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BackgroundEndoscopic 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.MethodsThis 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.ResultsIn 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.ConclusionsESD may be an alternative treatment option to surgery for EGCs meeting expanded indications, including undifferentiated-type tumors.

Background: Helicobacter pylori (HP) and Epstein–Barr virus (EBV) coinfection lead to chronic inflammation and contribute to the development of gastric cancer. However, studies examining the association between HP virulence factors and EBV infection in gastric cancer are limited. This study investigated the polymorphisms of HP virulence factors associated with EBV infection and their effects on clinical outcomes in EBV-associated gastric cancer (EBVaGC). Methods: A total of 96 HP isolates from 54 patients with gastric cancer were divided and analyzed based on EBV coinfection status. Polymerase chain reaction amplifications of virulence factors were conducted using DNA extracts from HP isolates cultured from gastric mucosal specimens. Results: EBV infection was significantly associated with gastric carcinoma with lymphoid stroma morphology and a proximal location in the stomach. Most HP strains from patients with gastric cancer were positive for cagA (100.0%), vacA (100.0%), and iceA1 (87.5%). Among HP isolates with EBV coinfection, the prevalence of iceA2 (21.7% vs. 0.0%, p < 0.001) and ureA (21.7% vs. 4.0%, p = 0.009) was significantly more frequent, and that of iceA1 (78.3% vs. 96.0%, p = 0.009) and vacA s1a (4.3% vs. 22.0%, p = 0.012) was less frequent than those of EBV– colonies. Multivariate analysis indicated that ureA (odds ratio, 6.148; 95% confidence interval [CI], 1.221 to 30.958; p = 0.028) was associated with EBVaGC. No significant difference in clinical outcomes was observed based on the presence of ureA expression in EBVaGC. Conclusions: In gastric cancer, regardless of EBV infection, most HP strains were highly virulent, testing positive for cagA, vacA, and iceA1. Although ureA was significantly associated with EBV infection, it did not influence the clinical outcomes of EBVaGC.

BackgroundLittle is known about the outcomes of gastric endoscopic submucosal dissection (ESD) in patients with chronic kidney disease (CKD). We compared the efficacy and safety of ESD between CKD and non-CKD patients.MethodsFrom January 2005 to December 2014, 102 CKD patients underwent ESD for gastric neoplasms at a tertiary medical institution were reviewed retrospectively. A propensity score-matched control group (102 patients) was selected from non-CKD patients to compare clinical outcomes between CKD and non-CKD patients.ResultsEn bloc resection (96.1%) and curative resection (88.2%) rates in the CKD group did not significantly differ from those in the non-CKD group. Median procedure times (25.0 vs. 21.5 min, p = 0.734) and perforation risk (p = 0.480) were similar between groups. The CKD group showed a tendency towards more bleeding events (p = 0.052) and had a significantly longer hospital stay (p = 0.001). In a subgroup analysis, stage 3 CKD patients exhibited a bleeding risk comparable to that exhibited by non-CKD patients (HR 1.35; 95% CI 0.36–5.06; p = 0.654), whereas stage 4 (HR 5.79; 95% CI 1.52–22.0; p = 0.010) and stage 5 (HR 4.80; 95% CI 1.58–14.6; p = 0.006) patients showed higher bleeding risks than non-CKD patients. In a multivariate analysis, stage 4/5 CKD was a significant predictor for bleeding risk (HR 4.99; 95% CI 1.32–18.8; p = 0.018).ConclusionsESD for gastric epithelial neoplasms can be performed in stage 3 CKD patients with comparable efficacy and safety to that performed in non-CKD patients. Stage 4 and 5 CKD patients should be closely monitored for bleeding events after ESD.

Background Although extragastric recurrence after endoscopic resection of early gastric cancer is rare, it is important because of its potentially fatal outcomes. We investigated the patterns of extragastric recurrence after endoscopic resection and evaluated the role of abdominal computed tomography in surveillance. Methods Between July 1994 and June 2014, 4915 patients underwent endoscopic resection of early gastric cancer. Because of follow-up periods of less than 6 months and consecutive surgery within 1 year, 810 patients were excluded. Thus, 4105 patients were retrospectively reviewed. Results The median follow-up period was 37 months (interquartile range 20–59.6 months). The overall incidence of extragastric recurrence was 0.37% ( n  = 15). In patients who underwent curative resection, the incidence was 0.14% ( n  = 5). There were three recurrences in the absolute indication group, six in the expanded indication group, and six in the beyond expanded indication group. The median time to extragastric recurrence was 17 months (interquartile range 16.5–43.2 months). Of the 15 extragastric recurrences, 11 were in the regional lymph nodes and 4 were in the liver, adrenal gland, and peritoneum. Sixty percent (9/15) of the extragastric recurrences occurred without intragastric lesions. Eleven recurrences were detected by abdominal computed tomography, and eight patients underwent curative surgery. Conclusions After endoscopic resection of early gastric cancer, regional lymph node recurrence is the predominant extragastric recurrence pattern, which can be detected via abdominal computed tomography and cured by rescue surgery. Abdominal computed tomography should be considered as a surveillance method, especially in patients with an expanded indication.

Background Although the rate of early detection and endoscopic treatment of gastric neuroendocrine tumors (NETs) is steadily increasing, there are insufficient studies on the long-term outcomes of endoscopic treatment. Therefore, we aimed to investigate the clinical features and long-term outcomes of endoscopic treatment for type 1 gastric NETs. Methods Subjects who underwent endoscopic treatment for gastric NETs between March 1997 and December 2015 were included. Clinical features and endoscopic treatment outcomes were retrospectively investigated by reviewing medical records. Results In total, 125 subjects underwent endoscopic treatment including forceps biopsy ( n = 21), argon plasma coagulation ( n = 1), endoscopic mucosal resection (EMR, n = 62), and endoscopic submucosal dissection (ESD, n = 41). In total, 103 patients with 114 lesions, who underwent EMR or ESD, were analyzed to evaluate endoscopic and oncologic outcomes. The rates of en bloc resection in the EMR and ESD groups were 91.5% and 97.7%, respectively. Complete resection rates were significantly higher in the ESD group than in the EMR group; it was also higher in < 1-cm small-sized lesions than in 1–2-cm large-sized lesions. Adverse events were similar between the two groups. During a median follow-up period of 63 months, local recurrence rates were 6.5% and 2.4% in the EMR and ESD groups, respectively, and the disease-free survival rate did not differ significantly between the groups. Conclusion Endoscopic treatment for type 1 gastric NETs less than 2 cm in diameter and confined to mucosal and submucosal layers could be an effective and safe treatment strategy based on the favorable long-term outcome.

Background 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. Methods 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. Results The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m 2 . 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. Conclusions 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.

BackgroundIn cases of subepithelial tumors (SETs) located in the cardiac area, a preoperative histologic diagnosis might be helpful in determining the requirement of surgery.AimTo investigate the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) in gastric SETs located in the cardia.MethodsThe data of 107 patients who underwent EUS-FNB, from 2012 to 2017, for tissue sampling of gastric SETs located in the cardia were collected. The clinicopathological data, EUS-related parameters, and surgical outcomes were retrospectively reviewed.ResultsThe EUS-FNB results were diagnostic in 86.9% (93/107) and nondiagnostic in 13.1% (14/107) of the patients. Immunostaining of the FNB specimens led to the diagnosis of gastrointestinal stromal tumor (GIST) in 25 SETs (23.4%), leiomyoma in 62 SETs (57.9%), heterotopic pancreas in 3 SETs (2.8%), and schwannoma in 2 SETs (1.9%). In the multivariate analysis, patients with GISTs showed significantly more inhomogeneous echogenicity [odds ratio (OR), 8.867], more cystic foci (OR, 26.98), and older age (OR, 1.087). In 26 patients who underwent surgical resection, the agreement between EUS-FNB and surgical pathological findings was 100% with respect to the diagnosis of GISTs (n = 20) and leiomyoma (n = 7). Among these cases, the proportion of high-risk GISTs was 20.0% (4/20), and no leiomyosarcoma was detected.ConclusionsAlthough a majority of the subepithelial lesions in the cardia of the stomach are benign, 20% of the cases diagnosed with GIST have a high malignant potential. Preoperative EUS-FNB might be a useful tool for decision-making regarding the ultimate management and outcomes of these lesions.

BackgroundAlthough upper gastrointestinal (GI) neoplasms are not rare in patients with familial adenomatous polyposis (FAP), few studies have focused on them and the long-term outcomes of their treatment by endoscopy. Therefore, we aimed to investigate the prevalence and endoscopic treatment outcomes of upper GI neoplasms in patients with FAP.MethodsAmong 215 patients diagnosed with FAP between January 1991 and December 2019, 208 who underwent esophagogastroduodenoscopy were eligible. The clinical features and endoscopic treatment outcomes of upper GI neoplasms were retrospectively investigated and analyzed.ResultsAmong the enrolled patients, 113 (54.3%) had one or more upper GI neoplasms: gastric adenoma (n = 34), gastric cancer (n = 7), nonampullary duodenal adenoma (n = 86), and ampullary adenoma (n = 53). Among patients with gastric neoplasms (n = 37), 24 (64.9%) underwent treatment (endoscopic treatment: 22, surgery: 2). No tumor-related mortality occurred during median follow-up of 106 months (interquartile range [IQR] 63–174). Endoscopic treatment was performed in 47 (54.7%) of 86 patients with nonampullary duodenal adenoma and in 32 (60.4%) of 53 patients with ampullary adenoma. No patient underwent surgery for duodenal neoplasms, and no tumor-related mortality occurred during median follow-up of 88 months (IQR 42–145). The proportion of patients with increased Spigelman stage at 2 years after the initial diagnosis or treatment was significantly higher in untreated group than in the group treated for duodenal neoplasms (27.3% vs. 0.0%, p = 0.001).ConclusionEndoscopic surveillance in FAP patients is important for the detection and treatment of upper GI neoplasms in early stage. In particular, endoscopic therapy for duodenal neoplasms can reduce the severity of duodenal polyposis.

Background Benign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy. Methods Subjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus. Results Twenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention. Conclusions EIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.

BackgroundUpper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods.MethodsTotal 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively.ResultsOf 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients.ConclusionsBleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.