Publications by authors named "Jeong-Sik Byeon"

301 Publications

Efficacy and Safety of TJP-008 Compared to 2 L PEG with Ascorbate in Colon Cleansing: A Randomized Phase 3 Trial.

Gut Liver 2021 Nov 23. Epub 2021 Nov 23.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Background/aims: Polyethylene glycol (PEG)-based bowel preparations are effective cleansing agents for colonoscopy. However, they require relatively large volumes to be used even with agents such as 2 L PEG with ascorbate (2LPEG). This phase 3, randomized, single-blinded, multicenter, parallel-group study compared the efficacy of 1 L PEG with high-dose ascorbate, TJP-008, to 2LPEG.

Methods: Patients undergoing colonoscopy were randomized (1:1:1) to receive TJP-008 as 1-day split dose (TJP-008-1) or 2-day split dose (TJP-008-2) regimen or to receive 2LPEG as a 2-day split dose regimen. Cleansing efficacy was evaluated using the Harefield Cleansing Scale. The primary endpoint was overall bowel cleansing success. Full analysis set (FAS) and per protocol set (PPS) analyses were performed.

Results: Of the 314 screened patients, efficacy was assessed in the following patient numbers (FAS/PPS): total (293/285), TJP-008-1 (98/94), TJP-008-2 (97/95), and 2LPEG (98/96). FAS revealed noninferiority between TJP-008 and 2LPEG with regard to overall success (TJP-008-2, 99.0%; TJP-008-1, 95.9%; 2LPEG, 94.9%; p=0.100 and p=0.733, respectively). PPS also showed noninferiority (p=0.721 and p=0.211, respectively). However, the PPS analyses showed a higher bowel cleansing score for TJP-008-2 for high-quality cleansing in the right colon (TJP-008-2 83.2% vs 2LPEG 62.5%; p=0.005).

Conclusions: TJP-008 is a new low-volume cleansing agent with a colon cleansing efficacy comparable to that of standard 2LPEG that exhibits significant safety and tolerability.
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http://dx.doi.org/10.5009/gnl210092DOI Listing
November 2021

Insufficient vaccination and inadequate immunization rates among Korean patients with inflammatory bowel diseases.

Medicine (Baltimore) 2021 Nov;100(45):e27714

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Abstract: This study aimed to evaluate self-reported vaccination rates, immunity, knowledge of and attitudes toward vaccination among Korean patients with inflammatory bowel disease (IBD) as well as to identify factors associated with proper vaccination.Between November 2013 and February 2015, consecutive patients with IBD were invited to complete a standardized questionnaire on vaccination. Moreover, immune status for common vaccine-preventable diseases was evaluated via serologic tests.A total of 310 patients with IBD were invited to the questionnaire survey and 287 patients (92.6%) who completed the questionnaires were finally enrolled (men, 188 [65.5%], median age at survey, 29.9 years [interquartile range, 22.3-39.2], ulcerative colitis: Crohn disease = 165:122]. Self-reported vaccine uptake rates were as follows: hepatitis A virus (HAV; 13.2%), hepatitis B virus (HBV; 35.2%), seasonal influenza (43.2%), pneumococcus (4.9%). Most of the patients (87.1%) did not know that proper vaccination has been recommended for patients with IBD. Up to 64.8% and 32.8% of patients were negative for IgG anti-HAV antibody and IgG HBV surface antibody, respectively. In a multivariable analysis, newspaper subscription (aOR [adjusted odds ratio] 2.185, 95% confidence interval [CI] 1.136-4.203, P = .019), ever recommendation of vaccination by a physician (aOR 2.456, 95% CI 1.240-4.862, P = .010), and use of anti-tumor necrosis factor agents (aOR 4.966, 95% CI 1.098-22.464, P = .037) showed a significant association with uptake of adult vaccines recommended for patients with IBD.Vaccine uptake rates, positivity of antibody to HAV and HBV, and knowledge of patients with IBD regarding vaccination were not sufficient. Proper educational information and recommendation from physicians could enhance awareness among patients with IBD about the need for vaccination and thereby improve vaccination rates.Trial registration number: NCT01984879.
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http://dx.doi.org/10.1097/MD.0000000000027714DOI Listing
November 2021

Risk and characteristics of tuberculosis after anti-tumor necrosis factor therapy for inflammatory bowel disease: a hospital-based cohort study from Korea.

BMC Gastroenterol 2021 Oct 20;21(1):390. Epub 2021 Oct 20.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.

Background: Anti-tumor necrosis factor (TNF) treatment for inflammatory bowel disease (IBD) increases the risk of tuberculosis (TB) infection. In the present study, we analyzed the clinical characteristics and risks of TB in Korean patients with IBD who received anti-TNF treatment.

Methods: The study included patients with IBD who were treated using anti-TNF agents between January 2001 and June 2018 at the Asan Medical Center. Overall, 1434 patients with ulcerative colitis or Crohn's disease were enrolled. We calculated the incidence of active TB infection after anti-TNF treatment and compared the clinical characteristics of the TB group with those of the non-TB group.

Results: Twenty-one patients (1.46%) developed active TB infection, and the incidence rate of active TB was 366.73 per 100,000 person-years. In total, 198 patients (14.9%) were positive for latent tuberculosis infection (LTBI), of whom only eight (4%) did not complete LTBI treatment. The age at which the anti-TNF therapy was started was significantly higher in the TB group than in the non-TB group (HR 1.041, 95% CI 1.014-1.069, p = 0.002), and as age increased, so did the incidence rate of active TB infection (linearity p < 0.001). There was no significant difference in the incidence rate of LTBI between the TB and non-TB groups (HR 0.896, 95% CI 0.262-3.066, p = 0.862).

Conclusions: In patients with IBD, the incidence rate of TB increased with age at anti-TNF therapy initiation. Active treatment of LTBI may lower the incidence of TB in patients with IBD who are to undergo anti-TNF therapy.
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http://dx.doi.org/10.1186/s12876-021-01973-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527666PMC
October 2021

Efficacy and safety of split-dose bowel preparation with 1 L polyethylene glycol and ascorbate compared with 2 L polyethylene glycol and ascorbate in a Korean population: a phase 4, multicenter, randomized, endoscopist-blinded study.

Gastrointest Endosc 2021 Oct 12. Epub 2021 Oct 12.

Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea. Electronic address:

Background And Aims: The 1-L PEG-based bowel preparation agent NER1006 (Plenvu) has shown high cleansing efficacy and tolerability in clinical trials in Europe and North America. However, no clinical trials have been reported yet in Asia. Therefore, the aim of this study was to evaluate the efficacy and safety of 1L PEG-based bowel preparation with Plenvu compared with 2L PEG plus ascorbate bowel preparation in a Korean population.

Methods: In this multicenter, endoscopist-blinded randomized study, patients at 9 hospitals in South Korea undergoing colonoscopy received either Plenvu or 2L PEG + ascorbate (2L PEG) with split dose. The primary endpoint was overall bowel cleansing success (Boston Bowel Preparation Scale (BBPS) ≥2 for all segmental colon). Secondary endpoints included high-quality bowel cleansing success (overall: BBPS = 9; segmental colon: BPPS = 3), the polyp detection rate (PDR), and adenoma detection rate (ADR).

Results: Out of 360 included patients, cleansing efficacy was analyzed in 346 (Plenvu, n=174; 2L PEG, n=172). The Plenvu group showed noninferior bowel cleansing success rates compared with 2L PEG (93.10% vs 91.86%, difference, 1.24%; 1-sided 97.5% lower confidence limit, -4.31%; P < .0001; P = 0.661). The Plenvu group had higher high-quality bowel cleansing success rates for overall and right colon segment than the 2L PEG group (49.43% vs 37.79%, p=0.029 and 60.92% vs 48.84%, p=0.024, respectively). The PDR was greater with Plenvu than with 2L PEG (48.85% vs 37.79%, p=0.038). However, ADR did not differ between the 2 groups (24.71% vs 20.35%, p=0.331). Although the treatment-emergent adverse events (TEAE) were slightly higher in the Plenvu than the 2L PEG group (65.71% vs 52.91%, p=0.015), the majority of TEAEs were mild (85.55%) and most patients recovered without any management (99.23%).

Conclusion: Plenvu showed noninferior overall bowel cleansing success rates to 2L PEG, but greater high-quality bowel cleansing in overall and right colon which might help improve the PDR in the Asian population.
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http://dx.doi.org/10.1016/j.gie.2021.09.041DOI Listing
October 2021

A Surveillance Endoscopy Strategy Based on Local Recurrence Rates after Colorectal Endoscopic Submucosal Dissection.

J Clin Med 2021 Oct 5;10(19). Epub 2021 Oct 5.

Asan Medical Center, Department of Gastroenterology, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.

Backgrounds: It is not clear when and how frequently surveillance endoscopy should be performed after colorectal endoscopic submucosal dissection (ESD). We aimed to suggest a surveillance endoscopy strategy by investigating the cumulative local recurrence rates and identifying risk factors for local recurrence after colorectal ESD.

Methods: We reviewed the medical records of 770 patients who underwent colorectal ESD for 778 lesions at our institution from 2005 to 2016. We investigated the cumulative local recurrence rates and risk factors for local recurrence.

Results: Local recurrence developed in 12 (1.5%) of 778 lesions during the follow-up period of 37.4 ± 31.7 months. The one-, three-, and five-year cumulative local recurrence rates were 0.4%, 1.7%, and 2.2%, respectively. The risk factors for local recurrence were piecemeal resection (odds ratio (OR) 3.948, 95% confidence interval (CI) 1.164-13.385; = 0.028) and histological incomplete resection (OR 8.713, 95% CI 2.588-29.334; < 0.001). Local recurrence tended to develop frequently after ESD of early cancers.

Conclusions: Short-term surveillance endoscopy should be recommended after piecemeal ESD, histological incomplete resection, and ESD of early colorectal cancers. Surveillance endoscopy with longer intervals can be suggested after en bloc ESD with the histological complete resection of benign colorectal tumors.
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http://dx.doi.org/10.3390/jcm10194591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509179PMC
October 2021

Sessile serrated lesions in patients with adenoma on index colonoscopy do not increase metachronous advanced adenoma risk.

Dig Endosc 2021 Oct 5. Epub 2021 Oct 5.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Objectives: Post-polypectomy surveillance intervals should be determined based on index colonoscopy findings. However, the risk of metachronous lesions, resulting from the coexistence of adenoma and sessile serrated lesions (SSLs), has rarely been addressed. We evaluated the impact of synchronous SSL on the risk of metachronous lesions within similar adenoma risk groups.

Methods: We retrieved individuals with one or more adenomas on index colonoscopy in a single-center retrospective cohort and stratified them into four groups depending on the presence of SSL and low-risk/high-risk adenoma (LRA/HRA). Participants who underwent surveillance colonoscopies at least 12 months apart were included. We compared the risks of metachronous lesions including HRA, advanced adenoma (AA), or SSL within similar adenoma risk groups according to the presence of SSL.

Results: Overall 4493 individuals were included in the analysis. The risk of metachronous HRA/AA was not significantly higher in the adenoma with SSL group compared with the adenoma without SSL group, irrespective of LRA (HRA, 6/86 vs. 231/3297, P = 1.00; AA, 0/86 vs. 52/3297, P = 0.64) or HRA (HRA, 11/64 vs. 240/1046, P = 0.36; AA, 3/64 vs. 51/1046, P = 1.00). However, the risk of metachronous SSL in individuals with synchronous SSL was higher than that in those without SSL for both LRA (15/86 vs. 161/3297, P < 0.001) and HRA groups (11/64 vs. 61/1046, P = 0.002).

Conclusion: The presence of synchronous SSL did not increase the risk of metachronous HRA/AA, compared with isolated adenoma, but increased the risk of metachronous SSL.
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http://dx.doi.org/10.1111/den.14159DOI Listing
October 2021

Short-term tolerability and effectiveness of methotrexate monotherapy in adult patients with Crohn's disease: a retrospective study.

Therap Adv Gastroenterol 2021 13;14:17562848211043017. Epub 2021 Sep 13.

Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.

Introduction: Immunomodulators remain fundamental for the medical treatment of Crohn's disease (CD). Methotrexate (MTX) is widely used as a second-line immunomodulator; however, there is a lack of recent data on MTX monotherapy among the Asian population with CD. Therefore, in this study, we aimed to investigate the tolerability and clinical outcomes of MTX in Korean patients with CD.

Methods: A retrospective chart review was performed for CD patients treated with MTX monotherapy or in combination with 5-aminosalicylic acid (5-ASA), at the Asan Medical Center, Seoul, South Korea. The tolerability of MTX monotherapy within 6 months was assessed and the clinical effectiveness of MTX was evaluated based on the Crohn's disease activity index (CDAI).

Results: In total, 85 patients were included, of which 29 (34.1%) discontinued MTX due to intolerability during the follow-up. Adverse events (AEs) were reported in 41 (48.2%) patients. The most common AE was gastrointestinal disorders (17/41) and only one patient experienced a serious AE, a systemic infection that required hospitalization. Among the 56 patients who tolerated MTX within 6 months, 44 (65.9%) showed a clinical response. Moreover, no factor was significantly associated with intolerability. The administration method was the only factor significantly associated with a response to MTX ( = 0.041). The adjusted odds ratio of parenteral injection compared to oral administration was 5.68 (95% confidence interval (CI), 1.07-30.08).

Conclusion: In this study, one-third of patients were intolerant to MTX; nonetheless, the response rate was as high as 65.9% among tolerant patients. In addition, no significant factors affected intolerability. In terms of the clinical response, parenteral injection could be better than oral administration.
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http://dx.doi.org/10.1177/17562848211043017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442506PMC
September 2021

Seroprevalence of viral infectious diseases and associated factors in Korean patients with inflammatory bowel diseases.

Korean J Intern Med 2021 Sep 6. Epub 2021 Sep 6.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background/aims: Data on the immunoprotective status against measles, mumps, rubella, varicella zoster virus (VZV), hepatitis A virus (HAV), and Epstein-Barr virus (EBV) infection in patients with inflammatory bowel disease (IBD) are still lacking. Therefore, we investigated the seropositivity rates for viral infectious diseases and the associated factors in Korean patients with IBD.

Methods: In this retrospective cohort study, serum immunoglobulin G antibody positivity rates against measles virus, mumps virus, rubella virus, VZV, HAV, and EBV viral capsid antigen (VCA) were measured in patients with Crohn's disease or ulcerative colitis (UC) who first visited the IBD clinic. Seropositivity rates and their associated factors were analyzed.

Results: Between January 2016 and December 2018, 263 patients were enrolled (male, 167 [67.3%]; UC, 134 [50.9%]). The median age at serological test was 30 years (interquartile range, 22 to 46). The seropositivity rates were 84.0%, 85.2%, 66.5%, 87.4%, 50.0%, and 93.7% for measles, mumps, rubella, VZV, HAV, and EBV, respectively. Younger age at serological test was associated with seronegative status for measles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.88 to 0.96), VZV (aOR, 0.83; 95% CI, 0.74 to 0.93), and HAV (aOR, 0.93; 95% CI, 0.91 to 0.95). Furthermore, IBD type-UC was associated with seronegative status against VZV (aOR, 0.33; 95% CI, 0.11 to 0.99).

Conclusions: Seropositivity rates for common viral infectious diseases in Korean patients with IBD were similar to those of the general population. In the younger age group, protective immunity against measles, VZV, and HAV is required, with proper vaccination, as necessary.
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http://dx.doi.org/10.3904/kjim.2020.386DOI Listing
September 2021

[Clinical and Technical Guideline for Endoscopic Ultrasound-guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy].

Korean J Gastroenterol 2021 08;78(2):73-93

Department of Internal Medicine, Cha University Bundang Medical Center, Cha University, Seongnam, Korea.

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence- based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.
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http://dx.doi.org/10.4166/kjg.2021.057DOI Listing
August 2021

Biomolecular imaging of colorectal tumor lesions using a FITC-labeled scFv-Cκ fragment antibody.

Sci Rep 2021 08 25;11(1):17155. Epub 2021 Aug 25.

Edisbiotech, Songpa-gu, Seoul, Republic of Korea.

For the sensitive diagnosis of colorectal cancer lesions, advanced molecular imaging techniques using cancer-specific targets have emerged. However, issues regarding the clearance of unbound probes and immunogenicity remain unresolved. To overcome these limitations, we developed a small-sized scFv antibody fragment conjugated with FITC for the real-time detection of colorectal cancer by in vivo molecular endoscopy imaging. A small-sized scFv fragment can target colon cancer secreted protein-2 (CCSP-2), highly expressed in colorectal adenocarcinoma tissues; moreover, its full-length IgG probe has been used for molecular imaging previously. To assess the efficacy of anti-CCSP-2 scFv-FITC, surgical specimens were obtained from 21 patients with colorectal cancer for ex vivo molecular fluorescence analysis, histology, and immunohistochemistry. Orthotopic mice were administered with anti-CCSP-2 scFv-FITC topically and intravenously, and distinct tumor lesions were observed by real-time fluorescence colonoscopy. The fluorescence imaging of human colon cancer specimens allowed the differentiation of malignant tissues from non-malignant tissues (p < 0.05), and the CCSP-2 expression level was found to be correlated with the fluorescence intensity. Here, we demonstrated the feasibility and safety of anti-CCSP-2 scFv-FITC for molecular imaging as well as its potential in real-time fluorescence colonoscopy for the differential diagnosis of tumor lesions.
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http://dx.doi.org/10.1038/s41598-021-96281-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387423PMC
August 2021

The Influence of Face Shields on the Quality of Colonoscopy in the Era of the COVID-19 Pandemic.

Gut Liver 2021 Aug 25. Epub 2021 Aug 25.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background/aims: The worldwide coronavirus disease 2019 pandemic has led endoscopists to use personal protective equipment (PPE) for infection prevention. This study aimed to investigate whether wearing a face shield as PPE affects the quality of colonoscopy.

Methods: We reviewed the medical records and colonoscopy findings of patients who underwent colonoscopies at Asan Medical Center, Korea from March 10 to May 31, 2020. The colonoscopies in this study were performed by five gastroenterology fellows and four expert endoscopists. We compared colonoscopy quality indicators, such as withdrawal time, adenoma detection rate (ADR), mean number of adenomas per colonoscopy (APC), polypectomy time, and polypectomy adverse events, both before and after face shields were added as PPE on April 13, 2020.

Results: Of the 1,344 colonoscopies analyzed, 715 and 629 were performed before and after the introduction of face shields, respectively. The median withdrawal time was similar between the face shield and no-face shield groups (8.72 minutes vs 8.68 minutes, p=0.816), as was the ADR (41.5% vs 39.8%, p=0.605) and APC (0.72 vs 0.77, p=0.510). Polypectomy-associated quality indicators, such as polypectomy time and polypectomy adverse events were also not different between the groups. Quality indicators were not different between the face shield and no-face shield groups of gastroenterology fellows, or of expert endoscopists.

Conclusions: Colonoscopy performance was not unfavorably affected by the use of a face shield. PPE, including face shields, can be recommended without a concern about colonoscopy quality deterioration.
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http://dx.doi.org/10.5009/gnl210063DOI Listing
August 2021

The Clinical Features of Inflammatory Bowel Disease in Patients with Obesity.

Can J Gastroenterol Hepatol 2021 2;2021:9981482. Epub 2021 Aug 2.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Methods: We retrospectively reviewed the medical records of IBD patients who visited Asan Medical center. We used a large, well-characterized referral center-based cohort. The clinical features of IBD patients with body mass index (BMI) over 30 and matched controls with BMI under 30 were compared.

Results: Among the 6,803 IBD patients enrolled in the Asan IBD Registry between June 1989 and December 2016, we identified 16 patients with Crohn's disease (CD) and 27 patients with ulcerative colitis (UC) whose BMI was over 30 at the time of diagnosis. Their clinical characteristics and course were compared with those of 64 and 108 matched patients with CD and UC, respectively. There were no significant differences in the risk of using steroids (hazards ratio (HR) = 0.633 and =0.254), immunomodulators (HR = 0.831 and =0.517), and anti-tumor necrosis factor (TNF) therapy (HR = 1.539 and =0.351) and risk of bowel resections (HR = 1.858 and =0.231) between CD patients with BMI over 30 and those with BMI under 30; similarly, UC patients did not show significant differences in the risk of using steroids (HR = 0.613 and =0.145), immunomodulators (HR = 0.492 and =0.111), anti-TNF therapy (HR = 0.385 and =0.095), and risk of colectomy (HR = 0.262 and =0.104). In the subgroup analysis, under-weight UC patients had a higher cumulative probability of needing steroids (HR = 0.2510 and =0.042), needing immunomodulators (HR = 0.097 and =0.014), and a higher risk of receiving colectomy (HR = 0.024 and =0.019) than obese UC patients.

Conclusions: Obese IBD patients with CD or UC did not show significantly different clinical features from nonobese IBD patients.
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http://dx.doi.org/10.1155/2021/9981482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352714PMC
October 2021

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections.

Clin Endosc 2021 Jul 27;54(4):505-521. Epub 2021 Jul 27.

Division of Gastroenterology, Department of Internal Medicine, Cha University Bundang Medical Center, Seongnam, Korea.

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.
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http://dx.doi.org/10.5946/ce.2021.185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357592PMC
July 2021

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections.

Gut Liver 2021 09;15(5):677-693

Division of Gastroenterology, Department of Internal Medicine, CHA University Bundang Medical Center, Seongnam, Korea.

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.
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http://dx.doi.org/10.5009/gnl210001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8444102PMC
September 2021

High Risk of Fractures Within 7 Years of Diagnosis in Asian Patients With Inflammatory Bowel Diseases.

Clin Gastroenterol Hepatol 2021 Jun 30. Epub 2021 Jun 30.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Electronic address:

Background & Aims: In this nationwide population-based study, we investigated the risk of vertebral and hip fractures in patients with inflammatory bowel disease (IBD).

Methods: Using data from the Korean National Health Insurance claims database gathered between 2007 and 2016, we calculated the incidence rate ratios (IRRs) of vertebral and hip fractures in patients with newly diagnosed IBD (n = 18,228; 64.1% male, 65.9% ulcerative colitis) compared with an age- and sex-matched control population (matching ratio, 1:10; n = 186,871).

Results: During a median follow-up period of 4.5 years, the incidence rate and IRR of vertebral and hip fractures in patients with IBD were 2.88 per 1000 person-years and 1.24 (95% CI, 1.08-1.42), respectively. The cumulative risk of vertebral and hip fractures in IBD patients was 0.6%, 1.4%, and 1.9% at 2, 5, and 7 years after diagnosis, respectively, and this risk of fracture in IBD patients was higher than that in matched controls (P = .002). The use of corticosteroids further increased the risk of fractures in IBD patients (IRR, 1.37; 95% CI, 1.13-1.65) compared with matched controls. The risk of fractures was significantly higher in patients with Crohn's disease (CD) (IRR, 1.56; 95% CI, 1.19-2.04) than in matched controls, and this risk remained higher in patients with CD without corticosteroid exposure (IRR, 1.62; 95% CI, 1.12-2.34). The risk of fracture increased with age and was particularly high in females and in those with comorbidities.

Conclusions: The risk of fractures was significantly high in newly diagnosed IBD patients, especially in those with CD regardless of corticosteroid exposure.
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http://dx.doi.org/10.1016/j.cgh.2021.06.026DOI Listing
June 2021

[Colonic Mass Secondary to Sevelamer-associated Rectal Ulcer].

Korean J Gastroenterol 2021 06;77(6):305-308

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

The phosphorous balance is clinically important in increasing the long-term outcomes and preventing complications of end-stage renal disease. Sevelamer is a phosphate binder used widely to regulate hyperphosphatemia. On the other hand, gastrointestinal side effects increase with increasing sevelamer intake. A 29-year-old male with end-stage renal disease of IgA nephropathy on maintenance hemodialysis was admitted for diffuse alveolar bleeding and pneumonia. He presented with a low-grade fever and watery diarrhea tinged with blood. Initially, a -associated diarrhea treatment was started with positive findings of toxin and culture. Despite this, there was no improvement in the symptoms even with the appropriate antibiotic treatment. Computed tomography of the abdomen and pelvis revealed an occlusive mass in the rectum and secondary obstructive changes in the sigmoid colon. The initial suspicion was a malignancy or fungal infection. Sigmoidoscopy with a biopsy identified the mass as a lump of mucous material with the entire lumen covered with exudate. The subsequent histopathology examination revealed a colonic mucosal injury and characteristic "fish scale"-like sevelamer crystals in the exudate. The diagnosis of a sevelamer-induced rectal ulcer was made. We report this case of a sevelamer-associated rectal ulcer of the sigmoid.
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http://dx.doi.org/10.4166/kjg.2021.037DOI Listing
June 2021

Anchoring the snare tip is a feasible endoscopic mucosal resection method for small rectal neuroendocrine tumors.

Sci Rep 2021 06 21;11(1):12918. Epub 2021 Jun 21.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.

Small rectal neuroendocrine tumors (NETs) can be treated using cap-assisted endoscopic mucosal resection (EMR-C), which requires additional effort to apply a dedicated cap and snare. We aimed to evaluate the feasibility of a simpler modified endoscopic mucosal resection (EMR) technique, so-called anchored snare-tip EMR (ASEMR), for the treatment of small rectal NETs, comparing it with EMR-C. We retrospectively evaluated 45 ASEMR and 41 EMR-C procedures attempted on small suspected or established rectal NETs between July 2015 and May 2020. The mean (SD) lesion size was 5.4 (2.2) mm and 5.2 (1.7) mm in the ASEMR and EMR-C groups, respectively (p = 0.558). The en bloc resection rates of suspected or established rectal NETs were 95.6% (43/45) and 100%, respectively (p = 0.271). The rates of histologic complete resection of rectal NETs were 94.1% (32/34) and 88.2% (30/34), respectively (p = 0.673). The mean procedure time was significantly shorter in the ASEMR group than in the EMR-C group (3.12 [1.97] vs. 4.13 [1.59] min, p = 0.024). Delayed bleeding occurred in 6.7% (3/45) and 2.4% (1/41) of patients, respectively (p = 0.618). In conclusion, ASEMR was less time-consuming than EMR-C, and showed similar efficacy and safety profiles. ASEMR is a feasible treatment option for small rectal NETs.
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http://dx.doi.org/10.1038/s41598-021-92462-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217176PMC
June 2021

Frequency of Positive Conversion of Interferon-Gamma Release Assay Results Among Patients With Inflammatory Bowel Disease Treated With Non-tumor Necrosis Factor Inhibitors.

Front Med (Lausanne) 2021 21;8:670242. Epub 2021 May 21.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Considering the risk of reactivation of latent tuberculosis infection (LTBI), not only before starting tumor necrosis factor inhibitors but also before non-TNF inhibitor therapy, LTBI screening is routinely recommended for patients with inflammatory bowel disease (IBD). However, data on the positive conversion of LTBI test results during non-TNF inhibitor therapy are scarce. Among IBD patients treated with vedolizumab and/or ustekinumab, a total of 91 patients who had negative baseline interferon-gamma release assay (IGRA) results, assessed by QuantiFERON-TB Gold In-tube or QuantiFERON-TB Gold Plus, were enrolled. Serial LTBI test results after starting non-TNF inhibitor therapy were collected, and patients' clinical characteristics were analyzed. Positive IGRA conversion was observed in six of 91 patients (6.6%). The cumulative IGRA conversion-free survival rates after starting therapy were 97.7% after 1 year and 86.7% after 2 years. Ulcerative colitis was more common among converters compared with non-converters (66.7 vs. 23.5%, = 0.040). Among six converters, four had been treated with vedolizumab, one with ustekinumab, and the other with vedolizumab followed by ustekinumab. All six patients had been previously exposed to TNF inhibitors before non-TNF inhibitor therapy: five to infliximab and one to both infliximab and adalimumab. After positive IGRA conversion, none of the six converters developed active tuberculosis while maintaining non-TNF inhibitor therapy (median 6.8 months, range 0.4-32.1 months). Positive IGRA conversion among IBD patients treated with vedolizumab and/or ustekinumab appears to occur somewhat frequently, but its clinical implications remain to be elucidated.
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http://dx.doi.org/10.3389/fmed.2021.670242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175966PMC
May 2021

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn's disease.

World J Gastroenterol 2021 May;27(19):2353-2365

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea.

Background: Acute severe lower gastrointestinal bleeding (LGIB) is an uncommon but challenging complication of Crohn's disease (CD).

Aim: To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.

Methods: A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center, a tertiary university hospital in Korea. Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB. A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.

Results: Multivariable Cox regression analysis revealed that early use of thiopurines [hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.48; 0.001] and female sex (HR: 0.51, 95%CI: 0.27-0.94; 0.031) were significantly associated with a lower risk of acute severe LGIB. The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups ( 0.139 and 0.769, respectively). The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group (22.1/100 13.2/100 patient-years; = 0.012). However, if hospitalizations due to bleeding episodes were excluded from the analysis, the hospitalization rate was not significantly different between the bleeding group and the matched non-bleeding group (14.5/100 13.2/100 patient-years; = 0.631).

Conclusion: Early use of thiopurines may reduce the risk of acute severe LGIB. History of acute severe LGIB may not have a significant prognostic value in patients with CD.
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http://dx.doi.org/10.3748/wjg.v27.i19.2353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130046PMC
May 2021

Oncological outcomes according to the treatment modality based on the size of rectal neuroendocrine tumors: a single-center retrospective study.

Surg Endosc 2021 May 19. Epub 2021 May 19.

Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

Background: Owing to an increased number of colonoscopy screenings, the incidence of diagnosed rectal neuroendocrine tumors (NETs) has also increased. Tumor size is one of the most frequently regarded factors when selecting treatment; however, it may not be the determinant prognostic variable. We aimed to evaluate oncological outcomes according to the treatment modality based on the size of rectal NETs.

Methods: A retrospective analysis was performed on patients who were treated for rectal NETs between March 2000 and January 2016 at the Asan Medical Center, Seoul, Korea. Patients who underwent endoscopic removal, local surgical excision, and radical resection were included. The primary outcome was recurrence-free survival (RFS). Data were specified and analyzed following the 2019 World Health Organization classification (WHO).

Results: A total of 644 patients were categorized under three groups according to the treatment modality used: endoscopic removal (n = 567), surgical local excision (n = 56), and radical resection (n = 21). Of a total of 35 recurrences, 27 were local, whereas eight were distant. The RFS rate did not differ significantly between the treatment groups in the same tumor-size group ([Formula: see text]1 cm group: P = .636, 1-2 cm group: P = .160). For T1 tumors, RFS rate was not different between local excision and radical resection ([Formula: see text]1 cm group: P = .452, 1-2 cm group: P = .700). Depth of invasion, a high Ki-67 index, and margin involvement were confirmed as independent risk factors for recurrence. Among patients treated with endoscopic removal, endoscopic biopsy was a significant factor for worse RFS (P < .001), while tumor size did not affect the RFS.

Conclusion: The current guideline recommends treatment options according to tumor size. However, more oncologically important prognostic factors include muscularis propria invasion and a higher Ki-67 index.
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http://dx.doi.org/10.1007/s00464-021-08527-6DOI Listing
May 2021

Adherence to Surveillance Guidelines after the Removal of Colorectal Polyps: A Multinational, Multicenter, Prospective Survey.

Gut Liver 2021 11;15(6):878-886

Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Background/aims: As the number of colonoscopies and polypectomies performed continues to increase in many Asian countries, there is a great demand for surveillance colonoscopy. The aim of this study was to investigate the adherence to postpolypectomy surveillance guidelines among physicians in Asia.

Methods: A survey study was performed in seven Asian countries. An email invitation with a link to the survey was sent to participants who were asked to complete the questionnaire consisting of eight clinical scenarios.

Results: Of the 137 doctors invited, 123 (89.8%) provided valid responses. Approximately 50% of the participants adhered to the guidelines regardless of the risk of adenoma, except in the case of tubulovillous adenoma ≥10 mm combined with high-grade dysplasia, in which 35% of the participants adhered to the guidelines. The participants were stratified according to the number of colonoscopies performed: ≥20 colonoscopies per month (high volume group) and <20 colonoscopies per month (low volume group). Higher adherence to the postpolypectomy surveillance guidelines was evident in the high volume group (60%) than in the low volume group (25%). The reasons for nonadherence included concern of missed polyps (59%), the low cost of colonoscopy (26%), concern of incomplete resection (25%), and concern of medical liability (15%).

Conclusions: A discrepancy between clinical practice and surveillance guidelines among physicians in Asia was found. Physicians in the low volume group frequently did not adhere to the guidelines, suggesting a need for continuing education and appropriate control. Concerns regarding the quality of colonoscopy and complete polypectomy were the main reasons for nonadherence.
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http://dx.doi.org/10.5009/gnl20166DOI Listing
November 2021

Comparison of outcomes of cyclosporine A and infliximab for steroid-refractory acute severe ulcerative colitis.

J Gastroenterol Hepatol 2021 Sep 18;36(9):2463-2470. Epub 2021 Apr 18.

Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.

Background And Aim: Data comparing the outcomes of cyclosporin A (CsA) and infliximab (IFX) as rescue therapy for steroid-refractory acute severe ulcerative colitis (SR-ASUC) among Asians are scarce.

Methods: In this single-center study, we retrospectively reviewed 121 patients with SR-ASUC according to the Truelove and Witts' criteria who received CsA or IFX as rescue therapy between 1995 and 2015. The cumulative rates of treatment failure and colectomy at 3 months were compared. Treatment failure was defined as colectomy, switch to other medications, acute flare-up events requiring steroid treatment, or adverse events leading to drug interruption.

Results: Among 121 patients with SR-ASUC (male, 55.6%; median disease duration, 47.1 months; extensive colitis, 61.2%), 23 received CsA as rescue therapy. Baseline characteristics (e.g. age at diagnosis, sex, disease duration, disease extent at rescue therapy, and Mayo score at treatment initiation) were comparable between the two groups. During follow-up (median, 45 months; interquartile range 29.3-61.8), 84 patients (69.4%) experienced treatment failure, and 25 patients (20.7%) underwent colectomy. The CsA group and the IFX group did not show significant differences in the cumulative rates of treatment failure (39.1% vs 34.7%, P = 0.714) and colectomy (26.1% vs 13.3%, P = 0.198) at 3 months. Previous use of azathioprine (odds ratio [OR] = 2.309, 95% confidence interval [CI] = 1.076-4.951, P = 0.032) was associated with treatment failure at 3 months. Mayo score > 10 at the time of rescue therapy was significantly associated with colectomy at 3 months (OR = 8.444, 95% CI = 2.592-27.506, P < 0.001).

Conclusion: Among Korean patients with SR-ASUC, the rates of treatment failure and colectomy at 3 months were not significantly different between the CSA and the IFX treatment groups.
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http://dx.doi.org/10.1111/jgh.15508DOI Listing
September 2021

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE).

Gut Liver 2021 05;15(3):354-374

Division of Gastroenterology, Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea.

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a task force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.
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http://dx.doi.org/10.5009/gnl20302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129669PMC
May 2021

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE).

Clin Endosc 2021 Mar 24;54(2):161-181. Epub 2021 Mar 24.

Division of Gastroenterology, Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea.

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in 8 categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.
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http://dx.doi.org/10.5946/ce.2021.069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039738PMC
March 2021

Endoscopic features and clinical outcomes of cytomegalovirus gastroenterocolitis in immunocompetent patients.

Sci Rep 2021 03 18;11(1):6284. Epub 2021 Mar 18.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.

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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http://dx.doi.org/10.1038/s41598-021-85845-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973552PMC
March 2021

Risk factors for rebleeding in Crohn's disease patients with acute severe lower gastrointestinal bleeding: With special reference to the role of anti-tumor necrosis factor therapy.

J Gastroenterol Hepatol 2021 Sep 31;36(9):2455-2462. Epub 2021 Mar 31.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Background And Aim: Acute severe lower gastrointestinal bleeding (LGIB) in patients with Crohn's disease (CD) is uncommon; however, it is a potentially life-threatening complication, and its recurrence is common. We thus aimed to identify the predictors for rebleeding in CD patients with acute severe LGIB and particularly focused on whether anti-tumor necrosis factor (TNF) therapy lowers the risk of rebleeding compared with conventional medical therapy (CMT) or surgery.

Methods: The risk of rebleeding was analyzed in 131 CD patients with acute severe LGIB. Patients were classified into the CMT group (n = 99), anti-TNF therapy group (n = 22), and surgery group (n = 10). No patients in the surgery group received anti-TNF therapy.

Results: During the median follow-up of 98 months after the first episode of acute severe LGIB, rebleeding occurred in 50.5%, 18.2%, and 30.0% of the CMT group, anti-TNF therapy group, and surgery group, respectively (P = 0.015). The cumulative risks of rebleeding at 1 and 10 years were 20.0% and 64.7% in the CMT group, 13.6% and 18.4% in the anti-TNF therapy group, and 0% and 40.7% in the surgery group, respectively (P = 0.020). Multivariable Cox regression analysis showed that anti-TNF therapy was associated with a lower risk of rebleeding compared with CMT (hazard ratio, 0.303; 95% confidence interval, 0.108-0.849; P = 0.023).

Conclusions: In CD patients with acute severe LGIB, anti-TNF therapy may reduce the risk of rebleeding compared with CMT. Although surgery is considered effective in preventing early rebleeding, concomitant anti-TNF therapy may be helpful in further lowering the long-term risk of rebleeding.
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http://dx.doi.org/10.1111/jgh.15495DOI Listing
September 2021

Development of Colon Cancer in a Patient with Longstanding Colonic Diffuse Ganglioneuromatosis: A Case Report.

Clin Endosc 2021 Mar 4. Epub 2021 Mar 4.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Colonic diffuse ganglioneuromatosis is an extremely rare disease in which multiple tumors derived from the ganglion cells, nerve fibers, and supporting cells are distributed in the colon. It is generally considered to be a benign neoplastic condition and is occasionally associated with rare hereditary conditions such as neurofibromatosis type I or multiple endocrine neoplasia type 2B. Here, we report a case of a patient in whom colon cancer developed 12 years after the initial diagnosis of colonic diffuse ganglioneuromatosis, which suggests a possible association between colonic diffuse ganglioneuromatosis and colorectal cancer.
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http://dx.doi.org/10.5946/ce.2021.013DOI Listing
March 2021

Key Principles of Clinical Validation, Device Approval, and Insurance Coverage Decisions of Artificial Intelligence.

Korean J Radiol 2021 03;22(3):442-453

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Artificial intelligence (AI) will likely affect various fields of medicine. This article aims to explain the fundamental principles of clinical validation, device approval, and insurance coverage decisions of AI algorithms for medical diagnosis and prediction. Discrimination accuracy of AI algorithms is often evaluated with the Dice similarity coefficient, sensitivity, specificity, and traditional or free-response receiver operating characteristic curves. Calibration accuracy should also be assessed, especially for algorithms that provide probabilities to users. As current AI algorithms have limited generalizability to real-world practice, clinical validation of AI should put it to proper external testing and assisting roles. External testing could adopt diagnostic case-control or diagnostic cohort designs. A diagnostic case-control study evaluates the technical validity/accuracy of AI while the latter tests the clinical validity/accuracy of AI in samples representing target patients in real-world clinical scenarios. Ultimate clinical validation of AI requires evaluations of its impact on patient outcomes, referred to as clinical utility, and for which randomized clinical trials are ideal. Device approval of AI is typically granted with proof of technical validity/accuracy and thus does not intend to directly indicate if AI is beneficial for patient care or if it improves patient outcomes. Neither can it categorically address the issue of limited generalizability of AI. After achieving device approval, it is up to medical professionals to determine if the approved AI algorithms are beneficial for real-world patient care. Insurance coverage decisions generally require a demonstration of clinical utility that the use of AI has improved patient outcomes.
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http://dx.doi.org/10.3348/kjr.2021.0048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909857PMC
March 2021

Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer.

Gastrointest Endosc 2021 08 19;94(2):394-404. Epub 2021 Feb 19.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background And Aims: We aimed to investigate whether endoscopic resection of T1 colorectal cancer (CRC) before surgery (secondary surgery) unfavorably affects long-term recurrence-free survival (RFS) compared with surgery without prior endoscopic resection (primary surgery).

Methods: We reviewed the medical records of patients who underwent radical surgery for T1 CRC with high-risk histologic features at a tertiary referral hospital in Korea between 2011 and 2016. The primary outcome was RFS. We performed 2 types of propensity score (PS) analyses to control for confounders.

Results: Of 852 patients, 388 underwent primary surgery and 464 secondary surgery. During the median follow-up period of 57.0 months (range, 41.0-63.0), cancer recurred in 18 patients (2.1%). The 5-year RFS rates did not differ between the primary and secondary surgery groups (97.0 vs 98.5%, P = .194). Further analyses of RFS rates according to nodal stages and number of high-risk histologic features showed no difference between groups. Moreover, RFS rates were not different between the groups after PS matching. In multivariable Cox proportional regression analysis, baseline serum carcinoembryonic antigen level was an independent risk factor for cancer recurrence (hazard ratio, 1.464; 95% confidence interval, 1.242-1.725; P < .001) but prior endoscopic resection of T1 CRC was not (P = .201). Both PS analyses consistently showed no increase in cancer recurrence risk in the secondary surgery group.

Conclusions: Our data showed no additional cancer recurrence risk by endoscopic resection before surgery of T1 CRC with high-risk histologic features.
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http://dx.doi.org/10.1016/j.gie.2021.02.021DOI Listing
August 2021

Machine learning approach for differentiating cytomegalovirus esophagitis from herpes simplex virus esophagitis.

Sci Rep 2021 02 11;11(1):3672. Epub 2021 Feb 11.

Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505, Republic of Korea.

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.
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http://dx.doi.org/10.1038/s41598-020-78556-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878749PMC
February 2021
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