Changing trends and characteristics of peptic ulcer disease:A multicenter study from 2010 to 2019 in Korea

BACKGROUND The clinical trend and characteristics of peptic ulcer disease(PUD)have not fully been investigated in the past decade.AIM To evaluate the changing trends and characteristics of PUD according to age and METHODS We analyzed seven hospital databases converted into the Observational Medical Outcomes Partnership-Common Data Model between 2010 and 2019.We classified patients with PUD who underwent rapid urease tests or Helicobacter pylori(H.pylori)serology into three groups:H.pylori-related,drug[nonsteroidal anti-inflammatory drugs(NSAIDs)or aspirin]-related,and idiopathic(H.pylori/NSAID/aspirin-negative)PUD and compared the yearly trends and characteristics among the three groups.RESULTS We included 26785 patients in 7 databases,and the proportion of old age(≥65 years)was 38.8%.The overall number of PUD exhibited no decrease,whereas PUD in old age revealed an increasing trend(P=0.01 for trend).Of the 19601 patients,41.8%had H.pylori-related,36.1%had drug-related,and 22.1%had idiopathic PUD.H.pylorirelated PUD exhibited a decreasing trend after 2014(P=0.01),drug-related PUD demonstrated an increasing trend(P=0.04),and idiopathic PUD showed an increasing trend in the old-age group(P=0.01)during 10 years.Patients with drug-related PUD had significantly more comorbidities and concomitant ulcerogenic drugs.The idiopathic PUD group had a significantly higher number of patients with chronic liver disease.CONCLUSION With the aging population increase,the effects of concomitant ulcerogenic drugs and preventive strategies should be investigated in drug-induced PUD.Further studies are required to clarify the relationship between idiopathic PUD and chronic liver disease.

Successful resolution of gastric perforation caused by a severe complication of pancreatic walled-off necrosis:A case report

BACKGROUND Pancreatic walled-off necrosis(WON)rarely causes critical gastric necrosis and perforation,which may develop when pancreatic WON squashes against the stomach.The Atlanta 2012 guidelines were introduced for acute pancreatitis and its related clinical entities.However,there are few reported cases describing the clinical course and resolution of pancreatic WON.CASE SUMMARY We report the case of a 45-year-old man who presented to the urgent emergency department with gastric perforation caused by a severe complication of pancreatic WON on computed tomography.The patient underwent an emergency distal pancreatectomy,splenectomy,and gastric wedge resection.Postoperative findings showed re-perforation of the gastric wall at a previously resected margin.Furthermore,endoscopic examination revealed an ulcerative area with a defect in the fundus.After diagnostic endoscopy,endoscopic vacuum-assisted closure was performed,and continuous suction was transferred over all tissues in contact with the sponge surface.The patient recovered without any further complications and was discharged in good condition at postoperative week 8.No recurrence occurred during the 6-mo follow-up period.CONCLUSION When managing a patient with serious gastric perforation complicated by pancreatic WON,a multidisciplinary treatment approach should be considered.

New magnifying endoscopic classification for superficial esophageal squamous cell carcinoma

AIM To assess the accuracy of a new magnifying endoscopy(ME)classification for predicting depth of invasion of superficial esophageal squamous cell carcinoma(SESCC).METHODS This study included a total of 70 lesions in 69 patients with SESCC who underwent ME with narrow-band imaging(ME-NBI)before resection from August 2010 to July 2016.Accuracy of ME-NBI for predicting depth of invasion of SESCC was analyzed by using a new ME classification proposed by the Japan Esophageal Society(JES),and interobserver agreement was assessed.RESULTS Overall accuracy of ME-NBI for estimating depth of invasion of SESCC was 78.6%.Sensitivity and specificity of type B1 for tumors limited to the epithelial layer(m1)or invading into the lamina propria(m2)were 71.4%and 100%,respectively.Sensitivity and specificity of type B2 for tumors invading into the muscularis mucosa(m3)or superficial submucosa(≤200μm,sm1)were94.4%and 73.1%,respectively,while those of type B3for tumors invading into the deep submucosa(>200μm,sm2)were 75.0%and 97.8%,respectively.Interobserver agreement was excellent(κ=0.86,95%CI:0.76-0.95).CONCLUSION The recently developed JES ME classification is useful for predicting depth of invasion of SESCC,with reliable interobserver agreement.

Acute distal common bile duct angle is risk factor for postendoscopic retrograde cholangiopancreatography pancreatitis in beginner endoscopist

BACKGROUND Post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)is a critical and poorly managed complication of ERCP.Endoscopists need to understand the risk factors for PEP.However,the majority of studies investigating ERCP-related risk factors have included well-trained endoscopists,with the issue of endoscopist experience on PEP incidence not having been systematically evaluated.AIM To explore the risk factors for PEP in beginner endoscopists without supervision.METHODS We performed a retrospective analysis of 293 patients,with naïve papilla and no history of pancreatitis,treated using bile duct cannulation.Patients were classified according to the endoscopist’s experience(beginner vs expert).The angle of the distal common bile duct(CBD)was measured as the angle between the lower wall of the bile duct and a vertical line extending to the lower wall of the bile duct on coronal view computed tomography.RESULTS After propensity matching,there were no differences between patients treated by the expert and beginner endoscopist with regard to age,sex,mean bile duct dilatation,and ratio of benign disease.The distal CBD angle was classified as acute(>30º)or obtuse(≤30º),based on the mean angle of 29.9ºfor the group.An acute distal CBD angle was a significant risk factor for PEP for beginner(P=0.049),but not expert.CONCLUSION For beginner endoscopists first performing unsupervised ERCP,cases with an obtuse distal CBD angle may be more appropriate to lower the risk of PEP.

Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis:Importance of the endoscopist’s expertise level

BACKGROUND Needle-knife fistulotomy(NKF)is used as a rescue technique for difficult cannulation.However,the data are limited regarding the use of NKF for primary biliary cannulation,especially when performed by beginners.AIM To assess the effectiveness and safety of primary NKF for biliary cannulation,and the role of the endoscopist’s expertise level(beginner vs expert).METHODS We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis,who underwent bile duct cannulation at a tertiary referral center.The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation.We assessed the rates of successful cannulation and adverse events.RESULTS The baseline characteristics did not differ between the experienced and lessexperienced endoscopists.The incidence rate of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy(8.9%vs 3.4%for beginner vs expert,P=0.039),but not in those who received NKF.In the multivariable analysis,a lower expertise level of the biliary endoscopist(P=0.037)and longer total procedure time(P=0.026)were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time(P=0.004)was significant risk factor of PEP in those who received NKF.CONCLUSION Primary NKF was effective and safe in patients with prominent and bulging ampulla,even when performed by less-experienced endoscopist.We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.