Inlet patch: heterotopic gastric mucosa--another contributor to supraesophageal symptoms?

Heterotopic Gastric Mucosa in the Proximal Esophagus: Prospective Study and Systematic Review on Relationships with Endoscopic Findings and Clinical Data

Cervical inlet patches (CIP) are common endoscopic findings with uncertain pathogenesis and clinical significance. We aimed to perform a systematic review and prospective study of clinical data and endoscopic findings related to CIP. It was a prospective single-center study conducted between 10/01/2017 and 9/01/2018. Forty patients with histopathologically confirmed CIP were compared with 222 individuals in the reference group. The systematic review was executed in accordance with the PRISMA guideline. Alcohol consumption tended to be higher among patients with CIP (3.0 ± 4.6 vs. 1.9 ± 5.0 standard drinks/week CIP patients and reference group, respectively; p < 0.001). Dysphagia was more frequent among patients with CIP (25% vs. 1.4%, CIP patients and reference group, respectively; p < 0.001), and sore throat and hoarseness were less frequent in patients with CIP (17.5% vs. 26.6% CIP patients and reference group, respectively; p < 0.01). In the multivariate regression analysis, the only risk factor of CIP occurrence was dysphagia (OR 21.9, 95%CI 4.9-98.6; p < 0.001). Sore throat and hoarseness were a reverse-risk factor of CIP diagnosis (OR 0.3, 95%CI 0.1-0.93; p = 0.04). Clinical data and coexisting endoscopic findings were not related to CIP. In the presented study, dysphagia was related to CIP occurrence, and sore throat and hoarseness tended to be less frequent among patients with CIP.

Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis

BACKGROUND

Cervical inlet patch (CIP), also called gastric inlet patch, is a heterotopic columnar mucosal island located in the cervical esophagus, which has been under-recognized by clinicians.

AIM

We conducted a systemic review and meta-analysis to explore the prevalence and clinical and endoscopic characteristics of CIP.

MATERIALS AND METHODS

Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The prevalence of CIP with 95% confidence interval (CI) was pooled by using a random-effect model. The association of CIP with demographics, clinical presentations, and endoscopic features was evaluated by odds ratios (ORs).

RESULTS

Fifty-three studies including 932,777 patients were eligible. The pooled prevalence of CIP was 3.32% (95% CI=2.86%-3.82%). According to the endoscopic mode, the pooled prevalence of CIP was higher in studies using narrow-band imaging than in those using white light and esophageal capsule endoscopy (9.34% vs. 2.88% and 0.65%). The pooled prevalence of CIP was higher in studies where the endoscopists paid specific attention to the detection of this lesion (5.30% vs. 0.75%). CIP was significantly associated with male (OR=1.24, 95% CI=1.09-1.42, P=0.001), gastroesophageal reflux disease (OR=1.32, 95% CI=1.04-1.68, P=0.03), reflux symptoms (OR=1.44, 95% CI=1.14-1.83, P=0.002), dysphagia (OR=1.88, 95% CI=1.28-2.77, P=0.001), throat discomfort (OR=4.58, 95% CI=1.00-21.02, P=0.05), globus (OR=2.95, 95% CI=1.52-5.73, P=0.001), hoarseness (OR=4.32, 95% CI=1.91-9.78, P=0.0004), cough (OR=3.48, 95% CI=1.13-10.72, P=0.03), Barrett's esophagus (OR=2.01, 95% CI=1.37-2.94, P=0.0003), and esophagitis (OR=1.62, 95% CI=1.27-2.07, P=0.0001).

CONCLUSION

CIP appears to be common by using narrow-band imaging, especially if the endoscopists would like to pay attention to the detection of this lesion. CIP is clearly associated with acid-related symptoms and Barrett's esophagus.

Influence of narrow-band imaging (NBI) and enhanced operator's attention during esophagus inspection on cervical inlet patches detection

PURPOSE

Heterotopic gastric mucosa in the upper esophagus (cervical inlet patches - CIP) may be easily missed during esophagogastroduodenoscopy (EGD) due to low awareness of this usually, but not invariably, benign lesion. Narrow-band imaging (NBI) emphasizes contrast between normal esophageal mucosa and CIP. The purpose of this study was to investigate how NBI use and enhanced attention of operator during inspection of upper esophagus impacts cervical inlet patch detection rate (CIPDR).

MATERIALS AND METHODS

This is a prospective, randomized study in which we enrolled 1000 patients, qualified for diagnostic EGD. The trial was divided into two parts; the first, when 6 operators performed EGD with standard attention (SA), and the second, when the same operators were asked to step up with attention at CIP (enhanced attention - EA). In both parts of the study, patients were randomized to NBI and white light endoscopy (WLE) in 1:1 ratio. The study is registered in ClinicalTrials.gov (No. NCT03015571).

RESULTS

Differences in CIPDR between WLE and NBI in SA and EA were not statistically different (5.6% vs 7.6%; p ​= ​0.3, and 7.6% vs 11.6%; p ​= ​0.1, respectively). In multivariate regression analysis, the only factors improving CIPDR were NBI with EA (NBI_EA, OR 3.31; 95%CI 1.57-6.98; p ​= ​0.003) and sedation (OR 1.97; 95%CI 1.27-3.05; p ​= ​0.002).

CONCLUSIONS

The use of NBI combined with EA significantly improves CIPDR.

Heterotopic gastric mucosa of the proximal esophageal (HGMPE) and its potential role in pediatric dysphonia and dysphagia

OBJECTIVE

Despite a reported incidence of HGMPE of 10%, proof of acid production, and an increased incidence of respiratory symptoms, the pediatric otolaryngology, swallowing and voice care literature is silent on this entity. This case series describes pediatric patients confirmed to have HGMPE with dysphonia and/or dysphagia.

METHODS

Retrospective case series of Pediatric Voice, Resonance, and Swallowing Center patients at a tertiary Children's Hospital in 2019.

SETTING

Tertiary academic medical center.

SUMMARY OF RESULTS

Three patients who underwent triple endoscopy for dysphonia or dysphagia were histologically diagnosed with HGMPE. Esophageal biopsies were otherwise normal. Two of the three patients resolved their primary aerodigestive symptoms following treatment with acid suppression and a protectant (sucralfate). The third patient reported significant improvement in symptoms by phone. The significance of this case series cannot be understated: 1) A need for increased awareness among pediatric otolaryngologists, voice care and swallowing professionals of this entity given its relatively common incidence of 10% offset by a dearth of presentations & scientific publications in our literature clearly exists. 2) Otolaryngologists have abandoned operative upper aerodigestive tract endoscopy in lieu of office-based less comprehensive videolaryngostroboscopy and fiberoptic endoscopic evaluation of swallowing. HGMPE & other esophageal disorders (i.e. eosinophilic esophagitis) support revisiting triple endoscopy in select patients where office endoscopy has failed to diagnose and successfully treat such patients. 3) Both acid suppression therapy and a protectant (sucralfate) may be useful in these patients. 4) Modification of rigid esophagoscopy technique to carefully assess the introitus and superior esophageal segment is paramount 5) Otolaryngologists over-diagnose & over-treat laryngopharyngeal reflux. The pediatric & adult literature is replete with significant safety warnings associated with acid suppression therapy and guidelines admonish their indiscriminate use, raising the liability bar of empiric treatment. Large scale prospective, randomized and controlled studies are needed to confirm the pathophysiologic role of this entity in pediatric aerodigestive disorders.

CONCLUSION

HGMPE is a clinical entity that can be easily missed upon swift entry into the esophagus with rigid endoscopy. Careful scrutiny and visualization of the proximal esophagus is critical in order to identify HGMPE, as there is a higher rate of laryngospasm, stricture, and potentially neoplasm in this population.

Gastric inlet patches: symptomatic or silent?

PURPOSE OF REVIEW

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

RECENT FINDINGS

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

SUMMARY

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.

Cervical inlet patch: new insights into diagnosis and endoscopic therapy

The cervical inlet patch is an island of heterotopic gastric mucosa, most commonly found in the proximal oesophagus. Its importance as a cause of throat symptoms has been recognised, particularly chronic globus sensation. This has led to a change in the Rome IV criteria for globus management, with emphasis on ruling out the condition. Proton pump inhibitors are often ineffective in resolving symptoms. Endoscopic studies on the use of ablative techniques, most recently radiofrequency ablation (RFA), have shown promise in reversing the CIP to mormal squamous mucosa, with subsequent symtpomatic resolution. The aim of this review is to update on the investigation and management of the CIP.

Esophageal Inlet Patch: An Under-Recognized Cause of Symptoms in Children

OBJECTIVES

To determine the incidence of inlet patch (IP) and to assess the clinical and pathological features, role of the diagnostic workup in treatment decision making, efficacy of medical and endoscopic therapy, and natural history in a pediatric population.

STUDY DESIGN

Consecutive patients aged <18 years (n = 1000) undergoing esophagogastroduodenoscopy were enrolled prospectively. Biopsy specimens were obtained from IPs and the proximal and distal esophagus, stomach, and duodenum. Multichannel intraluminal impedance and pH monitoring (MII-pH) was performed in all symptomatic patients. Symptomatic patients were treated with proton pump inhibitors for 8 weeks, and IP ablation by argon plasma coagulation (APC) was performed in unresponsive patients.

RESULTS

The endoscopic incidence of IP was 6.3%, with a cumulative missing rate of 5.8%. Thirty-five of the 63 patients (56%) were asymptomatic, 11 (17%) had symptoms clearly related to the underlying digestive disorder, and 17 (27%) had chronic IP-related symptoms. MII-pH was positive in 10 of the 28 symptomatic patients. All 17 patients with IP-related symptoms were unresponsive to proton pump inhibitors and were treated with APC, and all had achieved complete remission by the 3-year follow-up. Patients with underlying disorders were successfully treated with medical therapy, and asymptomatic patients remained symptom-free, with no endoscopic or histological changes seen at the 3-year follow-up.

CONCLUSION

IP is an under-recognized cause of symptoms in children with unexplained esophageal and respiratory symptoms. MII-pH and bioptic sampling are needed to exclude entities mimicking IP symptoms and to direct therapy. APC is safe and effective for treating IP-related symptoms.

Endoscopic diagnosis of cervical esophageal heterotopic gastric mucosa with conventional and narrow-band images

AIM: To compare the diagnostic yield of heterotopic gastric mucosa (HGM) in the cervical esophagus with conventional imaging (CI) and narrow-band imaging (NBI).

METHODS: A prospective study with a total of 760 patients receiving a CI examination (mean age 51.6 years; 47.8% male) and 760 patients undergoing NBI examination (mean age 51.2 years; 45.9% male). The size of HGM was classified as small (1-5 mm), medium (6-10 mm), or large (> 1 cm). A standardized questionnaire was used to obtain demographic characteristics, social habits, and symptoms likely to be related to cervical esophageal HGM, including throat symptoms (globus sensation, hoarseness, sore throat, and cough) and upper esophageal symptoms (dysphagia and odynophagia) at least 3 mo in duration. The clinicopathological classification of cervical esophageal HGM was performed using the proposal by von Rahden et al.

RESULTS: Cervical esophageal HGM was found in 36 of 760 (4.7%) and 63 of 760 (8.3%) patients in the CI and NBI groups, respectively (P = 0.007). The NBI mode discovered significantly more small-sized HGM than CI (55% vs 17%; P < 0.0001). For the 99 patients with cervical esophageal HGM, biopsies were performed in 56 patients; 37 (66%) had fundic-type gastric mucosa, and 19 had antral-type mucosa. For the clinicopathological classification, 77 patients (78%) were classified as HGM I (asymptomatic carriers); 21 as HGM II (symptomatic without morphologic changes); and one as HGM III (symptomatic with morphologic change). No intraepithelial neoplasia or adenocarcinoma was found.

CONCLUSION: NBI endoscopy detects more cervical esophageal HGM than CI does. Fundic-type gastric mucosa constitutes the most common histology. One-fifth of patients have throat or dysphagic symptoms.

Disturbed balance between SOX2 and CDX2 in human vitelline duct anomalies and intestinal duplications

Congenital gastric-type heteroplasia is common in intestinal duplications and anomalies, which originate from incomplete resorption of the omphalomesenteric duct during development. Two transcription factors determine the proximodistal specification of the gastrointestinal tract, SOX2, expressed exclusively in the proximal part of the primitive gut, and CDX2, expressed solely in the distal part. Aberrant expression of these factors may result in abnormal development and congenital abnormalities. Therefore, we analyzed the expression of SOX2 and CDX2 in a number of pediatric intestinal anomalies. We investigated the expression pattern of SOX2 and CDX2 in three congenital intestinal anomalies in which ectopic gastric tissue may be present, Meckel's diverticulum (N = 8), persistent ductus omphalomesentericus (N = 14), and intestinal duplications (N = 8). CDX2, but not SOX2, was detected in intestinal epithelial cells in tissue lacking gastric heteroplasia. In gastric-type heteroplasia, a reciprocal expression pattern existed between SOX2 and CDX2 in the gastric and intestinal tissues, respectively. Interestingly, patches of CDX2-positive cells were present within the gastric mucosa in a subset of Meckel's diverticula and intestinal duplications, suggesting that it is not the absence of CDX2, but rather the ectopic expression of SOX2 that leads to gastric tissue in the prospective intestinal tissue. This is in concordance with our previous mouse studies. Collectively, our data indicate that a fine balance between SOX2 and CDX2 expression in the gastrointestinal tract is essential for proper development and that ectopic expression of SOX2 may lead to malformations of the gut.

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Detailed esophageal function and morphological analysis shows high prevalence of gastroesophageal reflux disease and Barrett's esophagus in patients with cervical inlet patch

Although the pathogenesis of cervical inlet patch (CIP) is not fully understood, most authors consider it as a congenital abnormality, whereas others surmise it to be related to gastroesophageal reflux disease (GERD). We aimed to evaluate esophageal function and the prevalence of GERD and Barrett's esophagus in patients with CIP. GERD is defined by the presence of erosive esophagitis or an abnormal pH monitoring. Seventy-one consecutive patients with endoscopic and histological evidence of CIP were prospectively evaluated. Esophageal symptom analysis, 24-hour simultaneous biliary reflux and double-channel pH-monitoring, and esophageal manometry were carried out in 65/71 (92%) patients and in 25 matched controls. Six patients were not suitable for testing and were, therefore, excluded. The histological evaluation of the heterotopic islands showed cardia and/or oxyntic mucosa in 64/65 (98%) patients and specialized intestinal metaplasia (SIM) in one patient (2%). The cardia and/or oxyntic mucosa was accompanied by focally appearing pancreatic acinar metaplasia and pancreatic ductal metaplasia in 7/64 (11%) and in 1/64 (2%), superficial mucous glands in 6/64 (9%), and SIM in 2/64 (3%) cases. In total, SIM was present in three patients (5%), and one of them had low-grade dysplasia. At the gastroesophageal junction, 28 (43%) patients had columnar metaplasia, including nine (14%) patients with SIM. Erosive esophagitis was present in 37 (57%) cases. Thirty-two patients (49%) had abnormal acid reflux in the distal and 25 (38%) in the proximal esophagus. Abnormal biliary reflux was present in 25 (38%) cases. On the basis of endoscopic and pH studies, GERD was established in 44/65 (68%) patients. Typical reflux symptoms were common (33/65, 51%). The combined 24-hour biliary and double-channel pH-monitoring detected significantly more significant acidic reflux at both measurement points and significantly longer bile exposure time in the distal esophagus in patients with CIP. Acid secretion in the CIP was detected in three (5%) cases. Esophageal manometry revealed decreased LES pressure and prolonged relaxation with decreased peristaltic wave amplitude, and an increased number of simultaneous contractions in the esophageal body. The detailed evaluation of the esophageal morphology and function in subjects with CIP showed a high prevalence of GERD and Barrett's esophagus. Further studies are needed to evaluate whether combined acidic and biliary reflux is able to promote similar histomorphological changes in the CIP, as it is shown distally in patients with Barrett's esophagus.

Symptomatic gastric inlet patches in children treated with argon plasma coagulation: a case series

The pathologic potential of gastric inlet patches is now being recognized. A recent adult study has shown the effectiveness of argon plasma coagulation in ablating the patch and the associated symptoms. There are no reports of ablation in children. We report a case series of successful argon plasma coagulation of gastric inlet patches and their symptoms in 5 children.

A rare association of inlet patch with laryngospasm: a report of two children and literature review

The inlet patch (IP) is an area of heterotopic gastric mucosa in the cervical esophagus commonly seen during upper endoscopy. Although generally asymptomatic IP has been associated with esophageal and supraesophageal symptoms and, though rare, in adult with malignant transformation. We describe two cases of recurrent episodes of laryngospasm associated with IP. In both cases there was a good response to prolonged acid suppression therapy.

Inlet patch: clinical presentation and outcome in children

OBJECTIVES

An inlet patch (IP) is defined as heterotopic gastric mucosa located in the proximal esophagus. Little information is available in children. The aim of this retrospective study was to assess clinical significance, endoscopic and histological characteristics, and natural history of IP in children.

PATIENTS AND METHODS

This retrospective multicenter study included all of the cases of IP recorded in 7 tertiary French pediatric gastrointestinal centers. Information about demographics, clinical symptoms, endoscopic characteristics, histology, treatment, and evolution was collected.

RESULTS

Fifteen children were included (8 boys, 7 girls). The median age at diagnosis was 9.5 years (range 3.3-15 years). Five children had esophageal atresia and 9 had gastroesophageal reflux. Only 1 child was asymptomatic. Digestive symptoms (dysphagia, food impaction) were noted in 14 patients and respiratory or ear, nose, and throat symptoms in 6. At endoscopy, IP was characterized by a small, round salmon-pink lesion of the proximal esophagus. Helicobacter pylori was found in 2 patients. Proton pump inhibitor treatment was initiated in 14 children for a mean duration of 4.7 months (range 1-12 months). Two patients were lost to follow-up. Clinical symptoms disappeared in 5 patients and decreased in 3 others. One case of hematemesis was noted after a mean follow-up of 9 months. Recurrent symptoms were noted in 2 patients after treatment discontinuation.

CONCLUSIONS

IP is an uncommon but almost certainly underrecognized lesion in children, and may be the cause of digestive and respiratory symptoms in some children.

Heterotopic gastric mucosal patch of the esophagus is associated with higher prevalence of laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux (LPR) is common in clinical practice. Heterotopic gastric mucosal patch of the proximal esophagus (HGMP) is reported to cause LPR symptoms. This study assessed the prevalence of LPR symptoms and correlation with the size of HGMP. Four hundred and sixty-two patients undergoing endoscopy were carefully questioned regarding LPR symptoms experienced in the previous 12 weeks. The size of the HGMP was assessed and documented during endoscopy. Clinicopathological classifications were assigned (types I-V) accordingly. HGMP [median one patch (range 1-3), median size 15 mm [3-35] was detected in 26 (19 HGM type I and 7 HGM type II] patients giving a prevalence of 5.6%. Among the indications, there were significantly more LPR symptoms as referral indications among patients with HGMP. There were no significant differences in the endoscopic findings. On specific enquiries, significantly more HGMP patients had experienced any LPR symptoms (73.1 vs. 25.9%, p < 0.001) specifically chronic cough (p = 0.002), throat discomfort/hoarseness (p < 0.001), globus sensation (p = 0.004), regurgitation (p < 0.001). HGMP patients also had more heartburn (p = 0.001). Larger HGMP (≥ 15 mm) was only associated with more chronic cough (p = 0.022). In conclusion, patients with HGMP have significantly more LPR symptoms. However, most were mild and detected through specific enquiries. Interestingly, the size of HGMP did not significantly affect the prevalence of LPR symptoms.

Systematic review: the extra-oesophageal symptoms of gastro-oesophageal reflux disease in children

BACKGROUND

Extra-oesophageal symptoms are thought to be common, atypical symptoms of gastro-oesophageal reflux disease (GERD) in children.

AIM

To investigate the prevalence of GERD in children with extra-oesophageal symptoms or of extra-oesophageal symptoms in children with GERD, and the effect of GERD therapies on extra-oesophageal symptoms.

METHODS

A systematic review of articles in PubMed and EMBASE.

RESULTS

We identified 18 relevant articles. The pooled weighted average prevalence of GERD in asthmatic children was 23%, compared with 4% in healthy controls from the same five studies. The majority of studies evaluating the relationship between apparent life-threatening event (ALTE) and GERD did not suggest a causal relationship. Seven studies reported that respiratory symptoms, sinusitis and dental erosion were significantly more prevalent in children with GERD than in controls. Data from pharmacotherapeutic trials were inconclusive and provided no support for a causal relationship between GERD and extra-oesophageal symptoms.

CONCLUSIONS

Possible associations exist between GERD and asthma, pneumonia, bronchiectasis, ALTE, laryngotracheitis, sinusitis and dental erosion, but causality or temporal association were not established. Moreover, the paucity of studies, small sample sizes and varying disease definitions did not allow firm conclusions to be drawn. Most trials of GERD therapies showed no improvement in extra-oesophageal symptoms in children.

Prevalence of endoscopically identified heterotopic gastric mucosa in the proximal esophagus: endoscopist dependent?

GOALS

The aim of this study is to determine the prevalence of heterotopic gastric mucosa in the proximal esophagus (HGMPE) and whether thorough endoscopic search may influence such prevalence.

BACKGROUND

Heterotopic gastric mucosa in the esophagus (sometimes known as inlet patch) refers to a discrete area of gastric mucosa, with a spherical or ellipsoid configuration, that is typically located in the proximal esophagus. The prevalence of endoscopically diagnosed HGMPE varies from 0.1% to 10%. Endoscopic detection may be difficult as HGMPE is often located at or just below the upper esophageal sphincter. It might be associated with severe complications such as bleeding, perforation, fistula, and stricture formation, in addition to the development of adenocarcinoma.

STUDY

During a 2-year period, 455 consecutive patients with various gastrointestinal complaints underwent esophagogastroduodenoscopy by a single endoscopist (group 1). This endoscopist paid special attention to detecting HGMPE by thoroughly examining the proximal esophagus upon withdrawal of the endoscope. During the same period of time, endoscopy reports of 472 patients who underwent esophagogastroduodenoscopy in the same hospital by 3 other endoscopists were retrospectively reviewed (group 2). These endoscopists were aware of the existence of the HGMPE and reported that the presence of HGMPE would be included as an endoscopic finding in their reports.

RESULTS

In the first group, HGMPE was identified in 12 out of 455 patients (2.6%). Whereas in the second group, only 2 out of 472 patients (0.4%) had reports identifying HGMPE (P<0.01).

CONCLUSIONS

Endoscopic detection of HGMPE is influenced by the endoscopist's thorough search of this entity, and thus, more time devoted to such a search may lead to higher detection rates.

[Prophylactic gastric surgery]

A premalignant condition with high risk of gastric cancer is the basis for prophylactic gastric surgery. The germline mutation carrier in the E-cadherin gene has a lifetime risk of 70-80% for diffuse-type gastric cancer, and high-grade intraepithelial neoplasia has a 60-70% gastric cancer risk. Other premalignant conditions such as HNPCC syndrome (5% gastric cancer) and low-grade intraepithelial neoplasia (10% risk) are moderate risk factors for developing gastric cancer. They do not justify prophylactic surgery, but surveillance is required. In case high-grade intraepithelial neoplasia or early gastric cancer is detected, an option is extended radicality with total gastrectomy instead of subtotal gastric resection. Positive family history and early-onset of gastric cancer are risk factors to consider when discussing prophylactic gastrectomy or extended radicality.