New common bile duct morphological subtypes: Risk predictors of common bile duct stone recurrence.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment for removing common bile duct (CBD) stones. The risk factors for CBD stone recurrence after ERCP have been discussed for many years. However, the influence of CBD morphology has never been noticed. AIM: To evaluate CBD morphology and other predictors affecting CBD stone recurrence in average patients. METHODS: A retrospective analysis of 502 CBD stone patients who underwent successful therapeutic ERCP for stone extraction at our centre from February 2020 to January 2021 was conducted. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis. RESULTS: CBD morphology (P < 0.01), CBD diameter ≥ 1.5 cm [odds ratio (OR) = 2.20, 95%CI: 1.08-4.46, P = 0.03], and endoscopic biliary sphincterotomy with balloon dilation (ESBD) (OR = 0.35, 95%CI: 0.17-0.75, P < 0.01) are three independent risk factors for CBD stone recurrence. Furthermore, the recurrence rate of patients with the S type was 6.61-fold that of patients with the straight type (OR = 6.61, 95%CI: 2.61-16.77, P < 0.01). The recurrence rate of patients with the polyline type was 2.45-fold that of patients with the straight type (OR = 2.45, 95%CI: 1.14-5.26, P = 0.02). The recurrence rate of S type patients was 2.70-fold that of patients with the polyline type (OR = 2.70, 95%CI: 1.08-6.73, P = 0.03). Compared with no-ESBD, ESBD could decrease the risk of recurrence. CONCLUSION: CBD diameter ≥ 1.5 cm and CBD morphology, especially S type and polyline type, were associated with increased recurrence of CBD stones. In addition, ESBD was related to decreased recurrence. Patients with these risk factors should undergo periodic surveillance and standard prophylactic therapy.

Endoscopic radiofrequency ablation plus plastic stent placement versus stent placement alone for unresectable extrahepatic biliary cancer: a multicenter randomized controlled trial.

BACKGROUND AND AIMS: We sought to compare the efficacy and safety between endoscopic radiofrequency ablation (RFA) and stent placement alone in patients with unresectable extrahepatic biliary cancer (EBC). METHODS: In this randomized controlled trial, patients with locally advanced or metastatic cholangiocarcinoma (CCA) or ampullary cancer who were unsuitable for surgery were recruited from 3 tertiary centers. Eligible patients were randomly assigned to RFA plus plastic stent placement (RFA group) or plastic stent placement alone (stent placement alone group) in a 1:1 ratio. Both groups underwent 2 scheduled interventions with an interval of approximately 3 months. The primary outcome was overall survival (OS). RESULTS: Altogether, 174 participants completed the 2 index endoscopic interventions. No significant differences in baseline characteristics were noted between the 2 groups. The median OS was significantly higher in the RFA group (14.3 vs 9.2 months; hazard ratio, .488; 95% confidence interval, .351-.678; P < .001). A survival benefit was also shown in patients with CCA (13.3 vs 9.2 months; hazard ratio, .546; 95% confidence interval, .386-.771; P < .001). However, no significant between-group differences were found in jaundice control or stent patency duration. The postprocedural Karnofsky performance scores were significantly higher in the RFA group until 9 months (all P < .001). Adverse events were comparable between the 2 groups (27.6% vs 19.5%, P = .211), except for acute cholecystitis, which was more frequently observed in the RFA group (9 vs 0, P = .003). CONCLUSIONS: Compared with stent placement alone, additional RFA may improve OS and quality of life of patients with inoperable primary EBC who do not undergo systemic treatments. (Clinical trial registration number: NCT01844245.).

A pilot study on using chlorine dioxide gas for disinfection of gastrointestinal endoscopes.

OBJECTIVES: This pilot study of employing chlorine dioxide (CD) gas to disinfect gastrointestinal endoscopes was conducted to meet the expectations of many endoscopy units in China for a high-efficiency and low-cost disinfectant. METHODS: An experimental prototype with an active circulation mode was designed to use CD gas to disinfect gastrointestinal endoscopes. One type of testing device composed of polytetrafluoroethylene (PTFE) tubes (2 m long, inner diameter 1 mm) and bacterial carrier containers was used to simulate the channel of the endoscope. PTFE bacterial carriers inoculated with Bacillus atrophaeus with or without organic burden were used to evaluate the sporicidal activity of CD gas. Factors including exposure dosage, relative humidity (RH), and flow rate (FR) influencing the disinfection effect of CD gas were investigated. Moreover, an autoptic disinfecting test on eight real gastrointestinal endoscopes after clinical use was performed using the experimental prototype. RESULTS: RH, exposure dosage, organic burden, and the FR through the channel significantly (P<0.05) affected the disinfection efficacy of CD gas for a long and narrow lumen. The log reduction increased as FR decreased. Treatment with 4 mg/L CD gas for 30 min at 0.8 L/min FR and 75% RH, resulted in complete inactivation of spores. Furthermore, all eight endoscopes with a maximum colony-forming unit of 915 were completely disinfected. The cost was only 3 CNY (0.46 USD) for each endoscope. CONCLUSIONS: The methods and results reported in this study could provide a basis for further studies on using CD gas for the disinfection of endoscopes.

GSH2 promoter methylation in pancreatic cancer analyzed by quantitative methylation-specific polymerase chain reaction.

Tumor suppressor gene silencing via promoter hypermethylation is an important event in pancreatic cancer pathogenesis. Aberrant DNA hypermethylation events are highly tumor specific, and may provide a diagnostic tool for pancreatic cancer patients. The objective of the current study was to identify novel methylation-related genes that may potentially be used to establish novel therapeutic and diagnostic strategies against pancreatic cancer. The methylation status of the GS homeobox 2 (GSH2) gene was analyzed using the sodium bisulfite sequencing method. The GSH2 methylation ratio was examined in primary carcinomas and corresponding normal tissues derived from 47 patients with pancreatic cancer, using quantitative methylation-specific polymerase chain reaction. Methylation ratios were found to be associated with the patient's clinicopathological features. GSH2 gene methylation was detected in 26 (55.3%) of the 47 pancreatic cancer patients, indicating that it occurs frequently in pancreatic cancer. A significant association with methylation was observed for tumor-node-metastasis stage (P=0.031). GSH2 may be a novel methylation-sensitive tumor suppressor gene in pancreatic cancer and may be a tumor-specific biomarker of the disease.

Endoscopic retrograde appendicitis therapy (ERAT) : a multicenter retrospective study in China.

BACKGROUND: Endoscopic retrograde appendicitis therapy (ERAT) is a new procedure for the treatment of acute uncomplicated appendicitis. The aim of the study was to review the clinical outcomes of ERAT and further examine its effectiveness and safety. METHODS: The study was performed on patients who underwent ERAT for acute uncomplicated appendicitis at three tertiary hospitals in China from December 2009 to May 2013. Patient demographics, technique aspects of the ERAT procedures, clinical success (resolution of symptoms and normalization of laboratory tests), time until resumption of diet, and hospital stay were analyzed, and complications and recurrence were followed up. RESULTS: Forty-one patients were entered, among which 34 patients were definitely diagnosed as having acute uncomplicated appendicitis; in 7 patients, acute appendicitis was excluded by endoscopic retrograde appendicography. Thirty-three patients completed ERAT except one patient who failed appendiceal cannulation. Abdominal pain resolved immediately in 32 patients, and clinical success rate was 97 %. There was one failure case (3 %) that complicated perforation after 48 h received emergency appendectomy. The median follow-up period was 12 months (IQR = 9-23 months). During follow-up, there were no long-term complication; 2 patients (6.2 %) had recurrent abdominal pain and received appendectomy (one had a histologically normal appendix). CONCLUSIONS: ERAT is an effective method to diagnose and treat acute uncomplicated appendicitis. Multicenter prospective clinical trials are needed to confirm its utility and place in the management of suspected acute appendicitis.

Endoscopic diagnosis and treatment of esophageal cavernous lymphangioma.

The purpose of this paper is to identify the characteristic endoscopic findings in patients with esophageal cavernous lymphangioma and assess the efficacy of endoscopic techniques in the management of this disease. We retrospectively analyzed data from 6 patients who were diagnosed with esophageal cavernous lymphangioma by endoscopy and histologic evaluation. All patients underwent endoscopic resection of the tumor at our hospital between January 2010 and June 2011. Four male and 2 female patients, with a mean age of 48.2 ± 15.2 years (range, 35 to 77 y) with esophageal cavernous lymphangioma, who underwent endoscopy followed by endoscopic resection were included in this report. The lesions varied from 0.4 to 1.2 cm in diameter, with a mean size of 0.78 ± 0.26 cm. Endoscopy revealed dilated lymphatic channels beneath the surface epithelium of the lesion in all patients. An endoscopic ultrasound revealed that all lesions were multicystic and located in the submucosal layer. Histologic examination confirmed the initial diagnosis in all patients. Endoscopy plays an important role in the diagnosis of esophageal cavernous lymphangioma, with dilated lymphatic channels beneath the surface epithelium of the lesion being a characteristic endoscopic feature. Endoscopic ultrasonography is a useful tool to differentiate cavernous lymphangioma from other esophageal tumors. Endoscopic resection of esophageal cavernous lymphangioma was safe and effective in all of the analyzed cases.

Therapeutic transjejunal endoscopy for the treatment of biliary complications after choledochojejunostomy.

The present study aimed to assess the value of endoscopic jejunostomy for post-biliary intestinal anastomosis biliary complications. The clinical data of the endoscopic therapies by jejunal approach for post-biliary intestinal anastomosis biliary complications in 13 patients (16 surgeries in total) were retrospectively analyzed. The surgical success rate was 100% (16/16). Nasobiliary tube detention was performed for 2 patients, plastic stent placement for 5 and biliary metal stent placement for 4. The remaining two patients did not retain any drainage tube or bracket after surgery. The incidence rate of intraoperative anastomotic stenostomia was 76.9% (10/13). A noticeable postoperative decrease in bilirubin levels was observed in 10 patients. The level of gallstone-free patients was 75% (3/4). There were 10 cases in which cholangitis remission or no attack was identified. Post-operative incisional infection occurred in 3 patients, hepatophyma in 1 and an intestinal fistula in 1. Endoscopic therapy by jejunal approach for post-biliary intestinal anastomosis biliary complications has the virtue of being safe, effective and minimally invasive. It has extensive potential applications in clinical practice.

A comparative study on endoscopy treatment in rectal carcinoid tumors.

BACKGROUND: To investigate the advantages and disadvantages of various endoscopic resection methods for rectal carcinoid tumors. METHODS: A retrospective analysis of 3 types of endoscopic resection techniques for rectal carcinoid tumors was performed. The surgical time and the complication rate were compared between 30 patients who underwent conventional endoscopic mucosal resection (EMR), cap-assisted endoscopic mucosal resection (EMR-C), or endoscopic submucosal dissection (ESD). All rectal carcinoid tumors were under 1 cm and were treated in our center between January 2002 and January 2008. RESULTS: Ten patients underwent each surgical approach. All cases were pathologically diagnosed as rectal carcinoid tumors. One-time complete resection rates using the conventional EMR, EMR-C, and ESD were 80%, 100%, and 100%, respectively. The operation time ranged from 5 to 53 minutes for the conventional EMR group, from 4 to 7 minutes for the EMR-C group, and from 16 to 35 minutes for the ESD group. The average follow-up time for the 30 patients was 18.43 ± 9.76 months. There were no recurrent or metastatic cases. CONCLUSIONS: Endoscopic resection for rectal carcinoid tumors below 1 cm was safe. Considering the clinical efficacy, surgical time, and intraoperative complication rate, EMR-C may be the best endoscopic excision method.

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.

Systematic review: photodynamic therapy for unresectable cholangiocarcinoma.

BACKGROUND: Palliative therapies for unresectable cholangiocarcinoma such as stent, radiotherapy and chemotherapy have generally been disappointing. Therefore, it is necessary to find a new approach to fighting the disease. Several published clinical trials have reported the therapeutic effect of photodynamic therapy (PDT) for unresectable cholangiocarcinoma. OBJECTIVE: To assess the safety and efficacy of photodynamic therapy for patients with unresectable cholangiocarcinoma. METHODS: Relevant studies were retrieved from the Medline, Current Contents, Embase, and Cochrane Library databases. Inclusion of papers was determined by using a predetermined protocol; independent assessments and the final consensus decision were performed by two independent reviewers. Acceptable study designs included randomized controlled trials (RCTs), controlled clinical trials (CCTs), case studies, and case reports. Twenty studies met the inclusion criteria, and were tabulated and critically appraised in terms of characteristics, methods, outcomes, and complications. RESULTS: Twenty studies were included. The quality of the available evidence was low to moderate with the majority of studies being uncontrolled before and after design and thus limited by the retrospective nature of much of the available data. After PDT, it is reported that bilirubin serum levels declined, quality of life improved and survival time increased in most of the patients. At the same time, there were few complications. CONCLUSIONS: Based on currently available evidence, PDT was safe and effective for patients with inoperable cholangiocarcinoma.

[Relationship between expression of p57(kip2), cyclin E protein, PCNA, and clinicopathological factors in human pancreatic cancer].

BACKGROUND & OBJECTIVE: The abnormality of mammalian cell cycle regulation is an important cause of cell over-proliferation and oncogenesis. There were few reports about the relationship between p57(kip2) protein as negative factor of cell cycle regulation and pancreatic cancer. This article aims to investigate the effects of p57(kip2), cyclin E and proliferating cell nuclear antigen (PCNA) protein on the occurrence and progression of pancreatic cancer. METHODS: Expression of p57(kip2), cyclin E, and PCNA in tumor tissue and adjacent tissue from 32 patients with pancreatic cancer were detected using SP immunohistochemical technique. RESULTS: The positive-expression rate of p57(kip2) protein in tumor tissue of pancreatic cancer was 46.9%, which was lower than that in adjacent pancreatic tissue (75.0%) (Chi(2)=5.317, P< 0.05); p57(kip2) protein positive-expression was remarkably correlated with tumor cell differentiation (P< 0.05), but was not correlated with lymph node metastasis (P >0.05). The positive-expression rate of cyclin E in tumor tissues was 68.8%, which was higher than that in adjacent pancreatic tissue (43.8%) (Chi(2)=4.063,P< 0.05); Cyclin E positive-expression was remarkably correlated with tumor cell differentiation and lymph node metastasis (P< 0.05). The positive-expression rate of PCNA protein in tumor tissues was 71.9%, which was higher than that in adjacent pancreatic tissue (43.8%) (Chi(2)=5.189,P< 0.05); PCNA positive- expression was remarkably correlated with tumor cell differentiation and lymph node metastasis(P< 0.05). CONCLUSION: The decreased expression of p57(kip2) protein and over-expression of cyclin E and PCNA proteins may significantly related to genesis and progress of pancreatic cancer.

Expression of p57kip2, Rb protein and PCNA and their relationships with clinicopathology in human pancreatic cancer.

AIM: To investigate the effects of inhibiting factor of cell cycle regulation p57(kip2), retinoblastinoma protein (Rb protein) and proliferating cell nuclear antigen (PCNA) in the genesis and progression of human pancreatic cancer. METHODS: The expression of p57(kip2), Rb protein and PCNA in tumor tissues and adjacent tissues of 32 patients with pancreatic cancer was detected with SP immunohistochemical technique. RESULTS: p57(kip2) protein positive-expression rate in tumor tissues of pancreatic cancer was 46.9 %, which was lower than that in adjacent pancreatic tissues (75.0 %) (chi(2)=5.317, P<0.05), p57(kip2) protein positive-expression correlated significantly with tumor cell differentiation (well-differentiation versus moderate or low-differentiation, P<0.05) but did not correlate significantly with lymph node metastasis (lymph node metastasis versus non-lymph node metastasis, P>0.05); Rb gene protein positive-expression rate in tumor tissues was 50.0 %, which was also lower than that in adjacent pancreatic tissues (78.1 %) (chi(2)=5.497, P<0.05); PCNA positive-expression rate was 71.9 %, being higher than that in adjacent pancreatic tissues (43.8 %) (chi(2)=5.189, P<0.05), PCNA positive-expression also correlated significantly with tumor cell differentiation and lymph node metastasis (well-differentiation versus moderate or low- differentiation, lymph node metastasis versus non-lymph node metastasis, P<0.05). Rb protein positive-expression rate in the tumor tissues of p57(kip2) protein positive-expression group was 53.3 %; and Rb protein positive-expression rate in the tumor tissues of p57(kip2) protein negative-expression group was 47.1 %. There was no significant relationship between the two groups (r=0.16507, P>0.05). CONCLUSION: The decreased expression of p57(kip2), Rb protein or over-expression of PCNA protein might contribute to the genesis or progression of pancreatic cancer, p57(kip2), Rb protein and PCNA may play an important role in genesis and progression of pancreatic cancer.