Presume Why Probiotics May Not Provide Protection in Inflammatory Bowel Disease through an Azoxymethane and Dextran Sodium Sulfate Murine Model.

Recent studies have shown dysbiosis is associated with inflammatory bowel disease (IBD). However, trying to restore microbial diversity via fecal microbiota transplantation (FMT) or probiotic intervention fails to achieve clinical benefit in IBD patients. We performed a probiotic intervention on a simulated IBD murine model to clarify their relationship. IBD was simulated by the protocol of azoxymethane and dextran sodium sulfate (AOM/DSS) to set up a colitis and colitis-associated neoplasm model on BALB/c mice. A single probiotic intervention using Clostridium butyricum Miyairi (CBM) on AOM/DSS mice to clarify the role of probiotic in colitis, colitis-associated neoplasm, gut microbiota, and immune cytokines was performed. We found dysbiosis occurred in AOM/DSS mice. The CBM intervention on AOM/DSS mice failed to improve colitis and colitis-associated neoplasms but changed microbial composition and unexpectedly increased expression of proinflammatory IL-17A in rectal tissue. We hypothesized that the probiotic intervention caused dysbiosis. To clarify the result, we performed inverse FMT using feces from AOM/DSS mice to normal recipients to validate the pathogenic effect of dysbiosis from AOM/DSS mice and found mice on inverse FMT did develop colitis and colon neoplasms. We presumed the probiotic intervention to some extent caused dysbiosis as inverse FMT. The role of probiotics in IBD requires further elucidation.

Loss of ZNF215 imprinting is associated with poor five-year survival in patients with cytogenetically abnormal-acute myeloid leukemia.

Genomic imprinting is a form of epigenetic regulation and imprinted genes are silenced in a parental-specific manner. Imprinting is associated with various human diseases and cancers, but its roles in leukemogenesis remains elusive. In this study, the expression of a panel of 16 human imprinted genes was investigated using real-time quantitative polymerase chain reaction and 8 of them were further validated in 114 patients newly diagnosed with cytogenetically abnormal-acute myeloid leukemia (CA-AML) and 85 healthy subjects. Our results demonstrated upregulated expression of 8 imprinted genes (C15orf2, COPG2, H19, IGF2, PEG3-AS1, PRIM2, SLC22A3 and ZNF215) was observed in patients with CA-AML (p < 0.001). Patients' survival days were negatively correlated with the expression levels of H19 (p = 0.024), PGE3-AS1 (p = 0.038), and ZNF215 (p = 0.012). Multivariate logistic regression analysis further revealed the expression level ZNF215 can be used as a predictor for five-year survival for patients with CA-AML (p = 0.009) with a hazard ratio of 0.870 (95.0% confident interval: 0.784-0.965). Our results demonstrated that loss of imprinting of imprinted genes is critical for the leukemogenesis of AML under CA condition, and loss of ZNF215 imprinting is associated with poor five-year survival of patients with CA-AML.

Clinicopathological features and outcome of esophageal neuroendocrine tumor: A retrospective multicenter survey by the digestive endoscopy society of Taiwan.

BACKGROUND & AIMS: Esophageal neuroendocrine tumors (NET) are very rare and mostly carcinomic, carrying poor prognosis. There is still no guideline or consensus on the treatment for esophageal NET. METHODS: Patients with histologically-proven esophageal neuroendocrine tumor were recruited from 9 hospitals in Taiwan between 2002 and 2017. Clinical, laboratory, radiological, endoscopic, pathological data, treatment strategies, follow-up periods, and survivals were collected retrospectively. RESULTS: In total, 39 esophageal NET were analyzed and 38 were neuroendocrine carcinoma (NEC). Sixteen (41%) patients had mixed components with either adenocarcinoma (N = 9, 23%) or squamous-cell carcinoma (SCC) (N = 7, 18%). 64.1% of the patients experienced dysphagia and ulcerative mass was the most comment endoscopic finding. There was a higher proportion of drinkers (54.1%), betel chewers (21.6%) and smokers (64.9%) among the patients than in the general population in Taiwan. Five patients (12.8%) had been diagnosed with other cancers. Definite chemoradiotherapy (N = 14, 35.9%) and surgery (N = 7, 17.9%) were the major treatment. Patients with Ki-67% above the median level (50%) in the tumors tended to have worse survival (P = 0.06). However, presence of mixed component was not a significant survival predictor in our study (P = 0.56). CONCLUSION: Mixed component of an esophageal NET is commonly observed. Staged workup and the principle of treatment can follow that for the common cancer type of esophagus. The risk factors and behaviors of esophageal NEC in Taiwan seem to be similar to that of esophageal SCC.

Effect of extracorporeal low-energy shock wave on diabetic gastroparesis in a rat model.

BACKGROUND AND AIM: Delayed gastric emptying occurs in more than 50% of chronic diabetic patients, and this is associated with significant impairments in quality of life. Traditional therapy for delayed gastric emptying has focused on supportive treatment, and there is no significant effective therapy. The effect of low-energy shock wave on gastric motility is never studied. We investigated low-energy shock wave on gastric motility in a diabetic rat model. METHODS: Twenty-eight male Wistar rats were studied and separated in three groups in randomized order as control, diabetic rats received shock wave, and diabetic rats received the sham procedure. Antral area and motility were recorded using the transabdominal ultrasound. Blood was taken for measurement of gastric motility peptides. Subjects were killed for immunohistochemical stain analysis of enteric plexus of the stomach. RESULTS: We successfully induced 20 diabetic rats and set ultrasound for measuring rat gastric contract and emptying model and demonstrated that 6 weeks of low-energy shock wave could promote gastric contraction and emptying in diabetic rats. Moreover, we demonstrated that shock wave could increase defecation and feces and decrease serum cholesterol and triglycerol. However, no effect on glycohemoglobin and gastric motility peptides was recorded. In the immunohistochemical staining, shock wave increased expression of gastric myenteric neuron plexus. CONCLUSION: Low-energy shock wave can increase gastric contraction and emptying by activating axonal regeneration and increasing myenteric plexus, but not related with motility peptides.

The incidence and clinical associated factors of interval colorectal cancers in Southern Taiwan.

BACKGROUND/PURPOSE: Interval colorectal cancer (CRC) is an emerging issue in CRC screening and surveillance. The frequency of interval CRC and its associated factors have not been well studied in Eastern Asia. We aim to clarify the factors associated with interval CRC. METHODS: CRC patients who had negative colonoscopy results 6-36 months prior to cancer diagnosis were defined as cases of interval CRC. Patient characteristics, past history, colon preparation, colonoscopy findings, and pathology were retrospectively evaluated. A total of 670 patients with colorectal adenocarcinoma by pathology who also underwent colonoscopy before diagnosis from January 2005 to November 2014 were recruited. RESULTS: Twenty-two (3.28%) patients (65.7 ± 9.2 years old; 9 male) were diagnosed with interval CRC. The interval CRCs were predominantly located at the rectum and cecum, and presented as earlier stage cancers (Stage I and Stage II: 86.4%, Stage III and Stage IV: 13.6%). Factors associated with interval cancer include end-stage renal disease (ESRD) (hazard ratio: 10.494, 95% confidence interval: 2.131-51.681) and shorter ascending colon withdrawal time (interval cancer: noninterval cancer 2.00±0.82: 4.91±3.74 minutes; hazard ratio: 0.561, 95% confidence interval: 0.345-0.913). Prior polypectomy and tumor size also tended to be related to interval CRC. CONCLUSION: The prevalence of interval CRC in the present study is 3.28%. Comorbidity with ESRD and shorter ascending colon withdrawal time could be factors associated with interval CRC. Good colon preparation for the patients with ESRD and more ascending colon withdrawal time could reduce the interval CRC.

Deregulated expression of circadian clock genes in gastric cancer.

BACKGROUND: Gastric cancer (GC), an aggressive malignant tumor of the alimentary tract, is a leading cause of cancer-related death. Circadian rhythm exhibits a 24-hour variation in physiological processes and behavior, such as hormone levels, metabolism, gene expression, sleep and wakefulness, and appetite. Disruption of circadian rhythm has been associated with various cancers, including chronic myeloid leukemia, head and neck squamous cell carcinoma, hepatocellular carcinoma, endometrial carcinoma, and breast cancer. However, the expression of circadian clock genes in GC remains unexplored. METHODS: In this study, the expression profiles of eight circadian clock genes (PER1, PER2, PER3, CRY1, CRY2, CKIϵ, CLOCK, and BMAL1) of cancerous and noncancerous tissues from 29 GC patients were investigated using real-time quantitative reverse-transcriptase polymerase chain reaction and validated through immunohistochemical analysis. RESULTS: We found that PER2 was significantly up-regulated in cancer tissues (p < 0.005). Up-regulated CRY1 expression was significantly correlated with more advanced stages (stage III and IV) (p < 0.05). CONCLUSIONS: Our results suggest deregulated expressions of circadian clock genes exist in GC and circadian rhythm disturbance may be associated with the development of GC.

Altered expression of SIRT gene family in head and neck squamous cell carcinoma.

Head and neck squamous cell carcinoma (HNSCC) include a group of malignant neoplasms that arise from the upper aerodigestive tract and represent the seventh most common cause of cancer-related death. The overall 5-year survival rates have not significantly improved for decades in spite of the advances in the field of oncology and surgery, encouraging further research on factors that might modify disease prognosis. The silent information regulator (SIR) genes (Sirtuins) play key roles in cellular stress and are associated with aging-related diseases including cancer. Currently, seven human sirtuin (SIRT1-7) genes have been identified, but the roles of SIRT genes in HNSCC are still uncertain. Therefore, in this study, we used real-time quantitative reverse transcription-polymerase chain reaction to investigate the expressions of the seven SIRT genes in human HNSCC tissues to assess the changes in cancerous and noncancerous parts and the correlation with different tumor behaviors. Our results demonstrated that the expression levels of SIRT1, SIRT2, SIRT3, SIRT5, SIRT6, and SIRT7 were significantly downregulated in cancerous tissues compared with noncancerous tissues (all p<0.01). The expression levels of SIRT1, SIRT2, SIRT3, SIRT5, and SIRT7 showed downregulation in advanced stages in respect to early stages (p<0.05). These results indicate that the downregulation of SIRT genes expression may contribute to the development of cancer and trigger the neoplastic disease to more advanced stages. Our study indicates that SIRT genes expression could help in the diagnosis and represent a prognostic biomarker in HNSCC.

The effects of endoscopic-guided balloon dilations in esophageal and gastric strictures caused by corrosive injuries.

BACKGROUND: Esophageal stricture (ES) and gastric outlet obstruction (GOO) can occurred in patients injured by the ingestion of corrosive agents. These complications may occur concurrently but has not been reported in the literature. The aims of this study are to assess the effects and complications of endoscopic-guided balloon dilations (EBD) in patients with corrosive-induced upper gastrointestinal strictures, either ES or GOO alone and simultaneous occurrences of both (ES + GOO). METHODS: From July 2002 to December 2009, 36 patients with corrosive-induced upper gastrointestinal strictures in a tertiary hospital were recruited into this study. The patients were divided into three groups, ES group (n = 18), GOO (n = 7), and ES + GOO group (n = 11). All strictures were dilated under direct visualization by using through-the-scope balloon catheters to the end point of 15 mm. The end-point of treatment was successful ingestion of a solid or semisolid diet without additional dilation for more than 12 months. RESULTS: These 36 patients included 15 males and 21 females with average age of 47 years ranging from 25 to 79 years. The success rates for ES group is significantly better than GOO and ES + GOO group (83.3% vs. 57.1% vs. 36.4% p = 0.035). Less complications were observed in ES group than in GOO and ES + GOO group (16.7% vs. 42.9% vs. 36.4%, p = 0.041). GOO group needed more sessions of dilations in order to achieve success dilations than ES and GOO groups (13.7 ± 4.9 vs. 6.1 ± 4.7 vs. 5.5 ± 2.1, p = 0.011). CONCLUSIONS: Corrosive injuries complicated with ES can be effectively and safely treated by EBD. However, the success rates declined significantly in patients with GOO with or without ES and amore complications occurred.

Altered expression of imprinted genes in patients with cytogenetically normal­acute myeloid leukemia: Implications for leukemogenesis and survival outcomes.

Genomic imprinting, an epigenetic mechanism that regulates gene expression from parental chromosomes, holds substantial relevance in multiple cancers, including hematopoietic malignancies. In the present study, the expression of a panel of 16 human imprinted genes in bone marrow samples from 64 patients newly diagnosed with cytogenetically normal-acute myeloid leukemia (CN-AML) were examined alongside peripheral blood samples from 85 healthy subjects. The validated findings of the present study revealed significant upregulation of seven genes [COPI coat complex subunit gamma 2 (COPG2), H19 imprinted maternally expressed transcript (H19), insulin like growth factor 2 (IGF2), PEG3 antisense RNA 1 (PEG3-AS1), DNA primase subunit 2 (PRIM2), solute carrier family 22 member 3 SLC22A3 and Zinc finger protein 215 (ZNF215)] in patients with CN-AML (P<0.001). Notably, the expression level of H19 exhibited an inverse association with the survival duration of the patients (P=0.018), establishing it as a predictive marker for two- and five-year survival in patients with CN-AML. Kaplan-Meier analysis demonstrated that patients with lower H19 expression had superior two- and five-year survival rates compared with those with higher H19 expression. The results of the present study highlighted the association between loss of imprinting and leukemogenesis in CN-AML, underscoring the significance of H19 imprinting loss as a prognostic indicator for unfavorable two- and five-year survival in CN-AML patients.

Surveillance culture monitoring of double-balloon enteroscopy reprocessing with high-level disinfection.

BACKGROUND: Inadequate reprocessing of double-balloon enteroscopy (DBE) or of endoscopic accessories may result in iatrogenic infections and present a risk to public health. AIM: To use microbiological surveillance culture monitoring (SCM) to assess the adequacy of high-level disinfection (HLD) with standard reprocessing procedures of DBE. MATERIALS AND METHODS: We performed a prospective study on cultures collected from DBEs that had been treated by HLD by an automated endoscope washing machine (AEWM) decontamination cycle. This study included 42 cases with 57 cultures, which were collected consecutively between October 2009 and December 2010. In 31 cases, 31 cultures were collected from oral route DBE (mean patient age, 68·9 years), and in 23 cases, 26 cultures were collected from anal route DBE (mean patient age, 67·9 years). The results obtained were compared with those of our previous study of SCM on gastroscopy (GS) and colonoscopy (CS). The samples were collected by flushing 50 mL sterile distilled water into the suction channel and collecting the flow-through in a sterile container. The samples were then incubated at 37 °C and examined for bacterial growth. RESULTS: Before HLD, the positive culture rate was 83·9% (26/31) for the oral route DBE and 100% (26/26) for the anal route DBE (P = 0·0406). After HLD, the positive culture rate was 12·9% (4/31) for the oral route DBE and 19·2% (5/26) for the anal route DBE (P > 0·05). A linear trend relationship was found between positive SCM and the length and category of diagnostic instruments--GS, CS, oral route DBE and anal route DBE. CONCLUSIONS: Surveillance culture monitoring is a useful method to assess the effectiveness of HLD reprocessing of DBE. Machine washing may not achieve complete disinfection. Using AEWM regularly is mandatory to minimize cross-contamination and to ensure quality assurance. Additional procedures are necessary to employ for the longer and anal route DBE.

Randomized comparison of two non-bismuth-containing second-line rescue therapies for Helicobacter pylori.

BACKGROUND: Classical second-line anti-Helicobacter pylori includes proton-pump inhibitor, tetracycline, metronidazole, and bismuth salts, but alternative therapies are required owing to the restricted availability of the latter. Levofloxacin-containing triple therapy is recommended but is expensive. Besides, quinolone resistance in an endemic tuberculosis infection area like Taiwan is concerned. The low in vitro antibiotic resistance to amoxicillin and tetracycline in Taiwanese H. pylori strains implies that in vivo esomeprazole/amoxicillin/tetracycline (EAT) second-line rescue therapy may be effective. This study compared the efficacy of esomeprazole/amoxicillin/levofloxacin (EAL) and EAT second-line eradication therapies and determines the clinical factors influencing the efficacy of salvage regimens. MATERIALS AND METHODS: One hundred and twenty-eight patients who failed H. pylori eradication using the standard triple therapy for 7 days are randomly assigned to either EAL group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) for 7 days or EAT group (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, tetracycline 500 mg four times daily) for 14 days. Follow-up endoscopy or urea breath test was performed 8 weeks later to assess treatment response. RESULTS: The eradication rates of EAL and EAT groups were 78.1 versus 75.0%, p = .676 (in intention-to-treat analysis) and 80.3 versus 80%, p = .0964 (per-protocol analysis). Both groups exhibited similar drug compliance (95.3 vs 96.9%, p = .952) but more adverse events in the EAT group (6.3 vs 12.5%, p = .225). CONCLUSIONS: Despite low in vitro drug resistances to amoxicillin and tetracycline, the efficacy of 14-day EAT regimens attained an unacceptable report card of 75% eradication rates in intention-to-treat analysis and was not even superior to the 7-day EAL regimen. Drug-drug interaction between combined antibiotics should be considered other than in vivo drug resistances.

The efficacy of second-line anti-Helicobacter pylori therapy using an extended 14-day levofloxacin/amoxicillin/proton-pump inhibitor treatment--a pilot study.

BACKGROUND: Large meta-analyses of second-line Helicobacter pylori eradication with fluoroquinolone triple therapy have shown that neither 7-day nor 10-day therapy provides 90% or better treatment success. Reports describing second-line H. pylori eradication using 14-day fluoroquinolone-containing triple therapy are few. Current study aimed to determine the efficacy of a 14-day levofloxacin/amoxicillin/proton-pump inhibitor regimen as second-line therapy and the clinical factors influencing the outcome. MATERIALS AND METHODS: One-hundred and one patients who failed H. pylori eradication using the standard triple therapy for 7 days were randomly assigned to either a levofloxacin/amoxicillin/esomeprazole group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 14 days) or a esomeprazole/metronidazole/bismuth salt/tetracycline group (esomeprazole 40 mg twice daily, metronidazole 250 mg four times daily, tripotassium dicitrate bismuthate 300 mg four times daily, and tetracycline 500 mg four times daily for 14 days). Follow-up to assess treatment response consisted of either endoscopy or a urea breath test, which were carried out 8 weeks later. RESULTS: Eradication rates attained by levofloxacin/amoxicillin/esomeprazole and esomeprazole/metronidazole/bismuth salt/tetracycline treatments in the per-protocol analysis were 44/47 (93.6%; 95% CI = 86-99.8) and 43/47 (91.8%; 95% CI = 83.2-98.5). In the intention-to-treat analysis, these were 43/47 (86.3%; 95% CI = 76.5-96.1) in the LAE group (four lost to follow-up) and 43/50 (86%; 95% CI = 76-96) in the EMBT groups. The observed adverse events were 25.5% and 38.5% among the two groups. There was 100% drug compliance among the levofloxacin/amoxicillin/esomeprazole group. Levofloxacin-resistant strains occurred at a frequency of 32.3%. H. pylori eradication rates for the levofloxacin-susceptible strains and levofloxacin-resistant strains were 92% (11/12) and 33% (1/3) in the per-protocol analysis. CONCLUSIONS: A 14-day levofloxacin/amoxicillin/esomeprazole triple therapy approach provides a >90% per-protocol report card with the caveat that this approach is markedly less effective in the presence of fluoroquinolone resistance. Levofloxacin-resistant strains are increasing in Taiwan.

Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage.

BACKGROUND: Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). METHODS: From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45-90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. RESULTS: The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001). CONCLUSION: Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.

Intravenous non-high-dose pantoprazole is equally effective as high-dose pantoprazole in preventing rebleeding among low risk patients with a bleeding peptic ulcer after initial endoscopic hemostasis.

BACKGROUND: Many studies have shown that high-dose proton-pumps inhibitors (PPI) do not further reduce the rate of rebleeding compared to non-high-dose PPIs but we do not know whether intravenous non-high-dose PPIs reduce rebleeding rates among patients at low risk (Rockall score < 6) or among those at high risk, both compared to high-dose PPIs. This retrospective case-controlled study aimed to identify the subgroups of these patients that might benefit from treatment with non-high-dose PPIs. METHODS: Subjects who received high dose and non-high-dose pantoprazole for confirmed acute PU bleeding at a tertiary referral hospital were enrolled (n = 413). They were divided into sustained hemostasis (n = 324) and rebleeding groups (n = 89). The greedy method was applied to allow treatment-control random matching (1:1). Patients were randomly selected from the non-high-dose and high-dose PPI groups who had a high risk peptic ulcer bleeding (n = 104 in each group), and these were then subdivided to two subgroups (Rockall score ≥ 6 vs. < 6, n = 77 vs. 27). RESULTS: An initial low hemoglobin level, serum creatinine level, and Rockall score were independent factors associated with rebleeding. After case-control matching, the significant variables between the non-high-dose and high-dose PPI groups for a Rockall score ≥ 6 were the rebleeding rate, and the amount of blood transfused. Case-controlled matching for the subgroup with a Rockall score < 6 showed that the rebleeding rate was similar for both groups (11.1% in each group). CONCLUSION: Intravenous non-high-dose pantoprazole is equally effective as high-dose pantoprazole when treating low risk patients with a Rockall sore were < 6 who have bleeding ulcers and high-risk stigmata after endoscopic hemostasis.

Clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms: A single-center experience in Southern Taiwan.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) as an advanced endoscopic procedure can be considered for the removal of colorectal lesions with high suspicion of limited submucosal invasion or cannot be optimally removed by snare-based techniques. We aimed to analyze the clinical outcomes of ESD for colorectal neoplasms in our hospital. METHODS: We retrospectively enrolled 230 patients with 244 colorectal neoplasms who received ESD procedures from April 2012 to October 2020 at Kaohsiung Chang Gung Memorial Hospital. Clinicopathological data were collected by chart review. We also recorded ESD-related complications and clinical outcomes. RESULTS: The average age was 64 years old, with a mean follow-up time of 22.59 months. There was a loss of follow-up in 34 lesions. Most lesions were lateral spreading tumors of the non-granular type. The average ESD time was 51.9 minutes. Nine cases (3.7%) had procedure-related complications, including two intra-procedure perforations (0.8%) and seven delayed bleeding (2.9%) without procedure-related mortality. 241 lesions (98.8%) achieved en-bloc resection, while 207 lesions (84.8%) achieved R0 resection. Most lesions were tubulo-(villous) adenoma. Malignancy included 35 adenocarcinomas and 5 neuroendocrine tumors. No local recurrence was developed during follow-up. Multivariate analysis for long ESD time revealed significance in size ≥ 10 cm2 and endoscopist's experience < 3 years. Pre-ESD endoscopic ultrasound revealed good prediction in discrimination of mucosal (sensitivity: 0.90) and submucosal lesion (specificity: 0.67). CONCLUSIONS: ESD for colorectal neoplasms is an effective and safe technique. Size ≥ 10 cm2 and endoscopist's experience < 3 years were significantly associated with long procedure time. Pre-ESD EUS provided a good prediction for colorectal neoplasms in invasion depth.

Gastric metastasis of hepatocellular carcinoma via a possible existing retrograde hematogenous pathway.

BACKGROUND AND AIM: Hepatocellular carcinoma (HCC) tends to metastasize to extrahepatic organs. Stomach involvement has been seldom reported and has always been considered as direct invasion. This study aims to propose a possible existing pathway for the hematogenous metastasis of HCC to the stomach. METHODS: Only seven cases with stomach involvement were found from 8267 HCC patients registered at our hospital between 2000 and 2007. Their laboratory data, the findings of computed tomography and upper endoscopy, therapeutic procedures, such as esophageal variceal banding ligation (EVL), and transhepatic arterial embolization (TAE) were further studied. RESULTS: All seven patients were male. Liver cirrhosis was found in six patients (6/7 = 85.7%), HCC with portal vein thrombosis (PVT) in six patients (6/7 = 85.7%), splenomegaly in five patients (5/7 = 71.4%) and esophageal varices in five patients (5/7 = 71.4%). Six patients underwent TAE and one patient underwent EVL before the development of HCC in the stomach. Four patients had HCC at the cardia, one patient at the anterior wall of the high body and two patients at the greater curvature of the high body, far away from the original HCC. Six patients eventually developed distant metastasis. HCC with gastric metastasis developed 53-126 days after TAE in five patients and 74 days after EVL in one patient. CONCLUSIONS: When cirrhotic patients with portal hypertension have HCC with PVT, a hematogenous pathway can exist for gastric metastasis of tumor thrombi involving hepatofugal flow to the stomach after TAE or EVL apart from the major pathway of direct invasion.

Clinical features and outcomes of gastric neuroendocrine tumors after endoscopic diagnosis and treatment: A Digestive Endoscopy Society of Tawian (DEST).

Gastric neuroendocrine tumors (GNETs) are a heterogeneous group of neoplasm with varying biological characteristics. This study aimed to investigate the clinical features and outcomes of GNET patients after endoscopic diagnosis and treatment in a multicenter registry. Patients with GNETs confirmed histologically were recruited from 17 hospitals between January 2010 and April 2016 in Taiwan. Clinical, laboratory, radiological, endoscopic, pathological data, treatment strategies, follow-up periods, and survivals were collected retrospectively. Totally 187 (107 female, 80 male) patients were recruited. Mean ( ±â€Šstandard deviation [SD]) age and size of tumors were 63.2-year-old ( ±â€Š14.6) and 2.3-cm ( ±â€Š3.0). World Health Organization (WHO) grading were 93 (49.7%) G1, 26 (13.9%) G2, 40 (21.4%) G3, and 28 (15.0%) unknown. G3 patients were older (mean ±â€ŠSD, 71.6 ±â€Š12.4 vs. 60.9 ±â€Š14.3/56.7 ±â€Š15.4 years), larger (6.1 ±â€Š4.0 vs.1.2 ±â€Š1.3/2.4 ±â€Š2.5 cm), more distally located (35.0% vs. 7.6%/15.4%), lower proportion of superficial lesions (17.5% vs. 61.9%/53.8%) and higher rates of lymphovascular invasion (32.5% vs. 3.2%/7.7%) than G1/G2. There was no nodal or distant organ metastases despite different grading of lesions≦10 mm and those <20 mm limited to mucosa and submucosa layers. GNETs larger than 20 mm with G1, G2, and G3 had lymph node (LN) metastatic rates of 21.4%, 30.0%, and 59.3%, respectively. Survivals were different between grading for those >20 mm (log-rank test P = .02). Male gender (P = .01), deeper invasion (P = .0001), nodal (P < .0001), and distant organ metastases (P = .0001) were associated with worse outcome. In conclusion, treatment strategies for GNET should be decided by grading, size, invasiveness, and LN metastasis risk. Curative endoscopic resection is feasible for G1/2 lesions less than 20 mm and limited to mucosa/submucosa layers without lymphovascular invasion.

Endosonographic surveillance of 1-3 cm gastric submucosal tumors originating from muscularis propria.

AIM: To observe the natural course of 1-3 cm gastric submucosal tumors originating from the muscularis propria (SMTMPs). METHODS: By reviewing the computerized medical records over a period of 14 years (2000-2013), patients with 1-3 cm gastric SMTMPs who underwent at least two endoscopic ultrasound (EUS) examinations were enrolled. Tumor progression was defined as a ≥ 1.2 times enlargement in tumor diameter observed during EUS surveillance. All patients were divided into stationary and progressive subgroups and further analyzed. We also reviewed the patients in the progressive subgroup again in 2016. RESULTS: A total of 88 patients were studied, including 25 in the progressive subgroup. The mean time of EUS surveillance was 24.6 mo in the stationary subgroup and 30.7 mo in the progressive subgroup. Risk factors for tumor progression included larger tumor size and irregular border. Initial tumor size > 14.0 mm may be considered a cut-off size for predicting tumor progression. Seventeen patients underwent surgery, of whom 13 had gastrointestinal stromal tumors (GISTs) and 4 had leiomyomas. Tumor progression was found only in patients with GISTs. All of the tumors exhibited benign behaviors without metastasis until 2016. CONCLUSION: Most 1-3 cm gastric SMTMPs (71.6%) are indolent. Tumor progression was found only in GISTs, and it is a good predictor for differentiating GISTs from leiomyomas. Predictors of tumor progression include larger tumor size (> 14.0 mm) and irregular border.

Associated factors in Streptococcus bovis bacteremia and colorectal cancer.

Reports suggest that between 25% and 80% of patients with Streptococcus bovis/gallolyticus bacteremia have concomitant colorectal tumors. This retrospective study was aimed to identify associations between clinical characteristics and a finding of colorectal neoplasm in patients with S. bovis bacteremia who had colonoscopy examination. We retrospectively reviewed the records of patients with S. bovis bacteremia from Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, between January 2004 and January 2014. Clinical data including age, sex, comorbidities, blood culture, and colonoscopy findings were collected and their relationship to a finding of colorectal cancer was examined. A total of 107 patients with S. bovis bacteremia were identified, of whom 49 (72% male; age 65 ± 12 years) were investigated with colonoscopy; 15 of these patients (30.6%) had colorectal adenocarcinoma. Female sex (p = 0.014) and a history of noncolorectal malignancy (p = 0.004) were associated with a finding of colorectal adenocarcinoma. There were no associations with age, percentage of blood cultures, or the presence of diabetes mellitus, chronic liver disease, heart disease, or end-stage renal disease. Our results show that S. bovis bacteremia is associated with the presence of colorectal adenocarcinoma, especially in female patients, and concomitant existence of other malignancies.

A Randomized Control Trial Comparing 2 Levofloxacin-Containing Second-Line Therapies for Helicobacter pylori Eradication.

Summary of Trial Design.Lengthy exposure to quinolone-containing triple therapy in Helicobacter pylori eradication leads to the development of drug resistance. Sequential therapy with a quinolone and metronidazole -containing regimen appears to be an effective treatment option. This randomized controlled trial aimed to compare the efficacy of 5-plus 5 days' levofloxacin and metronidazole-containing sequential therapy (EALM) with that of 10-day levofloxacin-containing triple therapy (EAL) in second-line H pylori eradication treatment.One hundred and sixty-four patients who had failed the H pylori eradication attempts using the standard triple therapy (proton pump inhibitor bid, clarithromycin 500 mg bid, amoxicillin 1 g bid × 7 days) were randomly assigned to either an EALM therapy group (n = 82; esomeprazole 40 mg bid and amoxicillin 1 g bid for 5 days, followed by esomeprazole 40 mg bid, levofloxacin 500 mg qd, and metronidazole 500 mg tid, for 5 days) or a 10-day EAL therapy group (n = 82; levofloxacin 500 mg qd, amoxicillin 1 g bid, and esomeprazole 40 mg bid). One patient was lost to follow-up in each group. Follow-up for H pylori status was performed 4 to 8 weeks later.Eradication rates for the EALM and EAL groups were 90.2% (74/82, 95% confidence interval [CI] = 83.7%-96.8%) and 80.5% (66/82, 95% CI = 71.7%-89.2%, P = 0.077) in the intention-to-treat analysis; and 91.4% (74/81, 95% CI = 85.1%-97.6%) and 81.5% (66/81, 95% CI = 72.8%-90.1%, P = 0.067) in the per-protocol analysis. The adverse events for the EALM and EAL groups were 23.5% versus 11.1%, P = 0.038 but were all very mild and were well tolerated except for 1 patient with poor compliance. The compliances were 98.8% and 100%, respectively, between the 2 groups. An antibiotic resistance to levofloxacin was the clinical factor influencing the efficacy of H. pylori eradication therapy in the EAL group, and dual resistance to levofloxacin and metronidazole in the EALM group.Levofloxacin and metronidazole-containing sequential therapy achieved a >90% eradication rate as a second-line H pylori therapy. Dual antibiotic resistance to levofloxacin and metronidazole was the clinical factor influencing the efficacy of H pylori eradication therapy in the sequential therapy (ClinicalTrials.gov number: NCT02596620).