Gastroenterology Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Imaging Diagnosis of Splanchnic Venous Thrombosis Mon, 12 Oct 2015 11:45:48 +0000 Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach. S. Rajesh, Amar Mukund, and Ankur Arora Copyright © 2015 S. Rajesh et al. All rights reserved. Systemic Venous Inflow to the Liver Allograft to Overcome Diffuse Splanchnic Venous Thrombosis Sun, 11 Oct 2015 08:25:27 +0000 Diffuse splanchnic venous thrombosis (DSVT), formerly defined as contraindication for liver transplantation (LT), is a serious challenge to the liver transplant surgeon. Portal vein arterialisation, cavoportal hemitransposition and renoportal anastomosis, and finally combined liver and small bowel transplantation are all possible alternatives to deal with this condition. Five patients with preoperatively confirmed extensive splanchnic venous thrombosis were transplanted using cavoportal hemitransposition (4x) and renoportal anastomosis (1x). Median follow-up was 58 months (range: 0,5 to 130 months). Two patients with previous radiation-induced peritoneal injury died, respectively, 18 days and 2 months after transplantation. The three other patients had excellent long-term survival, despite the fact that two of them needed a surgical reintervention for severe gastrointestinal bleeding. Extensive splanchnic venous thrombosis is no longer an absolute contraindication to liver transplantation. Although cavoportal hemitransposition and renoportal anastomosis undoubtedly are life-saving procedures allowing for ensuring adequate allograft portal flow, careful follow-up of these patients remains necessary as both methods are unable to completely eliminate the complications of (segmental) portal hypertension. Cristian Lupascu, Tom Darius, Pierre Goffette, and Jan Lerut Copyright © 2015 Cristian Lupascu et al. All rights reserved. Recurrent Thrombotic Events after Discontinuation of Vitamin K Antagonist Treatment for Splanchnic Vein Thrombosis: A Multicenter Retrospective Cohort Study Mon, 05 Oct 2015 09:33:19 +0000 It is generally recommended that patients with splanchnic vein thrombosis (SVT) should receive a minimum of 3 months of anticoagulant treatment. However, little information is available on the long-term risk of recurrent thrombotic events. The aim of this study was to evaluate the risk of venous and arterial thrombosis after discontinuation of vitamin K antagonist (VKA) in SVT patients. Retrospective information from a cohort of SVT patients treated with VKA and followed by 37 Italian Anticoagulation Clinics, up to June 2013, was collected. Only patients who discontinued VKA and did not receive any other anticoagulant drug were enrolled in this study. Thrombotic events during follow-up were centrally adjudicated. Ninety patients were included: 33 unprovoked SVT, 27 SVT secondary to transient risk factors, and 30 with permanent risk factors. During a median follow-up of 1.6 years, 6 venous and 1 arterial thrombosis were documented, for an incidence of 3.3/100 patient-years (pt-y). The recurrence rate was highest in the first year after VKA discontinuation (8.2/100’pt-y) and in patients with permanent risk factors (10.2/100’pt-y). Liver cirrhosis significantly increased the risk of recurrence. In conclusion, the rate of recurrent vascular complications after SVT is not negligible, at least in some patient subgroups. Nicoletta Riva, Walter Ageno, Daniela Poli, Sophie Testa, Serena Rupoli, Rita Santoro, Teresa Lerede, Antonietta Piana, Monica Carpenedo, Alberto Nicolini, Piera Maria Ferrini, Giuliana Martini, Catello Mangione, Laura Contino, Carlo Bonfanti, Paolo Gresele, and Alberto Tosetto Copyright © 2015 Nicoletta Riva et al. All rights reserved. Budd-Chiari Syndrome in China: A Systematic Analysis of Epidemiological Features Based on the Chinese Literature Survey Sun, 04 Oct 2015 06:46:09 +0000 Background. Thousands of Budd-Chiari syndrome (BCS) studies have been published in China, and yet no one has explored its incidence or prevalence in the whole country. Methods. Three most commonly used Chinese language electronic databases were searched, and epidemiological data were extracted from the selected articles. Results. By the end of 2013, 20191 BCS cases were reported in China. The mean age of BCS patients was 36.29 ± 1.28 years, and ratio of male to female was 150/100. About 80% BCS patients were distributed in Henan, Shandong, Beijing, Jiangsu, and Anhui, and all of them except for Beijing were located in the downstream areas of Yellow River and the whole Huai River basin. The incidence and prevalence of BCS in China with and without the top 5 high-prevalence areas were estimated to be 0.88/million per year and 7.69/million and 0.28/million per year and 2.21/million, respectively. Conclusions. Most BCS patients in China are distributed in the downstream areas of Yellow River and the whole Huai River basin. The incidence and prevalence are comparable to those of Western countries without taking into account the top 5 high-prevalence areas. Wei Zhang, Xun Qi, Xitong Zhang, Hongying Su, Hongshan Zhong, Jingpu Shi, and Ke Xu Copyright © 2015 Wei Zhang et al. All rights reserved. Transumbilical Laparoscopic-Assisted Appendectomy in the Treatment of Acute Uncomplicated Appendicitis in Children Tue, 29 Sep 2015 08:02:34 +0000 Transumbilical laparoscopic-assisted appendectomy (TULAA) is increasingly being performed worldwide. The authors report their experience in the treatment of acute uncomplicated appendicitis in children with TULAA. From January 2008 to December 2012 all types of acute appendicitis were divided, according to the clinical and ultrasonographic findings, into complicated (appendiceal mass/abscess, diffuse peritonitis) and uncomplicated. Complicated appendicitis was treated by open appendectomy (OA). All patients with the suspicion of uncomplicated appendicitis were offered TULAA by all surgeons of the team. Conversion to open or laparoscopic appendectomy (LA) was performed in case of impossibility to complete TULAA, depending on the choice of surgeon. The histopathologic examination of appendix was always performed. 444 children (252 males) with acute appendicitis were treated. The mean age was 9.2 years (range, 2 to 14 years). Primary OA was performed in 144 cases. In 300 patients a transumbilical laparoscopic-assisted approach was performed. TULAA was completed in 252 patients. Conversion to OA was performed in 45 patients and to LA in 3. Conversion was related to the impossibility to adequately expose the appendix in 47 patients and bleeding in 1. The mean operative time for TULAA was 42 minutes. Histopathologic examination of the appendix removed by TULAA showed a phlegmonous/gangrenous type in 92.8% of cases. Among the 252 TULAA there were 11 cases of umbilical wound infection. TULAA is a feasible and effective procedure for uncomplicated appendicitis in children. It combines the advantages of open and laparoscopic technique (low operative time, low complications rate, and excellent cosmetic results). Carmine Noviello, Mercedes Romano, Ascanio Martino, and Giovanni Cobellis Copyright © 2015 Carmine Noviello et al. All rights reserved. Impact of Spleen Size on Outcomes in Laparoscopic Splenectomy in Children Mon, 28 Sep 2015 11:48:28 +0000 Background. The aim of our study is to compare the efficacy of laparoscopic splenectomy (LS) between enlarged spleens and normal sized spleens. Methods. From June 2006 to September 2012, 50 patients underwent LS. The patients consisted of 24 girls and 26 boys with the mean age of 8.64 years (1–18). The patients are divided into two groups according to spleen’s longitudinal length on the ultrasonography. Group I consisted of the normal sized spleens; Group II consisted of spleens that are exceeding the upper limit. Groups are compared in terms of number of ports, operative time, rate of conversion to open procedure, and length of hospital stay. Results. The mean number of ports was 3.27 and 3.46, the mean length of the operation was 116.36 min and 132.17 min, rate of conversion to open procedure was 9.09% and 10.25%, and the mean length of hospital stay was 3.36 days and 3.23 days, respectively, in Group I and Group II. Although there is an increase in the number of the ports, the operative time, rate of conversion to open procedure, and the length of hospital stay, the difference was not significant between groups (). Conclusion. LS is safe and effective in enlarged spleens as well as normal sized spleens. Cetin Ali Karadag, Basak Erginel, Ozgur Kuzdan, Nihat Sever, Melih Akın, Abdullah Yıldız, and Ali İhsan Dokucu Copyright © 2015 Cetin Ali Karadag et al. All rights reserved. Corrigendum to “Incidence and Paris Classification of Pediatric Inflammatory Bowel Disease” Mon, 21 Sep 2015 06:37:29 +0000 Katalin Eszter Müller, Peter Laszlo Lakatos, Maria Papp, and Gabor Veres Copyright © 2015 Katalin Eszter Müller et al. All rights reserved. Prevalence of Budd-Chiari Syndrome during Pregnancy or Puerperium: A Systematic Review and Meta-Analysis Sun, 20 Sep 2015 09:24:29 +0000 Women during pregnancy or puerperium are likely to develop Budd-Chiari syndrome (BCS). However, the reported prevalence of pregnancy-related BCS varied considerably among studies. Our study aims to systematically review this issue. Overall, 817 papers were initially identified via the PubMed, EMBASE, China National Knowledge Infrastructure, and Chinese Scientific and Technological Journal databases. Twenty of them were eligible. The prevalence of pregnancy-related BCS varied from 0% to 21.5%. The pooled prevalence was 6.8% (95% CI: 3.9–10.5%) in all BCS patients, 6.3% (95% CI: 3.8–9.4%) in primary BCS patients, and 13.1% (95% CI: 7.1–20.7%) in female BCS patients. Among them, one study was carried out in Africa with a prevalence of 10.6%; 14 studies in Asian countries with a pooled prevalence of 7.1% (95% CI: 3.1–12.6%); and 5 studies in European countries with a pooled prevalence of 5.0% (95% CI: 3.1–7.3%). The pooled prevalence was 6.7% (95% CI: 2.6–12.3%) in studies published before 2005 and 7.3% (95% CI: 4.2–12.5%) in those published after 2005. In conclusion, pregnancy is a relatively common risk factor for BCS, but there is a huge variation in the prevalence among studies. Physicians should be aware of pregnancy-related BCS. Weirong Ren, Xiang Li, Jia Jia, Yan Xia, Fengrong Hu, and Zhengyu Xu Copyright © 2015 Weirong Ren et al. All rights reserved. The Significance of Serum CA-125 Elevation in Chinese Patients with Primary Budd-Chiari Syndrome: A Multicenter Study Tue, 15 Sep 2015 06:58:36 +0000 Objective. To investigate the serum level of CA-125 and its corresponding clinical significance in Chinese patients with primary BCS. Methods. Serum CA-125 was measured in 243 patients with primary BCS receiving interventional treatment in the participating hospitals and in 120 healthy volunteers. The correlation between serum CA-125 levels and ascites volume, liver function, and prognosis was analyzed. Results. Serum CA-125 was significantly elevated in BCS patients compared to healthy volunteers (). Higher levels of CA-125 were found in BCS patients with abnormal hepatic function and low serum albumin levels and in patients with high volume of ascites compared to patients without these abnormalities. Serum CA-125 levels significantly correlated with ascites volume, serum level of alanine aminotransferase, aspartate aminotransferase, albumin, and Rotterdam BCS scores. The follow-up study indicated that the survival rate and asymptomatic survival rate after interventional treatment were lower in BCS patients with serum CA-125 > 175 U/mL (). Conclusion. Serum CA-125 was significantly higher in patients with primary BCS and had a positive correlation with the volume of ascites, severity of liver damage, and poor prognosis. Thus the serum CA-125 levels may be used to estimate the severity and prognosis of BCS in Chinese patients. De-lei Cheng, Hao Xu, Wei-fu Lv, Rong Hua, Hongtao Du, and Qing-qiao Zhang Copyright © 2015 De-lei Cheng et al. All rights reserved. Prevalence of Splanchnic Vein Thrombosis in Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies Mon, 14 Sep 2015 11:26:30 +0000 Splanchnic vein thrombosis (SVT) may be negatively associated with the prognosis of pancreatitis. We performed a systematic review and meta-analysis of literatures to explore the prevalence of SVT in pancreatitis. All observational studies regarding the prevalence of SVT in pancreatitis were identified via PubMed and EMBASE databases. The prevalence of SVT was pooled in the total of patients with pancreatitis. And it was also pooled in the subgroup analyses according to the stage and causes of pancreatitis, location of SVT, and regions where the studies were performed. After the review of 714 studies, 44 studies fulfilled the inclusion criteria. Meta-analyses showed a pooled prevalence of SVT of 13.6% in pancreatitis. According to the stage of pancreatitis, the pooled prevalence of SVT was 16.6% and 11.6% in patients with acute and chronic pancreatitis, respectively. According to the causes of pancreatitis, the pooled prevalence of SVT was 12.2% and 14.6% in patients with hereditary and autoimmune pancreatitis. According to the location of SVT, the pooled prevalence of portal vein, splenic vein, and mesenteric vein thrombosis was 6.2%, 11.2%, and 2.7% in pancreatitis. The prevalence of SVT in pancreatitis was 16.9%, 11.5%, and 8.5% in Europe, America, and Asia, respectively. Wenda Xu, Xingshun Qi, Jiang Chen, Chunping Su, and Xiaozhong Guo Copyright © 2015 Wenda Xu et al. All rights reserved. Impact of the Siewert Classification on the Outcome of Patients Treated by Preoperative Chemoradiotherapy for a Nonmetastatic Adenocarcinoma of the Oesophagogastric Junction Thu, 10 Sep 2015 12:41:14 +0000 The aim of the study is to analyze the impact of the Siewert classification on the pathological complete response (pcR), pattern of failure, and general outcome of patients treated, by preoperative chemoradiotherapy and surgery for an gastroesophageal junction adenocarcinoma (OGJA). From 2000 to 2008, the charts of 68 patients were retrospectively reviewed. Tumor staging reported was UST1/T2/T3/T4/unknown, respectively, n = 1/7/54/5/1 patients, and N0/N1/unknown, respectively, n = 9/58/1 patients. Patients received primary external-beam radiotherapy with concurrent chemotherapy followed by surgical resection (Siewert I: upper oesogastrectomy; Siewert II/III: total gastrectomy with lower oesophagectomy). Overall survival (OS), overall relapse rate (ORR), cumulative rate of local (CRLR), nodal (CRNR), and metastatic (CRMR) relapse, and their prognostic factors were retrospectively analyzed. Median follow-up was 77.5 months. Median OS was 41.7 ± 5.2 months. The 3-year ORR was 48%. Using univariate analysis ORR was significantly increased for patients with Siewert II/III compared to Siewert I tumors (27.3% versus 62%, ). Siewert I tumors had also statistically lower CRNR and CRMR compared to Siewert II/III tumors (0/9.1% versus 41.3/60.2% resp., ), despite an equivalent cumulative rate of local relapse and pathological complete response rate between the three groups. For OGJA treated with preoperative CRT and surgery, ORR and CRMR were lower for patients with Siewert I tumors in comparison with Siewert II/III tumors. Laurence Moureau-Zabotto, Eric Teissier, Didier Cowen, David Azria, Steve Ellis, and Michel Resbeut Copyright © 2015 Laurence Moureau-Zabotto et al. All rights reserved. Laparoscopic Appendectomy in Children: Preliminary Study in Pediatric Hospital Albert Royer, Dakar Thu, 10 Sep 2015 12:19:39 +0000 Appendiceal pathology’s management has benefited in recent years from the advent of laparoscopic surgery. This study is to make a preliminary assessment of laparoscopic management of acute and complicated appendicitis in children after a few months of practice at the University Hospital Albert Royer, Dakar. This is a retrospective study of 22 cases of patients, all operated on by the same surgeon. The parameters studied were age, sex, clinical data and laboratory features, radiological data, and results of surgical treatment. The mean age of patients was 9.5 years with a male predominance. The series includes 14 cases of acute appendicitis and 8 complicated cases. Appendectomy anterograde is practiced in 81% of cases. Appendectomy was associated with peritoneal wash in 17 patients including 9 cases of acute appendicitis. Drainage of Douglas pouch is performed in 2 patients with complicated appendicitis; the average production was 300 cc of turbid liquids and any complications were not founded. An abscess of Douglas pouch is noted in 2 patients with complicated appendicitis undrained. These Douglas abscesses were treated medically. No conversion of laparotomy was performed in the series. After an average of 8 months no other problems were noted. Mbaye Fall, Doudou Gueye, Ibrahima Bocar Wellé, Faty Balla Lo, Aloise Sagna, Marie Diop, and Ibrahima Fall Copyright © 2015 Mbaye Fall et al. All rights reserved. Proinflammatory Cytokines (IL-1α, IL-6) and Hepatocyte Growth Factor in Patients with Alcoholic Liver Cirrhosis Thu, 20 Aug 2015 13:11:42 +0000 Background. The aim of the study was to assess the activity of interleukin-1α, interleukin-6, and hepatocyte growth factor protein (HGF) in serum of patients with alcoholic liver cirrhosis. Materials and Methods. Sixty patients with alcoholic liver cirrhosis treated in various hospitals were randomly enrolled. The stage of cirrhosis was assessed according to the Child-Turcotte-Pugh scoring system. The control group consisted of ten healthy persons without liver disease, who did not drink alcohol. Additionally, the group of alcoholics without liver cirrhosis was included in the study. The activity of interleukin-1α, interleukin-6, and HGF in blood plasma of patients and controls was measured using the sandwich enzyme immunoassay technique with commercially available quantitative ELISA test kits. Results. Higher concentrations of HGF protein were demonstrated in patients with Child class B and Child class C liver cirrhosis, compared to controls and alcoholics without liver cirrhosis. Moreover, significantly higher concentrations of HGF protein were found in patients with Child class C liver cirrhosis compared to patients with Child class A liver cirrhosis . The concentrations of interleukin-1α in patients with Child class B and Child class C liver cirrhosis were significantly higher in comparison with controls. Significantly higher concentrations of interleukin-6 were demonstrated in Child class C, compared to Child class A. Andrzej Prystupa, Paweł Kiciński, Jarosław Sak, Anna Boguszewska-Czubara, Anna Toruń-Jurkowska, and Wojciech Załuska Copyright © 2015 Andrzej Prystupa et al. All rights reserved. Effects Comparison between Endoscopic Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy for Common Bile Duct Stone Removal Mon, 17 Aug 2015 13:51:03 +0000 Endoscopic sphincterotomy (EST) is a treatment of choice for stone extraction and is now most frequently used. The study was to compare the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and endoscopic sphincterotomy (EST) for common bile duct stone removal. Trials comparing the effects between EPLBD and EST treatment were searched according to the study protocol. Overall stone removal rate, complete removal rate in 1st session, treatment duration, mechanical lithotripsy using rate, and overall complication rate were compared using risk ratio (RR) and mean difference (MD) and their 95% confidence interval (CI) via RevMan 5.2 software. For overall stone removal rate, two therapies showed similar effect, but EPLBD showed better overall stone removal rate for stone >10 mm in diameter. For complete stone removal rate in 1st session, no difference was found, even for those with stone >10 mm in diameter; EPLBD showed longer treatment duration, higher mechanical lithotripsy using rate obvious overall complications rate, and more serious bleeding, whereas there were no significant differences for perforation, hyperamylasemia, pancreatitis, and cholecystitis/cholangitis. EPLBD showed better efficacy in certain conditions compared to EST, however with shortcomings, such as more duration, higher mechanical lithotripsy using rate, more serious overall complications rate, and bleeding. Yandong Guo, Chen Li, Shan Lei, and Fachao Zhi Copyright © 2015 Yandong Guo et al. All rights reserved. Enteroscopic Diagnosis and Management of Small Bowel Diverticular Hemorrhage: A Multicenter Report from the Taiwan Association for the Study of Small Intestinal Diseases Thu, 13 Aug 2015 12:31:26 +0000 Small bowel diverticulum is a rare cause of gastrointestinal bleeding. The diagnosis and treatment of small bowel diverticular hemorrhage is clinically challenging before the development of deep enteroscopy. In this multicenter study from the Taiwan Association for the Study of Small Intestinal Diseases (TASSID), 608 patients underwent deep enteroscopy for obscure gastrointestinal bleeding during January 2004 and April 2010 from eight medical centers in Taiwan. Small bowel diverticular hemorrhage account for 7.89% of obscure gastrointestinal bleeding in this study. Most of the patients received endoscopic therapy with an initial hemostasis rate of 85.71% and rebleeding rate of 20%. In this large case series investigating the enteroscopic management of small intestinal diverticular hemorrhage, we found that, as to patients with peptic ulcer hemorrhage, most of these patients can be successfully managed by endoscopic therapy before surgery in the era of deep enteroscopy. Yang-Yuan Chen, Cheng-Tang Chiu, Chen-Ming Hsu, Tsung-Hsing Chen, Yi-Chun Chiu, Yen-Chang Chu, Chen-Wang Chang, Hsiu-Po Wang, Deng-Chyang Wu, Tien-Yu Huang, and Hsu-Heng Yen Copyright © 2015 Yang-Yuan Chen et al. All rights reserved. Optimization of Deep Sedation with Spontaneous Respiration for Therapeutic Endoscopy Combining Propofol and Bispectral Index Monitoring Thu, 13 Aug 2015 07:06:47 +0000 Background/Aims. This study aimed to establish optimal propofol anesthesia for therapeutic endoscopy, which has not been established. Methodology. We retrospectively investigated data on 89 patients who underwent upper-GI endoscopic submucosal dissection or endoscopic mucosal resection under anesthesia with propofol. Examined doses of propofol were changed according to efficacy and/or adverse events and classified into 5 periods. A bispectral index (BIS) monitor was used at Period 5 to decrease the incidence of adverse events caused by oversedation. The initial dose of propofol was administered after bolus injection of pethidine hydrochloride (0.5 mg/kg), and 1.0 mL of propofol was added every minute until the patients fell asleep. Continuous and bolus infusion were performed to maintain sedation. When the patient moved or an adverse event occurred, the maintenance dose examined was increased or decreased by 5 mL/h regardless of body weight. Results. Dose combinations (introduction : maintenance) and patient numbers for each period were as follows: Period 1 (), 0.5 mg/kg : 5 mg/kg/h; Period 2 (), 0.33 mg/kg : 3.3 mg/kg/h; Period 3 (), 0.5 mg/kg : 3.3 mg/kg/h; Period 4 (), 0.5 mg/kg : 2.5 mg/kg/h; Period 5 (), 0.5 mg/kg : 2.5 mg/kg/h, using BIS monitor. During Period 5, an adverse event occurred in 10.0% of patients, which was lower than that for Periods 1–4. Conclusions. Period 5 propofol anesthesia with BIS protocol could be safe and useful for therapeutic endoscopy under deep sedation with spontaneous respiration. Kohei Matsumoto, Akihito Nagahara, Kenshi Matsumoto, Yoichi Akazawa, Hiroyuki Komori, Yuta Nakagawa, Tsutomu Takeda, Hiroya Ueyama, Yuji Shimada, Daisuke Asaoka, Mariko Hojo, and Sumio Watanabe Copyright © 2015 Kohei Matsumoto et al. All rights reserved. Endoscopic Submucosal Dissection for Gastric Subepithelial Tumors: A Single-Center Experience Tue, 11 Aug 2015 11:07:42 +0000 Background and Aims. Endoscopic submucosal dissection (ESD) has been accepted as a treatment modality for gastrointestinal epithelial tumors. Recently, ESD has been applied to resect subepithelial tumors (SETs) in the gastrointestinal tract, but clinical evidence on its efficacy and safety is limited. The aim of this study was to investigate the efficacy and safety of ESD for gastric SETs and to assess possible predictive factors for incomplete resection. Patients and Methods. Between January 2006 and December 2013, a total of 49 patients with gastric SET underwent ESD at our hospital. Clinicopathologic characteristics of patients and SETs, therapeutic outcomes, complications, and follow-up outcomes were evaluated. Results. The overall rates of en bloc resection and complete resection were 88% (43/49) and 84% (43/49), respectively. Complete resection rates in tumors originating from the submucosal layer were significantly higher than those in tumors originating from the muscularis propria layer (90% versus 56%, ). In multivariate logistic regression analyses, tumor location (upper third: odds ratio [OR] 12.639, 95% confidence interval [CI] 1.087–146.996, ) and layer of tumor origin (muscularis propria: OR 8.174, 95% CI 1.059–63.091, ) were independently associated with incomplete resection. Procedure-related bleeding and perforation rates were both 4%. No recurrence was observed in patients with complete resection at a median follow-up period of 29 months (range: 7–83 months). Conclusions. ESD is an effective, safe, and feasible treatment for gastric SETs. The frequency of incomplete resection increases in tumors located in the upper third of the stomach and in those originating from the muscularis propria layer. Jin Sung Lee, Gwang Ha Kim, Do Youn Park, Jong Min Yoon, Tae Wook Kim, Jong Hun Seo, Bong Eun Lee, and Geun Am Song Copyright © 2015 Jin Sung Lee et al. All rights reserved. A Novel Round Insulated Tip Papillotome as an Alternative to the Classic Needle-Knife for Precut Sphincterotomy in Endoscopic Retrograde Cholangiopancreatography Sun, 09 Aug 2015 12:23:21 +0000 Objective. The purpose of this study was to investigate the efficacy and safety of a new round insulated tip papillotome (r-ITP) as compared to that of the classic needle-knife sphincterotome (NKS) in difficult-to-cannulate endoscopic retrograde cholangiopancreatography (ERCP) patients. Materials and Methods. Patients with no exclusion criteria and an intact papilla referred for ERCP were invited to participate in the study. “Difficult-to-cannulate” patients, defined as failure to achieve deep biliary cannulation within five minutes from the first touch of papilla, with no more than ten attempts permitted, were randomly assigned for precut sphincterotomy using either the classic NKS or r-ITP. Results. Seventy and 69 patients were randomly assigned to the NKS and r-ITP groups, respectively. The groups were comparable regarding age, sex, indications, and associated conditions. There was no statistically significant difference in terms of successful cannulation or post-ERCP complications between the two groups. Only five patients (3.6%) developed mild to moderate post-ERCP pancreatitis and two had mild bleeding. No perforations or deaths were encountered. Conclusions. Although the round insulated tip papillotome was not shown to be superior to the classic NKS concerning efficacy and safety when used by an experienced endoscopist, it remains a simple, safe, and efficacious alternative. Birol Baysal, Hakan Akin, Omar Masri, Ali Tüzün İnce, and Hakan Senturk Copyright © 2015 Birol Baysal et al. All rights reserved. Dilemmas in Endoscopic Management of Rectal Neuroendocrine Tumors: A Case-Based Discussion Wed, 05 Aug 2015 09:29:54 +0000 Rectal neuroendocrine tumors are uncommon neoplasms that historically were regarded as having an indolent course. Due to the widespread use of screening colonoscopy neuroendocrine tumors of the rectum are identified with increasing frequency. More recent literature has suggested that rectal neuroendocrine tumors may progress in a more malignant fashion than previously believed. In this case-based discussion we present management dilemmas, analyze current guidelines, and highlight the role of endoscopic ultrasound, endoscopic resection, and surgery. Brian P. Rajca and Mihir S. Wagh Copyright © 2015 Brian P. Rajca and Mihir S. Wagh. All rights reserved. Regulators of Actin Dynamics in Gastrointestinal Tract Tumors Tue, 04 Aug 2015 15:59:04 +0000 Reorganization of the actin cytoskeleton underlies cell migration in a wide variety of physiological and pathological processes, such as embryonic development, wound healing, and tumor cell invasion. It has been shown that actin assembly and disassembly are precisely regulated by intracellular signaling cascades that respond to changes in the cell microenvironment, ligand binding to surface receptors, or oncogenic transformation of the cell. Actin-nucleating and actin-depolymerizing (ANFs/ADFs) and nucleation-promoting factors (NPFs) regulate cytoskeletal dynamics at the leading edge of migrating cells, thereby modulating cell shape; these proteins facilitate cellular movement and mediate degradation of the surrounding extracellular matrix by secretion of lytic proteases, thus eliminating barriers for tumor cell invasion. Accordingly, expression and activity of these actin-binding proteins have been linked to enhanced metastasis and poor prognosis in a variety of malignancies. In this review, we will summarize what is known about expression patterns and the functional role of actin regulators in gastrointestinal tumors and evaluate first pharmacological approaches to prevent invasion and metastatic dissemination of malignant cells. Konrad Steinestel, Eva Wardelmann, Wolfgang Hartmann, and Inga Grünewald Copyright © 2015 Konrad Steinestel et al. All rights reserved. The Frequent Adiponutrin (PNPLA3) Variant p.Ile148Met Is Associated with Early Liver Injury: Analysis of a German Pediatric Cohort Tue, 04 Aug 2015 13:20:21 +0000 Introduction. The common adiponutrin (PNPLA3) variant p.Ile148Met is associated with liver injury. Here, we investigate the association of this polymorphism with hepatic and metabolic traits in a pediatric cohort. Patients and Methods. The study cohort comprised 142 German children (age 5–9 years, 98 overweight, 19 children with NAFLD). Results. Overweight children presented with increased serum ALT () and GGT () activities. ALT activities differed significantly () between carriers of different PNPLA3 genotypes in the entire study cohort, in normal weight children () and in children younger than 7 years (). Carriers of the prosteatotic PNPLA3 genotype p.148Met/Met displayed higher ALT activities as compared to children with the frequent genotype p.148Ile/Ile (). The BMI was however a stronger predictor of ALT activities compared to the PNPLA3 genotype ( and , resp.). The variant was associated with increased serum glucose levels () and HOMA index () in carriers of the p.148Ile/Met genotype but did not affect other metabolic traits or the presence of NAFLD. Discussion. The frequent PNPLA3 variant p.Ile148Met is associated with serum ALT activities already at a young age. Marcin Krawczyk, Roman Liebe, Ina B. Maier, Anna Janina Engstler, Frank Lammert, and Ina Bergheim Copyright © 2015 Marcin Krawczyk et al. All rights reserved. Serum Indicators Reflecting Gastric Function May Also Correlate with Other Extragastric Diseases Mon, 03 Aug 2015 16:39:37 +0000 Aim. Serological indicators of organ function can reveal intrinsic links between different organs. The present study aimed to determine the correlations of serum indicators for gastric and extragastric function. Methods. A total of 823 individuals were enrolled. Data on indicators reflecting blood lipids, blood glucose, indexes of stomach, kidney, liver, and thyroid function, and H. pylori IgG antibody level were collected. Results. As creatine (Cr) levels increased, PGI (pepsinogen I), PGII concentrations, and PGI/II ratio increased monotonically from 79.7 to 105.15 µg/L, 6.5 to 8.4 µg/L, and 11.97 to 12.27, respectively (). As thyroid peroxidase antibody (TPOAb) levels increased, PGI level decreased from 100.85 to 84 µg/L () and as thyroid stimulating hormone (TSH) increased, PGI/II ratio increased monotonically from 11.54 to 12.68 (). As triglyceride (TG) levels increased, gastrin 17 (G17) concentrations increased monotonically from 1.73 to 2.7 pmol/L (). As serum glucose and glycated hemoglobin (HbA1C) increased, PGI/II concentrations increased monotonically from 11.98 to 12.67 and 9.7 to 13.54 (), respectively. Conclusions. Serum PG and G17 levels were associated with blood glucose and lipids, kidney function, and thyroid function but not with liver function. Serum indicators reflecting gastric function may correlate not only with primary diseases, but also with other extragastric diseases. Yuehua Gong, Wei Wang, Yi Li, and Yuan Yuan Copyright © 2015 Yuehua Gong et al. All rights reserved. Application of a Gastroduodenal Artery Graft for Reconstruction of the Hepatic Artery during Radical Resection of Hilar Cholangiocarcinoma Mon, 03 Aug 2015 16:34:58 +0000 This paper was designed to evaluate a novel surgical procedure of using a gastroduodenal artery graft for reconstruction of the hepatic artery during radical resection of hilar cholangiocarcinoma, which is citation-free and self-contained. In this paper we retrospectively analyzed the clinical data, surgical procedure, and follow-up results in nine patients who underwent hepatic artery reconstruction using a gastroduodenal artery graft during their radical resection of hilar cholangiocarcinoma and no artery thrombosis or other surgical complications were found after operation with minimum follow-up duration of three months. We recommended that a gastroduodenal artery graft was shown to be a good choice for hepatic artery resection after radical resection of hilar cholangiocarcinoma. Yurong Liang, Jing Wang, Xianjie Shi, Jiahong Dong, and Wanqing Gu Copyright © 2015 Yurong Liang et al. All rights reserved. Psychometrics of the Greek Chronic Liver Disease Questionnaire for Measuring HRQL Thu, 30 Jul 2015 12:08:27 +0000 The aim of the present study is to examine psychometric properties such as internal consistency reliability and construct validity of the Greek CLDQ. A sample of 366 eligible patients with chronic liver disease (CLD) self-administered the Greek version of the SF-36 Health Survey, the Chronic Liver Disease Questionnaire (CLDQ), and questions on sociodemographic status and treatment. Child Pugh Score was also collected. Hypothesized scale structure, reliability (Cronbach’s alpha), and construct validity (convergent, discriminant, and known groups) were assessed. Multitrait scaling confirmed scale structure of the CLDQ with good item convergence (100%) and discrimination (84.1%) rates. Cronbach’s alpha rated >0.70 for all scales. Spearman’s correlations between the CLDQ and SF-36 scales assessing similar health-related quality of life dimensions were strong ranging above 0.70 (). Construct validity was confirmed with satisfactory results for known-group comparisons. Most CLDQ scales discriminated significantly between patients according to disease severity, whereas all CLDQ scales discriminated between treatment receivers and nonreceivers. The overall psychometric results for the Greek version of the CLDQ confirmed it as a reliable and valid questionnaire. Evelina Pappa, Fotini Hatzi, Angelos A. Papadopoulos, and Dimitris Niakas Copyright © 2015 Evelina Pappa et al. All rights reserved. Serum Syndecan-1 Levels and Its Relationship to Disease Activity in Patients with Crohn’s Disease Wed, 29 Jul 2015 06:40:27 +0000 Background. Syndecan-1 (SDC-1), a member of the family of heparan sulfate proteoglycans, plays an important role in the resolution of inflammation. This study aimed to investigate the relationship between SDC-1 and disease activity in Crohn’s disease (CD). Methods. Serum samples of 54 patients with CD and 30 healthy controls were obtained. First, SDC-1 levels of the CD patients were compared to the control group. Subsequently, SDC-1 levels were analyzed in patients with CD in active and remission periods. Finally, SDC-1 efficacy in predicting disease activity was evaluated by performing correlation analysis between SDC-1 and C-reactive protein (CRP) and Crohn’s disease activity index (CDAI). Results. SDC-1 level was higher in the CD group (61.9 ± 42.6 ng/mL) compared with the control group (34.1 ± 8.0 ng/mL) . SDC-1 levels were higher in active CD patients (97.1 ± 40.3 ng/mL) compared with those in remission (33.7 ± 13.5 ng/mL) . A significant positive correlation was found between SDC-1 and CRP (, ) and between SDC-1 and CDAI (, ). Conclusion. Serum levels of SDC-1 are higher in CD compared to the normal population and can be an effective marker of disease severity. Cem Çekiç, Adnan Kırcı, Sezgin Vatansever, Fatih Aslan, Huriye Erbak Yılmaz, Emrah Alper, Mahmut Arabul, Elif Sarıtaş Yüksel, and Belkıs Ünsal Copyright © 2015 Cem Çekiç et al. All rights reserved. Choledochal Cyst in Adults: Etiopathogenesis, Presentation, Management, and Outcome—Case Series and Review Wed, 15 Jul 2015 07:58:07 +0000 Background. Choledochal cyst, a rare congenital cystic dilatation of biliary tree, is uncommon in adults. Their presentations differ from children and surgical management has evolved. Methods. A retrospective review of the records of all the patients above 15 years, who underwent therapeutic intervention in our hospital, was carried out. Results. Ten cases of choledochal cyst were found; 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (type I), excision of the diverticulum (type II), and ERCP sphincterotomy (type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Conclusion. Choledochal cyst is rare in adults. The typical triad of abdominal pain, jaundice, and mass is uncommon in adults. The surgical strategy aims for single stage complete excision of the cyst with hepaticojejunostomy. Norman Oneil Machado, Pradeep J. Chopra, Adil Al-Zadjali, and Shahzad Younas Copyright © 2015 Norman Oneil Machado et al. All rights reserved. Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival Mon, 13 Jul 2015 11:12:59 +0000 Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic. K. E. O’Sullivan, E. T. Hurley, and J. P. Hurley Copyright © 2015 K. E. O’Sullivan et al. All rights reserved. Gastric Electrical Stimulation with the Enterra System: A Systematic Review Sun, 12 Jul 2015 12:35:44 +0000 Background. Gastric electrical stimulation (GES) is a surgically implanted treatment option for refractory gastroparesis. Aim. To systematically appraise the current evidence for the use of gastric electrical stimulation and suggest a method of standardisation of assessment and follow-up in these patients. Methods. A systematic review of PubMed, Web of Science, DISCOVER, and Cochrane Library was conducted using the keywords including gastric electrical stimulation, gastroparesis, nausea, and vomiting and neuromodulation, stomach, central nervous system, gastric pacing, electrical stimulation, and gastrointestinal. Results. 1139 potentially relevant articles were identified, of which 21 met the inclusion criteria and were included. The quality of studies was variable. There was a variation in outcome measures and follow-up methodology. Included studies suggested significant reductions in symptom severity reporting over the study period, but improvements in gastric emptying time were variable and rarely correlated with symptom improvement. Conclusion. The evidence in support of gastric electrical stimulation is limited and heterogeneous in quality. While current evidence has shown a degree of efficacy in these patients, high-quality, large clinical trials are needed to establish the efficacy of this therapy and to identify the patients for whom this therapy is inappropriate. A consensus view on essential preoperative assessment and postoperative measurement is needed. Nikhil Lal, Sam Livemore, Declan Dunne, and Iftikhar Khan Copyright © 2015 Nikhil Lal et al. All rights reserved. Role of the Surgical Method in Development of Postoperative Cholangiocarcinoma in Todani Type IV Bile Duct Cysts Thu, 09 Jul 2015 14:29:20 +0000 Background. Our purpose was to investigate the association between the surgical approach for Todani type IV cysts and subsequent malignancy rate. Methods. The records of patients who received cyst excision from 1994 to 2013 were analyzed retrospectively for the following data: demographics, presenting symptoms, postoperative outcomes, malignant transformation, and follow-up reexaminations, including imaging, laboratory, and tumor marker tests. Results. Seven of the 196 patients initially treated at our hospital developed postoperative biliary malignancy, and the surgical approaches were extrahepatic bile duct cyst resection combined with hilar cholangioplasty and Roux-en-Y cystojejunostomy (), and intra- and extrahepatic bile duct cyst resection and Roux-en-Y hepaticojejunostomy (). The overall malignancy rate was 3.6% (7/196). Forty-eight patients initially treated at other hospitals developed malignancy postoperatively: 15 (31.2%) remained untreated and 33 (68.8%) had undergone incomplete resection procedures. Because Todani type IV cysts were seen in 268 patients, the postoperative malignancy rate of this group of patients was 12.3% (33/268). Conclusions. Radical resection of both intra- and extrahepatic cysts combined with hepatic resection and Roux-en-Y hepaticojejunostomy is associated with a reduced risk of subsequent cancer development. Procedures in which radical cyst excision is not performed are associated with a greater risk of subsequent malignancy. Hong-tian Xia, Tao Yang, Bin Liang, Jian-ping Zeng, and Jia-hong Dong Copyright © 2015 Hong-tian Xia et al. All rights reserved. Technical Aspects of Laparoscopic Distal Pancreatectomy for Benign and Malignant Disease: Review of the Literature Thu, 09 Jul 2015 08:21:45 +0000 Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. The most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation can be achieved preferably by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and left gastroepiploic artery (Warshaw technique). Several studies have suggested a higher rate of spleen preservation with laparoscopy. The radical antegrade modular pancreatosplenectomy has become mainstay for treating pancreatic cancer and can be performed laparoscopically as well. Evidence on the feasibility and safety of laparoscopic distal pancreatectomy for cancer is scarce. Despite the obvious advantages of laparoscopic surgery, postoperative morbidity remains relatively high, mainly because of the high incidence of pancreatic fistula. For decades, surgeons have tried to prevent these fistulas but to date no strategy has been confirmed to be effective in 2 consecutive randomized studies. Pragmatic multicenter studies focusing on technical aspects of laparoscopic distal pancreatectomy are lacking and should be encouraged. T. de Rooij, R. Sitarz, O. R. Busch, M. G. Besselink, and M. Abu Hilal Copyright © 2015 T. de Rooij et al. All rights reserved.