T-bet interferes with PD-1/PD-L1-mediated suppression of CD4+ T cell inflammation and survival in Crohn's disease.

Pathogenic inflammation mediated by overactive type 1 helper T cell (Th1) responses could exacerbate and perpetuate Crohn's disease. Programmed death (PD)-1 and its ligand PD-L1 pathway could be upregulated to suppress inflammation. We wondered why this pathway is ineffective at suppressing pathogenic Th1 inflammation in Crohn's disease patients. Here, we found that overexpression of T-bet via transfection significantly reduced the expression of PD-1. PD-L1 was capable of suppression proinflammatory CD4+ T cells, but T-bet transfection significantly reduced the susceptibility of CD4+ T cells toward PD-L1-mediated suppression, evidenced by the observations that at low PD-L1 concentration T-bet transfected and mock transfected CD4+ T cells presented comparable IL-2 production, but at high PD-L1 concentration, T-bet transfected CD4+ T cells presented significantly higher IL-2 than mock transfected CD4+ T cells. PD-L1 could significantly reduce the survival of CD4+ T cells from Crohn's disease patients, but interestingly, in the absence of PD-L1, the survival was better in mock transfected CD4+ T cells, while in the presence of PD-L1, the survival was better in T-bet transfected CD4+ T cells. Crohn's disease patients with greater severity presented higher T-bet expression and lower PD-1 expression in CD4+ T cells, demonstrating an association between T-bet expression and disease progression. We also discovered that stimulation with bacterial antigens could upregulate the expression of T-bet. Together, this study demonstrated that T-bet overexpression could interfere with PD-1/PD-L1-mediated suppression of CD4+ T cell inflammation and survival, and potentially contributed to the development and persistence of Crohn's disease.

Use of the Conventional Side-viewing Duodenoscope for Successful Endoscopic Retrograde Cholangiopancreatography in Postgastrectomy Patients.

OBJECTIVES: The aim of this study was to evaluate the usefulness of the conventional side-viewing duodenoscope for successful endoscopic retrograde cholangiopancreatography (ERCP) in postgastrectomy patients. METHODS: A total of 220 consecutive patients with bile duct stones or a distal common bile duct stricture who had previously undergone gastrectomy and were referred for ERCP were analyzed for the outcome of their ERCP. All ERCP procedures were performed using a conventional side-viewing duodenoscope. In patients who had undergone a Billroth II gastroenterostomy and total gastrectomy with Roux-en-Y reconstruction, we also used the procedure of retrieval balloon-assisted enterography. RESULTS: The study group included 220 patients who had previously undergone gastrectomy (77 women and 143 men; mean age, 72.2 y; range, 11 to 93 y). The overall enterography success rate was 90.5% (199/220), and the diagnostic and ERCP success rates were both 88.6% (195/220). Endoscopy was unsuccessful in 21 patients who received Billroth II gastroenterostomy and Roux-en-Y reconstruction. After successful endoscopy, diagnostic and ERCP success was not achieved in 4 patients with Billroth II gastroenterostomy, with or without Braun anastomosis, due to cannulation failure. The procedure-related complication rate was 5.5% (12/220), including immediate bleeding (0.9%, 2/220), pancreatitis (4.1%, 9/220), and perforation (0.5%, 1/220). There were no procedure-related deaths. CONCLUSIONS: The side-viewing duodenoscope is a useful instrument for performing successful ERCP in patients postgastrectomy. In addition, retrieval balloon-assisted enterography may improve the enterography success rate in postgastrectomy patients with Billroth II and Roux-en-Y reconstruction.

Bufalin induces cell cycle arrest and apoptosis in gallbladder carcinoma cells.

Bufalin, a major digoxin-like immunoreactive component of the Chinese medicine Chan Su, has been shown to exert a potential for anticancer activity against various human cancer cell lines in vitro. However, no detailed studies have so far been reported on its action on human gallbladder carcinoma cells. In this study, bufalin remarkably inhibited growth in human gallbladder cancer cells by decreasing cell proliferation, inducing cell cycle arrest and apoptosis in a dose-dependent manner. Bufalin also disrupted the mitochondrial membrane potential (ΔΨm) and regulated the expression of cell cycle and apoptosis regulatory molecules. Activation of caspase-9 and the subsequent activation of caspase-3 indicated that bufalin may be inducing mitochondria apoptosis pathways. Intraperitoneal injection of bufalin for 3 weeks significantly inhibited the growth of gallbladder carcinoma (GBC-SD) xenografts in athymic nude mice. Taken together, the results indicate that bufalin may be a potential agent for the treatment of gallbladder cancer.

B cells in Crohn's patients presented reduced IL-35 expression capacity.

Interleukin (IL)-35 has capacity to ameliorate experimental colitis and is upregulated in immune cells from active Crohn's disease (CD) patients. Nonetheless, CD continues to be an incurable disease with characteristics of chronic relapsing-remitting inflammation. In this study, we investigated the production of IL-35 by B cells from active CD patients and non-CD controls. Immediately ex vivo, the mRNA transcription of IL-12/IL-35 subunit IL12A was significantly higher in CD B cells than in control B cells, and the mRNA transcription of IL-27/IL-35 subunit EBI3 was significantly higher in mild CD and moderate CD B cells than in control B cells. However, we also found that CpG-activated B cells and BCR + CD40-activated B cells from CD subjects presented significantly lower IL12A and lower EBI3 transcription than their counterparts from control subjects. We further evaluated IL-35 protein secretion and confirmed that B cell-mediated IL-35 protein secretion was lower in CD patients than in controls. However, IL-35-Fc preconditioning was able to significantly increase IL-35 production from B cells and to eliminate the difference in IL-35 production capacity between controls and CD patients. Furthermore, these IL-35-Fc-preconditioned B cells were able to suppress IFN-γ and IL-17 production from CD4+CD25- T cells more potently than Fc control-preconditioned B cells. Rh IL-27Rα-Fc, a soluble form of B cell-specific IL-35 receptor, significantly increased IFN-γ and IL-17 production. Together, these data supported a role of B cell-mediated IL-35 in suppressing IFN-γ and IL-17 inflammation. However, despite the fact that CD B cells presented higher transcription of IL-35 subunits directly ex vivo, CD B cells also presented reduced capacity for further IL-35 production upon activation.

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration.

BACKGROUND: Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown. AIM: To explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China. METHODS: This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated. RESULTS: Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred. CONCLUSION: Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

Optimal dilation time for combined small endoscopic sphincterotomy and balloon dilation for common bile duct stones: a multicentre, single-blinded, randomised controlled trial.

BACKGROUND: Endoscopic sphincterotomy is the established treatment for common bile duct stones. Balloon dilation offers an alternative. Prolonged dilation (300 s) with a 10 mm diameter balloon decreases the occurrence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We aimed to determine the optimal duration of dilation for combined endoscopic sphincterotomy and balloon dilation for the removal of common bile duct stones. METHODS: We did a multicentre, single-blinded, randomised controlled trial at 15 tertiary surgical centres in China. Eligible patients (≥18 years) with native papilla and common bile duct stones (≤1·5 cm in size and <2 cm in diameter) undergoing ERCP were randomly assigned (1:1:1:1:1) to receive balloon dilation for 0, 30, 60, 180, or 300 s after deep bile duct cannulation. Randomisation was done by an independent statistician using a computer-generated randomisation list with a block size of ten, stratified by centre. Patients and outcome assessors, but not endoscopists and investigators, were masked to treatment allocation. Balloon dilation was done with controlled radial expansion balloons according to common bile duct stone size. Stones were removed using stone retrieval balloons or baskets. The primary endpoint was overall frequency of post-ERCP pancreatitis. The primary efficacy analysis and safety analyses were done in the modified intention-to-treat population, which included all randomly assigned patients with successful cannulation, but excluded those who withdrew consent after randomisation. This study was registered with ClinicalTrials.gov, number NCT02510495, and is complete. FINDINGS: Between July 29, 2015, and Dec 1, 2017, 3721 consecutive patients with common bile duct stones were recruited, 1718 of whom were excluded. The remaining 2003 patients underwent a small (3-5 mm) endoscopic sphincterotomy. 83 patients withdrew consent after the ERCP procedure, thus 1920 patients were included in the modified intention-to-treat analysis (0 s [n=371], 30 s [n=384], 60 s [n=388], 180 s [n=390], and 300 s [n=387]). Overall, post-ERCP pancreatitis occurred in 199 (10%) of 1920 patients (44 [12%] patients in the 0 s group, 28 [7%] in the 30 s group, 32 [8%] in the 60 s group, 36 [9%] in the 180 s group, and 59 [15%] in the 300 s group). Prolonged dilation (300 s) significantly increased the occurrence of post-ERCP pancreatitis compared with shorter balloon dilation (p=0·002). The frequency of post-ERCP pancreatitis was significantly lower in the 30, 60, and 180 s groups than in the 300 s group (relative risk [RR] 0·48, 95% CI 0·31-0·73; p=0·0005 vs the 30 s group; 0·54, 0·36-0·81; p=0·003 vs the 60 s group; 0·61, 0·41-0·89; p=0·01 vs the 180 s group). The frequency of post-ERCP pancreatitis was significantly higher in the 0 s group than the 30 s group (RR 1·62, 1·04-2·56; p=0·03). No difference in stone extraction (all ≥90%) was observed between groups. Following ERCP, 90 (5%) of 1920 patients had acute cholangitis, 14 (<1%) had acute cholecystitis, and five (<1%) had gastrointestinal bleeding, with no significant differences between groups. One (<1%) patient had Stapfer II perforation, which resolved spontaneously with conservative treatment. INTERPRETATION: A balloon dilation time of 30 s for combined endoscopic sphincterotomy and balloon dilation reduced the frequency of post-ERCP pancreatitis and was determined to be the optimum dilation time for the removal of common bile duct stones. FUNDING: National Natural Science Foundation of China, Gansu Competitive Foundation Projects for Technology Development and Innovation.

Laparoscopic-assisted versus open distal gastrectomy with D2 lymph node resection for advanced gastric cancer: effect of learning curve on short-term outcomes. a meta-analysis.

Laparoscopic-assisted distal gastrectomy (LADG) with D2 resection is gradually being performed for treating advanced gastric cancer. This meta-analysis aims to compare the clinical outcomes between LADG and open distal gastrectomy (ODG) when considering the impact of the learning curve. The PubMed, Embase, and ISI databases and the Cochrane Library were electronically searched. Randomized controlled trails and retrospective comparative studies published between 1994 and 2013 were collected. We divided the included studies into two subgroups according to whether the authors had experience of at least or fewer than 40 cases of LADG with D2 resection and then compared the operative time, intraoperative bleeding, the amount of resected lymph nodes, short-term recovery parameters, and complications between LADG and ODG groups. Ten comparative studies including 1100 patients were selected. Meta-analysis showed that when LADG was compared with ODG, surgeons with experience of at least 40 cases could achieve more resected lymph nodes (P=.002), reduced time to flatus (P<.0001), shortened time to liquid diet (P<.00001), and lower complication rates (P=.02). However, the above advantages of LADG faded in the subgroup of surgeons with experience of fewer than 40 cases. Our meta-analysis suggested that the learning curve has significant effects on most of the important surgical and short-term recovery outcome parameters. Accomplishment of 40 cases of LADG with D2 lymphadenectomy is required to achieve optimum proficiency.

Retrieval-balloon-assisted enterography for ERCP after Billroth II gastroenterostomy and Braun anastomosis.

AIM: To describe an optimal route to the Braun anastomosis including the use of retrieval-balloon-assisted enterography. METHODS: Patients who received a Billroth II gastroenterostomy (n = 109) and a Billroth II gastroenterostomy with Braun anastomosis (n = 20) between January 2009 and May 2013 were analyzed in this study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed under fluoroscopic control using a total length of 120 cm oblique-viewing duodenoscope with a 3.7-mm diameter working channel. For this procedure, we used a triple-lumen retrieval balloon catheter in which a 0.035-inch guidewire could be inserted into the "open-channel" guidewire lumen while the balloon could be simultaneously injected and inflated through the other 2 lumens. RESULTS: For the patients with Billroth II gastroenterostomy and Braun anastomosis, successful access to the papilla was gained in 17 patients (85%) and there was therapeutic success in 16 patients (80%). One patient had afferent loop perforation, but postoperative bleeding did not occur. For Billroth II gastroenterostomy, there was failure in accessing the papilla in 15 patients (13.8%). ERCP was unsuccessful because of tumor infiltration (6 patients), a long afferent loop (9 patients), and cannulation failure (4 patients). The papilla was successfully accessed in 94 patients (86.2%), and there was therapeutic success in 90 patients (82.6%). Afferent loop perforation did not occur in any of these patients. One patient had hemorrhage 2 h after ERCP, which was successfully managed with conservative treatment. CONCLUSION: Retrieval-balloon-assisted enterography along an optimal route may improve the ERCP success rate after Billroth II gastroenterostomy and Braun anastomosis.

ERCP for patients who have undergone Billroth II gastroenterostomy and Braun anastomosis.

Endoscopic retrograde cholangiopancreatography (ERCP) is efficacious in patients who have undergone Billroth II gastroenterostomies, but the success rate decreases in patients who also have experienced Braun anastomoses. There are currently no reports describing the preferred enterography route for cannulation in these patients. We first review the patient's previous surgery records, which most often indicate that the efferent loop is at the greater curvature of the stomach. We recommend extending the duodenoscope along the greater curvature of the stomach and then advancing it through the "lower entrance" at the site of the gastrojejunal anastomosis, along the efferent loop, and through the "middle entrance" at the site of the Braun anastomosis to reach the papilla of Vater. Ten patients who had each undergone Billroth II gastroenterostomy and Braun anastomosis between January 2009 and December 2011 were included in our study. The overall success rate of enterography was 90% for the patients who had undergone Billroth II gastroenterostomy and Braun anastomosis, and the therapeutic success rate was 80%. We believe that this enterography route for ERCP is optimal for a patient who has had Billroth II gastroenterostomy and Braun anastomosis and helps to increase the success rate of the procedure.

Radiofrequency ablation versus resection for colorectal cancer liver metastases: a meta-analysis.

BACKGROUND: No randomized controlled trial (RCT) has yet been performed to provide the evidence to clarify the therapeutic debate on liver resection (LR) and radiofrequency ablation (RFA) in treating colorectal liver metastases (CLM). The meta-analysis was performed to summarize the evidence mostly from retrospective clinical trials and to investigate the effect of LR and RFA. METHODOLOGY/PRINCIPAL FINDINGS: Systematic literature search of clinical studies was carried out to compare RFA and LR for CLM in Pubmed, Embase and the Cochrane Library Central databases. The meta-analysis was performed using risk ratio (RR) and random effect model, in which 95% confidence intervals (95% CI) for RR were calculated. Primary outcomes were the overall survival (OS) and disease-free survival (DFS) at 3 and 5 years plus mortality and morbidity. 1 prospective study and 12 retrospective studies were finally eligible for meta-analysis. LR was significantly superior to RFA in 3 -year OS (RR 1.377, 95% CI: 1.246-1.522); 5-year OS (RR: 1.474, 95%CI: 1.284-1.692); 3-year DFS (RR 1.735, 95% CI: 1.483-2.029) and 5-year DFS (RR 2.227, 95% CI: 1.823-2.720). The postoperative morbidity was higher in LR (RR: 2.495, 95% CI: 1.881-3.308), but no significant difference was found in mortality between LR and RFA. The data from the 3 subgroups (tumor<3 cm; solitary tumor; open surgery or laparoscopic approach) showed significantly better OS and DFS in patients who received surgical resection. CONCLUSIONS/SIGNIFICANCES: Although multiple confounders exist in the clinical trials especially the bias in patient selection, LR was significantly superior to RFA in the treatment of CLM, even when conditions limited to tumor<3 cm, solitary tumor and open surgery or laparoscopic (lap) approach. Therefore, caution should be taken when treating CLM with RFA before more supportive evidences for RFA from RCTs are obtained.