Congestive ischemic colitis successfully treated with anti-inflammatory therapy: A case report

BACKGROUND

Congestive ischemic colitis is a rare subtype of ischemic colitis with an unknown pathophysiology. Excluding conservative management, such as fasting, no established treatment exists; therefore, surgical intervention should be considered in some cases if symptoms worsen. Current literature suggests that anti-inflammatory agents may effectively treat congestive ischemic colitis.

CASE SUMMARY

We present the case of a 68-year-old female patient who underwent laparoscopic left hemicolectomy for transverse colon cancer 3 years ago. Postoperatively, follow-up included an annual colonoscopy and abdominal computed tomography (CT) at a local clinic. However, progressive erythema and edema of the sigmoid colon were observed 1 year postoperatively. Upon admission to our hospital, she complained of abdominal pain and diarrhea. Abdominal CT showed thickening of the sigmoid colon walls, and colonoscopy revealed erythema, edema, and multiple ulcers with exudate in the sigmoid colon. CT angiography showed engorgement of the sigmoid vasa recta without any vascular abnormalities. The diagnosis was congestive ischemic colitis, and we treated the patient with anti-inflammatory agents. After 2 mo of glucocorticoid therapy (20 mg once daily) and 7 mo of 5-aminosalicylate therapy (1 g twice daily), the ulcers completely healed. She has not experienced any recurrence for 2 years.

CONCLUSION

Anti-inflammatory therapy, specifically glucocorticoids and 5-aminosalicylate, has demonstrated promising efficacy and introduces potential novel treatment options for congestive ischemic colitis.

Differences in Factors Predicting Lymph Node Metastasis Between pT1 Rectal Cancer and pT1 Colon Cancer: A Retrospective Study

BACKGROUND

Studies have demonstrated conflicting results regarding factors that predict lymph node metastasis (LNM) in pT1 colorectal cancers. We hypothesized that these discrepancies could be related to different factors predicting LNM between rectal and colon cancer. This study aimed to compare predicting factors for LNM between pT1 rectal and colon cancer.

METHODS

This retrospective study evaluated a prospectively maintained database that included 380 patients with pT1 colorectal cancer from January 2010 to December 2020. Patients were grouped according to whether they had rectal or colon cancer, with or without LNM, and factors predicting LNM were analyzed.

RESULTS

In pT1 rectal cancer, LNM was associated with deeper submucosal (SM) invasion (P = .024) and a higher proportion of poorly differentiated tumors (P = .006). In pT1 colon cancer, LNM was associated with a higher proportion of moderately/poorly differentiated tumors (P = .002) and lymphatic invasion (P = .004). In the multivariate analysis for rectal cancer, depth of SM invasion (≥3000 μm) was an independent predictive factor for LNM (95% confidence interval [CI], 1.48-27.94; P = .013), whereas for colon cancer, moderately/poorly differentiated tumors (95% CI, 1.38-8.13; P = .008) and lymphatic invasion (95% CI, 1.44-11.78; P = .008) were independent predictive factors for LNM.

DISCUSSION

There were distinct differences in the factors predicting LNM between pT1 rectal cancer and colon cancer. These results suggest the necessity in differentiating between rectal and colon cancer when performing studies on LNM in pT1 colorectal cancer.

Clinical Effectiveness of Fluorescence Lymph Node Mapping Using ICG for Laparoscopic Right Hemicolectomy: A Prospective Case-Control Study

BACKGROUND

The distinction between D3 lymph nodes and actual lymphatic pathways in primary tumors can be difficult during surgery, making it challenging to confirm the completeness of D3 lymph node dissection. Fluorescence lymph node mapping (FLNM) is a promising method for lymph node visualization.

PURPOSE

This study aimed to assess whether FLNM enhances the effectiveness of D3 lymph node dissection in patients with right-sided colon cancer.

METHODS

Endoscopic submucosal indocyanine green injection were performed on the distal margin of the colon cancer. In an FLNM group, the lymphatic drainage pathway and distribution of D3 lymph nodes were explored. Pathological evaluations were conducted for the fluorescent D3 and non-fluorescent D3 lymph nodes.

RESULTS

The FLNM group showed a significantly higher number of harvested lymph nodes in the D3 area. In stage III patients, the proportion of D3 lymph node metastasis was significantly higher in the FLNM group. The harvested D3 lymph node count showed a proportional correlation with a metastatic lymph node count of up to 15.

CONCLUSION

FLNM could be considered a promising new strategy to potentially increase harvested D3 lymph node counts in colon cancer surgery.

Clinical outcomes of esophageal granular cell tumors with different endoscopic resection methods

Esophageal granular cell tumors (GCTs), the second most common subepithelial tumors (SETs) of the esophagus, are potentially malignant with no definite management guidelines available. We retrospectively enrolled 35 patients with endoscopically resected esophageal GCTs between December 2008 and October 2021 and evaluated the clinical outcomes from the various methods performed. Several modified endoscopic mucosal resections (EMRs) were performed for treating esophageal GCTs. Clinical and endoscopic outcomes were evaluated. Mean age of patients was 55.8 ± 8.2, with majority being men (57.1%). Mean tumor size was 7.2 ± 2.6 mm, most (80.0%) were asymptomatic and present in the distal third of the esophagus (77.1%). Endoscopic characteristics predominantly included broad-based (85.7%) and whitish-to-yellowish color changes (97.1%). Endoscopic ultrasound (EUS) of 82.9% of the tumors revealed homogeneous hypoechoic SETs originating from the submucosa. The five endoscopic treatment methods used were: ligation-assisted (77.1%), conventional (8.7%), cap-assisted (5.7%), and underwater (5.7%) EMRs and ESD (2.9%). Mean procedure time was 6.6 ± 2.1 min, and no procedure-associated complications were noted. The en-bloc and complete histologic resection rates were 100% and 94.3%, respectively. No recurrences were noted during follow-up, and no significant differences in the clinical outcomes of the different methods of endoscopic resection were found. Based on tumor characteristics and therapeutic outcomes, modified EMR methods can be effective and safe. However, there were no significant differences in the clinical outcomes of the different methods of endoscopic resection.

Vaccination in patients with inflammatory bowel disease-Asian perspectives: results of a multinational web-based survey in the 8th Asian Organization for Crohn's and Colitis meeting

Background/Aims

Long-term immunosuppressive therapies used to treat inflammatory bowel disease (IBD) are associated with an increased risk of infections, many of which can be prevented by vaccination. We assessed physicians' current approaches and clinical practices regarding vaccinations for IBD patients in different Asian countries/regions.

Methods

An internet-based survey was conducted among members of the Asian Organization for Crohn's and Colitis from September 2020 to November 2020. The questionnaire consisted of 2 parts covering general opinion on the relevance of vaccinations and clinical practice of vaccination.

Results

Overall, 384 Asian medical doctors responded to the survey. The majority of respondents considered it very (57.6%) or sufficiently (39.6%) important to perform vaccinations as recommended by the guidelines. About half of the Asian physicians (52.6%) were usually or always performing vaccinations. The influenza vaccine was the most frequently recommended vaccine for IBD patients. Half of the respondents (51.3%) did not recommend hepatitis A vaccine, especially in China (61.6%) and Japan (93.6%). The diphtheria, tetanus, and pertussis vaccine were never (35.2%) or rarely (29.4%) recommended.

Conclusions

The findings of this survey indicated similarities among countries/regions in terms of the current approaches and practices regarding vaccination of IBD patients; however, there are some differences that might reflect each country's domestic vaccination guidelines and health insurance particularly with certain vaccines in some countries/regions. Although Asian physicians largely recommend vaccination, more awareness among doctors and Asian consensus regarding differences in IBD vaccination among countries/regions may be required.

Clinical and endoscopic characteristics of sessile serrated lesions with dysplasia/carcinoma

BACKGROUND/AIMS

Some sessile serrated lesions (SSLs) progress into dysplasia and colorectal cancer, however, the clinical and endoscopic characteristics of SSLs with dysplasia remain to be determined. In this study, we elucidated these characteristics in SSLs with dysplasia/carcinoma, compared with those of SSLs without dysplasia.

METHODS

We retrospectively collected the clinical, endoscopic, and pathological data of 254 SSLs from 216 patients endoscopically resected between January 2009 and December 2020.

RESULTS

All SSLs included 179 without dysplasia and 75 with dysplasia/carcinoma, including 55 with low-grade dysplasia, 10 with high-grade dysplasia, and 10 with submucosal cancer. In clinical characteristics, SSLs with dysplasia/carcinoma were significantly associated with advanced age, metabolic diseases, and high-risk adenomas. In endoscopic characteristics, SSLs with dysplasia/carcinoma were significantly associated with the distal colon, large size, polypoid morphology, surface-changes, no mucus cap, and narrow-band imaging international colorectal endoscopic classification (NICE) type 2/3. In the multivariate analysis, high-risk adenomas (odds ratio [OR], 2.98; p = 0.01), large size (OR, 1.18; p < 0.01), depression (OR, 11.74; p = 0.03), and NICE type 2/3 (OR, 14.97; p < 0.01) were significantly associated with SSLs with dysplasia/carcinoma.

CONCLUSIONS

SSLs had a higher risk of dysplasia in the distal colon than in the proximal colon. SSLs with large size, depression, and adenomatous surface-patterns, as well as those in patients with high-risk adenomas, increased the risk of dysplasia/ carcinoma. This suggests that the clinical and endoscopic characteristics can aid in the diagnosis and management of SSLs with dysplasia/carcinoma.

Clinical outcomes and risk factors associated with poor prognosis after endoscopic resection of 10-20 mm rectal neuroendocrine tumors: a multicenter, retrospective study of 10-year experience

BACKGROUND

The efficacy of endoscopic resection for of 10-20 mm rectal neuroendocrine tumor (NET) remains controversial. We aimed to evaluate the clinical outcomes and risk factors associated with poor prognosis after endoscopic resection of 10-20 mm rectal NET and to determine the optimal treatment.

METHODS

Patients who underwent endoscopic resection for rectal NET in four tertiary hospitals were enrolled, and data on with the clinical outcomes and risk factors related to poor prognosis were retrospectively analyzed.

RESULTS

A total of 105 patients who underwent endoscopic submucosal resection (ESD; n = 65, 61.9%), modified endoscopic mucosal resection (mEMR; n = 31, 29.5%), and conventional EMR (cEMR; n = 9, 8.6%) were enrolled. The mean follow-up period was 41.2 ± 21.9 months. In the morphologic findings, the mean diameter was 11.6 mm (range 10-19); the shape was sessile (50.5%) and mixed type (49.5%), and surface depression was observed in 41.9% of patients. In the histologic findings, 87.6% of patients had G1 and 12.4% G2 tumor grade, and 3.8% of patients had lymphovascular invasion. The overall en bloc and histologically complete (R0) resections were 99.1% and 76.2%, respectively. cEMR was a less-frequently developed R0 resection. In the univariate and multivariate analyses for R0 resection, only surface depression was significantly associated. Regional or distant organs metastasis during follow-up developed in three patients (2.9%) and was significantly associated with female sex, redness, G2 tumor grade, and non-ESD methods.

CONCLUSION

Patients who underwent endoscopic resection of 10-20 mm rectal NET had good prognosis; therefore, endoscopic resection can be considered as the first-line treatment, particularly for 10-14 mm rectal NET. However, the risk factors, such as female sex, redness, G2 tumor grade and non-ESD methods, were associated with regional or distant metastases during follow-up. Therefore, patients with these risk factors should be carefully monitored.

A large and pedunculated inflammatory pseudotumor with pseudosarcomatous change of the cecum mimicking a malignant polyp: a case report and literature review

Inflammatory pseudotumor (IPT) is a rare benign tumor of unknown etiology that can occur in almost any organ system. It has neoplastic features such as local recurrence, invasive growth, and vascular invasion, leading to the possibility of malignant sarcomatous changes. The clinical presentations of colonic IPT may include abdominal pain, anemia, a palpable mass, and intestinal obstruction. A few cases of colonic IPT have been reported, but colonic IPT with pedunculated morphology is very rare. Furthermore, since it can mimic malignant polyps, understanding the endoscopic findings of colonic IPT is important for proper treatment. Herein, we present a case of colonic IPT with pseudosarcomatous changes, presenting as a large polyp, mimicking a malignant polyp in the cecum, along with a literature review.

Efficacy and safety of one-step knife compared to conventional insulated-tip knife for endoscopic submucosal dissection: a preliminary study with prospective data collection and retrospective review

BACKGROUND

Endoscopic submucosal dissection (ESD) is not as tiresome as gastrectomy, but it is a time-consuming procedure. One-step knife (OSK) is a novel knife that combines a knife for ESD and an injection needle into one sheath. In this study, we aimed to compare the insulated tip type of OSK and conventional knife (CK) in terms of procedure time and complication rate.

METHODS

Medical records of patients with ESD using CK between February and September 2020 were retrospectively reviewed. Subsequently, data from patients who underwent ESD using OSK by September 2021 were prospectively collected. Total procedure time, procedure time by location and complication rate in the OSK and CK group were compared.

RESULTS

In the study period, a total of 203 patients (OSK, 102 patients; CK, 101 patients) were analyzed. On multivariate analysis, using CK, body location, resection size ≥ 40 mm, and submucosal fibrosis were associated with longer procedure time. The total procedure time was statistically significantly reduced in the OSK group (median 11 vs. 17 min, p < 0.01). The procedure time for each location was more reduced in the body (median 14 vs. 19 min p < 0.01) than the antrum (median 10 vs. 14 min, p = 0.01) in the OSK group. There was no significant difference in post-ESD bleeding and perforation in the two groups (3.9 vs. 3.9%, p = 0.99 and 1.0 vs. 2.0%, p = 0.56).

CONCLUSIONS

OSK significantly reduced the total procedure time of ESD. OSK could be an effective and safe knife for gastric ESD, especially for body lesions.

Esophageal Stricture after Endoscopic Drainage of Esophageal Abscess as a Complication of Acute Phlegmonous Esophagitis: A Case Report

Esophageal abscess caused by acute phlegmonous esophagitis is rare but life-threatening. Rapid abscess drainage is an important part of the treatment, and endoscope-assisted intra-luminal abscess drainage is frequently performed. Although endoscopic drainage is less invasive than surgery, it has the potential to cause esophageal stricture as a complication. We present a rare case of esophageal stricture as a complication of intra-luminal drainage and evaluate a method to minimize the incidence of esophageal stricture complications.

Combination conventional endoscopy and endoscopic ultrasound can differentiate between esophageal granular cell tumors and leiomyomas

Esophageal leiomyomas and granular cell tumors (GCTs) are the 2 most common subepithelial tumors found in the esophagus. We attempted to differentiate the 2 tumors using endoscopic findings and endoscopic ultrasound (EUS) features. Between December 2008 and June 2021, a total of 38 esophageal GCTs and 11 esophageal leiomyomas originating from the muscularis mucosa were selected. Clinical characteristics and endoscopic features were retrospectively reviewed. Although esophageal GCTs are mainly located in the lower third of the esophagus (81.6%), esophageal leiomyomas are mainly located in the upper third of the esophagus (45.5%). Broad-based (84.2%, P = .002) and whitish-to-yellowish color changes (97.4%, P < .001) are significant endoscopic features of esophageal GCTs. The echogenicity of esophageal leiomyoma was similar to that of proper muscle echogenicity. However, the echogenicity of esophageal GCTs was hyperechoic compared to that of the proper muscle layer (90.0% vs 9.1%, respectively, P < .001). EUS revealed a clearer hyperechoic epithelial lining in the esophageal leiomyoma than in esophageal GCTs (100% vs 26.7%, respectively, P < .001). The 5 endoscopic factors (location of the lower third, broad base, whitish-to-yellowish color, hyper-echogenic, and unclear demarcated hyperechoic epithelial line) were counted to differentiate esophageal GCTs from esophageal leiomyomas. Tumors with 3 or more endoscopic factors were all esophageal GCTs. The characteristic endoscopic and EUS features of esophageal GCTs were broad-based, whitish-to-yellowish colored subepithelial tumors located in the lower third of the esophagus and hyperechoic tumor with an unclear demarcated hyperechoic epithelial line. A combination of these features can predict esophageal GCTs before endoscopic resection.

Multidisciplinary Treatment Strategy for Early Colon Cancer: A Review-An English Version

Treatment for early colon cancer has progressed rapidly, with endoscopic resection and minimally invasive surgery. It is important to select patients without risk of lymph node metastasis before deciding on endoscopic resection for early colon cancer treatment. Pathological risk factors include histologic grade of cancer cell differentiation, lymphovascular invasion, perineural invasion, tumor budding, and deep submucosal invasion. These risk factors for predicting lymph node metastasis are crucial for determining the treatment strategy of endoscopic excision and radical resection for early colon cancer. A multidisciplinary approach is emphasized to establish a treatment strategy for early colon cancer to minimize the risk of complications and obtain excellent oncologic outcomes by selecting an appropriate treatment optimized for the patient's stage and condition. Therefore, we aimed to review the optimal multidisciplinary treatment strategies, including endoscopy and surgery, for early colon cancer.

Underwater endoscopic mucosal resection of upper gastrointestinal subepithelial tumors: A case series pilot study (with video)

INTRODUCTION

Underwater endoscopic mucosal resection (UW-EMR) has been recently introduced as an effective technique for rectal third layer subepithelial tumors. Therefore, we aimed to assess the safety, efficacy, and procedure time of UW-EMR for upper gastrointestinal subepithelial tumors (SETs) originating from the deep mucosal and/or submucosal layers.

METHODS

Between August 2018 to July 2022, a total of 17 SETs (7 duodenal SETs, 6 gastric SETs, and 4 esophageal SETs) were included in this study. On endoscopic ultrasound examinations, the tumors were found to be embedded in the submucosa without muscularis propria invasion. All SETs were resected successfully using UW-EMR. The characteristics of the tumors and their R0 resection rate, adverse event rate, and recurrence rate were evaluated retrospectively.

RESULTS

The mean tumor size was 0.9 cm (range, 0.3-1.5 cm). En bloc resection and complete resection rates were 100%, respectively. The patients showed no complications such as perforation or bleeding. Histologic assessments of the resected tumors revealed 9 neuroendocrine tumors (7 on the duodenum, 2 on the stomach), 2 gastric cystica profunda, 1 gastric follicular lymphoma, 1 gastric fibromyxoma, 3 esophageal granular cell tumors, and 1 esophageal adenoid cystic carcinoma. The mean procedural time was 3.2 min (range, 1.3-8.7 minutes). The overall en bloc and complete resection rates were 100%, respectively. No recurrence was observed during the follow-up period.

CONCLUSION

UW-EMR is a safe and effective treatment for upper gastrointestinal SETs embedded in the submucosal layer. Further studies are needed to compare other endoscopic resection techniques.

Clinical outcomes of gastroduodenal neuroendocrine tumors according to their WHO grade: A single-institutional retrospective analysis

The management of gastroduodenal neuroendocrine tumor (NET) has been controversial between radical surgical resection and local excision including endoscopic resection. A gastroduodenal NET grade (G), measured by their mitotic rate and Ki67 proliferation index, is important to predict prognosis. In this study, we aimed to compare the clinical outcomes of gastroduodenal NET according to grades in order to identify poor prognostic factors of gastroduodenal NETs. Fifty-four gastroduodenal NETs diagnosed between December 2008 and December 2020 in a tertiary referral hospital were retrospectively reviewed. The clinical outcomes of gastroduodenal NETs, according to tumor grades and factors associated with NET G2-3, were analyzed. A total of 52 gastroduodenal NET patients was enrolled. The mean follow-up period was 56.2 ± 40.1 months. The mean size of gastric and duodenal NET was 7.9 ± 11.0 mm and 9.8 ± 7.6 mm, respectively. During the study period, 72.7% (16/22) of gastric NETs and 83.3% (25/30) of duodenal NETS were G1. All G1 gastroduodenal NETs showed no lymph node or distant metastasis during the study periods. All G3 gastroduodenal NETs showed metastasis (one lymph node metastasis and 3 hepatic metastases). Among metastatic NETs, the smallest tumor size was a 13 mm gastric G3 NET. Factors associated with G2-3 NETs were larger tumor size, mucosal ulceration, proper muscle or deeper invasion, and lymphovascular invasion. A small-sized gastroduodenal NET confined to submucosa without surface ulceration may be suitable for endoscopic resection. After local resection of a gastroduodenal NET (G1) without lymphovascular and muscle proper invasion, follow-up examination without radical surgical resection can be recommended. G3 NETs may be treated by radical surgical resection, regardless of tumor size.

Multidisciplinary treatment strategy for early colon cancer

Background: Treatment for early colon cancer has progressed rapidly with endoscopic resection and minimally invasive surgery. Selection of patients without risk of lymph node metastasis is necessary before deciding on endoscopic resection for early colon cancer treatment. We aimed to review the optimal multidisciplinary treatment strategies for early colon cancer, including endoscopy and surgery.Current Concepts: Pathological risk factors include histologic grade of cancer cell differentiation, lymphovascular invasion, perineural invasion, tumor budding, and deep submucosal invasion. These risk factors for predicting lymph node metastasis are crucial for determining the treatment strategy of endoscopic excision and radical resection for early colon cancer. Prediction of the depth of invasion in early colon cancer using endoscopic optical assessments is vital to determine the appropriate treatment method for endoscopic or surgical resection. Furthermore, optical assessment of pit and vascular patterns is useful for estimating the depth of submucosal invasion using magnifying chromoendoscopy and narrow-band imaging endoscopy. Performing an endoscopic and pathologic evaluation of the risk factors for lymph node metastasis is imperative when selecting endoscopic or surgical resection. Endoscopic treatments include cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. In addition, appropriate surgical treatment should be recommended for patients with early colon cancer with a high risk of lymph node metastasis.Discussion and Conclusion: A multidisciplinary approach should be recommended to establish an optimized treatment strategy, minimize the risk of complications, and obtain excellent oncologic outcomes via patienttailored treatment in patients with early colon cancer.

Olmesartan-associated Enteropathy with Acute Kidney Injury

Olmesartan, a recently introduced angiotensin II receptor blocker for hypertension, has been reported to cause drug-induced small bowel enteropathy. The diagnosis of olmesartan-associated enteropathy (OAE) needs clinical suspicion and the exclusion of coeliac disease, as it mimics coeliac sprue. Once diagnosed, it can be completely cured with the discontinuation of olmesartan. However, due to the extremely low incidence of OAE in Korea, clinical suspicion and diagnosis may be a challenge. The authors report the first case of OAE presenting with chronic diarrhea and acute kidney injury in Korea.

Efficacy of sigmoidoscopy for evaluating disease activity in patients with ulcerative colitis

Background

Endoscopic assessment of disease activity is a key parameter in the management of ulcerative colitis. Whether sigmoidoscopy alone is sufficient to evaluate the disease activity in ulcerative colitis lacks studies.

Methods

We retrospectively analyzed the medical records and endoscopic results of patients with ulcerative colitis followed by colonoscopy in seven tertiary hospitals between January 2012 and December 2018. Endoscopic disease activity was scored using the Mayo endoscopic subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for each segment from the colonoscopy images. Concordance was evaluated by comparing the highest MES and UCEIS in the rectosigmoid and proximal regions to confirm the usefulness of sigmoidoscopy.

Results

A total of 500 colonoscopic examinations from 333 patients were enrolled. Only in 7.6% [k(kappa): 0.893, r(Spearman): 0.906, p < 0.001] and 8.6% [k(kappa): 0.890, r(Spearman): 0.914; p < 0.001] of cases, MES and UCEIS scored more severely in the proximal colon. Comparison of active disease (MES ≥ 2) in the rectosigmoid area and the entire colon showed a high concordance rate [k(kappa): 0.899, r(Spearman): 0.904, p < 0.001]. Endoscopic healing (MES = 0) also showed a high concordance rate [k(kappa): 0.882, r(Spearman): 0.887, p < 0.001]. In 38 cases (7.6%) of patients with a higher MES in the proximal area, it was significantly higher in patients with previous extensive colitis.

Conclusions

Sigmoidoscopy and colonoscopy showed a high concordance rate. Therefore, sigmoidoscopy is considered a sufficient substitute for colonoscopy. However, colonoscopy should be considered in patients with previous extensive colitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02178-0.

Evidence of slow and variable choice-stepping reaction time in cancer survivors with chemotherapy-induced peripheral neuropathy

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is reported to affect up to 70 % of cancer survivors. Despite evidence that CIPN-related impairments often translate into balance and mobility deficits, the effects on stepping and quality of gait, well-documented risk factors for falls, are unclear.

AIMS

(i) Establish choice-stepping reaction time (CSRT) performance in survivors with CIPN compared to young and older healthy controls and people with Parkinson's disease; (ii) document walking stability; (iii) investigate relationships between stepping and gait data to objective and patient-reported outcomes.

METHODS

41 cancer survivors with CIPN (mean (SD) age: 60.8 (9.7) years) who were ≥3months post chemotherapy, performed tests of simple and inhibitory CSRT. Walking stability measures were derived from 3-D accelerometry data during the 6-minute walk test. CIPN was assessed using neurological grading and patient-reported outcome measures (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in CIPN Questionnaire scale EORTC CIPN20).

RESULTS

In both stepping tests, CIPN participants performed at the level of adults aged 10 years older and people with mild to moderate Parkinson's disease. Mean (SD) total stepping response times in both CSRT (1160 (190) milliseconds) and inhibitory CSRT (1191 (164) milliseconds) tests were not associated with objective neurological grading but were correlated with increased difficulty feeling the ground. Participants with lower-limb vibration sensation deficit had slower and more variable CSRT times. There were no associations between walking stability and objective measures of CIPN, and limited correlations with the EORTC-CIPN20.

CONCLUSIONS

Cancer survivors with CIPN showed deficits in voluntary stepping responses and seemed to compensate for their sensory and motor deficits by walking slower to maintain stability. Objective and patient-reported outcomes of CIPN were correlated with slower and more variable stepping response times. Future studies should aim to identify the causes of the apparent premature decline in cognitive-motor function and develop remediating interventions.

Changes in high-sensitivity C-reactive protein levels and metabolic indices according to grip strength in Korean postmenopausal women

OBJECTIVE

This study aimed to investigate the changes in high-sensitivity C-reactive protein (hs-CRP) level and metabolic indices such as blood pressure, serum lipid level and serum glucose level according to grip strength in postmenopausal women.

METHOD

Data from participants (postmenopausal women) in the Seventh Korea National Health and Nutrition Examination Survey 2018 were analyzed. Absolute handgrip strength was the sum of the maximal grip strength of both hands, and relative handgrip was calculated as absolute handgrip divided by the body mass index. We performed linear regression analysis after adjusting for confounders to assess the influence of grip strength on hs-CRP level and metabolic indices.

RESULTS

Linear regression analysis showed that after adjusting for confounders, with an increased absolute grip strength, systolic blood pressure and hs-CRP levels were decreased; however, the changes were not significant for the remaining indices. Relative grip strength was associated with hs-CRP levels and metabolic indices. With a high relative grip strength, hs-CRP, blood pressure, fasting blood glucose, hemoglobin A1c and triglyceride levels were decreased, while the high-density lipoprotein cholesterol level was increased.

CONCLUSION

Our study evaluated the overall health status using grip strength in postmenopausal women. The grip strength adjusted by body size was suitable in evaluating the overall health status, including inflammatory and metabolic indices. Additionally, increased grip strength was associated with a better health status in postmenopausal women.

Tumor grade 2 as the independent predictor for lymph node metastasis in 10-20 mm sized rectal neuroendocrine tumor

Purpose

Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10-20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10-20 mm sized rectal NET and utilize them to decide upon the treatment strategy.

Methods

Twenty-eight patients with 10-20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (-) groups, and their respective data were analyzed.

Results

Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (-) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17-1,188.64; P=0.010).

Conclusion

Tumor grade 2 was the independent factor predicting LNM in 10-20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Seven-day triple therapy is sufficient to eradicate infection caused by Helicobacter pylori without 23S rRNA point mutation

ABSTRACT

Tailored therapy based on dual priming oligonucleotide-based polymerase chain reaction (DPO-PCR) can be considered an alternative to overcome the low eradication rate in high clarithromycin-resistance areas. The triple therapy (TT) duration of the tailored approach in most studies was 7 days for patients without point mutation. However, recent western guidelines have recommended a treatment duration of 14 days. The aim of this study was to compare the success rate of 7 and 14 days of TT for eradicating Helicobacter pylori without point mutation, as determined by DPO-PCR.Between Feb 2016 and Feb 2019, medical records of patients who underwent DPO-PCR were reviewed. Patients without point mutation as determined by DPO-PCR were enrolled in this study. The eradication success rate and adverse events were evaluated.A total of 366 patients without A2142G and A2143G point mutation were enrolled. The success rates of 7-day and 14-day TT were 88.4% (168/190) and 85.9% (151/176) by intention to treat analysis (P = .453) and 90.8% (168/185) and 90.4% (151/167) by per-protocol analysis (P = .900), respectively. The adverse event rates showed no significant difference between the 2 groups.In patients without point mutation based on DPO-PCR results, 7-day TT is as effective as 14-day TT. Therefore, 7 days may be considered as a cost-effective treatment duration in Korea.

Comparison of biannual and annual endoscopic gastric cancer surveillance after endoscopic resection

BACKGROUND

Patients who received endoscopic resection (ER) for early gastric cancer (EGC) or high-grade dysplasia (HGD) are at high risk for the subsequent development of metachronous gastric cancer (MGC). This study aims to compare the detection rate and stage of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD.

METHODS

From September 2009 to August 2019, 859 patients who underwent ER for the treatment of EGC or HGD were analyzed, retrospectively. Patients received endoscopic surveillance twice a year (high-intensity group) or annually (low-intensity group) for 3 years.

RESULTS

A total of 521 patients were enrolled in this study (267 patients in the high-intensity group and 254 patients in the low-intensity group). During a mean follow-up of 5.3 ± 1.6 years, MGCs were found in 27 patients (16.9%) in the high-intensity group and 18 patients (7.1%) in the low-intensity group (P = 0.219). In patients with moderate to severe atrophy (Kimura-Takemoto grade C3 ~ O3), detection rates of MGC during 3 years from were 8.4% (16/191) and 2.2% (4/186), respectively (P = 0.007). Forty-four patients who received treatment for MGC, including endoscopic or surgical resection, were stage IA. Only one patient in the low-intensity group was diagnosed as stage IIIA advanced gastric cancer.

CONCLUSIONS

There was no significant difference in the detection rate of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD. However, biannual surveillance showed a higher detection rate during the first 3 years, especially for patients with moderate to severe gastric atrophy.

Absent or impaired rectoanal inhibitory reflex as a diagnostic factor for high-grade (grade III-V) rectal prolapse: a retrospective study

Background

Clinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse.

Methods

In this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated.

Results

Frequencies of fecal incontinence (p = 0.002) and feeling of prolapse (p < 0.001) were significantly higher in the high-grade group. The maximum resting (77.5 vs. 96 mmHg, p = 0.011) and squeezing (128.7 vs. 165 mmHg, p = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%, p < 0.001). In a multivariate analysis, the feeling of prolapse (odds ratio [OR], 23.88; 95% confidence interval [CI], 4.43–128.78; p < 0.001) and absent or impaired RAIR (OR, 5.36; 95% CI, 1.91–15.04, p = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse (p < 0.001). The sensitivity of absent or impaired RAIR as a predictor of high-grade prolapse was 63.3% and specificity 74.0%.

Conclusions

Absent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Optimal ICG dosage of preoperative colonoscopic tattooing for fluorescence-guided laparoscopic colorectal surgery

Background

Indocyanine green (ICG) is a multifunctional dye used in tumor localization, tissue perfusion, and lymph node (LN) mapping during fluorescence-guided laparoscopic colorectal surgery.

Purpose

This study aimed to establish the optimal protocol for preoperative endoscopic submucosal ICG injection to perform fluorescence lymph node mapping (FLNM), along with undisturbed fluorescent tumor localization and ICG angiography during a single surgery.

Methods

Colorectal cancer patients (n = 192) were enrolled from May 2017 to December 2019. Colonoscopic submucosal ICG injection was performed 12 to 18 h before surgery. ICG injection protocols were modified based on the total injected ICG (mg) and tattooing site number. The concentrations of ICG were gradually decreased from the standard dose (2.5 mg/ml) to the minimum dose (0.2 mg/ml). Successful FLNM (FLNM-s) was defined as distinct fluorescent LNs observed under NIR camera. The patient’s age, sex, body mass index (BMI), stage, cancer location, obstruction, and laboratory findings were compared between the FLNM-s and failed FLNM (FLNM-f) groups to identify clinical and pathological factors that affect FLNM.

Results

In the ICG dose section of 0.5 to 1 mg, the success rate was highest within all functions including FLNM, fluorescent tumor localization, and ICG angiography. FLNM-s was related to ICG dose (0.5–1 mg), multiple submucosal injections, location of cancer, camera light source, and lower BMI. In the multivariate analysis, camera light source, non-obesity, and multiple injections were independent factors for FLNM-s). The mean total number of harvested LNs was significantly higher in the FLNM-s group than that in the FLNM-f group (p < 0.001). The number of metastatic lymph nodes was comparable between the two groups (p = 0.859).

Conclusions

Preoperative, endoscopic submucosal ICG injection with dose range 0.5 to 1 mg would be optimal protocol for multifunctional ICG applications during fluorescence-guided laparoscopic colorectal surgery.

Usefulness and Complications of Needle Knife Fistulotomy as a Rescue Procedure in Patients with Pancreaticobiliary Disease

Background/Aims

Needle knife fistulotomy (NKF) is a technique to facilitate pancreatic and biliary duct access during ERCP. The double-guidewire technique (DGT) is also used in cases of difficult cannulation, but it can increase the incidence of post-ERCP-pancreatitis (PEP). This study examined the success and complication rates of NKF after unsuccessful standard cannulation or DGT in patients with pancreaticobiliary disease.

Methods

The data of 209 patients who received NKF as a rescue procedure between January 2009 and December 2016 were reviewed retrospectively. The cannulation success and complication rates were assessed.

Results

The overall cannulation success rate was 90.4%. The success rates of patients who received NKF after standard cannulation or DGT were similar (82.6% [142/172] and 73.0% [27/37], respectively, p=0.179). Furthermore, there was no significant difference in the incidence of procedure-related adverse events between the two groups (10.5% [18/172] and 16.2% [6/37], respectively, p=0.391). Endoscopic retrograde pancreatic drainage (ERPD) insertion decreased the incidence of PEP (0% [0/16] in ERPD and 14.6% [19/130] in non-ERPD, p=0.132) among patients who received PD cannulation.

Conclusions

NKF is an effective and safe method that can be considered for rescue management after the initial failure of standard cannulation or DGT. NKF following standard cannulation can be preferred over NKF following DGT because of the higher success rate and the lower rate of pancreatitis, but the difference was not significant. PD stenting in patients at high risk of PEP can be considered to decrease pancreatitis.

Changes in long term peripheral nerve biophysical properties in childhood cancer survivors following neurotoxic chemotherapy

OBJECTIVE

In the context of increasing numbers of childhood cancer survivors (CCS), this study aimed to enhance understanding of the biophysical basis for long term chemotherapy induced peripheral neuropathy from different chemotherapy agents in CCS.

METHODS

Detailed cross-sectional neurophysiological examination, using median nerve axonal excitability studies, alongside clinical assessments, in 103 long term CCS (10.5 ± 0.6 years post-treatment).

RESULTS

Cisplatin treated CCS (n = 16) demonstrated multiple sensory axonal excitability changes including increased threshold (P < 0.05), alterations in depolarising and hyperpolarising threshold electrotonus (P < 0.05) and reduction in resting and minimum IV slope (P < 0.01). Vincristine treated CCS (n = 73) were comparable to controls, except for prolonged distal motor latency (P = 0.001). No differences were seen in the non-neurotoxic chemotherapy group (n = 14). Abnormalities were more evident in the cisplatin subgroup with greater clinical neuropathy manifestations.

CONCLUSION

Persistent long term changes in axonal biophysical properties vary with different chemotherapy agents, most evident after cisplatin exposure. Longitudinal studies of nerve function during chemotherapy treatment are required to further evaluate these differences and their mechanistic basis.

SIGNIFICANCE

This study provides a unique biophysical perspective for persistent cisplatin related neurotoxicity in children, previously under recognised.

Deficiency in proliferative, angiogenic, and LH receptors in the follicle wall: implications of season toward the anovulatory condition

This study aimed to gain insight on the effect of different seasons of the year on the expression pattern of growth factor and hormone receptors involved in follicle development. A novel follicle wall biopsy technique was used to collect in vivo follicle wall layers (ie, granulosa, theca interna, and theca externa) and follicular fluid samples from growing dominant follicles, simultaneously and repeatedly, using the same mares during the spring anovulatory (SAN), spring ovulatory (SOV), summer (SU), and fall ovulatory (FOV) seasons. The immunofluorescent expression patterns of epidermal growth factor receptor (EGFR), Ki-67, vascular endothelial growth factor receptor (VEGFR), and LH receptor (LHR) were evaluated in each follicle wall layer, in addition to intrafollicular estradiol and nitric oxide (NO). Proliferative proteins (EGFR and Ki-67) were highly (P < 0.05-P < 0.001) expressed during the SOV season compared with the SAN and FOV seasons. Lower (P < 0.05-P < 0.001) expression of both proteins was observed during SU compared with the SOV season. The expression of VEGFR was greater (P < 0.05-P < 0.01) in the theca interna of dominant follicles during the SOV season compared with the SAN and SU seasons. Similarly, in the overall quantification, the VEGFR expression was greater (P < 0.001) during the SOV season compared with the SU and FOV seasons. A higher (P < 0.05) LHR expression was detected in the theca interna during the SOV season than the SAN season. Furthermore, a higher (P < 0.05-P < 0.001) expression of LHR was observed in the granulosa, theca interna, and in the overall quantification during the SOV season compared with the SU and FOV seasons. Intrafollicular NO concentration did not differ (P > 0.05) among different seasons of the year. The intrafollicular estradiol concentration was higher (P < 0.05) during the SU compared with the SAN season and higher (P < 0.05) during the FOV season compared with the SAN and SOV seasons. In conclusion, the synergistic effect of lower expression of proliferative protein, angiogenic, and LH receptors in at least some of the layers of the follicle wall seems to trigger dominant follicles toward the anovulation process during the spring and fall transitional seasons.

Comparison of the diagnostic performance of the 2017 and 2018 versions of LI-RADS for hepatocellular carcinoma on gadoxetic acid enhanced MRI

AIM

To compare the diagnostic performance of the 2017 (v2017) and 2018 versions (v2018) of the Liver Imaging-Reporting and Data System (LI-RADS) for hepatocellular carcinoma (HCC) using gadoxetic acid-enhanced magnetic resonance imaging (Gd-EOB-MRI) and to evaluate the effect in v2018.

MATERIALS AND METHODS

Treatment-naive patients at high-risk for HCC who underwent Gd-EOB-MRI were included. The LI-RADS categories were assigned according to v2017 and v2018. The diagnostic performances were compared between v2017 and v2018 according to the size and combination of imaging features.

RESULTS

A total of 117 patients with 137 observations were identified, including 89 HCCs; 76.2% (64/84) of observations with threshold growth were re-classified as subthreshold growth when using v2018 instead of v2017. The final categories changed in nine (14%) cases. For the combination of LR-5/LR-5V, there were no significant differences in sensitivity and specificity between the two versions (sensitivity, 64% versus 58.4%; specificity, 87.5% versus 85.4%; all p>0.05). For the combination of LR-4 and LR-5/5V, the diagnostic performance of v2018 was inferior to that of v2017 when considering only major features (accuracy, 86.1% versus 80.3%, respectively; p=0.013), particularly in observations measuring 10-20 mm, but was comparable after adding the ancillary features (accuracy, 86.9% versus 86.1%, respectively; p=1.00).

CONCLUSION

In LI-RADS v2018, although a considerable number of observations re-classified subthreshold growth, changes in the assigned categories were insignificant; overall diagnostic performance was comparable to that of v2017, but v2018 might emphasise the value of ancillary features in combination with major features for determining the probability of HCC.

Clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation: a 10-year study

Background

Upper gastrointestinal endoscopic examination is a relatively safe procedure; however, all endoscopic procedures are invasive and are associated with a risk of iatrogenic perforation. To evaluate clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation. Factors associated with surgical management or mortality were analyzed.

Methods

Between November 2008 and November 2018, the medical records of 149,792 upper gastrointestinal endoscopic procedures were evaluated. The mechanisms of perforations were categorized as electrocoagulation-induced or blunt trauma-induced injuries. The incidence and clinical outcomes of iatrogenic perforations based on the types of procedures performed were evaluated.

Results

Iatrogenic endoscopic perforations occurred in 28 cases (0.019%). Iatrogenic perforation-related mortality occurred in 3 patients. The iatrogenic perforation rate based on the types of procedures performed was as follows: diagnostic endoscopy = 0.002%, duodenal endoscopic mucosal resection = 0.9%, esophageal endoscopic submucosal dissection = 10.7%, gastric endoscopic submucosal dissection = 0.2%, endoscopic self-expandable metal stent insertion for malignant esophageal obstruction = 0.1%, duodenoscope-induced injury = 0.02%, endoscopic sphincterotomy = 0.08%, and ampullectomy = 6.8%. All electrocoagulation-induced perforations (n = 21) were managed successfully (15 cases of endoscopic closure, 5 cases treated conservatively, and 1 case treated surgically). Three patients died among those with blunt trauma-induced perforations (n = 7). The factors associated with surgical management or mortality were old age, poor performance status (Eastern Cooperative Oncology Group score ≥ 1), advanced malignancy, and blunt trauma.

Conclusions

Most cases of electrocoagulation-induced iatrogenic perforations can be treated using endoscopic clips. If endoscopic closure fails for blunt trauma-induced perforations, prompt surgical management is mandatory.

Possible indication of endoscopic resection in undifferentiated early gastric cancer

Endoscopic resection for early gastric cancer (EGC) without lymph node metastasis may be a valuable treatment option. To date, endoscopic resection for undifferentiated EGC is being investigated. We evaluated the risk of lymph node metastasis in undifferentiated EGC by examining the preoperative endoscopic findings and operated pathologic specimen. The medical records of patients who underwent surgical resection because of undifferentiated EGC between November 2008 and December 2015 were reviewed retrospectively. The risk factors associated with lymph node metastasis and the lymph node metastasis rate in the expanded indication of undifferentiated EGC were evaluated. A total of 376 patients with undifferentiated EGC (233 signet ring cell type and 143 poorly differentiated type) were analyzed. Lymph node metastasis was found in 9.8% of the patients. Among the patients who met the expanded criteria (59 patients), only one patient had lymph node metastasis (signet ring cell type without ulceration and 15 mm in size). The risk factors associated with lymph node metastasis were lesion size >20 mm (OR 3.013), scar deformity (OR 2.248), surface depression (OR 2.360), submucosal invasion (OR 3.427), and lymphovascular invasion (OR 6.296). Before endoscopic resection of undifferentiated EGC, careful selection of patients should be considered. The undifferentiated EGC with size ≥15 mm, scar deformity, surface depression, submucosal invasion, and lymphovascular invasion should be considered surgical resection instead of endoscopic resection.

Clinical implications of fecal calprotectin and fecal immunochemical test on mucosal status in patients with ulcerative colitis

Although fecal calprotectin (Fcal) and the fecal immunochemical test (FIT) have been associated with endoscopic activity in ulcerative colitis (UC), the clinical implications of each marker depending on the mucosal status are not well known.A total of 174 results obtained from 128 patients with UC who simultaneously underwent colonoscopy and fecal tests were retrospectively evaluated from March 2015 to February 2018. The correlation and predictability of fecal markers as a surrogate marker of endoscopic activity, and the sensitivity, specificity, and predictive value of fecal tests for mucosal healing were statistically evaluated.Both fecal tests showed a statistically significant correlation with Mayo Endoscopic Subscore (MES) (Fcal: r = 0.678, P < .001 and FIT: r = 0.635, P < .001) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) (Fcal: r = 0.711, P < .001 and FIT: r = 0.657, P < .001). Fcal was statistically superior to FIT in predictive accuracy for endoscopic activity (area under the curve [AUC]: 0.863 vs 0.765 with MES, P < .001 and AUC; 0.847 vs 0.757 with UCEIS, P < .001). FIT was superior to Fcal in sensitivity for mucosal healing (98.0% vs 78.4% with MES, 94.9% vs 74.6% with UCEIS).Fcal and FIT were well correlated with endoscopic activity in UC and can be surrogate markers of mucosal inflammation. Depending on mucosal status, Fcal was more accurate in predicting the endoscopic activity in active inflammation, whereas FIT was more sensitive in predicting the achievement of mucosal healing.

Clinical outcomes of endoscopic submucosal dissection for lesions on the proximal location between remnant and entire stomach

BACKGROUND

Tumors located on the proximal stomach are associated with a longer procedure time and lower en-block resection of endoscopic submucosal dissection (ESD). Additionally, it is more difficult to perform ESD for lesions after distal gastrectomy because of the narrow inner space. We aimed to evaluate the therapeutic outcomes of ESD for lesions on the remnant stomach compared with those on the upper third of the entire stomach.

METHODS

A total of 135 patients with a neoplasm located on the proximal stomach who received ESD between Aug 2008 and Dec 2016 were enrolled. We retrospectively reviewed en-bloc resection rate, complete resection rate, and complication rate according to whether distal gastrectomy was performed. Clinical outcomes were compared among the 1:2 propensity-matched groups.

RESULTS

Between the remnant stomach and entire stomach, the en-bloc [92% (23/25) and 92.0% (46/50), respectively; P = 1.000] and complete resection [84% (21/25) and 88.0 (44/50), respectively; P = 0.723] rates were not significantly different. In patients with lesions that indicated ESD, there was no significant difference in en-bloc and complete resection rates. In a multivariable analysis, submucosal fibrosis [odds ratio (OR) 5.9, 95% confidence interval (CI) 1.1-30.7] and submucosa invasive cancer (OR 10.1, 95% CI 1.4-74.3) were independent risk factors for incomplete resection.

CONCLUSIONS

ESD is a feasible therapeutic option for lesions located on the proximal stomach regardless the operation history of distal gastrectomy. However, the complete resection rate decreases for lesions with submucosal fibrosis or the submucosa invasion.

Efficacy of preoperative colonoscopic tattooing with indocyanine green on lymph node harvest and factors associated with inadequate lymph node harvest in colorectal cancer

Objective: Adequate lymph node harvest (LNH) in colorectal cancer is closely related to survival. This study aimed to evaluate the effect of preoperative colonoscopic tattooing (PCT) with indocyanine green (ICG) on adequate LNH in colorectal cancer. Materials and methods: A total of 1079 patients who underwent surgical resection for colorectal cancer were divided into two groups: a tattooing group and a non-tattooing group. The patients were retrospectively analyzed for the number and adequacy of LNH according to tumor locations and stages. Univariate and multivariate analysis for factors associated with adequate LNH were done. Results: There was no significant difference between the two groups in the number and adequacy of LNH according to tumor locations. However, T1 colorectal cancer in the tattooing group had significantly higher adequate LNH (91.6% vs 82.1%, OR 2.370, p = .048) and T1 and N0 rectal cancer in the tattooing group also had higher adequate LNH although there was no statistical significance (100% vs 82.4%, OR 12.088, p = .095; 96.9% vs 84.8%, OR 5.570, p = .099) when compared to the non-tattooing group. Male sex and T1 stage were significantly associated with inadequate LNH in multivariate analysis (OR 0.556 (95% CI 0.340-0.909), p = .019; OR 0.555 (95% CI 0.339-0.910), p = .019, respectively). Conclusion: PCT with ICG did not improve adequate LNH in colorectal cancer but effectively improved adequate LNH in early colorectal cancer. Male sex and early cancer were risk factors for inadequate LNH in colorectal cancer, so PCT is needed for adequate LNH in these patients.

Dose-related healing of artificial ulcers after endoscopic submucosal dissection using esomeprazole: A randomized controlled study

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standard procedure for treating gastric neoplasms. However, ESD causes larger artificial ulcers other than mucosal resection methods. We conducted this prospective randomized controlled study to evaluate the effect of stronger acid suppression on ESD ulcers caused by doubling the proton pump inhibitor (PPI) dose and compare the effects of 20-mg (standard dose) and 40-mg (double dose) esomeprazole (EswonampTM, Daewon Pharmaceutical Co., Ltd., Seoul, Korea) on ulcer healing.

METHODS

One hundred ninety-seven patients who underwent gastric ESD from July 2017 to December 2017 at Pusan National University Yangsan Hospital were enrolled and randomly assigned to the standard or double-dose group. Change in ulcer size from the day of ESD to 4 weeks after ESD and the scar-change rate were compared between the groups.

RESULTS

There were no significant differences in ulcer contraction (84.5% in 20 mg group vs 86.3% in 40 mg group, P = .91) or scar-change rate (30.9% vs 30.6%, P > .99) between the groups. In a multivariate analysis, initial ulcer size [odds ratio (OR) 0.24; 95% confidence interval (CI) 0.11-0.50] and early gastric cancer (OR 0.22, 95% CI 0.08-0.58) were significantly associated with delayed ulcer healing.

CONCLUSIONS

Both 40 and 20-mg esomeprazole have similar effects on ESD-induced ulcer area reduction, suggesting that strong acid suppression does not necessarily result in rapid artificial ulcer healing.

TRIAL REGISTRATION NUMBER

RCT no.: KCT0002885.

Conduction block in immune-mediated neuropathy: paranodopathy versus axonopathy

BACKGROUND AND PURPOSE

Conduction block is a pathognomonic feature of immune-mediated neuropathies. The aim of this study was to advance understanding of pathophysiology and conduction block in chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN).

METHODS

A multimodal approach was used, incorporating clinical phenotyping, neurophysiology, immunohistochemistry and structural assessments.

RESULTS

Of 49 CIDP and 14 MMN patients, 25% and 79% had median nerve forearm block, respectively. Clinical scores were similar in CIDP patients with and without block. CIDP patients with median nerve block demonstrated markedly elevated thresholds and greater threshold changes in threshold electrotonus, whilst those without did not differ from healthy controls in electrotonus parameters. In contrast, MMN patients exhibited marked increases in superexcitability. Nerve size was similar in both CIDP groups at the site of axonal excitability. However, CIDP patients with block demonstrated more frequent paranodal serum binding to teased rat nerve fibres. In keeping with these findings, mathematical modelling of nerve excitability recordings in CIDP patients with block support the role of paranodal dysfunction and enhanced leakage of current between the node and internode. In contrast, changes in MMN probably resulted from a reduction in ion channel density along axons.

CONCLUSIONS

The underlying pathologies in CIDP and MMN are distinct. Conduction block in CIDP is associated with paranodal dysfunction which may be antibody-mediated in a subset of patients. In contrast, MMN is characterized by channel dysfunction downstream from the site of block.

Piperlongumine-Eluting Gastrointestinal Stent Using Reactive Oxygen Species-Sensitive Nanofiber Mats for Inhibition of Cholangiocarcinoma Cells

BACKGROUND

The aim of this study is to fabricate drug-eluting gastrointestinal (GI) stent using reactive oxygen species (ROS)-sensitive nanofiber mats for treatment of cholangiocarcinoma (CCA) cell. A ROS-producing agent, piperlongumine (PL)-incorporated nanofiber mats were investigated for drug-eluting stent (DES) application.

METHODS

Selenocystamine-conjugated methoxy poly(ethylene glycol) (MePEG) was conjugated with poly(L-lactide) (PLA) to produce block copolymer (LEse block copolymer). Various ratios of poly(ε-caprolactone) (PCL) and LEse block copolymer were dissolved in organic solvent with PL, and then nanofiber mats were fabricated by electro-spinning techniques.

RESULTS

The higher amount of LEse in the blend of PCL/LEse resulted in the formation of granules while PCL alone showed fine nanofiber structure. Nanofiber mats composed of PCL/LEse polymer blend showed ROS-sensitive drug release, i.e., PL release rate from nanofiber mats was accelerated in the presence of hydrogen peroxide (H₂O₂) while nanofiber mats of PCL alone have small changes in drug release rate, indicating that PL-incorporated nanofiber membranes have ROS responsiveness. PL itself and PL released from nanofiber mats showed almost similar anticancer activity against various CCA cells. Furthermore, PL released from nanofiber mats properly produced ROS generation and induced apoptosis of CCA cells as well as PL itself. In HuCC-T1 cell-bearing mice, PL-incorporated nanofiber mats showed improvement in anticancer activity.

CONCLUSION

PL-incorporated ROS-sensitive nanofiber mats were coated onto GI stent and showed improved anticancer activity with ROS responsiveness. We suggested PL-incorporated ROS-sensitive nanofiber mats as a promising candidate for local treatment of CCA cells.

Preprocedural prediction of non-curative endoscopic submucosal dissection for early gastric cancer

Background and aim

Endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for early gastric cancer (EGC) without lymph node metastasis. However, additional surgical gastrectomy should be considered after non-curative endoscopic resection. We aimed to evaluate the predictive factors associated with non-curative endoscopic resection.

Methods

Between November 2008 and June 2015, a retrospective study was conducted in a single, tertiary, referral hospital. A total of 596 EGC lesions resected by ESD were analyzed. Non-curative endoscopic resection was defined as the occurrence of lesions associated with piecemeal resection, positive resection margins, lymphovascular invasion, or lesions that did not meet the expanded indications for ESD.

Results

The rate of non-curative endoscopic resection was 16.1%. The mean follow-up period was 35.3 ± 25.0 months. Associated predictive factors for non-curative endoscopic resection were female sex (OR, 2.470; p = 0.004), lesion size ≥ 20 mm (OR 3.714; p < 0.001), longer procedure time (OR 2.449, p = 0.002), ulceration (OR 3.538, p = 0.002), nodularity (OR 2.967, p<0.001), depression (OR 1.806, p = 0.038), undifferentiated carcinoma (OR 2.825, p = 0.031) and lesion located in the mid or upper third of stomach (OR 7.135 and OR 4.155, p<0.001, respectively). As the number of risk factors increased, the risk of non-curative ESD also increased.

Conclusions

Prior to selection of ESD, the risks associated with non-curative ESD should be considered so that appropriate treatment modalities may be selected.

Characteristics of overlooked synchronous gastric epithelial neoplasia after endoscopic submucosal dissection

Since endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for early gastric cancer (EGC) without risk of lymph node metastasis, synchronous gastric epithelial neoplasia is no longer rare in the clinical practice. Knowledge about the characteristics associated with synchronous gastric epithelial neoplasia is of great importance to prevent delayed diagnosis.Between November 2008 and December 2014, a retrospective study was conducted in a single tertiary referral hospital. Consecutive patients who underwent ESD due to EGC or high-grade dysplasia were analyzed to evaluate the incidence of synchronous gastric epithelial neoplasia and the factors associated with synchronous and overlooked synchronous lesions.A total of 488 patients were analyzed in this study. Synchronous lesions were found in 59 patients (12.1%) during the mean 37.7 months of follow-up. Among 77 synchronous lesions, 25 lesions (32.4%) were overlooked at the time of initial ESD. Age of ≥ 65 years, moderate to severe endoscopic atrophic gastritis, and elevated morphology of primary lesions were associated with synchronous gastric epithelial neoplasia. An important factor associated with overlooked lesions is the non-elevated morphology of lesions.Careful endoscopic examination of the whole stomach is necessary in patients who are older and who have moderate to severe atrophic gastritis and elevated morphology of lesions to prevent delayed diagnosis of synchronous gastric epithelial neoplasia, especially non-elevated lesions.

Is the Clinical Outcome Good or Bad in Patients Hospitalized Within 1 Year After Kidney Transplantation?

BACKGROUND

Although the hospitalization rate at early period of kidney transplantation (KT) is still high, the association between the hospitalization within 1 year after KT and graft survival is unclear. We investigated the incidence and causes of hospitalization and clinical outcome of the patients hospitalized within 1 year after KT.

METHODS

We retrospectively analyzed 174 KT recipients (KTRs) hospitalized within 1 year after KT between 2013 and 2015.

RESULTS

Among them, 84 (48%) KTRs were admitted within 1 year after KT, and the number of hospitalizations was 116. The mean time from KT to first hospitalization was 4.2 months. Seventy-eight percent of the patients were hospitalized for medical causes and 22% for surgical causes. The most common cause was cytomegalovirus infection (CMV) (23.3%), followed by acute rejection (11.2%) and urinary tract infection (10.3%). Recipients and donors in the hospitalized group were significantly older than the nonhospitalized group. The proportions of deceased donor KT, acute rejection, more than 50% panel-reactive antibody, and positive donor-specific antibody were significantly higher in the hospitalized group than in the nonhospitalized group. Graft and patient survivals were lower in the hospitalized group than in the nonhospitalized group. Deceased donor KT and acute rejection were independent risk factors for hospitalization.

CONCLUSION

The incidence of KTRs hospitalized within 1 year after KT was high. Most causes of hospitalization were CMV infection, acute rejection, and urinary tract infection. Therefore, the immunosuppression status of these patients should be closely monitored to reduce the hospitalization rate.