Jiong Lu

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones.

AIM To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones. METHODS Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores. RESULTS Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management. CONCLUSION Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patients condition, operators expertise and local resources should be taken into account in making treatment decisions.

miR‑203 inhibits tumor cell migration and invasion via caveolin‑1 in pancreatic cancer cells

Pancreatic cancer is one of the most lethal malignant diseases with the poorest prognosis and is the fourth leading cause of tumor-associated mortality in the industrialized world. microRNAs (miRNAs or miRs) are small noncoding RNAs of approximately 22 nucleotides long that are able to function as oncogenes or tumor suppressors in human cancer. In our study, overexpression of miR-203 in Panc-1 cells is sufficient to reduce migratory ability and invasiveness, and to induce upregulation of epithelial markers (Snail, ZO-1 and β-catenin) followed by a decrease of mesenchymal marker expression (Zeb-1, vimentin and fibronectin). We also found that the caveolin-1 mRNA or protein levels are modulated by miR-203 in Panc-1 cells. We found that exogenous miR-203 altered the level of cell migration and invasion, and the expression of associated proteins following caveolin-1 knockdown by small interfering RNA. These results demonstrate that miR-203 inhibits cell migration and invasion via caveolin-1 in pancreatic cancer cells, suggest that miR-203 expression may be a useful indicator of the metastatic potential and provide a new therapeutic target in this common malignancy.

Single-incision laparoscopic appendectomy vs conventional laparoscopic appendectomy: Systematic review and meta-analysis

AIM To assess the differences in clinical benefits and disadvantages of single-incision laparoscopic appendectomy (SILA) and conventional laparoscopic appendectomy (CLA). METHODS The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database were electronically searched up through January 2013 to identify randomized controlled trails (RCTs) comparing SILA with CLA. Data was extracted from eligible studies to evaluate the pooled outcome effects for the total of 1068 patients. The meta-analysis was performed using Review Manager 5.2.0. For dichotomous data and continuous data, the risk ratio (RR) and the mean difference (MD) were calculated, respectively, with 95%CI for both. For continuous outcomes with different measurement scales in different RCTs, the standardized mean difference (SMD) was calculated with 95%CI. Sensitivity and subgroup analyses were performed when necessary. RESULTS Six RCTs were identified that compared SILA (n = 535) with CLA (n = 533). Five RCTs had a high risk of bias and one RCT had a low risk of bias. SILA was associated with longer operative time (MD = 5.68, 95%CI: 3.91-7.46, P < 0.00001), higher conversion rate (RR = 5.14, 95%CI: 1.25-21.10, P = 0.03) and better cosmetic satisfaction score (MD = 0.52, 95%CI: 0.30-0.73, P < 0.00001) compared with CLA. No significant differences were found for total complications (RR = 1.15, 95%CI: 0.76-1.75, P = 0.51), drain insertion (RR = 0.72, 95%CI: 0.41-1.25, P = 0.24), or length of hospital stay (SMD = 0.04, 95%CI: -0.08-0.16, P = 0.57). Because there was not enough data among the analyzed RCTs, postoperative pain was not calculated. CONCLUSION The benefit of SILA is cosmetic satisfaction, while the disadvantages of SILA are longer operative time and higher conversion rate.

Down-regulation of FoxM1 leads to the inhibition of the epithelial-mesenchymal transition in gastric cancer cells

Emerging evidence suggests that FoxM1 may have a crucial role in the development and progression of human gastric cancer. Therefore, we sought to determine the role of FoxM1 in gastric cancer epithelial-mesenchymal transition (EMT). The down-regulation of FoxM1 expression by the transfection of cells with FoxM1 siRNA decreased cell migration, invasion, and proliferation. Moreover, the over-expression of FoxM1 promoted cell migration, invasion, and proliferation, which led to the acquisition of an EMT phenotype by up-regulating the protein expression of the mesenchymal cell markers ZEB1, ZEB2, and vimentin and by down-regulating the epithelial cell marker E-cadherin in gastric epithelial cells. More important, the depletion of FoxM1 levels in gastric cancer cells led to significant decreases in the NF-κB p65 subunit, cyclin D1, Hes-1, VEGF, and EpCAM protein levels. Real-time PCR examination showed that the down-regulation of FoxM1 expression significantly inhibited vimentin and N-cadherin expression compared to that in control cells. Most important, cells transfected with FoxM1 siRNA displayed an elongated/irregular fibroblastoid morphology and reduction of the vimentin expression. Our current study strongly suggests that FoxM1 signaling has important roles in tumor cell aggressiveness through the acquisition of the EMT phenotype in gastric cancer cells.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta‐analysis

OBJECTIVE The aim of this study was to compare the effectiveness of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the management of liver abscess. METHODS Electronic searches (Cochrane Library, MEDLINE, EMBASE, SCIE) were conducted to identify randomized controlled trials (RCTs) comparing PNA and PCD. A meta-analysis was subsequently performed. RESULTS A total of five RCTs covering 306 patients were included. The meta-analysis showed that outcomes in patients treated with PCD were superior to those in patients treated with PNA in terms of success rate [relative risk (RR): 0.81, 95% confidence interval (CI) 0.66-0.99; P = 0.04], clinical improvement [standardized mean difference (SMD): -0.73, 95% CI 0.36-1.11; P = 0.0001] and days to achieve a 50% reduction in abscess cavity size (SMD: -1.08, 95% CI 0.64-1.53; P < 0.00001). No significant differences were found in duration of hospitalization (mean difference: -0.17, 95% CI -2.10 to 1.75; P = 0.86) or procedure-related complications (RR: 0.50, 95% CI 0.10-2.63; P = 0.41). Days to achieve the total or near total resolution of the abscess cavity and mortality were not calculated because data in the RCTs in the meta-analysis were insufficient. CONCLUSIONS Both PNA and PCD are safe methods of draining liver abscesses. However, PCD is more effective than PNA because it facilitates a higher success rate, reduces the time required to achieve clinical relief and supports a 50% reduction in abscess cavity size. However, among successfully treated patients, the outcomes of PNA are comparable with those of PCD.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography: A meta-analysis and systematic review

AIM To assess the safety and efficacy of carbon dioxide (CO(2)) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO(2) insufflation with air insufflation during ERCP. The trials were included in the review irrespective of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes. Sensitivity and subgroup analyses were performed if necessary. RESULTS Seven double-blind RCTs involving a total of 818 patients were identified that compared CO(2) insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-randomization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO(2) insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insufflation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI: 0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO(2) level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI: -14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI: -0.26-0.17, P = 0.67) between the two groups. CONCLUSION CO(2) insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

Fast-Track Programs for Liver Surgery: A Meta-Analysis

Background and ObjectivesPlentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery.MethodsThe following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings.ResultsAltogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies.ConclusionsFast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.

Prognostic value of lymphovascular invasion in Bismuth-Corlette type IV hilar cholangiocarcinoma

AIM To assess the prognostic value of lymphovascular invasion (LVI) in Bismuth-Corlette type IV hilar cholangiocarcinoma (HC) patients. METHODS A retrospective analysis was performed on 142 consecutively recruited type IV HC patients undergoing radical resection with at least 5 years of follow-up. Survival analysis was performed by the Kaplan-Meier method, and the association between the clinicopathologic variables and survival was evaluated by log-rank test. Multivariate analysis was adopted to identify the independent prognostic factors for overall survival (OS) and disease-free survival (DFS). Multiple logistic regression analysis was performed to determine the association between LVI and potential variables. RESULTS LVI was confirmed histopathologically in 29 (20.4%) patients. Multivariate analysis showed that positive resection margin (HR = 6.255, 95%CI: 3.485-11.229, P < 0.001), N1 stage (HR = 2.902, 95%CI: 1.132-7.439, P = 0.027), tumor size > 30 mm (HR = 1.942, 95%CI: 1.176-3.209, P = 0.010) and LVI positivity (HR = 2.799, 95%CI: 1.588-4.935, P < 0.001) were adverse prognostic factors for DFS. The independent risk factors for OS were positive resection margin (HR = 6.776, 95%CI: 3.988-11.479, P < 0.001), N1 stage (HR = 2.827, 95%CI: 1.243-6.429, P = 0.013), tumor size > 30 mm (HR = 1.739, 95%CI: 1.101-2.745, P = 0.018) and LVI positivity (HR = 2.908, 95%CI: 1.712-4.938, P < 0.001). LVI was associated with N1 stage and tumor size > 30 mm. Multiple logistic regression analysis indicated that N1 stage (HR = 3.312, 95%CI: 1.338-8.198, P = 0.026) and tumor size > 30 mm (HR = 3.258, 95%CI: 1.288-8.236, P = 0.013) were associated with LVI. CONCLUSION LVI is associated with N1 stage and tumor size > 30 mm and adversely influences DFS and OS in type IV HC patients.

Relationship of tumor size with pathological and prognostic factors for hilar cholangiocarcinoma

Objective To determine the correlation of different tumor-size cutoffs with prognostic factors and survival outcomes to provide a reference for the modification of the T-stage classification in the DeOliveira staging system for hilar cholangiocarcinoma (HCCA). Materials and Methods We retrospectively analyzed 216 patients who underwent curative surgery for HCCA (mean tumor diameter, 2.8 cm) between 2000 and 2013. Univariate and multivariate logistic regression were used to assess the correlation of tumor-size cutoffs with various factors. Results Tumor differentiation (odds ratio [OR]: 1.649, 95% confidence interval [CI]: 1.065–2.555, P = 0.025), node status (OR: 1.971, 95% CI: 1.060–3.664, P = 0.032), resection margin (OR: 2.465, 95% CI: 1.024–5.937, P = 0.044), and hepatectomy (OR: 2.373, 95% CI: 1.226–4.593, P = 0.01) were independently correlated with the 2-cm cutoff, while tumor differentiation (OR: 1.755, 95% CI: 1.062–2.091, P = 0.028), node status (OR: 2.166, 95% CI: 1.054–4.452, P = 0.035), and tumor margin (OR: 2.539, 95% CI: 1.089–5.919, P = 0.031) were independently associated with the 3-cm cutoff. Conclusions The 2-cm and 3-cm cutoffs were strongly correlated with resection margin, node status, tumor differentiation and survival. The 2-cm cutoff may be added to the DeOliveira staging system.

Hepatobiliary and Pancreatic: Hepatic and renal angiomyolipomas associated with tuberous sclerosis complex

A young woman, aged 23, was admitted to hospital because of increasing abdominal distension over the preceding 3 months. She had been previously diagnosed with tuberous sclerosis complex. On examination, she had a large mass in the upper abdomen that extended to the umbilicus. She also had symmetrical nodules on the malar region of her face caused by angiofibromas (previously called adenoma sebaceum). Various blood tests including a complete blood count, liver function tests and tumor markers were within the reference range. She also had negative serological tests for hepatitis B and C. A contrast-enhanced computed tomography scan of the abdomen showed a large lesion in the left lobe of the liver, approximately 18 x 16 x 8 cm in size (Figure 1, upper). The lesion had a heterogeneous appearance with areas of low density and some areas of uneven enhancement. A similar lesion was also noted in the left kidney. Another image showed a lesion in the right lobe of the liver as well as two lesions in the left kidney (Figure 1, lower). No tumors were detected with a magnetic resonance imaging scan of the head. The hepatic tumors were removed at laparotomy. Histologically, the tumors were composed of blood vessels, smooth muscle cells and mature adipose tissue (Figure 2, upper). The appearance was consistent with hepatic angiomyolipomas. With immunohistochemistry, tissue was positive for HMB-45 (Figure 2, lower), MART-1 and SMA. Tuberous sclerosis complex is an autosomal dominant genetic disorder that involves multiple organ systems. It has an incidence of approximately 1:5000-10,000 live births and is caused by mutations in one of two tuberous sclerosis complex genes (TSC1 and TSC2). Common manifestations include epilepsy, mental retardation, skin manifestations and widespread hamartomas. Angiomyolipomas are relatively common in the kidney but rare in the liver. Furthermore, it is extremely rare to have angiomyolipomas in both the liver and kidneys. With imaging, the appearance of angiomyolipomas is somewhat variable depending on the relative proportions of the three tissue components within the tumor. In particular, it is sometimes difficult to differentiate hepatic angiomyolipomas from hepatocellular carcinomas. Although hepatic angiomyolipomas were initially thought to be entirely benign, recent reports have described malignant variants. Currently, some classifications include angiomyolipomas in the PEComa family of tumors (tumors originating from perivascular epithelioid cells) with the potential for malignant transformation.