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Digestive System Diseases - Top 30 Publications

Rectal Eversion Technique: A Method to Achieve Very Low Rectal Transection and Anastomosis With Particular Value in Laparoscopic Cases.

Transection of the rectum at the anorectal junction is required for proper resection in ulcerative colitis and restorative proctocolectomy. Achieving stapled transection at the pelvic floor is often challenging, particularly during laparoscopic proctectomy. Transanal mucosectomy and handsewn anastomosis are frequently used to achieve adequate resection. Rectal eversion provides an alternative for low anorectal transection and maintains the ability to perform stapled anastomosis.

Sacral Nerve Stimulation for Fecal Incontinence: How Long Should the Test Phase Be?

Decision-making for pulse generator implantation for sacral nerve stimulation in the management of fecal incontinence is based on the results of a test phase. Its duration is still a matter of debate.

A Pilot Study of the Prevalence of Anal Human Papillomavirus and Dysplasia in a Cohort of Patients With IBD.

Defective cell-mediated immunity increases the risk of human papillomavirus-associated anal dysplasia and cancer. There is limited information on anal canal disease in patients with IBD.

What Is the Risk of Anastomotic Leak After Repeat Intestinal Resection in Patients With Crohn's Disease?

Approximately half of Crohn's patients require intestinal resection, and many need repeat resections.

A Surgical Clostridium-Associated Risk of Death Score Predicts Mortality After Colectomy for Clostridium difficile.

A Clostridium difficile-associated risk of death score was recently developed and validated by using a national cohort of both nonsurgical and surgical patients admitted with C difficile infection. However, risk scores specifically derived from surgical cohorts and designed for patients with C difficile infection are currently unavailable.

Naples Prognostic Score, Based on Nutritional and Inflammatory Status, is an Independent Predictor of Long-term Outcome in Patients Undergoing Surgery for Colorectal Cancer.

The existing scores reflecting the patient's nutritional and inflammatory status do not include all biomarkers and have been poorly studied in colorectal cancers.

Initiation of a Transanal Total Mesorectal Excision Program at an Academic Training Program: Evaluating Patient Safety and Quality Outcomes.

Short-term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States.

Nodal Disease in Rectal Cancer Patients With Complete Tumor Response After Neoadjuvant Chemoradiation: Danger Below Calm Waters.

A subset of patients with rectal cancer who undergo neoadjuvant chemoradiation therapy will develop a complete pathologic tumor response. Complete nodal response is not universal in these patients and is difficult to assess clinically. Quantifying the risk of nodal disease would allow for targeted therapy with either radical resection or "watchful waiting."

Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes.

It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection.

Do Moderate Surgical Treatment Delays Influence Survival in Colon Cancer?

Studies examining treatment delay and survival after surgical treatment of colon cancer have varied in quality and outcome, with little evidence available regarding the safety of longer surgical treatment wait times.

Cell-free DNA levels and correlation to stage and outcome following treatment of locally advanced rectal cancer.

Accurate staging of rectal cancer remains essential for optimal patient selection for combined modality treatment, including radiotherapy, chemotherapy and surgery. We aimed at examining the correlation of cell free DNA with the pathologic stage and subsequent risk of recurrence for patients with locally advanced rectal cancer undergoing preoperative chemoradiation. We examined 75 patients with locally advanced rectal cancer receiving preoperative chemoradiation. Blood samples for translational use were drawn prior to rectal surgery. The level of cell free DNA was quantified by digital droplet PCR and expressed as copy number of beta 2 microglobulin. We found a median level of cell free DNA in the AJCC stages I-III of 3100, 8300, and 10,700 copies/mL respectively. For patients with 12 sampled lymph nodes or above, the median level of cell free DNA were 2400 copies/mL and 4400 copies/mL (p = 0.04) for node negative and node positive disease respectively. The median follow-up was 39 months and 11 recurrences were detected (15%). The median level for patients with recurrent disease was 13,000 copies/mL compared to 5200 copies/mL for non-recurrent patients (p = 0.08). We have demonstrated a correlation between the level of total cell free DNA and the pathologic stage and nodal involvement. Furthermore, we have found a trend towards a correlation with the risk of recurrence following resection of localized rectal cancer.

Establishment of cholangiocarcinoma cell lines from patients in the endemic area of liver fluke infection in Thailand.

Cholangiocarcinoma is a rare type of cancer which is an increasingly discernible health threat. The disease is usually very difficult in diagnosis and various treatment modalities are typically not effective. Cholangiocarcinoma is a complex and very heterogeneous malignancy characterized by tumor location, different risk factors, molecular profiling, and prognosis. Cancer cell lines represent an important tool for investigation in various aspects of tumor biology and molecular therapeutics. We established two cell lines, KKU-452 and KKU-023, which were derived from patients residing in the endemic area of liver fluke infection in Thailand. Both of tumor tissues have gross pathology of perihilar and intrahepatic mass-forming cholangiocarcinoma. Two cell lines were characterized for their biological, molecular and genetic properties. KKU-452 and KKU-023 cells are both adherent cells with epithelium morphology, but have some differences in their growth pattern (a doubling time of 17.9 vs 34.8 h, respectively) and the expression of epithelial bile duct markers, CK7 and CK19. Cytogenetic analysis of KKU-452 and KKU-023 cells revealed their highly complex karyotypes; hypertriploid and hypotetraploid, respectively, with multiple chromosomal aberrations. Both cell lines showed mutations in p53 but not in KRAS. KKU-452 showed a very rapid migration and invasion properties in concert with low expression of E-cadherin and high expression of N-cadherin, whereas KKU-023 showed opposite characters. KKU-023, but not KKU-452, showed in vivo tumorigenicity in xenografted nude mice. Those two established cholangiocarcinoma cell lines with unique characters may be valuable for better understanding the process of carcinogenesis and developing new therapeutics for the patients.

Insulin resistance and reduced metabolic flexibility: cause or consequence of NAFLD?

Whether non-alcoholic fatty liver disease (NAFLD) precedes insulin resistance (IR) or IR preludes/causes NAFLD has been long debated. Recent studies have shown that there are two phenotypes of NAFLD, 'genetic' vs 'metabolic' NAFLD. The former patients are more at risk of hepatocellular carcinoma and chronic liver disease the latter are more IR and at increased risk of type 2 diabetes (T2D). Even if they are not yet diabetics, from a metabolic point of view having NAFLD is equivalent to T2D with reduced peripheral glucose disposal and impaired suppression of hepatic glucose production, but without fasting hyperglycaemia. T2D develops only when hepatic autoregulation is lost and glucose production exceeds the capacity of muscle glucose disposal.In NAFLD adipocytes are resistant to the effect of insulin, lipolysis is increased and excess plasma free fatty acids (FFA) are taken up by other organs (mainly liver) where they are stored as lipid droplets or oxidized. Increased adiposity is associated with worsen severity of both 'genetic' and 'metabolic' NAFLD. FFA oxidative metabolism is increased in NAFLD and not shifted towards glucose during insulin infusion. Although this reduced metabolic flexibility is an early predictor of T2D, it can be seen also as a protective mechanism against excess FFA.In conclusion, IR precedes and causes 'metabolic' NAFLD, but not 'genetic' NAFLD. Reduced metabolic flexibility in NAFLD might be seen as a protective mechanism against FFA overflow, but together with IR remains a strong risk factor for T2D that develops with the worsening of hepatic regulation of glucose production.

Atrioesophageal Fistula: Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes.

Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF.

Comparison of the human gastric microbiota in hypochlorhydric states arising as a result of Helicobacter pylori-induced atrophic gastritis, autoimmune atrophic gastritis and proton pump inhibitor use.

Several conditions associated with reduced gastric acid secretion confer an altered risk of developing a gastric malignancy. Helicobacter pylori-induced atrophic gastritis predisposes to gastric adenocarcinoma, autoimmune atrophic gastritis is a precursor of type I gastric neuroendocrine tumours, whereas proton pump inhibitor (PPI) use does not affect stomach cancer risk. We hypothesised that each of these conditions was associated with specific alterations in the gastric microbiota and that this influenced subsequent tumour risk. 95 patients (in groups representing normal stomach, PPI treated, H. pylori gastritis, H. pylori-induced atrophic gastritis and autoimmune atrophic gastritis) were selected from a cohort of 1400. RNA extracted from gastric corpus biopsies was analysed using 16S rRNA sequencing (MiSeq). Samples from normal stomachs and patients treated with PPIs demonstrated similarly high microbial diversity. Patients with autoimmune atrophic gastritis also exhibited relatively high microbial diversity, but with samples dominated by Streptococcus. H. pylori colonisation was associated with decreased microbial diversity and reduced complexity of co-occurrence networks. H. pylori-induced atrophic gastritis resulted in lower bacterial abundances and diversity, whereas autoimmune atrophic gastritis resulted in greater bacterial abundance and equally high diversity compared to normal stomachs. Pathway analysis suggested that glucose-6-phospahte1-dehydrogenase and D-lactate dehydrogenase were over represented in H. pylori-induced atrophic gastritis versus autoimmune atrophic gastritis, and that both these groups showed increases in fumarate reductase. Autoimmune and H. pylori-induced atrophic gastritis were associated with different gastric microbial profiles. PPI treated patients showed relatively few alterations in the gastric microbiota compared to healthy subjects.

Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.

Percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy (PTGBD+LC) is one treatment option for patients with moderate to severe acute cholecystitis (AC). However, the impact of PTGBD on operative difficulties in performing LC is controversial. We designed this retrospective study to clarify the surgical outcomes after PTGBD+LC for the management of patients with moderate to severe AC.The medical records of 85 patients who underwent LC for moderate to severe AC from January 2013 to September 2016 were evaluated. They were divided into 2 groups based on the type of management: group A received PTGBD+LC, and group B received LC without drainage. We compared the patient characteristics, laboratory data which were obtained immediately before surgery or PTGBD at index admission, and surgical outcomes between the 2 groups. We also evaluated possible predictive factors associated with prolonged operative duration after PTGBD+LC.Patients in group A were older and had more comorbidities than those in group B. The laboratory tests obtained at index admission in group A showed higher serum levels of C-reactive protein (CRP) and alkaline phosphatase, and lower albumin levels than those in group B. The surgical outcomes after LC were similar between the 2 groups. However, operative duration was significantly shorter in group A (P = .012). In group A, a higher serum level of CRP was a predictive factor for a prolonged operation (hazard ratio 1.126; 95% confidence interval 1.012-1.253; P = .029). In conclusion, PTGBD+LC can shorten the operative duration in patients with moderate to severe AC, which might improve surgical outcomes in elderly patients with comorbidities, and elevated CRP values predicted a prolonged operation after PTGBD.

Hepatitis B virus infection in an HBsAb-positive lymphoma patient who received chemotherapy: A case report.

Tumor chemotherapy could weaken the immune system of patients, which might enhance the body sensitivities to the exogenous pathogens, among which the hepatitis B virus (HBV) infection should be concerned because of the higher chances of infection and the severe outcomes, especially in East Asia. The titer level of hepatitis B surface antibody (HBsAb) higher than 10 IU/L is considered to offer immunocompetent individuals adequate protection. However, whether this level is enough to the tumor patients during chemotherapy remains unclear.

Survival benefit of radiofrequency ablation for solitary (3-5 cm) hepatocellular carcinoma: An analysis for nationwide cancer registry.

We retrospectively compared overall survival (OS) and progression-free survival (PFS) of patients with single (3-5 cm) hepatocellular carcinoma (HCC) with Barcelona Clinic Liver Cancer (BCLC) stage A treated by surgical resection (SR), radiofrequency ablation (RFA), or transarterial chemoembolization (TACE).Of the 38,167 HCC patients registered between 2008 and 2010 at Korea Central Cancer Registry, National Cancer Center of South Korea, 13% patients were randomly abstracted, and 4596 patients could be analyzed. Of these 4596 patients, 337 patients with single 3 to 5 cm sized HCC with BCLC stage A were enrolled. OSs and PFSs among SR (n = 151), RFA (n = 36), and TACE groups (n = 150) were compared, respectively. Propensity score (PS) weighting was used to adjust differences among 3 groups.Median follow-up duration was 45 months (range, 1-73 months). After PS weighting, the cumulative OS rates were significantly higher in the SR (P < .001) and RFA (P = .027) groups than in the TACE group, respectively, but not statistically different between SR and RFA groups (P = .116). The cumulative PFS rates were significantly higher in the SR (P < .001) and RFA (P < .001) groups than in the TACE group, respectively. TACE (hazard ratio [HR] 2.46, P < .001), serum albumin (HR 0.57, P = .002), and tumor size (HR 1.66, P = .001) were predictors for OS. TACE (HR 3.14, P < .001), serum bilirubin (HR 1.38, P = .020), and tumor size (HR 1.32, P = .024) were predictors for PFS.RFA has better OS and PFS rates than TACE, and provides comparable survival outcomes compared with SR in single (3-5 cm) HCC with BCLC stage A.

Rare esophageal ulcers related to Behçet disease: A case report.

The fundamental pathogenesis of Behçet disease (BD) is still unclear and controversial. Many cases of oral aphthous ulcers and genital ulcers related to BD are reported; nevertheless, idiopathic giant esophageal ulcers related to BD are rare. A rare case for esophageal ulcers related to BD is presented.

Effective viral suppression is necessary to reduce hepatocellular carcinoma development in cirrhotic patients with chronic hepatitis B: Results of a 10-year follow up.

High viral load is an independent risk factor for development of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). Antiviral therapy can reduce but not eliminate the risk of HCC. The aim of this study was to identify the risk factors for HCC development in CHB patients during antiviral therapy.CHB patients with HBV DNA level ≥10 copies/mL, with or without compensated cirrhosis receiving adefovir were followed up every 6 months for 10 years (2004-2014). The primary endpoint was the development of HCC. The cumulative incidence and risk factors of HCC were evaluated by the Kaplan-Meier method and multivariate Cox proportional hazards models.At baseline, 28 of the 120 patients (23.3%) were cirrhotic. One patient developed HCC within 1 year, and therefore 119 patients were analyzed. At the end-point of follow-up, 59.7% (71/119) patients achieved virological remission (VR). Overall, 16 patients developed HCC, giving a 10-year cumulative incidence of 15.73%. Multivariate analysis showed that cirrhosis at baseline and failure to achieve VR were significant risk factors for HCC. The 10-year incidence of HCC was significantly higher in cirrhotic than noncirrhotic patients (43.16% vs. 7.05%, P < .0001). For cirrhotic patients, the 10-year incidence of HCC was significantly higher in patients without VR than those with VR (62.24% vs. 27.78%, P = .0139).Cirrhosis at baseline and failure to achieve VR during antiviral therapy were significant risk factors for HCC development in CHB patients. Effective viral suppression is necessary to reduce HCC development in cirrhotic CHB patients.

The pancreatic juice length in the stent tube as the predicting factor of clinical relevant postoperative pancreatic fistula after pancreaticoduodenectomy.

Several risk factors for pancreatic fistula had been widely reported, but there was no research focusing on the exocrine output of remnant gland.During the study period of January 2015 to September 2016, 82 patients accepted pancreaticoduodenectomy (PD, end-to-end dunking pancreaticojejunostomy with internal stent tube). All the data were collected, including preoperative medical status, operative course, final pathology, gland texture, pancreatic duct diameter, size of the stent, length of pancreatic juice in the stent tube, width of the pancreatic stump, diameter of the jejunum and the status of postoperative pancreatic fistula (POPF). POPF was defined according to International Study Group of Pancreatic Fistula criteria.The diameter of pancreatic duct in the POPF group was significantly smaller than that in the group without POPF (1.99 vs 2.90 mm, P = .000). The length of pancreatic juice in the stent tube in the POPF group was significantly longer than that in the group without POPF (18.04 vs 6.92 cm, P = .014). There were more pancreatic ductal adenocarcinoma cases and hard glands in the group without POPF. The length of pancreatic juice in the clinically relevant postoperative pancreatic fistula (CR-POPF) group was significantly longer than that in the grade A group (32.4 vs 9.21 cm, P = .000). Multivariate analysis identified gland texture and length of pancreatic juice as independent predictors for pancreatic fistula. Multivariate analysis also identified the length of pancreatic juice as an independent predictor for CR-POPF.The length of pancreatic juice in the stent tube might be a useful predictive factor of POPF after PD, especially for CR-POPF.

Severe enteropathy with villous atrophy in prolonged mefenamic acid users - a currently under-recognized in previously well-recognized complication: Case report and review of literature.

Mefenamic acid-induced enteropathy may be an under-recognized condition because few reported cases and no review of literature to comprehensively describe all reported cases exist. From inception until February 2017, a systematic literature search identified twenty original reports of cases of mefenamic acid-induced enteropathy. Additional five cases were identified at our hospital. All cases were included in the analyses.

Upper and lower gastrointestinal endoscopies in patients over 85 years of age: Risk-benefit evaluation of a longitudinal cohort.

After age 85, upper and lower gastrointestinal (GI) endoscopy may be indicated in 5% to 10% of inpatients, but the risk-benefit ratio is unknown. We studied patients older than 85 years undergoing upper and lower GI endoscopy.We analyzed a retrospective cohort of inpatients older than 85 years between 2004 and 2012, all explored by upper and complete lower GI endoscopy. Initial indications, including iron deficiency anemia (IDA), other anemias, GI bleeding, weight loss, and GI symptoms, were noted, as were endoscopy or anesthesia complications, immediate endoscopic diagnosis, and the ability to modify the patients' therapeutics. Deaths and final diagnosis for initial endoscopic indication were analyzed after at least 12 months.We included 55 patients, 78% women, with a median age, reticulocyte count, hemoglobin, and ferritin levels of 87 (85-99), 56 (24-214) g/L, 8.6 (4.8-12.9) g/dL, and 56 (3-799) μg/L, respectively. IDA was the most frequent indication for endoscopy (60%; n = 33). Immediate diagnoses were found in 64% of the patients (n = 35), including 25% with GI cancers (n = 14) and 22% with gastroduodenal ulcers or erosions (n = 12). Cancer diagnosis was associated with lower reticulocyte count (45 vs. 60 G/L; P = .02). Among the 35 diagnoses, 94% (n = 33) led to modifications of the patients' therapeutics, with 29% of the patients deciding on palliative care (n = 10). No endoscopic complications lead to death. Follow-up of >12 months was available in 82% (n = 45) of the patients; among these patients, 40% (n = 27) died after an average 24 ± 18 months. Cancer diagnosis was significantly associated with less ulterior red cell transfusion (0% vs. 28%; P = .02) and fewer further investigations (6.7% vs. 40%; P = .02).Upper and complete lower GI endoscopy in patients older than 85 years appears to be safe, and enables a high rate of immediate diagnosis, with significant modifications of therapeutics. GI cancers represented more than one-third of the endoscopic diagnoses.

Clinicopathological factors associated with HER2-positive gastric cancer: A meta-analysis.

The treatment of patients with advanced gastric cancer remains a most challenging task in the clinical practice. Recently, targeted therapies have significantly impacted the treatment strategy for many common malignancies. The use of trastuzumab, a monoclonal antibody against human epidermal growth factor receptor 2 (HER2; also known as ERBB2), plus chemotherapy proved to improve median overall survival in patients with advanced gastric cancer, compared with chemotherapy alone in Trastuzumab for Gastric Cancer (ToGA) trial. However, the prognostic value of HER2 status in gastric cancer remains controversial. Therefore, the aim of this study was to investigate the clinical pathology significance of HER2 overexpression in resectable gastric cancer for selecting the right patients with gastric cancer who may benefit from trastuzumab treatment.

Acute pancreatitis as an initial manifestation of parathyroid carcinoma: A case report and literature review.

Parathyroid carcinoma is a rare endocrine malignancy. Acute pancreatitis as an initial manifestation of parathyroid carcinoma has been rarely reported.

Circling Back for the Diagnosis.

Hepatitis C virus viremic rate in the Middle East and North Africa: Systematic synthesis, meta-analyses, and meta-regressions.

To estimate hepatitis C virus (HCV) viremic rate, defined as the proportion of HCV chronically infected individuals out of all ever infected individuals, in the Middle East and North Africa (MENA).

The RS4939827 polymorphism in the SMAD7 GENE and its association with Mediterranean diet in colorectal carcinogenesis.

The objective of our investigation is to study the relationship between the rs4939827 SNP in the SMAD7 gene, Mediterranean diet pattern and the risk of colorectal cancer.

Estimation of Direct Medical Costs Related to Chronic Hepatitis C: A Rationale for Early Antiviral Therapy.

Novel mouse models of hepatic artery infusion.

The liver has unique anatomy in that most blood flow to normal hepatocytes is derived from the portal venous system, whereas liver tumors obtain their nutrient blood supply exclusively from the hepatic artery. The focused arterial delivery of anticancer agents to liver tumors has been performed for decades; however, preclinical models to standardize drug regimens and examine novel agents have been lacking. The purpose of this study was to establish preclinical hepatic artery infusion (HAI) models in a mouse and to evaluate the safety and delivery capability of the models.