BACKGROUND Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events(AEs).To overcome these problems,endoscopic gallbladder stenting(...BACKGROUND Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events(AEs).To overcome these problems,endoscopic gallbladder stenting(EGBS)after percutaneous transhepatic gallbladder drainage(PTGBD)can be effective,as it mitigates inflammation and adhesion.AIM To examine the benefits of EGBS after PTGBD to assess its efficacy and impact on AEs.METHODS We retrospectively analyzed data from 35 patients who underwent EGBS after PTGBD at a single center between January 2016 and December 2023.The primary outcomes were technical success and AEs,and the rate of recurrent cholecystitis was evaluated.In addition,the reasons for the failure of the procedure were identified.RESULTS Among the 35 patients,the technical success rate was 77.1%and the final contrast of the cystic duct was successful in 97.1%of patients.The incidence of early AEs was relatively low(11.4%),with no instances of cystic duct perforation.The rate of recurrent cholecystitis was 3.7%,and no other biliary events were observed.CONCLUSION EGBS after PTGBD may be significantly beneficial,with a substantial success rate and minimal AEs in both short-and long-term follow-ups.展开更多
BACKGROUND The incidence of colorectal cancer(CRC)and preinvasive CRC(e.g.,early colon cancer and advanced adenoma)is gradually increasing in several countries.AIM To evaluate the trend in incidence of CRC and preinva...BACKGROUND The incidence of colorectal cancer(CRC)and preinvasive CRC(e.g.,early colon cancer and advanced adenoma)is gradually increasing in several countries.AIM To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.METHODS This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC,and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies.Colonoscopy-related complications by age group were also determined.RESULTS The incidence of CRC showed a rapid increase,then decreased after 2012 in the 50-75 year-age group.During the study period,the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age.Since 2009,the increase has been rapid,showing a pattern similar to the increase in colonoscopies.The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007.The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.CONCLUSION The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed.As the risk of colonoscopy-related hospitalization and death is high in the elderly,if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75,colonoscopy-related complications can be reduced for those aged 76 years or over.展开更多
BACKGROUND Small bowel tumors(SBTs)are a heterogeneous group of difficult-to-diagnose tumors that account for 2%-5%of all gastrointestinal tumors.Single-balloon enteroscopy greatly enhances the diagnosis and treatment...BACKGROUND Small bowel tumors(SBTs)are a heterogeneous group of difficult-to-diagnose tumors that account for 2%-5%of all gastrointestinal tumors.Single-balloon enteroscopy greatly enhances the diagnosis and treatment of SBTs.However,few epidemiological studies have been conducted in Taiwan to determine the clinical profile of SBTs.AIM To investigate the clinical characteristics,managements and prognosis of SBTs in a medical center in Taiwan.METHODS The study enrolled 51 patients aged 58.9±8.8 years(range,22-93)diagnosed with SBTs from November 2009 to July 2021.We retrospectively recorded clinical characteristics,indications,endoscopic findings,pathological results,management,and outcomes for further analysis.RESULTS A male preponderance was observed(56.8%).The most common indications were suspected small intestinal tumors(52.9%)and obscure gastrointestinal bleeding(39.2%).The most common tumor location was the ileum(41.2%).The performance of imaging studies(P=0.004)and the types of findings(P=0.005)differed significantly between malignant and benign SBTs.The most frequent imaging finding was a small intestinal mass(43.1%).The top three malignant tumor types were gastrointestinal stromal tumors(GISTs),adenocarcinomas,and lymphomas.Moreover,the proportions of benign and malignant tumors were 27.5%and 72.5%,respectively.The survival rates of patients with malignant tumors in the GIST and non-GIST groups differed significantly(P=0.015).Kaplan–Meier survival analysis showed a significant difference in survival between patients in the malignant and benign groups(P=0.04).All patients with lymphoma underwent chemotherapy(n=7/8,87.5%),whereas most patients with GISTs underwent surgery(n=13/14,92.8%).CONCLUSION Patients with GISTs have a significantly higher survival rate than those with other malignant SBTs.Therefore,a large-scale nationwide study is warranted to evaluate the population-based epidemiology of SBTs.展开更多
Inflammatory bowel disease(IBD)is chronic inflammation of the gastrointestinal tract that has a high epidemiological prevalence worldwide.The increasing disease burden worldwide,lack of response to current biologic th...Inflammatory bowel disease(IBD)is chronic inflammation of the gastrointestinal tract that has a high epidemiological prevalence worldwide.The increasing disease burden worldwide,lack of response to current biologic therapeutics,and treatment-related immunogenicity have led to major concerns regarding the clinical management of IBD patients and treatment efficacy.Understanding disease pathogenesis and disease-related molecular mechanisms is the most important goal in developing new and effective therapeutics.Sphingosine-1-phosphate(S1P)receptor(S1PR)modulators form a class of oral small molecule drugs currently in clinical development for IBD have shown promising effects on disease improvement.S1P is a sphingosine-derived phospholipid that acts by binding to its receptor S1PR and is involved in the regulation of several biological processes including cell survival,differentiation,migration,proliferation,immune response,and lymphocyte trafficking.T lymphocytes play an important role in regulating inflammatory responses.In inflamed IBD tissue,an imbalance between T helper(Th)and regulatory T lymphocytes and Th cytokine levels was found.The S1P/S1PR signaling axis and metabolism have been linked to inflammatory responses in IBD.S1P modulators targeting S1PRs and S1P metabolism have been developed and shown to regulate inflammatory responses by affecting lymphocyte trafficking,lymphocyte number,lymphocyte activity,cytokine production,and contributing to gut barrier function.展开更多
BACKGROUND The clinical trend and characteristics of peptic ulcer disease(PUD)have not fully been investigated in the past decade.AIM To evaluate the changing trends and characteristics of PUD according to age and MET...BACKGROUND The clinical trend and characteristics of peptic ulcer disease(PUD)have not fully been investigated in the past decade.AIM To evaluate the changing trends and characteristics of PUD according to age and METHODS We analyzed seven hospital databases converted into the Observational Medical Outcomes Partnership-Common Data Model between 2010 and 2019.We classified patients with PUD who underwent rapid urease tests or Helicobacter pylori(H.pylori)serology into three groups:H.pylori-related,drug[nonsteroidal anti-inflammatory drugs(NSAIDs)or aspirin]-related,and idiopathic(H.pylori/NSAID/aspirin-negative)PUD and compared the yearly trends and characteristics among the three groups.RESULTS We included 26785 patients in 7 databases,and the proportion of old age(≥65 years)was 38.8%.The overall number of PUD exhibited no decrease,whereas PUD in old age revealed an increasing trend(P=0.01 for trend).Of the 19601 patients,41.8%had H.pylori-related,36.1%had drug-related,and 22.1%had idiopathic PUD.H.pylorirelated PUD exhibited a decreasing trend after 2014(P=0.01),drug-related PUD demonstrated an increasing trend(P=0.04),and idiopathic PUD showed an increasing trend in the old-age group(P=0.01)during 10 years.Patients with drug-related PUD had significantly more comorbidities and concomitant ulcerogenic drugs.The idiopathic PUD group had a significantly higher number of patients with chronic liver disease.CONCLUSION With the aging population increase,the effects of concomitant ulcerogenic drugs and preventive strategies should be investigated in drug-induced PUD.Further studies are required to clarify the relationship between idiopathic PUD and chronic liver disease.展开更多
BACKGROUND Hepatobiliary scintigraphy(HBS)is a useful diagnostic imaging technique that uses radiotracers to evaluate the function of the gallbladder(GB)and biliary system.In segmented GB,some HBS images reveal a disc...BACKGROUND Hepatobiliary scintigraphy(HBS)is a useful diagnostic imaging technique that uses radiotracers to evaluate the function of the gallbladder(GB)and biliary system.In segmented GB,some HBS images reveal a discordant GB boundary as compared to anatomical images.AIM To evaluate the characteristics of HBS in segmented GB and determine the clinical relevance according to HBS characteristics.METHODS A total of 268 patients with chronic cholecystitis,gallstones,or biliary colic symptoms who underwent HBS between 2011 and 2020 were enrolled.Segmented GB was defined as segmental luminal narrowing of the GB body on computed tomography(CT)or magnetic resonance(MR)images,and HBS was examined 1 mo before or after CT or MR.Segmented GB was classified into 3 types based on the filling and emptying patterns of the proximal and distal segments according to the characteristics of HBS images,and GB ejection fraction(GBEF)was identified:Type 1 was defined as a normal filling and emptying pattern;Type 2 was defined as an emptying defect on the distal segment;and Type 3 was defined as a filling defect in the distal segment.RESULTS Segmented GB accounted for 63 cases(23.5%),including 36 patients(57.1%)with Type 1,18 patients(28.6%)with Type 2,and 9 patients(14.3%)with Type 3 emptying pattern.Thus,approximately 43%of HBS images showed a discordant pattern as compared to anatomical imaging of segmented GB.Although there were no significant differences in clinical symptoms,rate of cholecystectomy,or pathological findings based on the type,most gallstones occurred in the distal segment.Reported GBEF was 62.50%±24.79%for Type 1,75.89%±17.21%for Type 2,and 88.56%±7.20%for Type 3.Type 1 showed no difference in reported GBEF compared to the non-segmented GB group(62.50%±24.79%vs 67.40%±21.78%).In contrast,the reported GBEF was higher in Types 2 and 3 with defective emptying and filling when compared to Type 1(80.11%±15.70%vs 62.57%±24.79%;P=0.001).CONCLUSION In segmented GB,discordance in the filling patterns detected by HBS and anatomical imaging could lead to misinterpretation of GBEF.For this reason,clinicians should be cautious when interpreting HBS results in patients with segmented GB.展开更多
The intestinal lumen harbors a diverse consortium of microorganisms that participate in reciprocal crosstalk with intestinal immune cells and with epithelial and endothelial cells,forming a multi-layered barrier that ...The intestinal lumen harbors a diverse consortium of microorganisms that participate in reciprocal crosstalk with intestinal immune cells and with epithelial and endothelial cells,forming a multi-layered barrier that enables the efficient absorption of nutrients without an excessive influx of pathogens.Despite being a lung-centered disease,severe coronavirus disease 2019(COVID-19)affects multiple systems,including the gastrointestinal tract and the pertinent gut barrier function.Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)can inflict either direct cytopathic injury to intestinal epithelial and endothelial cells or indirect immune-mediated damage.Alternatively,SARS-CoV-2 undermines the structural integrity of the barrier by modifying the expression of tight junction proteins.In addition,SARS-CoV-2 induces profound alterations to the intestinal microflora at phylogenetic and metabolomic levels(dysbiosis)that are accompanied by disruption of local immune responses.The ensuing dysregu-lation of the gut-lung axis impairs the ability of the respiratory immune system to elicit robust and timely responses to restrict viral infection.The intestinal vasculature is vulnerable to SARS-CoV-2-induced endothelial injury,which simultaneously triggers the activation of the innate immune and coagulation systems,a condition referred to as“immunothrombosis”that drives severe thrombotic complications.Finally,increased intestinal permeability allows an aberrant dissemination of bacteria,fungi,and endotoxin into the systemic circulation and contributes,to a certain degree,to the over-exuberant immune responses and hyper-inflammation that dictate the severe form of COVID-19.In this review,we aim to elucidate SARS-CoV-2-mediated effects on gut barrier homeostasis and their implications on the progression of the disease.展开更多
BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from c...BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from centers or analysis of large databases.Although a meta-analysis has shown fewer adverse events as a composite(bleeding,pancreatitis,Perf)during ERCP performed at high-volume centers,there is very little real-world data on endoscopist and center procedural volumes,ERCP duration and complexity on the occurrence of Perf.AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume,ERCP time,and complexity from a national endoscopic repository.Patients from clinical outcomes research initiative-national endoscopic database(2000-2012)who underwent ERCP were stratified based on the endoscopist and center volume(quartiles),and total procedure duration and complexity grade of the ERCP based on procedure details.The effects of these variables on the Perf that occurred were studied.Continuous variables were compared between Perf and no perforations(NoPerf)using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.RESULTS A total of 14153 ERCPs were performed by 258 endoscopists,with 20 reported Perf(0.14%)among 16 endoscopists.Mean patient age in years 61.6±14.8 vs 58.1±18.8(Perf vs.NoPerf,P=NS).The cannulation rate was 100%and 91.5%for Perf and NoPerf groups,respectively.13/20(65%)of endoscopists were high-volume performers in the 4th quartile,and 11/20(55%)of Perf occurred in centers with the highest volumes(4th quartile).Total procedure duration in minutes was 60.1±29.9 vs 40.33±23.5(Perf vs NoPerf,P<0.001).Fluoroscopy duration in minutes was 3.3±2.3 vs 3.3±2.6(Perf vs NoPerf P=NS).50%of the procedures were complex and greater than grade 1 difficulty.3/20(15%)patients had prior biliary surgery.13/20(65%)had sphincterotomies performed with stent insertion.Peritonitis occurred in only 1/20(0.5%).CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers.However,Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.展开更多
Inflammasomes are multiprotein intracellular complexes which are responsible for the activation of inflammatory responses. Among various subtypes of inflammasomes, NLRP3 has been a subject of intensive investigation. ...Inflammasomes are multiprotein intracellular complexes which are responsible for the activation of inflammatory responses. Among various subtypes of inflammasomes, NLRP3 has been a subject of intensive investigation. NLRP3 is considered to be a sensor of microbial and other danger signals and plays a crucial role in mucosal immune responses, promoting the maturation of proinflammatory cytokines interleukin 1β(IL-1β) and IL-18. NLRP3 inflammasome has been associated with a variety of inflammatory and autoimmune conditions, including inflammatory bowel diseases(IBD). The role of NLRP3 in IBD is not yet fully elucidated as it seems to demonstrate both pathogenic and protective effects. Studies have shown a relationship between genetic variants and mutations in NLRP3 gene with IBD pathogenesis. A complex interaction between the NLRP3 inflammasome and the mucosal immune response has been reported. Activation of the inflammasome is a key function mediated by the innate immune response and in parallel the signaling through IL-1β and IL-18 is implicated in adaptive immunity. Further research is needed to delineate the precise mechanisms of NLRP3 function in regulating immune responses. Targeting NLRP3 inflammasome and its downstream signaling will provide new insights into the development of future therapeutic strategies.展开更多
Accurate diagnosis of Helicobacter pylori(H. pylori) infection is a crucial part in the effective management of many gastroduodenal diseases. Several invasive and non-invasive diagnostic tests are available for the de...Accurate diagnosis of Helicobacter pylori(H. pylori) infection is a crucial part in the effective management of many gastroduodenal diseases. Several invasive and non-invasive diagnostic tests are available for the detection of H. pylori and each test has its usefulness and limitations in different clinical situations. Although none can be considered as a single gold standard in clinical practice,several techniques have been developed to give the more reliable results. Invasive tests are performed via endoscopic biopsy specimens and these tests include histology,culture,rapid urease test as well as molecular methods. Developments of endoscopic equipment also contribute to the real-time diagnosis of H. pylori during endoscopy. Urea breathingtest and stool antigen test are most widely used noninvasive tests,whereas serology is useful in screening and epidemiological studies. Molecular methods have been used in variable specimens other than gastric mucosa. More than detection of H. pylori infection,several tests are introduced into the evaluation of virulence factors and antibiotic sensitivity of H. pylori,as well as screening precancerous lesions and gastric cancer. The aim of this article is to review the current options and novel developments of diagnostic tests and their applications in different clinical conditions or for specific purposes.展开更多
Helicobacter pylori (H. pylori) infection is well known to be associated with the development of precancerous lesions such as chronic atrophic gastritis (AG), or gastric intestinal metaplasia (GIM), and cancer. Variou...Helicobacter pylori (H. pylori) infection is well known to be associated with the development of precancerous lesions such as chronic atrophic gastritis (AG), or gastric intestinal metaplasia (GIM), and cancer. Various molecular alterations are identified not only in gastric cancer (GC) but also in precancerous lesions. H. pylori treatment seems to improve AG and GIM, but still remains controversial. In contrast, many studies, including meta-analysis, show that H. pylori eradication reduces GC. Molecular markers detected by genetic and epigenetic alterations related to carcinogenesis reverse following H. pylori eradication. This indicates that these changes may be an important factor in the identification of high risk patients for cancer development. Patients who underwent endoscopic treatment of GC are at high risk for development of metachronous GC. A randomized controlled trial from Japan concluded that prophylactic eradication of H. pylori after endoscopic resection should be used to prevent the development of metachronous GC, but recent retrospective studies did not show the tendency. Patients with precancerous lesions (molecular alterations) that do not reverse after H. pylori treatment, represent the “point of no return” and may be at high risk for the development of GC. Therefore, earlier H. pylori eradication should be considered for preventing GC development prior to the appearance of precancerous lesions.展开更多
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Ben...Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.展开更多
AIM:To investigate the diagnostic performance of acoustic radiation force impulse(ARFI) elastography for characterizing focal liver mass by quantifying their stiffness.METHODS:This prospective study included 62 patien...AIM:To investigate the diagnostic performance of acoustic radiation force impulse(ARFI) elastography for characterizing focal liver mass by quantifying their stiffness.METHODS:This prospective study included 62 patients with a focal liver mass that was well visualized on conventional ultrasonography performed in our institution from February 2011 to November 2011.Among them,12 patients were excluded for ARFI measurement failure due to a lesion that was smaller than the region of the interest and at an inaccessible location(deeper than 8 cm)(n = 7) or poor compliance to hold their breath as required(n = 5).Finally,50 patients with valid ARFI measurements were enrolled.If a patient had multiple liver masses,only one mass of interest was chosen.The masses were diagnosed by histological examination or clinical diagnostic criteria.During ultrasonographic evaluation,stiffness,expressed as velocity,was checked 10 times per focal liver mass and the surrounding liver parenchyma.RESULTS:After further excluding three masses that were non-diagnostic on biopsy,a total of 47 focal mass lesions were tested,including 39(83.0%) malignant masses [24 hepatocellular carcinomas(HCC),seven cholangiocellular carcinomas(CCC),and eight liver metastases] and eight(17.0%) benign masses(five hemangiomas and three focal nodular hyperplasias,FNH).Thirty-seven(74.0%) masses were confirmed by histological examination.The mean velocity was 2.48 m/s in HCCs,1.65 m/s in CCCs,2.35 m/s in metastases,1.83 m/s in hemangiomas,and 0.97 m/s in FNHs.Although considerable overlap was still noted between malignant and benign masses,significant differences in ARFI values were observed between malignant and benign masses(mean 2.31 m/s vs 1.51 m/s,P = 0.047),as well as between HCCs and benign masses(mean 2.48 m/s vs 1.51 m/s,P = 0.006).The areas under the receiver operating characteristics curves(AUROC) for discriminating the malignant masses from benign masses was 0.724(95%CI,0.566-0.883,P = 0.048),and the AUROC for discriminating HCCs from benign masses was 0.813(95%CI,0.649-0.976,P = 0.008).To maximize the sum of sensitivity and specificity,an ARFI value of 1.82 m/s was selected as the cutoff value to differentiate malignant from benign liver masses.Furthermore,the cutoff value for distinguishing HCCs from benign masses was also determined to be 1.82 m/s.The diagnostic performance of the sum of the ARFI values for focal liver masses and the surrounding liver parenchyma to differentiate liver masses improved(AUROC = 0.853;95%CI,0.745-0.960;P = 0.002 in malignant liver masses vs benign ones and AUROC = 0.948;95%CI,0.896-0.992,P < 0.001 in HCCs vs benign masses).CONCLUSION:ARFI elastography provides additional information for the differential diagnosis of liver masses.However,our results should be interpreted in clinical context,because considerable overlap in ARFI values existed among liver masses.展开更多
AIM To investigated the prognostic value of the neutrophillymphocyte ratio(NLR) in patients with acute pancreatitis and determined an optimal cut-off value for the prediction of adverse outcomes in these patients.METH...AIM To investigated the prognostic value of the neutrophillymphocyte ratio(NLR) in patients with acute pancreatitis and determined an optimal cut-off value for the prediction of adverse outcomes in these patients.METHODS We retrospectively analyzed 490 patients with acute pancreatitis diagnosed between March 2007 and December 2012. NLRs were calculated at admission and 24, 48, and 72 h after admission. Patients were grouped according to acute pancreatitis severity and organ failure occurrence, and a comparative analysis was performed to compare the NLR between groups. RESULTS Among the 490 patients, 70 had severe acute pancreatitis with 31 experiencing organ failure. The severe acute pancreatitis group had a significantly higher NLR than the mild acute pancreatitis group on all 4 d(median, 6.14, 6.71, 5.70, and 4.00 vs 4.74, 4.47, 3.20, and 3.30, respectively, P < 0.05). The organ failure group had a significantly higher NLR than the group without organ failure on all 4 d(median, 7.09, 6.72, 6.27, and 6.24 vs 4.85, 4.49, 3.35, and 2.34, respectively, P < 0.05). The optimal cut-off value for baseline NLR was 4.76 in predicting severity and 4.88in predicting organ failure in acute pancreatitis. CONCLUSION Elevated baseline NLR correlates with severe acute pancreatitis and organ failure.展开更多
To clarify the role of neoadjuvant concurrent chemoradiotherapy (NACCRT) followed by surgical resection for localized or locally advanced perihilar cholangiocarcinoma (CCA).METHODSWe retrospectively reviewed 57 patien...To clarify the role of neoadjuvant concurrent chemoradiotherapy (NACCRT) followed by surgical resection for localized or locally advanced perihilar cholangiocarcinoma (CCA).METHODSWe retrospectively reviewed 57 patients who underwent surgical resection with or without NACCRT for perihilar CCA; 12 patients received NACCRT and 45 patients did not received NACCRT. Patients with locally advanced perihilar CCA requiring NACCRT were defined as follows: (1) a mass involving unilateral branches of the portal vein or hepatic artery with insufficient volume of the anticipated remnant lobe; or (2) an infiltrating mass in the main portal vein that was too long for reconstruction, identified at preoperative staging.RESULTSThe median disease-free survival (DFS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 26.0 and 15.1 mo, respectively (P = 0.91). The median overall survival (OS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 32.9 and 27.1 mo, respectively (P = 0.26). The NACCRT group showed a downstaging tendency compared to the non-NACCRT group as compared with the tumor stage confirmed by histological examination after surgery and the tumor stage confirmed by imaging test at the time of diagnosis (P = 0.01).CONCLUSIONNACCRT does not prolong DFS and OS in localized or locally advanced perihilar CCA. However, NACCRT may allow tumor downstaging and improve tumor resectability.展开更多
Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endos...Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.展开更多
AIM:To evaluate the efficacy of cola treatment for gastric phytobezoars,including diospyrobezoars.METHODS:A total of 17 patients(range:48 to 78 years) with symptomatic gastric phytobezoars treated with cola and adjuva...AIM:To evaluate the efficacy of cola treatment for gastric phytobezoars,including diospyrobezoars.METHODS:A total of 17 patients(range:48 to 78 years) with symptomatic gastric phytobezoars treated with cola and adjuvant endoscopic therapy were reviewed.Three liters of cola lavage(10 cases) or drink(7 cases) were initially used,and then endoscopic fragmentation was done for the remnant bezoars by using a lithotripsy basket or a polypectomy snare.The overall success of dissolving a gastric phytobezoars with using three liters of cola and the clinical and endoscopic findings were compared retrospectively between four cases of complete dissolution by using only cola and 13 cases of partial dissolution with cola.RESULTS:After 3 L of cola lavage or drinking,a complete dissolution of bezoars was achieved in four patients(23.5%),while 13 cases(76.5%) were only partially dissolved.Phytobezoars(4 of 6 cases) were observed more frequently than diospyrobezoars(0 of 11) in the group that underwent complete dissolution(P = 0.006).Gender,symptom duration,size of bezoar and method of cola administration were not significantly different between the two groups.Twelve of 13 patients with residual bezoars were completely treated with a combination of cola and endoscopic fragmentation.CONCLUSION:The rate of complete dissolution with three liters of cola was 23.5%,but no case of diospyrobezoar was completely dissolved using this method.However,pretreatment with cola may be helpful and facilitate endoscopic fragmentation of gastric phytobezoars.展开更多
AIM To evaluate the prognostic value of the neutrophil-tolymphocyte ratio(NLR) and platelet-to-lymphocyte ratio(PLR) in patients with colorectal cancer(CRC).METHODS Between April 1996 and December 2010, medical record...AIM To evaluate the prognostic value of the neutrophil-tolymphocyte ratio(NLR) and platelet-to-lymphocyte ratio(PLR) in patients with colorectal cancer(CRC).METHODS Between April 1996 and December 2010, medical records from a total of 1868 patients with CRC were retrospectively reviewed. The values of simple inflammatory markers including NLR and PLR in predicting the long-term outcomes of these patients were evaluated using Kaplan-Meier curves and Cox regression models.RESULTS The median follow-up duration was 46 mo(interquartile range, 22-73). The estimation of NLR and PLR was based on the time of diagnosis. In multivariate Cox regression analysis, high NLR (≥ 3.0) and high PLR(≥ 160) were independent risk factors predicting poor long-term outcomes in patients with stage Ⅲ and Ⅳ CRC. However, high NLR and high PLR were not prognostic factors in patients with stage Ⅰ and Ⅱ CRC.CONCLUSION In this study, we identified that high NLR (≥ 3.0) and high PLR (≥ 160) are useful prognostic factors to predict long-term outcomes in patients with stage Ⅲ and Ⅳ CRC.展开更多
Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the success...Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.展开更多
AIM： To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS： This prospective, randomized, comparative tr...AIM： To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS： This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers （spurting or oozing） were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1：10000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS： There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups （P 〈 0.05）. The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group （20.3%） than in the 30 （5.3%） and 40 mL （2.8 %） epinephrine groups （P 〈 0.01）. There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group （51/76） than in the 20 （2/76） and 30 mL （5/76） epinephrine groups （P 〈 0.001）. Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group （P 〈 0.01）. Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups （P 〈 0.01）.CONCLUSION： Injection of 30 mL diluted epinephrine （1：10000） can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer （spurting or oozing） is 30 mL.展开更多
文摘BACKGROUND Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events(AEs).To overcome these problems,endoscopic gallbladder stenting(EGBS)after percutaneous transhepatic gallbladder drainage(PTGBD)can be effective,as it mitigates inflammation and adhesion.AIM To examine the benefits of EGBS after PTGBD to assess its efficacy and impact on AEs.METHODS We retrospectively analyzed data from 35 patients who underwent EGBS after PTGBD at a single center between January 2016 and December 2023.The primary outcomes were technical success and AEs,and the rate of recurrent cholecystitis was evaluated.In addition,the reasons for the failure of the procedure were identified.RESULTS Among the 35 patients,the technical success rate was 77.1%and the final contrast of the cystic duct was successful in 97.1%of patients.The incidence of early AEs was relatively low(11.4%),with no instances of cystic duct perforation.The rate of recurrent cholecystitis was 3.7%,and no other biliary events were observed.CONCLUSION EGBS after PTGBD may be significantly beneficial,with a substantial success rate and minimal AEs in both short-and long-term follow-ups.
文摘BACKGROUND The incidence of colorectal cancer(CRC)and preinvasive CRC(e.g.,early colon cancer and advanced adenoma)is gradually increasing in several countries.AIM To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.METHODS This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC,and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies.Colonoscopy-related complications by age group were also determined.RESULTS The incidence of CRC showed a rapid increase,then decreased after 2012 in the 50-75 year-age group.During the study period,the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age.Since 2009,the increase has been rapid,showing a pattern similar to the increase in colonoscopies.The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007.The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.CONCLUSION The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed.As the risk of colonoscopy-related hospitalization and death is high in the elderly,if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75,colonoscopy-related complications can be reduced for those aged 76 years or over.
文摘BACKGROUND Small bowel tumors(SBTs)are a heterogeneous group of difficult-to-diagnose tumors that account for 2%-5%of all gastrointestinal tumors.Single-balloon enteroscopy greatly enhances the diagnosis and treatment of SBTs.However,few epidemiological studies have been conducted in Taiwan to determine the clinical profile of SBTs.AIM To investigate the clinical characteristics,managements and prognosis of SBTs in a medical center in Taiwan.METHODS The study enrolled 51 patients aged 58.9±8.8 years(range,22-93)diagnosed with SBTs from November 2009 to July 2021.We retrospectively recorded clinical characteristics,indications,endoscopic findings,pathological results,management,and outcomes for further analysis.RESULTS A male preponderance was observed(56.8%).The most common indications were suspected small intestinal tumors(52.9%)and obscure gastrointestinal bleeding(39.2%).The most common tumor location was the ileum(41.2%).The performance of imaging studies(P=0.004)and the types of findings(P=0.005)differed significantly between malignant and benign SBTs.The most frequent imaging finding was a small intestinal mass(43.1%).The top three malignant tumor types were gastrointestinal stromal tumors(GISTs),adenocarcinomas,and lymphomas.Moreover,the proportions of benign and malignant tumors were 27.5%and 72.5%,respectively.The survival rates of patients with malignant tumors in the GIST and non-GIST groups differed significantly(P=0.015).Kaplan–Meier survival analysis showed a significant difference in survival between patients in the malignant and benign groups(P=0.04).All patients with lymphoma underwent chemotherapy(n=7/8,87.5%),whereas most patients with GISTs underwent surgery(n=13/14,92.8%).CONCLUSION Patients with GISTs have a significantly higher survival rate than those with other malignant SBTs.Therefore,a large-scale nationwide study is warranted to evaluate the population-based epidemiology of SBTs.
文摘Inflammatory bowel disease(IBD)is chronic inflammation of the gastrointestinal tract that has a high epidemiological prevalence worldwide.The increasing disease burden worldwide,lack of response to current biologic therapeutics,and treatment-related immunogenicity have led to major concerns regarding the clinical management of IBD patients and treatment efficacy.Understanding disease pathogenesis and disease-related molecular mechanisms is the most important goal in developing new and effective therapeutics.Sphingosine-1-phosphate(S1P)receptor(S1PR)modulators form a class of oral small molecule drugs currently in clinical development for IBD have shown promising effects on disease improvement.S1P is a sphingosine-derived phospholipid that acts by binding to its receptor S1PR and is involved in the regulation of several biological processes including cell survival,differentiation,migration,proliferation,immune response,and lymphocyte trafficking.T lymphocytes play an important role in regulating inflammatory responses.In inflamed IBD tissue,an imbalance between T helper(Th)and regulatory T lymphocytes and Th cytokine levels was found.The S1P/S1PR signaling axis and metabolism have been linked to inflammatory responses in IBD.S1P modulators targeting S1PRs and S1P metabolism have been developed and shown to regulate inflammatory responses by affecting lymphocyte trafficking,lymphocyte number,lymphocyte activity,cytokine production,and contributing to gut barrier function.
文摘BACKGROUND The clinical trend and characteristics of peptic ulcer disease(PUD)have not fully been investigated in the past decade.AIM To evaluate the changing trends and characteristics of PUD according to age and METHODS We analyzed seven hospital databases converted into the Observational Medical Outcomes Partnership-Common Data Model between 2010 and 2019.We classified patients with PUD who underwent rapid urease tests or Helicobacter pylori(H.pylori)serology into three groups:H.pylori-related,drug[nonsteroidal anti-inflammatory drugs(NSAIDs)or aspirin]-related,and idiopathic(H.pylori/NSAID/aspirin-negative)PUD and compared the yearly trends and characteristics among the three groups.RESULTS We included 26785 patients in 7 databases,and the proportion of old age(≥65 years)was 38.8%.The overall number of PUD exhibited no decrease,whereas PUD in old age revealed an increasing trend(P=0.01 for trend).Of the 19601 patients,41.8%had H.pylori-related,36.1%had drug-related,and 22.1%had idiopathic PUD.H.pylorirelated PUD exhibited a decreasing trend after 2014(P=0.01),drug-related PUD demonstrated an increasing trend(P=0.04),and idiopathic PUD showed an increasing trend in the old-age group(P=0.01)during 10 years.Patients with drug-related PUD had significantly more comorbidities and concomitant ulcerogenic drugs.The idiopathic PUD group had a significantly higher number of patients with chronic liver disease.CONCLUSION With the aging population increase,the effects of concomitant ulcerogenic drugs and preventive strategies should be investigated in drug-induced PUD.Further studies are required to clarify the relationship between idiopathic PUD and chronic liver disease.
基金reviewed and approved by the Jeonbuk National University Hospital Institutional Review Board,No.2021-07-005.
文摘BACKGROUND Hepatobiliary scintigraphy(HBS)is a useful diagnostic imaging technique that uses radiotracers to evaluate the function of the gallbladder(GB)and biliary system.In segmented GB,some HBS images reveal a discordant GB boundary as compared to anatomical images.AIM To evaluate the characteristics of HBS in segmented GB and determine the clinical relevance according to HBS characteristics.METHODS A total of 268 patients with chronic cholecystitis,gallstones,or biliary colic symptoms who underwent HBS between 2011 and 2020 were enrolled.Segmented GB was defined as segmental luminal narrowing of the GB body on computed tomography(CT)or magnetic resonance(MR)images,and HBS was examined 1 mo before or after CT or MR.Segmented GB was classified into 3 types based on the filling and emptying patterns of the proximal and distal segments according to the characteristics of HBS images,and GB ejection fraction(GBEF)was identified:Type 1 was defined as a normal filling and emptying pattern;Type 2 was defined as an emptying defect on the distal segment;and Type 3 was defined as a filling defect in the distal segment.RESULTS Segmented GB accounted for 63 cases(23.5%),including 36 patients(57.1%)with Type 1,18 patients(28.6%)with Type 2,and 9 patients(14.3%)with Type 3 emptying pattern.Thus,approximately 43%of HBS images showed a discordant pattern as compared to anatomical imaging of segmented GB.Although there were no significant differences in clinical symptoms,rate of cholecystectomy,or pathological findings based on the type,most gallstones occurred in the distal segment.Reported GBEF was 62.50%±24.79%for Type 1,75.89%±17.21%for Type 2,and 88.56%±7.20%for Type 3.Type 1 showed no difference in reported GBEF compared to the non-segmented GB group(62.50%±24.79%vs 67.40%±21.78%).In contrast,the reported GBEF was higher in Types 2 and 3 with defective emptying and filling when compared to Type 1(80.11%±15.70%vs 62.57%±24.79%;P=0.001).CONCLUSION In segmented GB,discordance in the filling patterns detected by HBS and anatomical imaging could lead to misinterpretation of GBEF.For this reason,clinicians should be cautious when interpreting HBS results in patients with segmented GB.
文摘The intestinal lumen harbors a diverse consortium of microorganisms that participate in reciprocal crosstalk with intestinal immune cells and with epithelial and endothelial cells,forming a multi-layered barrier that enables the efficient absorption of nutrients without an excessive influx of pathogens.Despite being a lung-centered disease,severe coronavirus disease 2019(COVID-19)affects multiple systems,including the gastrointestinal tract and the pertinent gut barrier function.Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)can inflict either direct cytopathic injury to intestinal epithelial and endothelial cells or indirect immune-mediated damage.Alternatively,SARS-CoV-2 undermines the structural integrity of the barrier by modifying the expression of tight junction proteins.In addition,SARS-CoV-2 induces profound alterations to the intestinal microflora at phylogenetic and metabolomic levels(dysbiosis)that are accompanied by disruption of local immune responses.The ensuing dysregu-lation of the gut-lung axis impairs the ability of the respiratory immune system to elicit robust and timely responses to restrict viral infection.The intestinal vasculature is vulnerable to SARS-CoV-2-induced endothelial injury,which simultaneously triggers the activation of the innate immune and coagulation systems,a condition referred to as“immunothrombosis”that drives severe thrombotic complications.Finally,increased intestinal permeability allows an aberrant dissemination of bacteria,fungi,and endotoxin into the systemic circulation and contributes,to a certain degree,to the over-exuberant immune responses and hyper-inflammation that dictate the severe form of COVID-19.In this review,we aim to elucidate SARS-CoV-2-mediated effects on gut barrier homeostasis and their implications on the progression of the disease.
文摘BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from centers or analysis of large databases.Although a meta-analysis has shown fewer adverse events as a composite(bleeding,pancreatitis,Perf)during ERCP performed at high-volume centers,there is very little real-world data on endoscopist and center procedural volumes,ERCP duration and complexity on the occurrence of Perf.AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume,ERCP time,and complexity from a national endoscopic repository.Patients from clinical outcomes research initiative-national endoscopic database(2000-2012)who underwent ERCP were stratified based on the endoscopist and center volume(quartiles),and total procedure duration and complexity grade of the ERCP based on procedure details.The effects of these variables on the Perf that occurred were studied.Continuous variables were compared between Perf and no perforations(NoPerf)using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.RESULTS A total of 14153 ERCPs were performed by 258 endoscopists,with 20 reported Perf(0.14%)among 16 endoscopists.Mean patient age in years 61.6±14.8 vs 58.1±18.8(Perf vs.NoPerf,P=NS).The cannulation rate was 100%and 91.5%for Perf and NoPerf groups,respectively.13/20(65%)of endoscopists were high-volume performers in the 4th quartile,and 11/20(55%)of Perf occurred in centers with the highest volumes(4th quartile).Total procedure duration in minutes was 60.1±29.9 vs 40.33±23.5(Perf vs NoPerf,P<0.001).Fluoroscopy duration in minutes was 3.3±2.3 vs 3.3±2.6(Perf vs NoPerf P=NS).50%of the procedures were complex and greater than grade 1 difficulty.3/20(15%)patients had prior biliary surgery.13/20(65%)had sphincterotomies performed with stent insertion.Peritonitis occurred in only 1/20(0.5%).CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers.However,Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.
文摘Inflammasomes are multiprotein intracellular complexes which are responsible for the activation of inflammatory responses. Among various subtypes of inflammasomes, NLRP3 has been a subject of intensive investigation. NLRP3 is considered to be a sensor of microbial and other danger signals and plays a crucial role in mucosal immune responses, promoting the maturation of proinflammatory cytokines interleukin 1β(IL-1β) and IL-18. NLRP3 inflammasome has been associated with a variety of inflammatory and autoimmune conditions, including inflammatory bowel diseases(IBD). The role of NLRP3 in IBD is not yet fully elucidated as it seems to demonstrate both pathogenic and protective effects. Studies have shown a relationship between genetic variants and mutations in NLRP3 gene with IBD pathogenesis. A complex interaction between the NLRP3 inflammasome and the mucosal immune response has been reported. Activation of the inflammasome is a key function mediated by the innate immune response and in parallel the signaling through IL-1β and IL-18 is implicated in adaptive immunity. Further research is needed to delineate the precise mechanisms of NLRP3 function in regulating immune responses. Targeting NLRP3 inflammasome and its downstream signaling will provide new insights into the development of future therapeutic strategies.
基金Supported by(in part)Grants from the Kaohsiung Medical University"Aim for the Top Universities Grant",grant No.KMU-TP104G00,No.KMU-TP104G03 and No.KMUTP104E25Ten Chan General Hospital,Chung-Li and KMU Joint Research Project,No.ST102004Kaohsiung Medical University Hospital,No.KMUH100-0R01
文摘Accurate diagnosis of Helicobacter pylori(H. pylori) infection is a crucial part in the effective management of many gastroduodenal diseases. Several invasive and non-invasive diagnostic tests are available for the detection of H. pylori and each test has its usefulness and limitations in different clinical situations. Although none can be considered as a single gold standard in clinical practice,several techniques have been developed to give the more reliable results. Invasive tests are performed via endoscopic biopsy specimens and these tests include histology,culture,rapid urease test as well as molecular methods. Developments of endoscopic equipment also contribute to the real-time diagnosis of H. pylori during endoscopy. Urea breathingtest and stool antigen test are most widely used noninvasive tests,whereas serology is useful in screening and epidemiological studies. Molecular methods have been used in variable specimens other than gastric mucosa. More than detection of H. pylori infection,several tests are introduced into the evaluation of virulence factors and antibiotic sensitivity of H. pylori,as well as screening precancerous lesions and gastric cancer. The aim of this article is to review the current options and novel developments of diagnostic tests and their applications in different clinical conditions or for specific purposes.
基金Supported by Grant,NIDDK,RO1DK63618 to KMD from the National Institutes of Health,Bethesda,MD
文摘Helicobacter pylori (H. pylori) infection is well known to be associated with the development of precancerous lesions such as chronic atrophic gastritis (AG), or gastric intestinal metaplasia (GIM), and cancer. Various molecular alterations are identified not only in gastric cancer (GC) but also in precancerous lesions. H. pylori treatment seems to improve AG and GIM, but still remains controversial. In contrast, many studies, including meta-analysis, show that H. pylori eradication reduces GC. Molecular markers detected by genetic and epigenetic alterations related to carcinogenesis reverse following H. pylori eradication. This indicates that these changes may be an important factor in the identification of high risk patients for cancer development. Patients who underwent endoscopic treatment of GC are at high risk for development of metachronous GC. A randomized controlled trial from Japan concluded that prophylactic eradication of H. pylori after endoscopic resection should be used to prevent the development of metachronous GC, but recent retrospective studies did not show the tendency. Patients with precancerous lesions (molecular alterations) that do not reverse after H. pylori treatment, represent the “point of no return” and may be at high risk for the development of GC. Therefore, earlier H. pylori eradication should be considered for preventing GC development prior to the appearance of precancerous lesions.
文摘Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
基金Supported by A Grant of the Korea Healthcare Technology R and D Project,Ministry of Health and Welfare,South Korea, A102065
文摘AIM:To investigate the diagnostic performance of acoustic radiation force impulse(ARFI) elastography for characterizing focal liver mass by quantifying their stiffness.METHODS:This prospective study included 62 patients with a focal liver mass that was well visualized on conventional ultrasonography performed in our institution from February 2011 to November 2011.Among them,12 patients were excluded for ARFI measurement failure due to a lesion that was smaller than the region of the interest and at an inaccessible location(deeper than 8 cm)(n = 7) or poor compliance to hold their breath as required(n = 5).Finally,50 patients with valid ARFI measurements were enrolled.If a patient had multiple liver masses,only one mass of interest was chosen.The masses were diagnosed by histological examination or clinical diagnostic criteria.During ultrasonographic evaluation,stiffness,expressed as velocity,was checked 10 times per focal liver mass and the surrounding liver parenchyma.RESULTS:After further excluding three masses that were non-diagnostic on biopsy,a total of 47 focal mass lesions were tested,including 39(83.0%) malignant masses [24 hepatocellular carcinomas(HCC),seven cholangiocellular carcinomas(CCC),and eight liver metastases] and eight(17.0%) benign masses(five hemangiomas and three focal nodular hyperplasias,FNH).Thirty-seven(74.0%) masses were confirmed by histological examination.The mean velocity was 2.48 m/s in HCCs,1.65 m/s in CCCs,2.35 m/s in metastases,1.83 m/s in hemangiomas,and 0.97 m/s in FNHs.Although considerable overlap was still noted between malignant and benign masses,significant differences in ARFI values were observed between malignant and benign masses(mean 2.31 m/s vs 1.51 m/s,P = 0.047),as well as between HCCs and benign masses(mean 2.48 m/s vs 1.51 m/s,P = 0.006).The areas under the receiver operating characteristics curves(AUROC) for discriminating the malignant masses from benign masses was 0.724(95%CI,0.566-0.883,P = 0.048),and the AUROC for discriminating HCCs from benign masses was 0.813(95%CI,0.649-0.976,P = 0.008).To maximize the sum of sensitivity and specificity,an ARFI value of 1.82 m/s was selected as the cutoff value to differentiate malignant from benign liver masses.Furthermore,the cutoff value for distinguishing HCCs from benign masses was also determined to be 1.82 m/s.The diagnostic performance of the sum of the ARFI values for focal liver masses and the surrounding liver parenchyma to differentiate liver masses improved(AUROC = 0.853;95%CI,0.745-0.960;P = 0.002 in malignant liver masses vs benign ones and AUROC = 0.948;95%CI,0.896-0.992,P < 0.001 in HCCs vs benign masses).CONCLUSION:ARFI elastography provides additional information for the differential diagnosis of liver masses.However,our results should be interpreted in clinical context,because considerable overlap in ARFI values existed among liver masses.
文摘AIM To investigated the prognostic value of the neutrophillymphocyte ratio(NLR) in patients with acute pancreatitis and determined an optimal cut-off value for the prediction of adverse outcomes in these patients.METHODS We retrospectively analyzed 490 patients with acute pancreatitis diagnosed between March 2007 and December 2012. NLRs were calculated at admission and 24, 48, and 72 h after admission. Patients were grouped according to acute pancreatitis severity and organ failure occurrence, and a comparative analysis was performed to compare the NLR between groups. RESULTS Among the 490 patients, 70 had severe acute pancreatitis with 31 experiencing organ failure. The severe acute pancreatitis group had a significantly higher NLR than the mild acute pancreatitis group on all 4 d(median, 6.14, 6.71, 5.70, and 4.00 vs 4.74, 4.47, 3.20, and 3.30, respectively, P < 0.05). The organ failure group had a significantly higher NLR than the group without organ failure on all 4 d(median, 7.09, 6.72, 6.27, and 6.24 vs 4.85, 4.49, 3.35, and 2.34, respectively, P < 0.05). The optimal cut-off value for baseline NLR was 4.76 in predicting severity and 4.88in predicting organ failure in acute pancreatitis. CONCLUSION Elevated baseline NLR correlates with severe acute pancreatitis and organ failure.
文摘To clarify the role of neoadjuvant concurrent chemoradiotherapy (NACCRT) followed by surgical resection for localized or locally advanced perihilar cholangiocarcinoma (CCA).METHODSWe retrospectively reviewed 57 patients who underwent surgical resection with or without NACCRT for perihilar CCA; 12 patients received NACCRT and 45 patients did not received NACCRT. Patients with locally advanced perihilar CCA requiring NACCRT were defined as follows: (1) a mass involving unilateral branches of the portal vein or hepatic artery with insufficient volume of the anticipated remnant lobe; or (2) an infiltrating mass in the main portal vein that was too long for reconstruction, identified at preoperative staging.RESULTSThe median disease-free survival (DFS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 26.0 and 15.1 mo, respectively (P = 0.91). The median overall survival (OS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 32.9 and 27.1 mo, respectively (P = 0.26). The NACCRT group showed a downstaging tendency compared to the non-NACCRT group as compared with the tumor stage confirmed by histological examination after surgery and the tumor stage confirmed by imaging test at the time of diagnosis (P = 0.01).CONCLUSIONNACCRT does not prolong DFS and OS in localized or locally advanced perihilar CCA. However, NACCRT may allow tumor downstaging and improve tumor resectability.
文摘Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.
文摘AIM:To evaluate the efficacy of cola treatment for gastric phytobezoars,including diospyrobezoars.METHODS:A total of 17 patients(range:48 to 78 years) with symptomatic gastric phytobezoars treated with cola and adjuvant endoscopic therapy were reviewed.Three liters of cola lavage(10 cases) or drink(7 cases) were initially used,and then endoscopic fragmentation was done for the remnant bezoars by using a lithotripsy basket or a polypectomy snare.The overall success of dissolving a gastric phytobezoars with using three liters of cola and the clinical and endoscopic findings were compared retrospectively between four cases of complete dissolution by using only cola and 13 cases of partial dissolution with cola.RESULTS:After 3 L of cola lavage or drinking,a complete dissolution of bezoars was achieved in four patients(23.5%),while 13 cases(76.5%) were only partially dissolved.Phytobezoars(4 of 6 cases) were observed more frequently than diospyrobezoars(0 of 11) in the group that underwent complete dissolution(P = 0.006).Gender,symptom duration,size of bezoar and method of cola administration were not significantly different between the two groups.Twelve of 13 patients with residual bezoars were completely treated with a combination of cola and endoscopic fragmentation.CONCLUSION:The rate of complete dissolution with three liters of cola was 23.5%,but no case of diospyrobezoar was completely dissolved using this method.However,pretreatment with cola may be helpful and facilitate endoscopic fragmentation of gastric phytobezoars.
文摘AIM To evaluate the prognostic value of the neutrophil-tolymphocyte ratio(NLR) and platelet-to-lymphocyte ratio(PLR) in patients with colorectal cancer(CRC).METHODS Between April 1996 and December 2010, medical records from a total of 1868 patients with CRC were retrospectively reviewed. The values of simple inflammatory markers including NLR and PLR in predicting the long-term outcomes of these patients were evaluated using Kaplan-Meier curves and Cox regression models.RESULTS The median follow-up duration was 46 mo(interquartile range, 22-73). The estimation of NLR and PLR was based on the time of diagnosis. In multivariate Cox regression analysis, high NLR (≥ 3.0) and high PLR(≥ 160) were independent risk factors predicting poor long-term outcomes in patients with stage Ⅲ and Ⅳ CRC. However, high NLR and high PLR were not prognostic factors in patients with stage Ⅰ and Ⅱ CRC.CONCLUSION In this study, we identified that high NLR (≥ 3.0) and high PLR (≥ 160) are useful prognostic factors to predict long-term outcomes in patients with stage Ⅲ and Ⅳ CRC.
文摘Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.
文摘AIM： To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS： This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers （spurting or oozing） were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1：10000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS： There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups （P 〈 0.05）. The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group （20.3%） than in the 30 （5.3%） and 40 mL （2.8 %） epinephrine groups （P 〈 0.01）. There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group （51/76） than in the 20 （2/76） and 30 mL （5/76） epinephrine groups （P 〈 0.001）. Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group （P 〈 0.01）. Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups （P 〈 0.01）.CONCLUSION： Injection of 30 mL diluted epinephrine （1：10000） can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer （spurting or oozing） is 30 mL.
