The human intestinal tract is home to an enormous bacterial flora. The host defense against microorganisms can be divided into innate and adaptive immunity. The former is the most immediate line of response to immunol...The human intestinal tract is home to an enormous bacterial flora. The host defense against microorganisms can be divided into innate and adaptive immunity. The former is the most immediate line of response to immunologic challenges presented by bacteria, viruses, and fungi. The mucosal immune system has evolved to balance the need to respond to pathogens while co-existing with commensal bacteria and food antigens. In inflammatory bowel disease （IBD）, this hyporesponsiveness or tolerance breaks down and inflammation supervenes driven by the intestinal microbial flora. Bacteria contain compounds and are recognized by a variety of receptors, including Toll-like receptors （TLRs） and NODs （a family of intracellular bacterial sensors） and are potent stimuli of innate immune responses. Several mutations in these receptors have been associated with development of IBD.展开更多
Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patie...Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.展开更多
AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: Al...AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.展开更多
AIM: To investigate the prevalence of human leukocyte antigen (HLA) DQ2/8 alleles in Southern Italians with liver and gastrointestinal (GI) diseases outside of celiac disease. METHODS: HLA DQ2/8 status was assessed in...AIM: To investigate the prevalence of human leukocyte antigen (HLA) DQ2/8 alleles in Southern Italians with liver and gastrointestinal (GI) diseases outside of celiac disease. METHODS: HLA DQ2/8 status was assessed in 443 patients from three ambulatory gastroenterology clinics in Southern Italy (University of Federico Ⅱ, Naples, Loreto Crispi Hospital, Ruggi D'Aragona Hospital, Salerno). Patients were grouped based on disease status [pre-post transplant liver disease, esophageal/gastric organic and functional diseases, irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD)] and DQ2/8 alleles, which correspond to a celiac disease genetic risk gradient. Subject allele frequencies were compared to healthy Italian controls. RESULTS: One hundred and ninety-six out of four hundred and forty-three (44.2%) subjects, median age 56 years and 42.6% female, were DQ2/8 positive. When stratifying by disease we found that 86/188 (45.7%) patients with liver disease were HLA DQ2/8 positive, 39/73 (53.4%) with functional upper GI diseases and 19/41 (46.3%) with organic upper GI diseases were positive. Furthermore, 38/105 (36.2%) patients with IBS and 14/36 (38.9%) with IBD were HLA DQ2/8 positive (P = 0.21). Compared to healthy controls those with functional upper GI diseases disorders had a 1.8 times higher odds of DQ2/8 positivity. Those with liver disease had 1.3 times the odds, albeit not statistically significant, ofDQ2/8 positivity. Both those with IBS and IBD had a lower odds of DQ2/8 positivity compared to healthy controls. CONCLUSION: The proportion of individuals HLA DQ2/8 positive is higher in those with liver/upper functional GI disease and lower in IBS/IBD as compared to general population estimates.展开更多
Gastrointestinal ultrasound is a practical,safe,cheap and reproducible diagnostic tool in inflammatorybowel disease gaining global prominence amongst clinicians.Understanding the embryological processes of the intesti...Gastrointestinal ultrasound is a practical,safe,cheap and reproducible diagnostic tool in inflammatorybowel disease gaining global prominence amongst clinicians.Understanding the embryological processes of the intestinal tract assists in the interpretation of abnormal sonographic findings.In general terms,the examination principally comprises interrogation of the colon,mesentery and small intestine using both lowfrequency and high-frequency probes.Interpretation of findings on GIUS includes assessment of bowel wall thickness,symmetry of this thickness,evidence of transmural changes,assessment of vascularity using Doppler imaging and assessment of other specific features including lymph nodes,mesentery and luminal motility.In addition to B-mode imaging,transperineal ultrasonography,elastography and contrast-enhanced ultrasonography are useful adjuncts.This supplement expands upon these features in more depth.展开更多
BACKGROUND Post-operative enteral nutrition via gastric or jejunal feeding tubes is a common and standard practice in managing the critically ill or post-surgical patient.It has its own set of complications,including ...BACKGROUND Post-operative enteral nutrition via gastric or jejunal feeding tubes is a common and standard practice in managing the critically ill or post-surgical patient.It has its own set of complications,including obstruction,abscess formation,necrosis,and pancreatitis.We present here a case of small bowel obstruction caused by enteral nutrition bezoar.It is the second recorded incidence of this complication after pancreaticoduodenectomy in the medical literature.CASE SUMMARY The 70-year-old female presented to our institution for a pancreaticoduodenectomy(Whipple’s procedure)for pancreatic adenocarcinoma.On day 5 post-operative,having failed to progress and developing symptoms of small bowel obstruction,she underwent a computed tomography scan,which showed features of mechanical small bowel obstruction.Following this,she underwent an emergency laparotomy and small bowel decompression.The recovery was long and protracted but,ultimately,she was discharged home.A literature search of reports from 1966-2020 was conducted in the MEDLINE database.We identified eight articles describing a total of 14 cases of small bowel obstruction secondary to enteral feed bezoar.Of those 14 cases,all but 4 occurred after upper gastrointestinal surgery;all but 1 case required further surgical intervention for deteriorating clinical picture.The postulated causes for this include pH changes,a reduction in pancreatic enzymes and gastric motility,and the use of opioid medication.CONCLUSION Enteral feed bezoar is a complication of enteral feeding.Despite rare incidence,it can cause significant morbidity and potential mortality.展开更多
AIM To elucidate longitudinal changes of an endoscopic Barrett esophagus(BE), especially of short segment endoscopic BE(SSBE). METHODS This study comprised 779 patients who underwent two or more endoscopies between Ja...AIM To elucidate longitudinal changes of an endoscopic Barrett esophagus(BE), especially of short segment endoscopic BE(SSBE). METHODS This study comprised 779 patients who underwent two or more endoscopies between January 2009 and December 2015. The intervals between the first and the last endoscopy were at least 6 mo. The diagnosis of endoscopic BE was based on the criteria proposed by the Japan Esophageal Society and was classified as long segment(LSBE) and SSBE, the latter being further divided into partial and circumferential types. The potential background factors that were deemed to affect BE change included age, gender, antacid therapy use, gastroesophageal reflux disease-suggested symptoms, esophagitis, and hiatus hernia. Time trends of a new appearance and complete regression were investigated by Kaplan-Meier curves. The factors that may affect appearance and complete regression were investigated by χ~2 and Student-t tests, and multivariable Cox regression analysis. RESULTS Incidences of SSBE and LSBE were respectively 21.7% and 0%, with a mean age of 68 years. Complete regression of SSBE was observed in 61.5% of initial SSBE patients, while 12.1% of initially disease free patients experienced an appearance of SSBE. Complete regressions and appearances of BE occurred constantly over time, accounting for 80% and 17% of 5-year cumulative rates. No LSBE development from SSBE was observed. A hiatus hernia was the only significant factor that facilitated BE development(P = 0.03) or hampered(P = 0.007) BE regression. CONCLUSION Both appearances and complete regressions of SSBE occurred over time. A hiatus hernia was the only significant factor affecting the BE story.展开更多
In this letter,we discuss the highlights of the paper by Hu et al,including how patient-derived organoids may be beneficial to hepatobiliary pancreatic research.The article provides a review of how organoids can be us...In this letter,we discuss the highlights of the paper by Hu et al,including how patient-derived organoids may be beneficial to hepatobiliary pancreatic research.The article provides a review of how organoids can be used in drug sensitivity testing;looking at ways in which successful organoids are created.The literature included in the review revealed heterogeneity in organoid establishment inclu-ding some differences between organoids from resected tumours compared with liquid biopsies.Additional research is required in creating organoids from liquid biopsies and optimizing these techniques for widespread clinical practice.The article raises awareness of limitations of organoids with suggestions of how co-culture or microfluid platforms may help to simulate the tumour microenvir-onment for better model fidelity.The article provides a comprehensive review of how organoids are being used in drug testing and ideas about how to harvest or produce these in future.展开更多
BACKGROUND Lymphadenectomy of the infrapyloric region remains technically demanding in laparoscopic radical gastrectomy.Traditional vessel-guided approaches often result in incomplete dissection and higher complicatio...BACKGROUND Lymphadenectomy of the infrapyloric region remains technically demanding in laparoscopic radical gastrectomy.Traditional vessel-guided approaches often result in incomplete dissection and higher complication rates,especially at station No.6.AIM To propose a mesentery-based strategy for infrapyloric lymphadenectomy and evaluate its safety,feasibility,and efficacy.METHODS By identifying key anatomical landmarks and defining the inferior mesenteric boundary of the pyloric region(right gastro-omental mesentery),this approach enables full exposure and en bloc resection of anterior and posterior mesenteric planes,with proximal ligation at the root of feeding vessels.A retrospective cohort study was conducted on 330 gastric cancer patients who underwent D2 lymphadenectomy(D2)from January 2020 to December 2021.Outcomes were compared between 165 patients treated with D2 plus complete mesogastric excision(D2+CME)and 165 matched controls receiving conventional D2.RESULTS The D2+CME group demonstrated significantly improved surgical outcomes,including shorter total operative time(279.19±45.50 minutes vs 301.25±52.30 minutes,P<0.001),reduced infrapyloric dissection time(22.24±3.80 minutes vs 27.58±4.20 minutes,P<0.001),and lower blood loss(4.71±1.12 mL vs 24.83±6.35 mL,P<0.001).More lymph nodes were retrieved overall(43.80±10.05 vs 37.25±8.80,P<0.001),particularly at station No.6(5.26±0.87 vs 4.14±0.41,P<0.001).Postoperative recovery indicators and hospital stay were comparable between groups,while the complication rate was significantly lower in the D2+CME group(20%vs 30.3%,P=0.042).CONCLUSION The mesentery-based approach enables safe pyloric lymphadenectomy.Systematic mesogastric excision improves operative efficiency and lymph node yield,especially at station No.6,offering potential oncological benefits in gastric cancer surgery.展开更多
Owing to the complex and often asymptomatic presentations,the diagnosis of biliopancreatic diseases,including pancreatic and biliary malignancies,remains challenging.Recent technological advancements have remarkably i...Owing to the complex and often asymptomatic presentations,the diagnosis of biliopancreatic diseases,including pancreatic and biliary malignancies,remains challenging.Recent technological advancements have remarkably improved the diagnostic accuracy and patient outcomes in these diseases.This review explores key advancements in diagnostic modalities,including biomarkers,imaging techniques,and artificial intelligence(AI)-based technologies.Biomarkers,such as cancer antigen 19-9,KRAS mutations,and inflammatory markers,provide crucial insights into disease progression and treatment responses.Advanced imaging modalities include enhanced computed tomography(CT),positron emission tomography-CT,magnetic resonance cholangiopancreatography,and endoscopic ultrasound.AI integration in imaging and pathology has enhanced diagnostic precision through deep learning algorithms that analyze medical images,automate routine diagnostic tasks,and provide predictive analytics for personalized treatment strategies.The applications of these technologies are diverse,ranging from early cancer detection to therapeutic guidance and real-time imaging.Biomarker-based liquid biopsies and AI-assisted imaging tools are essential for non-invasive diagnostics and individualized patient management.Furthermore,AI-driven models are transforming disease stratification,thus enhancing risk assessment and decision-making.Future studies should explore standardizing biomarker validation,improving AI-driven diagnostics,and expanding the accessibility of advanced imaging technologies in resource-limited settings.The continued development of non-invasive diagnostic techniques and precision medicine approaches is crucial for optimizing the detection and management of biliopancreatic diseases.Collaborative efforts between clinicians,researchers,and industry stakeholders will be pivotal in applying these advancements in clinical practice.展开更多
BACKGROUND The colon is the hollow viscera that proportionally has the lowest vascular supply and is more predisposed to ischemic colitis.In the context of end-stage liver disease,various components may explain this g...BACKGROUND The colon is the hollow viscera that proportionally has the lowest vascular supply and is more predisposed to ischemic colitis.In the context of end-stage liver disease,various components may explain this group's greater predisposition to colonic ischemic events.Furthermore,portal hypertension generates a process of coagulopathy,impairing local vascularization.This case report describes a case of ischemic colitis with small-vessel occlusion found during liver transplantation in a patient with decompensated end-stage liver disease.CASE SUMMARY A 64-year-old man with liver cirrhosis due to non-alcoholic steatohepatitis and hepatocellular carcinoma.The patient underwent liver transplantation due to hepatic decompensation.The donor was a 53-year-old man who had died of a hemorrhagic stroke.Cavitary examination revealed diffuse ischemic colitis with significant distention and necrosis.Due to the condition of the colon,a subtotal colectomy was performed.Liver transplantation with warm ischemia time of 35 minutes,cold ischemia of 6 hours 30 minutes and total ischemia time of 7 hours 5 minutes.The patient improved clinically with oral tract function and physiotherapy,but unfortunately,he developed a bloodstream infection,a new septic shock and died six months after surgery.CONCLUSION Simultaneous total colectomy and orthotopic liver transplantation represent a rare situation.Ischemic events have a high mortality rate in the general population and are particularly important in cirrhotic patients.展开更多
Objective:Pathologic complete response(pCR)following neoadjuvant therapy(NAT)for gastric cancer(GC)is rare but associated with a favorable prognosis.This study aims to reassess the optimal response population(ORP)foll...Objective:Pathologic complete response(pCR)following neoadjuvant therapy(NAT)for gastric cancer(GC)is rare but associated with a favorable prognosis.This study aims to reassess the optimal response population(ORP)following NAT by evaluating the prognostic outcomes associated with various T and N stages,utilizing multicenter data from China.Methods:Patients who underwent NAT following radical gastrectomy at 10 tertiary hospitals in China between2008 and 2021 were included.The ORP was introduced to explore the disease-free survival(DFS),overall survival(OS),recurrence patterns,and influencing factors following propensity score matching(PSM).Results:A total of 1,076 patients were enrolled in this study(median follow-up period:60 months).We defined ORP as a pCR or tumor infiltration of the mucosal or submucosal layer without lymph node metastasis(pCR or yp T1N0)after NAT.The ORP group comprised 136 patients(12.6%),while the non-ORP group comprised 940patients(87.4%).After applying a 1:4 PSM,we obtained an ORP group of 136 patients and non-ORP group of 544patients.Survival analysis demonstrated that both the 3-year OS(before PSM:89.0%vs.55.0%,P<0.001;after PSM:89.0%vs.55.4%,P<0.001)and DFS(before PSM:85.8%vs.49.7%,P<0.001;after PSM:85.8%vs.50.6%,P<0.001)were significantly superior in the ORP group compared to that in the non-ORP group.Remarkably,adjuvant chemotherapy did not impact the prognosis of patients in the ORP group(3-year OS:89.0%vs.89.7%,P=0.988;3-year DFS:84.9%vs.89.7%,P=0.700).Conclusions:This study reevaluates patients with ORP following NAT,providing a more comprehensive and accurate depiction of the potential beneficiary group and survival outcomes in patients with locally advanced GC.展开更多
Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for &a...Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for > 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.展开更多
Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder in primary and secondary care. It is characterised by abdominal discomfort, pain and changes in bowel habits that ca...Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder in primary and secondary care. It is characterised by abdominal discomfort, pain and changes in bowel habits that can have a serious impact on the patient’s quality of life. The pathophysiology of IBS is not yet completely clear. Genetic, immune, environmental, inflammatory, neurological and psychological factors, in addition to visceral hypersensitivity, can all play an important role, one that most likely involves the complex interactions between the gut and the brain (gut-brain axis). The diagnosis of IBS can only be made on the basis of the symptoms of the Rome III criteria. Because the probability of organic disease in patients fulfilling the IBS criteria is very low, a careful medical history is critical and should pay particular attention to the possible comorbidities. Nevertheless, the severity of the patient’s symptoms or concerns sometimes compels the physician to perform useless and/or expensive diagnostic tests, transforming IBS into a diagnosis of exclusion. The presence of alarming symptoms (fever, weight loss, rectal bleeding, significant changes in blood chemistry), the presence of palpable abdominal masses, any recent onset of symptoms in patient aged over 50 years, the presence of symptoms at night, and a familial history of celiac disease, colorectal cancer and/or inflammatory bowel diseases all warrant investigation. Treatment strategies are based on the nature and severity of the symptoms, the degree of functional impairment of the bowel habits, and the presence of psychosocial disorders. This review examines and discusses the pathophysiological aspects and the diagnostic and therapeutic approaches available for patients with symptoms possibly related to IBS, pointing out controversial issues and the strengths and weaknesses of the current knowledge.展开更多
During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn's disease (CD) patients wil...During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn's disease (CD) patients will undergo an operation during their lifetime. For UC patients requiring surgery, total proctocolectomy and ileoanal pouch anastomosis (IPAA) is the operation of choice as it provides a permanent cure and good quality of life. Nevertheless a permanent stoma is a good option in selected patients, especially the elderly. Minimally invasive surgery has replaced the conventional open approach in many specialized centres worldwide. Laparoscopic colectomy and restorative IPAA is rapidly becoming the standard of care in the treatment of UC requiring surgery, whilst laparoscopic ileo-cecal resection is already the new gold standard in the treatment of complicated CD of terminal ileum. Short term advantages of laparoscopic surgery includes faster recovery time and reduced requirement for analgesics. It is, however, in the long term that minimally invasive surgery has demonstrated its superiority over the open approach. A better cosmesis, a reduced number of incisional hernias and fewer adhesions are the long term advantages of laparoscopy in IBD surgery. A reduction in abdominal adhesions is of great benefit when a second operation is needed in CD and this influences positively the pregnancy rate in young women undergoing restorative IPAA. In developing the therapeutic plan for IBD patients it should be recognized that the surgical approach to the abdomen has changed and that surgical treatment of complicated IBD can be safely performed with a true minimally invasive approach with great patient satisfaction.展开更多
AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS:A retrospective study of records...AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS:A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre,were reviewed.Amoebic and hydatid abscesses were excluded.Demographic,clinical,radiological,and microbiological characteristics,as well as surgical/radiological interventions,were recorded.RESULTS:Sixty-three patients(42 males,21 females) aged 65(±14) years[mean±(SD) ]had prodromal symptoms for a median(interquartile range;IQR) of 7(5-14) d.Only 59%of patients were febrile at presentation;however,the serum C-reactive protein was elevated in all 47 in whom it was measured.Liver function tests were non-specifically abnormal.67%of patients had a solitary abscess,while 32%had>3 abscesses with a median(IQR) diameter of 6.3(4-9) cm.Causative organisms were:Streptococcus milleri 25%,Klebsiella pneumoniae 21%,and Escherichia coli 16%.A presumptive cryptogenic cause was most common (34%).Four patients died in this series:one from sepsis,two from advanced cancer,and one from acute myocardial infarction.The initial procedure was radiological aspiration±drainage in 54 and surgery in two patients.17%underwent surgical management during their hospitalization.Serum hypoalbuminaemia[mean (95%CI) :32(29-35) g/L vs 28(25-31) g/L,P=0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.CONCLUSION:PLA is a diagnostic challenge,because the presentation of this condition is non-specific.Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs;However,a small proportion of patients still require surgical drainage.展开更多
AIM:To investigate the association and quantify the relationship between diabetes mellitus(DM) and gastric cancer(GC) by an updated meta-analysis.METHODS:The initial PubMed search identified 1233publications. Studies ...AIM:To investigate the association and quantify the relationship between diabetes mellitus(DM) and gastric cancer(GC) by an updated meta-analysis.METHODS:The initial PubMed search identified 1233publications. Studies not reporting GC or those not reporting actual number of GC were excluded. Twelve pertinent studies were retrieved from the PubMed database or from a manual search and considered for the meta-analysis. Pooled risk ratios and 95%CI were estimated by a random-effects model. Subgroup analysis was performed according to gender or geographical regions. Heterogeneity and publication bias were evaluated by I2and funnel plot analysis,respectively.RESULTS:DM was significantly associated with GC with a RR of 1.41(P = 0.006)(95%CI:1.10-1.81).Subgroup analyses revealed that both sexes showed a significant association with GC,with a greater magnitude of risk in females(RR = 1.90; 95%CI:1.27-2.85;P = 0.002) than in males(RR = 1.24; 95%CI:1.08-1.43;P = 0.002). In addition,the link between DM and GC was significant in East Asian DM patients(RR = 1.77;95%CI:1.38-2.26; P < 0.00001) but not in Western DM patients(RR = 1.23; 95%CI:0.90-1.68; P = 0.2).There was no evidence of publication bias,but the results indicated significant heterogeneity.CONCLUSION:This updated meta-analysis has provided evidence of positive DM-GC associations. The limited information on potentially important clinical confounding factors in each study deserves further investigation.展开更多
The development of endoscopic ultrasound(EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on...The development of endoscopic ultrasound(EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal(GI) and pancreaticobiliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate indepth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn's disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.展开更多
Inflammatory bowel disease(IBD),the most important being Crohn's disease and ulcerative colitis,results from chronic dysregulation of the mucosal immune system in the gastrointestinal tract.Although the pathogenes...Inflammatory bowel disease(IBD),the most important being Crohn's disease and ulcerative colitis,results from chronic dysregulation of the mucosal immune system in the gastrointestinal tract.Although the pathogenesis of IBD remains unclear,it is widely accepted that genetic,environmental,and immunological factors are involved.Recent studies suggest that intestinal epithelial defenses are important to prevent inflammation by protecting against microbial pathogens and oxidative stresses.To investigate the etiology of IBD,animal models of experimental colitis have been developed and are frequently used to evaluate new anti-inflammatory treatments for IBD.Several models of experimental colitis that demonstrate various pathophysiological aspects of the human disease have been described.In this manuscript,we review the characteristic features of IBD through a discussion of the various chemically induced experimental models of colitis(e.g.dextran sodium sulfate-,2,4,6-trinitrobenzene sulfonic acid-,oxazolone-,acetic acid-,and indomethacin-induced models).We also summarize some regulatory and pathogenic factors demonstrated by these models that can,hopefully,be exploited to develop future therapeutic strategies against IBD.展开更多
AIM：To compare narrow-band imaging（NBI）without image magnification,and chromoendoscopy with Lugol＇s solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma（SCC）in patient...AIM：To compare narrow-band imaging（NBI）without image magnification,and chromoendoscopy with Lugol＇s solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma（SCC）in patients with head and neck cancer.METHODS：This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas,Sao Paulo University Medical School,Brazil,between August 2006 and Feb-ruary 2007.Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed,and the discovered lesions were mapped,recorded and sent for biopsy.The results of the three methods were compared regarding sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood value and negative likelihood value.RESULTS：Of the 129 patients,nine（7%）were diag-nosed with SCC,5 of which were in situ and 4 which were intramucosal.All carcinomas were detected through NBI and Lugol chromoendoscopy.Only 4 le-sions were diagnosed through conventional examination,all of which were larger than 10 mm.CONCLUSION：NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC,and produces results comparable to those obtained with 2.5%Lugol chromoendoscopy.展开更多
文摘The human intestinal tract is home to an enormous bacterial flora. The host defense against microorganisms can be divided into innate and adaptive immunity. The former is the most immediate line of response to immunologic challenges presented by bacteria, viruses, and fungi. The mucosal immune system has evolved to balance the need to respond to pathogens while co-existing with commensal bacteria and food antigens. In inflammatory bowel disease （IBD）, this hyporesponsiveness or tolerance breaks down and inflammation supervenes driven by the intestinal microbial flora. Bacteria contain compounds and are recognized by a variety of receptors, including Toll-like receptors （TLRs） and NODs （a family of intracellular bacterial sensors） and are potent stimuli of innate immune responses. Several mutations in these receptors have been associated with development of IBD.
文摘Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.
文摘AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.
文摘AIM: To investigate the prevalence of human leukocyte antigen (HLA) DQ2/8 alleles in Southern Italians with liver and gastrointestinal (GI) diseases outside of celiac disease. METHODS: HLA DQ2/8 status was assessed in 443 patients from three ambulatory gastroenterology clinics in Southern Italy (University of Federico Ⅱ, Naples, Loreto Crispi Hospital, Ruggi D'Aragona Hospital, Salerno). Patients were grouped based on disease status [pre-post transplant liver disease, esophageal/gastric organic and functional diseases, irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD)] and DQ2/8 alleles, which correspond to a celiac disease genetic risk gradient. Subject allele frequencies were compared to healthy Italian controls. RESULTS: One hundred and ninety-six out of four hundred and forty-three (44.2%) subjects, median age 56 years and 42.6% female, were DQ2/8 positive. When stratifying by disease we found that 86/188 (45.7%) patients with liver disease were HLA DQ2/8 positive, 39/73 (53.4%) with functional upper GI diseases and 19/41 (46.3%) with organic upper GI diseases were positive. Furthermore, 38/105 (36.2%) patients with IBS and 14/36 (38.9%) with IBD were HLA DQ2/8 positive (P = 0.21). Compared to healthy controls those with functional upper GI diseases disorders had a 1.8 times higher odds of DQ2/8 positivity. Those with liver disease had 1.3 times the odds, albeit not statistically significant, ofDQ2/8 positivity. Both those with IBS and IBD had a lower odds of DQ2/8 positivity compared to healthy controls. CONCLUSION: The proportion of individuals HLA DQ2/8 positive is higher in those with liver/upper functional GI disease and lower in IBS/IBD as compared to general population estimates.
文摘Gastrointestinal ultrasound is a practical,safe,cheap and reproducible diagnostic tool in inflammatorybowel disease gaining global prominence amongst clinicians.Understanding the embryological processes of the intestinal tract assists in the interpretation of abnormal sonographic findings.In general terms,the examination principally comprises interrogation of the colon,mesentery and small intestine using both lowfrequency and high-frequency probes.Interpretation of findings on GIUS includes assessment of bowel wall thickness,symmetry of this thickness,evidence of transmural changes,assessment of vascularity using Doppler imaging and assessment of other specific features including lymph nodes,mesentery and luminal motility.In addition to B-mode imaging,transperineal ultrasonography,elastography and contrast-enhanced ultrasonography are useful adjuncts.This supplement expands upon these features in more depth.
文摘BACKGROUND Post-operative enteral nutrition via gastric or jejunal feeding tubes is a common and standard practice in managing the critically ill or post-surgical patient.It has its own set of complications,including obstruction,abscess formation,necrosis,and pancreatitis.We present here a case of small bowel obstruction caused by enteral nutrition bezoar.It is the second recorded incidence of this complication after pancreaticoduodenectomy in the medical literature.CASE SUMMARY The 70-year-old female presented to our institution for a pancreaticoduodenectomy(Whipple’s procedure)for pancreatic adenocarcinoma.On day 5 post-operative,having failed to progress and developing symptoms of small bowel obstruction,she underwent a computed tomography scan,which showed features of mechanical small bowel obstruction.Following this,she underwent an emergency laparotomy and small bowel decompression.The recovery was long and protracted but,ultimately,she was discharged home.A literature search of reports from 1966-2020 was conducted in the MEDLINE database.We identified eight articles describing a total of 14 cases of small bowel obstruction secondary to enteral feed bezoar.Of those 14 cases,all but 4 occurred after upper gastrointestinal surgery;all but 1 case required further surgical intervention for deteriorating clinical picture.The postulated causes for this include pH changes,a reduction in pancreatic enzymes and gastric motility,and the use of opioid medication.CONCLUSION Enteral feed bezoar is a complication of enteral feeding.Despite rare incidence,it can cause significant morbidity and potential mortality.
文摘AIM To elucidate longitudinal changes of an endoscopic Barrett esophagus(BE), especially of short segment endoscopic BE(SSBE). METHODS This study comprised 779 patients who underwent two or more endoscopies between January 2009 and December 2015. The intervals between the first and the last endoscopy were at least 6 mo. The diagnosis of endoscopic BE was based on the criteria proposed by the Japan Esophageal Society and was classified as long segment(LSBE) and SSBE, the latter being further divided into partial and circumferential types. The potential background factors that were deemed to affect BE change included age, gender, antacid therapy use, gastroesophageal reflux disease-suggested symptoms, esophagitis, and hiatus hernia. Time trends of a new appearance and complete regression were investigated by Kaplan-Meier curves. The factors that may affect appearance and complete regression were investigated by χ~2 and Student-t tests, and multivariable Cox regression analysis. RESULTS Incidences of SSBE and LSBE were respectively 21.7% and 0%, with a mean age of 68 years. Complete regression of SSBE was observed in 61.5% of initial SSBE patients, while 12.1% of initially disease free patients experienced an appearance of SSBE. Complete regressions and appearances of BE occurred constantly over time, accounting for 80% and 17% of 5-year cumulative rates. No LSBE development from SSBE was observed. A hiatus hernia was the only significant factor that facilitated BE development(P = 0.03) or hampered(P = 0.007) BE regression. CONCLUSION Both appearances and complete regressions of SSBE occurred over time. A hiatus hernia was the only significant factor affecting the BE story.
文摘In this letter,we discuss the highlights of the paper by Hu et al,including how patient-derived organoids may be beneficial to hepatobiliary pancreatic research.The article provides a review of how organoids can be used in drug sensitivity testing;looking at ways in which successful organoids are created.The literature included in the review revealed heterogeneity in organoid establishment inclu-ding some differences between organoids from resected tumours compared with liquid biopsies.Additional research is required in creating organoids from liquid biopsies and optimizing these techniques for widespread clinical practice.The article raises awareness of limitations of organoids with suggestions of how co-culture or microfluid platforms may help to simulate the tumour microenvir-onment for better model fidelity.The article provides a comprehensive review of how organoids are being used in drug testing and ideas about how to harvest or produce these in future.
基金Supported by the Natural Science Foundation Program in Fujian Province of China,No.2023J011726.
文摘BACKGROUND Lymphadenectomy of the infrapyloric region remains technically demanding in laparoscopic radical gastrectomy.Traditional vessel-guided approaches often result in incomplete dissection and higher complication rates,especially at station No.6.AIM To propose a mesentery-based strategy for infrapyloric lymphadenectomy and evaluate its safety,feasibility,and efficacy.METHODS By identifying key anatomical landmarks and defining the inferior mesenteric boundary of the pyloric region(right gastro-omental mesentery),this approach enables full exposure and en bloc resection of anterior and posterior mesenteric planes,with proximal ligation at the root of feeding vessels.A retrospective cohort study was conducted on 330 gastric cancer patients who underwent D2 lymphadenectomy(D2)from January 2020 to December 2021.Outcomes were compared between 165 patients treated with D2 plus complete mesogastric excision(D2+CME)and 165 matched controls receiving conventional D2.RESULTS The D2+CME group demonstrated significantly improved surgical outcomes,including shorter total operative time(279.19±45.50 minutes vs 301.25±52.30 minutes,P<0.001),reduced infrapyloric dissection time(22.24±3.80 minutes vs 27.58±4.20 minutes,P<0.001),and lower blood loss(4.71±1.12 mL vs 24.83±6.35 mL,P<0.001).More lymph nodes were retrieved overall(43.80±10.05 vs 37.25±8.80,P<0.001),particularly at station No.6(5.26±0.87 vs 4.14±0.41,P<0.001).Postoperative recovery indicators and hospital stay were comparable between groups,while the complication rate was significantly lower in the D2+CME group(20%vs 30.3%,P=0.042).CONCLUSION The mesentery-based approach enables safe pyloric lymphadenectomy.Systematic mesogastric excision improves operative efficiency and lymph node yield,especially at station No.6,offering potential oncological benefits in gastric cancer surgery.
文摘Owing to the complex and often asymptomatic presentations,the diagnosis of biliopancreatic diseases,including pancreatic and biliary malignancies,remains challenging.Recent technological advancements have remarkably improved the diagnostic accuracy and patient outcomes in these diseases.This review explores key advancements in diagnostic modalities,including biomarkers,imaging techniques,and artificial intelligence(AI)-based technologies.Biomarkers,such as cancer antigen 19-9,KRAS mutations,and inflammatory markers,provide crucial insights into disease progression and treatment responses.Advanced imaging modalities include enhanced computed tomography(CT),positron emission tomography-CT,magnetic resonance cholangiopancreatography,and endoscopic ultrasound.AI integration in imaging and pathology has enhanced diagnostic precision through deep learning algorithms that analyze medical images,automate routine diagnostic tasks,and provide predictive analytics for personalized treatment strategies.The applications of these technologies are diverse,ranging from early cancer detection to therapeutic guidance and real-time imaging.Biomarker-based liquid biopsies and AI-assisted imaging tools are essential for non-invasive diagnostics and individualized patient management.Furthermore,AI-driven models are transforming disease stratification,thus enhancing risk assessment and decision-making.Future studies should explore standardizing biomarker validation,improving AI-driven diagnostics,and expanding the accessibility of advanced imaging technologies in resource-limited settings.The continued development of non-invasive diagnostic techniques and precision medicine approaches is crucial for optimizing the detection and management of biliopancreatic diseases.Collaborative efforts between clinicians,researchers,and industry stakeholders will be pivotal in applying these advancements in clinical practice.
文摘BACKGROUND The colon is the hollow viscera that proportionally has the lowest vascular supply and is more predisposed to ischemic colitis.In the context of end-stage liver disease,various components may explain this group's greater predisposition to colonic ischemic events.Furthermore,portal hypertension generates a process of coagulopathy,impairing local vascularization.This case report describes a case of ischemic colitis with small-vessel occlusion found during liver transplantation in a patient with decompensated end-stage liver disease.CASE SUMMARY A 64-year-old man with liver cirrhosis due to non-alcoholic steatohepatitis and hepatocellular carcinoma.The patient underwent liver transplantation due to hepatic decompensation.The donor was a 53-year-old man who had died of a hemorrhagic stroke.Cavitary examination revealed diffuse ischemic colitis with significant distention and necrosis.Due to the condition of the colon,a subtotal colectomy was performed.Liver transplantation with warm ischemia time of 35 minutes,cold ischemia of 6 hours 30 minutes and total ischemia time of 7 hours 5 minutes.The patient improved clinically with oral tract function and physiotherapy,but unfortunately,he developed a bloodstream infection,a new septic shock and died six months after surgery.CONCLUSION Simultaneous total colectomy and orthotopic liver transplantation represent a rare situation.Ischemic events have a high mortality rate in the general population and are particularly important in cirrhotic patients.
基金supported by the construction funds for“high-level hospitals and clinical specialties”of Fujian Province(No.[2021]76)。
文摘Objective:Pathologic complete response(pCR)following neoadjuvant therapy(NAT)for gastric cancer(GC)is rare but associated with a favorable prognosis.This study aims to reassess the optimal response population(ORP)following NAT by evaluating the prognostic outcomes associated with various T and N stages,utilizing multicenter data from China.Methods:Patients who underwent NAT following radical gastrectomy at 10 tertiary hospitals in China between2008 and 2021 were included.The ORP was introduced to explore the disease-free survival(DFS),overall survival(OS),recurrence patterns,and influencing factors following propensity score matching(PSM).Results:A total of 1,076 patients were enrolled in this study(median follow-up period:60 months).We defined ORP as a pCR or tumor infiltration of the mucosal or submucosal layer without lymph node metastasis(pCR or yp T1N0)after NAT.The ORP group comprised 136 patients(12.6%),while the non-ORP group comprised 940patients(87.4%).After applying a 1:4 PSM,we obtained an ORP group of 136 patients and non-ORP group of 544patients.Survival analysis demonstrated that both the 3-year OS(before PSM:89.0%vs.55.0%,P<0.001;after PSM:89.0%vs.55.4%,P<0.001)and DFS(before PSM:85.8%vs.49.7%,P<0.001;after PSM:85.8%vs.50.6%,P<0.001)were significantly superior in the ORP group compared to that in the non-ORP group.Remarkably,adjuvant chemotherapy did not impact the prognosis of patients in the ORP group(3-year OS:89.0%vs.89.7%,P=0.988;3-year DFS:84.9%vs.89.7%,P=0.700).Conclusions:This study reevaluates patients with ORP following NAT,providing a more comprehensive and accurate depiction of the potential beneficiary group and survival outcomes in patients with locally advanced GC.
基金Supported by the National Institute for Health Research(NIHR)Biomedical Research Centre(BRC)at the Royal Marsden NHS Foundation Trust and Institute of Cancer Research and the Robert McAlpine Charity(partly,for Khurum Khan)
文摘Colorectal cancer (CRC) is one of the commonest cancers with 1.2 million new cases diagnosed each year in the world. It remains the fourth most common cause of cancer-related mortality in the world and accounts for > 600000 cancer-related deaths each year. There have been significant advances in treatment of metastatic CRC in last decade or so, due to availability of new active targeted agents and more aggressive approach towards the management of CRC, particularly with liver-only-metastases; however, these drugs work best when combined with conventional chemotherapy agents. Despite these advances, there is a lack of biomarkers to inform us about the accurate management of the patients with metastatic CRC. It is therefore imperative to carefully select the patients with comprehensive multi-disciplinary team input in order to optimise the management of these patients. In this review we will discuss various treatment options available in management of colorectal liver metastases with potential guidance on how and when to choose these options along with consideration on future directions in management of this disease.
文摘Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder in primary and secondary care. It is characterised by abdominal discomfort, pain and changes in bowel habits that can have a serious impact on the patient’s quality of life. The pathophysiology of IBS is not yet completely clear. Genetic, immune, environmental, inflammatory, neurological and psychological factors, in addition to visceral hypersensitivity, can all play an important role, one that most likely involves the complex interactions between the gut and the brain (gut-brain axis). The diagnosis of IBS can only be made on the basis of the symptoms of the Rome III criteria. Because the probability of organic disease in patients fulfilling the IBS criteria is very low, a careful medical history is critical and should pay particular attention to the possible comorbidities. Nevertheless, the severity of the patient’s symptoms or concerns sometimes compels the physician to perform useless and/or expensive diagnostic tests, transforming IBS into a diagnosis of exclusion. The presence of alarming symptoms (fever, weight loss, rectal bleeding, significant changes in blood chemistry), the presence of palpable abdominal masses, any recent onset of symptoms in patient aged over 50 years, the presence of symptoms at night, and a familial history of celiac disease, colorectal cancer and/or inflammatory bowel diseases all warrant investigation. Treatment strategies are based on the nature and severity of the symptoms, the degree of functional impairment of the bowel habits, and the presence of psychosocial disorders. This review examines and discusses the pathophysiological aspects and the diagnostic and therapeutic approaches available for patients with symptoms possibly related to IBS, pointing out controversial issues and the strengths and weaknesses of the current knowledge.
文摘During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn's disease (CD) patients will undergo an operation during their lifetime. For UC patients requiring surgery, total proctocolectomy and ileoanal pouch anastomosis (IPAA) is the operation of choice as it provides a permanent cure and good quality of life. Nevertheless a permanent stoma is a good option in selected patients, especially the elderly. Minimally invasive surgery has replaced the conventional open approach in many specialized centres worldwide. Laparoscopic colectomy and restorative IPAA is rapidly becoming the standard of care in the treatment of UC requiring surgery, whilst laparoscopic ileo-cecal resection is already the new gold standard in the treatment of complicated CD of terminal ileum. Short term advantages of laparoscopic surgery includes faster recovery time and reduced requirement for analgesics. It is, however, in the long term that minimally invasive surgery has demonstrated its superiority over the open approach. A better cosmesis, a reduced number of incisional hernias and fewer adhesions are the long term advantages of laparoscopy in IBD surgery. A reduction in abdominal adhesions is of great benefit when a second operation is needed in CD and this influences positively the pregnancy rate in young women undergoing restorative IPAA. In developing the therapeutic plan for IBD patients it should be recognized that the surgical approach to the abdomen has changed and that surgical treatment of complicated IBD can be safely performed with a true minimally invasive approach with great patient satisfaction.
文摘AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS:A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre,were reviewed.Amoebic and hydatid abscesses were excluded.Demographic,clinical,radiological,and microbiological characteristics,as well as surgical/radiological interventions,were recorded.RESULTS:Sixty-three patients(42 males,21 females) aged 65(±14) years[mean±(SD) ]had prodromal symptoms for a median(interquartile range;IQR) of 7(5-14) d.Only 59%of patients were febrile at presentation;however,the serum C-reactive protein was elevated in all 47 in whom it was measured.Liver function tests were non-specifically abnormal.67%of patients had a solitary abscess,while 32%had>3 abscesses with a median(IQR) diameter of 6.3(4-9) cm.Causative organisms were:Streptococcus milleri 25%,Klebsiella pneumoniae 21%,and Escherichia coli 16%.A presumptive cryptogenic cause was most common (34%).Four patients died in this series:one from sepsis,two from advanced cancer,and one from acute myocardial infarction.The initial procedure was radiological aspiration±drainage in 54 and surgery in two patients.17%underwent surgical management during their hospitalization.Serum hypoalbuminaemia[mean (95%CI) :32(29-35) g/L vs 28(25-31) g/L,P=0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.CONCLUSION:PLA is a diagnostic challenge,because the presentation of this condition is non-specific.Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs;However,a small proportion of patients still require surgical drainage.
文摘AIM:To investigate the association and quantify the relationship between diabetes mellitus(DM) and gastric cancer(GC) by an updated meta-analysis.METHODS:The initial PubMed search identified 1233publications. Studies not reporting GC or those not reporting actual number of GC were excluded. Twelve pertinent studies were retrieved from the PubMed database or from a manual search and considered for the meta-analysis. Pooled risk ratios and 95%CI were estimated by a random-effects model. Subgroup analysis was performed according to gender or geographical regions. Heterogeneity and publication bias were evaluated by I2and funnel plot analysis,respectively.RESULTS:DM was significantly associated with GC with a RR of 1.41(P = 0.006)(95%CI:1.10-1.81).Subgroup analyses revealed that both sexes showed a significant association with GC,with a greater magnitude of risk in females(RR = 1.90; 95%CI:1.27-2.85;P = 0.002) than in males(RR = 1.24; 95%CI:1.08-1.43;P = 0.002). In addition,the link between DM and GC was significant in East Asian DM patients(RR = 1.77;95%CI:1.38-2.26; P < 0.00001) but not in Western DM patients(RR = 1.23; 95%CI:0.90-1.68; P = 0.2).There was no evidence of publication bias,but the results indicated significant heterogeneity.CONCLUSION:This updated meta-analysis has provided evidence of positive DM-GC associations. The limited information on potentially important clinical confounding factors in each study deserves further investigation.
基金Supported by The frame of European Social FoundHuman Resources Development Operational Programme 2007-2013project No.POSDRU/159/1.5/S/133377
文摘The development of endoscopic ultrasound(EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal(GI) and pancreaticobiliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate indepth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn's disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.
基金National Institute of Health grants,No. DK64289,DK74454,and DK43351),IBD grants from the Eli and Edythe Broad Medical Foundation
文摘Inflammatory bowel disease(IBD),the most important being Crohn's disease and ulcerative colitis,results from chronic dysregulation of the mucosal immune system in the gastrointestinal tract.Although the pathogenesis of IBD remains unclear,it is widely accepted that genetic,environmental,and immunological factors are involved.Recent studies suggest that intestinal epithelial defenses are important to prevent inflammation by protecting against microbial pathogens and oxidative stresses.To investigate the etiology of IBD,animal models of experimental colitis have been developed and are frequently used to evaluate new anti-inflammatory treatments for IBD.Several models of experimental colitis that demonstrate various pathophysiological aspects of the human disease have been described.In this manuscript,we review the characteristic features of IBD through a discussion of the various chemically induced experimental models of colitis(e.g.dextran sodium sulfate-,2,4,6-trinitrobenzene sulfonic acid-,oxazolone-,acetic acid-,and indomethacin-induced models).We also summarize some regulatory and pathogenic factors demonstrated by these models that can,hopefully,be exploited to develop future therapeutic strategies against IBD.
文摘AIM：To compare narrow-band imaging（NBI）without image magnification,and chromoendoscopy with Lugol＇s solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma（SCC）in patients with head and neck cancer.METHODS：This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas,Sao Paulo University Medical School,Brazil,between August 2006 and Feb-ruary 2007.Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed,and the discovered lesions were mapped,recorded and sent for biopsy.The results of the three methods were compared regarding sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood value and negative likelihood value.RESULTS：Of the 129 patients,nine（7%）were diag-nosed with SCC,5 of which were in situ and 4 which were intramucosal.All carcinomas were detected through NBI and Lugol chromoendoscopy.Only 4 le-sions were diagnosed through conventional examination,all of which were larger than 10 mm.CONCLUSION：NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC,and produces results comparable to those obtained with 2.5%Lugol chromoendoscopy.
