• Artificial ulcer
• Endoscopic submucosal dissection
• Gastric ulcer
• Meta-analysis
• Outcome
• Risk factors
• Systematic review

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Korean Society of Gastrointestinal Endoscopy

• ESD, endoscopic submucosal dissection
• Endoscopic submucosal dissection
• PPI, proton-pump inhibitor
• Ulcer
• Vonoprazan
• pH

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by <i>en bloc</i> fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Anti-ulcer medication
• endoscopic submucosal dissection
• network meta-analysis
• potassium-competitive acid blocker
• proton-pump inhibitor

Background: Endoscopic submucosal dissection (ESD) was commonly used for en bloc resection in gastric cancer and adenoma with the risk of delayed bleeding after ESD. We conducted a direct and indirect comparison meta-analysis to evaluate the best choice in preventing post-ESD bleeding among proton pump inhibitors (PPIs), histamine₂-receptor antagonists (H₂RAs), and the most widely used potassium-competitive acid blocker, vonoprazan.

Methods: The Pubmed, Cochrane Library, and Embase were searched for randomized trials. We pooled odds ratios (OR) for preventing post-ESD bleeding using meta-analysis.

Results: Sixteen randomized trials met the inclusion criteria including 2,062 patients. Direct comparisons showed slightly significant efficacy in PPIs rather than H₂RAs in preventing post-ESD bleeding [OR: 1.83; 95% confidence interval (CI): 1.10 to 3.05] and vonoprazan was better than PPIs (OR: 0.46; 95% CI: 0.25 to 0.86). The adjusted indirect comparison indicated vonoprazan was superior to H₂RAs (OR: 0.30, 95% CI: 0.12 to 0.74). In subgroup analysis, PPIs had similar efficacy as H₂RAs in 4 weeks, while PPIs were better than H₂RAs in 8 weeks’ treatment (OR: 1.91; 95% CI: 1.08 to 3.40). The superiority of vonoprazan than PPIs was more significant in combination therapy (OR: 0.18; 95% CI: 0.04 to 0.69). There was a significant difference in vonoprazan for 8 weeks of medication (OR: 0.44; 95% CI: 0.21 to 0.92).

Conclusions: The effects of vonoprazan is better than PPIs than H₂RAs in preventing bleeding after ESD. When vonoprazan combined with mucosal protective antiulcer drug in treatment or used in 8 weeks of medication, the efficacy may be even better.

• delayed bleeding
• endoscopic submucosal dissection
• histamine2-receptor antagonists
• proton pump inhibitors
• vonoprazan

• Anti-ulcer medication
• Endoscopic submucosal dissection
• Proton-pump inhibitor
• Vonoprazan

• Early gastric cancer
• Early gastric neoplasm
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Endoscopic treatment
• Polypectomy

Objectives: Gastric endoscopic submucosal dissection (ESD) is currently a standard procedure. ESD enables en-bloc resection of large lesions, while inducing larger artificial ulcers to a greater extent than conventional procedures. Several studies have reported that proton pump inhibitors (PPIs) prevent delayed bleeding and expedite the artificial ulcer healing process. Esomeprazole, an S-isomer of omeprazole, is reportedly one of strongest inhibitors of gastric acid secretion. Previous studies have examined the effectiveness of esomeprazole. Our goal was to verify the effects of esomeprazole on artificial ulcers in a prospective study.

Methods: A total of 185 patients underwent ESD for gastric neoplasms at our hospital between January 2013 and June 2015. Among these 185 patients, 49 post-ESD scar lesions were included in this prospective trial. First, 20 mg esomeprazole was orally administered to all subjects before and after the procedure. We then evaluated the delayed bleeding rate and ulcer scarring rates at 4 weeks and 8 weeks after the procedure by using a gastric ulcer stage system.

Results: There was one case of delayed bleeding (2.0%). Regardless of Helicobacter pylori infection status, ulcer scarring rates at weeks 4 and 8 were respectively 28.6% (14/49) and 98% (48/49).

Conclusions: Our results suggest that oral administration of esomeprazole alone may be sufficient for prompt healing of artificial gastric ulcers induced by ESD (UMIN000009367).

• artificial ulcer
• endoscopic submucosal dissection
• esomeprazole
• gastric intraepithelial neoplasm
• ulcer healing

• Age Factors
• Carcinoma/pathology
• Carcinoma/surgery
• Endoscopic Mucosal Resection
• Fibrinolytic Agents/therapeutic use
• Fibrosis
• Gastric Mucosa/surgery
• Gastrointestinal Hemorrhage/epidemiology
• Gastroscopy
• Heart Diseases/epidemiology
• Histamine H2 Antagonists/therapeutic use
• Humans
• Hypertension/epidemiology
• Liver Cirrhosis/epidemiology
• Neoplasm Invasiveness
• Odds Ratio
• Postoperative Hemorrhage/epidemiology
• Proton Pump Inhibitors/therapeutic use
• Renal Insufficiency, Chronic/epidemiology
• Risk Factors
• Second-Look Surgery
• Sex Factors
• Stomach Diseases/epidemiology
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Stomach Ulcer/epidemiology
• Tumor Burden

• Education, Graduate
• Interdisciplinary Studies
• Research/education
• Research Personnel/education
• Research Personnel/psychology
• Terminology as Topic

• Antithrombotic agents
• Bleeding
• Endoscopic submucosal dissection
• Prevention
• Risk factor

• Anticoagulants/therapeutic use
• Aspirin/therapeutic use
• Comorbidity
• Endoscopic Mucosal Resection
• Endoscopy, Gastrointestinal
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Neoplasms/surgery
• Hemostasis, Surgical
• Histamine H2 Antagonists/therapeutic use
• Humans
• Kidney Failure, Chronic/epidemiology
• Kidney Failure, Chronic/therapy
• Platelet Aggregation Inhibitors/therapeutic use
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/prevention & control
• Proton Pump Inhibitors/therapeutic use
• Renal Dialysis/statistics & numerical data
• Risk Factors
• Tumor Burden

• bleeding peptic ulcer
• endoscopic examination
• endoscopic hemostasis
• gastroduodenal ulcer bleeding
• upper gastrointestinal bleeding

Endoscopic submucosal dissection (ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy (SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.

• Endoscopic submucosal dissection
• Second-look endoscopy
• Early gastric cancer

AIM: To compare the efficacy of proton pump inhibitors (PPIs) plus rebamipide vs PPIs alone for the treatment of ulcers induced by endoscopic submucosal dissection (ESD).

METHODS: Keyword and MeSH searches of PubMed, EMBASE, OVID, Cochrane Library, Wanfang Database and CNKI from the inception of each database to February 2015 were performed to identify all available randomized controlled trials comparing the effects of PPIs plus rebamidide and PPIs alone on healing ulcers after ESD. Two independent reviewers assessed the studies for inclusion and exclusion based on methodological quality criteria.

RESULTS: A total of five studies involving 670 patients were included. The pooled data suggested a significantly higher rate of ulcer healing after ESD among patients treated with PPIs plus rebamipide than those treated with PPIs alone (OR = 2.68, 95%CI: 1.81-3.97). The combination therapy was found to be significantly more effective than the use of PPIs alone for all ESD ulcers greater than 20 mm in size (OR = 4.77, 95%CI: 2.22-10.26). The ulcer reduction rate in the combination group was higher than that in the PPI alone group after four weeks of treatment (MD = 68.39, 95%CI: 35.73-101.05).

CONCLUSION: The results of this meta-analysis indicate that the combination therapy of PPIs plus rebamipide is more efficient than PPI monotherapy in healing ESD-induced ulcer, particularly large ulcers. However, more high-quality trials are needed to confirm these findings.

• Endoscopic submucosal dissection
• Proton-pump inhibitors
• Rebamipide
• Meta-analysis

AIM: To compare the therapeutic effects of proton pump inhibitors vs H₂ receptor antagonists for upper gastrointestinal bleeding in patients after successful endoscopy.

METHODS: We searched the Cochrane library, MEDLINE, EMBASE and PubMed for randomized controlled trials until July 2014 for this study. The risk of bias was evaluated by the Cochrane Collaboration’s tool and all of the studies had acceptable quality. The main outcomes included mortality, re-bleeding, received surgery rate, blood transfusion units and hospital stay time. These outcomes were estimated using odds ratios (OR) and mean difference with 95% confidence interval (CI). RevMan 5.3.3 software and Stata 12.0 software were used for data analyses.

RESULTS: Ten randomized controlled trials involving 1283 patients were included in this review; 678 subjects were in the proton pump inhibitors (PPI) group and the remaining 605 subjects were in the H₂ receptor antagonists (H₂RA) group. The meta-analysis results revealed that after successful endoscopic therapy, compared with H₂RA, PPI therapy had statistically significantly decreased the recurrent bleeding rate (OR = 0.36; 95%CI: 0.25-0.51) and receiving surgery rate (OR = 0.29; 95%CI: 0.09-0.96). There were no statistically significant differences in mortality (OR = 0.46; 95%CI: 0.17-1.23). However, significant heterogeneity was present in both the numbers of patients requiring blood transfusion after treatment [weighted mean difference (WMD), -0.70 unit; 95%CI: -1.64 - 0.25] and the time that patients remained hospitalized [WMD, -0.77 d; 95%CI: -1.87 - 0.34]. The Begg’s test (P = 0.283) and Egger’s test (P = 0.339) demonstrated that there was no publication bias in our meta-analysis.

CONCLUSION: In patients with upper gastrointestinal bleeding after successful endoscopic therapy, compared with H₂RA, PPI may be a more effective therapy.

• H₂ receptor antagonist
• Proton pump inhibitor
• Upper gastrointestinal bleeding
• Randomized controlled trial
• Meta-analysis

• Adult
• Aged
• Aged, 80 and over
• Chi-Square Distribution
• Endoscopy, Gastrointestinal/adverse effects
• Female
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/drug therapy
• Gastrointestinal Hemorrhage/etiology
• Hemostatics/adverse effects
• Hemostatics/therapeutic use
• Histamine H2 Antagonists/adverse effects
• Histamine H2 Antagonists/therapeutic use
• Humans
• Male
• Middle Aged
• Odds Ratio
• Patient Selection
• Proton Pump Inhibitors/adverse effects
• Proton Pump Inhibitors/therapeutic use
• Risk Factors
• Treatment Outcome

Endoscopic submucosal dissection (ESD) is useful for treating gastric tumors. Several trials have shown the efficacy of 4 or 8 weeks of proton pump inhibitor (PPI) administration for post-ESD ulcers. However, if the size of the post-ESD ulcer is larger than predicted, PPI administration alone might not be sufficient for the ulcer to heal within 4 weeks. There is no report about the efficacy of post-ESD gastric ulcers by esomeprazole. We examined retrospectively the efficacy of a combination therapy of esomeprazole plus rebamipide, a mucosal-protective antiulcer drug, on the acceleration of post-ESD ulcer healing comparing with omeprazole plus rebamipide.

We reviewed the medical records of patients who underwent ESD for gastric neoplasia. We conducted a case-control study to compare the healing rates within 4 weeks effected by esomeprazole plus rebamipide (group E) and omeprazole plus rebamipide (group O). The sizes of the artificial ulcers were divided into normal-sized or large-sized.

The baseline characteristics did not differ significantly between the two groups except age and sex. Stage S1 disease was observed in 27.6% and 38.7% of patients after 4 weeks of treatment in the group E and O, respectively. In large-sized artificial ulcers, the healing rate of stage S1 in group E is significantly higher than that in group O in 4 weeks.(25% VS 0%:P = 0.02)

The safety and efficacy profiles of esomeprazole plus rebamipide and omeprazole and rebamipide are similar for the treatment of ESD-induced ulcers. In large-sized ulcers, esomeprazole plus rebamipide promotes ulcer healing.

• endoscopic submucosal dissection
• esomeprazole
• gastric neoplasm
• omeprazole
• rebamipide