Evidence-based clinical practice guidelines for cholelithiasis 2016

BACKGROUND: This clinical practice guideline addresses six questions related to liberation from mechanical ventilation in critically ill adults. It is the result of a collaborative effort between the American Thoracic Society (ATS) and the American College of Chest Physicians (CHEST). METHODS: A multidisciplinary panel posed six clinical questions in a population, intervention, comparator, outcomes (PICO) format. A comprehensive literature search and evidence synthesis was performed for each question, which included appraising the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The Evidence-to-Decision framework was applied to each question, requiring the panel to evaluate and weigh the importance of the problem, confidence in the evidence, certainty about how much the public values the main outcomes, magnitude and balance of desirable and undesirable outcomes, resources and costs associated with the intervention, impact on health disparities, and acceptability and feasibility of the intervention. RESULTS: Evidence-based recommendations were formulated and graded initially by subcommittees and then modified following full panel discussions. The recommendations were confirmed by confidential electronic voting; approval required that at least 80% of the panel members agree with the recommendation. CONCLUSIONS: The panel provides recommendations regarding liberation from mechanical ventilation. The details regarding the evidence and rationale for each recommendation are presented in the American Journal of Respiratory and Critical Care Medicine and CHEST

Clinical outcomes of endoscopic resection for nonampullary duodenal high-grade dysplasia and intramucosal carcinoma.

This study retrospectively analyzed the clinical outcomes of endoscopic resection of 26 sporadic (i. e., not associated with polyposis syndrome) nonampullary duodenal lesions representing high-grade dysplasia or intramucosal carcinoma (duodenal HGD/IMC) in 23 patients. No severe complications such as perforation were observed, but three cases of delayed bleeding were seen. The use of endoscopic clips significantly decreased the delayed bleeding rate (0/19, 0%) compared with cases in which clips were not used (3/7, 42.9%; P = 0.013, χ2 test). Eighteen lesions (69.2%) were removed by en bloc resection. The follow-up period after resection was 25.5 ± 23.3 months. Two lesions (7.7%) that recurred locally were detected at the first surveillance endoscopy 3 months after resection. These lesions were 22 and 15 mm in size respectively and were resected piecemeal. Endoscopic resection is an effective and safe procedure for treating duodenal HGD/IMC. En bloc resection and prophylactic clip usage are encouraged.

Risk factors for recurrent bile duct stones after endoscopic papillotomy.

BACKGROUND: The long term outcome of endoscopic papillotomy (EPT) is not well known. The aims of this study were to clarify the clinical course of post-EPT patients and to detect predictors for bile duct stone recurrence. METHODS: A total of 1042 consecutive patients who underwent EPT for bile duct stones from December 1975 to September 1998 were prospectively followed up. Patients were divided into four groups according to gall bladder (GB) status: "acalculous GB" group, "calculous GB" group, "cholecystectomy" group, and "prior cholecystectomy" group. Reliable follow up information was obtained for 983 (94.3%) of the 1042 patients. The following factors were considered in the evaluation of predisposing risk factors for recurrence of bile duct stones: age, sex, gall bladder status, periampullary diverticulum, number of bile duct stones, diameter of bile duct stones, diameter of bile duct, lithotripsy, precutting, pneumobilia, and early complications. RESULTS: Recurrence occurred in 111 patients. The "acalculous GB" group was less prone to recurrence than the "prior cholecystectomy" group and the "calculous GB" group. The relative risks (RR) for the latter two compared with the former group were 2.26 (95% confidence interval (CI) 1.24-4.14; p=0.0078) and 2.16 (95% CI 1.21-3.87; p=0.0093), respectively. Other prognostic factors were lithotripsy (RR 2.37; 95% CI 1.47-3.81; p=0.0004) and pneumobilia (RR 1.57; 95% CI 1.01-2.43; p=0.044). CONCLUSIONS: Gall bladder status, lithotripsy, and pneumobilia were significantly related to bile duct stone recurrence after EPT.

Long-term follow-up after treatment of Mirizzi syndrome by peroral cholangioscopy.

BACKGROUND: The standard treatment for Mirizzi syndrome is surgical, although endoscopic and percutaneous management have also been described. The aim of this study was to evaluate the usefulness of shock wave lithotripsy combined with peroral cholangioscopy and its long-term outcome in patients with Mirizzi syndrome. METHODS: The records of 25 patients with Mirizzi syndrome who underwent endoscopic treatment between April 1990 and November 1998 were retrospectively reviewed. Shock wave lithotripsy was performed under direct vision with a "mother-baby" endoscope system in 2 patients with type I and 23 with type II Mirizzi syndrome (12 men and 13 women, mean age 60 years). Follow-up data were obtained from clinical records or through telephone interviews. RESULTS: In the two patients with type I, the cholangioscopic approach failed and both patients underwent open cholecystectomy. The 23 patients with type II were all successfully treated with shock wave lithotripsy alone. The cholangioscopic approach was unsuccessful in the treatment of residual gallbladder stones. Follow-up data were obtained in all but one patient (mean 43.6 months, range 4 to 103 months). Of the 23 patients with type II, 12 with no gallbladder stones had remained asymptomatic during the follow-up period. Of the 6 patients with type II with large residual gallbladder stones, 4 had acute cholangitis due to stone migration 6, 9, 28, and 34 months after endoscopic treatment. Two patients died during the follow-up period, one of non-biliary causes and the other of coexistent gallbladder carcinoma. CONCLUSIONS: Endoscopic treatment of Mirizzi syndrome using peroral cholangioscopy is a safe and effective alternative to surgery, especially in patients with the type II syndrome. A favorable long-term outcome depends on the absence of large residual gallbladder stones.

Quantitative analysis of bowel gas using plain abdominal radiograph in patients with irritable bowel syndrome.

OBJECTIVE: Ideally, the diagnosis of irritable bowel syndrome (IBS) would be achieved using a minimal number of procedures. It is presumed that bowel gas is related to IBS, and it is easily visualized by plain abdominal radiograph. In the present study, to clarify the relationship between IBS and the quantity of bowel gas, the measured bowel gas volume using plain abdominal radiographs was compared with the pathology of IBS. METHODS: Plain abdominal radiographs were digitized and transmitted to a computer (computed radiography) in 30 IBS patients and 30 normal controls. The quantity of bowel gas, determined as the pixel value on images and standardized by physique, was defined as the gas volume score (GVS). Using the mean +/- 2SD of GVS in the control group as the normal score, IBS patients were divided into three groups: high, normal, and low. To examine the sequential reproducibility of a similar quantity of bowel gas, a second plain abdominal radiography was performed about 2 months later, and the GVS were compared. The colonic transit time was determined using radiopaque markers. RESULTS: There was a strong correlation between the quantities of bowel gas measured by two independent gastroenterologists. The mean GVS of IBS patients was significantly higher than that in the control group (p < 0.001). The sequential reproducibility was recognized in all 10 IBS patients. There was no significance between colonic transit time and GVS, nor between symptoms and GVS. CONCLUSIONS: Abdominal gas was analyzed objectively by using GVS, and GVS was considered to represent a useful tool for the diagnosis of IBS.

Peroral pancreatoscopy in the diagnosis of mucin-producing tumors of the pancreas.

BACKGROUND: Mucin-producing tumor of the pancreas is an increasingly recognized clinical entity. However, the differentiation of benign from malignant mucin-producing tumors of the pancreas is challenging. Peroral pancreatoscopy as recently developed may have potential for the diagnosis of mucin-producing tumors of the pancreas. METHODS: The subjects were 41 patients with clinically diagnosed mucin-producing tumors of the pancreas, 40 of whom underwent surgical resection. Autopsy findings were available in another patient with unresectable disease. Histologically, hyperplasia was identified in 3 patients, mildly atypical adenoma in 11, severely atypical adenoma in 16, and adenocarcinoma in 11. Peroral pancreatoscopy was performed before surgery or pathologic examination. The findings were retrospectively evaluated and compared with the histopathologic diagnosis. RESULTS: Pancreatoscopic observation was successful in 30 patients (73.2%). Elevated lesions were identified in 22 (73.3%). Villous or vegetative elevations and red color markings were frequently found in severely atypical adenoma or adenocarcinoma. Tumor location (main or branch duct type) did not correlate with survival after resection. Partial resection was performed in 7 of 30 patients with nonmalignant tumors and resulted in favorable outcomes. CONCLUSION: Peroral pancreatoscopy can be used to differentiate benign mucin-producing tumors of the pancreas (hyperplasia and mildly atypical adenoma) from the more dysplastic lesions (severely atypical adenoma and adenocarcinoma) and may provide useful information for determining the type of surgery to be performed.

Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis.

BACKGROUND: Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients. METHODS: Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed. RESULTS: The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis. CONCLUSIONS: Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.

[Characteristic findings of endoscopic retrograde pancreatography in the diagnosis of chronic pancreatitis with inflammatory mass].

Chronic pancreatitis with inflammatory mass (CPM) is difficult to differentiate from pancreatic cancer. To clarify the characteristic findings of CPM, we performed endoscopic retrograde pancreatography (ERP) in 39 patients. The pancreatogram showed smooth stenosis at the site of the mass in 26/39 cases (66.6%), irregular stenosis in 6 (15.4%), obstruction in 4 (10.3%), and no stenosis in 3 (7.7%). In the case of stenosis on ERP, the length of the stenosis correlated with the size of the mass. The pancreatogram distal to the mass showed dilatation in 26/35 cases (74.3%), 18 (51.4%) of which were simple dilatation. A follow-up study of 5 cases showed that all the stenoses had remained, and that the pancreatitis was aggravated in 2 cases. These findings suggest that CPM causes local stenoses of the pancreatic duct in many cases, and consequently may aggravate the stage of chronic pancreatitis.

[Treatment of common bile duct stones by peroral cholangioscopy].

Endoscopic papillotomy (EPT) has become a popular form of treatment in managing common bile duct stones. But it may fail in difficult cases such as large stones of over 20 mm, confluence stones, and impacted stones. Over the past 5 years, our success rate in clearing the bile duct by conventional endoscopic techniques (mechanical lithotripsy) was about 90 per cent. Recently, we have performed electrohydraulic lithotripsy or laser lithotripsy with peroral cholangioscopy in these difficult cases. Complete clearance of the duct was obtained in all 23 patients who underwent peroral cholangioscopic lithotripsy. No complication occurred. In conclusion, peroral endoscopic treatment of common bile duct stones should be safe and effective.

[Immunoreactivity of pulmonary tuberculosis patients to tuberculous antigens purified by affinity columns coupled with monoclonal antibodies directed to Mycobacterium tuberculosis].

Immunoaffinity-purified antigens (MAb-Ags) of Mycobacterium tuberculosis, which has been obtained in a previous study by use of anti-M. tuberculosis monoclonal antibodies and designated MTA 2a (24 kD), MTA 6a (19 kD) and MTA 8a (19 kD), were examined for their antigenicity by determining the responsiveness to these antigens of pulmonary tuberculosis (TB) patients and non-tuberculous controls. Serum anti-MAb-Ags ELISA antibody levels in TB patients were significantly higher than those in non-tuberculosis controls, including patients with atypical mycobacterial infection and Mantoux-test-positive healthy individuals. MAb-Ags stimulated proliferation of peripheral blood lymphocytes (PBL) from TB patients as determined by 3H-thymidine uptake of PBL. MAb-Ags also stimulated PBL from TB patients to increase T4/T8 ratio and Ia-positive T cells. After stimulation with MAb-Ags, increase of IL-2 receptor-positive T cells in PBL from TB patients was not significantly higher than that in PBL from healthy persons. Responses of PBL from non-tuberculosis controls to MAb-Ags varied considerably, and the response was either none or weak, in some cases, or as high as that of PBL from TB patients, in the other cases. In general, MAb-Ags stimulated PBL from TB patients and some of Mantoux test-positive persons to almost the same extent as PPDs did.

[Molecular cloning and expression of Mycobacterium tuberculosis Aoyama B peptide antigen genes in Escherichia coli--a gene encoding 60 kD antigen (AT201) and immunological activity of recombinant peptides (15 and 60 kD)].

To obtain recombinant peptides related to PPDs, we constructed a genomic library from the DNA of Mycobacterium tuberculosis Aoyama B, a standard strain in Japan to manufacture PPDs, using plasmid vectors pUC18 series. Seven clones reacting the anti-PPDs-rabbit-serum on immunoblotting were obtained, and restriction map was analysed. A nucleotide sequence and a putative open reading frame (ORF) of pAT01, encoding 15kD peptide, as well as the mode of expression was reported previously). In this study, nucleotide sequence of 60 kD peptide gene was determined, and the comparative database analysis (GENBANK) revealed a striking level of homology to so called mycobacterial heat shock protein. The expression mode of pAT201 encoding 60 kD, as well as pAT01 encoding 15 kD peptide, indicated that these peptides were not hybrid proteins with the lacZ gene product, but they were consisted of peptides only mycobacterial source. Therefore, 15 kD and 60 kD directly were subjected to immunological studies. The peptides were extracted from E. coli, carrying pAT01 or pAT201, purified through series of DEAE chromatography and followed by Detoxi-Gel to remove LPS. 15 kD peptide behaved almost similar to PPDs both in the DTH skin reaction and the lymphocyte proliferation response on guinea pigs or rats in respect to sensitivity. However, 60 kD was unique in that, and it behaved like a general mitogen. We discussed role of 60 kD peptide, comparing with the common antigen, generally found in most species of bacteria as the heat shock protein.

Mycobacterium avium-Mycobacterium intracellular complex-induced suppression of T-cell proliferation in vitro by regulation of monocyte accessory cell activity.

Heat-killed whole Mycobacterium avium-Mycobacterium intracellulare complex (MAC) and its lipid component impaired the capacity of human peripheral blood mononuclear cells to proliferate in vitro in response to concanavalin A (ConA), purified protein derivative of tuberculin (PPD), and to a lesser degree, phytohemagglutinin stimulation. Inhibition by MAC was not contingent upon prior exposure of the donor to MAC or other mycobacteria and occurred with lymphocytes from tuberculin-negative as well as -positive subjects. The suppression was not due to the toxicity of MAC. The suppression by MAC was not blocked by indomethacin. Adherent cell depletion and cell mixing experiments with T cells indicated that monocytes and not T cells were a major contributor to the immunosuppression observed. However, neither interleukin-1 production nor the expression of HLA-DR (Ia antigen) by monocytes was suppressed by MAC treatment. On the other hand, treatment of monocytes with MAC or MAC-derived lipid resulted in significant decreases in CD11b, a member of the leukocyte function-associated molecule-1 and LeuM3 (CD14) molecule. Anti-CD18 (beta-chain of the leukocyte function-associated molecule-1 family) monoclonal antibody had suppressive effects on ConA- and PPD- but not phytohemagglutinin-induced in vitro lymphocyte blastogenesis. We suggest that MAC and MAC-derived lipid suppress the ConA- and PPD-induced T-cell proliferations by blocking the expression of accessory molecules on the surfaces of monocytes which might be involved in nonspecific monocyte-T-cell interactions and not by inhibiting either monocyte Ia antigen expression or interleukin-1 production by monocytes.

[Production of monoclonal antibodies for Mycobacterium tuberculosis Aoyama-B and immunological activity of the affinity-purified antigens].

Nine hybridomas of BALB/c mouse, producing monoclonal antibodies (MAb: MTA 1-9) directed to Mycobacterium tuberculosis AOYAMA-B (M. tbc AB), were established. The MAbs reacted to M. tbc AB antigens, forming a main band of 32 KD, 24 KD or 19 KD on immunoblotting, except MTA 1 that reacted with 58 KD in addition to 32 KD antigen. Immunoglobulin isotypes of MAbs were IgM, IgG 1 or IgG 2b. On a mode of reactivity of ELISA against various mycobacterial antigens, MAbs were divided into two categories: those reacting to human type mycobacterial antigens alone and those reacting both to the human and non-human type. The MAbs could further be classified into 4 groups by subtle discrimination of ELISA reactivity to the antigens. Three kind of MAb-affinity-purified antigens (MAb-Ag) from M. tbc AB were obtained. Immunogenic activities of the three MAb-Ags, together with that of control PPDs were examined. Every MAb-Ag showed positive reaction in ELISA, DTH skin test and [3H]TdR incorporation of lymphnode cells, on M. tbc AB sensitized rabbit, guinea pig and rat, respectively, with almost equal level of those of PPDs. However, in some occasions, MAb-Ags positively reacted in animals primed by non-human type mycobacteria. It was discussed that whether a homogeneous antigen like MAb-Ag, bearing limited number of epitopes, could be as immunogenic as PPDs consisting of multi-components.