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.

Detection, extinguishing, and monitoring of a coal fire in Xinjiang, China.

Coal fire is a global catastrophe. Xinjiang suffers the most severe coal fire in China and even in the world. Coal firefighting work has been being conducted for decades in Xinjiang. In this paper, coal fire detection, extinguishing, and monitoring approaches that were derived from coal firefighting experience are introduced in detail by taking the Fifth Fire Area (FFA) of the Heshituoluogai coal fire for instance. We first introduce the geology and fire situation in the FFA. Before developing efficient strategies to extinguish it, magnetic and self-potential methods are adopted to delineate the extent of the fire. A composite index is proposed to better indicate the fire. The comprehensive coal firefighting method is illustrated in detail, which consists of surface cooling, excavation and leveling, borehole drilling, borehole water injection and grouting, and loess backfill. The subsequent temperature and CO monitoring records show that the fire is extinguished successfully without burnback. The methodology presented here provides guidance and reference for putting out other coal fires around the world.

Genetically Regulated Bilirubin and Risk of Non-alcoholic Fatty Liver Disease: A Mendelian Randomization Study.

Mildly elevated serum bilirubin levels were reported to be associated with decreased risk of non-alcoholic fatty liver disease (NAFLD). Whether this is a causal relationship remains unclear. We tested the hypothesis that genetically elevated plasma bilirubin levels are causally related to reduce risk of NAFLD. A total of 403 eligible participants were enrolled. NAFLD was determined by liver ultrasonography. The uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) gene variants (UGT1A1 *6 and UGT1A1 *28) were genotyped through sequencing. We applied a Mendelian randomization approach to assess the effects of genetically elevated bilirubin levels on NAFLD. NAFLD was diagnosed in 19% of participants in our study (NAFLD = 76; Non-NAFLD = 327). The variants of UGT1A1 *28 and UGT1A1 *6 were strongly associated with increased total bilirubin (TB), direct bilirubin (DB), and indirect bilirubin (IB) levels (each P < 0.001). These two common variants explain 12.7% (TB), 11.4% (IB), and 10.2% (DB) of the variance in bilirubin levels, respectively. In logistic regression model, after multifactorial adjustment for sex, age, aminotransferase (ALT), white blood count (WBC), and body mass index (BMI), variant UGT1A1 *28 (OR = 1.39; 95%CI: 0.614-3.170; P = 0.43) and UGT1A1 *6 (OR = 1.64, 95%CI, 0.78-3.44; P = 0.19) genotypes were not significantly associated with the risk of NAFLD. Moreover, the plasma bilirubin level (TB, IB, and DB) were not significantly associated with the risk of NAFLD (P > 0.30). A Mendelian randomization analysis of the UGT1A1 variants suggests that bilirubin is unlikely causally related with the risk of NAFLD.

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.

Pancreatic Stent or Rectal Indomethacin-Which Better Prevents Post-ERCP Pancreatitis?: A Propensity Score Matching Analysis.

We investigated and compared 2 clinical strategies to prevent postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).We retrospectively reviewed data from patients who underwent ERCP between 2008 and 2014. Of 623 patients at high risk for PEP, 145 were treated with prophylactic pancreatic stent placement (PSP) only, and 478 were treated with rectal indomethacin (RI) only, for PEP prevention. Patients were matched by one-to-one propensity score matching (PSM) by risk factors, with overall PEP incidence as primary outcome, and moderate or severe PEP and complication rates as secondary outcomes.Of 623 patients with high-risk factors, 145 pairs were generated after PSM. Thirty-two patients developed pancreatitis-10 (6.9 %) in the PSP group and 22 (15.2 %) in the RI group (P = 0.025). Moderate-to-severe pancreatitis developed in 5 patients (2.8%) in the PSP group and 14 patients (9.7 %) in the RI group (P = 0.047).Although indomethacin represents an easy, inexpensive treatment, prophylactic PSP is still the better prevention strategy for PEP.

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.

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.

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.

Dilation-assisted stone extraction: an alternative method for removal of common bile duct stones.

BACKGROUND: Dilation-assisted stone extraction, also termed small endoscopic sphincterotomy (EST) plus endoscopic papillary balloon dilatation, is more efficient than EST alone for removal of large common bile duct (CBD) stones. However, whether this technique can be used for all stones is unclear. AIM: This study was designed to evaluate the efficacy and complications of dilation-assisted stone extraction for CBD stones. METHODS: A total of 462 patients with CBD stones were randomized to undergo either dilation-assisted stone extraction (group A) or EST (group B). The efficacy and complications of the two techniques were compared. RESULTS: Groups A and B showed similar outcomes in terms of stone removal. The short-term and 1-year complication rates were also similar between the two groups. However, the first-session stone removal rate in group A was significantly higher than that in group B. Mechanical lithotripsy was required significantly more often in group B than in group A. The total procedure time and total fluoroscopy time in group A were significantly shorter than those in group B. CONCLUSIONS: Dilation-assisted stone extraction and EST are safe and effective techniques for the treatment of CBD stones. Dilation-assisted stone extraction has high efficiency. This technique is an alternative method for removal of CBD stones.

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.