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.).

Is appendoscope a new option for the treatment of acute appendicitis?

Acute appendicitis is a common surgical emergency. It is commonly caused by obstruction of the appendiceal lumen due to fecaliths, tumors, or lymphoid hyperplasia. For over a century, appendectomy has been the primary treatment for acute appendicitis. Abraham Groves performed the first open appendectomy in 1883. In 1983, Kurt Semm completed the first laparoscopic appendectomy, heralding a new era in appendectomy. However, appendectomy is associated with certain complications and a rate of negative appendectomies. Studies have suggested controversy over the impact of appendectomy on the development of inflammatory bowel disease and Parkinson's disease, but an increasing number of studies indicate a possible positive correlation between appendectomy and colorectal cancer, gallstones, and cardiovascular disease. With the recognition that the appendix is not a vestigial organ and the advancement of endoscopic te-chnology, Liu proposed the endoscopic retrograde appendicitis therapy. It is an effective minimally invasive alternative for treating uncomplicated acute appendicitis. Our team has developed an appendoscope with a disposable digital imaging system operated through the biopsy channel of a colonoscope and successfully applied it in the treatment of appendicitis. This article provides an overview of the progress in endoscopic treatment for acute appendicitis and offers a new perspective on the future direction of appendiceal disease treatment.

First human case report of Crohn's disease with coexistent acute appendicitis treated by endoscopic retrograde appendicitis therapy.

Background: The coexistence of Crohn's disease (CD) and acute appendicitis (AA) is rare. In this situation, therapeutic experience is lacking and the strategy is paradoxical and intractable. Appendectomy is the gold standard for the treatment of AA whereas a nonsurgical approach is recommended for CD. Case summary: A 17-year-old boy was hospitalized for right lower abdominal pain with fever of 3 days. He had the CD for 8 years. Two years ago, he underwent surgery for anal fistula with the complication of CD. His temperature was elevated at 38.3°C at admission. On physical examination, there was McBurney tenderness with mild rebound tenderness. Abdominal ultrasonography showed that the appendix was notably enlarged and dilated at 6.34 cm long and 2.76 cm wide. These findings were suggestive of uncomplicated AA in this patient with active CD. Endoscopic retrograde appendicitis therapy (ERAT) was performed. The patient had complete pain relief immediately after the procedure without tenderness in the right lower abdomen. During 18 mo follow-up, he had no more attacks in his right lower abdomen. Conclusion: ERAT was effective and safe in a CD patient with coexisting AA. Such cases can avoid surgery and its-related complications.

Elevation of platelet count in patients with colorectal cancer predicts tendency to metastases and poor prognosis.

BACKGROUNDS/AIMS: Thrombocytosis had been found to be associated with tumor metastasis and poor prognosis in malignant tumors including colorectal cancer (CRC). In the present study, we investigated the relationship between the platelet and the biological features in patients with CRC in China. METHODOLOGY: The correlation of platelet counts of 150 cases with CRC with their clinicopathological characteristics was explored. Furthermore, the survival impact of preoperative platelet count was also investigated. RESULTS: Statistically significant correlations between the platelet count and the lymph node and distance metastasis (p=0.016 and 0.014), vascular and perinural invasion (p=0.025 and 0.016) as well as TNM clinical stages (p=0.014) except for the age, gender and grades (p=0.245, 0.276 and 0.324, respectively) were found. In addition, 5-year survival of patients with high platelet count and normal platelet count were 13.30% and 56.30%, respectively (p=0.000). Meanwhile, concurrent with lymph node and distance metastasis, perinural invasion and clinical stages (p=0.000, 0.022, 0.034 and 0.000), platelet count (p=0.010) was also found to be an independent prognostic factor in CRC in our study through multivariate analysis. CONCLUSIONS: Elevated platelet might play some role in the progress of CRC and preoperative platelet count might be a prognostic indicator in the CRC patients.

Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report.

BACKGROUND: Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare. CASE SUMMARY: A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT). CONCLUSION: For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.

Interventional endoscopic ultrasound for a symptomatic pseudocyst secondary to gastric heterotopic pancreas.

Heterotopic pancreas (HP) is a relatively uncommon entity that is defined as pancreatic tissue without a true anatomical or vascular connection to the pancreas. HP does not cause symptoms in most cases but can occasionally produce various manifestations, including nausea, vomiting, abdominal pain, and even heterotopic pancreatitis. Here, we report an unusual case in which heterotopic pancreatitis complicated by the formation of a pseudocyst that caused gastric outlet obstruction was diagnosed based on serum hyperamylasemia and findings from endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA) cytology. EUS-guided single pigtail stent insertion was successfully performed for recurrent gastric outlet obstruction. The patient has remained healthy and symptom-free during 4 years of surveillance. In the context of the relevant literature, the described case is a rare case of HP complicated by a pseudocyst treated via EUS-FNA and stent insertion.