Objectives Endoscopic submucosal dissection (ESD) has become a standard minimally invasive treatment for selected patients with early gastric cancer (EGC). This study presents the first nationwide survey of patients with EGC treated with ESD in 2023, conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research. Methods Data were retrospectively collected from participating referral centers across Korea using a standardized case report form covering patient characteristics, tumor features, procedural details, histopathological findings, and clinical outcomes. Descriptive and comparative analyses were conducted to summarize nationwide ESD practice patterns and outcomes. Results Data from 5460 ESD cases from 5250 patients across 27 institutions were analyzed. The mean age was 67.4 years, with 74.1% males. Multiple synchronous lesions were identified in 3.7%. Most lesions were located in the lower third of the stomach (64.0%), and differentiated-type adenocarcinomas accounted for 87.8%. The en bloc and complete resection rates were 99.2% and 91.4%, respectively. Curative resection was achieved in 80.5%, whereas local non-curative resection (L-NCR) and surgical non-curative resection (S-NCR) were identified in 2.8% and 16.7%, respectively. Additional surgery was performed more frequently in patients with S-NCR than in those with L-NCR (59.3% vs. 24.7%). The bleeding and perforation rates were 3.6% and 0.9%, respectively, and were mostly managed conservatively or endoscopically. The median length of hospitalization was 4.0 days. Conclusions This first nationwide survey provides a comprehensive overview of the current practice of EGC treatment using ESD in Korea, demonstrating high technical success and safety, and establishing a baseline dataset for future longitudinal research.

Argon plasma coagulation (APC) has been proposed for the treatment of gastric low-grade dysplasia (LGD), but comparative data with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are insufficient. We investigated the clinical outcomes of APC, EMR, and ESD for small gastric LGD. We retrospectively included 2128 patients treated with APC (n = 799), EMR (n = 404), or ESD (n = 925) for gastric LGD ≤ 20 mm at 12 tertiary centers in Korea between 2017 and 2021. Local recurrence and adverse events (AEs) were evaluated. To minimize selection bias, inverse probability of treatment weighting (IPTW) was applied. The overall incidence of AEs was significantly lower in the APC group (0.8

BACKGROUND:Our previous randomized controlled trial reported that Helicobacter pylori eradication reduced the risk of metachronous gastric cancer over a median follow-up of 5.9 years in patients with early gastric cancer (EGC) and improved corpus gastric atrophy (GA) at the specific 3 year follow-up time. This study aimed to evaluate the long-term effects of H. pylori eradication on GA and intestinal metaplasia (IM) at trial closeout. METHODS:Among 470 patients randomized between 2003 and 2013, 327 who were assessed for GA and IM at both baseline and 3-year follow-up time were included in the study. At trial closeout, H. pylori status, GA, and IM were assessed. Main outcomes were improvement in GA and IM at the corpus lesser curvature (LC) according to the H. pylori status at the closeout time. The secondary outcomes included the Operative Link for Gastritis Assessment (OLGA) and Operative Link for Gastric Intestinal Metaplasia assessment (OLGIM) stage improvements. RESULTS:At a median follow-up of 5.9 years (interquartile range: 4.0-8.2 years), an improvement in GA grades at the corpus LC was observed in 88 of the 150 patients (58.7%) in the H. pylori-eradicated group and 31 of the 158 patients (19.6%) in the H. pylori-persistent group (odds ratio [OR] in the H. pylori-eradicated group, 5.81; 95% confidence interval [CI], 3.49-9.68). IM grades showed greater improvement in the H. pylori-eradicated group (42.4% [67/158 patients]) compared with the H. pylori-persistent group (18.6% [31/167 patients]); OR in the eradicated group (3.23; 95% CI, 1.96-5.33). Similarly, the H. pylori-eradicated group exhibited significantly higher rates of improvement in both OLGA (OR 6.48; 95% CI, 3.85-10.91) and OLGIM stages (OR 2.31; 95% CI, 1.42-3.77). CONCLUSIONS:In patients with EGC who have far advanced histologic changes in the background mucosa, H. pylori eradication was associated with a significant improvement in GA and IM.

PURPOSE:The operative link on gastritis assessment (OLGA) and operative link on gastritis assessment based on intestinal metaplasia (OLGIM) are established tools for stratifying the risk of gastric neoplasm development. This study evaluated whether OLGA and OLGIM staging can predict metachronous gastric neoplasms (adenoma or cancer) after endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC) without current Helicobacter pylori infection. MATERIALS AND METHODS:This retrospective cohort study enrolled 494 patients with EGC without current H. pylori infection who underwent ESD between 2004 and 2015. The primary endpoint was the incidence of metachronous gastric neoplasms. High risk was defined as OLGA or OLGIM stage III-IV. RESULTS:Of the included patients, 55.4% (250/451) and 55.9% (276/494) were classified as high risk according to OLGA and OLGIM staging, respectively. During a median follow-up of 6.8 years, the incidence of metachronous gastric neoplasm was 26.6 cases per 1,000 person-years. According to OLGA staging, the high-risk group had a significantly higher incidence of metachronous neoplasms than the low-risk group (33.3 vs. 17.8 cases per 1,000 person-years, log-rank test P=0.012). Similarly, according to OLGIM staging, the high-risk group demonstrated a significantly higher incidence than the low-risk group (35.2 vs. 16.6 cases per 1,000 person-years, P=0.002). CONCLUSIONS:In patients with EGC without current H. pylori infection, OLGA and OLGIM staging are useful for assessing the risk of metachronous gastric. The current 5-year endoscopic surveillance interval after ESD may be further optimized according to patient risk stratified by OLGA or OLGIM stages.

Subepithelial lesions (SELs) of the upper gastrointestinal tract are commonly detected during endoscopic examinations and encompass a broad spectrum of benign and potentially malignant tumors. Although most SELs are asymptomatic and found incidentally, accurate diagnosis remains challenging owing to their subepithelial location, necessitating advanced imaging and tissue acquisition techniques. Endoscopic ultrasonography plays a crucial role in differentiating SELs, although its diagnostic accuracy remains limited. The Korean College of Helicobacter and Upper Gastrointestinal Research has developed evidence-based practice guidelines for the diagnosis and endoscopic treatment of SELs to address the need for standardized clinical management. These guidelines were established through a systematic review of existing literature and expert consensus, resulting in 11 key recommendations for addressing diagnostic strategies, surveillance intervals, biopsy techniques, and indications for endoscopic or surgical resection.

Objectives: The annual incidence of new Helicobacter pylori infections evaluated by serological test in Korean adults has been reported to be 2.1%–3.3%. This study evaluated the rate of new H. pylori infections using the urea breath test (UBT) and the factors associated with new infection.Methods: In this prospective observational study, we recruited participants from the National Cancer Screening Program who tested negative for H. pylori infection by both rapid urease test and histology between November 2007 and December 2014. The participants underwent the UBT to check their follow-up H. pylori infection status from August 2015 to December 2017. The primary outcome of this study was new H. pylori infection.Results: A total of 192 participants were enrolled in this study. During the mean follow-up of 4.1 years from the initial negative tests for H. pylori infection, a new infection occurred in six participants (3.1%, 6/192 participants). According to analyses using the logistic regression model, age (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.02–1.26) and corpus atrophy (OR, 9.83; 95% CI, 1.59–60.98) were associated with the new H. pylori infection in univariate analyses. However, no significant factors were identified in multivariate analysis.Conclusions: New H. pylori infection rarely occurred in Korean adults, with a rate of 3.1%. However, no independent risk factors for new infection were identified.

Objectives:Low-grade gastric adenomas (LGA) are managed using a variety of methods, unlike high-grade adenomas or early gastric cancers, which follow more standardized treatment protocols. This study aimed to assess the current practices and follow-up strategies used by South Korean gastroenterologists in managing LGA. Methods:An online survey was created with Google Forms and distributed to South Korean gastroenterologists via email or paper instructions containing a Quick Response code. Results:A total of 130 South Korean gastroenterologists responded to the survey. The size criteria for endoscopic treatment of LGAs were as follows: size-independent (68.5%), ≥5 mm (13.1%), ≥1 cm (16.2%), ≥1.5 cm (0.8%), and ≥2 cm (1.5%). Treatment decisions, such as performing endoscopic submucosal dissection, were primarily influenced by lesion size (88.5%), endoscopic appearance (62.3%), and location (41.5%). For lesions ≥1.5 cm, 85.3% (n=111) of respondents favored endoscopic submucosal dissection, whereas for lesions ≤1 cm, endoscopic mucosal resection or argon plasma coagulation was preferred. Regarding follow-up endoscopy intervals, most respondents (70.0%) conducted follow-up within 6 months post-endoscopic resection, with subsequent endoscopies at 1-year intervals. Conclusions:This study provides a detailed overview of the current management strategies for LGAs among South Korean gastroenterologists, highlighting the variability in approaches. Further research is required to develop more standardized guidelines for the management and surveillance of LGA.

Background/Aims:The Korean guidelines for Helicobacter pylori treatment were revised in 2020, however, the extent of adherence to these guidelines in clinical practice remains unclear. Herein, we initiated a prospective, nationwide, multicenter registry study in 2021 to evaluate the current management of H. pylori infection in Korea. Methods:This interim report describes the adherence to the revised guidelines and their impact on first-line eradication rates. Data on patient demographics, diagnoses, treatments, and eradication outcomes were collected using a web-based electronic case report form. Results:A total of 7,261 patients from 66 hospitals who received first-line treatment were analyzed. The modified intention-to-treat eradication rate for first-line treatment was 81.0%, with 80.4% of the prescriptions adhering to the revised guidelines. The most commonly prescribed regimen was the 14-day clarithromycin-based triple therapy (CTT; 42.0%), followed by tailored therapy (TT; 21.2%), 7-day CTT (14.1%), and 10-day concomitant therapy (CT; 10.1%). Time-trend analysis demonstrated significant increases in guideline adherence and the use of 10-day CT and TT, along with a decrease in the use of 7-day CTT (all p<0.001). Multivariate logistic regression analysis revealed that guideline adherence was significantly associated with first-line eradication success (odds ratio, 2.03; 95% confidence interval, 1.61 to 2.56; p<0.001). Conclusions:The revised guidelines for the treatment of H. pylori infection have been increasingly adopted in routine clinical practice in Korea, which may have contributed to improved first-line eradication rates. Notably, the 14-day CTT, 10-day CT, and TT regimens are emerging as the preferred first-line treatment options among Korean physicians.

BACKGROUND AND AIMS:Helicobacter pylori (Hp) infection is associated with metachronous gastric cancer (GC) after endoscopic submucosal dissection resection (ESD) in patients with early GC (EGC), but this association has not been well investigated in elderly patients. This study investigated whether Hp infection status was associated with metachronous GC after ESD in patients aged ≥ 75 years. METHODS:This retrospective study involved 298 EGC patients aged ≥ 75 years who underwent ESD. The Hp-negative group (n = 233) included patients with negative or eradicated Hp infection, whereas the Hp-positive group (n = 65) included patients with persistently positive infection or failed eradication. The primary outcome was metachronous GC occurring at ≥ 1 year after ESD. RESULTS:The median patient age was 78 years (interquartile range [IQR]: 76-80 years). During a median follow-up of 4.4 years (IQR: 2.9-5.9 years), metachronous GC occurred in 16 (6.9% [16/233], 16.3 cases/1000 person-year) and 10 (15.4% [10/65], 37.5 cases/1000 person-year) patients in the Hp-negative and Hp-positive groups, respectively. The incidence of metachronous cancer was higher in the Hp-positive group than in the Hp-negative group (p = 0.035, log-rank test). In a multivariate analysis, persistent Hp infection was an independent risk factor for metachronous GC (age- and sex-adjusted hazard ratio, 2.33; 95% CI: 1.05-5.17). CONCLUSIONS:Persistent H. pylori infection status was associated with a higher risk of metachronous GC, and H. pylori treatment needs to be provided in elderly patients aged ≥ 75 years and older with EGC undergoing ESD.

Gastritis is a disease characterized by inflammation of the gastric mucosa. It is very common and has various classification systems such as the updated Sydney system. As there is a lot of evidence that Helicobacter pylori infection is associated with the development of gastric cancer and that gastric cancer can be prevented by eradication, H. pylori gastritis has been emphasized recently. The incidence rate of gastric cancer in Korea is the highest in the world, and due to the spread of screening endoscopy, atrophic gastritis and intestinal metaplasia are commonly diagnosed in the general population. However, there have been no clinical guidelines developed in Korea for these lesions. Therefore, this clinical guideline has been developed by the Korean College of Helicobacter and Upper Gastrointestinal Research for important topics that are frequently encountered in clinical situations related to gastritis. Evidence-based guidelines were developed through systematic review and de novo processes, and eight recommendations were made for eight key questions. This guideline needs to be periodically revised according to the needs of clinical practice or as important evidence about this issue is published in the future.

Recently, proton beam therapy (PBT) has gathered attention for improving outcomes and reducing toxicities in various cancers; however, the evidence for esophageal squamous cell carcinoma (ESCC) is lacking. Our study retrospectively evaluated the outcomes of PBT for ESCC patients at a single institute. The patients treated with PBT between November 2015 and February 2022 were included in the study, excluding those with distant metastases or those that had undertaken prior treatment for esophageal cancer (EC). The 3 year overall survival (OS) and progression-free survival (PFS) rates were calculated based on stage grouping. The patterns of failure, salvage treatment outcomes, and toxicity profiles were analyzed. The median follow-up was 35.1 months, and 132 patients were analyzed. The 3 year OS and PFS rates for the stages I, II, and III disease cases were 81.0%, 62.9%, and 51.3%; and 70.6%, 71.8%, and 39.8%, respectively. Nineteen patients presented isolated local progression, ten patients underwent appropriate salvage procedures, and nine were successfully salvaged. One patient with isolated regional progression was also salvaged. No cases of grade ≥ 4 lymphopenia were observed. One patient had grade 4 pericardial effusion and esophageal fistula. For the patients with ESCC, PBT is an effective treatment in terms of the survival outcomes and toxicities.

Countries differ in their treatment expertise and research results regarding gastric cancer; hence, treatment guidelines are diverse based on evidence and medical situations. A comprehensive and comparative review of each country's guidelines is imperative to understand the similarities and differences among countries. We reviewed and compared five gastric cancer treatment guidelines in terms of endoscopic, surgical, perioperative, and palliative systemic treatment based on evidence levels and recommendation grades, as well as the postoperative follow-up strategies for each guideline. The Korean, Chinese, and European guidelines provided evidence and grading of the recommendations. The United States guidelines suggested categories for evidence and consensus. The Japanese guidelines suggested evidence and recommendations only for systemic treatment. The Korean and Japanese guidelines described endoscopic treatment, surgery, and lymphadenectomy in detail. The Chinese, United States, and European guidelines more intensively considered perioperative chemotherapy. In particular, the indications for chemotherapy and the regimens recommended by each guideline differed slightly. Considering their medical situations, each guideline had some diversity in terms of adopting evidence, which resulted in heterogeneous recommendations. This review will help medical personnel to comprehensively understand the diversity in gastric cancer treatment guidelines for each country in terms of evidence and recommendations.

INTRODUCTION: Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. METHODS: This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. RESULTS: Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size (P < 0.001) and carpeting of polyps (P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. DISCUSSION: We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.

Gastric papillary adenocarcinoma is considered a differentiated adenocarcinoma in the current endoscopic submucosal dissection indication guidelines. However, the safety of endoscopic submucosal dissection remains controversial. Currently, data regarding which papillary early gastric cancer should be considered for endoscopic submucosal dissection are unavailable. Thus, the aim of this study was to investigate lymph node metastasis and the safety of endoscopic submucosal dissection in patients with papillary early gastric cancer. This observational study recruited 4264 consecutive patients with early gastric cancer who underwent curative gastrectomy between October 2000 and December 2017 at the National Cancer Center, Korea. Of these, 45 had pathologically confirmed papillary early gastric cancer, 2106 had differentiated non-papillary early gastric cancer, and 2113 had undifferentiated early gastric cancer. Logistic regression analysis was performed to identify risk factors for lymph node metastasis. Mucosal tumors were less common in papillary early gastric cancer (37.9%) than in differentiated non-papillary early gastric cancer (48.8%) and undifferentiated early gastric cancer (60.4%) (both P < .001). Lymph node metastasis was more common in papillary early gastric cancer (20.0%) than in differentiated non-papillary early gastric cancer (9.2%) and undifferentiated early gastric cancer (11.7%; both P < .001). In multivariate analysis, non-mixed-type papillary early gastric cancer showed marginally increased odds of lymph node metastasis than differentiated early gastric cancer (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.0-6.3). Rates of lymph node metastasis (1/10, 10%) and angiolymphatic invasion (2/10, 20%) for papillary early gastric cancer meeting expanded criteria were higher than those for other histology types meeting endoscopic submucosal dissection absolute or expanded criteria (P = .03 and P < .001, respectively). Endoscopic submucosal dissection should be considered carefully for papillary early gastric cancer, especially if it meets expanded endoscopic submucosal dissection indications since it is associated with high rates of submucosal invasion and lymph node metastasis.

Background/Aims Intralesional steroid injections have been administered as prophylaxis for stenosis after esophageal endoscopic submucosal dissection. However, this method carries a risk of potential complications such as perforation because a fine needle is used to directly puncture the postoperative ulcer. We devised a new method of steroid intralesional infusion using a spray tube and evaluated its efficacy and safety. Methods Intralesional steroid infusion using a spray tube was performed on 27 patients who underwent endoscopic submucosal dissection for superficial esophageal cancer with three-quarters or more of the lumen circumference resected. The presence or absence of stenosis, complications, and the number of endoscopic balloon dilations (EBDs) performed were evaluated after treatment. Results Although stenosis was not observed in 22 of the 27 patients, five patients had stenosis and dysphagia requiring EBD. The stenosis in these five patients was relieved after four EBDs. No complications related to intralesional steroid infusion using the spray tube were observed. Conclusions Intralesional steroid infusion using a spray tube is a simple and safe technique that is adequately effective in preventing stenosis (clinical trial number, UMIN000037567).