Hoi-Hung Chan

EUS-guided photodynamic therapy of the pancreas: a pilot study

BACKGROUND Photodynamic therapy of pancreatic cancer by using percutaneously placed light catheters has been reported. The feasibility and safety of EUS-guided photodynamic therapy of the pancreas was studied in a porcine model. METHODS After injection of porfimer sodium, a 19-gauge needle was inserted into the pancreas, the liver, the spleen, and the kidney under EUS guidance. A small diameter quartz optical fiber was passed through the EUS needle and used to illuminate the tissue with laser light. The tissue response to photodynamic therapy was examined. RESULTS Localized tissue necrosis was achieved in all organs, without significant complication. There was no significant difference in inflammation induced by photodynamic therapy within the various organs. CONCLUSIONS EUS-guided photodynamic therapy is a safe and simple technique that can induce small areas of focal tissue ablation within the liver, the pancreas, the kidney, and the spleen, and potentially could be used to treat a variety of benign and malignant conditions.

Eradication of Helicobacter pylori prevents ulcer development in patients with ulcer-like functional dyspepsia

Although the eradication of Helicobacter pylori infection benefits patients with gastric or duodenal ulcers, the value of eradicating the infection in the patients with functional dyspepsia (FD) remains controversial.

Improved survival in patients receiving medical therapy as compared with banding ligation for the prevention of esophageal variceal rebleeding

Both medical therapy and endoscopic variceal ligation (EVL) have proven to be comparable in the prevention of variceal rebleeding. However, the long‐term results are still lacking. Our previous study enrolled 121 patients with history of esophageal variceal bleeding and randomized to receive EVL (EVL group, 60 patients) or drug therapy, nadolol plus isosorbide‐5‐mononitrate (N+I) (N+I group, 61 patients) to prevent variceal rebleeding. The EVL group received ligation regularly until variceal obliteration. The N+I group received N+I during the study period. Patients were followed for up to 8 years. After a median follow‐up of 82 months, recurrent upper gastrointestinal bleeding developed in 28 patients (47%) in the EVL group and 49 patients (80%) in the N+I group (P = 0.001). Recurrent bleeding from esophageal varices occurred in 18 patients (30%) in the EVL group and 39 patients (64%) in the N+I group. The actuarial probability of rebleeding from esophageal varices was lower in the EVL group (P = 0.001). A total of 42 patients of the EVL group and 30 patients of the N+I group died (P = 0.013). The multivariate Cox analysis indicated that age, serum albumin, presence of encephalopathy, and treatment were the factors predictive of mortality. Conclusion: Our long‐term follow‐up study showed that combination of N+I therapy was inferior to banding ligation in the reduction of variceal rebleeding, but with enhanced survival. (HEPATOLOGY 2008;48:580–587.)

Gastrointestinal metastasis in hepatocellular carcinoma: Radiological and endoscopic studies of 11 cases

Background : From October 1990 to January 1999, 11 of 2237 hepatoma patients at our hospital had gastrointestinal tract metastasis. We describe the radiological and endoscopic features, clinical course and prognoses of those patients.

Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones

BackgroundLethal pancreatitis has been reported after treatment for common bile duct stones using small endoscopic papillary balloon dilation.MethodsWe retrospectively evaluated the safety and efficacy of using large balloon dilation alone without the use of sphincterotomy for the treatment of large common bile duct stones in Kaohsiung Veterans General Hospital. Success rate of stone clearance, procedure-related adverse events and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded.ResultsA total of 247 patients were reviewed in the current study. The mean age of the patients was 71.2 years. Most of them had comorbidities. Mean stone size was 16.4 mm. Among the patients, 132 (53.4%) had an intact gallbladder and 121 (49%) had a juxtapapillary diverticulum. The mean size of dilating balloon used was 13.2 mm. The mean duration of the dilating procedure was 4.7 min. There were 39 (15.8%) patients required the help of mechanical lithotripsy while retrieving the stones. The final success rate of complete retrieval of stones was 92.7%. The rate of pancreatic duct enhancement was 26.7% (66/247). There were 3 (1.2%) adverse events and 6 (2.4%) intra-procedure bleeding incidents. All patients recovered completely after conservative and endoscopic treatment respectively, and no procedure-related mortality was noted. 172 patients had a follow-up duration of more than 6 months and among these, 25 patients had recurrent common bile duct stones. It was significantly correlated to the common bile duct size (p = 0.036)ConclusionsEndoscopic papillary large balloon dilation alone is simple, safe, and effective in dealing with large common bile duct stones in relatively aged and debilitated patients.

Low-dose terlipressin plus banding ligation versus low-dose terlipressin alone in the prevention of very early rebleeding of oesophageal varices.

Background: Very early rebleeding is frequently encountered in patients with acute oesophageal variceal bleeding. A trial was designed to assess the efficacy and safety in patients with no active bleeding at endoscopy, receiving banding ligation association with terlipressin to prevent very early rebleeding. Methods: Patients with no active variceal bleeding at endoscopy were evaluated. Eligible patients were randomised to receive terlipressin infusion alone for 5 days (Terlipressin group) or banding ligation plus terlipressin infusion for 2 days (Combined group). Primary endpoints were treatment failure and very early rebleeding. Results: The terlipressin group was composed of 46 patients and the Combined group was composed of 47 patients. Both groups were comparable in terms of baseline data. Forty-eight-hour haemostasis was achieved in 91% in the Terlipressin group and 98% in the Combined group (p = 0.20). Very early rebleeding within 48–120 h occurred in 7 patients (15%) in the Terlipressin group but not in any patients (0%) in the Combined group (p = 0.006). Treatment failure was 24% in the Terlipressin group and 2% in the Combined group (p = 0.002). Multivariate analysis revealed that treatment (OR 0.081; 95% CI 0.010 to 0.627) was the only predictive factor of very early rebleeding. Blood requirement was significantly lower in the Combined group than in the Terlipressin group. Complications and 6-week survival were similar in both groups. Conclusions: Combination of banding ligation and terlipressin infusion for 2 days was superior to only infusion of terlipressin for 5 days in the reduction of very early rebleeding and treatment failure in patients with inactive variceal bleeding at endoscopy. Trial registration number: ISRCTN28353453

A randomized, controlled trial of banding ligation plus drug therapy versus drug therapy alone in the prevention of esophageal variceal rebleeding

Background & Aims:  Both medications with beta‐blockers and isosorbide‐5‐mononitrate and endoscopic variceal ligation have been proven plausible in the prevention of variceal rebleeding. However, the relative efficacy and safety of the combined treatment for preventing rebleeding remains unresolved.

Endoscopic mucosal resection for gastric epithelial neoplasms: a study of 39 cases with emphasis on the evaluation of specimens and recommendations for optimal pathologic analysis.

Endoscopic mucosal resection of gastric neoplasms is a curative technique that avoids surgery and its potential complications. Infrequently performed in the West, the limitations, pitfalls and challenges provided by this new therapeutic modality are not well known by general surgical pathologists. We evaluated a series of 39 endoscopic mucosal resections and assessed the correlation between original biopsies and final diagnoses, depth of excision, status of deep and lateral margins, artifactual changes and recurrence rate. The tumors consisted of 24 intramucosal carcinomas, six high-grade dysplasias, eight low-grade dysplasias and one submucosal invasive carcinoma. The preresection diagnoses corresponded to the final evaluation in 63% of the cases with previous biopsies. In 37% of the cases, the biopsies under-diagnosed the neoplasia. The rate of positive margins was 38%. Iatrogenic changes, that is, intramucosal hemorrhage and electrodiathermic burn, were noted in 44% of the cases but hindered the pathologic evaluation in only 10% of the cases. Persistence or recurrence was observed in only seven cases and there was no progression to advanced adenocarcinoma. Based on our experience, we offer some recommendations in order to provide optimal pathologic analysis of endoscopic mucosal resection specimens.

Upregulation of hepatoma-derived growth factor is involved in murine hepatic fibrogenesis

BACKGROUND & AIMS Hepatoma-derived growth factor (HDGF) expression is correlated with progression of hepatocellular carcinoma. Since liver fibrosis frequently occurs before hepatoma development, this study investigated the expression profile of HDGF and its relationship with transforming growth factor-beta (TGF-beta) signaling in experimental models of hepatofibrogenesis. METHODS Liver fibrosis was induced in mice receiving bile duct ligation (BDL) or carbon tetrachloride (CCl(4)) administration. The expression levels of HDGF and other fibrosis-related markers were measured using quantitative RT-PCR, Western blotting, and enzyme-linked immunosorbent assays. Hepatic HDGF overexpression was achieved by adenovirus gene delivery. Rat hepatocytes were used to study the interplay between HDGF and TGF-beta1. RESULTS In both liver fibrosis models, HDGF de novo synthesis significantly increased during the progression of fibrosis. The HDGF upregulation was observed mainly in hepatocytes and correlated with the expression of TGF-beta1 and collagen COL1A1 and COL1A2 proteins. Hepatic HDGF overexpression itself deteriorated hepatocellular structure and integrity, and aggravated the extents of BDL- and CCl(4)-induced liver fibrosis with concomitant upregulation of TGF-beta1 and COL1A1. Exogenous TGF-beta1 stimulated HDGF expression only in cultured primary hepatocytes grown on collagen matrix, whereas exogenous HDGF also increased TGF-beta1 production in hepatocytes in a collagen-dependent manner. Moreover, HDGF enhanced Smad2 phosphorylation dose-dependently and the TGF-beta1-driven luciferase activities. CONCLUSION HDGF plays a pro-fibrogenic role during liver fibrosis in mice through activation of TGF-beta pathway. The mutual regulation between TGF-beta1 and HDGF may facilitate a vicious cycle to promote the progression of hepatic fibrogenesis.

The characteristics and the prognosis for patients presenting with actively bleeding esophageal varices at endoscopy

BACKGROUND It remains unresolved whether the prognosis is worse for patients who present with actively bleeding varices at endoscopy compared with those in whom variceal bleeding has stopped. METHODS Patients with acute esophageal variceal bleeding were enrolled in this study and were divided into two groups: an active bleeding group and an inactive bleeding group. All patients had band ligation shortly after endoscopic examination and underwent elective ligation procedures until the varices were obliterated. Patients were followed for 1 year or until death. Short- and long-term prognoses were compared. RESULTS The active bleeding group included 54 patients and the inactive bleeding included 251 patients. Initial hemostasis was achieved in 93% in the active group and 99% in the inactive group ( p = not significant). The rate of recurrent variceal bleeding within 30 days was 24% in the active bleeding group vs. 12% in the inactive bleeding group ( p = 0.01); the mortality rates were 18% and 8%, respectively ( p = 0.03 in a single statistical test; however, Bonferroni correction for the multiple testing of data removed this significance). The rate of recurrent variceal bleeding within 1 year was 37% in the active bleeding group and 27% in the inactive bleeding group ( p = 0.06); the mortality rates were 22% and 21%, respectively ( p = not significant). CONCLUSIONS Whether variceal bleeding is active or inactive at endoscopy, variceal ligation is equally effective for control of bleeding. The rates of recurrent bleeding and mortality at 1 month were significantly higher among patients with active bleeding. However, the mortality rate was similar for both groups at 1 year.