Alterations and clinical relevance of gut microbiota in patients with Peutz-Jeghers syndrome: A prospective study.

OBJECTIVE: In this case-control study we aimed to investigate the intestinal microbiota profile of patients with Peutz-Jeghers syndrome (PJS) and its association with polyp growth. METHODS: Thirty-two PJS patients and 35 healthy controls were enrolled. Fecal samples of all participants were collected for gut microbiota analysis via 16S rRNA gene (regions V3-V4) sequencing. SPSS version 22.0 and R software version 3.1.0 were used for the statistical analysis. RESULTS: The richness was comparable, while the overall structure of the gut microbiota differed significantly between the PJS and control groups (weighted UniFrac, P = 0.001; unweighted UniFrac, P = 0.008). Significantly different abundances of two phyla, seven families, and 18 genera as well as twenty-nine differentially enriched functional modules (false discovery rate, P < 0.05) between the two groups were identified. Morganella was positively associated with the median number of polyps (JPN; r = 0.96, P < 0.001) and number of newly discovered polyps in the jejunum between two recent endoscopic resections (JPNG; r = 0.78, P = 0.04). Desulfovibrio was positively associated with JPNG (r = 0.87, P = 0.01). Blautia was negatively associated with the median maximum size of polyps in the jejunum (JPS). Anaerostipes was negatively associated with JPN, JPNG and JPS. Clostridium XVIII and Fusicatenibacter were negatively associated with JPN and JPS, respectively. CONCLUSIONS: We found remarkably different gut microbiota of patients with PJS compared to healthy individuals and associations between specific fecal bacteria and clinical features of PJS. These findings may provide a new perspective for the management of PJS in clinical practice.

Large-scale, national, family-based epidemiological study on Helicobacter pylori infection in China: the time to change practice for related disease prevention.

BACKGROUND AND AIMS: Current practice on Helicobacter pylori infection mostly focuses on individual-based care in the community, but family-based H. pylori management has recently been suggested as a better strategy for infection control. However, the family-based H. pylori infection status, risk factors and transmission pattern remain to be elucidated. METHODS: From September 2021 to December 2021, 10 735 families (31 098 individuals) were enrolled from 29 of 31 provinces in mainland China to examine family-based H. pylori infection, related factors and transmission pattern. All family members were required to answer questionnaires and test for H. pylori infection. RESULTS: Among all participants, the average individual-based H. pylori infection rate was 40.66%, with 43.45% for adults and 20.55% for children and adolescents. Family-based infection rates ranged from 50.27% to 85.06% among the 29 provinces, with an average rate of 71.21%. In 28.87% (3099/10 735) of enrolled families, there were no infections; the remaining 71.13% (7636/10 735) of families had 1-7 infected members, and in 19.70% (1504/7636), all members were infected. Among 7961 enrolled couples, 33.21% had no infection, but in 22.99%, both were infected. Childhood infection was significantly associated with parental infection. Independent risk factors for household infection were infected family members (eg, five infected members: OR 2.72, 95% CI 1.86 to 4.00), living in highly infected areas (eg, northwest China: OR 1.83, 95% CI 1.57 to 2.13), and large families in a household (eg, family of three: OR 1.97, 95% CI 1.76 to 2.21). However, family members with higher education and income levels (OR 0.85, 95% CI 0.79 to 0.91), using serving spoons or chopsticks, more generations in a household (eg, three generations: OR 0.79, 95% CI 0.68 to 0.92), and who were younger (OR 0.57, 95% CI 0.46 to 0.70) had lower infection rates (p<0.05). CONCLUSION: Familial H. pylori infection rate is high in general household in China. Exposure to infected family members is likely the major source of its spread. These results provide supporting evidence for the strategic changes from H. pylori individual-based treatment to family-based management, and the notion has important clinical and public health implications for infection control and related disease prevention.

Effects of probiotics on gastric microbiota and its precombination with quadruple regimen for Helicobacter pylori eradication.

OBJECTIVES: This study aimed to assess the efficacy and safety of probiotics for Helicobacter pylori (H. pylori) eradication therapy as well as their effects on gastric microbiota. METHODS: Patients who had failed H. pylori eradication therapy for at least twice were prospectively enrolled during March 2019 and March 2021. A 2-week administration of compound Lactobacillus acidophilus probiotic (1 g thrice daily) followed by a 10-day quadruple bismuth-containing H. pylori eradication therapy was administrated. Endoscopy was performed, and gastric biopsy samples were obtained for drug sensitivity testing and 16S rRNA gene sequencing before and after probiotic treatment. Eradication was evaluated by the 13 C-urea breath test at least 4 weeks after treatment completion. Adverse events (AEs) were recorded. RESULTS: Thirty-seven patients were included. Probiotic supplementation had no effects on the diversity, community structure, and composition of gastric microbiota and no inhibition on H. pylori activity. However, it increased some of the beneficial bacteria such as Blautia, Dorea, and Roseburia (P < 0.05). The overall eradication rate was 97.3% (95% confidence interval [CI] 91.8%-100%). AEs, mainly dizziness, nausea, diarrhea, and chest distress, were detected in six individuals, all of which were resolved upon cessation of antibiotic administration. Dyspeptic symptoms were improved after probiotic supplementation and at treatment completion (both P < 0.001). CONCLUSIONS: H. pylori-infected individuals might benefit from probiotics followed by a quadruple bismuth-containing eradication therapy. Further studies with large sample sizes are warranted.

Changhai advanced endoscopy courses for ERCP (CHANCE) training program: A short-term training model in China.

BACKGROUND: There is huge shortage of ERCP practitioners (ERCPists) in China, and ERCP training is urgently needed. ChangHai Advanced eNdoscopy Courses for ERCP (CHANCE) is a 4-month program for ERCP training since 2004. This study evaluated the efficiency of this short-term training model, and reported on the ERCP careers of the trainees following completion of the CHANCE program. METHODS: This study was a retrospective investigation included all the CHANCE trainees from Jan 2004 to Dec 2014. Questionnaires were sent to all trainees. The career competence percentage, ERCP careers and predictive factors of career competence were investigated and analyzed. RESULTS: A total of 413 trainees participated in the CHANCE program over 11 years covered by the survey and 258 questionnaires were valid for the study. The mean (SD) age of the trainees was 35.36 (4.17), and the male to female ratio was 4.4:1. The average follow-up time was 7.77 (3.44) years. A total of 173 (67.1%) trainees had achieved career competence. In terms of ERCP careers, the mean annual ERCP volume was 120.60 (96.67), with a complication percentage of 8.2%. Hospital qualification, compliance with follow-up learning guidance, participating academic activity, and practitioner type were identified predictive factors of career competence. CONCLUSIONS: As a short-term training program, the CHANCE achieved an acceptable career competence percentage, providing endoscopists more chances to learn ERCP and giving them appropriate training guidance for career competence. This training mode is worth promoting in developing countries with shortage of ERCPists.

Chinese Consensus Report on Family-Based Helicobacter pylori Infection Control and Management (2021 Edition).

OBJECTIVE: Helicobacter pylori infection is mostly a family-based infectious disease. To facilitate its prevention and management, a national consensus meeting was held to review current evidence and propose strategies for population-wide and family-based H. pylori infection control and management to reduce the related disease burden. METHODS: Fifty-seven experts from 41 major universities and institutions in 20 provinces/regions of mainland China were invited to review evidence and modify statements using Delphi process and grading of recommendations assessment, development and evaluation system. The consensus level was defined as ≥80% for agreement on the proposed statements. RESULTS: Experts discussed and modified the original 23 statements on family-based H. pylori infection transmission, control and management, and reached consensus on 16 statements. The final report consists of three parts: (1) H. pylori infection and transmission among family members, (2) prevention and management of H. pylori infection in children and elderly people within households, and (3) strategies for prevention and management of H. pylori infection for family members. In addition to the 'test-and-treat' and 'screen-and-treat' strategies, this consensus also introduced a novel third 'family-based H. pylori infection control and management' strategy to prevent its intrafamilial transmission and development of related diseases. CONCLUSION: H. pylori is transmissible from person to person, and among family members. A family-based H. pylori prevention and eradication strategy would be a suitable approach to prevent its intra-familial transmission and related diseases. The notion and practice would be beneficial not only for Chinese residents but also valuable as a reference for other highly infected areas.

Juvenile polyposis syndrome might be misdiagnosed as familial adenomatous polyposis: a case report and literature review.

BACKGROUND: Juvenile polyposis syndrome (JPS) is a rare disorder characterized by the presence of multiple juvenile polyps in the gastrointestinal tract, and germline mutations in SMAD4 or BMPR1A. Due to its rarity and complex clinical manifestation, misdiagnosis often occurs in clinical practice. CASE PRESENTATION: A 42-year-old man with multiple pedunculated colorectal polyps and concomitant rectal adenocarcinoma was admitted to our hospital. His mother had died of colon cancer. He was diagnosed with familial adenomatous polyposis (FAP) and underwent total proctocolectomy and ileal pouch anal anastomosis. Two polyps were selected for pathological examination. One polyp had cystically dilated glands with slight dysplasia. The other polyp displayed severe dysplasia and was diagnosed as adenoma. Three years later, his 21-year-old son underwent a colonoscopy that revealed more than 50 pedunculated colorectal juvenile polyps. Both patients harbored a germline pathogenic mutation in BMPR1A. Endoscopic resection of all polyps was attempted but failed. Finally, the son received endoscopic resection of polyps in the rectum and sigmoid colon, and laparoscopic subtotal colectomy. Ten polyps were selected for pathological examination. All were revealed to be typical juvenile polyps, with cystically dilated glands filled with mucus. Thus, the diagnosis of JPS was confirmed in the son. A review of the literatures revealed that patients with JPS can sometimes have adenomatous change. Most polyps in patients with JPS are benign hamartomatous polyps with no dysplasia. A review of 767 colorectal JPS polyps demonstrated that 8.5% of the polyps contained mild to moderate dysplasia, and only 0.3% had severe dysplasia or cancer. It is difficult to differentiate juvenile polyps with dysplasia from adenoma, which could explain why juvenile polyps have been reported to have adenomatous changes in patients with JPS. Therefore, patients with JPS, especially those with concomitant dysplasia and adenocarcinoma, might be easily diagnosed as FAP in clinical practice. CONCLUSIONS: Juvenile polyp with dysplasia is often diagnosed as adenoma, which might lead to the misdiagnosis of JPS as FAP. The differential diagnosis of JPS versus FAP, should be based on comprehensive evaluation of clinical presentation, endoscopic appearance and genetic investigations; not on the presence or absence of adenoma.

Double-balloon enteroscopy for retrieving retained small-bowel video capsule endoscopes: a systematic review.

Background and aim: Capsule retention is the most common adverse event associated with video capsule endoscopy. The use of double-balloon enteroscopy-assisted capsule endoscope retrieval has been increasingly reported in recent years. However, evidence is limited regarding its success rate, associated factors, and subsequent clinical outcomes.Methods: A systematic review of relevant studies published before January 2019 was performed. Successful retrieval rate and associated factors, rate of endoscopic balloon dilation, and outcomes after double-balloon enteroscopy were summarized and pooled.Results: Within 154 associated original articles, 12 including 150 cases of capsule retrieval by double-balloon enteroscopy were included. The estimated pooled successful retrieval rate was 86.5% (95% confidence interval, 75.6-95.1%). Anterograde approach and capsules retained in the jejunum or trapped by malignant strictures were associated with a higher successful retrieval rate than the retrograde approach (62/83 [74.7%] vs. 10/38 [26.3%], p < .001) and capsules retained in the ileum (41/41 [100.0%] vs. 43/58 [74.1%], p < .001) or trapped by benign strictures (21/21 [100.0%] vs. 65/83 [78.3%], p = .043). Endoscopic balloon dilation was performed in 38.8% (95% confidence interval, 22.3-56.3%) of patients with benign strictures. Two perforations (1.3%) were reported as severe adverse events after double-balloon enteroscopy. A significantly lower surgery rate was found among cases with successful video capsule removal compared with unsuccessful cases (7.2% vs. 38.5%, p = .002).Conclusions: Double-balloon enteroscopy is feasible and safe for removing retained video capsule endoscopes, and its use could decrease the need for surgery in patients with benign strictures and facilitate subsequent surgery in patients with malignant strictures.

The role of double-balloon enteroscopy in reducing the maximum size of polyps in patients with Peutz-Jeghers syndrome: 12-year experience.

OBJECTIVE: This study aimed to evaluate the role of double-balloon enteroscopy (DBE) in treating intestinal polyps in patients with Peutz-Jeghers syndrome (PJS). METHODS: All patients diagnosed with PJS who underwent a polypectomy under DBE from October 2006 to December 2018 were enrolled. Their clinical records, including surgical history, the method of DBE insertion, the number of DBE procedures, and the maximum size and number of the resected polyps, were retrospectively reviewed. RESULTS: Altogether 97 patients were enrolled. For both antegrade and retrograde DBE the maximum size of the resected polyps during the second hospitalization was significantly smaller than that during the first hospitalization (antegrade DBE: [2.13 ± 1.51] cm vs [3.63 ± 0.92] cm, P = 0.012; retrograde DBE: [1.20 ± 1.10] cm vs [2.95 ± 1.95] cm, P = 0.03), but was significantly larger than that during the third hospitalization (antegrade DBE: [2.13 ± 1.51] cm vs [0.88 ± 0.70] cm, P = 0.012; retrograde DBE: [1.20 ± 1.10] cm vs [0.46 ± 0.40] cm, P = 0.048). The interval between the second and third hospitalizations was significantly longer than that between the first and second hospitalizations ([899.00 ± 382.12] days vs [537.27 ± 326.28] days, P = 0.027). The success rate of total enteroscopy was 58.3% (28/48), which was not affected by a history of laparotomy (61.5% vs 52.4%, P = 0.528). The complication rate was 4.4%. CONCLUSION: DBE is clinically safe and effective for the diagnosis and treatment of intestinal polyps in patients with PJS.

Fifth Chinese National Consensus Report on the management of Helicobacter pylori infection.

BACKGROUND: Since the 'Fourth Chinese National Consensus Report on the management of H. pylori infection' was published in 2012, three important consensuses (Kyoto global consensus report on H. pylori gastritis, The Toronto Consensus for the Treatment of H. pylori Infection in Adults and Management of H. pylori infection-the Maastricht V/Florence Consensus Report) have been published regarding the management of H. pylori infection. MATERIALS AND METHODS: A Delphi method was adopted to develop the consensus of relevant 'statements'. First, the established 'statements' were sent to experts via email. Second, after undergoing two rounds of consultation, the initial statements were discussed face to face and revised in the conference item by item on 16 December 2016. Finally, 21 core members of conferees participated in the final vote of statements. Voting for each statement was performed using an electronic system with levels of agreements shown on the screen in real time. RESULTS: Consensus contents contained a total of 48 "statements" and related 6 parts, including indications for H. pylori eradication, diagnosis, treatment, H. pylori and gastric cancer, H. pylori infection in special populations, H. pylori and gastrointestinal microbiota. CONCLUSIONS: Recommendations are provided on the basis of the best available evidence.

Epidemiology of obscure gastrointestinal bleeding in China: A single-center series and comprehensive analysis of literature.

OBJECTIVE: To determine the etiologies of obscure gastrointestinal bleeding (OGIB) in a Chinese population using a retrospective case series and a systematic analysis of the literatures on OGIB in Chinese patients. METHODS: A large enteroscopy database in a tertiary endoscopic center was searched to identify patients with OGIB from 2010 to 2016. The patients' characteristics and diagnostic findings were collected and analyzed. A comprehensive search of the literature was carried out to harvest all relevant studies published from 2004 to 2016. RESULTS: In total, 708 patients were included in the case series. The most common causes of OGIB were inflammatory diseases (36.3%), non-small bowel lesions (10.2%) and neoplasms (10.0%). A systematic analysis of the literatures included 39 studies providing relevant data for 3145 patients with a pooled detection rate of 84.2%. Inflammatory lesions (27.4%), neoplasms (18.5%), vascular lesions (16.1%) and diverticula or intestinal duplication (11.9%) were the most common causes of OGIB. CONCLUSIONS: Inflammatory lesions, neoplasms, vascular lesions and diverticula or intestinal duplication are the most common in Chinese OGIB patients, while in pediatric patients diverticula or intestinal duplication, vascular lesions and Crohn's disease are prevalent. Furthermore, the etiologies of OGIB distribute differently across different areas in China.

Captopril pretreatment protects the lung against severe acute pancreatitis induced injury via inhibiting angiotensin II production and suppressing Rho/ROCK pathway.

Acute pancreatitis (AP) usually causes acute lung injury, which is also known as acute pancreatitis associated lung injury (APALI). This study aimed to investigate whether captopril pretreatment was able to protect lung against APALI via inhibiting angiotensin II (Ang II) production and suppressing Rho/ROCK (Rho kinase) pathway in rats. Severe AP (SAP) was introduced to rats by bile-pancreatic duct retrograde injection of 5% sodium taurocholate. Rats were randomly divided into three groups. In the sham group, sham operation was performed; in the SAP group, SAP was introduced; in the pre-cpl + SAP group, rats were intragastrically injected with 5 mg/kg captopril 1 hour prior to SAP induction. Pathological examination of the lung and pancreas, evaluation of pulmonary vascular permeability by wet/dry ratio and Evans Blue staining, detection of serum amylase, Western blot assay for Ang II receptor type 1 (AT1), RhoA, ROCK (Rho kinase), and MLCK (myosin light chain kinase) were performed after the animals were sacrificed at 24 hours. After the surgery, characteristic findings of pancreatitis were observed, accompanied by lung injury. The serum amylase, Ang II, and lung expression of AT1, RhoA, ROCK, and MLCK increased dramatically in SAP rats. However, captopril pretreatment improved the histological changes, reduced the pathological score of the pancreas and lung, inhibited serum amylase and Ang II production, and decreased expression of AT1, RhoA, ROCK, and MLCK in the lung. These findings suggest that captopril pretreatment is able to protect the lung against APALI, which is, at least partially, related to the inhibition of Ang II production and the suppression of the Rho/ROCK pathway.

Clinical Features and Endoscopic Treatment of Chinese Patients With Hereditary Pancreatitis.

OBJECTIVES: Hereditary pancreatitis (HP) has been rarely investigated in China. We aimed to describe clinical features and mutation frequency of Chinese patients with HP and to evaluate outcomes of endoscopic treatments. METHODS: Inpatients diagnosed with HP from January 1995 to March 2013 were included. Demographic and clinical data including first onset age, age at diagnosis, sex, main symptoms, radiological findings, and outcomes of endoscopic treatments were collected. Mutations in serine protease inhibitor Kazal type 1 (SPINK1), PRSS1, and cystic fibrosis transmembrane conductance regulator (CFTR) were analyzed. RESULTS: A total of 22 inpatients with HP (male, 12; female, 10) participated in this study. Mean (SD) age at first onset and at diagnosis were 24.5 (11.9) years and 29.1 (11.2) years, respectively. The predominant radiological feature was pancreatic calcifications. Thirty-nine endoscopic retrograde cholangiopancreatography procedures were successfully performed on 19 cases. In the final long-term follow-up, 21 patients got complete or incomplete remission after endoscopic retrograde cholangiopancreatography and/or surgery. Genetic analyses were available in 20 patients, and mutation rates of R122H, N29I, and A16V in PRSS1 were 60%, 25% and 5%, respectively. CONCLUSIONS: As compared with previous studies, our patient cohort, with a relatively higher frequency of R122H mutation, showed a much lower surgery rate, and endoscopic interventions may be recommended to be the first-line treatment.

Peptic ulcer bleeding in China: a multicenter endoscopic survey of 1006 patients.

OBJECTIVE: We aimed to describe the clinical picture, management and outcomes of Chinese patients with peptic ulcer bleeding (PUB), especially in those with high risks. METHODS: A multicenter endoscopic survey was conducted. All consecutive patients with endoscopy confirmed PUB from October 2010 to June 2011 were enrolled. Data including patients' gender, age, symptoms and endoscopic findings, Forrest classification, and endoscopic and medical treatment were documented. High-risk ulcer was defined as Forrest grades Ia to IIb upon endoscopy. Rates of rebleeding, surgery and mortality were recorded. RESULTS: In all, 1006 patients were included. Of these 437 (43.4%) were categorized with high-risk PUB, among whom 110 (25.2%) received endoscopic treatment, and the success rate was 99.1%. Rebleeding rates 1-3 days, 4-5 days and 6-30 days after treatment in high-risk patients who did and did not receive endoscopic treatment were 10.9% versus 10.4%, 3.6% versus 3.7% and 0.9% versus 1.5%, respectively. The surgery rates of high-risk patients with or without endoscopic treatment were 1.8% (2/110) versus 1.8% (6/327). During the 9-month study period, two patients with high-risk PUB died, therefore, the overall mortality rate of high-risk PUB was 0.5% (2/437). CONCLUSION: The study suggests that the proportions of high-risk PUB in China is 43.4%, while rebleeding and surgery rate after endoscopic treatment as well as the mortality rate of high-risk PUB in China are 15.6%, 1.8% and 0.5%, respectively.

EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study.

BACKGROUND: Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 ((125)I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model. OBJECTIVE: To evaluate the safety and efficacy of direct celiac ganglion irradiation with (125)I seeds for the relief of moderate to severe pain secondary to unresectable PC. DESIGN: Prospective study. SETTING: Single, tertiary care referral center. PATIENTS: This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC. INTERVENTION: All patients underwent EUS-guided direct celiac ganglion irradiation with (125)I seeds. Follow-up was conducted at least once weekly until death. MAIN OUTCOME MEASUREMENTS: Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up. RESULTS: Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred. LIMITATIONS: Uncontrolled study. CONCLUSIONS: EUS-guided direct celiac ganglion irradiation with (125)I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.

Incidence of hyperamylasemia after endoscopic ultrasound-guided fine needle aspiration of pancreatic lesions: a multicenter study from China.

OBJECTIVES: There have been few reports regarding the incidence of hyperamylasemia after endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In particular, the potential risk factors involved in the development of hyperamylasemia have not been analyzed owing to the small number of cases reported. The aim of this study was to evaluate hyperamylasemia and associated risk factors after EUS-FNA of a large sample of pancreatic lesions. METHODS: Patients who underwent EUS-FNA for treatment of a pancreatic lesion were recruited from 6 medical centers in China. RESULTS: A total of 1023 patients presenting with pancreatic lesions between January 2004 and June 2008 were enrolled in this study, with 48 (4.7%) of the 1023 patients presenting with hyperamylasemia 3 hours after the procedure. These patients had a mean ± SD serum amylase level of 331.64 ± 138.60 UI/L. With the use of unconditional logistic regression analysis, the incidence of hyperamylasemia was found to be affected by the type of cystic lesion present and the gauge of the needle used. In 4 (0.4%) of the 1023 patients, acute pancreatitis developed. CONCLUSIONS: The overall incidence of hyperamylasemia after EUS-FNA is relatively low. However, the type of cystic lesion present and the gauge of the needle (19G) used for EUS-FNA may represent risk factors for the incidence of hyperamylasemia.

Soluble triggering receptor expressed on myeloid cells in severe acute pancreatitis: a biological marker of infected necrosis.

PURPOSE: The diagnosis and treatment of secondary infection of pancreatic necrotic tissue remain a major challenge. The level of soluble triggering receptor expressed on myeloid cells (sTREM-1) in fine needle aspiration (FNA) fluid may be a good marker of infected necrosis. METHODS: Patients with a clinical suspicion of secondary infection of necrotic tissue were enrolled. The serum levels of C-reactive protein, amylase, procalcitonin (PCT), and sTREM-1 and the fluid levels of sTREM-1, PCT, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and amylase were examined. When infected necrosis was defined, the first step was percutaneous or endoscopic drainage. If there was no improvement after 72 h, an open necrosectomy was performed. RESULTS: In 30 patients with suspected infection, 18 patients were diagnosed as having secondary infection of necrotic tissue. The levels of sTREM-1 and PCT in FNA fluid were found to have the closest correlation with the diagnosis of infected necrosis [sTREM-1: area under the receiver operating characteristic curve (AUC) 0.972; 95% confidence interval (95%CI) 0.837-1.000; PCT: AUC 0.903; 95%CI 0.670-0.990, P > 0.05]. A fluid sTREM-1 cutoff value of 285.6 pg/ml had a sensitivity of 94.4% and a specificity of 91.7%. In a multiple logistic regression analysis, an sTREM-1 level of more than 285 pg/ml and a PCT level of more than 2.0 ng/ml in FNA fluid were independent predictors of infected necrosis. CONCLUSIONS: The fluid level of sTREM-1 will help in the rapid and accurate diagnosis of secondary infection of necrotic tissue in patients with severe acute pancreatitis (SAP).

Endoscope-assisted brachytherapy for pancreatic cancer: From tumor killing to pain relief and drainage.

Locally advanced or metastatic pancreatic cancer has been a long-term challenge to clinicians, due to the poor overall survival rate compared with that of other gastrointestinal malignancies. Recently, with the emerging applications of therapeutic endoscopic ultrasonography (EUS), EUS- guided fine needle injection with antitumor agents is considered a promising modality. In this review, we summarize recently published data on the efficacy of endoscope guided interventional procedures with radioactive seeds. Firstly, EUS-guided iodine-125 seed implantation was reported to have a short-term efficacy on pancreatic cancer, with a three-month partial remission rate of 13.6% to 27%. Thereafter, feasibility of celiac ganglion radiation was tested in animal models to achieve pain relief. Recently, a seed-based stent has been introduced in the endoscopic retrograde cholangio-pancreatography (ERCP) drainage of biliary obstruction caused by pancreatic cancer, with a response rate of 72.7%. In addition, we discuss the potential of radioactive seed-based, endoscope-assisted interventional treatment of patients with locally advanced pancreatic cancer. Further studies should focus on the precise amount and distribution of seeds with the aim to improve the survival rate as well as the quality of life.

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review.

BACKGROUND: EUS-guided FNA (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Although previous studies have evaluated the accuracy of EUS-FNA, little is known about the complications of EUS-FNA. Moreover, the frequency and severity of complications may vary from center to center and may be related to differences in individual experience. OBJECTIVE: To systematically review the morbidity and mortality associated with EUS-FNA. DESIGN: MEDLINE and EMBASE were searched to identify relevant English-language articles. MAIN OUTCOME MEASUREMENTS: EUS-FNA-specific morbidity and mortality rates. RESULTS: We identified 51 articles with a total of 10,941 patients who met our inclusion and exclusion criteria; the overall rate of EUS-FNA-specific morbidity was 0.98% (107/10,941). In the small proportion of patients with complications of any kind, the rates of pancreatitis (36/8246; 0.44%) and postprocedure pain (37/10,941; 0.34%) were 33.64% (36/107) and 34.58% (37/107), respectively. The mortality rate attributable to EUS-FNA-specific morbidity was 0.02% (2/10,941). Subgroup analysis showed that the morbidity rate was 2.44% in prospective studies compared with 0.35% in retrospective studies for pancreatic mass lesions (P=.000), whereas it was 2.33% versus 5.07% for pancreatic cysts (P=.036). LIMITATIONS: Few articles reported well-designed, prospective studies and few focused on overall complications after EUS-FNA. CONCLUSIONS: EUS-FNA-related morbidity and mortality rates are relatively low, and most associated events are mild to moderate in severity.

Alarm features and age for predicting upper gastrointestinal malignancy in Chinese patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper gastrointestinal malignancy: an endoscopic database review of 102,665 patients from 1996 to 2006.

OBJECTIVE: Patients with dyspepsia with alarm features are suspected of having upper gastrointestinal (GI) malignancy; however, the true value of alarm features in predicting an underlying malignancy for patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper GI malignancy is uncertain. The aim of the present study was to determine the diagnostic accuracy of alarm features in predicting upper GI malignancy by reviewing an endoscopic database consisting of >100,000 Chinese patients. METHODS: A retrospective analysis of prospectively collected data was conducted in a single tertiary medical centre. Consecutive patients who underwent oesophagogastroduodenoscopy (OGD) for dyspepsia in 1996-2006 were enrolled. The data including gender, age, symptoms, and endoscopic and pathological findings were analysed. The main outcome measure was the diagnostic accuracy of individual alarm feature. RESULTS: 102,665 patients were included in the final analysis. Among all the 4362 patients with malignancy, 52% (2258/4362) had alarm features. Among 15 235 patients who had alarm features, 2258 (14.8%) were found to have upper GI malignancy. The pooled sensitivity and specificity of the alarm features were 13.4% and 96.6%, respectively. Only the feature of dysphagia in patients between 36 and 74 years old had a positive likelihood ratio (PLR) >10 for malignancy prediction, while all other alarm features in other age groups had a PLR <10. CONCLUSIONS: For uninvestigated Chinese patients with dyspepsia with high background prevalence of H pylori infection and upper GI malignancy, alarm features and age, except for dysphagia in patients between 36 and 74 years old, had limited predictive value for a potential malignancy; therefore, prompt endoscopy may be recommended for these patients. However, less invasive, inexpensive screening methods with high diagnostic yield are still needed to reduce unnecessary endoscopy workload.