Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) has become an important method to diagnose and treat biliary-pancreatic diseases. Perforations are infrequent but serious complications can occur during ERCPs. However, it is unclear which patients are suitable for surgery and when these patients should receive surgery. Aim: To analyze the outcome of 45 patients with endoscopic retrograde cholangiopancreatography (ERCP) related perforation. Materials and methods: We retrospectively reviewed all 45 patients with ERCP-related perforation between January 2003 and December 2017, and observed the location and causes of perforation, treatment strategies, and mortality. Results: Twenty thousand four hundred and seventy-nine patients received ERCP procedures from January 2003 to December 2017 in our digestive endoscopy center. Forty-five patients suffered from ERCP-related perforations. The incidence rate of ERCP-related perforations was 0.22%. Twenty-six patients suffered from periampullary perforations, 15 patients suffered from duodenal wall perforations, 1 patient suffered from a fundus perforation, 1 patient suffered from a residual gallbladder duct perforation, 1 patient suffered from a papillary diverticulum perforation, and 1 patient suffered from an intrahepatic bile duct perforation. Six patients with duodenal perforations underwent surgery, and the other patients received conservative treatment. One patient with a duodenal perforation and ERCP-related pancreatitis died of heart failure, and all the other patients recovered. The mortality rate was 2.2%. Conclusion: Endoscopic closure is seen as the first method for treating Stapfer type I perforations in the early phase, and surgery is seen as a remedial method when local treatment was failed. The Stapfer type II to type IV perforations can recover by conservative treatment.

Fecal microbiota transplantation as an effective initial therapy for pancreatitis complicated with severe Clostridium difficile infection: A case report.

BACKGROUND: Moderately severe acute pancreatitis (MSAP) is a critical form of acute pancreatitis that is related with high morbidity and mortality. Severe Clostridium difficile infection (sCDI) is a serious and rare nosocomial diarrheal complication, especially in MSAP patients. Fecal microbiota transplantation (FMT) is a highly effective treatment for refractory and recurrent CDI (rCDI). However, knowledge regarding the initial use of FMT in patients suffering from sCDI is limited. CASE SUMMARY: Here, we report an MSAP patient complicated with sCDI who was treated by FMT as a first-line therapy. The patient was a 51-year-old man who suffered from diarrhea in his course of acute pancreatitis. An enzyme immunoassay was performed to detect toxins, and the result was positive for toxin-producing C. difficile and toxin B and negative for C. difficile ribotype 027. The colonoscopy revealed pseudomembranous colitis. Due to these findings, sCDI was our primary consideration. Because the patient provided informed consent for FMT treatment, we initially treated the patient by FMT rather than metronidazole. Diarrhea resolved within 5 d after FMT. The patient remained asymptomatic, and the follow-up colonoscopy performed 40 d after discharge showed a complete recovery. Our case is the first reported in China. CONCLUSION: This case explores the possibilities of initially using FMT to treat severe CDI. Moreover, FMT may become a critical component of the treatment for severe CDI in MSAP patients.

Combination of dual serum fluorescence, AFP and hepatic function tests is valuable to identify HCC in AFP-elevated liver diseases.

Serum alpha-fetoprotein (AFP) levels elevated in benign liver diseases (BLD) represent a challenge in hepatocellular carcinoma (HCC) diagnosis. The present study aimed to develop a simple method to identify HCC in AFP-elevated liver diseases based on combining serum fluorescence and general clinical data. Serum specimens and clinical data were collected from 201 HCC and 117 BLD (41 liver cirrhosis, 76 chronic hepatitis) patients with abnormal serum AFP levels. Dual serum fluorescence (autofluorescence and cell-free DNA-related fluorescence) intensities were sequentially measured and expressed as 6 fluorescence indicators. The diagnostic value of these fluorescence and clinical data were evaluated alone and in combination by the area under receiver operating characteristic curve (AUROC). All fluorescence indicators significantly differed between HCC and BLD and some of them were more valuable for diagnosing HCC than AFP (AUROC 0.782-0.801 vs. 0.752). The diagnostic model established with fluorescence indicators, AFP, hepatic function tests and age showed that AUROC, sensitivity, specificity and accuracy were 0.958 (95% CI 0.936-0.979), 92.0%, 88.9% and 92.3%, respectively, and positive rates in AFP-negative, early and small HCCs were 73.8%, 81.6% and 74.3%, respectively. In conclusion, the combination of dual serum fluorescence, AFP, hepatic function tests and age is simple and valuable for identifying HCC in serum AFP-elevated liver diseases.

Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage.

BACKGROUND: Infected pancreatic necrosis (IPN) is a serious local complication of acute pancreatitis, with high mortality. Minimally invasive therapy including percutaneous catheter drainage (PCD) has become the preferred method for IPN instead of traditional open necrosectomy. However, the efficacy of double-catheter lavage in combination with percutaneous flexible endoscopic debridement after PCD failure is unknown compared with surgical necrosectomy. METHODS: A total of 27 cases of IPN patients with failure PCD between Jan 2014 and Dec 2015 were enrolled in this retrospective cohort study. Fifteen patients received double-catheter lavage in combination with percutaneous flexible endoscopic debridement, and 12 patients underwent open necrosectomy. The primary endpoint was the composite end point of major complications or death. The secondary endpoint included mortality, major complication rate, ICU admission length of stay, and overall length of stay. RESULTS: The primary endpoint occurrence rate in double-catheter lavage in combination with percutaneous flexible endoscopic debridement group (8/15, 53%) was significantly lower than that in open necrosectomy group (11/12, 92%) (RR = 1.71, 95% CI = 1.04 - 2.84, P < 0.05). Though the mortality between two groups showed no statistical significance (0% vs. 17%, P = 0.19), the rate of new-onset multiple organ failure and ICU admission length of stay in the experimental group was significantly lower than that in open necrosectomy group (13% vs. 58%, P = 0.04; 0 vs. 17, P = 0.02, respectively). Only 40% of patients required ICU admission after percutaneous debridement, which was markedly lower than the patients who underwent surgery (83%; P < 0.05). CONCLUSIONS: Double-catheter lavage in combination with percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and convenience in patients with IPN after PCD failure as compared to open necrosectomy.

Simple and robust diagnosis of early, small and AFP-negative primary hepatic carcinomas: an integrative approach of serum fluorescence and conventional blood tests.

The diagnosis of early, small and alpha-fetoprotein (AFP)-negative primary hepatic carcinomas (PHCs) remains a significant challenge. We developed a simple and robust approach to noninvasively detect these PHCs. A rapid, high-throughput and single-tube method was firstly developed to measure serum autofluorescence and cell-free DNA (cfDNA)-related fluorescence using a real-time PCR system, and both types of serum fluorescence were measured and routine laboratory data were collected in 1229 subjects, including 353 PHC patients, 331 liver cirrhosis (LC) patients, 213 chronic hepatitis (CH) patients and 332 normal controls (NC). The results showed that fluorescence indicators of PHC differed from those of NC, CH and LC to various extents, and all of them were not associated with age, gender, or AFP level. The logistic regression models established with the fluorescence indicators alone and combined with AFP, hepatic function tests and blood cell analyses were valuable for distinguishing early, small, AFP-negative and all PHC from LC, CH, NC and all non-PHC, with areas under the receiver operating characteristic curves 0.857-0.993 and diagnostic accuracies 80.2-97.7%. Conclusively, serum autofluorescence and cfDNA-related fluorescence are able to be rapidly and simultaneously measured by our simple method and valuable for diagnosing early, small and AFP-negative PHCs, especially integrating with AFP and conventional blood tests.

A comparative analysis of colonoscopy findings in a Chinese and American tertiary hospital.

BACKGROUND/AIMS: To compare the colonoscopy findings of a tertiary Chinese hospital with those of an American tertiary hospital. MATERIALS AND METHODS: Hundred consecutive colonoscopies performed in August 2008 at the First Affiliated Hospital of Nanchang University in China and at the Emory University Hospital, United States of America, were investigated. The endoscopic findings and the histopathology results were statistically compared. RESULTS: The average age of Chinese patients who underwent colonoscopy in this study was 45.23±15.38 years, whereas that of American patients was 55.38±12.11 years; no difference in sex ratio was observed (p=0.202) between the two populations. Screening colonoscopy accounted for 38% of patients in the American group and zero patients in the Chinese group. Polyps and diverticula were the most common findings in both groups. Abnormal findings in the American patients were three times higher than those in the Chinese patients. Proximal colon polyps were more common in the American group. Conversely, proximal colon diverticula were more common in the Chinese group. The prevalence of non-neoplasm lesions was not different between the two groups (p=0.232); the prevalence of adenomas significantly increased in patients who were more than 50 years old in both groups and was higher in the American group (p=0.038). CONCLUSION: The prevalence of bowel diseases in American patients was higher than that in Chinese patients. Polyps and diverticula were the main bowel abnormalities in both groups. Chinese patients lacked awareness of colonoscopy screening and should be enhanced aged 50 years old or older, because the prevalence of advanced neoplasia was increased in this age group in both groups.

Single-channel endoscopic closure of large endoscopy-related perforations.

BACKGROUND AND STUDY AIMS: Gastrointestinal endoscopy procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic submucosal dissection (ESD), and colonoscopy are widely used for the diagnosis or treatment of digestive diseases. Perforation is a rare but potentially lethal complication. Large perforations usually require immediate endoscopic or surgical repair. Endoscopic closure using a nylon loop pouch suture is usually performed with a double-channel endoscope. This paper describes the endoscopic closure of large procedure-related perforations using a single-channel endoscope. PATIENTS AND METHODS: A total of 10 patients with large perforations (2.5 - 4.0 cm), which occurred during ERCP, ESD, or colonoscopy, were treated using the single-channel endoscope technique. RESULTS: All perforations were successfully closed using a nylon loop pouch suture through the single-channel endoscope. No surgery or further endoscopic intervention was required. CONCLUSIONS: Nylon loop pouch suture through a single-channel endoscope was easy to perform and was feasible for the closure of large gastrointestinal perforations.

Differences in clinical features of Crohn's disease and intestinal tuberculosis.

AIM: To investigate the clinical features of Crohn's disease (CD) and intestinal tuberculosis (ITB) with a scoring system that we have developed. METHODS: A total of 25 CD and 40 ITB patients were prospectively enrolled from August 2011 to July 2012. Their characteristics and clinical features were recorded. Laboratory, endoscopic, histologic and radiographic features were determined. The features with a high specificity were selected to establish a scoring system. The features supporting CD scored +1, and those supporting ITB scored -1; each patient received a final total score. A receiver operating characteristic (ROC) curve was used to determine the best cut-off value for distinguishing CD from ITB. RESULTS: Based on a high specificity of differentiating between CD and ITB, 12 features, including longitudinal ulcers, nodular hyperplasia, cobblestone-like mucosa, intestinal diseases, intestinal fistula, the target sign, the comb sign, night sweats, the purified protein derivative test, the interferon-γ release assay (T-SPOT.TB), ring ulcers and ulcer scars, were selected for the scoring system. The results showed that the average total score of the CD group was 3.12 ± 1.740, the average total score of the ITB group was -2.58 ± 0.984, the best cutoff value for the ROC curve was -0.5, and the diagnostic area under the curve was 0.997, which was statistically significant (P < 0.001). The patients whose total scores were higher than -0.5 were diagnosed with CD; otherwise, patients were diagnosed with ITB. Overall, the diagnostic accuracy rate and misdiagnosis rate of this scoring system were 97% and 3%, respectively. CONCLUSION: Some clinical features are valuable for CD and ITB diagnosis. The described scoring system is key to differentiating between CD and ITB.

Computed tomographic enterography adds value to colonoscopy in differentiating Crohn's disease from intestinal tuberculosis: a potential diagnostic algorithm.

BACKGROUND: Crohn's disease and intestinal tuberculosis (ITB) are chronic granulomatous disorders that are difficult to distinguish. Computed tomographic enterography (CTE) yields striking findings for Crohn's disease in the small bowel but its role in differentiating Crohn's from ITB is undefined. This prospective study aimed to investigate the value of CTE for differential diagnosis between Crohn's disease and ITB. PATIENTS AND METHODS: 105 consecutive patients (67 Crohn's, 38 ITB) who underwent CTE and colonoscopy were enrolled. CTE findings and colonoscopic parameters were compared between Crohn's disease and ITB by blinded reviewers. Based on univariate and multiple logistic regression analyses, a diagnostic algorithm combining colonoscopy and CTE was formulated. and its performance validated on 60 new patients (40 Crohn's, 20 ITB). RESULTS: On univariate analysis of CTE findings, proximal small-bowel involvement, asymmetrical mural thickening, segmental small-bowel lesions, mural stratification, the comb sign, and mesentery fibrofatty proliferation were significantly more common in Crohn's disease, whereas mesenteric lymph node change (calcification or central necrosis) and focal ileocecal lesions were more common in ITB. On multivariate analysis, segmental small-bowel involvement (odds ratio [OR] 0.104, 95 % confidence interval [95 %CI] 0.022 - 0.50), and comb sign (OR 0.02, 95 %CI 0.003 - 0.26) were independent predictors of Crohn's. Combining CTE and colonoscopic findings increased the accuracy of diagnosing either Crohn's disease or ITB from 66.7 % (70/105) to 95.2 % (100/105) in the development set (P < 0.001). Sensitivity, specificity, and area under the curve for receiver-operating characteristic (ROC) in the validation dataset were 92.5 %, 80 %, and 0.862 (95 %CI 0.75 - 0.98), respectively. CONCLUSIONS: CTE adds unique information to colonoscopy in differential diagnosis between Crohn's disease and ITB, allowing correct diagnosis in most patients.

Use of natural orifice translumenal endoscopic surgery in the diagnosis of suspected tuberculous peritonitis: a retrospective case series of 7 patients.

BACKGROUND AND OBJECTIVE: In cases of ascites of unknown etiology, tuberculosis peritonitis (TBP) is a possible cause but a diagnostic challenge. This retrospective case series assessed the effectiveness and safety of diagnostic natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and the Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) in 7 consecutive patients with suspected TBP. SUBJECTS AND METHODS: Between September 2011 and August 2012, peritoneal biopsy was performed using transgastric NOTES for subsequent histology in 7 consecutive hospitalized patients who presented with ascites and were diagnosed with suspected TBP. The outcome measures included diagnostic accuracy and procedure-related morbidities. RESULTS: Diagnostic NOTES was successfully completed in all 7 patients. Peritoneoscopy with NOTES went uneventfully and lasted 5-10 minutes. Typical peritoneal nodules characteristic of TBP were identified in all patients and confirmed pathologically as TBP. No clinically significant adverse events occurred in any patients following NOTES, except for 1 patient who experienced mild and transient pyrexia. Postoperative blood culture detected no microbial growth. Follow-up upper gastrointestinal endoscopy showed that the gastric wall wound healed well with minimal scarring. All patients were prescribed a standard four-drug antituberculosis chemotherapy regimen. The treatment outcomes were determined to be effective or curative, and no relapse was detected within the follow-up period. CONCLUSIONS: NOTES is an effective and safe diagnostic technique in patients with suspected TBP presenting as ascites of unknown etiology.

Combined use of AFP, CEA, CA125 and CAl9-9 improves the sensitivity for the diagnosis of gastric cancer.

BACKGROUND: The detection of serum tumor marker becomes a common method for screening tumors. However, this method has not been widely used for routine gastric cancer screening. In this study we aimed to determine whether the combined use of tumor markers may increase the sensitivity for the diagnosis of gastric cancer. METHODS: Serum AFP, CEA, CA125 and CA19-9 levels were measured in 149 patients with gastric cancer, 111 patients with benign gastric diseases and 124 healthy people, who visited the First Affiliated Hospital of Nanchang University from May 2011 to May 2012. Statistical analysis including receiver operating characteristic (ROC) curve, the area under the curve (AUC), and logistic regression analysis was performed to evaluate the diagnostic value of these markers on gastric cancer. RESULTS: Serum levels of CEA, CA125, and CA19-9 in gastric cancer group were higher than that in the benign gastric disease group and the healthy control group (P <0.005). The sensitivity of AFP, CEA, CA125 and CA19-9 in the diagnosis of gastric cancer was 4.7-20.8% individually, and increased to 40.3% in combination. By using optimal cut-off value, the sensitivity of CEA, CA125, and CA19-9 for the diagnosis of gastric cancer was improved. Especially, the sensitivity of CEA increased to 58.4% and the sensitivity of combined use of four markers increased to 69.1%. The age and gender had no effects on the diagnostic value of these markers. CONCLUSIONS: The determination and application of optimal cut-off values based on ROC curve and logistic regression analysis could improve the diagnosis of gastric cancer based on common tumor markers.

Aquaporin 5 promotes the proliferation and migration of human gastric carcinoma cells.

Aquaporin 5 (AQP5) promotes the progression and invasion of several cancers, but its role in the tumorigenesis of human gastric carcinoma (GC) has not been clearly defined. Here, we investigated the potential functions of AQP5 in the proliferation and migration of human GC. RT-PCR and western blotting were used to detect the expression of AQP5 in human GC cell lines. Immunohistochemistry was applied to evaluate the expression of AQP5 in human GC tissues and corresponding normal tissues. Following ectopic overexpression of AQP5 or inhibition of AQP5 by its inhibitor, acetazolamide (AZA), cell proliferation and migration of AGS cells were analyzed by MTT assay, colony formation assay, and wound healing assay. Heterogeneous expression of AQP5 mRNA and protein was observed in human GC cell lines MKN45, MKN28, AGS, and SGC7901. AQP5 was up-regulated in GC tissues in comparison to corresponding normal tissues. AQP5 protein was mainly localized in the cell membrane. Overexpression of AQP5 was correlated with enhanced lymph node metastasis. In vitro, overexpression of AQP5 notably enhanced, while inhibition of AQP5 by AZA significantly attenuated the proliferation and migration of AGS cells. Our data indicate that AQP5 may play an important role in the tumorigenesis and progression of human GC and suggest that AQP5 is a potential therapeutic target against GC.

Derivation and validation of a prediction rule for estimating advanced colorectal neoplasm risk in average-risk Chinese.

No prediction rule is currently available for advanced colorectal neoplasms, defined as invasive cancer, an adenoma of 10 mm or more, a villous adenoma, or an adenoma with high-grade dysplasia, in average-risk Chinese. In this study between 2006 and 2008, a total of 7,541 average-risk Chinese persons aged 40 years or older who had complete colonoscopy were included. The derivation and validation cohorts consisted of 5,229 and 2,312 persons, respectively. A prediction rule was developed from a logistic regression model and then internally and externally validated. The prediction rule comprised 8 variables (age, sex, smoking, diabetes mellitus, green vegetables, pickled food, fried food, and white meat), with scores ranging from 0 to 14. Among the participants with low-risk (≤3) or high-risk (>3) scores in the validation cohort, the risks of advanced neoplasms were 2.6% and 10.0% (P < 0.001), respectively. If colonoscopy was used only for persons with high risk, 80.3% of persons with advanced neoplasms would be detected while the number of colonoscopies would be reduced by 49.2%. The prediction rule had good discrimination (area under the receiver operating characteristic curve = 0.74, 95% confidence interval: 0.70, 0.78) and calibration (P = 0.77) and, thus, provides accurate risk stratification for advanced neoplasms in average-risk Chinese.

Endoscopic management of gastrointestinal smooth muscle tumor.

AIM: To systematically evaluate the efficacy and safety of endoscopic resection of gastrointestinal smooth muscle tumors (SMTs, including leiomyoma and leiomyosarcoma) and to review our preliminary experiences on endoscopic diagnosis of gastrointestinal SMTs. METHODS: A total of 69 patients with gastrointestinal SMT underwent routine endoscopy in our department. Endoscopic ultrasonography (EUS) was also performed in 9 cases of gastrointestinal SMT. The sessile submucosal gastrointestinal SMTs with the base smaller than 2 cm in diameter were resected by "pushing" technique or "grasping and pushing" technique while the pedunculated SMTs were resected by polypectomy. For those SMTs originating from muscularis propria or with the base size >or= 2 cm, ordinary biopsy technique was performed in tumors with ulcers while the "Digging" technique was performed in those without ulcers. RESULTS: 54 cases of leiomyoma and 15 cases of leiomyosarcoma were identified. In them, 19 cases of submucosal leiomyoma were resected by "pushing" technique and 10 cases were removed by "grasping and pushing" technique. Three cases pedunculated submucosal leiomyoma were resected by polypectomy. No severe complications developed during or after the procedure. No recurrence was observed. The diagnostic accuracy of ordinary and the "Digging" biopsy technique was 90.0% and 94.1%, respectively. CONCLUSION: Endoscopic resection is a safe and effective treatment for leiomyomas with the base size

Detection of mRNAs of GA733 genes by RT-PCR in exfoliated cells of pleural and peritoneal effusions and its clinical values.

OBJECTIVE: To evaluate the diagnostic values of the detection of mRNAs of GA733 gene family in exfoliated cells of pleural and peritoneal effusions. METHODS: Sixty specimens of pleural and peritoneal fluids from 60 patients were collected. GA733-1 and GA733-2 mRNA in the exfoliated cells were detected by qualitative RT-PCR, and their diagnostic values were assessed. Patients Sixty patients with pleural or peritoneal effusions, from May 2003 and August 2004, aged 23-85 (average 56.5 years). RESULTS: GA733-1 and GA733-2 mRNA were positive in 5 (13.9%) and 27 (75.0%) of 36 malignant specimens, and in 1 and 7 of 11 cause-unknown specimens, respectively, but both of them were negative in all 13 benign specimens, and the difference of GA733-2 mRNA positive rates among the three groups was significant (P<0.005), but that of GA733-1 mRNA was not (P>0.05). GA733-1 and GA733-2 mRNA were positive in 4 (15.4%) and 22 (84.6%) of 26 cytological positive specimens, and in 1 and 6 of 6 suspicious specimens, and in 1 (3.5%) and 6 (21.4%) of 28 negative specimens, respectively and the difference of GA733-2 mRNA positive rates among the three groups was significant (P<0.005), but that of GA733-1 mRNA was not (P>0.05). Sensitivity, specificity and accuracy of detection for GA733-2 mRNA for diagnosis of malignant effusions were 75.0%, 100% and 81.6%, respectively. CONCLUSIONS: The detection of GA733-2 mRNA by qualitative RT-PCR is sensitive and highly specific for the diagnosis of malignant pleural and peritoneal effusions, while the diagnostic value of GA733-1 mRNA needs to be further investigated.