Endoscopic stenting for laparoscopic sleeve gastrectomy leaks.

OBJECTIVE: Laparoscopic sleeve gastrectomy is a widely accepted and effective bariatric surgery method. The rate of leakage at the staple-line has been reported to be between 1.5 and 5%. Aside from the use of percutaneous drainage, re-laparoscopy, or abdominal sepsis control by laparotomy, endoscopic esophagogastric stent placement is increasingly preferred as a treatment method. Because laparoscopic sleeve gastrectomy is a widely used modality in our hospital, we aimed to evaluate the rate of leaks and the results of stent placements in our patients. MATERIAL AND METHODS: Between January 1st 2010 and August 31st 2014, laparoscopic sleeve gastrectomy was performed on 236 patients by three surgeons. The demographic information and postoperative discharge summaries were collected and analyzed with the permission of the hospital ethics committee. Information about leak treatment management was also collected. RESULTS: Leaks after laparoscopic sleeve gastrectomy in four patients were stented in the first postoperative month. Short (12 cm) Hanora® (M.I.Tech, Gyeonggi-do, Korea) self-expandable coated stents were placed in two patients, and long (24 cm) Hanora® self-expandable coated stents were placed in the other two. The stents were removed after one month in two patients, two and a half months later in one, and five months later in another patient. The leaks were demonstrated to be healed in all patients after stent removal. Endoscopic stent revision was performed in one patient due to migration of the stent and in another for stent breakage. CONCLUSION: The success rate of treatment of leaks after laparoscopic sleeve gastrectomy by stent placement has been variable in the literature. The success in early stent placement has been shown to be related to physician expertise. According to the results of our patients, we suggest that endoscopic stent placement in the early stage after controlling sepsis is an effective method in the management of leaks.

High prevalence of muscle weakness and probable sarcopenia in patients with inflammatory bowel disease.

BACKGROUND: This study aimed to determine the prevalence of probable sarcopenia and sarcopenia in patients with inflammatory bowel disease (IBD) by using the European Working Group on Sarcopenia in Older People (EWGSOP2) diagnostic criteria. METHODS: Sarcopenia was assessed by using the sequential four-step algorithm. (1) Find: Sarcopenia risk by simple clinical symptom index (strength, assistance walking, rise from a chair, climb stairs, and falls [SARC-F questionnaire]). (2) Assess: Probable sarcopenia by low muscle strength on handgrip. (3) Confirm: Confirmed sarcopenia by low appendicular skeletal muscle mass on bioimpedance analysis. (4) Severity: Severe sarcopenia by low 4-m gait speed test. RESULTS: A total of 129 adult patients with IBD younger than 65 years and 50 age- and sex-matched healthy control (HC) participants were included to the study. Handgrip strength, gait speed, and SARC-F scores were significantly lower in patients with IBD than in the HCs (P = 0.032, <0.0001, and <0.0001, respectively). Based on the EWGSOP2 definition, 17.8% of patients with IBD had probable sarcopenia, and six patients had confirmed sarcopenia. According to the ethnicity-based population thresholds, 34.9% of patients with IBD had probable sarcopenia, and two patients had confirmed sarcopenia. Corticosteroid use within the past year was identified as an independent risk factor for low muscle strength (P = 0.012; odds ratio, 4.133), along with advanced age and disease activity. CONCLUSION: One-third of the patients younger than 65 years with IBD had probable sarcopenia, defined as low muscle strength, whereas the incidence of confirmed sarcopenia remained relatively low.

Serum levels of omentin, chemerin and adipsin in patients with biopsy-proven nonalcoholic fatty liver disease.

OBJECTIVE: The novel adipokines omentin, chemerin, and adipsin are associated with insulin resistance and the components of the metabolic syndrome. We assayed circulating levels of these molecules and examined their association with clinical, biochemical, and histological phenotypes in patients with nonalcoholic fatty liver disease (NAFLD). MATERIAL AND METHODS: Serum levels of omentin, chemerin, and adipsin were assayed by enzyme-linked immunosorbent assay in 99 patients with biopsy-proven NAFLD and 75 control subjects. We analyzed associations between adipokines and the characteristics of patients with NAFLD using multivariable linear regression models. RESULTS: Adipsin levels did not differ between patients and controls, whereas both omentin and chemerin levels were significantly higher in patients with biopsy-proven NAFLD than in controls (both p values <0.001). Serum omentin levels were significantly associated with C-reactive protein (r = 0.29, p < 0.01) and the degree of hepatocyte ballooning (r = 0.27, p < 0.01), whereas chemerin showed a modest association with liver fibrosis (r = 0.22, p = 0.04). After stepwise linear regression analysis adjusting for potential confounders, serum omentin levels retained their independent significance as a predictor of hepatocyte ballooning in patients with NAFLD (ß = 1.42; t = 2.79, p < 0.01). CONCLUSIONS: Our results suggest that serum omentin levels are raised in patients with NAFLD regardless of potential confounders and represent an independent predictor of hepatocyte ballooning.

Effects of vitamin D level on survival in patients with hepatocellular carcinoma.

Background and Aim: Hepatocellular carcinoma (HCC) is a life-threatening condition of the liver, often concurrent with vitamin D deficiency. In this study, we investigated the relationship between HCC patients' vitamin D levels and overall survival. Materials and Methods: We retrospectively enrolled patients that were being followed on their HCC diagnosis. We collected and examined data on patients' 25-OH vitamin D levels one month before diagnosis or at any point thereafter. We took levels below 10 ng/mL to indicate severe deficiency, levels between 10 ng/mL and 20 ng/mL to indicate moderate deficiency, and levels between 20 ng/mL and 30 ng/mL to indicate mild deficiency. We then analyzed the effects of vitamin D levels on patients' survival for each of these brackets. Results: We included 85 patients in our survival analyses. We found 9 ng/mL to be the significant cutoff vitamin D level for survival. Vitamin D levels were lower in cases of advanced disease. Univariate analysis showed that advanced Barcelona Clinic Liver Cancer (BCLC) grades, vitamin D levels below 9 ng/mL, and alpha-fetoprotein (AFP) levels above 400 ng/dL had a negative significant effect on survival. Multivariate analysis showed that only advanced BCLC grades and AFP levels above 400 ng/dL had a negative significant effect. Conclusion: In our study's cohort, HCC grades and AFP levels had a substantial negative impact on patients' overall survival. We found no connection, however, between vitamin D levels and overall survival.

Effect of carbon dioxide versus room air insufflation on post-colonoscopic pain: A prospective, randomized, controlled study.

BACKGROUND/AIMS: Room air (RA) and carbon dioxide (CO2) are widely used to insufflate the colon to examine the mucosa in colonoscopy. Pain, discomfort, and bloating can be seen during and after colonoscopy secondary to bowel distention. This study aimed to investigate the effect of CO2 on post-procedure pain sensation (PPPS) in comparison with RA. MATERIALS AND METHODS: Patients were randomly assigned to the RA and CO2 insufflation groups in a 1:1 ratio. The visual analog scale (VAS) was used to measure the pain before and after the colonoscopy. VAS score of 0 was accepted as the absence of pain and above 0 was accepted as the presence of pain. The primary outcome was to investigate the effect of CO2 insufflation on PPPS. Secondary outcomes were to investigate the other contributing factors affecting PPPS and the effect of CO2 on PPPS in patients with inflammatory bowel disease (IBD). RESULTS: A total of 204 patients were enrolled in the study. No significant difference in PPPS was seen between the 2 groups at any point in time after the colonoscopy. Furthermore, there was no significant difference in pain sensation between the CO2 and RA groups in patients with IBD. When we investigated the other contributing factors to pain sensation, body-mass index (BMI) was found to be significant at 30 minutes and BMI and colonoscopy time were found to be significant at 6 hours afterwards. CONCLUSION: We found no favorable effect of CO2 insufflation on PPPS in colonoscopy, including in patients with IBD.

Annual contrast-enhanced magnetic resonance imaging is highly effective in the surveillance of hepatocellular carcinoma among cirrhotic patients.

OBJECTIVES: Biannual ultrasonography, a globally accepted surveillance method, has low sensitivity in detecting early-stage hepatocellular carcinoma (HCC). We aimed to investigate the effectiveness of a surveillance strategy using annual contrast-enhanced MRI to detect HCCs at early-stage. MATERIALS AND METHODS: We reviewed the data of 294 patients with consistent annual contrast-enhanced MRI and biannual alpha fetoprotein (AFP) surveillance between 2008 and 2017. Patients were stratified for HCC risk as low-intermediate-high risk group using Toronto risk score. HCCs were classified according to Barcelona Clinic Liver Cancer staging system. RESULTS: Thirty-five (11.9%) HCCs were detected with annual surveillance MRI. Of those, 30 (85.8%) were early-stage and 15 (42.9%) were very early-stage. The majority of patients (82.9%) with surveillance detected HCC were high risk at the entry. MRI had sensitivity of 83.3 and 80% with a specificity of 95.4 and 91.4%, for detecting early and very early-stage HCC, respectively. Addition of AFP to MRI displayed similar sensitivity and specificity rates to detect early and very early HCCs. The area under the curve of MRI alone and combination with AFP was not statistically different (Any-HCC: 0.905 vs. 0.924; Early-HCC: 0.853 vs. 0.885; Very early-HCC: 0.838 vs. 0.885, respectively, all P values >0.2). CONCLUSION: Annual MRI strategy demonstrated a satisfactory performance in the surveillance of HCC, in terms of detecting most of the lesions in earlier curable stages and indicating high sensitivity with no additional benefit of biannual AFP. New risk stratified screening algorithms may further increase the yield of HCC surveillance among cirrhotic patients.

Clinical significance of isolated abnormal intestinal findings in magnetic resonance enterography in patients with suspected small bowel disease.

PURPOSE: Magnetic resonance imaging (MRE) is a well-established adjunct diagnostic tool for the diagnosis of Crohn's Disease (CD), as ileocolonoscopy can sometimes be falsely reassuring when CD skips distal terminal ileum. We aimed to determine the frequency and clinical significance of isolated abnormal small bowel findings in MRE with normal ileal view in ileoscopy. METHODS: We retrospectively reviewed findings from 1611 MRE studies that were conducted between 2012 and 2018 to detect patients bearing abnormal intestinal findings and having full ileocolonoscopy. After exclusion of normal or repetitive MRE scans and previously known CD, 147 patients with abnormal MRE detected. MRE scans were categorized as suspicious of CD and non-specific findings. RESULTS: Out of 147 patients with abnormal MRE, 122 (83%) had terminal ileum involvement in MRE consistent with ileoscopy findings. Twenty-five (17%) patients were found to have solitarily abnormal intestinal findings in MRE with normal ileoscopy. Only 3 (12%) were diagnosed with CD initially, and all had MRE findings suspicious of CD. The remainder 40% (n = 10) were diagnosed with non-Crohn's small bowel disease after further investigation, while in the other 48% (n = 12) abnormal MRE findings could not be explained with any organic disease in the follow-up. CONCLUSION: The present study demonstrated that only a small portion of patients with isolated abnormal intestinal findings in MRE is CD, and more than that are non-crohn's small bowel diseases. These findings, even if they carry the suspicion of CD, do not transform to CD in the long-term follow-up.

External validation of the Toronto hepatocellular carcinoma risk index in Turkish cirrhotic patients.

OBJECTIVES: Toronto hepatocellular carcinoma risk index is developed to stratify cirrhotic patients according to 10-year hepatocellular carcinoma risk. We aimed to validate the performance of Toronto hepatocellular carcinoma risk index in a large Turkish cohort. MATERIALS AND METHODS: We retrospectively reviewed the database of 1287 cirrhotic patients followed-up in a 10-year period (February 2008 to January 2018). All patients were stratified into three groups based on the Toronto hepatocellular carcinoma risk index score as follows: low-risk, < 120; intermediate risk, 120 to 240; and high risk, > 240. Area under the curve and optimal cutoff value of Toronto hepatocellular carcinoma risk index were obtained from receiver operator curve. To reveal the parameters related with hepatocellular carcinoma development, logistic regression analysis was conducted. The cumulative incidences of hepatocellular carcinoma were calculated using the Kaplan-Meier method, and the curves were compared using the log-rank test. RESULTS: Out of 403 enrolled patients, 57 developed hepatocellular carcinoma. The median Toronto hepatocellular carcinoma risk index value was higher in hepatocellular carcinoma (+) group comparing to hepatocellular carcinoma (-) group [267 (70-366) vs. 224 (36-366), P < 0.001]. Out of 57 detected hepatocellular carcinomas, 45 (78.9%) were high risk, 11 (19.3%) were intermediate risk, and only one (1.8%) was low risk at the entry. The area under the curve of the Toronto hepatocellular carcinoma risk index to predict hepatocellular carcinoma was 0.750 (95% confidence interval, 0.683-0.817, P < 0.001). The optimal cutoff value of Toronto hepatocellular carcinoma risk index was 239.5, giving a sensitivity of 78.9% and specificity of 62.7%. As a result, Toronto hepatocellular carcinoma risk index remained to be the only significant parameter that has an affect on hepatocellular carcinoma development [adjusted-odds ratio: 1.016 (95% confidence interval, 1.007-1.024), P<0.001]. CONCLUSION: The present study validated the performance of Toronto hepatocellular carcinoma risk index in Turkish cirrhotic patients to predict hepatocellular carcinoma risk, which can be considered as a tool for personalized surveillance.

Treatment of Hermansky-Pudlak syndrome Associated granulomatous colitis with anti-TNF agents: case series and review of literature.

Hermansky-Pudlak syndrome is a rare syndrome characterized by bleeding diathesis due to platelet dysfunction, oculocutaneous albinism and other systemic involvements. Granulomatous colitis may occur in the disease course and have similarities with Crohn's disease. Herein, we present four cases with Hermansky-Pudlak syndrome associated colitis with the longest follow-up period having various responses to different anti-TNF agents. Four patients with Hermansky-Pudlak syndrome colitis were started on anti-TNF agents between 2008 and 2013. After a mean follow-up period of 7.5 years, two of four patients exhibited a significant improvement in symptoms, whereas the other two experienced undesirable disease course. Although having many similarities with Crohn's disease; Hermansky-Pudlak syndrome colitis appears to have lower anti-TNF response rates. Pathophysiological differences need to be enlightened to find more appropriate therapeutic targets for Hermansky-Pudlak syndrome colitis.

Helicobacter pylori: management in 2013.

Helicobacter pylori (H. pylori) is a prevalent, worldwide, chronic infection. Choice of treatment can be modified according to antibiotic-resistance rates of H. pylori. The ideal therapeutic regimen for H. pylori infection should achieve an eradication rate of ≥ 80%. In some countries, triple therapy with a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole is still the best option. Bismuth-containing quadruple therapy consisting of bismuth salts, tetracycline, metronidazole and PPI, may be the preferred option in countries with clarithromycin resistance > 20%. Sequential therapy including a PPI and amoxicillin given for the first 5 d, followed by triple therapy including a PPI, clarithromycin, and nitroimidazole antimicrobial (all twice daily) for the remaining 5 d, can be another option for the first-line treatment of H. pylori. Recent data suggest that treatment with PPI, levofloxacin, and amoxicillin for 10 d is a good choice for second-line therapy. Concomitant therapy consisting of PPI, amoxicillin, clarithromycin and metronidazole is another option for second-line treatment. If second-line treatment also fails, it is recommended to culture H. pylori from biopsy specimens and perform antimicrobial susceptibility testing. Rescue treatment should be based on antimicrobial susceptibility.

Serum osteopontin levels as a predictor of portal inflammation in patients with nonalcoholic fatty liver disease.

BACKGROUND: Osteopontin is a secreted phosphorylated glycoprotein that is expressed by a variety of cell types and that mediates numerous and diverse biological functions. Osteopontin knockout mice are protected from obesity-induced hepatic steatosis. In the present study, we sought to investigate whether serum osteopontin concentrations are associated with liver histology in patients with nonalcoholic fatty liver disease. METHODS: Serum levels of osteopontin were measured by enzyme-linked immunosorbent assay in 179 well-characterized patients with nonalcoholic fatty liver referred for liver histology and 123 control subjects. RESULTS: Serum osteopontin levels were markedly higher in patients with nonalcoholic fatty liver disease than in controls (p<0.001). Multivariable analysis showed that osteopontin levels were strongly and independently associated with both portal inflammation (ß=0.294, p<0.01) and serum aminotransferase levels (aspartate aminotransferase: ß=0.295, p<0.01; alanine aminotransferase; ß=0.285, p<0.01). CONCLUSION: In summary, these data demonstrate that serum levels of osteopontin are elevated in nonalcoholic fatty liver disease and are a significant independent predictor of portal inflammation in this clinical entity.

Circulating vaspin levels and epicardial adipose tissue thickness are associated with impaired coronary flow reserve in patients with nonalcoholic fatty liver disease.

BACKGROUND: Patients with nonalcoholic fatty liver disease (NAFLD) have a reduced coronary flow reserve (CFR) and an increased risk of cardiovascular disease. The fat cells that surround coronary arteries may play a central and underrecognized role in development of cardiovascular disease through the systemic secretion of adipokines. We therefore evaluated the relation of epicardial fat thickness, serum levels of epicardial fat-related adipokines (chemerin and vaspin), and CFR in patients with NAFLD. METHODS: We investigated 54 patients with biopsy-proven NAFLD and 56 age- and sex-matched controls. CFR and epicardial fat thickness (EFT) were measured by transthoracic echocardiography. Serum levels of chemerin and vaspin were measured by ELISA. RESULTS: EFT was significantly higher (0.64 ± 0.13 vs. 0.54 ± 0.10 cm, P<0.001) and CFR significantly lower (2.11 ± 0.45 vs. 2.52 ± 0.62, P < 0.001) in patients with NAFLD than in controls. Serum levels of vaspin and chemerin were both significantly increased in patients with NAFLD compared with controls. Stepwise regression analysis showed that EFT (ß=-0.53, t=-3.7, P<0.001), serum vaspin levels (ß=-0.30, t=-2.5, P=0.014), and liver fibrosis (ß=-0.31, t=-2.11, P=0.041), in the order they entered into the model, were independent predictors of CFR in NAFLD patients. CONCLUSION: Our data suggest the presence of a complex interplay between EFT, serum vaspin, and liver histology in promoting an impaired hyperemic stimulation of coronary blood flow in patients with NAFLD.

Serum levels of vaspin, obestatin, and apelin-36 in patients with nonalcoholic fatty liver disease.

The novel adipokines vaspin, obestatin, and apelin-36 are associated with insulin resistance and the components of the metabolic syndrome. We assayed circulating levels of these molecules and examined their association with clinical, biochemical, and histologic phenotypes in patients with nonalcoholic fatty liver disease (NAFLD). Serum levels of vaspin, obestatin, and apelin-36 were assayed by enzyme-linked immunosorbent assay in 91 patients with biopsy-proven NAFLD and 81 controls. We analyzed associations between adipokines and the characteristics of patients with NAFLD using multivariable linear regression models. Univariable analysis showed that concentrations of vaspin and apelin-36 were significantly higher in patients with NAFLD than in controls, whereas no differences in obestatin levels were found. Serum vaspin levels showed a statistically significant association with C-reactive protein (r = 0.378, P < .001) and liver fibrosis scores (r = 0.401, P < .001), whereas apelin-36 levels showed a modest association with homeostasis model assessment of insulin resistance (r = 0.204, P < .01). After stepwise linear regression analysis, serum vaspin levels were the only independent predictor of liver fibrosis scores in patients with NAFLD (ß = 0.37, t = 3.99, P < .01). Serum vaspin levels are raised in patients with NAFLD regardless of potential confounders and represent an independent predictor of liver fibrosis scores. These findings support further investigation of this novel adipokine in metabolic liver diseases.

Circulating levels of vascular endothelial growth factor A and its soluble receptor in patients with biopsy-proven nonalcoholic fatty liver disease.

BACKGROUND AND AIMS: Vascular endothelial growth factor A (VEGF) is a multifunctional cytokine affecting angiogenesis and vascular function. The biological activity of VEGF is modulated by its soluble receptor VEGFR-1 (sVEGFR-1). We explored the associations of VEGF and sVEGFR-1 concentrations with liver histology in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD). METHODS: The study was comprised of 99 patients with NAFLD and 75 healthy controls. Serum VEGF and sVEGFR-1 concentrations were measured using commercially available enzyme-linked immunosorbent assays. RESULTS: Serum VEGF levels did not differ in patients with NAFLD (1882 ± 942 pg/mL) compared with healthy controls (1985 ± 945 pg/mL, p = 0.42). However, compared with healthy subjects, levels of sVEGFR-1 were significantly lower in patients with NAFLD (1.59 ± 0.58 ng/mL vs. 1.16 ± 0.34 ng/mL, respectively, p <0.001). After allowance for potential confounders, serum sVEGFR-1 levels retained their independent significance as a predictor of liver fibrosis in patients with NAFLD (ß = -0.19; t = -1.81, p <0.05). CONCLUSIONS: Our results show that patients with biopsy-proven NAFLD have a significant reduction in serum sVEGFR-1 concentrations that predict the degree of liver fibrosis, independent of potential confounders.

Microalbuminuria in nondiabetic patients with nonalcoholic fatty liver disease: association with liver fibrosis.

Recent evidence has suggested an association between microalbuminuria and ultrasound-diagnosed nonalcoholic fatty liver disease (NAFLD) in patients with diabetes and prediabetes. However, few data are available on the occurrence of microalbuminuria in nondiabetic subjects with histologically proven NAFLD. We thus evaluated the relationships between microalbuminuria and liver histology in a hospital-based sample of 87 adults with biopsy-proven NAFLD from Turkey. An albumin excretion rate less than 30 mg/d was considered within the reference range, whereas an albumin excretion rate from 30 to 300 mg/d was considered to indicate microalbuminuria. Compared with those without microalbuminuria (n = 73), NAFLD patients with microalbuminuria (n = 14) had significantly higher homeostasis model assessment of insulin resistance values (3.9 +/- 1.3 vs 5.8 +/- 3.7, P < .001). There were no differences in the prevalence of microalbuminuria in patients with definite nonalcoholic steatohepatitis, borderline nonalcoholic steatohepatitis, and simple fatty liver. In the entire study cohort, mean fibrosis scores were significantly higher in patients with microalbuminuria than in those without (1.27 +/- 0.26 vs 0. 80 +/- 0.11, P < .05). This difference persisted after adjustment for potential confounders. These results indicate the presence of a significant association between the severity of insulin resistance and microalbuminuria in patients with NAFLD. In addition, microalbuminuria may identify NAFLD patients with higher fibrosis scores.

Interstitial pneumonitis associated with pegylated interferon-alpha 2a and ribavirin for chronic hepatitis C infection: a case report.

Interstitial pneumonitis is a rare but potentially fatal side effect occurring from 2 weeks to 16 weeks after the initiation of treatment with pegylated interferon alpha and ribavirin for chronic hepatitis C.Herein, we present a 68-year-old man with chronic hepatitis C virus infection who developed interstitial pneumonitis association with pegylated interferon after 36 weeks initiation of pegylated interferon-alpha and ribavirin therapy. He did not recover after discontinuation of pegylated interferon/ribavirin and improved by steroid therapy.

Human serum complement C3 and factor H in the syndrome of hemolysis, elevated liver enzymes, and low platelet count.

PROBLEM: Hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP syndrome) is a life-threatening variant of severe pre-eclampsia in pregnant women. The complement system may play a role in the pathogenesis of this condition. We sought to determine serum complement 3 (C3) levels and its regulatory protein complement factor H (FH) in the HELLP syndrome. METHOD OF STUDY: Twenty-two pre-eclamptic patients with HELLP syndrome (mean age: 27.8 +/- 6.2 years), 21 pre-eclamptic patients without HELLP syndrome (mean age: 27.5 +/- 6.8 years) and 24 normotensive, healthy pregnant women (mean age: 26.1 +/- 4.4 years) were included in this study. Serum concentrations of C3 and FH were measured in all participants. RESULTS: Concentrations of C3 and FH did not differ significantly between the study groups. In patients with the HELLP syndrome, FH levels were positively associated with platelet count. CONCLUSION: These findings did not support a major role of complement activation in the HELLP syndrome. In patients with HELLP, lower levels of FH are correlated with a reduced platelet count.