Clinical Endoscopy

Remimazolam, a novel drug, for safe and effective endoscopic sedation: Jae Min Lee, Yehyun Park, Dong Won Ahn, Jun Kyu Lee, Kwang Hyuck Lee; Received February 7, 2024 Accepted May 8, 2024 Published online January 14, 2025; DOI: https://doi.org/10.5946/ce.2024.026 [Epub ahead of print]

Abstract PDF PubReader ePub: Remimazolam is a novel benzodiazepine with unique pharmacokinetic and pharmacodynamic properties, making it an ideal candidate for sedation during endoscopic procedures. Distinguished by its rapid onset and short duration of action, remimazolam offers a safer and more efficient alternative to traditional sedatives, such as midazolam and propofol, with fewer side effects, such as hypotension, bradycardia, and respiratory depression. This article reviews the characteristics of remimazolam and its practical advantages, including ease of use, quick recovery time, and minimal residual sedation, emphasizing its potential to improve patient safety and procedural efficiency in clinical endoscopy settings.

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Post-polypectomy colorectal bleeding: current strategies and the way forward: Nilanga Nishad, Mo Hameed Thoufeeq; Received September 3, 2024 Accepted September 23, 2024 Published online November 27, 2024; DOI: https://doi.org/10.5946/ce.2024.241 [Epub ahead of print]

Abstract PDF PubReader ePub: Post-endoscopic mucosal resection (EMR) bleeding, or clinically significant post-EMR bleeding, is influenced by factors such as polyp size, right-sided colonic lesions, laterally spreading tumors, anticoagulant use, and comorbidities like cardiovascular or chronic renal disease. The optimal prophylactic therapy for post-EMR bleeding remains unknown, with no consensus on specific criteria for its application. Moreover, prophylactic measures, including clipping, suturing, and coagulation, have produced mixed results. Selective clipping in high-risk patients is cost-effective, whereas universal clipping is not. Studies and meta-analyses indicate that routine prophylactic clipping does not generally reduce post-polypectomy bleeding but may be beneficial in cases of large proximal lesions. Some studies have revealed that the post-polypectomy bleeding risk after EMR of transverse colonic lesions is lower than that of the ascending colon and caecum, suggesting limited efficacy of clipping in the transverse colon. Cost-effectiveness studies support selective clipping in high-risk groups, and newer static agents such as PuraStat are alternatives; however, their cost-effectiveness is undetermined. Further research is required to establish clear guidelines and refine prophylactic strategies to prevent post-EMR bleeding.

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Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review: Tan Minh Le, Van Huy Tran, Kyu Sung Chung, Seong Woo Jeon; Received June 10, 2024 Accepted August 14, 2024 Published online November 8, 2024; DOI: https://doi.org/10.5946/ce.2024.150 [Epub ahead of print]

Abstract PDF PubReader ePub: Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.

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Image-enhanced endoscopy in upper gastrointestinal disease: focusing on texture and color enhancement imaging and red dichromatic imaging: Jae Yong Park; Received June 14, 2024 Accepted July 21, 2024 Published online November 6, 2024; DOI: https://doi.org/10.5946/ce.2024.159 [Epub ahead of print]

Abstract PDF PubReader ePub: Endoscopic examination plays a crucial role in the diagnosis of upper gastrointestinal (UGI) tract diseases. Despite advancements in endoscopic imaging, the detection of subtle early cancers and premalignant lesions using white-light imaging alone remains challenging. This review discusses two novel image-enhanced endoscopy (IEE) techniques–texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI)–and their potential applications in UGI diseases. TXI enhances texture, brightness, and color tone, which improves the visibility of mucosal irregularities and facilitates earlier detection of neoplastic lesions. Studies have suggested that TXI enhances the color differences between lesions and the surrounding mucosa and improves the visibility of the lesion. TXI aids in the diagnosis of various UGI diseases, including early gastric cancer, esophageal cancer, premalignant conditions such as atrophic gastritis and Barrett’s esophagus, and duodenal tumors. RDI utilizes specific wavelengths to enhance the visualization of deep blood vessels or bleeding points, aiding in the rapid and accurate identification of bleeding sources during endoscopic procedures. Although promising, TXI and RDI require further large-scale studies across diverse populations to establish their clinical utility, diagnostic performance, and cost-effectiveness before integration into the guidelines. Standardized training is also required for effective utilization. Overall, these IEE techniques has the potential to improve the diagnosis and management of UGI.

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The impact of linked color imaging on adenoma detection rate in colonoscopy: a systematic review and meta-analysis: Bruna Haueisen Figueiredo Zwetkoff, Luiz Ronaldo Alberti, Fábio Gontijo Rodrigues, Nelson Carvas Junior, José Celso Ardengh, Otavio Micelli Neto, Fernando Rodrigues Guzman, Marcelo Morganti Ferreira Dias, Guilherme Camarotti de Oliveira Canejo, Carlos Eduardo Oliveira dos Santos; Received March 26, 2024 Accepted May 16, 2024 Published online October 24, 2024; DOI: https://doi.org/10.5946/ce.2024.072 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Colorectal cancer prevention relies on surveillance colonoscopy, with the adenoma detection rate as a key factor in examination quality. Linked color imaging (LCI) enhances lesion contrast and improves the examination performance. This systematic review and meta-analysis aimed to evaluate the effect of LCI on adenoma detection rate in adults who underwent colonoscopy.
Methods
We searched the Medline, PubMed, BIREME, LILACS, and Scientific Electronic Library Online databases for randomized controlled trials comparing the use of LCI versus white light (WL), published up to March 2023. The outcomes included lesion characteristics, number of adenomas per patient, and the additional polyp detection rate.
Results
Sixteen studies were included in the analysis, which showed that LCI was more accurate than WL in detecting adenomas, with an increased number of adenomas detected per patient. Although LCI performed well in terms of lesion size, morphology, and location, the subgroup analyses did not reveal any statistically significant differences between LCI and WL. The addition of LCI did not result in significant improvements in the detection of serrated lesions, and there were no differences in the withdrawal time between groups.
Conclusions
LCI has been shown to be effective in detecting colonic lesions, improving the number of adenomas detected per patient and improving polyp detection rate without negatively affecting other quality criteria in colonoscopy.

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Predictors of failure of percutaneous endoscopic gastrostomy tube placement: a retrospective study in a tertiary care center in the USA: Ryan Xin, Cassandra Sanossian, Melissa Fazzari, Brandon Mui, Marouf Hossain, Jennifer Katz; Received May 9, 2024 Accepted September 10, 2024 Published online January 23, 2025; DOI: https://doi.org/10.5946/ce.2024.118 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure used to initiate enteral feeding. To our knowledge, there are no previous studies that analyze predictors of PEG failure. This study aims to identify risk factors for failure of inpatient PEG placement.
Methods
A retrospective chart review was conducted of inpatients in the Montefiore Health System who were scheduled to undergo PEG placement from 2016 to 2020 (n=1,138). Patient, endoscopist, and procedural characteristics were summarized using descriptive statistics, both overall and stratified by whether the PEG was successfully placed.
Results
The overall success rate of PEG placement was 89%. The most common indications included stroke (31%), dementia (27%), and ventilator use (24%). Patient characteristics, including body mass index (BMI) (p=0.16) and indication for PEG placement (p=0.06), were not significantly associated with PEG failure. Instead, endoscopist and procedural characteristics were found to be significant, including type of attending (p<0.001), location of case (p=0.02), and category of anesthesia (p<0.001).
Conclusions
PEG placement remains a highly successful procedure. Endoscopist and procedural characteristics, not patient characteristics, were associated with PEG placement success. Notably, patient BMI and indication for PEG placement could not be used to risk stratify candidates for PEG placement.

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Influence of sarcopenia on clinical outcomes in peptic ulcer bleeding: a retrospective single-center analysis in Korea: Ji Hoon Yu, Hyun Tak Lee, Seok Ki Jang, Ah Young Lee, Jun-young Seo; Received July 30, 2024 Accepted October 13, 2024 Published online January 21, 2025; DOI: https://doi.org/10.5946/ce.2024.209 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Peptic ulcer bleeding (PUB) is a major cause of nonvariceal gastrointestinal bleeding. As the older population increases, the prevalence of sarcopenia is also growing. Although sarcopenia influences the prognosis of various diseases, its association with clinical outcomes of PUB remains unknown. Therefore, this study aimed to explore this correlation.
Methods
We retrospectively analyzed 2,050 patients who underwent esophagogastroduodenoscopy for suspected gastrointestinal bleeding between January 2014 and December 2021. Patients who underwent computed tomography scans were included for sarcopenia evaluation based on the psoas muscle index, defined as the total psoas area normalized by the square of the height of the patient. Sarcopenia was defined using specific cutoffs: ≤7.3 cm2/m2 and ≤5.1 cm2/m2 for men and women, respectively. The primary outcome measured was the 30-day mortality rate.
Results
Out of 358 patients, 149 were diagnosed with sarcopenia. The 30-day mortality rate was significantly higher in patients with sarcopenia than in those without. Multivariate regression analysis revealed significant associations between sarcopenia, a high age, blood tests, and comorbidity score, and administration of inotropic agents with 30-day mortality.
Conclusions
Our study showed that the presence of sarcopenia, elevated comorbidity scores, and use of inotropes were associated with higher 30-day mortality rates. Considering that sarcopenia may influence the clinical outcomes in patients with PUB, it is crucial to manage patients with sarcopenia with particular care.

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Bowel preparation for small bowel capsule endoscopy: standard regimen with 2 L polyethylene glycol versus 1 L polyethylene glycol plus ascorbate: Riccardo Caccia, Alessandro Rimondi, Luca Elli, Matilde Topa, Flaminia Cavallaro, Carmine Gentile, Lucia Scaramella, Nicoletta Nandi, Reena Sidhu, Pinhas Eidler, Maurizio Vecchi, Gian Eugenio Tontini; Received April 22, 2024 Accepted August 3, 2024 Published online January 2, 2025; DOI: https://doi.org/10.5946/ce.2024.097 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Optimization of bowel preparation for small bowel capsule endoscopy (SBCE) is debated. Guidelines recommend 2 L of iso-osmolar polyethylene glycol (PEG) to improve SBCE visibility. We compared the efficacy of the standard 2 L PEG solution with a 1 L PEG plus ascorbate (PEG-ASC) preparation, which has already been established for large-bowel preparation.
Methods
Between October 2020 and February 2022, patients undergoing SBCE were assigned to receive 2 L PEG or 1 L PEG-ASC bowel preparation on an even- or odd-day basis. Bowel cleanliness was evaluated using the small bowel mucosal visibility scoring system (SBMVSS).
Results
Following propensity score matching using a random forest method, two comparable populations of patients treated with 2 L PEG (n=74, male 41%, 53±17 years) and 1 L PEG-ASC (n=74, male 42%, 55±21 years) were obtained from the original cohort of 221 consecutive SBCE patients. Our results showed a trend towards more frequent adequate mucosal visibility with 1 L PEG-ASC compared to 2 L PEG (small bowel mucosal visibility ≥2 in all three small bowel tertiles, p=0.07), as per the SBMVSS score. No significant differences were observed in the diagnostic yield (p=1.00), visibility score=9 (p=0.85), SBCE completeness (p=0.33), or adequate mucosal visibility in each tertile (p=0.61, p=0.74, and p=0.70 for the first, second, and third tertiles, respectively).
Conclusions
Our study suggests the non-inferiority of the 1 L PEG-ASC solution over the standard 2 L PEG for SBCE preparation.

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In-room cytologic evaluation by trained endosonographer for determination of procedure end in endoscopic ultrasound-guided fine needle biopsy of solid pancreatic lesions: a prospective study in Taiwan: Weng-Fai Wong, Yu-Ting Kuo, Wern-Cherng Cheng, Chia-Tung Shun, Ming-Lun Han, Chieh-Chang Chen, Hsiu-Po Wang; Received May 30, 2024 Accepted August 5, 2024 Published online December 12, 2024; DOI: https://doi.org/10.5946/ce.2024.143 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is an essential tool for tissue acquisition in solid pancreatic tumors. Rapid on-site evaluation (ROSE) by cytologists ensures diagnostic accuracy. However, the universal application of the ROSE is limited by its availability. Therefore, we aimed to investigate the feasibility of determining the end of the procedure based on the results of in-room cytological evaluation by trained endosonographers (IRCETE).
Methods
A training course focusing on the cytological interpretation of common pancreatic tumors was provided to the three endosonographers. After training, the decision to terminate EUS-FNB was made based on IRCETE results. The diagnostic accuracy, concordance rate of diagnostic categories, and sample adequacy were compared with those determined by board-certified cytologists and macroscopic on-site evaluation (MOSE).
Results
We enrolled 65 patients with solid pancreatic tumors, most of whom were malignant (86.2%). The diagnostic accuracy was 90.8% when the end of the procedure was determined based on IRCETE, compared to 87.7% and 98.5% when determined by MOSE and cytologists, respectively (p=0.060). Based on the cytologists’ results, the accuracy of IRCETE in diagnostic category interpretation was 97.3%.
Conclusions
In the absence of ROSE, IRCETE can serve as a supplementary alternative to MOSE in determining the end of tissue sampling with a high accuracy rate.

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Flexible endoscopic treatment of Zenker’s diverticulum: a retrospective study in a single center from Turkey: Kerem Kenarli, Bülent Ödemiş; Received June 30, 2024 Accepted August 15, 2024 Published online December 12, 2024; DOI: https://doi.org/10.5946/ce.2024.180 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: We aimed to contribute to the literature by sharing the findings of patients treated by cricopharyngeal myotomy with a flexible endoscopic septal division.
Methods
This retrospective study included patients with Zenker’s diverticulum who underwent cricopharyngeal myotomy with a traditional flexible endoscopic septal division at our center. Clinical success was defined as a significant reduction in dysphagia score, and relapse was defined as an increase in dysphagia score occurring at any time over 1 month after the procedure.
Results
Fifteen patients with symptomatic Zenker’s diverticulum were treated with 16 cricopharyngeal myotomies. A dysphagia score of 100% indicated clinical success, but three (20%) of the patients experienced recurrence during follow-up.
Conclusions
While advances in interventional flexible endoscopy have opened doors for novel treatments, cricopharyngeal myotomy based on traditional flexible endoscopic septal division remains a reliable approach for treating Zenker’s diverticulum.

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Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage in hypervascular hepatocellular carcinoma: a retrospective study from Japan: Kenneth Tachi, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Ahmed Mohammed Sadek, Hossam El-Din Shaaban Mahmoud Ibrahim, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto; Received April 2, 2024 Accepted July 29, 2024 Published online November 11, 2024; DOI: https://doi.org/10.5946/ce.2024.079 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Biliary obstruction drainage in patients with hepatocellular carcinoma (HCC) is associated with symptom palliation, improved access to chemotherapy, and improved survival. Stent placement and exchange via endoscopic retrograde cholangiopancreatography biliary drainage risk traversing the HCC, a hypervascular tumor and causing bleeding. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) potentially prevents procedure-related bleeding. Therefore, we evaluated the efficacy and safety of EUS-HGS as an alternative treatment for biliary obstruction in patients with HCC.
Methods
This was a retrospective study of all EUS-HGS procedures performed in patients with HCC at the Aichi Cancer Center Hospital, Japan, from February 2017 to August 2023.
Results
A total of 14 EUS-HGS procedures (42.9% primary) were attempted in 10 HCC patients (mean age 71.5 years, 80.0% male). Clinical and technical success rates were 92.9% and 90.9%, respectively. The observed procedure details in the 13 successful procedures included B3 puncture (53.8%), 22-G needle (53.8%), fully covered self-expandable metal stent (100%), and mean procedure time (32.7 minutes). There was no bleeding. Mild complications occurred in 27.3%. All patients resumed oral intake within 24 hours.
Conclusions
EUS-HGS is a technically feasible and clinically effective initial or salvage drainage option for the treatment of biliary obstruction in patients with HCC.

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Improved visibility of palisade vessels within Barrett’s esophagus using red dichromatic imaging: a retrospective cross-sectional study in Japan: Chise Ueda, Shinwa Tanaka, Tetsuya Yoshizaki, Hirofumi Abe, Masato Kinoshita, Hiroya Sakaguchi, Hiroshi Takayama, Hitomi Hori, Ryosuke Ishida, Shinya Houki, Hiroshi Tanabe, Eri Nishikawa, Madoka Takao, Toshitatsu Takao, Yoshinori Morita, Takashi Toyonaga, Yuzo Kodama; Received May 13, 2024 Accepted August 8, 2024 Published online November 11, 2024; DOI: https://doi.org/10.5946/ce.2024.122 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Visualization of palisade vessels (PVs) in Barrett’s esophagus is crucial for proper assessment. This study aimed to determine whether red dichromatic imaging (RDI) improves PV visibility compared with white-light imaging (WLI) and narrow-band imaging (NBI).
Methods
Five expert and trainee endoscopists evaluated the PV visibility in Barrett’s esophagus using WLI, NBI, and RDI on 66 images from 22 patients. Visibility was rated on a 4-point scale: 4, excellent; 3, good; 2, fair; and 1, poor. The color difference between the most recognizable PV spots and surrounding areas with undetectable blood vessels was also analyzed.
Results
Mean visibility scores were 2.6±0.7, 2.3±0.6, and 3.4±0.4 for WLI, NBI, and RDI, respectively. The RDI scores were significantly higher than the WLI (p<0.001) and NBI (p<0.001) scores. These differences were recognized by trainees and expert endoscopists. Color differences in PVs were 7.74±4.96 (WLI), 10.43±5.09 (NBI), and 15.1±6.54 (RDI). The difference in RDI was significantly higher than that in WLI (p<0.001) and NBI (p=0.006).
Conclusions
RDI significantly improved PV visibility compared to WLI and NBI based on objective and subjective measures.

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Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study: Kazuya Akahoshi, Kazuki Inamura, Kazuaki Akahoshi, Shigeki Osada, Shinichi Tamura, Yoshihiro Oishi, Masafumi Oya, Hidenobu Koga; Received April 21, 2024 Accepted June 10, 2024 Published online October 10, 2024; DOI: https://doi.org/10.5946/ce.2024.094 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM.
Methods
This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis.
Results
Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%).
Conclusions
ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

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Safety and efficacy of trans-afferent loop endoscopic ultrasound-guided pancreaticojejunostomy for post pancreaticoduodenectomy anastomotic stricture using the forward-viewing echoendoscope: a retrospective study from Japan: Ahmed Sadek, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Kenneth Tachi; Received April 12, 2024 Accepted May 31, 2024 Published online August 26, 2024; DOI: https://doi.org/10.5946/ce.2024.089 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is a well-established procedure for managing pancreaticojejunostomy anastomotic strictures (PJAS) post-Whipple surgery. In this study, we examined the effectiveness and safety of EUS-guided pancreaticojejunostomy (EUS-PJS).
Methods
This retrospective, single-arm study was performed at Aichi Cancer Center Hospital on 10 patients who underwent EUS-guided pancreaticojejunostomy through the afferent jejunal loop using a forward-viewing echoendoscope when endoscopic retrograde pancreatography failed. Our primary endpoint was technical success rate, defined as successful stent insertion. The secondary endpoints were early and late adverse events.
Results
A total of 10 patients underwent EUS-PJS between February 2019 and October 2023. The technical success rate was 100%. The median procedure time was 23.5 minutes. No remarkable early or late adverse events related to the procedure, except for fever, occurred in two patients. The median follow-up duration was 9.5 months, and the median number of stent exchanges was two. A stent-free state was achieved in three patients.
Conclusions
EUS-PJS for PJAS management after pancreaticoduodenectomy appears to be an effective and safe procedure with the potential advantages of fewer reinterventions and the creation of a permanent drainage fistula.

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Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy
Tadahisa Inoue, Rena Kitano, Tomoya Kitada, Kazumasa Sakamoto, Satoshi Kimoto, Jun Arai, Kiyoaki Ito
Digestive Diseases and Sciences.2024;[Epub] CrossRef

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Refractory duodenal ulcer caused by portal stent graft exposure: Gil Ho Lee, Choong-Kyun Noh, Kee Myung Lee; Received August 27, 2024 Accepted October 1, 2024 Published online January 14, 2025; DOI: https://doi.org/10.5946/ce.2024.232 [Epub ahead of print]

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Endoscopic resection utilizing bilateral endoscopies for complete membranous anastomotic closure: Jianchang Wei, Ping Yang, Shanqi Zeng, Jie Cao, Tong Zhang; Received April 30, 2024 Accepted June 19, 2024 Published online August 20, 2024; DOI: https://doi.org/10.5946/ce.2024.100 [Epub ahead of print]

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Comments on ‘Development of colonic stent simulator using three-dimensional printing technique: a simulator development study in Korea’: Dae Jin Jung, Gwang Ha Kim; Received October 9, 2024 Accepted October 23, 2024 Published online January 10, 2025; DOI: https://doi.org/10.5946/ce.2024.272 [Epub ahead of print]

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