SpyGlass-guided laser lithotripsy versus laparoscopic common bile duct exploration for large common bile duct stones: a non-inferiority trial.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is the first choice of treatment for large common bile duct (CBD) stones. Recently, single-operator cholangioscopy (SpyGlass system) has been introduced widely in referral and large medical centers. Several studies have reported favorable results for treatment of large CBD stones guided by SpyGlass. We evaluated the clinical efficacy and safety of SpyGlass-guided laser lithotripsy LCBDE for treatment of large CBD stones. METHODS: From August 2015 to August 2018, 157 patients with large bile duct stones who met the inclusion criteria were randomly divided into two groups: SpyGlass-guided laser lithotripsy (Group A) and LCBDE (Group B). The efficacy and complications were compared between the groups. RESULTS: Although the first-session stone removal rate in Group A was significantly lower than that in Group B, Group A was not inferior to Group B in terms of total stone removal rate. Compared with Group B, Group A had shorter hospital stay and enhanced recovery. The short-term complication rates were also similar between the two groups. CONCLUSIONS: The clinical efficacy of SpyGlass-guided laser lithotripsy for the treatment of large CBD stones is not inferior to that of LCBDE, and it is less invasive. SpyGlass-guided laser lithotripsy is an important option for treatment of large CBD stones.

Randomized controlled trial: Standard versus supplemental bowel preparation in patients with Bristol stool form 1 and 2.

BACKGROUND: Bristol stool form 1 and 2 is an important predictor of inadequate bowel preparation. AIM: To evaluate the efficacy of supplemental preparation in bowel cleansing quality among patients with Bristol stool form 1 and 2, as well as the feasibility of tailored bowel preparation guided by Bristol stool form scale. METHODS: Patients with Bristol stool form 1 and 2 from 3 Chinese tertiary hospitals randomly received either 2 L PEG-ELP (group A) or 10 mg bisacodyl plus 2 L PEG-ELP (group B); patients with Bristol stool form 3 to 7 received 2 L PEG-ELP (group C) for bowel preparation. The primary endpoint is the rate of adequate bowel reparation for the whole colon. The adequate bowel preparation rate for separate colon segments, the polyp detection rate (PDR), tolerability, acceptability, sleeping quality and compliance were evaluated as secondary endpoints. RESULTS: 700 patients were randomized. In per-protocol analysis, patients in group B attained significantly higher successful preparation rate than group A (88.7% vs. 61.2%, p<0.001) and similar with group C (88.7% vs. 85.0%, p = 0.316). The PDR in group B was significantly higher than group A (43.2% vs. 25.7%, p<0.001). Acceptability was much higher in group B and C. CONCLUSIONS: 10 mg bisacodyl plus 2 L PEG-ELP can significantly improve both bowel preparation quality and PDR in patients with Bristol stool form 1 and 2. Bristol stool form scale may be an easy and efficient guide for tailored bowel preparation before colonoscopy.

Bile acids but not acidic acids induce Barrett's esophagus.

Barrett's esophagus (BE) is associated with the development of esophageal adenocarcinoma (EAC). Bile acids (BAs) refluxing into the esophagus contribute to esophageal injury, which results in BE and subsequent EAC. We developed two animal models to test the role of BAs in the pathogenesis of BE. We surgically generated BA reflux, with or without gastric acid, in rats. In a second experiment, we fed animals separately with BAs and gastric acid. Pathologic changes were examined and the expression of Muc2 and Cdx2 in BE tissue was tested by immunostaining. Inflammatory factors in the plasma, as well as differentiation genes in BE were examined through highly sensitive ELISA and semi-quantitative RT-PCR techniques. We found that BAs are sufficient for the induction of esophagitis and Barrett's-like metaplasia in the esophagus. Overexpression of inflammatory cells, IL-6, and TNF-α was observed both in animals fed with BAs and surgically generated BA reflux. Furthermore, elevated levels of Cdx2, Muc2, Bmp4, Kit19, and Tff2 (differentiation genes in BE) were found in BA-treated rats. In conclusion, BAs, but not gastric acid, are a major causative factor for BE. We confirmed that BAs contribute to the development of BE by inducing the inflammatory response in the esophagus. Inhibiting BAs may be a promising therapy for BE.

CC chemokine receptor 6 expression predicts poor prognosis in hepatocellular carcinoma.

BACKGROUND: Recent studies have demonstrated that the CC chemokine receptor 6 (CCR6) may be involved in tumorigenesis and tumor progression of various human malignancies. The aim of this study was to investigate the clinical significance and prognostic value of CCR6 expression in human hepatocellular carcinoma (HCC). METHODS: CCR6 protein levels were evaluated by Western blot in samples from 25 HCC and matched adjacent noncancerous liver tissues. CCR6 protein expression levels were also examined by immunohistochemistry in association with clinicopathologic features and prognosis in 212 HCC patients. The effects of CCR6 on HCC cell proliferation and invasion were examined in vitro. RESULTS: Western blot analysis showed significantly higher CCR6 protein in HCC than that in matched adjacent noncancerous liver tissues. By immunohistochemistry, CCR6 expression correlated with multicentricity (P = 0.014) and vascular invasion (P = 0.009). Importantly, CCR6 expression was an independent prognostic factor for the overall survival of HCC patients [hazard ratio = 3.07, 95% confidence interval (CI) = 1.94-4.76, P = 0.013]. In vitro data revealed that CCR6 promoting HCC cell proliferation through regulating p21, p27, and cyclin D1. CONCLUSIONS: CCR6 could be used as a molecular marker to predict prognosis for HCC. J. Surg. Oncol. 2014; 110:151-155. © 2014 Wiley Periodicals, Inc.

Modified laparoscopic intragastric surgery and endoscopic full-thickness resection for gastric stromal tumor originating from the muscularis propria.

BACKGROUND: This study aimed to evaluate the feasibility and security of the modified laparoscopic intragastric surgery (MLIGS) and the endoscopic full-thickness resection (EFR) for the treatment of gastric stromal tumors (GSTs) originating from the muscularis propria. METHODS: The study population was 18 patients with GSTs of the intraluminal muscularis propria layer. Eight were treated by MLIGS performed according to the following procedures: (1) gastroscopy was used to expose and confirm the location of the tumor; (2) a laparoscope light was placed in the cavity using the trocar at the navel, with the remaining two trocars penetrating both the abdominal and stomach walls; (3) the operation was performed in the gastric lumen using laparoscopic instruments with gastroscope monitoring, and the tumor was resected; (4) the tumor tissue was removed orally using a grasping forceps; (5) and the puncture holes and perforation in the stomach were sutured using titanium clips. The remaining 10 patients were treated by EFR, which involved (1) injection of normal saline into the submucosa and precutting of the mucosal and submucosal layer around the lesion, (2) a circumferential incision as deep as the muscularis propria around the lesion, (3) an incision into the serosal layer around the lesion, (4) completion of full-thickness incision to the tumor, (5) closure of the gastric wall defect with clips. RESULTS: The GSTs all were resected completely. The two groups did not differ significantly in terms of tumor size, hospital stay, or abdominal pain time. But in the MLIGS group, the operation time and blood loss were significantly decreased compared with the EFR group. No postoperative complications occurred in the MLIGS group, whereas one peritoneal abscess occurred in the EFR group. The pathology of all the resected specimens showed GST. No case of implantation or metastasis was found. CONCLUSIONS: Both MLIGS and EFR are feasible and effective treatments for GSTs from the muscularis propria. Moreover, both are minimally invasive.

New-style laparoscopic and endoscopic cooperative surgery for gastric stromal tumors.

AIM: To evaluate the feasibility and safety of a new style of laparoscopic and endoscopic cooperative surgery (LECS), an improved method of laparoscopic intragastric surgery (LIGS) for the treatment of gastric stromal tumors (GSTs). METHODS: Six patients were treated with the new-style LECS. Surgery was performed according to the following procedures: (1) Exposing and confirming the location of the tumor with gastroscopy; (2) A laparoscopy light was placed in the cavity using the trocar at the navel, and the other two trocars penetrated both the abdominal and stomach walls; (3) With gastroscopy monitoring, the operation was carried out in the gastric lumen using laparoscopic instruments and the tumor was resected; and (4) The tumor tissue was removed orally using a gastroscopy basket, and puncture holes and perforations were sutured using titanium clips. RESULTS: Tumor size ranged from 2.0 to 4.5 cm (average 3.50 ± 0.84 cm). The operative time ranged from 60 to 130 min (average 83.33 ± 26.58 min). Blood loss was less than 20 mL and hospital stay ranged from 6 to 8 d (average 6.67 ± 0.82 d). The patients were allowed out of bed 12 h later. A stomach tube was inserted for 72 h after surgery, and a liquid diet was then taken. All cases had single tumors which were completely resected using the new-style LECS. No postoperative complications occurred. Pathology of all resected specimens showed GST: no cases of implantation or metastasis were found. CONCLUSION: New-style LECS for GSTs is a quick, optimized, fast recovery, safe and effective therapy.