Jin Ook Jang

Background/Objectives: Artificial ulcers after gastric endoscopic submucosal dissection (ESD) generally heal within 8 weeks with proton pump inhibitor (PPI) therapy; however, delayed bleeding remains a clinically relevant complication. Esomeprazole/sodium bicarbonate is an immediate-release PPI formulation; its role after ESD is unclear. Methods: This single-center retrospective study included 923 patients who underwent gastric ESD from July 2017 through December 2025. Late delayed bleeding, defined as bleeding after second-look endoscopy, was compared between patients receiving esomeprazole/sodium bicarbonate (n = 532) and conventional esomeprazole (n = 391) using Firth logistic regression adjusted for calendar period and clinical factors. Eight-week artificial ulcer healing was assessed descriptively only in the esomeprazole/sodium bicarbonate group (n = 527). Results: Late delayed bleeding occurred in 26/923 patients (2.8%): 16/532 (3.0%) in the esomeprazole/sodium bicarbonate group and 10/391 (2.6%) in the conventional esomeprazole group. PPI formulation was not associated with late delayed bleeding (adjusted OR 0.872; 95% CI 0.313–2.427). Submucosal fibrosis (adjusted OR 4.502; 95% CI 1.969–10.292), antiplatelet use (adjusted OR 3.620; 95% CI 1.617–8.103), and anticoagulant use (adjusted OR 6.783; 95% CI 1.323–34.770) were independently associated with bleeding. All 26 patients with bleeding were men; sex was therefore excluded from the model. Complete healing was observed in 510/527 patients (96.8%); ulcer diameter ≥ 40 mm was independently associated with incomplete healing (adjusted OR 7.114; 95% CI 2.664–18.998). Conclusions: No statistically significant difference in late delayed bleeding was detected between formulations, although a clinically meaningful difference cannot be excluded. Healing was assessed only in the esomeprazole/sodium bicarbonate group and could not be compared between formulations. Late delayed bleeding was associated with submucosal fibrosis and antithrombotic therapy.

The utility of ¹⁸ F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for T1 esophageal cancer is unclear. This study analyzed the usefulness of FDG-PET for T1 esophageal squamous cell carcinoma (ESCC). Medical records of patients with T1 ESCC between December 2008 and July 2024 at Pusan National University Yangsan Hospital were retrospectively reviewed. The preoperative FDG-PET/CT findings and final pathological results of patients with T1 ESCC confirmed by surgery or endoscopic resection were compared. Among the 133 patients with T1 ESCC, 84 (63.2%) had mucosal cancer, 49 (36.8%) had submucosal cancer, and 9 (6.8%) had lymph node metastasis. The maximal standardized uptake value (SUVmax) of the PET/CT images was positively correlated with the invasion depth ( r = 0.670; P < .001) and tumor length ( r = 0.518; P < .001). PET confirmed FDG uptake in 8 cases of mucosal cancer and 35 cases of submucosal cancer (9.5% vs 71.4%; P < .001). The negative predictive value and positive predictive value of FDG-PET/CT for identifying mucosal cancer were 84% and 81%, respectively. Of the 8 mucosal cancers in which FDG uptake was observed during PET, 5 (62.5%) were whole or near-circumferential lesions. FDG uptake observed using PET/CT was positively correlated with the invasion depth and tumor length of T1 ESCC. FDG-PET/CT may provide complementary information for risk stratification in patients with T1 ESCC.

Background: Endoscopic submucosal dissection (ESD) is widely used for the treatment of gastric neoplasia; however, the large artificial ulcer created during the procedure requires several weeks to heal. Although proton pump inhibitors (PPIs) are routinely administered after ESD, evidence comparing individual PPIs for artificial ulcer healing in real-world practice remains limited. This study compared the effectiveness of oral ilaprazole and oral esomeprazole as maintenance therapy after gastric ESD. Methods: This retrospective single-center study included patients who underwent gastric ESD between January 2020 and December 2024. All patients received intravenous PPI therapy for two days after ESD and were subsequently prescribed either oral ilaprazole 20 mg once daily or esomeprazole 40 mg once daily for 8 weeks. The primary outcome was complete artificial ulcer healing at 8 weeks. The secondary outcome was post-discharge delayed bleeding. Results: A total of 229 patients were analyzed (147 in the esomeprazole group and 82 in the ilaprazole group). The overall 8-week ulcer healing rate was 94.3%, with no significant difference between the ilaprazole and esomeprazole groups (97.5% vs. 92.5%, p = 0.114). In multivariate analysis, artificial ulcer size ≥ 30 mm was the only independent predictor of incomplete ulcer healing (odds ratio 20.850, 95% confidence interval 1.884–230.712, p = 0.013). Post-discharge delayed bleeding occurred in 8 patients (3.4%), all in the esomeprazole group (p = 0.032). No treatment-related adverse events were observed. Conclusions: Ilaprazole demonstrated ulcer-healing efficacy comparable to esomeprazole after gastric ESD. Artificial ulcer size ≥ 30 mm was the principal determinant of delayed healing, whereas the treatment group was not independently associated with healing outcomes. Ilaprazole may be considered a reasonable maintenance PPI option in routine post-ESD management.

Composite gangliocytoma/neuroma and neuroendocrine tumors (CoGNETs) are extremely rare periampullary neoplasms composed of neuroendocrine epithelial, Schwannian spindle, and ganglion cells. Although endoscopic papillectomy or surgery have been used to treat ampullary CoGNETs, underwater endoscopic mucosal resection (UEMR) for periampullary lesions has not been previously described. In this study, we present a case of a 53-year-old man referred to our hospital with an incidentally detected subepithelial tumor in the second portion of the duodenum. Endoscopic ultrasound revealed a 13×10-mm homogeneous, hypoechoic, and well-demarcated submucosal mass. UEMR was performed under conscious sedation without submucosal injection, achieving safe en bloc resection within 12 min. Histopathology revealed a 2.0×1.5×1.2-cm lesion composed of mixed neuroendocrine epithelial, Schwannian spindle, and ganglion cells. Immunohistochemical staining was positive for chromogranin A, synaptophysin, CD56, neuron-specific enolase, and S-100, confirming CoGNET with a Ki-67 index of <1% and no lymphovascular or perineural invasion. Follow-up endoscopy 3 months later revealed only a post-resection scar without residual or recurrent tumors. This appears to be the first reported case of periampullary CoGNET successfully treated with UEMR. Therefore, UEMR might represent a safe and effective therapeutic option for selected periampullary subepithelial tumors.

Esophageal submucosal tumors are increasingly identified through routine upper endoscopy, often performed as part of health screenings. Although many of these lesions are benign, some have malignant potential, necessitating accurate diagnosis and appropriate resection. Underwater endoscopic mucosal resection (UEMR) has gained attention as a novel technique that enables mucosal resection without submucosal injection, offering advantages in terms of safety and efficacy. However, data regarding its use for esophageal submucosal tumors are limited. This retrospective single-center study included 31 patients who underwent UEMRs for esophageal submucosal tumors between 2020 and 2024. The inclusion criteria were lesions <15 mm in diameter, confined to the submucosal layer, as confirmed by endoscopic ultrasound. Clinical variables, including age, sex, lesion characteristics, procedural details, and histopathological findings, were reviewed. Outcomes included en bloc and pathological complete (R0) resection rates, complications, and recurrence during follow-up. Among the 31 patients (mean age: 57.0 ± 12.5 years; 61% male), the most common lesion location was the lower esophagus (45.2%). Most lesions measured 5 to 10 mm (51.6%). Histopathologic diagnoses included leiomyomas (38.7%), granular cell tumors (32.3%), inflammatory fibroid polyps, and other benign entities. All lesions were resected en bloc using UEMR, with a 100% R0 resection rate. No major complications, including bleeding or perforation, occurred. During a follow-up period of up to 37 months, no recurrence was observed, including in cases of granular cell tumors or adenoid cystic carcinomas. UEMR is a safe and effective technique for managing esophageal submucosal tumors, demonstrating high en bloc and R0 resection rates with no major complications. These findings support UEMR as a favorable option for the resection of small esophageal submucosal tumors, providing a rationale for further prospective studies comparing UEMR with conventional endoscopic mucosal resection, band ligation-assisted endoscopic mucosal resection, and endoscopic submucosal dissection.

Background: Esophageal squamous cell carcinoma (ESCC) typically occurs in older individuals. The etiology and clinical characteristics of ESCC in relatively younger patients under 60 years of age remain unclear. Understanding whether age affects tumor behavior or prognosis is important for improving patient management. This study aimed to analyze the characteristics of ESCC diagnosed before the age of 60. Methods: We retrospectively reviewed the medical records of ESCC patients diagnosed between December 2008 and May 2025. A total of 516 patients were divided into two groups based on whether they were aged 60 or above. Medical history, clinical features, and outcomes were compared between the two groups. Results: There were 100 patients under 60 years and 416 patients aged 60 and above. The median ages were 55 (range 41–59) and 72 (range 60–95), respectively. Younger patients had a significantly stronger association with heavy drinking (72.0% vs. 39.2%, p < 0.001) and smoking (76.0% vs. 55.0%, p < 0.001). There was a trend toward more advanced disease (Stage IV: 26.0% vs. 18.5%, p = 0.094) and metastatic presentation (18.0% vs. 13.9%, p = 0.305) in the under-60 group. Despite being younger with better performance status and fewer comorbidities, their overall survival did not differ from that of older patients (HR 0.92; 95% CI, 0.67–1.26; p = 0.593). Conclusions: Patients diagnosed with ESCC under the age of 60 showed a stronger association with heavy alcohol consumption and smoking and more frequent presentation with advanced-stage disease compared with older patients. Younger age did not confer a better prognosis, highlighting the importance of early detection and timely intervention regardless of patient age.

Esophageal Rupture Occurred During the Endoscopic Removal of a Lodged Denture

Duodenal neuroendocrine tumors are increasingly identified incidentally during screening endoscopy. While surgical resection is standard, the role of endoscopic resection, particularly for grade 1 and 2 tumors, remains under discussion. This study aimed to evaluate the feasibility and outcomes of diagnostic endoscopic resection in grade 1 or 2 duodenal neuroendocrine tumors. We retrospectively reviewed 40 patients with grade 1 or 2 duodenal neuroendocrine tumors treated at a single tertiary center between November 2008 and July 2023. Clinical, endoscopic, and histopathologic features were analyzed, including resection methods, complications, and long-term outcomes. The mean tumor size was 7.4 ± 0.9 mm, with 80% of tumors 10 mm. Ligation-assisted endoscopic mucosal resection may be preferred for subcentimeter lesions. Diagnostic endoscopic resection should be considered in selected patients to avoid unnecessary surgery.

Despite advancements in diagnostic techniques, the accurate identification and management of localized terminal ileitis or ulcers (LTIU) remains challenging, with a wide range of associated diseases presenting with similar clinical and endoscopic features. This retrospective observational study aimed to determine the etiology and discrimination of various diseases in patients with symptomatic LTIU. Data on demographics, clinical manifestations, and endoscopic findings were collected and analyzed statistically using descriptive and inferential methods, including frequency analysis and chi-square tests. Among the 224 patients who underwent LTIU on ileocolonoscopy, 110 (49.1%) had symptoms, of which 71 (64.5%) had specific etiologies on initial testing and after 6 months of follow-up. Definitive diagnoses were ascertained, with Crohn disease (CD) and Behçet disease (BD) being the most common diseases in this cohort, accounting for 27.3% (30 patients) and 18.2% (20 patients) of cases, respectively. Other diagnoses included infectious enteritis in 10 (9.1%) patients, drug-induced enteropathy in 5 (4.5%), intestinal tuberculosis in 5 (4.5%), and lymphoma in 1 (0.9%). Additionally, 39 patients (35.5%) had nonspecific ulcers. After 1 year of treatment, symptomatic and endoscopic resolution was noted in 7 out of 30 patients (23.3%) with CD and 10 out of 20 (50.0%) with BD. Of the 39 patients initially diagnosed with nonspecific ulcers with persistent symptoms, 2 were eventually diagnosed with CD. The high proportion of diagnosed diseases among symptomatic patients with LTIU underscores the importance of early and accurate diagnosis in guiding appropriate treatment strategies. These findings highlight the need for further research to refine diagnostic approaches and optimize patient outcomes in this challenging clinical scenario.

Byung-Soo Park, Sung Hwan Cho, Gyung Mo Son, Hyun Sung Kim, Jin Ook Jang, Dae Gon Ryu, Su Jin Kim, Su Bum Park, Hyung Wook Kim. Journal of Minimally Invasive Surgery 2025;28:19-24. https://doi.org/10.7602/jmis.2025.28.1.19