External validation and improvement of LiFe score as a prediction tool in critically ill cirrhosis patients.

AIM: The LiFe (liver, injury, failure, evaluation) score, calculated according to arterial lactate, total bilirubin, and international normalized ratio (INR), is a novel score for risk prediction in intensive care unit (ICU) patients with cirrhosis. The present study aimed to externally validate and optimize the LiFe score for predicting outcomes in critically ill cirrhosis patients. METHODS: The study used the single-center database Medical Information Mart for Intensive Care-III (MIMIC-III) for analysis. A total of 536 critically ill cirrhosis patients from the MIMIC-III database were analyzed. Routine clinical and laboratory variables were included to compare survivors with non-survivors. The LiFe score was then regraded into three groups to calculate the optimal cut-off values. RESULTS: In-ICU mortality occurred in 169 (31.5%) of the patients. Survivor and non-survivor cohorts were similar in age, gender, and etiology of cirrhosis. Multivariate analyses of in-ICU mortality identified four independent variables: total bilirubin, creatinine, INR, and arterial lactate. An external validation of the LiFe score showed good accuracy for predicting in-ICU mortality with an area under the receiver operating characteristic curve of 0.708. In addition, a significant positive correlation exists between LiFe score and acute-on-chronic liver failure grade (r = 0.393, P < 0.001). A log-rank test comparing the strata of simplified LiFe scores found that in-ICU mortality rates were 16.8%, 27.7%, and 51.7%, respectively, among patients in the three simplified risk categories. CONCLUSIONS: The LiFe score, based on laboratory tests, can be useful as a preliminary and convenient scoring tool in a broad cohort of critically ill cirrhosis patients. Simplified risk categories to stratify patients into three groups improves its feasibility and generalizability for clinical application.

Is It Necessary to Intubate the Cecum to Examine the Whole Colorectum During Endoscopic Polypectomy?

BACKGROUND The official guidelines are unclear about whether endoscopic polypectomy should intubate the whole cecum or just intubate the location of the endoscopy inspection. Therefore, the objective of this study was to provide a new perspective of assisting endoscopists make better decisions and decrease the missing detection rate in clinical practice. MATERIAL AND METHODS We retrospectively reviewed records of 8923 patients who underwent endoscopic polypectomy, and 394 participants were included after screening by inclusion and exclusion criteria. We collected and analyzed data on the size, shape, and location of polyps and the clinical experience level of endoscopists in this retrospective study. RESULTS Among the 394 cases, 152 (38.6%) had additional lesions detected through the second endoscopic polypectomy after the first colonoscopy was performed, showing statistically significant differences between the missing group and non-missing group on actual polys (P<0.05). No significant differences were detected between the 2 groups (P>0.05) in age, sex, withdrawal time, and examination period. Regarding the location, 50.4% of the missing lesions were found on the relatively proximal colon of the detected polyps in the first colonoscopy. In addition, the level of experience of endoscopists was significantly different between the missing group and the non-missing group (P<0.05). CONCLUSIONS The characteristics of polyps and the level of endoscopist experience play important roles in the detection of polyps in the colorectum. Moreover, it may be necessary to intubate the cecum to examine the whole colorectum during endoscopic polypectomy.

Ling classification applied in the preoperative safety and effectiveness assessment of POEM.

BACKGROUND AND STUDY AIMS: At present, peroral endoscopic myotomy (POEM) has been considered as the recommended treatment for achalasia, as it causes trauma to a smaller area and has fewer short-term serious complications than other treatments. However, due to the different morphology of esophagus, not all the patients with achalasia are eligible to receive POEM surgery. And the purpose of our study was to apply Ling classification, which proser Linghu put forward in 2011, in the preoperative assessment of POEM, expecting to reduce the occurrence rate of complications during or post-POEM. PATIENTS AND METHODS: The clinical data of 341 achalasia patients were collected and classified, according to the endoscopic pictures related to the middle and the lower parts of the esophagus. The correlation between Ling classification and LESP or Eckardt score was analyzed for the efficiency estimation, and the correlation of Ling classification and incidence of complications was counted for the safety evaluation. RESULTS: Ling classification was correlated with the LESP of 95 patients and Eckardt score of 131 patients. Compared to preoperative data, post-POEM LESP and Eckardt score both decreased significantly in all types of Ling classification (p < 0.05), while no significant difference in the decrease degree of either LESP or Eckardt score was found among different types of Ling classification (p > 0.05). This means Ling classification may not directly affect the postoperative efficacy of POEM. By analyzing the correlation between Ling classification and intraoperative complications, we found that the differences of total complications, gas-related complication and mucosal injury were all significant among all types of Ling classification (p < 0.05). CONCLUSIONS: Ling classification can be applied in the preoperative assessment of the safety and efficacy of POEM, and it might provide a guideline for how to reduce the complications during POEM surgery.

Peroral endoscopic myotomy can improve esophageal motility in patients with achalasia from a large sample self-control research (66 patients).

BACKGROUND: Peroral endoscopic myotomy (POEM) as a new approach to achalasia attracts broad attention. The primary objective of this study was to evaluate the results with esophageal motility after POEM through the first large sample clinical research. PATIENTS AND METHODS: We have a self-control research with all patients (205 in total) who underwent POEM from 2010 to 2014 at our Digestive Endoscopic Center, 66 patients of which underwent high resolution manometry (HRM) before and after POEM in our motility laboratory. Follow-ups last for 5.6 months on average. Outcome variables analyzed included upper esophageal sphincter pressure (UESP), upper esophageal sphincter residual pressure (UESRP), lower esophageal sphincter pressure (LESP), lower esophageal sphincter residual pressure (LESRP) and esophageal body peristalsis. We have a statistical analysis to illustrate how POEM impacts on the change of esophageal motility. RESULTS: The symptoms related to dysphagia were relieved in 95% of patients in recent term after POEM. While HRM showed a statistically significant reduction of URSRP, LESP and LESRP (P<0.01), however, peristalsis was not consistently affected. There were 11 patients who had undergone other prior endoscopic treatment (endoscopic dilation or botulinum toxin injection) and 55 patients had not. The statistical difference (P>0.05) did not occur for these two groups on LESP and LESRP reduction. CONCLUSIONS: POEM clearly relieved the symptoms related to dysphagia by lowering the pressure of upper esophageal sphincter (UES) and lower esophageal sphincter (LES),and other endoscopic treatment before POEM did not affect the improvement of LES pressure. These results are concluded from our short-term follow-up study, while the long-term efficacy remains to be further illustrated. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR-TRC-12002204).