Kyu Jong Kim

Technical issues and new devices of ESD of early gastric cancer

Endoscopic submucosal dissection (ESD) is a highly refined technique compared to conventional endoscopic mucosal resection. It enables complete resection of early gastric cancer (EGC) which has no possibility of lymph node metastasis. Indication for ESD of EGC generally entails early gastric cancer confined to the mucosa with well differentiated histology, though there are clinically suitable expanded criteria. As ESD requires specific skill and expertise, endoscopists need to be familiarized with basic methods and the use of special devices. The essence of the technique is to dissect the submucosal layer with direct vision and maintain the cutting plane above the underlying proper muscle layer. Although there are some differences in the detailed technical aspect, the cardinal method of ESD is now well established and standardized. Furthermore, research and development of new ESD devices that render more efficient, safe ESD are still in progress to improve the overall result of ESD on early gastric cancer.

Normal 24-hour Ambulatory Esophageal pH Values in Koreans

BACKGROUND/AIMS Twenty-four-hour ambulatory esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to quantify normal distal esophageal acid parameters in healthy Koreans. METHODS Thirty healthy adults who were not on medication and were free from gastrointestinal symptoms were analyzed. Ambulatory esophageal acid (pH <4) exposure parameters were recorded at 5 cm above the lower esophageal sphincter. RESULTS The 95th percentiles for reflux parameters assessed in the distal esophagus were as follows: percentage of total time with pH <4, 5.10%; percentage of upright time with pH <4, 7.88%; percentage of supine time with pH <4, 4.00%; number of reflux episodes, 62.7; number of reflux episodes with pH <4 for >5 minutes, 5.3; and the longest single acid-exposure episode, 21.3 minutes. CONCLUSIONS Physiological gastroesophageal reflux occurs frequently in healthy Koreans. These data provide a reference range that could be utilized in studies involving Korean subjects.

Genetic Alterations in Gastric Carcinomas and Adjacent Mucosa Detected by Comparative Genomic Hybridization (CGH)

PURPOSE Comparative genomic hybridization (CGH) was used to detect any amplified or deleted chromosomal regions in tumors by mapping their locations on normal metaphase chromosomes. METERIALS AND METHODS Twenty-six gastric carcinomas and their adjacent mucosa were screened for chromosomal aberrations using CGH. RESULTS All carcinomas had chromosomal aberrations, and chromosomal material was more likely to be gained than lost. Ten out of 26 adjacent mucosa had chromosomal aberrations, and a gain was less frequently observed than a tumor (1.6/2.6). The most common gains were detected on 13q (58.3%), 8q (30.8%), 6q (27.0%), and 20p (19.2%), while the most frequent losses were detected on 17p (38.5%) and 16q (7.2%). The most commonchromosomal aberrations in the adjacent mucosa were a gain of 13q (11.5%) and a loss of 17q (11.5%). The tumors had more chromosomal gains of 2q, 3q, and 13q and more losses of 17p and 16q than the adjacent mucosa. CONCLUSION S: The most common gain in the tumors was detected on 13q, 8q, 6q, and 20p, and the most frequent loss was on 17p and 16q. While CGH may be useful in predicting the prognosis or therapeutic decision of gastric carcinomas, further study of several candidate genes, such as DP1, FLT1, c-myb, AIB1, BTAK, is needed to clarify gastric carcinogenesis and its progression.

A 43-year-old female with Dysphagia: what is your diagnosis by high-resolution manometric finding?

A 43-year-old female was admitted to our hospital with dysphagia for both liquids and solid foods for 2 months. A high-resolution manometry (HRM; version 2.1; Manoscan; Sierra Scientific Instruments Inc., Los Angeles, CA) was performed (Fig. 1). The resting esophagogastric junction (EGJ) pressure in expiration and inspiration were 69 mmHg and 54 mmHg, respectively. The mean integrated relaxation pressure (IRP) with 10 swallows of 5 mL was 40.7 mmHg. This pattern of deglutitive pressure topography was very unswerving during 10 water swallows. The black isobaric contour was set at 30 mmHg in the presented topography. What is your diagnosis with this high-resolution manometry finding? This HRM finding of one swallow shows impaired EGJ relaxation with 57.8 mmHg of IRP, absent peristalsis, and pan-esophageal pressurization from the upper esophageal sphincter (UES) to the EGJ. It was consistent with achalasia and associated esophageal compression based on the Chicago classification of distal esophageal motility disorders.1 Incomplete deglutitive EGJ relaxation with mean IRP and/or mean intrabolus pressure ≥15 mmHg is an essential feature in the diagnosis of achalasia. However, there is no significant pressurization within the body of the esophagus in classic achalasia with impaired EGJ relaxation. In achalasia with esophageal compression as in this case, there is a rapid pan-esophageal pressurization from the UES to the EGJ with >30 mmHg intrabolus pressure in ≥20% of swallows. In spastic achalasia, there is a rapidly propagated pressurization attributable to spastic contractions in which the contractile front velocity is >8 cm/sec in ≥20% of swallows.1,2

W1992 Incidentally Detected Colonic Mass By FDG PET-CT

G A A b st ra ct s with colorectal cancer (CRC) in Tayside, Scotland between March 2000 and September 2007. Data came from the CRC database at Ninewells Hospital. Patients with FOBT screen detected cancers (SCR) were identified from the Scottish Bowel Screening Pilot Study and were then linked to the cancer database. Patients not identified as screen detected were deemed to be symptomatic (SYM). The age range of SYM patients was limited to that of subjects who had been invited for bowel screening (50-69 years). RESULTS: There were 437 (60.2% males) SYM and 187 (64.7% males) SCR patients. As expected, there was a significant difference in stage distribution with 83 (19.0%) of the SYM group compared with 77 (41.6%) of the SCR group diagnosed at Dukes A (P<0.0001). By the end of the study period 115 (26.3%) of the SYM group had died from CRC compared to 25 (13.4%) of the SCR group (P<0.0001). Within all three Dukes stages there were significant differences in the T stage distribution in the two groups with consistently more favourable distributions for the SCR group (all P< 0.04). In Dukes A 40.9% were staged as T1 and 59% as T2 in the SYM group compared to 58.4% and 41.6% in SCR group. Within Dukes B 90.6% were stage T3 and 9.4% as T4 in the SCR group compared to 77.3% and 22.7% in the SYM group. Within Dukes C a similarly favourable shift in the T stage was seen in the SCR group. When anatomical site was examined there was a significant difference (P=0.02) in the anatomical distribution of cancers in the two groups with a preponderance of left colon tumours in the SCR group at the expense of right colonic and rectal tumours. When the stage distribution in the different anatomical sites was scrutinised the proportion of Stage A cancers in the right colon, left colon and rectum was 6.6%, 20.6% and 26.6% respectively compared with 24.3%, 43.8% and 50% respectively for the SCR group. CONCLUSION: In this cohort of patients defined by age and location, it was found that Dukes staging may be misleading is assessing screen-detected cancers as they had a more favourable T stage distribution within each Dukes stage. In addition, screening appeared to slightly underdiagnose right sided and rectal cancers, and although stage at presentation improved from the right colon to the rectum in the symptomatic cancers this was mirrored by significantly better stage distributions in all anatomical sites in the screen-detected group.