developed abdominal pain after successful laparoscopic surgical management.