Faming Zhang

Should We Standardize the 1,700-Year-Old Fecal Microbiota Transplantation?

To the Editor: We reviewed the multicenter long-term follow-up study using the fecal microbiota transplantation (FMT) for recurrent Clostridium diffi cile infection by Brandt group ( 1 ). Th e study demonstrated effi cacy with 91 % primary cure rate and 98 % secondary cure rate. Th e results further showed that 97 % patients expressed willingness to undergo another FMT in the future, and 53 % stated that they would choose FMT as a fi rst-line treatment before antibiotics. We believe the transplanted feces from a healthy donor can possibly preserve 1,000 – 1,150 functional bacteria species ( 2 ) and can eventually re-establish a “ healthy ” functional microbiota in the recipient. However, we think that the effi cacy and willingness of patients are not enough to invite wider practice unless there is a standardized methodology for fecal preparation and administration. Th e concept of FMT is not new in the English literature. Brandt et al. ( 1 ) and Borody et al. ( 3 ) noted that this idea was possibly fi rst used in veterinary medicine by the Italian anatomist Fabricius Aquapendente in the 17th century. However, we report much earlier literary evidence of human fecal transplantation. During the Dong-jin dynasty in the 4th century in China, Ge Hong, a well-known traditional Chinese medicine doctor, described the use of human fecal suspension by mouth for patients who had food poisoning or severe diarrhea. Th is yielded positive results and was considered a medical miracle that brought patients back from brink of death. 2 . Qin J , Li R , Raes J et al. A human gut microbial gene catalogue established by metagenomic sequencing . Nature 2010 ; 464 : 59 – 65 . 3 . Borody TJ , Warren EF , Leis SM et al. Bacteriotherapy using fecal fl ora: toying with human motions . J Clin Gastroenterol 2004 ; 38 : 475 – 83 . 4 . Ge H (Dongjin Dynasty). Zhou Hou Bei Ji Fang . Tianjin Science & Technology Press: Tianjin , 2000 . 5 . Li S (Ming Dynasty). Ben Cao Gang Mu . Huaxia Press: Beijing , 2011 . 6 . Borody TJ , Khoruts A . Fecal microbiota transplantation and emerging applications . Nat Rev Gastroenterol Hepatol 2011 ; 9 : 88 – 96 .

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 Crohns 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.

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.

Fascin and cortactin expression is correlated with a poor prognosis in hepatocellular carcinoma.

Objectives The aim of this study was to investigate the relationship between fascin and cortactin protein expression and clinicopathological parameters and survival time in patients with hepatocellular carcinoma (HCC). Methods A total of 77 specimens of HCC and seven specimens of normal liver tissues were collected. The expressions of fascin and cortactin were examined by immunohistochemical staining. The patients from whom the HCCs were taken were also followed up. In these 74 patients, Kaplan–Meier was used to assess survival outcomes. Results The data revealed that fascin and cortactin expressions were upregulated in the HCC samples. The positive expression of fascin significantly correlated with histological differentiation and metastasis. The positive expression of cortactin significantly correlated with histological differentiation, metastasis, and T stage (International Union Against Cancer). Survival time of the patients with positive fascin expression and positive cortactin expression was significantly decreased, and the median survival duration was short. Conclusion Fascin and cortactin might be important indicators of the malignancy and metastasis of liver cancer, and may have predictive value in the prognosis of HCC.

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 Crohns 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 Crohns 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.

Lentiviral-mediated Smad4 RNAi promotes SMMC-7721 cell migration by regulation of MMP-2, VEGF and MAPK signaling

Hepatocellular carcinoma (HCC) is a highly malignant cancer characterized by rapid progression, easy metastasis and frequent recurrence. Previous studies have shown that the Smad4 signaling pathway plays an important role in the cell growth and apoptosis of HCC. However, the effect of Smad4 signaling on the invasion and migration of HCC cells remains unclear. The present study aimed to examine the effects of the transforming growth factor (TGF)-β1-Smad4 signaling pathway on the migration of HCC cells. Lentiviral vectors expressing miRNA against Smad4 were constructed to block the expression of Smad4 in HCC cells, and transwell units were used to investigate the invasive potential of SMMC-7721 cells before and after TGF-β1 treatment. mRNA levels of matrix metalloproteinase (MMP)-2 and -9 were analyzed by reverse-transcription PCR, and concentrations of vascular endothelial growth factor (VEGF), p-JNK, p-p38 and p-Erk1/2 proteins were analyzed by Western blotting. The results indicate that TGF-β1 induced cellular invasion in the SMMC-7721 cells. These effects were almost completely blocked by the knockdown of Smad4. Reverse-transcription PCR and Western blot analysis revealed that MMP-2, VEGF, p-JNK and p-p38 were up-regulated by the silencing of Smad4, while the expression of MMP-9 and p-Erk1/2 was not affected by Smad4 silencing with or without TGF-β1 stimulation. These findings suggest that TGF-β1-induced SMMC-7721 cell invasion by the up-regulation of MMP-2 and VEGF is Smad4-dependent. The activation of MMP-2 and VEGF may be an important mechanism by which Smad4 is involved in metastasis. TGF-β1-Smad4 signaling may regulate SMMC-7721 cell migration through the activation of the MAPK pathway.

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.

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%; χ(2) 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.

Pancreaticobiliary maljuction combining with pancreas divisum: Report of four cases

Pancreaticobiliary maljunction (PBM) is an unusual anomalous condition in which the pancreatic duct and bile duct merge outside the duodenal wall and form a long common channel. Pancreas divisum (PD) is a congenital anomaly in which the dorsal and ventral pancreatic ducts fail to fuse. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosing PD and magnetic resonance cholangiopancreatography (MRCP) is the non-invasive choice. In this study, four cases of patients with unusual PBM in addition to PD are described. The patients presented with abdominal pain, which was caused by distal biliary stricture diagnosed by MRCP. The patients received ERCP and had a good prognosis.

A pilot animal and clinical study of autologous blood solution compared with normal saline for use as an endoscopic submucosal cushion

Normal saline is the most popular agent used during endoscopic submucosal injection. However, endoscopists have never identified an optimal submucosal injection solution, which is not only safe and cost-effective but has a unique lifting ability with endoscopic submucosal cushion and causes less tissue damage. This study aimed to evaluate the effectiveness and microscopic characteristics of a blood solution, including whole blood and plasma solution, as a submucosal cushioning agent, compared with normal saline. Endoscopic submucosal dissection (ESD) procedures in pig stomachs were performed by injecting plasma solution (n=4) and normal saline (n=4). A total of 38 patients with gastrointestinal neoplasms underwent endoscopic musocal resection (EMR) procedures. Of 38 EMRs, 7 used whole blood injection, and 31 of 38 acting as the control group used normal saline. A tissue damage scoring system was developed based on injection-induced hydrops and tears for the evaluation of tissue damage. In animal experiments, the lifting time of the injection with normal saline in the pig colon was shorter than that of the group with plasma solution (18.25±5.44 min vs. 6.5±2.38 min, P=0.007). In animal experiments with ESD procedures in the stomach, the hydrops in the normal saline injection group were more extensive than those in the group with plasma (P=0.011). The degree of tearing in the group with normal saline was observed to be less than that in the group with plasma (P=0.008). In patients with EMR, using the histological scoring method, it was determined that the degree of hydrops in the group with normal saline injection was more extensive than that in the group with whole blood (P<0.001). The effective submucosal tearing in the group with normal saline was less than that in the group with blood (P<0.001). The blood solution, including whole blood and plasma solution, as a novel submucosal injection agent, may outperform normal saline with a unique lifting ability, less pronounced tissue damage and marked effective submucosal blunt dissection.