Background and Aim
Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico‐epidemiological outcomes due ...to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes.
Methods
Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated.
Results
Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range IQR, 56–75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow‐up period of 52 months (IQR, 34–70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518).
Conclusions
Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding.
Background and Aim
Optimal treatment modalities for each of the three subtypes of achalasia are still under debate. Differences in prognosis and long‐term outcomes between peroral endoscopic myotomy ...(POEM) and balloon dilation (BD) are also unclear. We aimed to compare the treatment outcomes of BD and POEM in each subtype of achalasia by using information from the manometry database of a tertiary referral center in Korea.
Methods
Data from 5207 esophageal manometry procedures performed between 1989 and 2016 were analyzed. The medical records and results of esophagography and esophagogastroduodenoscopy were also reviewed.
Results
We identified 264 patients (116 men and 148 women) with diagnosis of achalasia during the study period. POEM and BD were carried out on 64 and 177 patients, respectively. There was a significant difference in the time to relapse between the POEM group and the BD group (P = 0.002). At the 24‐month follow‐up, the clinical success rates of POEM and BD were 91.8% and 68.0%, respectively. The hazard ratio of symptom return was 6.54 for BD compared with POEM (95% confidence interval 2.12–20.22, P = 0.001). After a follow‐up period of 24 months, the success rate of POEM was significantly higher than that of BD for all subtypes of achalasia. However, only that of types I and II was statistically significant (type 1: 92.0% vs 51.1%, P = 0.004; type 2: 92.3% vs 59.8%, P = 0.007; and type3: 91.7% vs 55.6%, P = 0.051).
Conclusions
Peroral endoscopic myotomy was more effective than BD in providing mid‐long‐term remission in patients with all manometric subtypes of achalasia.
Background and Aim
There are few cases of duodenal mucosa‐associated lymphoid tissue (MALT) lymphoma reported in the literature, and little is known about the clinical course of this disease. Here, ...we aimed to characterize the clinical features of duodenal MALT lymphoma by comparison with gastric MALT lymphoma.
Methods
Thirteen patients diagnosed with duodenal MALT lymphoma at Asan Medical Center from March 1997 to February 2017 were included in this retrospective study, along with patients with gastric MALT lymphoma, matched by age and sex at a 1:10 ratio.
Results
Median age of patients with duodenal MALT lymphoma was 49 (range 20–72) years, and 53.8% (7/13) were male. Comparison of patient characteristics indicated that Helicobacter pylori infection (46.2% vs 90.8%, P < 0.001) and lymph node metastasis (23.1% vs 5.4%, P = 0.049) rates differed between patients with duodenal and gastric MALT lymphoma. Overall complete remission (61.5% vs 86.2%, P = 0.021) and complete remission after initial H. pylori eradication therapy (50% vs 87.7%, P = 0.037) were significantly lower in patients with duodenal than gastric MALT lymphoma. Complications including bleeding, stricture, and transformation to high‐grade lymphoma occurred in a total of seven patients (4.9%), with a higher incidence in patients with duodenal than gastric MALT lymphoma (38.5% vs 1.5%, P < 0.001).
Conclusions
Duodenal MALT lymphoma is very rare, and treatment outcomes appear to be inferior to those of gastric MALT lymphoma.
The endoscopic features between herpes simplex virus (HSV) and cytomegalovirus (CMV) esophagitis overlap significantly, and hence the differential diagnosis between HSV and CMV esophagitis is ...sometimes difficult. Therefore, we developed a machine-learning-based classifier to discriminate between CMV and HSV esophagitis. We analyzed 87 patients with HSV esophagitis and 63 patients with CMV esophagitis and developed a machine-learning-based artificial intelligence (AI) system using a total of 666 endoscopic images with HSV esophagitis and 416 endoscopic images with CMV esophagitis. In the five repeated five-fold cross-validations based on the hue-saturation-brightness color model, logistic regression with a least absolute shrinkage and selection operation showed the best performance (sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve: 100%, 100%, 100%, 100%, 100%, and 1.0, respectively). Previous history of transplantation was included in classifiers as a clinical factor; the lower the performance of these classifiers, the greater the effect of including this clinical factor. Our machine-learning-based AI system for differential diagnosis between HSV and CMV esophagitis showed high accuracy, which could help clinicians with diagnoses.
Background
Although many epidemiologic studies have evaluated the effect of Helicobacter pylori eradication on gastric cancer, the effect is still uncertain in general populations. We evaluated ...whether H. pylori eradication would affect the incidence of gastric cancer in healthy asymptomatic populations.
Materials and methods
We performed a retrospective cohort study in 38 984 asymptomatic individuals, who underwent health screening examinations more than twice between 2005 and 2016. We investigated the incidence of gastric cancer among 3 groups: those without H. pylori infection (Hp‐negative group), those with H. pylori eradication (eradication group), and those without H. pylori eradication (non‐eradication group).
Results
The cumulative incidence of gastric cancer was 54.5 cases per 100 000 person‐years during a median of 6.4 years. In a multivariate analysis using the Cox proportional hazard model, the cumulative incidence of gastric cancer in the non‐eradication group was significantly higher than those in the Hp‐negative (hazard ratio HR 4.12, P < .001) and eradication groups (HR 2.73, P = .001). However, the cumulative incidence of gastric cancer was not significantly different between the eradication and Hp‐negative groups. Other risk factors for gastric cancer occurrence were age, smoking, family history of gastric cancer, and gastric atrophy. The standardized incidence ratios of the age groups above 40 and below 70 in the eradication group were all significantly decreased.
Conclusions
Helicobacter pylori eradication reduced the cumulative incidence of gastric cancer in healthy asymptomatic population, and the effect of H. pylori eradication on the prevention of gastric cancer was observed in all ages.
Background and Aim
Guidelines for selecting the eradication regimen for Helicobacter pylori reinfection remain unclear. This study aimed to evaluate the eradication rate of H. pylori reinfection in ...patients with a previous infection successfully eradicated with index triple therapy.
Methods
This was a single‐center, retrospective case–control study. A total of 10 468 H. pylori‐infected patients treated with proton‐pump inhibitor‐based triple eradication therapy at a tertiary medical institution between 2005 and 2016 were enrolled. We reviewed the medical records of the enrolled patients and compared the treatment outcomes in those with H. pylori reinfection after a successful eradication.
Results
Helicobacter pylori infection was successfully eradicated with the index triple therapy in 7770 patients (74.2%). Among 3567 patients followed up for > 1 year, H. pylori reinfection occurred in 420 (11.8%; 3.06% per person‐year) during a median follow‐up of 39.1 months (interquartile range, 23.5–58.7 months). Of these patients, 164 received eradication therapy for reinfection (triple therapy in 102 and quadruple therapy in 62) and had follow‐up data. Triple therapy showed an eradication rate of 78.4% for H. pylori reinfection, which was not significantly different from that of the index triple therapy (P = 0.394). Quadruple therapy for reinfection exhibited a better eradication rate (87.1%) than triple therapy but without statistical significance (P = 0.237).
Conclusions
Retreatment with triple therapy for H. pylori reinfection after successful eradication of prior infection showed comparable outcomes to the index triple therapy. Bismuth‐containing quadruple therapy for reinfection tended to have a better eradication rate than did triple therapy.
Few studies have focused on preoperative nutritional status of esophageal cancer patients eligible for upfront surgery. We aimed to investigate the association of preoperative nutritional status with ...prognosis of patients who undergo upfront surgery for esophageal cancer. A total of 274 patients who underwent upfront surgery for esophageal squamous cell carcinoma between January 2012 and December 2016 were eligible. Preoperative nutritional status was evaluated using prognostic nutritional index (PNI) scoring system, nutritional risk screening 2002 (NRS 2002), and controlling nutritional status. The median age was 63 years (interquartile range, 58-70) and 94.7% of patients were male. The pathological stages were Stage I-74.5% (204/274), Stage II-20.4% (56/274), and Stage III-5.1% (14/274). Multivariate analysis revealed that advanced stage, a low PNI, and a high NRS 2002 were independent predictors of overall survival. During median follow-up period of 55 mo, overall survival rates were lower in the high NRS 2002 group (P < 0.001). A high NRS 2002 score was associated with frequent postoperative complications, especially pneumonia and anastomosis site leakage (P = 0.003). The poor preoperative nutritional status with a high NRS 2002 is associated with postoperative complications as well as poor overall survival in patients with upfront surgery for esophageal cancer.
Supplemental data for this article is available online at
https://doi.org/10.1080/01635581.2022.2042573
Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, acute and chronic complications of PEG have been reported. We aimed to determine risk factors associated with ...complications and 30-day mortality after PEG, based on 11 years of experience at a single tertiary hospital.
In total, 401 patients who underwent first PEG insertion at the Asan Medical Center, Seoul, Korea, between January 2005 and December 2015 were eligible. Medical records were retrospectively reviewed to determine clinical characteristics and outcomes of 139 and 262 patients who underwent pull-type and introducer-type PEG, respectively.
The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m
. Acute and chronic complications developed in 96 (23.9%) and 105 (26.2%) patients. Acute ileus and chronic tube obstruction were significantly more frequent in the introducer-type PEG group (p = 0.033 and 0.001, respectively). The 30-day mortality rate was 5.0% (median survival: 10.5 days). Multivariate analysis revealed that underlying malignancy was a predictor of acute complications; age ≥ 70 years and diabetes mellitus were predictors of chronic complications. The median follow-up was 354 days. Neurologic disease and malignancy were the most common indications for PEG. Neurologic diseases were classified into two groups: stroke and the other neurologic disease group (including dementia, Parkinson's disease, neuromuscular disease, and hypoxic brain damage). Multivariate analysis showed that 30-day mortality was significantly lower in the other neurologic disease group and higher in patients with platelet count < 100,000/μL, and C-reactive protein (CRP) ≥ 5 mg/dL.
PEG is a relatively safe and feasible procedure, but it was associated with significantly higher early mortality rate in patients with platelet count < 100,000/μL or CPR≥5mg/dL, and lower early mortality rate in neurologic disease group including dementia, Parkinson's disase, neuromuscular disease, and hypoxic brain damage. In addition, acute complications in patients with underlying malignancy, and chronic complications in patients aged ≥70 and those with diabetes mellitus should be considered during and after PEG.
We aimed to investigate the endoscopic features and clinical course of CMV gastroenterocolitis in immunocompetent patients. We reviewed the medical records and endoscopic images of 86 immunocompetent ...patients with CMV gastroenterocolitis. Immunocompetent patients were defined as those without congenital or acquired immunodeficiency syndrome, use of anti-cancer chemotherapeutic and immunosuppressive agents, and inflammatory bowel diseases. The mean age was 65.5 ± 11.8 years and 53 (61.6%) were male. Sixty-eight (79.1%) patients had comorbidities. Upper gastrointestinal-dominant, small bowel-dominant, and colon-dominant types were observed in 19, 7, and 60 patients, respectively. Endoscopic features could be classified into discrete ulcerative type with/without exudate and diffuse erythematous type with/without exudate. Antiviral treatment with ganciclovir was initiated in 51 patients (59.3%), 40 of whom improved and 1 improved after changing ganciclovir to foscarnet. Thirty-three patients (38.4%) improved without antiviral treatment. Surgery was necessary in two patients because of colon perforation before antiviral treatment. Another two patients underwent surgery because of sigmoid stricture and cecal perforation during antiviral treatment. Endoscopic type was not associated with clinical outcomes, such as surgery and death. CMV gastroenterocolitis in immunocompetent patients mostly occur in older patients with comorbidities, and the endoscopic features vary with no association with clinical outcomes.
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