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1.  Endoscopic Resection for Synchronous Esophageal Squamous Cell Carcinoma and Gastric Adenocarcinoma in Early Stage Is a Possible Alternative to Surgery 
Gut and Liver  2015;9(1):59-65.
Background/Aims
We investigated the clinical outcomes according to the method of treatment in synchronous esophageal and gastric cancer.
Methods
Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were diagnosed in 79 patients between 1996 and 2010. We divided the patients into four groups according to treatment; Group 1 received surgical resection for both cancers or surgery for gastric cancer with chemoradiotherapy for esophageal cancer (n=27); Group 2 was treated by endoscopic resection with or without additional treatment (n=14); Group 3 received chemoradiotherapy only (n=18); and Group 4 received supportive care only (n=20).
Results
The median survival times in groups 1 and 2 were 86 and 60 months, respectively. The recurrence rate and mortality were 23% and 48%, respectively, in group 1 and 21% and 4%, respectively, in group 2. The median survival time was 12 months in group 3 and 9 months in group 4. Multivariate analysis showed that age (p<0.001) and treatment group (p=0.019) were significantly associated with death. Compared with group 1, treatment in the intensive care unit (p=0.003), loss of body weight (p=0.042), and decrease in hemoglobin (p=0.033) were worse in group 1.
Conclusions
Endoscopic resection for synchronous esophageal and gastric cancer could be considered as a possible alternative to surgery for early-stage cancer.
doi:10.5009/gnl13255
PMCID: PMC4282858  PMID: 25170061
Synchronous; Esophageal neoplasms; Stomach neoplasms
2.  Comparison of Clinical Outcomes Associated with Pull-Type and Introducer-Type Percutaneous Endoscopic Gastrostomies 
Clinical Endoscopy  2014;47(6):530-537.
Background/Aims
Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea.
Methods
We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed.
Results
The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population.
Conclusions
PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.
doi:10.5946/ce.2014.47.6.530
PMCID: PMC4260101  PMID: 25505719
Percutaneous endoscopic gastrostomy; Pull type; Introducer type; Complication; Indication for PEG
3.  Clinical Outcomes Associated with Treatment Modalities for Gastrointestinal Bezoars 
Gut and Liver  2014;8(4):400-407.
Background/Aims
With technical and instrumental advances, the endoscopic removal of bezoars is now more common than conventional surgical removal. We investigated the clinical outcomes in a patient cohort with gastrointestinal bezoars removed using different treatment modalities.
Methods
Between June 1989 and March 2012, 93 patients with gastrointestinal bezoars underwent endoscopic or surgical procedures at the Asan Medical Center. These patients were divided into endoscopic (n=39) and surgical (n=54) treatment groups in accordance with the initial treatment modality. The clinical feature and outcomes of these two groups were analyzed retrospectively.
Results
The median follow-up period was 13 months (interquartile range [IQR], 0 to 77 months) in 93 patients with a median age of 60 years (IQR, 50 to 73 years). Among the initial symptoms, abdominal pain was the most common chief complaint (72.1%). The bezoars were commonly located in the stomach (82.1%) in the endoscopic treatment group and in the small bowel (66.7%) in the surgical treatment group. The success rates of endoscopic and surgical treatment were 89.7% and 98.1%, and the complication rates were 12.8% and 33.3%, respectively.
Conclusions
Endoscopic removal of a gastrointestinal bezoar is an effective treatment modality; however, surgical removal is needed in some cases.
doi:10.5009/gnl.2014.8.4.400
PMCID: PMC4113045  PMID: 25071905
Bezoars; Endoscopy; Surgery
4.  Meta-Analysis of First-Line Triple Therapy for Helicobacter pylori Eradication in Korea: Is It Time to Change? 
Journal of Korean Medical Science  2014;29(5):704-713.
Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea.
Graphical Abstract
doi:10.3346/jkms.2014.29.5.704
PMCID: PMC4024949  PMID: 24851029
Helicobacter pylori; Eradication; Triple Therapy
5.  A Planned Prospective, Randomized, Placebo-Controlled Multicenter Trial Assessing the Effect of Helicobacter pylori Eradication on the Healing of Iatrogenic Ulcer after Endoscopic Resection of Gastric Neoplasm 
Gut and Liver  2010;4(4):514-517.
Background/Aims
Helicobacter pylori eradication may facilitate the healing of iatrogenic ulcer after endoscopic resection of gastric neoplasm. This study involved designing a randomized, double-blinded, placebo-controlled, multicenter trial, performed by the Korean College of Helicobacter and Upper Gastrointestinal Research and the Medical Research Collaboration Center, Seoul National University Hospital.
Methods
We intend to enroll up to 232 patients H.-pylori-positive patients who have gastric adenoma or early gastric cancer after endoscopic resection. The enrolled patients are being randomly allocated to the H.-pylori-eradication-plus-proton-pump-inhibitor group or the placebo-plus-proton-pump-inhibitor group based on their histology results and the size of the resected specimen. After random allocation, the iatrogenic ulcer size and stage are evaluated at 4- and 8-week follow-ups (with a window of ±7 days). The primary end point is the healing rate of the ulcer by stage, and the secondary end point is the rate of ulcer size reduction, relief rate from ulcer-related symptoms, and adverse-event rates.
Results
More than 90% of the target subjects have already been enrolled into the study and are receiving ongoing periodic monitoring by the Medical Research Collaboration Center.
Conclusions
Completion of the study should reveal whether H. pylori eradication can facilitate the healing of ulcer after endoscopic resection in Korea.
doi:10.5009/gnl.2010.4.4.514
PMCID: PMC3021608  PMID: 21253301
Helicobacter pylori; Iatrogenic ulcer; Endoscopic resection; Eradication; Medical Research Collaboration Center
6.  Intralesional Steroid Injection to Prevent Stricture after Near-Circumferential Endosopic Submucosal Dissection for Superficial Esophageal Cancer 
Clinical Endoscopy  2013;46(6):643-646.
Stricture frequently occurs after endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma with near- or whole-circumferential mucosal defects, and post-ESD stricture is difficult to treat and usually requires multiple sessions of endoscopic balloon dilatation. Intralesional steroid injection has previously been used to prevent stricture; however, there have been few experiences with this method after near- or whole-circumferential ESD. We present a case of a single session of intralesional steroid injection performed immediately after near-circumferential ESD to prevent post-ESD stricture. After a follow-up period of 6 months, the patient showed good outcome without dysphagia.
doi:10.5946/ce.2013.46.6.643
PMCID: PMC3856266  PMID: 24340258
Injections, intralesional; Esophageal stenosis; Endoscopic submucosal dissection; Esophageal neoplasms
7.  Inhibition of 15-hydroxyprostaglandin dehydrogenase by Helicobacter pylori in Human Gastric Carcinogenesis 
Helicobacter pylori (H pylori) infection induces a chronic inflammatory response, which promotes gastric carcinogenesis. 15-hydroxyprostaglandin dehydrogenase (15–PGDH) plays a key role as a tumor suppressor in gastrointestinal cancers. The aim of this study was to elucidate the role of 15-PGDH in gastric carcinogenesis associated with H pylori. 15-PGDH expression in gastric biopsies from H pylori-infected (n=25) and non-infected (n=15) subjects was analyzed by quantitative real-time PCR, western blot analysis, and immunohistochemisty. 15-PGDH DNA methylation was evaluated by methylation specific PCR and pyrosequencing. The expression of 15-PGDH, Snail, ERK1/2, TLR4 and MyD88 in response to H pylori infection was assessed by immunoblot analysis. Compared to negative specimens, H pylori positive specimens had 2-fold lower 15-PGDH mRNA levels and significantly less 15-PGDH protein. In four H pylori infected subjects with longitudinal follow-up, the suppression of 15-PGDH expression was reversed by H pylori eradication therapy. In parallel with suppressing 15-PGDH expression, H pylori infection activated expression of TLR4 and MyD88 expression, increased levels of phospho-ERK1/2, and increased expression of epidermal growth factor receptor (EGFR)-Snail. Inhibition of Snail and MyD88 reversed suppression of 15-PGDH expression and small interfering Myd88 reduced phosphorylated ERK1/2. Similarly, treatment with an ERK1/2 and EGFR inhibitor also restored 15-PGDH expression. Heliocobacter pylori appeared to promote gastric carcinogenesis by suppressing15-PGDH. This process is mediated by the TLR4/MyD88 pathway via ERK1/2 or EGFR - Snail transcriptional regulation. 15-PGDH may be a useful marker and a potential therapeutic target in H pylori-induced gastric carcinogenesis.
doi:10.1158/1940-6207.CAPR-12-0389
PMCID: PMC3796116  PMID: 23430757
Gastric cancer; Helicobacter pylori; 15-prostaglandin dehydrogenase
8.  15-Hydroxyprostaglandin Dehydrogenase in Colorectal Mucosa as a Potential Biomarker for Predicting Colorectal Neoplasms 
Journal of Korean Medical Science  2013;28(8):1154-1160.
15-Hydroxyprostaglandin dehydrogenase (15-PGDH) is downregulated during the early stages of colorectal carcinogenesis. The aim of the present study was to investigate the potential role of 15-PGDH in normal-appearing colorectal mucosa as a biomarker for predicting colorectal neoplasms. We obtained paired tumor and normal tissues from the surgical specimens of 32 sporadic colorectal cancer patients. mRNA expression of 15-PGDH was measured using a quantitative real-time PCR assay. We evaluated the association between 15-PGDH mRNA expression in normal-appearing mucosa, the presence of synchronous adenoma, and the cumulative incidence of metachronous adenoma. The relative 15-PGDH expression of normal-appearing mucosa in patients with synchronous adenoma was significantly lower than in patients without synchronous adenoma (0.71 vs 1.00, P = 0.044). The patients in the lowest tertile of 15-PGDH expression in normal-appearing mucosa were most likely to have synchronous adenoma (OR: 10.5, P = 0.024). Patients with low 15-PGDH expression in normal-appearing mucosa also demonstrated more advanced stage colorectal cancer (P = 0.045). However, there was no significant difference in the cumulative incidence of metachronous adenoma according to 15-PGDH mRNA expression in normal-appearing mucosa (P = 0.333). Hence, 15-PGDH in normal-appearing colorectal mucosa can be a useful biomarker of field effect for the prediction of sporadic synchronous neoplasms.
doi:10.3346/jkms.2013.28.8.1154
PMCID: PMC3744702  PMID: 23960441
15-Hydroxyprostaglandin Dehydrogenase; Biological Markers; Colorectal Neoplasms
9.  Regression of Advanced Gastric MALT Lymphoma after the Eradication of Helicobacter pylori 
Gut and Liver  2012;6(2):270-274.
A 66-year-old female presented with a 1-month history of dyspepsia. An initial upper gastrointestinal endoscopy with biopsy revealed a low-grade mucosa-associated lymphoid tissue (MALT) lymphoma. A rapid urease test was positive for Helicobacter pylori. Endoscopic ultrasound (EUS) and computed tomography (CT) revealed a 30×15-mm lymph node (LN) in the subcarinal area. Histopathologic and phenotypic analyses of the biopsy specimens obtained by EUS-guided fine-needle aspiration revealed a MALT lymphoma, and the patient was diagnosed with a stage 4E gastric MALT lymphoma. One year after H. pylori eradication, the lesion had disappeared, as demonstrated by endoscopy with biopsy, CT, fusion whole-body positron emission tomography, and EUS. Here, we describe a patient with gastric MALT lymphoma that metastasized to the mediastinal LN and regressed following H. pylori eradication.
doi:10.5009/gnl.2012.6.2.270
PMCID: PMC3343168  PMID: 22570759
Marginal zone B-cell lymphoma; Stomach
10.  Genetic Evaluation of ALADIN Gene in Early-Onset Achalasia and Alacrima Patients 
Background/Aims
ALADIN gene has been known to cause achalasia, alacrima, adrenal abnormalities and a progressive neurological syndrome. A considerable proportion of achalasia patients has been known to show alacrima (decreased secretion of tear). However, the genetic mechanism between achalasia and alacrima has not been defined yet. We postulated that ALADIN gene may be involved in the occurrence of early-onset achalasia; thus, we investigated the correlation of ALADIN gene in early-onset achalasia patients.
Methods
From 1989 to 2007, patients who were diagnosed as primary achalasia before age 35 were enrolled. All of the enrolled patients were asked for (1) blood sampling for DNA, (2) Shirmer test and (3) dysphagia questionnaires.
Results
The ALADIN gene in exon 1, 2, 10, 11 and 12 from 19 patients was investigated (M:F = 12:7). The mean age of patients at diagnosis was 27 ± 5 (15-35) years old. Eight out of 19 (42%) showed alacrima by the positive Shirmer test. In spite of thorough exam in the genetic study, there was no definite abnormal genetic finding in this study.
Conclusions
A considerable number of achalasia patients showed alacrima. Due to the limitation of this study, it is difficult to conclude that early-onset achalasia may have significant correlations with the ALADIN gene.
doi:10.5056/jnm.2011.17.2.169
PMCID: PMC3093009  PMID: 21602994
AAAS protein; Esophageal achalasia; Human; Shirmer test
11.  Low Levels of Pepsinogen I and Pepsinogen I/II Ratio are Valuable Serologic Markers for Predicting Extensive Gastric Corpus Atrophy in Patients Undergoing Endoscopic Mucosectomy 
Gut and Liver  2010;4(4):475-480.
Background/Aims
The levels of pepsinogen (PG) I and the PGI/II ratio are useful serologic markers for chronic atrophic gastritis. This study evaluated the performance and clinical implications of these markers in patients undergoing endoscopic mucosectomy.
Methods
We enrolled 142 consecutive patients with early gastric tumors and Helicobacter pylori infection who were eligible for mucosectomy. Chronic gastritis and atrophy were assessed using four defined biopsy procedures. Serum PGs were measured by an enzyme immunoassay. Optimal diagnostic cut-offs and performance were determined using receiver operating characteristic curves.
Results
The PGI level and the PGI/II ratio decreased with corpus-dominant gastritis and as atrophy advanced toward the corpus greater curvature (GC). For the presence of corpus GC atrophy, the areas under the PGI and PGI/II-ratio curves were 0.82 and 0.77, respectively. The optimal cut-off levels were 59.3µg/L for PGI (sensitivity, 83.3%; specificity, 78.4%) and 3.6µg/L for PGI/II ratio (sensitivity, 70.0%; specificity, 78.4%). Using these serologic cut-off levels, we found that the frequency of corpus tumor location differed significantly (32.9% vs 11.1% for PGI <59.3 and ≥59.3µg/L, respectively; and 31.1% vs 14.8% for PGI/II ratio <3.5 and ≥3.5, respectively; p<0.05).
Conclusions
A low PGI level and PGI/II ratio are valuable serologic markers for predicting corpus GC atrophy, and have clinical implications with respect to the corpus location of tumors in mucosectomy patients.
doi:10.5009/gnl.2010.4.4.475
PMCID: PMC3021602  PMID: 21253295
Pepsinogens; Atrophic gastritis; Stomach neoplasia; Helicobacter pylori; Endoscopy
12.  Benign Bronchoesophageal Fistula in Adults: Endoscopic Closure as Primary Treatment 
Gut and Liver  2010;4(4):508-513.
Background/Aims
Benign bronchoesophageal fistula (BEF) is a rare condition that is usually treated surgically; however, less invasive endoscopy procedures have been attempted to overcome the disadvantages of surgery. The aim of this study was thus to determine the results of endoscopic management as a primary treatment in patients with BEF.
Methods
We retrospectively analyzed data from 368 patients with BEF who were treated at a tertiary care, academic medical center between January 2000 and August 2009.
Results
Benign causes were found for only 18 of the 368 patients. Of these, seven were treated endoscopically and the others by surgery or other methods. The first endoscopy procedures failed in all seven patients, with second trials of endoscopy performed in four patients at a median of 8 days (range, 3 to 11 days) after the first procedure. The second endoscopic procedure was successful in two out of four patients; one patient showed no recurrence of the fistula, whereas the second patient experienced a recurrence after 24 months. All patients underwent successful surgical procedures after the failure of endoscopic treatment, with no further recurrences.
Conclusions
Although we observed a low rate of success for primary endoscopic treatment of benign BEF, the invasive nature of surgery suggests the need for a prospective study with a large number of patients to evaluate the efficacy of less invasive procedures such as endoscopic treatment.
doi:10.5009/gnl.2010.4.4.508
PMCID: PMC3021607  PMID: 21253300
Esophageal fistula; Endoscopy; Fibrin glue
13.  The Influence of CYP2C19 Polymorphism on Eradication of Helicobacter pylori: A Prospective Randomized Study of Lansoprazole and Rabeprazole 
Gut and Liver  2010;4(2):201-206.
Background/Aims
The CYP2C19 polymorphism plays an important role in the metabolism of various proton-pump inhibitors. Several trials have produced conflicting data on eradication rates of Helicobacter pylori (H. pylori) among CYP2C19 genotypes. We investigated whether the CYP2C19 genotype affects the eradication rate of H. pylori by direct comparing the effects of lansoprazole- and rabeprazole-based triple therapies.
Methods
A total of 492 patients infected with H. pylori was randomly treated with either 30 mg of lansoprazole or 20 mg of rabeprazole plus 500 mg of clarithromycin and 1,000 mg of amoxicillin twice daily for 1 week. CYP2C19 genotype status was determined by a PCR-restriction-fragment-length polymorphism method. After 7 to 8 weeks, H. pylori status was evaluated by a C13-urea breath test.
Results
Four hundred and sixty-three patients were analyzed, and the eradication rate was 75.2% in a per-protocol analysis. Eradication rates for the lansoprazole regimen (n=234) were 73.8%, 80.7%, and 85.4% in the homozygous extensive (HomEM), heterozygous extensive (HetEM), and poor metabolizers (PM) groups, respectively (p=0.303). In the case of the rabeprazole regimen (n=229), the eradication rates were 68.6%, 73.0%, and 71.9% in the HomEM, HetEM, and PM groups, respectively (p=0.795).
Conclusions
The efficacies of triple therapies that include lansoprazole or rabeprazole are not affected by CYP2C19 genetic polymorphisms.
doi:10.5009/gnl.2010.4.2.201
PMCID: PMC2886925  PMID: 20559522
Helicobacter pylori; CYP2C19; Proton pump inhibitor; Lansoprazole; Rabeprazole
14.  Clinicopathologic Characteristics of Barrett's Cancer in Korea 
Gut and Liver  2008;2(3):193-198.
Background/Aims
The incidence of Barrett's cancer is increasing in Western countries, but there have been only a few case reports of this condition in Korea. The aim of this study was to elucidate the endoscopic and pathologic characteristics of Barrett's cancer in a single center in Korea.
Methods
We retrospectively reviewed the demographic, endoscopic, and pathologic characteristics of six patients with Barrett's cancer, defined as a tumor centered above the esophagogastric junction and surrounded by Barrett's esophagus.
Results
All six patients were male, and three (50%) were symptomatic. Barrett's cancer had developed from short-segment Barrett's esophagus in all patients. All tumors were located on the right side of the lower esophagus and showed hyperemic mucosal changes. Three patients were treated surgically and three by endoscopic resection. All cases had pathologic evidence of Barrett's cancer.
Conclusions
Early detection of Barrett's cancer requires meticulous endoscopic observations of subtle mucosal color and morphological changes around the esophagogastric junction.
doi:10.5009/gnl.2008.2.3.193
PMCID: PMC2871641  PMID: 20485646
Barrett esophagus; Esophageal neoplasms
15.  Peritoneal Dissemination from Malignant Fibrous Histiocytoma of the Buttock: Unusual Metastases from a Rare Tumor 
Gut and Liver  2008;2(3):213-215.
We report a case of malignant fibrous histiocytoma (MFH) of the right buttock with multiple metastases to the lung, bone, and small intestine. He received resection and end-to-end anastomosis of the jejunum for the jejunal metastatic tumor, and mass excision of the metastatic tumor of the left femur followed by closed reduction and internal fixation and palliative radiotherapy. In addition, he received palliative radiotherapy to the metastatic pulmonary tumor with suspicious invasion into the thoracic aorta. However, one month after the completion of the aggressive local treatments, metastatic tumors recurred in the abdominal cavity, an extremely unusual site, resulting in peritoneal dissemination. He died of progressive disease 5 months after the initial diagnosis.
doi:10.5009/gnl.2008.2.3.213
PMCID: PMC2871643  PMID: 20485650
Malignant fibrous histiocytoma; Buttock; Peritoneal cavity; Neoplasm seeding
16.  Infarction and Perforation of the Small Intestine due to Tumor Emboli from Disseminated Rectal Cancer 
Gut and Liver  2008;2(2):130-132.
Small bowel perforation due to hematogenous metastatic tumor emboli is a rare event, especially in a patient with rectal cancer. We report a 75-year-old man with relapsed rectal cancer who developed an acute abdomen, which was found to be due to a perforated terminal ileum. Emergency surgery involved segmental resection and ileostomy. The pathology of the resected small bowel showed multifocal and extensive metastatic tumor emboli in the entire wall, leading to transmural infarction followed by perforation, without a discrete tumor mass. The pathology with immunohistochemistry showed a rectal tumor that was positive for CK-20 but negative for CK-7 and TTF-1. This extremely rare complication of rectal cancer resulted from ischemia and infarct caused by disseminated metastatic tumor emboli without direct invasion or mass formation.
doi:10.5009/gnl.2008.2.2.130
PMCID: PMC2871583  PMID: 20485623
Small intestine; Infarction; Intestinal perforation; Rectal cancer; Tumor embolism
17.  Recurrent Lower Gastrointestinal Bleeding from Congenital Arteriovenous Malformation in the Terminal Ileum Mimicking Intestinal Varicosis: A Case Report 
Journal of Korean Medical Science  2007;22(4):746-749.
We report on an exceptional vascular cause of gastrointestinal hemorrhage. A 30-yr-old man was admitted because of recurrent hematochezia. Colonoscopy showed circumferential, erythematous, and nodular vascular distensions with hematocystic spots in the terminal ileum resembling varicosis and subsequent computed tomography with 3-dimensional angiographic reconstruction revealed a vascular architecture around the terminal ileum. No other potential source of bleeding was identified. The patient was treated by ileocecectomy and the final diagnosis was of an arteriovenous malformation confined to the terminal ileum. He has been followed-up without a further hemorrhagic episode.
doi:10.3346/jkms.2007.22.4.746
PMCID: PMC2693832  PMID: 17728522
Congenital; Arteriovenous Malformation; Ileum; Varix; Bleeding

Results 1-17 (17)