Philip Wy Chiu

Effects of intravenous and oral esomeprazole in the prevention of recurrent bleeding from peptic ulcers after endoscopic therapy.

OBJECTIVES:The use of intravenous proton-pump inhibitors (PPIs) has shown to reduce recurrent bleeding and improve patient outcome after endoscopic hemostasis on patients with peptic ulcer. However, the efficacy of oral PPI is uncertain. Studies from Asia indicated that even oral PPI can achieve the same therapeutic effect. This study is designed to compare the efficacy of high-dose intravenous PPI to oral PPI in preventing recurrent bleeding after endoscopic hemostasis.METHODS:This is a single-center, randomized-controlled, double-blind, and double-dummy study. Patients had Forrest IA/IB or IIA/IIB peptic ulcer bleeding and received endoscopic hemostasis before recruitment into the study. They were randomized to receive either (i) esomeprazole IV bolus at a dose of 80u2009mg plus infusion at 8u2009mg/h for 72u2009h and oral placebo every 12u2009h (IVP group), or (ii) IV placebo bolus plus infusion for 72u2009h and high-dose oral esomeprazole at a dose of 40u2009mg every 12u2009h (ORP group). Patients were followed up for 30 days after index bleeding. The primary end point was defined as the 30-day recurrent bleeding after successful endoscopic hemostasis.RESULTS:A total of 118 patients were randomized to the IVP group and 126 to the ORP group in this study. In all, 39.8% in the IVP and 42.9% in the ORP group used non-steroidal anti-inflammatory drug and/or aspirin before bleeding. In the IVP group (vs. ORP), Forrest IA represented 1.7% (5.6%), IB 41.5% (38.1%), IIA 52.5% (50.8%), and IIB 4.2% (5.6%). Recurrent bleeding in 30 days was reported in 7.7% of patients in the IVP group and 6.4% of patients in the ORP group, and the difference of recurrent bleeding was −1.3% (95% CI: −7.7%, 5.1%). There was no difference in blood transfusion, repeated endoscopic therapy, and hospital stay between the two groups.CONCLUSIONS:High-dose oral esomeprazole at 40u2009mg BID may be considered as a useful alternative to IV bolus plus infusion of esomeprazole in the management of ulcer bleeding in patients who are not candidates for high-dose IV infusion. However, as this study was stopped prematurely and was not designed as an equivalency trial, a much larger study would be necessary to document whether there is equivalency or non-inferiority of the two treatments in a heterogeneous patient population.

Colorectal cancer screening of the general population in East Asia

In recent years, the incidence of colorectal cancer (CRC) has been increasing, and CRC has been becoming the major cause of cancer deaths in Asian countries. Therefore, an organized screening program to reduce CRC incidence and mortality is currently implemented in each country. In the present review, we summarize the current status and future perspectives of CRC screening of the general population in East Asian and South‐East Asian countries. The fecal occult blood test is widely used for CRC screening in these countries, and its effectiveness in reducing CRC incidence and mortality has been demonstrated; however, the low participation rate in CRC screening programs is a problem to be solved in every country. Improvement in the public awareness of CRC and promotion of CRC screening by physicians will help to raise the participation rate and reduce the number of deaths caused by CRC. Regarding screening colonoscopy, several studies have recently demonstrated its effectiveness in reducing CRC incidence and mortality. However, at present, CRC screening colonoscopy is not adopted as a primary population‐based screening tool because of staffing constraints in relation to large population sizes, increased medical costs, and potential adverse events (e.g. perforation and drug‐induced anaphylaxis). Further study is required to consider colonoscopy as CRC screening that is established in Western countries.

Role of antisecretory agents for gastric endoscopic submucosal dissection

Gastric endoscopic submucosal dissection (ESD) causes artificial gastric ulcers and there is no consensus regarding the optimal perioperative management in terms of prevention of intra‐ or postoperative bleeding and promotion of healing. Traditionally, 8‐week administration of proton pump inhibitors (PPI) and mucosal protective agents were used in the same way as for peptic ulcer management. However, recent studies have revealed that prior use of PPI might reduce intraoperative bleeding or early‐phase postoperative bleeding, and combination of histamine‐2 receptor antagonist (H2RA), and second‐look endoscopy might have a similar effect on postoperative bleeding to PPI. Additionally, the advantage of PPI over H2RA is not proven and the optimal duration of PPI may be shortened until 2u2009weeks when the deteriorating factors for ESD ulcer are excluded. Furthermore, mucosal protective agents may facilitate ulcer healing. Further studies are needed to determine the optimal treatment protocol before and after ESD for both prevention of bleeding complication and promotion of ulcer healing, by using available antisecretory agents and mucosal protective agents.

Hospital Authority audit of the outcome of endoscopic resection of superficial upper gastro-intestinal lesions in Hong Kong

OBJECTIVESnTo review the short-term outcome of endoscopic resection of superficial upper gastro-intestinal lesions in Hong Kong.nnnDESIGNnHistorical cohort study.nnnSETTINGnAll Hospital Authority hospitals in Hong Kong.nnnPATIENTSnThis was a multicentre retrospective study of all patients who underwent endoscopic resection of superficial upper gastro-intestinal lesions between January 2010 and June 2013 in all government-funded hospitals in Hong Kong.nnnMAIN OUTCOME MEASURESnIndication of the procedures, peri-procedural and procedural parameters, oncological outcomes, morbidity, and mortality.nnnRESULTSnDuring the study period, 187 lesions in 168 patients were resected. Endoscopic mucosal resection was performed in 34 (18.2%) lesions and endoscopic submucosal dissection in 153 (81.8%) lesions. The mean size of the lesions was 2.6 (standard deviation, 1.8) cm. The 30-day morbidity rate was 14.4%, and perforations and severe bleeding occurred in 4.3% and 3.2% of the patients, respectively. Among patients who had dysplasia or carcinoma, R0 resection was achieved in 78% and the piecemeal resection rate was 11.8%. Lateral margin involvement was 14% and vertical margin involvement was 8%. Local recurrence occurred in 9% of patients and 15% had residual disease. The 2-year overall survival rate and disease-specific survival rate was 90.6% and 100%, respectively.nnnCONCLUSIONnEndoscopic mucosal resection and endoscopic submucosal dissection were introduced in low-to-moderate-volume hospitals with acceptable morbidity rates. The short-term survival was excellent. However, other oncological outcomes were higher than those observed in high-volume centres and more secondary procedures were required.

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong

The demand for blood products continues to grow in an unsustainable manner in Hong Kong. While anaemia associated with gastrointestinal bleeding (GIB) is the leading indication for transfusion, there is no local recommendation regarding best practices for transfusion. We aimed to provide evidence-based recommendations regarding management of anaemia in patients with acute and chronic GIB. We reviewed all original papers, meta-analyses, systematic reviews, or guidelines that were available in PubMed. For acute GIB, a restrictive transfusion strategy, targeting a haemoglobin threshold of 7 to 8 g/dL, should be adopted because overtransfusion is associated with significantly higher all-cause mortality and re-bleeding. A liberal transfusion strategy should only be considered in patients with co-existing symptomatic coronary artery disease, targeting a haemoglobin threshold of 9 to 10 g/dL. When acute GIB settles, patients should be prescribed iron supplements if iron deficiency is present. For chronic GIB, iron stores should be replenished aggressively via iron supplementation before consideration of blood transfusion, except in patients with symptoms of severe anaemia. Oral iron replacement is the preferred first-line therapy, while intravenous iron is indicated for patients with inflammatory bowel disease, poor response or poor tolerability to oral iron, and in whom a rapid correction of iron deficit is preferred. Intravenous iron is underutilised and the risk of anaphylactic reaction to current preparations is extremely low. These recommendations are provided to local clinicians to facilitate judicious and appropriate use of red cell products and iron replacement therapy in patients with GIB.

Correlation of CBD/CHD angulation with recurrent cholangitis in patients treated with ERCP.

Background and study aims: Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) for bile duct stone extraction has a major role in the treatment of cholangitis. It is well known that certain risk factors predispose to recurrence of such stones. The aims of this study were to evaluate the correlation between angulation of the common bile duct (CBD), right hepatic duct (RHD), and left hepatic duct (LHD) with recurrent cholangitic attacks and to elucidate other risk factors that may be associated with these attacks. Patients and Methods: This is retrospective study included 62 patients who had undergone therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. Their medical records were followed until May 1, 2009. The RHD, LHD, and CBD angulation and CBD diameter were measured on cholangiography prior to any endoscopic procedures. Results: Among these 62 patients, 6 (9.7u200a%) had recurrence of cholangitis. Both angles of the RHD and the CBD were significantly smaller in the group with recurrence (Pu200a=u200a0.001, Pu200a=u200a0.004). A CBD angle ≤u200a130o and RHD angle ≤u200a125o were found to be significantly associated with an increased risk of recurrence (RRu200a=u200a10.526, Pu200a=u200a0.033; RRu200a=u200a24.97, Pu200a=u200a0.008) in multivariate analysis. Cholecystectomy was not a protective factor against recurrence of cholangitis (Pu200a=u200a0.615). Conclusions: Angulation of the CBD (≤u200a130°) and RHD (≤u200a125°) on ERCP are independent risk factors for recurrent cholangitis. Further prospective studies using these data may be warranted for a more accurate estimation and verification of the risk factors predisposing to recurrent cholangitis.

Endoscopic innovation through animal experiments: a new in- vitro platform

The development in endoscopy has been tremendous since the conceptof inspecting inside humans gastrointestinal tractfirst introduced in 1806. Flexible video endoscope became available with the advances in fiberoptics, image processing and technologies in CCD. In 1970s, the performance of sphincterotomy upon ERCP marked the start of the era of therapeutic endoscopy (1). The concept of en-bloc resection for early gastrointestinal cancers withendoscopic submucosal dissection (ESD) adopted the principles of surgery and applied through endoscopy using innovative instruments (2,3)). Natural Orifices Transluminal Endoscopic Surgery (N.O.T.E.S.) became the next logical step for the development of endoscopic surgery (4). The concept of N.O.T.E.S. is to achieve surgical procedures through the natural orifices of human body without skin incisions. This revolutionary idea, however, cannot be applied to human immediately as the feasibility, safety and effectiveness of these procedures were not completely understand. Animal model became a very important means to establish the achievability of new endoscopic diagnostic and therapeutic procedures (5). These in-vitro experiments, however, were limited by the use of large scale animals toaccommodate large diameter of an ordinary endoscope which is at least 9mm. Establishment of a tumor model in these large scale animal is extremely difficult when compared to nude mice models.

Current development in single-incision laparoscopic surgery

This article reviews current developments in single‐incision laparoscopic surgery, with a focus on reported experiences in cholecystectomy. Difficulties and likely future developments in single‐incision laparoscopic surgery are also discussed.