Duodenal Research Articles

Value and limitation of endoscopic ultrasonography on the diagnosis of gastrointestinal submucosal tumor prior to endoscopic resection

Objective To investigate the efficacy and limitation of endoscopic ultrasonography(EUS) on the diagnosis of gastrointestinal submucosal tumor (SMT) prior to endoscopic resection. Methods Data of 211 patients, who were confirmed as gastrointestinal SMT before operation and received endoscopic resection for gastrointestinal submucosal tumor at Department of Gastroenterology, Shanghai Ruijin Hospital from January 2016 to December 2018 were analyzed. The value and limitation of EUS for SMT were investigated according to the final pathology. Results For the lesion distribution, 66 were in esophagus, 108 in stomach, 2 in duodenum and 35 in rectum. The accuracy of tumor origin by EUS was 99.5% (210/211). The accuracy of tumor nature by EUS was 75.8% (160/211). For the lesions originated from different locations, the diagnostic accuracy for lesion originated from esophageal mucosa/submucosa, esophageal muscularis propria, gastric mucosa/submucosa, gastric muscularis propria, duodenal submucosa, rectal mucosa/submucosa by EUS were 90.0%(54/60), 83.3%(5/6), 31.0%(13/42), 89.4%(59/66), 50.0%(1/2), 82.9%(29/35), respectively. With respect to hypoechoic lesions, leiomyoma, leiomyoma/gastrointestinal stromal tumor, and neuroendocrine tumor were the predominant type of tumor originated from esophageal mucosa, gastrointestinal muscularis propria and rectal mucosa/submucosal, respectively. Conclusion Although EUS is indispensible for the diagnosis of gastrointestinal submucosal tumor, it plays a limited role in the differential diagnosis of various lesions originated from gastric mucosa and submucosa. Since part of the submucosal tumors may be potential for malignant development, an diagnosis made by EUS should be more careful. Key words: Endoscopy; Endoscopic ultrasonography; Submucosal tumor

Factors affecting ampullary access of ERCP after Billroth II gastrectomy

Objective To investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy. Methods A retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017. Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access, and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors. Results A total of 345 ERCP sessions were collected. The successful ampullary access and cannulation rate were 82.3% (284/345) and 89.1% (253/284), respectively. The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3%, 61/92) and failure of selective cannulation (33.7%, 31/92). The ERCP-related complication rate was 14.2% (49/345), with post-ERCP pancreatitis rate was 3.2% (11/345). Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717, 95%CI: 2.581-23.068. P<0.001), with Braun anastomosis (OR=8.737, 95%CI: 2.479-30.797, P=0.001), and no cap-assisted forward-viewing gastroscope (OR=2.774, 95%CI: 1.283-5.997, P=0.009) were independent risk factors for failure of ampullary access. According to the B value of each risk factor in logistic regression analysis, that is, no cap-assisted as 1 point, the first ERCP attempt as 2 points, and Braun anastomosis as 2 points, the area under ROC curve was 0.773. When the cut-off point was 2.5, the sensitivity and specificity were 75.0% and 70.8%, respectively. Conclusion The first ERCP attempt, with Braun anastomosis, and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients. Early identification of high-risk patients may help to improve the success rate of ampullary access. Key words: Cholangiopancreatography, endoscopic retrograde; Gastrectomy, Billroth Ⅱ; Risk factors

Prevalence of Helicobacter pylori infection rate in heterotopic gastric mucosa in histological analysis of duodenal specimens from patients with duodenal ulcer.

Heterotopic gastric mucosa in the duodenal bulb is a rare congenital disorder with varied clinical presentations. The mechanism of formation of a duodenal ulcer is failure of balance of the attack factor and the defense factor, which is the same as the mechanism of formation of a gastric ulcer. However, the true etiology of the duodenal ulcer remains unknown. Gastric mucosa can secrete gastric juice which injures itself, but the duodenal mucosa does not contain cells secreting a digestive enzyme. We assume that duodenal ulcers are caused by the presence of heterotopic gastric mucosa that can secrete gastric acid. This study was designed to assess the prevalence and associations of heterotopic gastric mucosa in duodenal ulcers. The present study included 137 patients who underwent biopsy or resection of duodenal ulcer. We detected gastric foveolar metaplasia due to inflammation from a heterotopic gastric mucosa using immunohistochemical staining. Heterotopic gastric mucosa consists of foveolar epithelium (MUC5AC-positive) and fundic gland (H⁺K⁺ ATPase-positive parietal cells, pepsinogen I-positive chief cells and MUC6-positive mucous neck cells), whereas gastric metaplasia is composed of foveolar epithelium without fundic glands. These specimens were stained with toluidine blue for detection of Helicobacter pylori infection. Among the 137 patients with duodenal ulcer, 76 cases (55%) had heterotopic gastric mucosa in the obtained specimens, and Helicobacter pylori was found in 45 cases (59%,45/76) among those with heterotopic gastric mucosa. Our results suggest that heterotopic gastric mucosa was strongly associated with concurrent duodenal ulcer.

PD1 inhibitor-induced apoptotic enteropathy in the duodenum

PD1 inhibitor-induced apoptotic enteropathy in the duodenum

Association of juxtapapillary duodenal diverticulum with pancreaticobiliary diseases and with diagnosis and treatment of endoscopy

Objective To study the relationship between juxtapapillary duodenal diverticulum (JPDD) and pancreaticobiliary diseases, and the effect of JPDD on the diagnosis and treatment of ERCP. Methods A retrospective analysis was performed on data of 1 230 patients who had received ERCP in general surgery departments of Shengjing Hospital of China Medical University from January 2012 to January 2017. The patients were divided into JPDD group (n=360) and non-JPDD group (n=870) according to whether JPDD was found. Patients with JPDD were divided into intradiverticular papilla group (n=41) and non-intradiverticular papilla group (n=319) according to whether the papilla located in diverticulum. The incidence of pancreaticobiliary diseases, success rate of cannulation, success rate of stones removal, and incidence of postoperative complications among each group were compared by using chi-square test or Fisher′s exact probability. P<0.05 was statistically significant. Results The incidence of choledocholithiasis, primary choledocholithiasis and recurrent choledocholithiasis were 87.78% (316/360) , 31.11% (112/360) , and 6.67% (24/360) , respectively, in the JPDD group, and 75.52% (657/870) , 19.08% (166/870) , and 4.02% (35/870) , respectively, in the non-JPDD group. There were significant differences between the two groups (χ2=23.158, P 0.05) . The incidence of recurrent choledocholithiasis in the intradiverticular papilla group and the non-intradiverticular papilla group were 14.63% (6/41) and 5.64% (18/319) , respectively, with significant difference (χ2=4.721, P=0.030) . There were no significant differences between the two groups in the incidence of choledocholithiasis and primary choledocholithiasis, the success rate of cannulation and complete stones removal during the first ERCP session, as well as the incidence of postoperative hemorrhage, pancreatitis and hyperamylasemia (all P>0.05) . Conclusion JPDD is associated with the occurrence of primary choledocholithiasis. JPDD patients, especially the patients with intradiverticular papilla, are more likely to have recurrent choledocholithiasis after ERCP treatment. Key words: Cholangiopancreatography, endoscopic retrograde; Juxtapapillary duodenal diverticulum; Intradiverticular papilla

Endoscopic resection for non-ampullary duodenal neuroendocrine tumors: a retrospective study

Objective To assess the diagnostic accuracy of preoperative endoscopic ultrasonography (EUS) for tumor size and invasion of non-ampullary duodenal neuroendocrine tumors (NA-DETs) and to compare the efficacy and safety of endoscopic submucosal dissection (ESD) and modified ESD for the treatment of NA-DETs. Methods Data of 22 patients with 22 NAD-NETs confirmed by histopathological examinations from January 2007 to January 2018 were retrospectively analyzed. ESD was performed on 13 tumors, and modified ESD was performed on 9 tumors. R0 resection rate, procedure time and incidence of procedure-related complications in the ESD group and the modified ESD group were compared. The postoperative pathological results were used as the gold standard to assess the accuracy of preoperative EUS in diagnosing tumor size and invasion of NA-DETs. Results The mean size of NA-DETs was 6.9±1.5 mm. The accuracy in assessing the invasion depth by EUS was 95.5% (21/22) compared with histological results. R0 resection was achieved in 13/13 (100.0%) of the ESD group and in 7/9 (77.8%) of the modified ESD group (P=1.000) . The procedure time was significantly shorter in the modified ESD group than that in the ESD group (16.0±2.2 min VS 29.8±4.9 min, P<0.001) . Intraoperative perforation occurred in one patient and delayed perforation occurred in one patient in the ESD group. Delayed bleeding occurred in one patient in the modified ESD group. Follow-up data were available in all cases with a mean period of 30.0±24.8 months. No cases of local recurrence or distant metastasis were detected in the follow-up period. Conclusion EUS can accurately assess the size and depth of NAD-NETs. Modified ESD can provide comparable clinical outcomes to ESD for NAD-NETs ≤10 mm in diameter that are confined to the submucosa. Key words: Neuroendocrine tumors; Duodenum; Safety; Efficiency; Endoscopic submucosal dissection

The diagnostic evaluation of magnetic resonance enteroclysis in inflammatory bowel disease

Objective This study aims to investigate diagnosis accuracy of magnetic resonance enteroclysis (MRE) and evaluation of image quality in inflammatory bowel disease (IBD). Methods A total of 132 patients were assumed inflammatory bowel disease and their MRE were retrospectively evaluated. Imaging feature of MRE and histopathologic results by surgery and endoscope were compared. The sensitivity, specificity and diagnostic performance were calculated and image quality of MRE were evaluated by using the quadrature method. Results A total of 530 small intestine segments were analyzed according to evaluation criteria. Imaging quality of 323, 170, 29 and 8 small intestine segments were graded 1, 2, 3 and 4 respectively. Consistency for scoring of imaging quality and evaluation of IBD in intestine segments between observers was pretty good (k=0.73). Scoring of imaging quality was the highest in distal ileum (1.12) and terminal ileum(1.15) and scoring was the lowest in duodenum (1.92) and jejunum(1.6). The sensitivity, specificity and diagnostic agreement rate of MRE in inflammatory bowel disease were 94.3%, 92.6% and 94.7% respectively, including 2 false positive and 6 false negative result. Conclusions MRE can provide high performance in diagnosis of inflammatory bowel disease and good image quality. Key words: Inflammatory bowel diseases; Colitis, ulcerative; Crohn disease; Contrast media; Fluoroscopy; Magnetic resonance imaging

Ansa pancreatica. Review of the literature

Ansa pancreatica is a reversed S-shaped pancreatic duct arising from the main pancreatic duct of Wirsung and ending at or near the minor duodenal papilla. Described for the first time in 1961, it is a rare anatomic variant of the pancreatic ducts system and is characterized by the absence of the accessory duct of Santorini. It probably serves as a counter measure after the accessory duct obliteration, in order to maintain sufficient pancreatic juice drainage. The literature concerning ansa pancreatica seems to be rather poor, compared to other anatomic variants and congenital anomalies of the pancreatic ducts. We tried to define the ansa pancreatica incidence among general population and highlight the possible differences between different populations, and to define its possible correlation with pancreatitis. The existing data correlate ansa pancreatica with recurrent acute pancreatitis and pancreatitis in alcoholics. Despite the lack of extended data, ansa pancreatica is a rare anatomic variant, proven to play an important role in certain clinical conditions.

Endoscopic ultrasound guided biliary drainage in patients with biliary obstruction and surgically altered anatomy

Objective To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with biliary obstruction and surgically altered anatomies. Methods We collected data from 33 patients with biliary obstruction and surgically altered anatomies from January 2016 to January 2018 in Zhejiang University School of Medicine Affiliated Hangzhou First People’s Hospital who underwent EUS-guided biliary drainage after unsuccessful ERCP. The operation success rate, clinical success rate, complication rate, hospital stay were studied. Results Of 33 patients, 31 were successfully operated and stented using endoscopic ultrasound puncture: 14 patients through the stomach, 17 patients through the duodenum; 8 patients by the rendezvous approach. The operation success rate was 93.9%. Of the 33 patients, 28 had a significant decrease in jaundice, with a clinical success rate of 84.9%. Complications consisted of 2 patients with bleeding and 1 patient with cholangitis. These patients improved after conservative treatment. The complications rate was 9.1%. The hospital stay was (12.4±5.7) d. Conclusion EUS-BD can be the first choice for patients with biliary obstruction and surgically altered anatomy after failed endoscopic retrograde cholangiography in centers with expertise in EUS-BD procedures. Key words: Biliary tract diseases; Biliary obstruction; Anatomies, surgically altered; Biliary drainage, endoscopic ultrasound-guided

Gastroscopy-Induced Pancreatitis: A Rare Cause of Post-Procedure Abdominal Pain

A 52-year-old man presented to the emergency department a few hours post gastroscopy with biopsies of the second part of the duodenum (D2) and colonoscopy with severe acute abdominal pain. On examination he had peri-umbilical tenderness. Subsequent laboratory and biochemical investigations revealed acute pancreatitis. The patient went on to develop complications of acute pancreatitis including bilateral pleural effusions and ascites. He was managed conservatively and was discharged home on day 16 of admission with a plan for elective laparoscopic cholecystectomy in the future. J Med Cases. 2019;10(5):126-128 doi: https://doi.org/10.14740/jmc3304

Time-Dependent Changes in the Intestinal Microbiome of Gilts Exposed to Low Zearalenone Doses.

Zearalenone is a frequent contaminant of cereals and their by-products in regions with a temperate climate. This toxic molecule is produced naturally by Fusarium fungi in crops. The aim of this study was to determine the influence of low zearalenone doses (LOAEL, NOAEL and MABEL) on the intestinal microbiome of gilts on different days of exposure (days 7, 21 and 42). Intestinal contents were sampled from the duodenal cap, the third part of the duodenum, jejunum, caecum and the descending colon. The experiment was performed on 60 clinically healthy gilts with average BW of 14.5 ± 2 kg, divided into three experimental groups and a control group. Group ZEN5 animals were orally administered ZEN at 5 μg /kg BW, group ZEN10—10 μg ZEN/kg BW and group ZEN15—15 µg ZEN/kg BW. Five gilts from every group were euthanized on analytical dates 1, 2 and 3. Differences in the log values of microbial counts, mainly Escherichia coli and Enterococcus faecalis, were observed between the proximal and distal segments of the intestinal tract on different analytical dates as well as in the entire intestinal tract. Zearalenone affected the colony counts of intestinal microbiota rather than microbiome diversity, and its effect was greatest in groups ZEN10 and ZEN15. Microbial colony counts were similar in groups ZEN5 and C. In the analysed mycobiome, ZEN exerted a stimulatory effect on the log values of yeast and mould counts in all intestinal segments, in particular in the colon, and the greatest increase was noted on the first analytical date.

Clinical efficacy of Da Vinci robot-assisted radical gastrectomy for gastric cancer

Objective To explore the clinical efficacy of Da Vinci robot-assisted radical gastrectomy for gastric cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 472 patients who underwent radical gastrectomy for gastric cancer in the 940 Hospital of the People′s Liberation Joint Service from June 2016 to June 2018 were collected. There were 372 males and 100 females, aged (57±11)years, with a range from 17 to 85 years. Patients underwent gastrointestinal angiography, magnetic resonance imaging, computed tomography or gastrointestinal endoscopy before surgery, and were diagnosed with gastric cancer by biopsy. Of the 472 patients, 241 underwent Da Vinci robot-assisted radical gastrectomy for gastric cancer were allocated into robotic group and 231 underwent laparoscopy-assisted radical gastrectomy were allocated into laparoscopic group. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect the tumor recurrence and metastasis and survival of patients up to January 30, 2019. Measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was done using the t test. Measurement data with skewed distribution were described as M (range). Count data were described as absolute number or percentage, and the chi-square test was used for comparison between groups. Comparison of ordinal data was done using the rank-sum test. The accumulative survival rate, tumor-bearing survival rate and mortality of tumor recurrence were calculated by the Kaplan-Meier method, and Log-rank test was used for survival analysis. Results (1) Surgical situations: 472 patients underwent successful operation, with R0 margin. Cases with total gastrectomy + D2 lymph node dissection + Roux-en-Y anastomosis, cases with distal subtotal gastrectomy + D2 lymph node dissection + Billroth Ⅱ anastomosis, operation time, upper margin distance, lower margin distance, tumor diameter, cases with shallow muscular invasion, deep muscular invasion, subserosal invasion and serosal invasion (depth of tumor invasion)were 107, 134, (234±44)minutes, (4±3)cm, (6±4)cm, (5 ±3)cm, 8, 17, 32, 184 in the robotic group, and 94, 137, (239±46)minutes, (4±3)cm, (6±4) cm, (5±3)cm, 7, 19, 30, 175 in the laparoscopic group, respectively; there was no significant difference in above indicators between the two groups (χ2=0.200, 2.459, t=-1.212, -1.074, -0.420, -1.236, Z=0.171, P>0.05). The volume of intraoperative blood loss, number of lymph nodes dissected in total gastrectomy, number of lymph nodes dissected in distal subtotal gastrectomy were (126±113)mL, 45±14, and 36±18 in the robotic group, and (149±132) mL, 39±14, 30±16 in the laparoscopic group, showing statistically significant differences between the two groups (t=-2.093, 3.275, 2.195, P 0.05). Eighteen out of 472 patients had complications. There were 3 cases of anastomotic leakage in the robotic group, 2 cases of gastroplegia, 1 case of duodenal stump, and 1 case of pulmonary infection, with a incidence of postoperative complication as 2.90%(7/241). There were 4 cases of anastomotic leakage in the laparoscopic group, 1 case of gastroplegia, 1 case of duodenal stump, and 3 cases of pulmonary infection, with a incidence of postoperative complication as 3.90%(9/231). There was no statistically significant difference in the incidence of postoperative complication between the two groups (χ2=1.503, P>0.05). Patients with digestive tract fistula were re-explored and performed continuous flushing-negative pressure aspiration and nutritional support treatment, and then discharged after improvement. Patients with gastroplegia and lung infection were discharged after corresponding conservative treatment. (3) Follow-up and survival: 404 out of 472 patients were followed up for 7-31 months, with a median follow-up time of 19 months, including 212 in the robotic group and 192 in the laparoscopic group. The 3-year survival rates were 96.70% and 91.67% in the robotic group and laparoscopic group, with no statistically significant difference between the two groups (χ2=1.037, P>0.05). During the follow-up, the tumor-bearing survival rate and mortality of tumor recurrence of the robotic group were 0.47% and 2.36%, respectively, versus 1.04% and 6.77% of the laparoscopic group, with statistically significant differences between the two groups (χ2=3.198, 4.208, P<0.05). Conclusion The Da Vinci robot-assisted radical gastrectomy for gastric cancer is safe and effective, which can reduce volume of intraoperative blood loss, shorten the postoperative recovery time, increase the number of lymph node dissection, however, it will increase the treatment expense. Key words: Gastric neoplasms; Gastric cancer; Radical gastrectomy; Efficacy; Economy; Da Vinci robotic surgical system; Laparoscopy

Endoscopic papillary balloon dilation in treatment of choledocholithiasis associated with peripapillary duodenal diverticulum

Objective To evaluate the use of endoscopic papillary balloon dilation in treatment of choledocholithiasis associated with peripapillary duodenal diverticulum. Methods From January 2017 to July 2018, a retrospective study was conducted on 124 patients with choledocholithiasis associated with peripapillary duodenal diverticula at the Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University. These patients were divided into the small endoscopic sphincterotomy combined with balloon dilation group (sEST+ EPBD, n=60) and the simple papillary balloon dilation group (EPBD n=64). The operation time, one-time success rate of stone removal, complication and hospitalization stay were compared between the two groups of patients. Results The hospitalization expenses of the EPBD group was significantly less than the sEST+ EPBD group (P 0.05). Conclusions Compared with sEST+ EPBD, treatment of choledocholithiasis in patients with peripapillary duodenal diverticula using simple balloon dilation shortened the operation time, did not increase the complication rates and hospitalization stay. The procedure was safe and effective, and resulted in almost the same one-time success rate of stone removal. Key words: Endoscopic retrograde cholangiopancreatography; Parapapillary duodenal diverticula; Choledocholithiasis; Endoscopic papillary balloon dilation

Detection of major duodenal papilla using full-spectrum endoscopy: a randomized controlled trial

Objective To evaluate the efficiency and safety of full-spectrum endoscopy for detection of major duodenal papilla. Methods Patients underwent painless gastroscopy in Chinese PLA General Hospital from March 2017 to December 2017 were enrolled and randomly divided into two groups according to random number method. The group A underwent conventional gastroscopy, and the group B underwent full-spectrum endoscopy. The detection rate of major duodenal papilla was calculated and compared between the two groups. Results A total of 100 patients were recruited in the study, including 51 in the group A and 49 in the group B. The whole detection rate of major duodenal papilla of the group B was higher than that of the group A [79.59% (39/49) VS 41.18% (21/51), χ2=15.366, P=0.000]. There was no statistical difference on the whole plus partial detection rate of major duodenal papilla between the two groups [100.00% (49/49) VS 92.16% (47/51), χ2=2.221, P=0.136]. All patients completed endoscopy examination succesfully without bleeding, peforation or death. Conclusion With the broad view-field, full-spectrum endoscopy is useful to improve the efficiency and safety in detection of major duodenal papilla. Key words: Endoscopy; Full-spectrum gastroscopy; Major duodenal papilla; Diagnosis

Diet Rendah Protein Meningkatkan Jumlah Neuron Nitrergik Duodenum dan Jejunum Serta Menurunkan Bobot Badan Tikus Wistar (LOW PROTEIN DIET INCREASES THE NUMBER OF DUODENUM, JEJUNUM NITRERGIC NEURONS AND REDUCES BODY WEIGHT IN THE WISTAR RATS)

Protein is very important for the growth, development and activity in rats. The impact of lack protein intake to gastrointestinal, especially in the small intestine, the number of nitrergic neurons, and changes in body weight in Wistar rats has not been studied. Therefore the aims of this study to examine the effect of a low-protein diet for 4 weeks on the number of duodenal, jejunal, ilealnitrergicneuron and changes in body weight in Wistar rats. Nine male Wistar (Rattusnorvegicus) rats, aged 1 month, with an average body weight of 120 grams used in this study. The rats were adapted for 7 days in individual cages with a normal diet (containing 24% protein) and drinking ad libitum. After being adapted all rats were divided into 3 groups (K-24, K-14, and K-4), consist of 3 rats. Then all rats fasted for 12-hours. Each group received treatment as follows: K-24 group (as a control) was given a diet containing 24% of protein, K-14 group was given a diet containing 14% of protein, and K-4 group was given a diet containing 4% of protein . Diet and drinking water are given ad libitum. Along of treatment for 4 weeks.body weights and blood glucose were measured every weeks, then all rats were euthanized and sample tissues of duodenum, jejunum, and ileum were then were obtained for histopathological preparations using the NADPH-d technique. Data on the number of nitrergicmyenteric neurons in the duodenum, jejunum, and ileum, body weight gain, and blood glucose levels were statistically analyzed by single factor design Anova. The results of this study concluded that a low protein diet (14% and 4% protein) for 4-weeks in the duodenum, jejunum have been increased the number of nitrergic neurons, on the other hand, in the ileum have been decreased the number of nitrergic neurons, reduced body weight, and did not increase blood glucose levels in Wistar rats.

EUS-guided biliary drainage using a fully covered self-expandable metal stent for malignant obstructive jaundice

Objective To study the therapeutic effects of EUS-guided biliary drainage (EUS-BD) using a nitinol fully covered self-expandable metal stents in patients with malignant obstructive jaundice after failed ERCP. Methods From January 2016 to January 2018, all patients with malignant obstructive jaundice who failed ERCP underwent EUS-guided biliary drainage using nitinol fully covered self-expandable metal stent at Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine. The operation success rate, liver functional recovery time, complication rate, length of hospital stay and survival time were observed. Results Of 36 patients who underwent EUS-guided biliary drainage, 34 were successfully performed, with 19 through the stomach, and 15 through the duodenum. The operation success rate was 94.4% (34/36). The liver functional recovery time of the 34 patients were 25.8 ± 6.5 days. One patient developed hemobilia and one cholangitis, both improved after conservative treatment. The total complication rate was 5.6% (2/36). The hospital stay and survival time were 21.5 ± 4.7 days and 220.5 ± 54.8 days, respectively. Conclusion EUS-BD using nitinol fully covered self-expandable metal stents was a feasible and effective treatment in patients with malignant biliary obstruction after failed ERCP. Key words: Jaundice, obstructive; Neoplasms; Palliative care; Endoscopic ultrasonography(EUS); Bile duct stent; Biliary drainage

Effects of a probiotic on the morphology and mucin composition of pig intestine.

Although the use of probiotics in human and animal medicine is growing, their mode of action remains poorly understood. This study examined the effects of a multi-strain probiotic (SLAB51™) on the morphology and carbohydrate composition of mucins secreted by goblet cells of intestinal crypts in growing-finishing pigs. Sections of duodenum, caecum and colon from pigs fed for 12 weeks with an orally administered control basal diet (No-Pro) or one with a probiotic blend (Pro) were processed for microscopic analysis and stained with (1) haematoxylin-eosin for structural and morphometrical investigation; (2) conventional histochemistry (periodic acid-Schiff, Alcian Blue pH 2.5, high iron diamine staining) for neutral, acidic non-sulphated, and sulphated mucin analysis; and (3) FITC-labelled MAA-II and SNA lectins for α2,3- and α2,6-sialomucin identification. Compared with No-Pro samples, Pro samples displayed (1) increased goblet cell numbers in all investigated tract crypts; (2) an increase in acidic non-sulphomucins but a decrease in neutral, sulphated and α2,6-sialomucin-secreting goblet cells in the duodenum; (3) decreased crypt depth, an increase in α2,6-sialomucin secretory goblet cells, and a loss of goblet cell-secreting α2,3-sialomucins, which appeared on the apical surface of crypt fundus epithelial cells in the caecum; and (4) an increase in α2,6-sialomucin-producing goblet cells in the colon. Results suggest that treatment with SLAB51™ induces region-specific changes in the morphology and carbohydrate composition of mucins secreted along intestinal tracts of growing-finishing pigs. These changes could ameliorate the health status of the animals, which displayed higher growth performance and meat quality than controls (Tufarelli et al., 2017).

How I do it: Flexible 3‐D endoscope for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3-D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3-D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm2 vs 434.7 s/cm2 ; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3-D endoscope for carrying out ESD. Ten patients received ESD using the 3-D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm2 . The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3-D endoscope with an excellent 3-D view enhancing depth perception. Future study should be conducted to compare 3-D against 2-D endoscopes for ESD.

Analysis of risk factors of pulmonary infection in patients over 60 years of age after radical resection for gastric cancer

To investigate the risk factors of postoperative pulmonary infection (PPI) in patients over 60 years of age with gastric cancer after radical gastrectomy. Clinicopathological data of 373 patients over 60 years of age who underwent radical gastrectomy at Department IV of Gastrointestinal Cancer Center, Peking University Cancer Hospital, from April 2009 to December 2016 were retrospectively collected in this case-control study. The clinicopathological characteristics of patients with postoperative pulmonary infection (including postoperative atelectasis) and those without pulmonary infection were compared. A Student t-test (reported as Mean±SD if data matching normal distribution) or Mann-Whitney U test [reported as median (quartile) if data did not conform to normal distribution] was used to analyze continuous variables. A χ² test or Fisher exact tests (reported as number and percentage) was used for categorical variables. Multivariable logistic regression was used to analyze the risk factors for pulmonary infection after operation of gastric cancer.PPI was defined as postoperative patients with elevated body temperature (>38.0 degrees centigrade) for more than 24 hours; cough and expectoration; positive sputum bacteria culture;recent infiltration, consolidation or atelectasis confirmed by chest imaging examination. Among 373 patients, 50 cases had PPI(13.4%, PPI group), 323 cases had no PPI(86.6%, non-PPI group). There were 39 (78.0%) and 178(55.1%) patients with comorbidities (including hypertension, diabetes and cardiopulmonary disease) preoperatively in PPI and non-PPI group, respectively. The difference between two groups was statistically significant (χ²=9.325,P=0.002). The incidence of preoperative hypoalbuminemia in PPI group was also significantly higher than that in non-PPI group [10.0%(5/50) vs. 3.1% (10/323),χ²=4.098, P=0.048]. Compared to non-PPI group, the rate of total gastrectomy [54.0%(27/50) vs. 34.4% (111/323), χ²=12.501, P=0.002], postoperative wound pain [34.0%(17/50) vs. 11.8% (38/323),χ²=16.928, P<0.001], secondary operation [6.0%(3/50) vs. 0.6% (2/323), χ²=6.032, P=0.014] and the rate of gastric tube removal later than 7 days postoperatively [96.0%(48/50) vs. 84.5%(273/323),χ²=4.811, P=0.028] were significantly higher in PPI group, respectively. The postoperative hospital stay was also prolonged in PPI group [16.0(9.5) days vs. 12.0(5.0) days, U=4 275.0, P<0.001]. Multivariate logistic regression analysis showed that preoperative comorbidities (OR=4.008, 95%CI:1.768-9.086, P=0.001), abdominal infection (OR=3.164, 95%CI:1.075-9.313, P=0.037), and wound pain (OR=3.428, 95%CI:1.557-7.548, P=0.002) were independent risk factors for PPI in patients over 60 years of age with gastric cancer. Furthermore, 50 patients with pulmonary infection were classified according to the length of latency and the type of infection. The patients with PPI latency ≤ 3 days were classified as early onset (34 cases, 68.0%), and those with latency ≥ 4 days as delayed onset (16 cases, 32.0%); PPI combined with surgical infection (including anastomotic leakage, abdominal infection, duodenal stump leakage, wound infection, etc.) was classified into mixed infection group (13 cases, 26.0%), with non-surgical infection as simple infection group (37 cases, 74.0%). The results showed that the pulmonary infection occurred 0 to 12 days (median 3 days) before surgical infection in mix infection group. The incidence of previous chronic obstructive pulmonary disease (COPD) in patients with early onset was significantly higher than that in patients with delayed onset [17.6%(6/34) vs. 0, χ²=5.005, P=0.025], and the incidence of mixed infection in patients with delayed onset was significantly higher than that in patients with early onset [50%(8/16) vs. 14.7%(5/34), χ²=6.730, P=0.009],but there was no significant difference in postoperative hospital stay between the two groups[17.0(9.8) days vs. 14.0(9.5) days, U=224.0, P=0.317]. Postoperative pulmonary infection is common in gastric cancer patients over 60 years of age. Preoperative comorbidities, abdominal infection and wound pain are independent risk factors for postoperative pulmonary infection. Pulmonary infection within 3 days after operation is associated with preoperative COPD. For patients suffering from PPI after the 4th day,attentions should be paid to abdominal infection and anastomotic leakage.

Clinical effects and prognostic analysis of radical surgery for primary gallbladder cancer

Clinical effects and prognostic analysis of radical surgery for primary gallbladder cancer