Xiangdong Wang

Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.

Endoscopic submucosal dissection (ESD) has been widely used for resection of esophageal neoplastic lesions, but there are still technical challenges in treating large ones. Based on the development of tunneling technique, we report the first series in which the new technique of endoscopic submucosal tunnel dissection (ESTD) was used to remove large lesions in the esophagus. ESTD was attempted in five consecutive patients with esophageal lesions for which resection was indicated. In the operation, once the margin of the lesions had been marked, a submucosal tunnel was created by submucosal dissection from the oral incision to the anal incision. Bilateral resection was then performed to remove the lesion completely. The average length of the five lesions was 5.7 cm, and their extent as a proportion of the whole circumference of the lumen ranged from one third to four fifths. Operative time ranged from 50 minutes to 120 minutes (mean, 77 minutes). En bloc resection with negative lateral and basal margins was achieved in all lesions without complications.

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.

Stent implantation through rendezvous technique of PTBD and ERCP: The treatment of obstructive jaundice

OBJECTIVE:  To study the technical method and clinical value of stent implantation through the rendezvous technique of percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice.

Changes in the spectrum of gastric polyps in the Chinese population

AIM To evaluate the change in spectrum of gastric polyps in the Chinese population in the past ten years. METHODS A total of 157902 consecutive patients undergoing esophagogastroduodenoscopy (EGD) from 2004 to 2013 in a tertiary hospital were retrospectively reviewed using an EGD database. Endoscopic records of 4043 patients diagnosed with gastric polyps were recalled for analysis. Data including demographics, information on polyps such as location, pathological diagnosis, reflux esophagitis and Helicobacter pylori infection were obtained. We focused on epithelial polyps, especially hyperplastic polyps, fundic gland polyps and adenomas, and histological classification of specimens from biopsy and endoscopic polypectomy was performed by professional pathologists, based on the updated guidelines. To explore the age distribution of gastric polyps over time, we divided patients with polyps into four groups: A (aged < 30 years), B (aged 30-44 years), C (aged 45-59 years) and D (aged > 60 years). Differences in localization, age, and sex distribution of gastric polyps were analyzed by statistical software. RESULTS A total of 157902 EGD procedures were performed in ten years at our digestive endoscopy center, of which 4043 cases were diagnosed with gastric polyps confirmed by pathology. There were 2574 (63%) female and 1469 (37%) male patients with an average age of 54.7 years. The overall prevalence of gastric polyps was 2.6% (4043/157902). Our database demonstrated a rising prevalence of gastric polyps over the decade, increasing from 1.0% (80/8025) to 4.70% (828/17787) between 2004 and 2013. There has been a change in the spectrum of gastric polyps with the frequencies of FGPs increasing from 19% (15/80) to 77% (638/828) and hyperplastic polyps decreasing from 65% (52/80) to 15% (123/828). Moreover, data on 1921 polyps in 828 patients diagnosed with gastric polyps in 2013 showed that FGP was the most common type in the current polyp spectrum, making up 81.3% (1562/1921). Location and age distribution of gastric polyps have also altered. The prevalence of polyps located in the antrum decreased from 37.5% (30/80) to 9.30% (77/828), with an increasing prevalence of polyps in the corpus, from 45% (36/80) to 64.25% (532/828). The constituent ratio of older patients (aged > 60 years) in the polyp population decreased from 62.5% (50/80) to 32.13% (266/828), while that of patients aged 45-60 years showed an increased trend. CONCLUSION There was a shift change in the spectrum of gastric polyps in the Chinese population with altered location and age distribution in the past ten years.

GLUT-1 overexpression as an unfavorable prognostic biomarker in patients with colorectal cancer

Background Glucose transporter-1 (GLUT-1) exhibits altered expression in colorectal cancer (CRC). The aim of this study was to explore the association between GLUT-1 and survival conditions, as well as clinical features in CRC by meta-analysis. Materials and Methods Relevant studies were searched through predefined strategies, hazard ratios (HRs), odds ratios (ORs), and their 95% confidence intervals (CIs) were used as effective measures. Results A total of 14 studies with 2,077 patients were included in this meta-analysis. The results showed that GLUT-1 was not significantly associated with overall survival (OS) (HR=1.28, 95% CI=0.86–1.91, p=0.22) or disease-free survival (DFS) (HR=1.71, 95% CI=0.78–3.72, p=0.179). However, subgroup analysis indicated that GLUT-1 was a significant biomarker for poor DFS in rectal cancer (HR=2.47, 95% CI=1.21–5.05, p=0.013). GLUT-1 expression was also found to be significantly correlated with the presence of lymph node metastasis (n=8, OR=2.14, 95% CI=1.66–2.75, p<0.001), T stage (n=6, OR=1.73, 95% CI=1.17–2.58, p=0.007), higher Dukes stage (n=5, OR=2.92, 95% CI=2.16–3.95, p<0.001), female sex (n=4, OR=2.92, 95% CI=2.16–3.95, p<0.001), and presence of liver metastasis (n=3, OR=1.82, 95% CI=1.06–3.12, p=0.03). Conclusion In conclusion, this meta-analysis showed that GLUT-1 was associated with poor DFS in rectal cancer (RC). Furthermore, GLUT-1 was also an indicator of aggressive clinical features in CRC.

Association of preoperative obstructive jaundice with postoperative infectious complications following pancreaticoduodenectomy.

BACKGROUND/AIMS The aim of this study was to evaluate the effects of obstructive jaundice on Infectious Complications of the patients who underwent pancreaticoduodenectomy. METHODOLOGY One-hundred and sixteen consecutive patients without preoperative biliary drainage underwent pancreaticoduodenectomy from January 2006 to April 2010 and their data of post-operative complication were analyzed. Different level of bilirubin and different times of jaundice on infectious complications of the patients underwent pancreaticoduodenectomy were analysis. RESULTS Patients with severe jaundice (Total bilirubin ≥5 mg/dL; n = 55), had a higher incidence in subsequent infectious complications than the patients with total bilirubin level of less than 5 mg/dL (n = 61) (36.06% vs. 56.36%, p <0.05). The patients with preoperative TB level of 5 or more sub classified according to the duration of jaundice. However, two groups without statistical significance in terms of post-operative complications. There were no significant differences in post-operative mortality rate among the different groups. CONCLUSIONS The elevated serum bilirubin increases the rate of infectious complications of the patients underwent pancreaticoduodeneotomy.

Comparison of endoscopic ultrasound, computed tomography and magnetic resonance imaging in assessment of detailed structures of pancreatic cystic neoplasms

AIM To evaluate the advantages of endoscopic ultrasound (EUS) in the assessment of detailed structures of pancreatic cystic neoplasms (PCNs) compared to computed tomography (CT) and magnetic resonance imaging (MRI). METHODS All patients with indeterminate PCNs underwent CT, MRI, and EUS. The detailed information, including size, number, the presence of a papilla/nodule, the presence of a septum, and the morphology of the pancreatic duct of PCNs were compared among the three imaging modalities. The size of each PCN was determined using the largest diameter measured. A cyst consisting of several small cysts was referred to as a mother-daughter cyst. Disagreement among the three imaging modalities regarding the total number of mother cysts resulted in the assumption that the correct number was the one in which the majority of imaging modalities indicated. RESULTS A total of 52 females and 16 males were evaluated. The median size of the cysts was 42.5 mm by EUS, 42.0 mm by CT and 38.0 mm by MRI; there was no significant difference in size as assessed among the three imaging techniques. The diagnostic sensitivity and ability of EUS to classify PCNs were 98.5% (67/68) and 92.6% (63/68), respectively. These percentages were higher than those of CT (73.1%, P < 0.001; 17.1%, P < 0.001) and MRI (81.3%, P = 0.001; 20.3%, P < 0.001). EUS was also able to better assess the number of daughter cysts in mother cysts than CT (P = 0.003); however, there was no significant difference between EUS and MRI in assessing mother-daughter cysts (P = 0.254). The papilla/nodule detection rate by EUS was 35.3% (24/68), much higher than those by CT (5.8%, 3/52) and MRI (6.3%, 4/64). The detection rate of the septum by EUS was 60.3% (41/68), which was higher than those by CT (34.6%, 18/52) and by MRI (46.9%, 30/64); the difference between EUS and CT was significant (P = 0.02). The rate of visualizing the pancreatic duct using EUS was 100%, whereas using CT and MRI it was less than 10%. CONCLUSION EUS helps visualize the detailed structures of PCNs and has many advantages over CT and MRI. EUS is valuable in the diagnosis and assessment of PCNs.