Jiangyun Meng

Treatment of obesity by endoscopic gastric intramural injection of botulinum toxin A: a randomized clinical trial.

BACKGROUND/AIMS Botulinum toxin A (BTX-A) is an inhibitor of muscular contractions in both striated and smooth muscle. The purpose of this study was to observe the safety and efficacy of endoscopic injections of BTX-A into the gastric wall in obese patients. METHODOLOGY Twenty obese patients (BMI >28 kg/m2) were randomized into two groups: Group 1 (200 U BTX-A) and Group 2 (300 U BTX-A). For each patient, 20 puncture sites were selected into the gastric wall. Body weights and BMIs were recorded and gastric emptying times were determined before treatment and 1, 4 and 12 weeks after treatment. Blood samples for cholesterol, triglycerides, insulin, leptin, motilin, peptide tyrosine (PYY) and ghrelin levels were obtained before treatment and 1, 4 and 12 weeks after treatment. RESULTS Nineteen patients completed the follow-up. Both groups showed significant body weight and BMI decrease (p<0.05) with decreased TG levels. The gastric emptying times were longer than those before treatment in both groups, especially at the 1-week point (p<0.05). A significant decrease in fasting ghrelin levels in all 19 obese patients was found after BTX-A administration 4 weeks later, and PYY levels in all 19 patients decreased, especially at the 12-week point. No severe complications were observed. CONCLUSIONS Endoscopic multi-punctures of BTX-A including fundic injections may decrease body weight and BMI by delaying the gastric emptying time. The effect of BTX-A on ghrelin levels may also be involved in the reduction of appetite.

Comparison of two editions of Tokyo guidelines for the management of acute cholangitis

The Tokyo guidelines from 2007 (TG07) and 2013 (TG13) were compared for the management of acute cholangitis (AC).

Predictive factors of endoscopic submucosal dissection procedure time for gastric superficial neoplasia

AIM To identify the determinants of endoscopic submucosal dissection (ESD) operation time. METHODS This investigation was conducted as a single-center, prospective study in which ESD was performed by the same endoscopist at the Chinese PLA General Hospital. A total of 173 patients underwent ESD operations performed by Dr. Lu from July 2007 to December 2011, and 183 lesions were enrolled. Patient gender, age, tumor location, gross type, tumor size, pathological type and adhesions were recorded prospectively. The order of treatment represented the experience of the operator. Univariate analysis and multivariate analysis were performed to evaluate the relationships between these factors and ESD procedure time. RESULTS Univariate analysis showed the ESD time was closely related to the gender (P = 0.0210), tumor size (P < 0.0001), location (P < 0.0001), gross type (P < 0.0001) and adhesion (P = 0.0010). The surgical proficiency level was associated with ESD time in unit area (P < 0.0001). Multivariate analysis revealed that the ESD time was positively correlated with tumor size (P < 0.0001), adhesion (P < 0.0001) and location (P < 0.0001), but negatively correlated with surgical proficiency level (P = 0.0046). CONCLUSION Large tumor size, adjacency to the cardia, and adhesion are predictors of a long ESD time, whereas high surgical proficiency level predicts a short ESD time.

Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study

BACKGROUND Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved. OBJECTIVE To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques. DESIGN Experimental study. SETTING Animal laboratory. PATIENTS Thirty-four dogs, 14 for nonsurvival study and 20 for survival study. INTERVENTIONS The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing. MAIN OUTCOME MEASUREMENTS Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing. RESULTS Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04). LIMITATIONS Animal study. CONCLUSIONS Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.

Verification of the Tokyo Guidelines for Acute Cholangitis Secondary to Benign and Malignant Biliary Obstruction: Experience from a Chinese Tertiary Hospital

BACKGROUND The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcots triad (P<0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and 15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS The TG07 are more reliable than Charcots triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.

Endoscopic Submucosal Tunnel Dissection for Large Gastric Neoplastic Lesions: A Case-Matched Controlled Study

Aim To evaluate the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) for resection of large superficial gastric lesions (SGLs). Methods The clinicopathological records of patients performed with ESTD or endoscopic submucosal dissection (ESD) for SGLs between January 2012 and January 2014 were retrospectively reviewed. 7 cases undergoing ESTD were enrolled to form the ESTD group. The cases were individually matched at a 1 : 1 ratio to other patients performed with ESD according to lesion location, ulcer or scar findings, resected specimen area, operation time and operators, and the matched cases constituting the ESD group. The treatment outcomes were compared between the two groups. Results The mean specimen size was 46 mm. 10 lesions were located in the cardia and 4 lesions in the lesser curvature of the lower gastric body. En bloc resection was achieved for all lesions. The mean ESTD resection time was 69 minutes as against 87.7 minutes for the ESD (P = 0.01). The mean resection speed was faster for ESTD than for ESD (18.86 mm2/min versus 13.76 mm2/min, P = 0.03). There were no significant differences regarding the safety and curability during the endoscopic follow-up (mean 27 months). Conclusions ESTD is effective and safe for the removal of SGLs and appears to be an optimal option for patients with large SGLs at suitable sites.

Non-radiation endoscopic removal of common bile duct stone assisted with abdominal ultrasonography in a pregnant patient

A common bile duct stone was detected in a pregnant patient who was in her second trimester. Avoiding the use of fluoroscopy, abdominal ultrasonography-assisted endoscopic removal of the stone was successful.