Background
Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) meeting the expanded indication is considered investigational. We aimed to compare long-term outcomes of ESD and ...surgery for EGC in the expanded indication based on each criterion.
Methods
This study included 1823 consecutive EGC patients meeting expanded indication conditions and treated at a tertiary referral center: 916 and 907 patients underwent surgery or ESD, respectively. The expanded indication included four discrete criteria: (I) intramucosal differentiated tumor, without ulcers, size >2 cm; (II) intramucosal differentiated tumor, with ulcers, size ≤3 cm; (III) intramucosal undifferentiated tumor, without ulcers, size ≤2 cm; and (IV) submucosal invasion <500 μm (sm1), differentiated tumor, size ≤3 cm. We selected 522 patients in each group by propensity score matching and retrospectively evaluated each group. The primary outcome was overall survival (OS); the secondary outcomes were disease-specific survival (DSS), recurrence-free survival (RFS), and treatment-related complications.
Results
In all patients and subgroups meeting each criterion, OS and DSS were not significantly different between groups (OS and DSS, all patients:
p
= 0.354 and
p
= 0.930; criteria I:
p
= 0.558 and
p
= 0.688; criterion II:
p
= 1.000 and
p
= 1.000; criterion III:
p
= 0.750 and
p
= 0.799; and criterion IV:
p
= 0.599 and
p
= 0.871). RFS, in all patients and criterion I, was significantly shorter in the ESD group than in the surgery group (
p
< 0.001 and
p
< 0.003, respectively). The surgery group showed higher rates of late and severe treatment-related complications than the ESD group.
Conclusions
ESD may be an alternative treatment option to surgery for EGCs meeting expanded indications, including undifferentiated-type tumors.
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high‐resolution manometry (HRM). Fifty‐two diverse international experts ...separated into seven working subgroups utilized formal validated methodologies over two‐years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
Key updates in the CCv4.0 include a protocol inclusive of varying positions and provocative tests, recognitions of conclusive and inconclusive patterns, requirement of clinically relevant symptoms for a conclusive diagnosis of EGJOO, distal esophageal spasm or hypercontractile esophagus, and increasingly stringent criteria for EGJOO and IEM.The classification using CCv4.0 is based on the primary position (either supine or upright), while assessment of swallows in the secondary position and with provocation provides supportive data, particularly for inconclusive settings.
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Postprocedural bleeding is known to be relatively low after argon plasma coagulation (APC) for gastric neoplasms; however, there are few studies proving the effect of antithrombotic agents. This ...study aimed to analyze the incidence of delayed bleeding (DB) based on antithrombotic agents administered and to identify the risk factors for DB in APC for gastric tumors.
A total of 785 patients with 824 lesions underwent APC for single gastric neoplasm between January 2011 and January 2018. After exclusion, 719 and 102 lesions were classified as belonging to the non-antithrombotics (non-AT) and AT groups, respectively. The clinical outcomes were compared between the two groups, and we determined the risk factors for DB in gastric APC.
Of the total 821 cases, DB occurred in 20 cases (2.4%): 17 cases in the non-AT group and three cases in the AT group (2.4% vs 2.9%, p=0.728). Multivariate analysis of the risk factors for DB confirmed the following significant, independent risk factors: male sex (odds ratio, 7.66; 95% confidence interval, 1.02 to 57.69; p=0.048) and chronic kidney disease (odds ratio, 4.51; 95% confidence interval, 1.57 to 13.02; p=0.005). Thromboembolic events and perforation were not observed in all patients regardless of whether they took AT agents.
AT therapy is acceptably safe in gastric APC because it does not significantly increase the incidence of DB. However, patients with chronic kidney disease or male sex need to receive careful follow-up on the incidence of post-APC bleeding.
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.
Real-time polymerase chain reaction (RT-PCR) is a fast and simple method for the simultaneous detection of clarithromycin (CLR) resistance and
. We evaluated the effectiveness of RT-PCR compared to ...that of the rapid urease test (RUT) and assessed its value in verifying CLR resistance.
A total of 70 specimens with confirmed
infection in culture were enrolled and analyzed in this prospective study. All specimens were subjected to RT-PCR assay using fluorescence melting peak signals to detect
infection and CLR resistances caused by either A2142G or A2143G mutations in the 23S ribosomal RNA gene (23S rRNA). The results were compared to those of RUT and antimicrobial susceptibility culturing tests to investigate the efficacy of RT-PCR.
Among the 70 specimens analyzed, the positivity rate was 97.1% (68/70) with RT-PCR and 82.9% (58/70) with RUT. CLR resistance (minimum inhibitory concentration >1.0 μg/mL) was confirmed in 18.6% (13/70), and fluorescence melting curve analysis showed that 84.6% (11/13) had point mutations in 23S rRNA. Ten specimens had only A2143G mutation, and one specimen contained both A2142G and A2143G mutations.
RT-PCR assay was found to be more efficient than RUT in detecting
infection and could effectively verify CLR resistance compared to the antimicrobial susceptibility culturing test. Considering the high sensitivity and accessibility of RT-PCR method, it could be used to easily detect CLR-resistant
, thus helping clinicians select suitable treatment regimen and improve the eradication rate.
Epstein-Barr virus (EBV) and
(HP) coinfection may synergistically induce severe inflammatory responses in the stomach tissue, increasing the risk of developing gastric cancer. We aimed to analyze the ...effect of EBV and HP coinfection on the clinicopathologic features and prognosis of gastric cancer, as well as to evaluate the role of EBV infection in non-gastric carcinoma with lymphoid stroma (non-GCLS).
Overall, 956 patients who underwent surgery for gastric cancer between September 2014 and August 2015 were eligible and divided into groups, according to GCLS morphology, EBV infection, and HP infection. Clinicopathologic characteristics and oncologic outcomes were analyzed retrospectively.
EBV and HP coinfection was significantly associated with male sex, proximal location, GCLS morphology, and equivocal p53 expression (p<0.001). Multivariate analysis revealed that EBV infection alone (hazard ratio HR, 0.362; 95% CI, 0.131 to 0.996; p=0.049) and lower third location (HR, 0.624; 95% CI, 0.413 to 0.943; p=0.025) were inversely correlated with overall survival. During median follow-up period of 72 months, overall survival rate was not significantly different between the EBV and HP coinfection group and others (97.6% vs 86.8%; log-rank p=0.144). In non-GCLS patients (n=920), overall survival rate was not significantly different between the EBV infection group and others (96.9% vs 86.4%; log-rank p=0.126).
EBV and HP coinfection is not an independent prognostic factor for gastric cancer. EBV infection status, regardless of HP infection, affects the clinicopathologic features of all types of gastric cancer. However, it does not lead to a significant difference in overall survival of non-GCLS patients.
Achalasia Park, Kwangbeom; Jung, Kee Wook
The Korean Journal of Helicobacter and Upper Gastrointestinal Research,
09/2022, Letnik:
22, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Achalasia is characterized by peristaltic failure and incomplete relaxation of the lower esophageal sphincter. The incidence and prevalence of achalasia increase with age, although achalasia can ...affect all age groups. The pathophysiology of achalasia involves the loss of inhibitory ganglion cells in the myenteric plexus of the esophagus. Its main symptoms include dysphagia, chest pain, regurgitation, and weight loss. The method of diagnosing achalasia has evolved from conventional manometry in the 1970s to high-resolution manometry in the 2010s. High-resolution manometry based on spatiotemporal plots can diagnose achalasia more precisely than conventional manometry. Moreover, novel parameters such as integrated relaxation pressure (IRP) (according to the Chicago classification) have increased diagnostic accuracy. However, cases of achalasia presenting with normal IRP have been reported. Therefore, the novel Chicago classification version 4.0 has adopted additional tests. These tests include the stress test for esophageal motor disorders, timed barium esophagography, and test using a functional lumen imaging probe that measures the distensibility of the esophagogastric junction. Achalasia was previously treated using surgical myotomy, balloon dilation, and botulinum toxin injection. However, peroral endoscopic myotomy (POEM) has recently become the mainstay treatment. POEM has a higher clinical success rate and a lower complication rate than surgical myotomy. Esophageal cancer and pulmonary conditions such as aspiration pneumonia are possible complications of achalasia. In this review, the current knowledge regarding achalasia together with novel diagnostic and therapeutic strategies are discussed.
Antithrombotic (AT) therapy has been known to increase post–endoscopic resection (ER) bleeding risk; however, there are few studies quantifying the effect of AT agents. This study aimed to analyze ...the incidence of delayed bleeding (DB) based on AT agents administered and to identify the proper timing of drug cessation.
Between January 2011 and March 2017, 7752 patients with 8242 lesions underwent ER for single gastric neoplasm. After a 2:1 propensity score matching using age, sex, specimen size, tumor location, diagnosis, chronic kidney disease, and liver cirrhosis, 798 and 399 lesions were classified as belonging to the matched control (MC) group and AT group, respectively. The clinical outcomes were compared between the 2 groups.
The DB rate of the MC and AT groups was 6.3% and 10.0%, respectively. There was no significant difference in the early DB rate between the 2 groups; however, the late DB rate of the AT group was higher than the MC group. The continuation group of the AT group had a higher incidence of DB than their matched control subjects (15.9% vs 5.1%; odds ratio, 3.55; 95% confidence interval, 1.24-10.14; P = .018). In patients taking anticoagulants, heparin bridging therapy (HBT) increased the incidence of DB compared with non-HBT (35.7% vs 10.0%; odds ratio, 5.00; 95% confidence interval, 1.11-22.50; P = .036). No thromboembolic events were observed in patients taking AT agents.
Patients receiving AT therapy had a higher incidence of DB than those not receiving AT therapy, especially with the continued administration of AT agents and HBT.
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