Esophago-gastro-duodenoscopy (EGD) was performed with videoendoscopes that worked in high-resolution, white light mode and AFI mode (EVIS-FQ260Z; Olympus Medical Systems Co. Ltd, Tokyo, Japan). Before ESD, the extent of atrophic fundic gastritis in AFI images was assessed and categorized into six types that were based on the Kimura–Takemoto classification.13 If the cardia was surrounded by purple mucosa (AF-C-1, AF-C-2 and AF-C-3), it was defined as closed type (Fig. 1), and if there was a green mucosa on the

cardia (AF-O-1, AF-O-2 and AF-O-3), it was defined as open type (Fig. 2). Two biopsy specimens were taken at each site from the greater curvature of the antrum, and the greater and lesser curvature of the corpus. Biopsy specimens were fixed in formalin, embedded in paraffin, serially sectioned, and stained with hematoxylin and eosin. Severity of neutrophil (activity) and lymphocytic infiltration (inflammation), Afatinib glandular atrophy (atrophy) and intestinal metaplasia was graded according to the updated Sydney system14 (none, 0; mild, 1; moderate, 2; and severe, 3). Presence or absence of H. pylori was assessed histologically by Giemsa staining. Patients were considered to be infected with H. pylori if any of the serum tests or histology was positive. Infected patients

were treated with 1 week of anti-H. Idelalisib supplier pylori therapy that consisted of amoxicillin 1500 mg, clarithromycin 800 mg and rabeprazole 20 mg, 3 months after ESD. Successful eradication was diagnosed by urea breath test (UBiT-IR 300; Otsuka Electronics Co. Ltd, Osaka, Japan). The patients who failed Celecoxib the first regimen were retreated with second-line therapy of amoxicillin 1500 mg, metronidazole 500 mg and rabeprazole 20 mg. Patients in whom H. pylori was not eradicated after second-line therapy were followed up as those with persistent H. pylori infection. Two months after ESD, EGD was performed before eradication therapy to exclude the presence of synchronous multiple neoplasia. After that, surveillance endoscopy was scheduled annually after

eradication therapy to diagnose metachronous EGC, using AFI videoendoscopy. The detected lesions were biopsied and removed by ESD if the histological findings of the biopsy specimens indicated that they were category 3–5 according to the revised Vienna classification.15 Metachronous EGC was defined as lesions diagnosed as category 4 or 5 that were detected > 1 year after eradication therapy. Incidence of metachronous EGC was thoroughly studied by the end of June 2010. Statistical analysis was performed with SPSS version 11.0 (SPSS, Chicago, IL, USA). The scores for neutrophil and lymphatic infiltration, glandular atrophy and intestinal metaplasia according to the Updated Sydney System and the serum level of pepsinogen were compared by Mann–Whitney U-test. Other clinical characteristics (sex, type of extension of atrophy, alcohol and smoking habits) were compared by the χ2 test or Fisher’s exact test when it was appropriate.