Gastroenterology Research and Practice The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Role of the Aspartate Transaminase and Platelet Ratio Index in Assessing Hepatic Fibrosis and Liver Inflammation in Adolescent Patients with HBeAg-Positive Chronic Hepatitis B Sun, 05 Jul 2015 08:50:34 +0000 This study described an index of aspartate aminotransferase-to-platelet ratio index (APRI) to assess hepatic fibrosis with limited expense and widespread availability compared to the liver biopsy in adolescent patients with CHB. Yu Zhijian, Li Hui, Yao Weiming, Lin Zhanzhou, Chen Zhong, Zheng Jinxin, Wang Hongyan, Deng Xiangbin, Yang Weizhi, Li Duoyun, Liu Xiaojun, and Deng Qiwen Copyright © 2015 Yu Zhijian et al. All rights reserved. Clinical Efficacy of Various Diagnostic Tests for Small Bowel Tumors and Clinical Features of Tumors Missed by Capsule Endoscopy Thu, 02 Jul 2015 11:19:34 +0000 Background. We aimed to evaluate the efficacy of various diagnostic tools such as computerized tomography (CT), small bowel follow-through (SBFT), and capsule endoscopy (CE) in diagnosing small bowel tumors (SBTs). Additionally, we aimed to evaluate the clinical features of SBTs missed by CE. Methods. We retrospectively studied 79 patients with histologically proven SBT. Clinical data were analyzed with particular attention to the efficacy of CT, SBFT, and CE in detecting SBT preoperatively. We also analyzed the clinical features of SBTs missed by CE. Results. The most common symptoms of SBT were bleeding (43%) and abdominal pain (13.9%). Diagnostic yields were as follows: CT detected 55.8% of proven SBTs; SBFT, 46.1%; and CE, 83.3%. The sensitivity for detecting SBTs was 40.4% for CT, 43.9% for SBFT, and 79.6% for CE. Two patients with nondiagnostic but suspicious findings on CE and seven patients with negative findings on CE were eventually found to have SBT. These nine patients were eventually diagnosed with gastrointestinal stromal tumor (4), small polyps (3), inflammatory fibroid polyp (1), and adenocarcinoma (1). These tumors were located in the proximal jejunum (5), middle jejunum (1), distal jejunum (1), and proximal ileum (1). Conclusion. CE is more efficacious than CT or SBFT for detecting SBTs. However, significant tumors may go undetected with CE, particularly when located in the proximal jejunum. Jung Wan Han, Sung Noh Hong, Hyun Joo Jang, Seong Ran Jeon, Jae Myung Cha, Soo Jung Park, Jung Sik Byeon, Bong Min Ko, Eun Ran Kim, Hwang Choi, and Dong Kyung Chang Copyright © 2015 Jung Wan Han et al. All rights reserved. MELD Score Is Not Related to Spontaneous Bacterial Peritonitis Wed, 01 Jul 2015 12:35:29 +0000 This study investigates the correlation between SBP and repeated paracentesis, and its relation to MELD score, in cirrhotic patients with refractory ascites in an outpatient setting. Through the data base, 148 cirrhotic patients were prospectively included in the study with refractory ascites undergoing relief paracentesis from March 2012 to March 2013. Demographics data, etiology of liver disease, MELD score, and inscription on the waiting list for liver transplantation were analyzed. The ascites removed was analyzed through cellular count and culture for the diagnosis of spontaneous bacterial peritonitis. The cirrhotic patients underwent a total of 854 paracentesis procedures in the ambulatory setting during the study period. Eighty-one patients (54%) were on the waiting list for liver transplantation. Patients on the liver transplant list had higher associated costs due to a higher total number of outpatient paracentesis procedures (394.7 ± 512.3 versus 291.7 ± 384.7) and a higher volume drained per procedure (6.5 ± 8.5 versus 4.8 ± 6.4). There were 28 episodes of SBP (3.3%) diagnosed in 24 patients. In conclusion, the prevalence of asymptomatic SBP in cirrhotic patients with refractory ascites undergoing repeated paracentesis is low. MELD score is not related to spontaneous bacterial peritonitis. Luciana Haddad, Tatiana Morgado Conte, Liliana Ducatti, Lucas Nacif, Luiz Augusto Carneiro D’Albuquerque, and Wellington Andraus Copyright © 2015 Luciana Haddad et al. All rights reserved. Narrow-Band Imaging Magnifying Endoscopy versus Lugol Chromoendoscopy with Pink-Color Sign Assessment in the Diagnosis of Superficial Esophageal Squamous Neoplasms: A Randomised Noninferiority Trial Wed, 01 Jul 2015 10:48:53 +0000 Previous studies have shown the high diagnostic accuracy of narrow-band imaging magnifying endoscopy (NBI-ME) and Lugol chromoendoscopy with pink-color sign assessment (LCE-PS) for superficial esophageal squamous cell carcinoma (SESCC). However, there has been no controlled trial comparing these two diagnostic techniques. We conducted a randomized noninferiority trial to compare the diagnostic accuracy of NBI-ME and LCE-PS. We recruited patients with, or with a history of, squamous cell carcinoma in the head and neck region or in the esophagus. They were randomly assigned to either NBI-ME or LCE-PS. When lesions > 5 mm in diameter were found as brownish areas on NBI or as Lugol-voiding lesions (LVL), they were evaluated to determine whether they are SESCC on the basis of the findings of NBI-ME or PS in the LVL. NBI-ME and LCE-PS were completed in 147 patients each. There was no significant difference in all diagnostic values between the two techniques. Compared with LCE-PS, NBI-ME showed a significantly shorter examination time but a larger number of misdiagnosed lesions especially in patients with many irregularly shaped multiform LVLs. Compared with LCE-PS, NBI-ME might be similarly accurate and less invasive, but less reliable in patients with many LVLs, in the diagnosis of SESCC. Kenichi Goda, Akira Dobashi, Noboru Yoshimura, Masayuki Kato, Hiroyuki Aihara, Kazuki Sumiyama, Hirobumi Toyoizumi, Tomohiro Kato, Masahiro Ikegami, and Hisao Tajiri Copyright © 2015 Kenichi Goda et al. All rights reserved. CT Imaging Findings after Stereotactic Radiotherapy for Liver Tumors Mon, 29 Jun 2015 11:31:18 +0000 Purpose. To study radiological response to stereotactic radiotherapy for focal liver tumors. Materials and Methods. In this IRB-approved, HIPAA-compliant study CTs of 68 consecutive patients who underwent stereotactic radiotherapy for liver tumors between 01/2006 and 01/2010 were retrospectively reviewed. Two independent reviewers evaluated lesion volume and enhancement pattern of the lesion and of juxtaposed liver parenchyma. Results. 36 subjects with hepatocellular carcinoma (HCC), 25 with liver metastases, and seven with cholangiocarcinoma (CCC) were included in study. Mean follow-up time was 5.6 ± 7.1 months for HCC, 6.4 ± 5.1 months for metastases, and 10.1 ± 4.8 months for the CCC. Complete response was seen in 4/36 (11.1%) HCCs and 1/25 (4%) metastases. Partial response (>30% decrease in long diameter) was seen in 25/36 (69%) HCCs, 14/25 (58%) metastases, and 7/7 (100%) of CCCs. Partial response followed by local recurrence (>20% increase in long diameter from nadir) occurred in 2/36 (6%) HCCs and 4/25 (17%) metastases. Liver parenchyma adjacent to the lesion demonstrated a prominent halo of delayed enhancement in 27/36 (78%) of HCCs, 19/21 (91%) of metastases, and 7/7 (100%) of CCCs. Conclusion. Sustainable radiological partial response to stereotactic radiotherapy is most frequent outcome seen in liver lesions. Prominent halo of delayed enhancement of the adjacent liver is frequent finding. Olga R. Brook, Eavan Thornton, Mishal Mendiratta-Lala, Anand Mahadevan, Vassilious Raptopoulos, Alexander Brook, Robert Najarian, Robert Sheiman, and Bettina Siewert Copyright © 2015 Olga R. Brook et al. All rights reserved. Neutrophil Gelatinase-Associated Lipocalin: A New Marker of Renal Function in C-Related End Stage Liver Disease Sun, 28 Jun 2015 11:22:59 +0000 Background/Aims. Renal impairment is a common complication of cirrhosis. Serum creatinine is less sensitive in these patients. Measurement of the glomerular filtration rate (GFR) is the gold standard but time consuming. The aim is to validate plasma NGAL (pNGAL) and urinary NGAL (uNGAL) as markers of renal function in patients with HCV related cirrhosis. Patient and Methods. One hundred HCV related end stage liver cirrhosis patients were randomized into two groups: Group I (), patients with GFR < 60 mL/m measured by isotope scanning of the kidney (Renogram), and Group II (), patients with GFR ≥ 60 mL/m. The pNGAL and uNGAL were measured within 2 days of the Renogram. Results. Both groups were matched with age, sex, and Child Pugh score. There was statistically significant difference between both groups regarding serum creatinine (1.98 ± 1.04 versus 1.38 ± 0.88 mg/dL; ) and pNGAL level (5.79 ± 2.06 versus 7.25 ± 3.30 ng/dL; ). Both groups were comparable () for the uNGAL (6.00 ± 0.78 versus 6.03 ± 0.96 ng/mL). Unlike uNGAL, the pNGAL positively correlated with total GFR by Renogram (; ). With a cutoff ≥4 ng/mL, pNGAL had 94.3% sensitivity and 1.5% specificity and PPV = 34, NPV = 33.3, LR+ = −175.1, and LR− = −60.6. Conclusion. The pNGAL is a promising marker of the renal function in patients with cirrhosis. Omkolsoum Mohamed Alhaddad, Ayman Alsebaey, Mohamed Omar Amer, Hala Hany El-Said, and Tary Abdel Hamid Salman Copyright © 2015 Omkolsoum Mohamed Alhaddad et al. All rights reserved. A New Twist to a Chronic HCV Infection: Occult Hepatitis C Wed, 24 Jun 2015 11:14:57 +0000 Background. The prevalence of occult hepatitis C infection (OCI) in the population of HCV-RNA negative but anti-HCV positive individuals is presently unknown. OCI may be responsible for clinically overt recurrent disease following an apparent sustained viral response (SVR) weeks to years later. Purpose. To review the available current literature regarding OCI, prevalence, pathogenic mechanisms, clinical characteristics, and future directions. Data Sources. Searching MEDLINE, article references, and national and international meeting abstracts for the diagnosis of OCI (1990–2014). Data Synthesis. The long-term followup of individuals with an OCI suggests that the infection can be transient with the loss of detectable HCV-RNA in PPBMCs after 12–18 months or alternatively exist intermittently and potentially long term. The ultimate outcome of HCV infection is decided by interplay between host immune responses, antiviral therapies, and the various well-identified viral evasion mechanisms as well as the presence of HCV infection within extrahepatic tissues. Conclusion. The currently widely held assumption of a HCV-cure in individuals having had “SVR” after 8–12 weeks of a course of DAA therapy as recently defined may not be entirely valid. Careful longitudinal followup utilizing highly sensitive assays and unique approaches to viral isolation are needed. Bashar M. Attar and David Van Thiel Copyright © 2015 Bashar M. Attar and David Van Thiel. All rights reserved. Amrubicin Monotherapy for Patients with Platinum-Refractory Gastroenteropancreatic Neuroendocrine Carcinoma Tue, 23 Jun 2015 09:46:02 +0000 Objective. Patients with gastroenteropancreatic neuroendocrine carcinoma (NEC) have a poor prognosis. Platinum-based combination chemotherapy is commonly used as first-line treatment; however, the role of salvage chemotherapy remains unknown. This study aimed to analyze the efficacy and safety of amrubicin monotherapy in patients with platinum-refractory gastroenteropancreatic NEC. Methods. Among 22 patients with advanced gastroenteropancreatic NEC, 10 received amrubicin monotherapy between September 2007 and May 2014 after failure of platinum-based chemotherapy. The efficacy and toxicity of the treatment were analyzed retrospectively. Results. Eight males and two females (median age, 67 years (range, 52–78)) received platinum-based chemotherapy, including cisplatin plus irinotecan (, 70%), cisplatin plus etoposide (, 20%), and carboplatin plus etoposide (, 10%) before amrubicin therapy. Median progression-free survival and overall survival after amrubicin therapy were 2.6 and 5.0 months, respectively. Two patients had partial response (20% response rate), and their PFS were 6.2 months and 6.3 months, respectively. Furthermore, NEC with response for amrubicin had characteristics with a high Ki-67 index and receipt of prior chemotherapy with cisplatin and irinotecan. Grade 3-4 neutropenia and anemia were observed in four and five patients, respectively. Conclusion. Amrubicin monotherapy appears to be potentially active and well-tolerated for platinum-refractory gastroenteropancreatic NEC. Takayuki Ando, Ayumu Hosokawa, Hiroki Yoshita, Akira Ueda, Shinya Kajiura, Hiroshi Mihara, Sohachi Nanjo, Haruka Fujinami, Jun Nishikawa, Kohei Ogawa, Takahiko Nakajima, Johji Imura, and Toshiro Sugiyama Copyright © 2015 Takayuki Ando et al. All rights reserved. Effect of Modified Roux-en-Y Gastric Bypass Surgery on GLP-1, GIP in Patients with Type 2 Diabetes Mellitus Thu, 18 Jun 2015 12:15:39 +0000 The type 2 diabetes mellitus (T2DM) is one of the most serious diseases that threaten public health. Modified gastric bypass surgery has been applied to the treatment of T2DM patients in the 1990s, but the therapeutic mechanism to this function is still unclear. The aim of this study was to further clarify the effect and the mechanism of modified gastric bypass surgery on glucose metabolism in patients with T2DM. In the study, the incretin indexes and blood glucose indexes were analyzed before surgery and 1 week and 1, 3, and 6 months after surgery. The results suggested that modified Roux-en-Y gastric bypass can promote GLP-1 secretion in patients with T2DM, while reducing the secretion of GIP. Thus it could effectively control blood glucose of patients with T2DM. Shao-Wei Xiong, Jing Cao, Xian-Ming Liu, Xing-Ming Deng, Zeng Liu, and Fang-Ting Zhang Copyright © 2015 Shao-Wei Xiong et al. All rights reserved. Interferon Treatment of Hepatitis C Reinfection after Liver Transplantation: A Meta-Analysis Thu, 18 Jun 2015 11:25:44 +0000 Background. Graft reinfection with hepatitis C (HCV) after liver transplantation is a significant problem in transplant hepatology. This meta-analysis was performed to compare the effectiveness and risk of adverse events of interferon-based therapy with no treatment after liver transplantation. Methods. We searched electronic databases up to July 31, 2013, to obtain relevant research reports that satisfied the inclusion criteria. Meta-analyses were done on randomized controlled trials (RCTs) and nonrandomized trials. Results. A meta-analysis was performed on 2 RCTs and 2 cohort studies comprising a total of 326 patients (171 of whom accepted interferon-based antiviral therapy). The treatment group was found to have higher virological response (VR) rates than controls at 12, 24, 48, and 72 weeks. Patients in the antiviral group had higher sustained virological response (SVR) rates and lower mean alanine aminotransferase levels relative to controls at 48 weeks, but more total serious adverse events (AEs) than controls. Conclusions. Interferon-based treatment has some efficacy in the treatment of HCV graft reinfection following liver transplantation. Yaqin Chen, Gang Wu, Hongmin Zhang, Hua Xu, Hong Li, Ling Chen, Yixuan Yang, Peng Hu, Dazhi Zhang, Hong Ren, and Huaidong Hu Copyright © 2015 Yaqin Chen et al. All rights reserved. Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation Wed, 17 Jun 2015 11:27:52 +0000 Background. The optimal time interval between the last ingestion of bowel prep and sedation for colonoscopy remains controversial, despite guidelines that sedation can be administered 2 hours after consumption of clear liquids. Objective. To determine current practice patterns among anesthesiologists and gastroenterologists regarding the optimal time interval for sedation after last ingestion of bowel prep and to understand the rationale underlying their beliefs. Design. Questionnaire survey of anesthesiologists and gastroenterologists in the USA. The questions were focused on the preferred time interval of endoscopy after a polyethylene glycol based preparation in routine cases and select conditions. Results. Responses were received from 109 anesthesiologists and 112 gastroenterologists. 96% of anesthesiologists recommended waiting longer than 2 hours until sedation, in contrast to only 26% of gastroenterologists. The main reason for waiting >2 hours was that PEG was not considered a clear liquid. Most anesthesiologists, but not gastroenterologists, waited longer in patients with history of diabetes or reflux. Conclusions. Anesthesiologists and gastroenterologists do not agree on the optimal interval for sedation after last drink of bowel prep. Most anesthesiologists prefer to wait longer than the recommended 2 hours for clear liquids. The data suggest a need for clearer guidelines on this issue. Deepak Agrawal, Javier Marull, Chenlu Tian, and Don C. Rockey Copyright © 2015 Deepak Agrawal et al. All rights reserved. Efficacy of Laparoscopic Mini Gastric Bypass for Obesity and Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis Wed, 17 Jun 2015 08:15:13 +0000 Background. Controversies on the utility of laparoscopic mini gastric bypass (LMGB) in weight loss and type 2 diabetes mellitus (T2DM) control still exist. Methods. We conducted a comprehensive literature search of PubMed, EMBASE, and Cochrane Library. Review Manager was used to perform the meta-analysis and the weighted mean difference (WMD) and/or odds ratio with 95% confidence interval (95% CI) were used to evaluate the overall size effect. Results. The literature search identified 16 studies for systematic review and 15 articles for meta-analysis. Compared with LAGB, LSG, and LRYGB, LMGB showed significant weight loss [WMD, −6.58 (95% CI, −9.37, −3.79), (LAGB); 2.86 (95% CI, 1.40, 5.83), (LSG); 10.33 (95% CI, 4.30, 16.36), (LRYGB)] and comparable/higher T2DM remission results [86.2% versus 55.6%, (LAGB); 89.1% versus 76.3%, (LAGB); 93.4% versus 77.6%, (LAGB)]; LMGB also had shorter learning curve and less operation time than LRYGB [WMD, −35.2 (95% CI, −46.94, −23.46)]. Conclusions. LMGB appeared to be effective in weight loss and T2DM remission and noninferior to other bariatric surgeries. However, clinical utility of LMGB needs to be further validated by future prospective randomized controlled trials. Yingjun Quan, Ao Huang, Min Ye, Ming Xu, Biao Zhuang, Peng Zhang, Bo Yu, and Zhijun Min Copyright © 2015 Yingjun Quan et al. All rights reserved.