Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies. OBJECTIVE: This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness in preventing complications, avoiding hospital readmissions, improving self-care practices, and enhancing quality of life outcomes was assessed. METHODS: A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care using the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app. RESULTS: The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (χ21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (χ21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03). CONCLUSIONS: Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients' self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e.

Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review.

Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.

Clinical values of Barcelona Clinic Liver Cancer subgroup and up-to-7 criteria in intermediate stage hepatocellular carcinoma with transcatheter arterial chemoembolization.

BACKGROUND: Transarterial chemoembolization (TACE) is a recommended treatment for patients with intermediate stage hepatocellular carcinoma (HCC) but with variable treatment outcomes. AIM: To determine factors for predicting outcomes of TACE in patients with intermediate stage B HCC. METHODS: Patients with Barcelona Clinic Liver Cancer (BCLC) stage B HCC who underwent TACE as the primary treatment were enrolled at Taichung Veterans General Hospital from January 2005 to December 2009. Patients were assigned to either the objective responder (OR) group or the non-OR group according to mRECIST criteria. Clinical and radiological characteristics were compared between the 2 groups. The overall survival of enrolled subjects was analyzed. RESULTS: In 128 enrolled patients, 66 (51.6%) were in the OR group and 62 (48.4%) in the non-OR group. Compared with the non-OR group, the OR group had a significantly smaller HCC size (6.55 cm vs 9.50 cm, P = 0.001) and was within the up-to-7 criteria (50% vs 26.7%, P = 0.001). After multivariable analyses, these significant associations still existed. Overall survival rate of all the subjects averaged 20.65 ± 13.26 mo. The survival rate at 1-year was 64.8%, 2-year was 46.9%, and 3-year was 31.2%. For those patients with OR to TACE, smaller tumor size and within up-to-7 criteria were associated with significantly better overall survival. Those patients with subgroup B1 had the highest OR ratio (75%) and better overall survival (26.70 ± 12.07 mo) after TACE. CONCLUSION: BCLC stage B HCC patients with smaller tumor size or within up-to-7 criteria had better survival outcomes to TACE. BCLC stage B subgroup is useful to predict refractoriness to TACE.

The Combining of Tyrosine Kinase Inhibitors and Immune Checkpoint Inhibitors as First-Line Treatment for Advanced Stage Hepatocellular Carcinoma.

AIM: Hepatocellular carcinoma (HCC) is one of the most common cancers. Tyrosine kinase inhibitors (TKIs), including sorafenib (SOR) and lenvatinib (LEN), as well as immune checkpoint inhibitors (ICIs), including nivolumab (NIVO) and pembrolizumab (PEMBRO), have been approved for the treatment of advanced HCC. The aim of the study is to determine whether advanced-stage HCC patients should receive a combination of TKI and ICI as first-line therapy. METHODS: Data for subjects with BCLC stage C HCC, who were receiving combining TKI and ICI as first-line therapy at Taichung Veterans General Hospital from April 2019 to July 2021, were evaluated. The general and therapeutic outcome data were collected and analyzed. RESULTS: A total of 33 patients were enrolled (8 SOR/NIVO, 4 SOR/PEMBRO, 11 LEN/NIVO, and 10 LEN/PEMBRO). All cases belonged to Child-Pugh class A. The objective response rate was 48.5%, and disease control rate was 72.7%. The average progression-free survival (PFS) and overall survival (OS) of all patients was 9.2 and 17.0 months, respectively. The use of PEMBRO, when compared with NIVO, had a significantly positive impact towards achieving an objective response, defined as either complete response or partial response (OR 5.54, p = 0.045). PFS and OS between the different TKIs or ICIs had no differences. The most adverse event was fatigue (36.4%), and most cases were mild and manageable. CONCLUSION: Combining TKI and ICI provides an acceptable antitumor efficacy in first-line therapy for advanced-stage HCC patients. The survival outcomes between different TKIs or ICIs display no differences.

Efficacy of Lenvatinib and Sorafenib in the Real-World First-Line Treatment of Advanced-Stage Hepatocellular Carcinoma in a Taiwanese Population.

AIM: Currently, atezolizumab combined with bevacizumab is the standard first-line treatment for unresectable hepatocellular carcinoma (HCC), but lenvatinib or sorafenib are still recommended for these patients for some reasons. The aim of the study was to determine the outcomes of Taiwanese patients with advanced-stage HCC who received lenvatinib or sorafenib. METHODS: Data on patients with BCLC stage C HCC who were receiving lenvatinib or sorafenib as the first-line therapy from May 2018 to August 2020 was collected. The individuals with lenvatinib and sorafenib were propensity score-matched at a ratio of 1:2. RESULTS: A total of 22 patients with lenvatinib and 44 patients with sorafenib were enrolled. The ORR (36.4% vs. 11.4%, p = 0.023) and DCR (81.9% vs. 56.9%, p = 0.039) were both higher in the lenvatinib group compared with the sorafenib group. The median overall survival (OS) of the lenvatinib group and the sorafenib group was 9.36 months and 8.36 months, respectively. The best median OS was detected in patients receiving lenvatinib and having an objective tumor response (11.29 months), with a significant difference (p = 0.031) compared with the other groups. CONCLUSION: Lenvatinib, compared to sorafenib, had better ORR and DCR, but similar OS, in Taiwanese patients with advanced-stage HCC. The patients with an objective tumor response had a better OS.

Therapeutic benefits of combined sorafenib for intermediate hepatocellular carcinoma unresponsive to transarterial chemoembolization in a Chinese population.

OBJECTIVE: Transarterial chemoembolization (TACE) is the treatment modality for intermediate, or Barcelona Clinic Liver Cancer stage B, hepatocellular carcinoma (HCC), but its beneficial effect on outcomes is still unsatisfactory. This study aimed to assess the outcomes of combined TACE and sorafenib for patients with intermediate HCC. METHODS: Patients with intermediate HCC who were receiving TACE alone (the monotherapy group), or combined TACE and sorafenib (the combined therapy group) from January 2013 to June 2018 were enrolled. RESULTS: Altogether 64 patients were enrolled, of whom 34 were assigned to the monotherapy group and 30 to the combined therapy group. A prolonged time-to-progression (TTP) (mean 14.46 mo vs 6.39 mo, P = 0.001) was noted in the combined therapy group compared with the monotherapy group. Overall survival (OS) (mean 18.96 mo vs15.44 mo, P = 1.000) between the two groups did not differ significantly. After adjustment, there were no significant differences in the 12-18 month mortality rate between the two groups. CONCLUSION: Patients with intermediate HCC receiving combined TACE and sorafenib had a better TTP, but not OS, than those receiving TACE alone.

Benefits of the Seattle biopsy protocol in the diagnosis of Barrett's esophagus in a Chinese population.

AIM: To investigate the benefits of the Seattle protocol in the diagnosis of Chinese individuals with Barrett's esophagus. METHODS: Subjects enrolled were patients from one center with endoscopically-suspected esophageal metaplasia. These patients first received narrow-band imaging-targeted biopsy, and later, the Seattle protocol-guided biopsy, within a period from October 2012 to December 2014. Those cases without initial pathologic patterns of intestinal metaplasia (IM) and then appearance or loss of IM tissue were designated as Group A or B, respectively. Those with initial pathologic patterns of IM, which then persisted or were lost were designated as Group C or D, respectively. RESULTS: The number of cases for each group was as follows: A: 20, B: 78, C: 31 and D: 14. The distribution of the Prague criteria M levels of Group A was significantly higher than Group B (P = 0.174). Among these groups, Group C had the highest proportions of hiatus hernia (54.8%), long segment Barrett's esophagus (29%), and also the highest Prague criteria M levels. The sensitivity of IM detection was 69.2% for the narrow-band imaging-targeted biopsy and 78.5% for the Seattle protocol-guided biopsy. The difference was not significant (P = 0.231). The number of detectable dysplasias increased from one case via the NBI-target biopsy to five cases via the Seattle protocol-guided biopsy, including one case of adenocarcinoma. CONCLUSION: The Seattle protocol improved the IM detection in our subjects with higher Prague criteria M levels and disclosed more cases with dysplastic tissues.

The incidence of esophageal cancer and dysplasia in a Chinese population with nondysplastic Barrett's esophagus.

AIM: The aim of this study was to investigate the incidence of dysplastic transformation of Barrett's esophagus (BE) in a Chinese population. METHOD: Data from nondysplastic BE patients at Taichung Veterans General Hospital were collected from May 2008 to June 2017. The enrolled individuals received regular upper gastrointestinal (UGI) endoscopy during follow up. The pathological transformations, including low-grade dysplasia (LGD), high-grade dysplasia (HGD), or esophageal adenocarcinoma (EAC), were collected prospectively until June 2017. Rates of progression were calculated in cases with a diagnosis of dysplasia or EAC. RESULTS: There were 51 subjects who met the inclusion criteria, with a mean follow up of 3.71 years (SD, 1.61) and a total follow up of 189.1 patient-years. Eight cases (15.7%) developed LGD, with a calculated incidence rate of 2.9% per year. The mean time to development of LGD was 3.26 years (SD, 2.68-3.84). One subject (2%) developed EAC, with a calculated incidence rate of 0.4% per year. No case with HGD was detected. CONCLUSION: In a Chinese population with nondysplastic BE, 15.7% of cases developed LGD, with an incidence rate of 2.9% per year, and 2% of cases developed EAC, with an incidence rate of 0.4% per year.

Low Expression of Transforming Growth Factor ß in the Epithelium of Barrett's Esophagus.

BACKGROUND: The aim of this study was to investigate the expression of transforming growth factor ß (TGF-ß) in the different stages of Barrett's esophagus (BE). METHODS: Paired endoscopic esophageal biopsy samples were obtained from patients with BE prospectively. Subjects were classified into three groups: BE, BE with dysplasia, and adenocarcinoma (AC) arising from BE. Biopsy specimens over normal esophageal epithelium and gastric cardiac epithelium of limited cases were done. Four cell lines, HETA1 (human esophageal epithelium), CA-A and CP-C (non-dysplastic metaplasia), and OE33 (AC) were analyzed for quantitative mRNA and Western blotting of TGF-ß. RESULTS: All 30 subjects with BE were enrolled. Expression of TGF-ß mRNA in BE were significantly (P < 0.01) lower than that in the normal esophagus and cardiac epithelium. The BE tissue showed a lower positive ratio of TGF-ß immunohistochemical (IHC) stain than the cardiac epithelium. The expression of TGF-ß mRNA in the cell lines CA-A, CP-3, OE-33, was significantly (P < 0.05) lower than that in the cell line HETA-1. The Western blotting result showed lower TGF-ß protein expression of the cell lines CA-A, CP-3, and OE-33. CONCLUSIONS: The expression of TGF-ß was lower in the tissue of BE.

Differences of risk factors and clinical presentations in male and female Taiwanese individuals with Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is a disorder more often found in obese men. Differences between the two genders are not known in the Asian countries. Here, we studied their gender differences in the Taiwanese population in terms of risk factors and clinical presentations. METHODS: Data from Taichung Veteran General Hospital were prospectively collected during an approximately two year-period (October 2012 to December 2014). Patients all underwent endoscopic surveillance, and BE was diagnosed based on the typical pattern of intestinal metaplasia. The patient characteristics were compared between the two genders. RESULTS: We enrolled 152 BE patients: 103 men and 49 women. We found in the males, when compared with the females, significantly older mean age, higher waist circumference, greater BMI (ratio of obesity BMI ≧25 kg/m2), and more cases with dyslipidemia and hiatus hernia. Long-segment BE and high-grade dysplasia/adenocarcinoma appeared only in males. Self-reported reflux symptoms were noted 80.6% in men and 89.8% in women. In those with dysplastic BE, we found these patients having higher ratios of obesity, hiatus hernia, alcohol drinking, cigarette smoking and reflux symptom. CONCLUSION: Gender differences were found in our BE patients, males were older in age, more obese, and suffered more serious signs from BE in terms of both endoscopic and pathologic presentations.

Health-related quality of life of subjects with Barrett's esophagus in a Chinese population.

AIM: The aim of this study was to investigate health-related quality of life (HRQoL) of a Chinese population with Barrett's esophagus (BE). METHODS: Data from subjects with BE from a single hospital were prospectively collected from October 2012 to December 2014. The exclusion criteria included total esophagectomy, severe cardiopulmonary deficiency, malignancy, or other unsuitable conditions for scope. All the enrolled cases were asked to complete the Reflux Disease Questionnaire (RDQ), the short form-12, (SF-12), and the Hospital Anxiety and Depression Scale (HADS). RESULTS: In total, 139 subjects were enrolled, and the mean age of the cases was 61.85 years old. Most subjects had short-segment BE (SSBE) (92.8%) and non-dysplastic BE tissue (94.2%). The mean physical and mental composite scores, PCS and MCS, of SF-12 were 44.14 and 45.53, respectively. The SF-12 scores in BE individuals were similar in men and women, elderly and non-elderly, LSBE and SSBE, coexisting EE and no-EE, and dysplastic and non-dysplastic. The appearance of reflux symptoms tended to decrease SF-12 scores in affected individuals, especially heartburn. The rates of anxiety and depression accounted for 25.2% and 17.3% of these cases, respectively. CONCLUSION: Our study found HRQoL in BE patients was strongly associated with presentation of reflux symptoms.

The Diagnostic Value of Alarm Features for Identifying Types and Stages of Upper Gastrointestinal Malignancies.

BACKGROUND: Upper gastrointestinal (GI) malignancies are an uncommon cause of dyspepsia but of great concern. The aim of this study was to determine the association between alarm features and each type and stage of upper GI malignancies. METHODS: Patients who underwent endoscopy for symptoms of dyspepsia between January 2008 and December 2009 were retrospectively collected. Alarm features studied in this study were dysplasia, body weight loss and GI bleeding. Patients were classified according to the findings of endoscopy and histological reports. RESULTS: A total of 3,926 patients were included in the study, with 82 (2.1%) cases with GI malignancies. The specificity and negative predictive value of alarm features ranged from 93.8% to 99.8%, but the sensitivity and positive predictive value ranged from 11.6% to 29.3%. The only variable with a positive predictive value was dysphagia (66.7%). The patients with esophageal cancers and upper gastric cancers had the highest ratio of alarm features, most body weight loss and dysphagia. There was a positive correlation between alarm features and advanced stages of gastric cancers, with the exception of GI bleeding sign. CONCLUSION: Although alarm features had a low sensitivity in identifying patients with upper GI malignancies, the presence of alarm features did help diagnose esophageal or upper gastric cancer and the sign of GI bleeding for early gastric cancer. In addition, dysphagia and weight loss are associated with higher stages of gastric cancer.

Alcohol and tea consumption are associated with asymptomatic erosive esophagitis in Taiwanese men.

OBJECTIVE: Asymptomatic erosive esophagitis (AEE) is commonly found in men, and might be a risk factor of developing esophageal adenocarcinoma. We aimed to determine if specific dietary habits increase the risk of AEE in asymptomatic Taiwanese men. METHODS: We recruited male adults undergoing upper gastrointestinal endoscopy for health check. We excluded subjects with reflux symptoms, or taking anti-reflux medications or drugs that potentially impair lower esophageal sphincter function or cause mucosal injury. The frequency of consuming reflux-provoking diets including alcohol, tea, coffee, tomato/citric juice, chocolate, sweet food, and spicy food was assessed. The erosive esophagitis was diagnosed based on the Los Angeles Classification after endoscopy. Frequent consumption of a specific diet was defined as ≥4 days/week of consuming that diet. RESULTS: A total of 1256 participants were recruited. After excluding 424 ineligible subjects, AEE was identified in 180 (22%) among 832 asymptomatic subjects. The risk of AEE increased with the number of days per week of consuming alcohol or tea: nondrinkers (19%, 17%), occasional drinkers (<1 day/week; 19%, 15%), regular drinkers (1-3 days/week; 26%, 21%), frequent drinkers (4-6 days/week; 32%, 22%), and daily drinkers (42%, 28%), respectively (trend test P < 0.001 for both). Multivariate analysis showed that hiatus hernia (adjusted odds ratio (aOR) 5.0, 95% confidence interval (CI) 2.6-9.6), drinking alcohol ≥4 days/week (aOR 2.3, 95% CI 1.3-4.0), and drinking tea ≥4 days/week (aOR 1.6, 95% CI 1.1-2.3) are independent risk factors of AEE. The risk of AEE was 3.8 times greater for those drinking both alcohol and tea ≥4 days/week than the non-drinkers. CONCLUSIONS: Frequent alcohol and tea consumption increased the risk of AEE in Taiwanese men.

Impact of Obesity on a Chinese Population with Erosive Esophagitis and Barrett's Esophagus.

BACKGROUND/AIMS: The aim of this study was to investigate the associations between obesity and erosive esophagitis (EE) or Barrett's esophagus (BE) in a Chinese population. METHODS: Data from subjects were retrospectively collected from 2006 to 2009. Individuals with BE were identified and age- and sex-matched at a 1:2 ratio with normal esophagocardial junction and EE patients. The subjects were stratified into two groups: the normal weight group and overweight/ obesity group (body mass index ≥25 mg/m²) or the normal waist group and abdominal obesity group (waist circumference ≥90 cm for men and ≥80 cm for women). RESULTS: Overall, 45%, 72%, and 52% were overweight/obese and 23%, 65%, and 18% had abdominal obesity in the normal, EE, and BE groups, respectively. Positive associations were identified between EE and overweight/obesity (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.75 to 5.66) and abdominal obesity (OR, 6.22; 95% CI, 3.34 to 11.57); however, the associations were nonsignificant between BE and overweight/obesity (OR, 1.32; 95% CI, 0.67 to 2.61) or abdominal obesity (OR, 0.73; 95% CI, 0.31 to 1.73). Female BE patients had a significantly increased rate of being overweight/obese. CONCLUSIONS: Obesity is a contributing factor in EE. The association of BE and obesity was not significant, with the exception of female BE cases.

Association of metabolic syndrome with erosive esophagitis and Barrett's esophagus in a Chinese population.

BACKGROUND: Metabolic syndrome has been highlighted as a risk factor for several gastrointestinal diseases, including gastroesophageal reflux disease and Barrett's esophagus (BE). The aim of this study was to investigate the association of metabolic syndrome with erosive esophagitis (EE) and BE. METHODS: Data were retrospectively collected from patients who visited the Medical Screening Center at Taichung Veterans General Hospital, Taichung, Taiwan from January 2006 to December 2009. All patients underwent an open-access transoral upper gastrointestinal endoscopy, and serum laboratory data were collected. The exclusion criteria included prior gastric surgery, or presence of esophageal varices or peptic ulcers. These patients were assigned to groups according to their endoscopic findings as follows: (1) normal group; (2) EE group; and (3) BE group. Metabolic syndrome was diagnosed based on the International Diabetes Federation criteria. RESULTS: There were 560/6499 (8.6%) patients, 214/1118 (9.6%) patients, and 19/95 (20%) patients with metabolic syndrome in the normal, EE, and BE groups, respectively. There was a significantly higher percentage of cases with hypertriglyceridemia in the EE group (67%) compared with the other groups. The BE group had significantly higher rates of central obesity (33%) and hypertension (29.5%) compared with rates in the normal and EE groups. After adjusting for confounders, the positive association with metabolic syndrome still existed in both the EE group (adjusted odds ratio=2.43; 95% confidence interval=1.02-3.44) and the BE group (adjusted odds ratio=2.82; 95% confidence interval=2.05-3.88). CONCLUSION: Our research indicated that in fact there is a greater risk of concurrent metabolic syndrome in patients with EE or BE.

Heartburn and regurgitation have different impacts on life quality of patients with gastroesophageal reflux disease.

AIM: To investigate the impact of heartburn and regurgitation on the quality of life among patients with gastroesophageal reflux disease (GERD). METHODS: Data from patients with GERD, who were diagnosed according to the Montreal definition, were collected between January 2009 and July 2010. The enrolled patients were assigned to a heartburn or a regurgitation group, and further assigned to an erosive esophagitis (EE) or a non-erosive reflux disease (NERD) subgroup, depending on the predominant symptoms and endoscopic findings, respectively. The general demographic data, the scores of the modified Chinese version of the GERDQ and the Short-form 36 (SF-36) questionnaire scores of these groups of patients were compared. RESULTS: About 108 patients were classified in the heartburn group and 124 in the regurgitation group. The basic characteristics of the two groups were similar, except for male predominance in the regurgitation group. Patients in the heartburn group had more sleep interruptions (22.3% daily vs 4.8% daily, P = 0.021), more eating or drinking problems (27.8% daily vs 9.7% daily, P = 0.008), more work interferences (11.2% daily vs none, P = 0.011), and lower SF-36 scores (57.68 vs 64.69, P = 0.042), than patients in the regurgitation group did. Individuals with NERD in the regurgitation group had more impaired daily activities than those with EE did. CONCLUSION: GERD patients with heartburn or regurgitation predominant had similar demographics, but those with heartburn predominant had more severely impaired daily activities and lower general health scores. The NERD cases had more severely impaired daily activity and lower scores than the EE ones did.

Transarterial embolization of metastatic mediastinal hepatocellular carcinoma.

This paper introduces an innovative treatment for extra-hepatic metastasis of hepatocellular carcinoma. A 71-year-old patient had a stable liver condition following treatment for hepatocellular carcinoma, but later developed symptomatic mediastinal metastasis. This rapidly growing mediastinal mass induced symptoms including cough and hoarseness. Serial sessions of transarterial embolization (TAE) successfully controlled this mediastinal mass with limited side effects. The patient's survival time since the initial diagnosis of the mediastinal hepatocellular carcinoma was 32 mo, significantly longer than the 12 mo mean survival period of patients with similar diagnoses: metastatic hepatocellular carcinoma and a liver condition with a Child-Pugh class A score. Currently, oral sorafenib is the treatment of choice for metastatic hepatocellular carcinoma. Recent studies indicate that locoregional treatment of extra-hepatic metastasis of hepatocellular carcinomas might also significantly improve the prognosis in patients with their primary hepatic lesions under control. Many effective locoregional therapies for extrahepatic metastasis, including radiation and surgical resection, may provide palliative effects for hepatocellular carcinoma-associated mediastinal metastasis. This case report demonstrates that TAE of metastatic mediastinal hepatocellular carcinoma provided this patient with tumor control and increased survival time. This finding is important as it can potentially provide an alternative treatment option for patients with similar symptoms and diagnoses.

Comparison of Risk Factors and Disease Severity Between Old and Young Patients With Gastroesophageal Reflux Disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) tends to relapse and develop complications. The aim of the study was to compare the risk factors and disease severity of GERD in young and old patients. METHODS: Data from patients with GERD were collected between January and November 2009. The enrolled cases were assigned to the younger group if they were below 65 years, or the elderly group if 65 years or older. The general demographic data, lifestyle characteristics and endoscopic findings of the two groups were compared. RESULTS: Among all enrolled 111 patients, 78 and 33 patients were classified in the younger and elderly groups, respectively. The elderly group had significantly more men than the younger group did (72.7% vs 39.7%, P = 0.001). Lower rates of smoking (3% vs 6.4%, P = 0.029) and tea drinking (21.3% vs 34.6%, P = 0.001) were noted in the elderly patients, but similar rates of alcohol and coffee drinking. There were more severe esophagitis, esophagocardiac junction (ECJ) ulcers (21.2% vs. 2.6%, P = 0.003) and hiatal hernia (36.4% vs 16.9%, P = 0.025) in the elderly group. CONCLUSION: Elderly GERD patients were more likely to be male, and having severe esophagitis, but lower rates of cigarette smoking and tea drinking, than those of younger patients.

Composite pH predicts esomeprazole response in laryngopharyngeal reflux without typical reflux syndrome.

OBJECTIVES/HYPOTHESIS: Factors predicting the efficacy of proton pump inhibitors (PPIs) in patients with suspected laryngopharyngeal reflux (LPR) are unclear. PPI treatment in patients without concomitant esophageal syndrome remains controversial. We investigated whether composite pH can predict PPI treatment response for LPR with or without concomitant typical reflux syndrome (CTRS). STUDY DESIGN: Prospective, open-label therapeutic cohort study. METHODS: Patients with LPR in a tertiary center divided by presence (n = 65) and absence (n = 42) of CTRS underwent 24-hour esophagopharyngeal pH test and took esomeprazole (40 mg, twice daily) for 12 weeks. Positive composite pH was defined as the presence of 1) excessive pharyngeal acid reflux, and/or 2) excessive distal esophageal acid reflux. A responder was defined as a patient with ≥50% reduction in primary laryngeal symptoms. The change in reflux symptoms was determined using the reflux symptom index (RSI) questionnaire. Logistic regression and mixed model were used to evaluate the predictability of the composite pH parameter. RESULTS: After 8 and 12 weeks of treatment, participants with positive composite pH were 10.3-fold (95% confidence interval [CI], 1.7-61.5; P = .01) and 7.9-fold (95% CI, 1.4-44.8; P = .02) more likely to respond, respectively, than participants with negative composite pH among patients without CTRS. However, no difference was found in those with CTRS. Weekly repeated measures of RSI yielded similar findings. CONCLUSIONS: In patients with suspected LPR without CTRS, a composite pH parameter, which incorporates pharyngeal and distal esophageal acid reflux, may predict response to esomeprazole therapy.

Association of heartburn and laryngopharyngeal symptoms with endoscopic reflux esophagitis, smoking, and drinking.

OBJECTIVES: This study was conducted to investigate the association of laryngopharyngeal symptoms and heartburn with endoscopic esophagitis, smoking, and drinking. The clinical importance of the Reflux Symptom Index (RSI) in predicting endoscopic esophagitis was also evaluated. STUDY DESIGN: Case series with planned data collection. SUBJECTS AND METHODS: From November 2006 to February 2007, 156 adults received a whole-body physical check-up. They filled out the RSI questionnaire and were dichotomized into either a "no problem group" or a "possible patients group" according to their scores on the RSI. All subjects received an esophagoscopy. The relationship between RSI score and endoscopic esophagitis, smoking, and drinking was analyzed. RESULTS: Voice change, but not heartburn, was significantly associated with endoscopic reflux esophagitis. Based on the RSI scores, some items in addition to voice change were significantly associated with smoking or drinking but not with endoscopic esophagitis. CONCLUSIONS: While screening patients for reflux esophagitis by using the RSI questionnaire, there is little value in using heartburn to predict endoscopic esophagitis in Taiwanese people. On the other hand, a husky voice might be a good clinical indicator of patients at risk of having reflux esophagitis.