Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.

AIM

To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.

METHODS

A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events.

RESULTS

There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis.

CONCLUSION

Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.

Fecal microbiota transplantation cured epilepsy in a case with Crohn’s disease: The first report

Fecal microbiota transplantation (FMT) is a promising strategy that involves reconstruction of gut microbiota. Recently, it has been considered as a treatment of Crohn’s disease (CD) and certain neurological diseases. Here, to the best of our knowledge, we report the first case that used FMT to achieve remission of intestinal and neurological symptoms in a girl with CD and a 17-year history of epilepsy. During the 20 mo of follow-up, FMT has proved its efficacy in preventing relapse of seizures after withdrawing the antiepileptic drugs. Furthermore, this finding highlights the role of microbiota-gut-brain axis and inspires a novel treatment for epilepsy through remodeling gut microbiota.

An analysis of 342 patients with refractory gastroesophageal reflux disease symptoms using questionnaires, high-resolution manometry, and impedance-pH monitoring

Symptoms of refractory gastroesophageal reflux disease (GERD) are commonly encountered in clinical practice. The aim of this study was to analyze the data obtained from questionnaires, high-resolution manometry (HRM), and ambulatory impedance-pH monitoring in patients with persisting GERD symptoms and to explore the possible underlying causes for this clinical presentation. After completing the questionnaires, the selected patients underwent endoscopy, HRM, and ambulatory impedance-pH monitoring. Based on the results of these investigations, we divided the patients into 4 groups: reflux esophagitis (RE), hypersensitive esophagus (HE), functional heartburn (FH), and nonerosive gastroesophageal reflux disease (NERD). The data from 342 patients were analyzed. One hundred twenty-nine (37.72%) patients experienced refractory GERD symptoms related to acid reflux. The scores on some scales in the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire differed significantly among groups (all P < 0.05). Liquid reflux occurred more frequently in patients with GERD (RE and NERD), while gas reflux was more common in non-GERD patients (FH and HE; all P < 0.05). The RE and NERD groups showed more percent bolus exposure time (BET) when upright (all P < 0.05). Acid exposure time (AET) in the RE and NERD groups was longer than that in the HE and FH groups (all P < 0.05). Fewer than half of the patient symptoms were related to acid reflux. The GSRS questionnaire may be an optimal indicator for patients with refractory GERD symptoms. BET and AET are useful indices to distinguish GERD from other diseases. Gas reflux is probably related to persisting symptoms in FH and HE patients.

Cap-assisted endoscopic sclerotherapy for hemorrhoids: Methods, feasibility and efficacy

AIM: To evaluate the methodology, feasibility, safety and efficacy of a novel method called cap-assisted endoscopic sclerotherapy (CAES) for internal hemorrhoids.

METHODS: A pilot study on CAES for grade I to III internal hemorrhoids was performed. Colon and terminal ileum examination by colonoscopy was performed for all patients before starting CAES. Polypectomy and excision of anal papilla fibroma were performed if polyps or anal papilla fibroma were found and assessed to be suitable for resection under endoscopy. CAES was performed based on the requirement of the cap, endoscope, disposable endoscopic long injection needle, enough insufflated air and sclerosing agent.

RESULTS: A total of 30 patients with grade I to III internal hemorrhoids was included. The follow-up was more than four weeks. No bleeding was observed after CAES. One (3.33%) patient claimed mild tenesmus within four days after CAES in that an endoscopist performed this procedure for the first time. One hundred percent of patients were satisfied with this novel procedure, especially for those patients who underwent CAES in conjunction with polypectomy or excision of anal papilla fibroma.

CONCLUSION: CAES as a novel endoscopic sclerotherapy should be a convenient, safe and effective flexible endoscopic therapy for internal hemorrhoids.

Endoscopic transpancreatic septotomy as a precutting technique for difficult bile duct cannulation

AIM: To evaluate the technique of transpancreatic septotomy (TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth II gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients (36 transpancreatic septotomies and 33 needle-knife sphincterotomies).

RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy (NKS) groups were 97.2% (35/36) and 96.9% (32/33), respectively, which were not significantly different (P > 0.05). Complications occurred in 11 cases, including acute pancreatitis (n = 6), bleeding (n = 2), and cholangitis (n = 3). The total frequency of complications in the TS group was lower than that in the NKS group (8.3% vs 24.2%, P < 0.05).

CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.

Cholecystectomy does not significantly increase the risk of fatty liver disease

AIM: To investigate the relationship between cholecystectomy and fatty liver disease (FLD) in a Chinese population.

METHODS: A total of 32428 subjects who had voluntarily undergone annual health checkups in the Second Affiliated Hospital of Nanjing Medical University from January 2011 to May 2013 were included in this study. Basic data collection, physical examination, laboratory examination, and abdominal ultrasound examination were performed.

RESULTS: Subjects undergoing cholecystectomy were associated with greater age, female sex, higher body mass index, and higher levels of systolic blood pressure, diastolic blood pressure, fasting plasma glucose, total cholesterol, and triglycerides. However, no significant differences were found in high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, albumin, and serum uric acid. The overall prevalence of FLD diagnosed by ultrasonography was high at 38.4%. The prevalence of FLD was significantly higher for subjects who had undergone cholecystectomy (46.9%) than those who had not undergone cholecystectomy (38.1%; χ² test, P < 0.001). Cholecystectomy was positively associated with FLD (OR = 1.433, 95%CI: 1.259-1.631). However, after adjusting for possible factors associated with FLD, multivariate regression analysis showed that the association between cholecystectomy and FLD was not statistically significant (OR = 1.096; 95%CI: 0.939-1.279).

CONCLUSION: According to our study results, cholecystectomy may not be a significant risk factor for FLD.

Fecal microbiota transplantation and prednisone for severe eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by patchy or diffuse eosinophilic infiltration of the bowel wall to a variable depth and various gastrointestinal manifestations. We describe a case of severe eosinophilic gastroenteritis presenting as frequent bowel obstruction and diarrhea in a 35-year-old man. The patient was misdiagnosed and underwent surgery because of intestinal obstruction when he was first admitted to a local hospital. Then he was misdiagnosed as having Crohn’s disease in another university teaching hospital. Finally, the patient asked for further treatment from our hospital because of the on-going clinical trial for treating refractory Crohn’s disease by fecal microbiota transplantation. Physical examination revealed a slight distended abdomen with diffuse tenderness. Laboratory investigation showed the total number of normal leukocytes with neutrophilia as 90.5%, as well as eosinopenia, monocytopenia and lymphocytopenia. Barium radiography and sigmoidoscopy confirmed inflammatory stenosis of the sigmoid colon. We diagnosed the patient as having eosinophilic gastroenteritis by multi-examinations. The patient was treated by fecal microbiota transplantation combined with oral prednisone, and was free from gastrointestinal symptoms at the time when we reported his disease. This case highlights the importance of awareness of manifestations of a rare disease like eosinophilic gastroenteritis.

Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy

OBJECTIVES

Achalasia is an oesophageal disorder characterized by abnormalities of peristalsis and impaired swallowing-induced relaxation. The therapeutic approach at present remains palliative. Peroral endoscopic myotomy (POEM) is thought to be less invasive and to maintain the function of the lower oesophageal sphincter postoperatively. However, the effects of POEM still need to be evaluated and understood.

METHODS

We analysed the outcome for 45 achalasia patients who underwent POEM in our centre, described the details of surgery and evaluated the effects by 4 s integrated relaxation pressure (4s-IRP). All patients were followed up for at least 2 years and were assessed by the dysphagia score, the Eckardt score, oesophageal manometry and the gastro-oesophageal reflux disease (GERD) Q-questionnaire. According to the new Chicago classification of oesophageal motility using high-resolution manometry, the patients were diagnosed and classified into types I, II and III.

RESULTS

The average age of the patients was 46.32 ± 19.04 years (range 26-72 years), and the ratio of women to men was 1.81. All patients were suffering from dysphagia; more than half of them experienced regurgitation. The data revealed that POEM considerably reduced the 4s-IRP, dysphagia score and Eckardt score postoperatively (all P < 0.05). The patients with type III achalasia had higher values of 4s-IRP than the others (type I, P = 0.025; type II, P = 0.022) before treatment and at 3 months after treatment (type I, P = 0.028; type II, P = 0.047). In type I patients, GERD symptoms were more likely to appear at 24 months after POEM than in type II and III patients (P = 0.001 and P < 0.001, respectively).

CONCLUSIONS

Peroral endoscopic myotomy provides definite relief of symptoms in these patients with achalasia and offers them long-term therapeutic benefit. Considering the risks of surgery, we believe that POEM is a better choice than surgery for achalasia patients and carries lower risk. However, our study is a preliminary exploration; therefore, larger-scale studies are needed for further research on POEM.

Human des-γ-carboxy prothrombin: Cloning, expression and monoclonal antibody preparation

AIM: To clone and express human des-γ-carboxy prothrombin (DCP), a valuable serum marker for hepatocellular carcinoma (HCC), and to prepare the monoclonal antibody (mAb) against DCP.

METHODS: The DCP gene was cloned into the prokaryotic expression vector pCold II. The recombinant construct was expressed in BL21 Escherichia coli strain, and the recombinant protein with an N-terminal 6-His tag was purified by nickel chelate-nitrilotriacetic-acid (Ni-NTA) affinity chromatography. The purified protein was used to immunize the Balb/c mice for mAb preparation. The sensitivity and specificity of the mAb were assessed by indirect enzyme-linked immunosorbent assay (ELISA), Western blot and immunohistochemistry.

RESULTS: The recombinant DCP protein was successfully expressed and purified, and its molecular weight was approximately 23 kDa. One hybridoma cell line stably secreting anti-DCP monoclonal antibody named 3B5 was obtained. Western blot analysis and immunohistochemistry indicated that the DCP mAb showed specific combination with DCP. ELISA detection indicated that the titer of the mAb was 1:2.43 × 10⁵. The immunoglobulin isotype of the mAb was identified as IgG2a.

CONCLUSION: The successful preparation of DCP mAb may lay a solid foundation for the research of the use of DCP in early diagnosis of HCC.

ERCP for treatment of choledocholithiasis in patients with liver cirrhosis

AIM: To explore the indications, operational skills and risk factors of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of choledocholithiasis with cirrhosis.

METHODS: Clinical data for 41 patients with choledocholithiasis with cirrhosis who underwent ERCP at the Second Affiliated Hospital of Nanjing Medical University from June 2002 to June 2013 were retrospectively analyzed. Intra-ERCP and post-ERCP complications and mortality rate were observed.

RESULTS: Nine patients were classified as Child-Pugh A, nineteen as Child-Pugh B, and thirteen as Child-Pugh C. The success rate of ERCP was 97.6% (40/41). Complications included bleeding and infection, which occurred only in patients with Child-Pugh C disease (all cured afterwards). Intraoperative and postoperative hemorrhage occurred in one respective case. Severe pulmonary infection occurred in 1 patient, who died 3 d post operation. No postoperative pancreatitis or perforation was found. Two patients were lost to follow-up. Of the other patients, 6 died of primary malignant tumor or liver cirrhosis-related complications in 2 mo to 3 years, and 33 patients are still alive.

CONCLUSION: ERCP has a considerable risk and difficulty in the treatment of choledocholithiasis in patients with cirrhosis and therefore needs to perform by experienced endoscopists. Patients with Child-Pugh A and B disease can undergo ERCP, but those with Child-Pugh C can not undergo ERCP until their liver function and general condition are improved after conservative therapies.

Fecal microbiota transplantation for severe enterocolonic fistulizing Crohn’s disease

The concept of fecal microbiota transplantation (FMT) has been used in traditional Chinese medicine at least since the 4^th century. Evidence from recent human studies strongly supports the link between intestinal bacteria and inflammatory bowel disease. We proposed that standardized FMT might be a promising rescue therapy for refractory inflammatory bowel disease. However, there were no reports of FMT used in patients with severe Crohn’s disease (CD). Here, we report the successful treatment of standardized FMT as a rescue therapy for a case of refractory CD complicated with fistula, residual Barium sulfate and formation of intraperitoneal large inflammatory mass. As far as we know, this is the first case of severe CD treated using FMT through mid-gut.

Fecal microbiota transplantation: from the 4th century to 2013

Intestinal microbiota has been defined as a dynamic human organ. Many diseases occur as a result of the disorder of intestinal microbiota. Human fecal microbiota transplantation (FMT), which was originally reported in China in the 4^th century, has become popular in recent years, since it shows an amazing effect in the treatment of pseudomembranous colitis and recurrent Clostridium difficile infection (CDI). It has not only been proposed as a first-line treatment for recurrent CDI but also been utilized to treat inflammatory bowel disease, irritable bowel syndrome, metabolic syndrome, and chronic fatigue syndrome. The mechanism behind the therapeutic effects of FMT is still unclear. The most widely accepted hypothesis is that FMT can use the whole intestinal microbiota from a healthy donor to replace the patient's disordered gut microbiota. At present, FMT is still in the beginning stage, and there is an urgent need to develop standardized protocols and to conduct safety analysis. This review tries to present the past, present and future of FMT by introducing the relationship between gut flora and diseases and the utilization of FMT.

Endoscopic retrieval of 28 foreign bodies in a 100-year-old female after attempted suicide

Foreign body ingestion is a common emergency situation in children with one or a few objects having been ingested. Here we report our experience using endoscopic retrieval in a female centenarian with dyspnea and foreign bodies in the esophagus. She attempted suicide by swallowing 26 coins and two other foreign bodies. A gastroscope was used to remove all foreign bodies in the lower esophagus. In total, 26 coins, one ferrous ring and one cylindrical plastic object were retrieved. To our knowledge, this is the first clinical report on retrieval of so many foreign bodies in a single case.

Anticancer effects of sodium butyrate on hepatocellular carcinoma cells in vitro

In the present study, we investigated the anticancer effects of sodium butyrate (NaBu) on hepatocellular carcinoma (HCC) cells in vitro. As a histone deacetylase (HDAC) inhibitor, NaBu upregulated Ac-H3 and inhibited HDAC4 protein expression in a time- and dose-dependent manner. MTT assays showed that treatment with NaBu at high concentrations significantly inhibited the growth of various HCC cells. Exposure to NaBu for 24 h induced cell cycle arrest in the SMMC-7721 and HepG2 cells. NaBu also induced the apoptosis of SMMC‑7721 cells. The expression levels of cell cycle- and apoptosis-related proteins were further investigated by western blot analysis using specific antibodies. The results provided a possible mechanism responsible for the inhibitory effects of NaBu on the growth of HCC cells. To further analyze the role of NaBu in cell migration, wound healing and Transwell assays were performed, indicating that NaBu significantly inhibits cell migration/invasion in HCC cells. Transforming growth factor-β1 (TGF-β1)-induced epithelial to mesenchymal transition (EMT) has been associated with tumor cell migration and invasion. The EMT markers, E-cadherin, vimentin and N-cadherin, were regulated by TGF-β1, while NaBu inhibited this process in which HDAC4 and matrix metalloproteinase (MMP)7 may be involved. Based on our findings, we propose that NaBu may be useful as an anticancer drug for HCC therapy.

Clinical significance of expression of Klotho and β-Catenin in esophageal squamous cell carcinoma

AIM: To investigate the clinical significance of expression of Klotho and β-Catenin in esophageal carcinoma.

METHODS: Tissue microarray technique and immunohistochemistry were used to examine Klotho and β-Catenin expression in 75 esophageal carcinoma tissue specimens and matched tumor-adjacent esophageal tissue. Correlations between Klotho and β-Catenin expression and clinical and pathological features were then analyzed.

RESULTS: The positive rate of Klotho expression was significantly lower in esophageal carcinoma tissue than in tumor-adjacent tissue (14.9% vs 63.4%, P < 0.05). The expression of Klotho was correlated with tumor invasion and clinical stage (both P < 0.05). The positive rate of β-Catenin expression was significantly higher in esophageal carcinoma tissue than in tumor-adjacent tissue (80.0% vs 16.4%, P < 0.05). The expression of Klotho was correlated with lymph node metastasis and tumor clinical stage (r = -0.276, P < 0.05).

CONCLUSION: The positive rates of Klotho and β-Catenin expression differed significantly between esophageal carcinoma and tumor-adjacent tissue. Klotho and β-Catenin may be used as important markers for esophageal carcinoma and are helpful for prognosis prediction in esophageal carcinoma.

MYH rs3219476 and rs3219472 polymorphisms and risk of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a rare but devastating malignancy. Up to 90% of patients presenting with CCA have no identifiable risk factors. The base excision repair (BER) pathway has a principal role in the repair of mutations caused by oxidized or reduced bases. The MutY homolog (MUTYH, MYH) is one of the key proteins in the BER pathway, but the role of MYH in the tumorigenesis of CCA is largely unknown. In this study, we investigated the influence of MYH rs3219476 and rs3219472 polymorphisms on CCA incidence. MYH genotypes were detected using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. We found that for rs3219472, compared with subjects carrying the MYH G/G genotype, those with the A/A genotype had a 2.816-fold higher risk of CCA [odds ratio (OR)=2.816, 95% confidence interval (CI)=0.992-7.999, P=0.047). For rs3219476, compared with subjects carrying the MYH T/T genotype, those with the T/G genotype had a reduced risk of CCA (OR=0.359, 95% CI=0.17-0.758, P=0.006). Our findings suggest that since significantly increased CCA risk was found in individuals with a homozygous variant genotype for rs3219472, it may be a biomarker for screening individuals at high risk of developing the disease.

Microbial profile and antibiotic sensitivity pattern in bile cultures from patients with acute mild biliary pancreatitis

AIM: To study the profile of pathogen strains from bile of patients with acute mild biliary pancreatitis and their resistance to antimicrobial agents.

METHODS: Bile samples from 96 patients with acute mild biliary pancreatitis were cultured and tested for antibiotic susceptibility.

RESULTS: The most common organism was enterococci (27%), followed by Escherichia coli (19.2%), Pseudomonas aeruginosa (11.5%), and Klebsiella pneumoniae (10.3%). None of Gram-positive strains were resistant to telicoplanin and vancomycin. The percentage of Gram-negative strains that were sensitive to amikacin was highest (85.7%), followed by imipenem (81%), piperacillin and tazobactam (57.1%), cefepime hydrochloride (28.6%), and levofloxacin (19.0%). The percentage of ESBLs-producing bacteria in Gram-negative strains was 66.7%.

CONCLUSION: Enterococci have been found more commonly in patients with acute mild biliary pancreatitis. Combined antibiotic treatment with biliary decompression as early as possible is suggested for biliary obstructive infection. After biliary decompression, antibiotics will be selected according to the results of susceptibility test.

Pyogenic liver abscess: An analysis of 58 cases

AIM: To analyze the clinical features of pyogenic liver abscess (PLA) to provide the basis for early diagnosis and treatment of this disease.

METHODS: The clinical data for 58 patients with PLA who were treated in the Second Affiliated Hospital of Nanjing Medical University from June 2000 to December 2011 were retrospectively analyzed to determine the clinical features, and laboratory, imaging, and microbiologic findings as well as the treatment outcome.

RESULTS: Fever and chills (94.8%) were the most common clinical manifestations, followed by right upper quadrant pain (58.6%). Twenty-seven cases (46.5%) had diabetes mellitus. The most common laboratory abnormality was increased alkaline phosphatase (ALP) (77.6%), followed by increased white blood cell (WBC) count (70.7%) and fibrinogen (FIB) (60%). The most commonly identified organism was Klebsiella pneumoniae (17.2%). The majority of patients had solitary liver abscess (86.2%), and most of liver abscesses were found in the right hepatic lobe with an average diameter of 7.1 cm ± 4.0 cm (1-24 cm). All patients underwent combined antibiotic treatment. Ultrasound or CT-guided needle aspiration or continuous drainage after needle aspiration of pyogenic liver abscess was performed in 26 patients (44.8%). Surgery was required in 3 patients (5.2%). One patient (1.7%) died due to septic shock after admission.

CONCLUSION: Patients who have fever, chills, and right upper quadrant pain should be considered of pyogenic liver abscess, especially in patients with diabetes, biliary tract disease, or cancer. Elevated ALP, WBC and FIB were more commonly seen than positive bacterial culture in PLA patients, which may have suggestive significance in clinical diagnosis. Antibiotics combined with needle aspiration or continuous drainage after needle aspiration are safe and effective treatments.

Association between body mass index and erosive esophagitis: A meta-analysis

AIM: To conduct a meta-analysis to estimate the determinants of the association between erosive esophagitis (EE) and body mass index (BMI).

METHODS: We identified the studies using PubMed. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. Meta-analyses were performed to verify the risk factors, such as obesity and gender.

RESULTS: Twenty-one studies were included in this systematic review. These studies demonstrated an association between increasing BMI and the presence of EE [95% confidence interval (CI): 1.35-1.88, overweight, odds ratio (OR) = 1.60, P value homogeneity = 0.003, 95% CI: 1.65-2.55, obese, OR = 2.05, P < 0.01]. The heterogeneity disappeared by stratifying for gender. No publication bias was observed in this meta-analysis by the Egger method.

CONCLUSION: This analysis demonstrates a positive association between BMI and the presence of EE, especially in males. The risk seems to progressively increase with increasing weight.

Loss of Smad4 expression inhibits epithelial-mesenchymal transition in SMMC-7721 cells

AIM: To investigate the influence of loss of Smad4 expression on TGF-β1-induced epithelial-mesenchymal transition in the human hepatocellular carcinoma cell line SMMC-7721.

METHODS: The influence of loss of Smad4 expression on the expression of β-catenin and Vimentin mRNAs and proteins was evaluated by RT-PCR and Western blot. Immunofluorescence was used to analyze the location and fluorescence intensity of Smad4, β-catenin, Vimentin in non-transfected SMMC-7721 cells and those transfected with Smad-specific siRNAs (RNAi-Smad4-2 and RNAi-Smad4-12) or unspecific siRNA (RNAi-NC).

RESULTS: Compared to non-transfected SMMC-7721 cells and those tranfected with RNAi-NC, the expression of β-catenin mRNA and protein remarkably increased in SMMC-7721 cells transfected with RNAi-Smad4-2 or RNAi-Smad4-12 (all P < 0.05). Loss of Smad4 expression promoted β-catenin nuclear translocation. Immunofluorescence assay revealed that β-catenin fluorescence was located in the nuclei of non-transfected SMMC-7721 cells and those tranfected with RNAi-NC, but in the cytoplasm of SMMC-7721 cells transfected with RNAi-Smad4-2 or RNAi-Smad4-12. On the other hand, loss of Smad4 expression down-regulated Vimentin protein expression (P < 0.05) and cytoplasmic fluorescence intensity, but had no significant impact on Vimentin mRNA expression in SMMC-7721 cells and those transfected with different siRNAs.

CONCLUSION: Loss of Smad4 expression regulates β-catenin and Vimentin and therefore plays an important role in inhibiting epithelial-mesenchymal transition in SMMC-7721 cells.

Endoscopic resection of gastrointestinal lipomas with negative pressure using a transparent cap: an analysis of 16 cases

AIM: To evaluate the efficacy and safety of endoscopic resection of gastrointestinal lipomas with negative pressure using a transparent cap.

METHODS: The clinical data for 16 patients who were diagnosed with gastrointestinal lipoma by gastroscopy or colonoscopy and underwent endoscopic resection with negative pressure using a transparent cap from January 2008 to July 2011 were retrospectively analyzed. The clinical efficacy, safety and complications of this procedure were evaluated.

RESULTS: The procedure was successful in all the 16 cases. Oozing of blood was observed intraoperatively in two cases, and clips were used to close the wound. No complications such as perforation and massive hemorrhage occurred during the operation. During 1 to 36 months of follow-up, no recurrences were observed.

CONCLUSION: Endoscopic resection of gastrointestinal lipomas with negative pressure using a transparent cap is effective, safe and simple.

Clinical significance of expression of Klotho in gastric cancer

AIM: To examine the expression of Klotho in gastric cancer and to analyze its relationship with the biological behaviors of gastric cancer.

METHODS: Tissue microarray technique and immunohistochemistry were used to examine Klotho expression in 75 gastric cancer tissue and tumor-adjacent tissue specimens. The correlation between Klotho expression and clinicopathological features of gastric cancer was then analyzed.

RESULTS: The positive rate of Klotho expression was significantly lower in gastric cancer than in tumor-adjacent tissue (76.0% vs 90.6%, P<0.05). Klotho expression was negatively correlated with tumor stage and lymph node metastasis (both P<0.05), but showed no significant correlation with sex, age, tumor size and pathological grade (all P>0.05).

CONCLUSION: Down-regulation of Klotho expression in gastric cancer may contribute to tumor metastasis and development. Klotho might be a novel and useful molecular marker for predicting outcome and lymph node metastasis in gastric cancer.

Progress in understanding the relationship between Klotho and the insulin/IGF-1 signaling pathway

Klotho was originally identified as an anti-aging gene that can regulate the aging process and aging-related diseases, including the metabolism of vitamin K, calcium and phosphorus and the function of the cardiovascular system and immune system. Insulin/insulin-like growth factor-1 (IGF-1) signaling pathway is also involved in the aging process and can extend life span when altered. Recent findings prove that there is close association between the anti-aging role of Klotho and the insulin/IGF-1 signaling pathway. This paper aims to elucidate the relationship between Klotho and the insulin/IGF-1 signaling pathway.

EMT- and microRNA-related signaling pathways in tumors

Epithelial-mesenchymal transition (EMT) refers to the process by which cells transit from epithelial phenotype to mesenchymal phenotype. EMT is critical for tumor invasion and metastasis, however, the underlying mechanism is little known so far. It has been known that complex signaling pathways are involved in this process. MicroRNAs also play an important role in tumors via many EMT-related signaling pathways. Numerous studies have established that there is a link between EMT-related signaling pathways and microRNAs in tumors. This review focuses on the action mechanism of various EMT-related signaling pathways and their relationship with microRNAs in tumors.

A De Novo mutation of STK11 gene in a Chinese patient with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is an autosomal-dominant inherited disorder characterized by mucocutaneous pigmentation, hamartomatous polyposis of the gastrointestinal tract, and an increased risk for the development of both gastrointestinal and extraintestinal malignancies. Germline mutation of the STK11 gene, which encodes a serine-threonine kinase, is responsible for PJS. We collected blood samples from a Chinese PJS family consisting of a total of four individuals (one male and three females) including one PJS patient. The whole coding region of STK11 was amplified by polymerase chain reaction and products analyzed by direct sequencing. Molecular analysis of the STK11 gene in this case of PJS revealed a substitution of thymine 217 for adenine (C.217T > A) in exon 1, resulting in a change of codon 73 from cysteine to serine (C73S). The point mutation was not found in normal individuals in this PJS family or in 100 control individuals. The results presented here enlarge the spectrum of mutations of the STK11 gene by identifying a de novo mutation in a PJS patient and further support the hypothesis that STK11 mutations are disease-causing mutations for PJS.

Role of Smad4 in cancer invasion and metastasis

Transforming growth factor beta (TGF-β) is a ubiquitous and essential regulator of cellular and physiologic processes including proliferation, differentiation, migration, cell survival, angiogenesis and immunosurveillance. The tumor suppressor gene Smad4 (DPC4) is the central intracellular mediator of transforming growth factor-β-Smad(TGF-β-Smad) signaling, which is a key pathway in cancer invasion and metastasis. This review focuses on the mechanisms whereby the Smads are modified and regulated, and summarizes current views on the role of Smad4 in tumorigenesis, with emphasis on cancer invasion and metastasis.

Role of transforming growth factor-beta1-smad signal transduction pathway in patients with hepatocellular carcinoma

AIM: To explore the role of transforming growth factor-beta1 (TGF-β1)-smad signal transduction pathway in patients with hepatocellular carcinoma.

METHODS: Thirty-six hepatocellular carcinoma specimens were obtained from Qidong Liver Cancer Institute and Department of Pathology of the Second Affiliated Hospital of Nanjing Medical University. All primary antibodies (polyclonal antibodies) to TGF-β1, type II Transforming growth factor-beta receptor (TβR-II), nuclear factor-kappaB (NF-κB), CD34, smad4 and smad7,secondary antibodies and immunohistochemical kit were purchased from Zhongshan Biotechnology Limited Company (Beijing, China). The expressions of TGF-β1, TβR-II, NF-κB, smad4 and smad7 proteins in 36 specimens of hepatocellular carcinoma (HCC) and its adjacent tissue were separately detected by immunohistochemistry to observe the relationship between TGF-β1 and TβR-II, between NF-κB and TGF-β1, between smad4 and smad7 and between TGF-β1 or TβR-IIand microvessel density (MVD). MVD was determined by labelling the vessel endothelial cells with CD34.

RESULTS: The expression of TGF-β1, smad7 and MVD was higher in HCC tissue than in adjacent HCC tissue (P<0.01, P <0.05, P <0.01 respectively). The expression of TβR-IIand smad4 was lower in HCC tissue than in its adjacent tissue (P <0.01, P <0.05 respectively). The expression of TGF-β1 protein and NF-κB protein was consistent in HCC tissue. The expression of TGF-β1 and MVD was also consistent in HCC tissue. The expression of TβR-IIwas negatively correlated with that of MVD in HCC tissue.

CONCLUSION: The expressions of TGF-β1, TβR-II, NF-κB, smad4 and smad7 in HCC tissue, which are major up and down stream factors of TGF-β1-smad signal transduction pathway , are abnormal. These factors are closely related with MVD and may play an important role in HCC angiogenesis. The inhibitory action of TGF-β1 is weakened in hepatic carcinoma cells because of abnormality of TGF-β1 receptors (such as TβR-II) and postreceptors (such as smad4 and smad7). NF-κB may cause activation and production of TGF-β1.

Expression of TGF- b1, TGF-β1RII and NF-k B in hepatocellular carcinoma

AIM: To explore the expression of TGF-β1, TGF-β1RII and NF-κB in hepatocellular carcinoma (HCC) tiussues.

METHODS: Immunohistochemistry was used to detect the expression of TGF-β1, TGF-βRII and NF-κB protein in 30 HCC and the corresponding cancer-adjacent tissues. The expression of TGF-β1 mRNA was determined in 30 HCC and the corresponding cancer-adjacent tissues by in situ hybridization. Vascular endothelial cells were labeled with CD34 to observe the microvessel density (MVD). Then the relationships between TGF-β1 protein and MVD, TGF-β1RII protein and MVD, NF-κB and TGF-β1 protein as well as between TGF-β1 protein and mRNA were analyzed.

RESULTS: The expression of TGF-β1 protein and mRNA in HCC tissues were significantly higher than those in the cancer-adjacent tissues (Mean optical density: 0.0725±0.0102 vs 0.0442±0.0103, P < 0.01; 0.1043±0.0350 vs 0.0620±0.0225,P < 0.01). The MVD in HCC tissues was also markedly higher than that in the cancer-adjacent tissues (31.23±9.25 vs4.24±2.10, P < 0.01). The level of NF-κB expression was significantly higher than that in the cancer-adjacent tissues (0.0723±0.0210 vs 0.0305±0.0116, P < 0.01), while the level of TGF-βRII was lower (0.0402±0.0113 vs 0.0669±0.0157, P < 0.01). Obviously positive relationships existed between TGF-β1 protein and MVD (t = 3.25, P < 0.01), TGF-β1 mRNA and TGF-β1 protein (χ² = 8.21, P < 0.01) as well as between NF-κB and TGF-β1 protein (χ² = 9.075, P < 0.01), but the expression of TGF-β RIIprotein was negatively related to MVD.

CONCLUSION: TGF-β1, TGF-β1RII and NF-κB protein is abnormally expressed in HCC tissues and they are significantly related to MVD. They may play important roles in the angiogenesis of hepatocellular carcinoma. NF-κB may mediate the activation and production of TGF-β1.

Structure elucidation of glycan of glycoconjugate LbGp3 isolated from the fruit of Lycium barbarum L

The structure of the repeat unit of the glycan of glycoconjugate LbGp3 with pronounced immunoactivity, isolated from the fruit of Lycium barbarum L. was elucidated based on methylation analysis, partial acid hydrolysis and 1H, 13C NMR spectroscopy of the original glycan and products of its partial hydrolysis.