Nonthalee Pausawasdi

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma.

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia–Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio‐frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia–Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Erythrocyte sedimentation rate and C-reactive protein for the prediction of severity of acute pancreatitis.

Objectives: To investigate the performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for predicting severe acute pancreatitis (AP). Methods: Fifty patients with AP were prospectively enrolled. Erythrocyte sedimentation rate and CRP were measured at admission and every 12 hours for 48 hours after admission. Results: The patients mean age was 50 ± 2.2 years, 64% were male, and 30% developed severe AP. Patients with severe AP had higher levels of ESR (77 ± 4.7 vs 50 ± 4.8 mm/h; P = 0.002) and CRP (218 ± 30.7 vs 97 ± 12.1 mg/L; P <0.001) at 36 hours after admission compared with those with mild AP. Erythrocyte sedimentation rates of 60 mm/h or greater predict severe AP at 36 hours with a sensitivity, specificity, and positive and negative predictive values of 86%, 57%, and 48% and 90%, whereas CRP of 150 mg/L or greater provided the results of 86%, 87%, and 75% and 93%, respectively. Elevation of either ESR or CRP at 24 hours increased the sensitivity and negative predictive value to 100%, and elevation of both ESR and CRP increased the specificity and PPV to 100%. Conclusions: Erythrocyte sedimentation rate can predict severe AP with a slightly inferior performance to CRP. Combined ESR and CRP at 24 hours can predict severe AP accurately.

An FDTD Interaction Scheme of a High-Intensity Nanosecond-Pulsed Electric-Field System for In Vitro Cell Apoptosis Applications

A finite-difference time-domain analysis of a high-intensity nanosecond-pulsed electric-field (nsPEF) system, composed of a pulse-forming line (PFL) and a universal electroporation cuvette, is described. The simulation scheme is based on interactions of 1-D transmission-line equations for the PFL and 3-D Maxwells curl equations for the cuvette volume. Simulations incorporate system adjustment to facilitate maximum transfer of electrical energy from the PFL to the cuvette medium. Experimental validation of the voltage across the cuvette electrodes through the laboratory-constructed nsPEF system with an energy density of ~1 J/cm3 reveals an overall agreement with some discrepancies. The distribution profiles of the transient field inside the cell suspension area during the excitation of 5-kV 10-ns pulses would adequately account for the feasibility of using an integrated model as a design benchmark for the interaction physics of the generated nanosecond pulses and culture vessel. The observed nsPEF effects on cells include increased transmembrane potentials across organelle membranes without permanently damaging the cell membrane, increasing the probability of electric field interactions with intracellular structures.

Meta-Analytic Bayesian Model For Differentiating Intestinal Tuberculosis from Crohn's Disease.

Objectives:Distinguishing intestinal tuberculosis (ITB) from Crohns disease (CD) is difficult, although studies have reported clinical, endoscopic, imaging, and laboratory findings that help to differentiate these two diseases. We aimed to produce estimates of the predictive power of these findings and construct a comprehensive model to predict the probability of ITB vs. CD.Methods:A systematic literature search for studies differentiating ITB from CD was conducted in MEDLINE, PUBMED, and EMBASE from inception until September 2015. Fifty-five distinct meta-analyses were performed to estimate the odds ratio of each predictive finding. Estimates with a significant difference between CD and ITB and low to moderate heterogeneity (I2<50%) were incorporated into a Bayesian prediction model incorporating the local pretest probability.Results:Thirty-eight studies comprising 2,117 CD and 1,589 ITB patients were included in the analyses. Findings in the model that significantly favored CD included male gender, hematochezia, perianal disease, intestinal obstruction, and extraintestinal manifestations; endoscopic findings of longitudinal ulcers, cobblestone appearance, luminal stricture, mucosal bridge, and rectal involvement; pathological findings of focally enhanced colitis; and computed tomographic enterography (CTE) findings of asymmetrical wall thickening, intestinal wall stratification, comb sign, and fibrofatty proliferation. Findings that significantly favored ITB included fever, night sweats, lung involvement, and ascites; endoscopic findings of transverse ulcers, patulous ileocecal valve, and cecal involvement; pathological findings of confluent or submucosal granulomas, lymphocyte cuffing, and ulcers lined by histiocytes; a CTE finding of short segmental involvement; and a positive interferon-γ release assay. The model was validated by gender, clinical manifestations, endoscopic, and pathological findings in 49 patients (27 CD, 22 ITB). The sensitivity, specificity, and accuracy for diagnosis of ITB were 90.9%, 92.6%, and 91.8%, respectively.Conclusions:A Bayesian model based on the meta-analytic results is presented to estimate the probability of ITB and CD calibrated to local prevalence. This model can be applied to patients using a publicly available web application.

The prevalence of steatohepatitis in chronic hepatitis B patients and its impact on disease severity and treatment response.

The clinical significance of steatohepatitis in chronic hepatitis B remains unclear. This study aimed to determine the prevalence and risk factors for steatohepatitis in chronic hepatitis B, and to determine its correlation with liver fibrosis and response to antiviral therapy.

Endoscopic ultrasound forum summary from the asian pacific digestive week 2012

Pradermchai Kongkam, Benedict M. Devereaux, Ryan Ponnudurai, Thawee Ratanachu-ek, Anand V. Sahai, Takuji Gotoda, Suthep Udomsawaengsup, Jacques Van Dam, Nonthalee Pausawasdi, Somchai Limsrichemrern, Dong-Wan Seo, Shomei Ryozawa, Yoshiki Hirooka, Yongyut Sirivatanauksorn, Siyu Sun, Sundeep Punamiya, Takao Itoi, Bancha Ovartlanporn, Ichiro Yasuda, Tiing Leong Ang, Hsiu-Po Wang, Khek Yu Ho, Heng Boon Yim, Kenjiro Yasuda, Christopher J.L. Khor

Endoscopic ultrasonography evaluation for pancreatic cysts: Necessity or overkill?

Incidental pancreatic cysts have become gradually more recognized in clinical practice as a result of increased use of transabdominal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). These lesions consist of inflammatory cysts (pseudocysts) and pancreatic cystic neoplasms (PCN) which have been classified as benign, premalignant and malignant. The diagnosis and management strategy of incidentally discovered pancreatic cysts can be challenging as the majority of them are PCN and CT or MRI alone may not be sufficient to provide an accurate diagnosis. Endoscopic ultrasound (EUS)‐guided fine‐needle aspiration provides a method to obtain cyst fluid for analysis and the recently developed EUS‐based technology including contrast‐enhanced ultrasound, cystoscopy and needle‐based confocal laser endomicroscopy allows endosonographers to gain additional useful information. The current data suggest that EUS evaluation of pancreatic cysts offers some benefits especially in cases of inconclusive CT or MRI.

Therapeutic High-Density Barium Enema in a Case of Presumed Diverticular Hemorrhage

Many patients with lower gastrointestinal bleeding do not have an identifiable source of bleeding at colonoscopy. A significant percentage of these patients will have recurrent bleeding. In many patients, the presence of multiple diverticula leads to a diagnosis of presumed diverticular bleeding. Current treatment options include therapeutic endoscopy, angiography, or surgical resection, all of which depend on the identification of the diverticular source of bleeding. This report describes a case of recurrent bleeding in an elderly patient with diverticula but no identifiable source treated successfully with barium impaction therapy. This therapeutic modality does not depend on the identification of the bleeding diverticular lesion and was well tolerated by our 86-year-old patient.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

Objectives Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures. Methods Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question. Results A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required. Conclusions The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

Evaluation of a novel, hybrid model (Mumbai EUS II) for stepwise teaching and training in EUS-guided biliary drainage and rendezvous procedures

Background and aims u2002EUS-guided biliary drainage (EUS-BD) and rendezvous (EUS-RV) are acceptable rescue options for patients with failed endoscopic retrograde cholangiopancreatography (ERCP). However, there are limited training opportunities at most centers owing to low case volumes. The existing models do not replicate the difficulties encountered during EUS-BD. We aimed to develop and validate a model for stepwise learning of EUS-BD and EUS-RV, which replicates the actual EUS-BD procedures. Methods u2002A hybrid model was created utilizing pig esophagus and stomach, with a synthetic duodenum and biliary system. The model was objectively assessed on a grade of 1u200a–u200a4 by two experts. Twenty-eight trainees were given initial training with didactic lectures and live procedures. This was followed by hands-on training in EUS-BD and EUS-RV on the hybrid model. Trainees were assessed for objective criteria of technical difficulties. Results u2002Both the experts graded the model as very good or above for all parameters. All trainees could complete the requisite steps of EUS-BD and EUS-RV in a mean time of 11 minutes (8u200a–u200a18 minutes). Thirty-six technical difficulties were noted during the training (wrong scope position, 13; incorrect duct puncture, 12; guidewire related problems, 11). Technical difficulties peaked for EUS-RV, followed by hepaticogastrostomy (HGS) and choledochoduodenostomy (CDS) (20, 9, and 7, P u200a=u200a0.001). At 10 days follow-up, nine of 28 trainees had successfully performed three EUS-RV and seven EUS-BD procedures independently. Conclusions u2002The Mumbai EUS II hybrid model replicates situations encountered during EUS-RV and EUS-BD. Stepwise mentoring improves the chances of success in EUS-RV and EUS-BD procedures.