Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Prognostic Factors for Severe-to-Fatal Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Prospective Cohort Study.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.

Does endoscopic sphincterotomy contribute to the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis after endoscopic biliary stenting for malignant biliary obstruction? A multicenter prospective cohort study.

BACKGROUND: There is no consensus on the necessity of endoscopic sphincterotomy (ES) to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after endoscopic stenting in patients with malignant biliary obstruction. We investigated the incidence of PEP after endoscopic biliary stenting for malignant biliary obstruction with or without ES in a multicenter prospective cohort study. METHODS: We enrolled 807 patients who underwent endoscopic biliary stenting for malignant biliary obstruction with a native papilla at 36 hospitals between April 2017 and March 2018. The incidence of PEP in patients with or without ES was compared for subgroups based on stent type, placement method, and patient background. Univariate and multivariate analysis was performed to investigate the incidence of PEP in all stenting patients. RESULTS: Plastic and metal stents (MS) were inserted in 598 and 209 patients, respectively. The incidence of PEP in patients with or without ES was 7.9% and 7.4%, respectively among all stenting patients. The incidences of PEP with or without ES in plastic stent insertion patients, patients with MS insertion, stent insertions across the papilla, stent insertions across the papilla in patients without main pancreatic duct obstruction, and fully covered MS insertions across the papilla were compared. There was no overall significant difference in the incidence of PEP between those with or without ES. Multivariate logistic regression analysis for the incidence of PEP in all stenting patients revealed obstruction of the main pancreatic duct at the pancreatic head and epinephrine spraying on the papilla were significant factors; there was no significant difference in the incidence of PEP between patients with or without ES. CONCLUSION: Endoscopic sphincterotomy may not contribute to the prevention of PEP after endoscopic biliary stenting for malignant biliary obstruction, even in cases of insertion with a fully covered MS across the papilla.

Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVES: The reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post-ERCP pancreatitis (PEP). METHODS: Patients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs. RESULTS: A total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP-related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire-assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post-ERCP administration of non-steroidal anti-inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla. CONCLUSIONS: In patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP. REGISTRATION: This study was registered in the University Hospital Medical Information Network (UMIN000024820).

Supplemental LED inter-lighting compensates for a shortage of light for plant growth and yield under the lack of sunshine.

Supplemental lighting can enhance yield when sunlight is limited, as in winter. As the effect of frequent cloudy or rainy days in other seasons on plant growth and yield remains unclear, we investigated the effect on tomato (Solanum lycopersicum) and compensation by supplemental LED inter-lighting. Plants were grown under 30% shade cloth on 0%, 40%, or 60% of days. Lower leaves were illuminated with red and blue LED inter-lighting modules from right after first anthesis, or not illuminated. Shading during 40% and 60% of days diminished daily light integral (DLI) by 26% and 40%, respectively, and reduced shoot dry weight by 22.0% and 23.3%, yield by 18.5% and 23.3%, and fruit soluble solids content by 12.3% and 9.3%. In contrast, supplemental inter-lighting improved the light distribution within plants and compensated DLI, and maintained similar yield and soluble solids content in both shade treatments as in the control. These results clearly show that supplemental LED inter-lighting could efficiently compensate for a shortage of light for plant growth, photosynthesis and thus yield under the lack of sunshine.

Root Zone Cooling and Exogenous Spermidine Root-Pretreatment Promoting Lactuca sativa L. Growth and Photosynthesis in the High-temperature Season.

Root zone high-temperature stress is a major factor limiting hydroponic plant growth during the high-temperature season. The effects of root zone cooling (RZC; at 25°C) and exogenous spermidine (Spd) root-pretreatment (SRP, 0.1 mM) on growth, leaf photosynthetic traits, and chlorophyll fluorescence characteristics of hydroponic Lactuca sativa L. grown in a high-temperature season (average temperature > 30°C) were examined. Both treatments significantly promoted plant growth and photosynthesis in the high-temperature season, but the mechanisms of photosynthesis improvement in the hydroponic grown lettuce plants were different between the RZC and SRP treatments. The former improved plant photosynthesis by increasing stoma conductance (G s) to enhance CO2 supply, thus promoting photosynthetic electron transport activity and phosphorylation, which improved the level of the photochemical efficiency of photosystem II (PSII), rather than enhancing CO2 assimilation efficiency. The latter improved plant photosynthesis by enhancing CO2 assimilation efficiency, rather than stomatal regulation. Combination of RZC and SRP significantly improved P N of lettuce plants in a high-temperature season by both improvement of G s to enhance CO2 supply and enhancement of CO2 assimilation. The enhancement of photosynthetic efficiency in both treatments was independent of altering light-harvesting or excessive energy dissipation.

Nighttime Supplemental LED Inter-lighting Improves Growth and Yield of Single-Truss Tomatoes by Enhancing Photosynthesis in Both Winter and Summer.

Greenhouses with sophisticated environmental control systems, or so-called plant factories with solar light, enable growers to achieve high yields of produce with desirable qualities. In a greenhouse crop with high planting density, low photosynthetic photon flux density (PPFD) at the lower leaves tends to limit plant growth, especially in the winter when the solar altitude and PPFD at the canopy are low and day length is shorter than in summer. Therefore, providing supplemental lighting to the lower canopy can increase year-round productivity. However, supplemental lighting can be expensive. In some places, the cost of electricity is lower at night, but the effect of using supplemental light at night has not yet been examined. In this study, we examined the effects of supplemental LED inter-lighting (LED inter-lighting hereafter) during the daytime or nighttime on photosynthesis, growth, and yield of single-truss tomato plants both in winter and summer. We used LED inter-lighting modules with combined red and blue light to illuminate lower leaves right after the first anthesis. The PPFD of this light was 165 µmol m(-2) s(-1) measured at 10 cm from the LED module. LED inter-lighting was provided from 4:00 am to 4:00 pm for the daytime treatments and from 10:00 pm to 10:00 am for the nighttime treatments. Plants exposed only to solar light were used as controls. Daytime LED inter-lighting increased the photosynthetic capacity of middle and lower canopy leaves, which significantly increased yield by 27% in winter; however, photosynthetic capacity and yield were not significantly increased during summer. Nighttime LED inter-lighting increased photosynthetic capacity in both winter and summer, and yield increased by 24% in winter and 12% in summer. In addition, nighttime LED inter-lighting in winter significantly increased the total soluble solids and ascorbic acid content of the tomato fruits, by 20 and 25%, respectively. Use of nighttime LED inter-lighting was also more cost-effective than daytime inter-lighting. Thus, nighttime LED inter-lighting can effectively improve tomato plant growth and yield with lower energy cost compared with daytime both in summer and winter.

Comparison Between Endoscopic Biliary Stenting and Nasobiliary Drainage in Patients with Acute Cholangitis due to Choledocholithiasis: Is Endoscopic Biliary Stenting Useful?

BACKGROUND/AIMS: To clarify whether or not use of an endoscopic biliary stenting (EBS) is superior to endoscopic nasobiliary drainage (ENBD) in cases of acute cholangitis due to choledocholithiasis. METHODOLOGY: Of 447 patients with choledocholithiasis who were treated in the Department of Gastroenterology, Fukuoka University Chikushi Hospital between January 1994 and September 2006, the subjects were 99 moderate acute cholangitis patients who underwent endoscopic drainage as initial treatment. Clinical efficacy, complications and patient satisfaction (meal intake rete) were investigated in the EBS group (67 patients) and the ENBD group (32 patients). RESULTS: There were no significant differences in the improvement in inflammation, total bilirubin, or biliary enzymes between the EBS and ENBD groups. Catheter occlusion was seen in three patients (4%) in the EBS group, and the catheter was self-extracted by three patients (10%) in the ENBD group. CONCLUSION: In moderate acute cholangitis due to choledocholithisis, the treatment efficacy and safety of EBS are equal to those of ENBD, and EBS appears to be a better choice in elderly patients in particular.

Prevalence and clinicopathological features of autoimmune pancreatitis in Japanese patients with inflammatory bowel disease.

OBJECTIVES: The purpose of this study was to clarify the clinicopathological characteristics of autoimmune pancreatitis (AIP) in Japanese patients with inflammatory bowel disease (IBD). METHODS: The clinicopathological findings of 7 patients with IBD whose definite AIP was diagnosed in our hospital according to the International Consensus Diagnostic Criteria were reviewed. RESULTS: Five (0.5%) of 961 patients with ulcerative colitis (UC) and 2 (0.3%) of 790 patients with Crohn disease had AIP. All of 7 patients whose AIP was diagnosed were type 2. The rate of elevated values of serum immunoglobulin G4 was 0%. Most patients with the diagnosis of IBD preceded that of AIP, and disease activity of IBD were active. Granulocyte epithelial lesion is similar to the cryptitis seen in colonic tissue of UC. All of 7 patients were given corticosteroids, immunomodulators, and/or biological agents for IBD. One patient had a recurrence. CONCLUSIONS: The frequency of AIP in Japanese patients with IBD was low. All cases were type 2 and responded well to corticosteroids, immunomodulators, and biological agents. Autoimmune pancreatitis in UC patients may be an extraintestinal manifestation of UC.