Endoscopic diagnosis and treatment of hepatobiliary and pancreatic diseases can only be performed through the bile duct or pancreatic duct or through the artificial duct, which is established under the guidance of endoscopic ultrasound or by natural orifice transluminal endoscopic surgery ( NOTES) . At present, in addition to continuing popularization of hepatobiliary and pancreatic endoscopy, we should break the technical boundaries and train the relevant personnel, strengthen academic cooperation to improve NOTES and pediatric biliary and pancreatic endoscopy, promote the development of biliary and pancreatic endoscopy via the Chinese Society of Endoscopy, and carry out research and development of new equipment in China, thus improving the endoscopic diagnosis and treatment of hepatobiliary and pancreatic diseases.
With the development of endoscopic ultrasonography ( EUS) , new EUS-based natural orifice transluminal endoscopic surgery ( NOTES) techniques have emerged, such as EUS-guided drainage and debridement of infectious pancreatic necrosis, pancreatic pseudocyst drainage, biliopancreatic duct drainage, gallbladder drainage and cholecystolithotomy, and gastroenterostomy. This article reviews the clinical application of EUS-based NOTES techniques in pancreaticobiliary diseases.
Conventional imaging examinations including transabdominal ultrasound, computerized tomography, and magnetic resonance imaging which have certain limitations in diagnosis of pancreaticobiliary diseases. Endoscopic techniques can scan gallbladder, bile duct and pancreas with high resolution images from which obtained close to digest track. Therefore, they play an important role in diagnosis of pancreaticobiliary diseases. The rapid development of new techniques including endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, intraductal ultrasound, and Spy Glass Direct Visualization System help improving the diagnosis accuracy of pancreaticobiliary diseases. The article reviews the application of new endoscopic techniques in pancreaticobiliary diseases.
Endoscopic retrograde cholangiopancreatography ( ERCP) is a well-established advanced endoscopic technique for the diagnosis and treatment of pancreatobiliary diseases. New advances have been made in the treatment concept and techniques of ERCP in recent years.This article elaborates on the recent advances in ERCP, including the application of pancreatic duct stent, non-steroidal anti-inflammatory drugs, and aggressive hydration to prevent postoperative pancreatitis, covered metal stent for the treatment of benign bile duct stenosis, intraluminal radiofrequency ablation for malignant bile duct stenosis, extracorporeal shockwave lithotripsy and covered metal stent for the treatment of chronic pancreatitis, peroral choledochoscopy for qualitative diagnosis of bile duct stenosis and huge refractory stones, definition of difficult intubation, timing of pre-cut technique, and ERCP after gastrointestinal reconstruction.
Endoscopic retrograde cholangiopancreatography ( ERCP) , as the main means of digestive endoscopy, plays an important role in the minimally invasive treatment of some pancreaticobiliary diseases, such as biliary drainage, external drainage, and pancreatic duct stenting for the decompression treatment of biliary stricture and pancreatic duct stricture and the treatment of pancreatic fistula. In recent years, with the progress in interventional endoscopic ultrasonography ( EUS) , EUS-guided puncture and stent implantation can be used to complete decompression of the bile duct and pancreatic duct when ERCP intubation is not successful or ERCP is unable to complete decompression of the bile duct and pancreatic duct due to postoperative anatomical changes, which provides a new choice of treatment for biliary and pancreatic diseases and reflects the complementary role of EUS and ERCP in the treatment of biliary and pancreatic diseases.
Abstract: Objective To investigate the spleen stiffness of patients with chronic hepatitis and liver cirrhosis by spleen acoustic radiation force impulse ( ARFI) , aspartate aminotransferase-to-platelet ratio index ( APRI) , and aspartate aminotransferase/alanine aminotransferase ratio ( AAR) , as well as the clinical value of these three noninvasive techniques in predicting esophageal varices ( EV) in patients with liver cirrhosis. Methods A total of 247 patients with chronic hepatitis and liver cirrhosis were enrolled, and ARFI was used to measure real-time spleen stiffness. APRI and AAR were calculated. Gastroscopy was performed within one week before and after measurement to clarify the degree of EV. With the results of gastroscopy as the gold standard, the receiver operating characteristic ( ROC) curve was used to compare the clinical value of spleen ARFI value, APRI, and AAR in the diagnosis of EV in patients with liver cirrhosis. The t-test was used for comparison of continuous data between two groups. Results There were significant differences between the EV group ( n = 169) and the non-EV group ( n = 78) in spleen ARFI stiffness ( 3. 64 ± 0. 53 m/s vs 2. 97 ± 0. 65 m/s, t =-7. 93, P < 0. 001) , APRI ( 0. 87 ±0. 91 vs 0. 52 ± 0. 80, t =-2. 90, P = 0. 004) , and AAR ( 1. 54 ± 0. 67 vs 1. 29 ± 0. 55, t =-2. 93, P = 0. 004) . Spleen ARFI, APRI, and AAR had an area under the ROC curve of 0. 80, 0. 72, and 0. 63, respectively, in predicting EV in patients with liver cirrhosis; there was a significant difference between spleen ARFI stiffness and AAR ( P = 0. 005) , while there was no significant difference between spleen ARFI stiffness and APRI ( P = 0. 10) . Conclusion ARFI is a real-time ultrasound elastography technique, and compared with APRI and AAR, spleen stiffness measured by ARFI can predict EV in patients with chronic hepatitis and liver cirrhosis more accurately and noninvasively and thus holds promise for clinical application.
Objective To investigate the clinical effect of tegafur, gimeracil, and oteracil ( S-1) in the treatment of circulating tumor cell ( CTC) -positive patients after radical surgery for primary hepatic carcinoma ( PHC) . Methods A total of 56 CTC-positive patients after radical surgery for PHC who were admitted to Chongqing Cancer Hospital from June 2014 to January 2016 were enrolled and randomly divided into treatment group and control group, with 28 patients in each group. The two groups were observed in terms of the change in the number of CTCs after treatment, toxic and side effects, and disease-free survival time. The t-test was used for comparison of continuous data between groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between groups; the Kaplan-Meier method was used to plot survival curves and the Breslow test was used for comparison of survival rates between the two groups. Results There were significant differences in the number of CTCs between the two groups at 3 months ( 2. 1 ± 1. 2 vs 3. 8 ± 1. 2, t = 5. 52, P < 0. 000 1) , 6 months ( 1. 9 ± 1. 3 vs 4. 0 ± 1. 4, t = 5. 96, P < 0. 000 1) , 12 months ( 1. 5 ± 1. 2 vs 4. 5 ± 1. 5, t = 8. 17, P < 0. 000 1) , and 18 months ( 1. 6 ± 1. 4 vs 5. 5 ± 0. 9, t = 12. 33, P < 0. 000 1) after treatment. The treatment group had a significant reduction in the number of CTCs at one month after treatment ( t = 8. 10, P < 0. 000 1) . The control group had a significant increase in the number of CTCs over time. The treatment group had a significantly longer disease-free survival time than the control group ( t = 5. 279, P = 0. 021 6) , and there was a significant difference in the time to progression between the treatment group and the control group ( 11. 8 ± 2. 4 months vs 10. 8 ± 2. 3 months, t = 4. 31, P < 0. 05) . No patient died during the observation period. Five patients in the treatment group experienced adverse events, among whom 2 had gastrointestinal reaction, 2 had liver injury, and 1 had myelosuppression, and all of them were improved after symptomatic treatment, without any influence on the administration of therapeutic drugs. No patient experienced grade ≥III side effects. Conclusion S-1 can increase the disease-free survival time of CTC-positive patients after radical surgery for PHC and does not increase toxic and side effects.
Objective To investigate the clinical effect of laparoscopic cholecystectomy ( LC) in the treatment of acute calculous cholecystitis. Methods A retrospective analysis was performed for the clinical data of 86 patients with acute calculous cholecystitis who underwent LC in Department of General Surgery in Nanjing Jiangning Hospital Affiliated to Nanjing Medical University from May 2016 to May 2017. Results The surgery was performed within 1 week after disease onset, with a time of operation of 60-130 minutes ( mean 75. 5 ± 10. 5 minutes) , an intraoperative blood loss of 40-200 ml ( mean 70 ± 11. 2 ml) , and a length of postoperative hospital stay of 3-14 days ( mean6 ± 1. 5 days) . Of all 86 patients, 40 had simple acute cholecystitis, 38 had acute pyogenic cholecystitis, 5 had acute gangrenous cholecystitis, and 3 had an acute exacerbation of chronic cholecystitis; 6 patients were converted to open surgery, and 80 underwent a successful surgery, among whom one underwent primary duodenal repair due to cholecystoduodenal fistula. Intraoperative cholangiography was performed for 20 patients, among whom one was found to have common bile duct stones, and then common bile duct exploration and T-tube drainage were performed; two patients were found to have bile duct injury, which was repaired during surgery, and T-tube drainage was performed for one patient and primary suture was performed for the other patient. One patient experienced bile leakage after surgery and was cured after conservative treatment; all the other patients had no complications such as bile leakage and bleeding. Conclusion For acute calculous cholecystitis, indications should be strictly followed and laparoscopy should be adequately mastered. LC is safe and effective with little trauma.
Objective To summarize our experience in endoscopic naso-gallbladder drainage ( ENGBD) -assisted laparoscopic subtotal cholecystectomy ( LSC) in patients with chronic atrophic cholecystitis. Methods A retrospective analysis was performed for the clinical data of 124 patients with chronic atrophic cholecystitis complicated by secondary common bile duct stones who were admitted to Department of Hepatobiliary Surgery in Chongqing Hospital of Armed Police Force, Department of General Surgery in The Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, and Department of General Surgery in Chongqing Traditional Chinese Medicine Hospital from January 2007 to December 2016. All patients underwent endoscopic retrograde cholangiopancreatography ( ERCP) , sphincterotomy, and lithotomy. The patients undergoing ENGBD were enrolled as experimental group ( group A with 47 patients) , and those undergoing endoscopic nasobiliary drainage ( ENBD) were enrolled as control group ( group B with 77 patients) . All patients were treated with laparoscopic cholecystectomy ( LC) or LSC after ERCP, and the patients in difficult conditions were converted to open cholecystectomy ( OC) . The t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups.Results Compared with group B, group A had a significantly higher success rate of LSC ( 53. 2% vs 20. 8%) and a significantly lower proportion of patients undergoing OC ( 4. 3% vs 35. 1%) . Due to the complicated conditions such as internal fistula between the gallbladder and adjacent organs ( including Mirizzi syndrome) , unsuspected gallbladder carcinoma, and cystic duct abnormalities, group B had a great difficulty in the placement of ENGBD, which led to injuries in the hepatic artery/vein, and some patients were converted to open surgery due to concerns of bile duct injury. Conclusion In patients with chronic atrophic cholecystitis with secondary choledocholithiasis, ENGBD after ERCP helps with the successful performance of LSC and can effectively reduce the proportion of conversion to laparotomy.
Objective To investigate the clinical effect and safety of primary duct closure ( PDC) in laparoscopic cholecystectomy ( LC) combined with laparoscopic common bile duct exploration ( LCBDE) . Methods A retrospective analysis was performed for 76 patients with gallstones complicated by common bile duct stones who were admitted to Department of Hepatobiliary and Pancreatic Surgery in The First Affiliated Hospital of Hainan Medical University from July 2015 to July 2017, and among these patients, 20 underwent LC + LCBDE + PDC ( PDC group) and 56 underwent LC + LCBDE + T-tube drainage ( TTD) ( TTD group) . The two groups were observed and compared in terms of time of operation, intraoperative blood loss, time to gastrointestinal functional recovery after surgery, time to extraction of abdominal drainage tube, length of postoperative hospital stay, and incidence rates of related complications ( residual common bile duct stones, biliary fistula, and biliary tract infection) . The patients were followed up for 2-12 months after surgery. The t-test was used for comparison of continuous data between groups; the chi-square test was used for comparison of categorical data between groups. Results All patients underwent a successful laparoscopic surgery, and no patient was converted to open surgery. There were significant differences between the PDC group and the TTD group in time of operation ( 106. 2 ± 15. 8 min vs 147. 5 ± 23. 2 min, t =-2. 87, P = 0. 036) , time to gastrointestinal functional recovery after surgery ( 32. 9 ± 8. 1 h vs 49. 4 ± 6. 5 h, t =-3. 61, P = 0. 021) , time to extraction of abdominal drainage tube ( 3. 5 ±1. 3 d vs 5. 7 ±2. 6 d, t =-2. 64, P =0. 034) , and length of postoperative hospital stay ( 6. 3 ±1. 5 d vs 11. 4 ±2. 0 d, t =-26. 34, P < 0. 001) . There were no significant differences between the two groups in intraoperative blood loss, postoperative biliary fistula, residual bile duct stones, and biliary tract infection ( all P > 0. 05) . Conclusion A preliminary study of limited cases in our hospital shows that if patients are suitable, PDC is safe and effective in LC and LCBDE.
Objective To investigate the clinical effect of laparoscopic versus open hepatectomy in the treatment of patients with regional hepatolithiasis. Methods A total of 87 patients with regional hepatolithiasis who were admitted to The First People's Hospital of Xianyang from January 2010 to June 2017 were enrolled. Among these patients, 38 underwent laparoscopic hepatectomy ( laparoscopic group) and 49 underwent open hepatectomy ( open group) . Propensity score matching was conducted to balance confounding factors between the two groups and then the perioperative indices were compared between the two groups. The t-test was used for comparison of continuous data between groups, and the chi-square test or Fisher's exact test was used for comparison of categorical data between groups. Results A total of 27 pairs of patients were matched successfully. There were no significant differences between the two groups in the type of hepatectomy, a combination with common bile duct exploration, rate of intraoperative hepatic portal occlusion, time of operation, rate of intraoperative blood transfusion, intraoperative stone clearance rate, total postoperative complications, and incidence of serious complication ( all P > 0. 05) .Compared with the open group, the laparoscopic group had significantly lower intraoperative blood loss ( 126. 4 ± 18. 7 ml vs 143. 2 ± 24. 1 ml, t = 2. 862, P = 0. 006) and shorter length of hospital stay ( 11. 7 ± 2. 3 d vs 13. 4 ± 1. 9 d, t = 2. 961, P = 0. 004) . Conclusion Laparoscopic hepatectomy has a comparable clinical effect to open hepatectomy in the treatment of regional hepatolithiasis and has the advantages of low intraoperative blood loss and rapid postoperative recovery.
Objective To investigate the clinical features of type 1 autoimmune pancreatitis ( AIP) , and to deepen the understanding of this disease, reduce false positive rate, and enhance people' s awareness of this disease. Methods A retrospective analysis was performed for the clinical data of 13 patients with type 1 AIP who were admitted to The First Hospital of Jilin University from January 2012 to December 2016, including general status, clinical manifestations, laboratory serological examination, imaging findings, histopathological findings, treatment, and prognosis. Results Of all 13 patients, there were 9 male and 4 female patients with a mean age of 60. 08 ± 9. 47 years. Major clinical manifestations included jaundice ( 69. 2%) , abdominal pain ( 61. 5%) , and weight loss ( 61. 5%) . The most common organ involved was bile duct ( 46. 2%) , and 30. 8% of the patients had sclerosing cholangitis. Of all patients, 23. 1% had diabetes. As for serological markers, 92. 30% patients had more than 2 times increase in Ig G4, and 7. 69% had 1-2 times increase in Ig G4; 53. 85% patients had an increase in CA19-9; 69. 23% patients had an increase in total bilirubin; more than two thirds of the patients had an increase in aminotransferases or gamma-glutamyl transpeptidase. As for imaging findings, 53. 8% patients had diffuse enlargement of the pancreas on CT, 46. 2% had focal enlargement of the pancreas, and 46. 2% patients had low-density cyst-like shadow in pancreatic lesions. Pathological examination showed fibrous connective tissue proliferation with infiltration of lymphocytes and plasma cells. All patients were given standard glucocorticoid therapy ( initial dose of prednisone: 30-40 mg/d) and the remission rate of glucocorticoid therapy was 100%. The follow-up time was 12 months, and one patient experienced multiple recurrences in the course of the disease. Conclusion Type 1 AIP is the local manifestation of Ig G4-associated disease in the pancreas, which often occurs in middle-aged and elderly men, and most patients are complicated by extrapancreatic lesions. Glucocorticoid therapy is effective and most patients have good prognosis. Recurrence often occurs in the case of no standard or long-term glucocorticoid therapy.
Objective To investigate the effect of diclofenac sodium on the level of non-steroidal anti-inflammatory drug-activated gene-1 ( NAG-1) in patients with post-ERCP pancreatitis ( PEP) . Methods A total of 120 patients who underwent ERCP in The First Affiliated Hospital of Anhui Medical University from September 2012 to October 2013 were enrolled and randomly divided into diclofenac sodium group and control group, with 60 patients in each group. The patients in the diclofenac sodium group were given intramuscular injection of Olfen ( containing diclofenac sodium 75 mg) immediately after ERCP. Blood samples were collected before surgery and at 3 and 24 hours after surgery, and the level of amylase was measured. The incidence of abdominal pain was also observed and the incidence rate of PEP was calculated for both groups. RT-PCR and Western blot were used to measure the mRNA and protein expression of NAG-1 in plasma. An repeated-measures analysis of variance was used for comparison of continuous data; a univariate analysis of variance was used for data meeting the requirements of sphericity test, and the Greenhouse-Geisser correction method was used for data which did not meet the requirements of sphericity test. The chi-square test was used for comparison of categorical data between groups. Results The diclofenac sodium group had a significantly lower incidence rate of PEP than the control group [6. 67% ( 4/60) vs 20. 00% ( 12/60) , χ2= 4. 62, P = 0. 03].The diclofenac sodium group had a significantly lower level of amylase than the control group at 3 and 24 hours after surgery ( at 3 hours after surgery: 202. 70 ± 120. 44 U/L vs 283. 57 ± 178. 39 U/L, t = 2. 06, P < 0. 05; at 24 hours after surgery: 209. 13 ± 157. 14 U/L vs 305. 97 ±208. 69 U/L, t = 2. 03, P < 0. 05) . At 3 hours after ERCP, the diclofenac sodium group had significant increases in the mRNA and protein expression of NAG-1 in plasma and significantly higher mRNA and protein expression of NAG-1 than the control group ( all P < 0. 01) .Conclusion Diclofenac sodium can prevent PEP, possibly by promoting the level of NAG-1.
Objective To investigate the clinical effect and safety of balloon-assisted enteroscopy combined with endoscopic retrograde cholangiopancreatography ( ERCP) in patients with altered gastrointestinal anatomy. Methods A total of 12 patients who were admitted to General Hospital of Beijing Military Region from April 2016 to October 2017 and underwent balloon-assisted ERCP after surgical alteration of gastrointestinal anatomy were enrolled, among whom 4 underwent choledochoenterostomy and 8 underwent pancreaticoduodenectomy.Double-balloon enteroscopy was performed for 4 patients and single-balloon enteroscopy was performed for 8 patients. A retrospective analysis was performed for treatment outcome, complications, and prognosis. Results A total of 10 patients underwent balloon-assisted ERCP successfully, resulting in an overall success rate of 83. 3%, and among these patients, 2 had simple anastomotic stenosis and 8 had anastomotic stenosis and intrahepatic bile duct stones. Among the two patients who did not complete ERCP, one had severe anastomotic stenosis which prevented the guide wire from entering the bile duct, and the other patient had a small angle of R-Y intestinal anastomosis which prevented the lens and the cannula from entering the afferent loop. After surgery, one patient experienced jaundice and one experienced perforation of the gastrointestinal tract, resulting in an incidence rate of complications of 16. 7%, and both patients were cured after conservative treatment. Conclusion Balloon-assisted ERCP has good safety and a marked clinical effect with unique complications, as well as a lower success rate than conventional ERCP.
Objective To investigate the clinical features and prognosis of patients with different types of hepatitis B virus-related acute-on-chronic liver failure ( HBV-ACLF) . Methods A retrospective analysis was performed for the clinical data of 296 patients with HBV-ACLF who were admitted to 302 Hospital of PLA from January to December, 2016 and diagnosed based on recommendations of the World Congress of Gastroenterology, and according to the pathogenesis, these patients were divided into chronic hepatitis group ( type A group with 53 patients) , compensated cirrhosis group ( type B group with 151 patients) , and decompensated cirrhosis group ( type C group with 92 patients) . Laboratory markers, incidence of comorbidities, and prognosis were analyzed for all groups. An analysis of variance was used for comparison of normally distributed continuous data with homogeneity of variance between multiple groups, and the least significant difference t-test was used for further comparison between two groups; the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data or continuous data with heterogeneity of variance between groups. The Pearson's chi-square test was used for comparison of categorical data between groups. Results There were significant differences in albumin, alanine aminotransferase, and cholinesterase between the three groups ( all P < 0. 05) , and the type A group had the highest levels, followed by the type B group and the type C group.The type A group had significantly higher levels of aspartate aminotransferase and platelet count than the type B group and the type C group ( all P < 0. 05) . The type A group and the type B group had a significantly higher level of total cholesterol than the type C group ( both P<0. 05) . Compared with the type A group and the type B group, the type C group had significantly higher incidence rates of ascites/pleural effusion ( 90. 22% vs 69. 81%/88. 08%, χ2= 12. 964, P < 0. 05) and hepatorenal syndrome ( 43. 48% vs 18. 87%/28. 48%, χ2= 10. 691, P < 0. 05) . The type B group and type C group had a significantly higher incidence rate of peritonitis than the type A group ( 40. 40%/48. 91% vs 22. 64%, χ2= 9. 718, P < 0. 05) . There was a significant difference in improvement rate between the three groups ( 52. 83% vs 45. 70% vs 32. 61%, χ2= 6. 593, P < 0. 05) . Conclusion There are significant differences in biochemical parameters, comorbidities, and prognosis between HBV-ACLF patients with HBV-related chronic hepatitis, compensated cirrhosis, and decompensated cirrhosis.Such a typing method helps to explore treatment measures and assess prognosis.
Objective To investigate the value of Model for End-Stage Liver Disease ( MELD) score combined with neutrophil-lymphocyte ratio ( NLR) in predicting the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure ( HBV-ACLF) . Methods A retrospective analysis was performed for the clinical data of 133 HBV-ACLF patients who were admitted to The Affiliated Hospital of Southwest Medical University from June 2014 to December 2016, and according to the prognosis at 3 months after treatment, these patients were divided into death group with 72 patients and survival group with 61 patients. NLR, hepatic and renal function, and coagulation function were measured within 24 hours after admission, and the MELD score was also determined. The t-test was used for comparison of continuous data between groups, and a multivariate dichotomous logistic regression analysis was used to identify the association of related factors with the prognosis of HBV-ACLF patients. The receiver operating characteristic ( ROC) curve was used to analyze the area under the ROC curve ( AUC) of MELD score combined with NLR, in order to evaluate the value of MELD score combined with NLR in predicting the short-term prognosis of HBV-ACLF patients. Results Compared with the survival group, the death group had significantly higher age, total bilirubin, creatinine ( Cr) , prothrombin time, international normalized ratio, MELD score, and NLR and a significantly lower prothrombin time activity ( PTA) ( t =-5. 888, -2. 064, -3. 707, -3. 517, -3. 410, -5. 908, -2. 830 and 4. 169, all P<0. 05) . Age ( odds ratio [OR]= 1. 110) , Cr ( OR = 1. 092) , MELD score ( OR = 1. 305) , and NLR ( OR = 1. 289) were risk factors for the prognosis of HBV-ACLF patients, while PTA was a protective factor ( OR = 0. 872, P < 0. 05) . MELD score had a higher AUC than NLR ( 0. 777 vs 0. 680) ; PTA had an AUC of 0. 304, and NLR combined with MELD score had an AUC of 0. 843. PTA, MELD score, and NLR had the highest Youden index of 0. 32, 0. 28, and 0. 43, respectively, at cut-off values of 35%, 23. 29, and 2. 06. The probability of death was 92. 6% when the MELD score exceeded 23. 29 and NLR exceeded 2. 06. Conclusion MELD score combined with NLR has a good value in predicting the short-term prognosis of patients with HBV-ACLF.
Objective To investigate the clinical features and diagnosis and treatment of acute fatty liver of pregnancy ( AFLP) . Methods A retrospective analysis was performed for the clinical data of 12 patients with AFLP who were diagnosed and treated in Department of Infectious Diseases, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, from April 2012 to March 2017, including general data, clinical manifestations, laboratory markers, imaging examinations, treatment, and prognosis. Results All 12 patients developed AFLP in late pregnancy, and major clinical manifestations included gastrointestinal symptoms, liver failure, jaundice, and coagulation disorder. All patients were given multimodality therapy to protect the liver, improve coagulation, and reduce infection; 11 patients underwent cesarean section; 6 underwent blood filtration; 5 underwent plasma exchange. One patient died, resulting in a mortality rate of 8. 3%; 5 perinatal infants died, resulting in a mortality rate of 35. 7%. Conclusion In patients with AFLP, early diagnosis, timely termination of pregnancy, maximum symptomatic/supportive treatment, and control of infection, as well as the artificial liver support system, is the key to improving the prognosis of mothers and infants.
Objective To investigate the clinical features of patients with drug-induced liver injury ( DILI) in China in the last five years.Methods Related databases were searched for original case reports on DILI in China published from January 2012 to December 2017, and a total of 202 articles with 26 015 DILI patients were included in this analysis. Sex, age, geographical distribution, causative drugs, clinical features, and prognosis were summarized and analyzed. Categorical data were expressed as rate ( %) or constituent ratio. Results Of all 26 015 patients, 12 885 ( 49. 53%) were male and 13 130 ( 50. 47%) were female, with a mean age of 46. 86 years. The five most common causative drugs were traditional Chinese medicine ( TCM) ( 34. 68%) , anti-tubercular agents ( 15. 81%) , anti-microbial drugs ( 12. 04%) , antitumor drugs ( 9. 09%) , and analgesic-antipyretic drugs ( 6. 17%) . Major clinical manifestations included fatigue ( 50. 37%) , jaundice ( 52. 68%) , and poor appetite ( 43. 59%) . A total of 158 articles recorded the typing of 19994 DILI patients, among whom 58. 84% had the hepatocellular type, 21. 79% had the cholestasis type, and 19. 37% had the mixed type. Liver biopsy had a certain value in the diagnosis of DILI. Major therapies for DILI included withdrawal of suspected drugs, anti-inflammatory treatment, and liver protection. A total of 179 articles reported the prognosis of 22 030 patients, among whom 11 159 ( 50. 65%) were cured, 8742 ( 39. 68%) were improved, 1176 ( 5. 34%) had no response, and 353 patients ( 1. 60%) died. Conclusion There is a similar incidence rate of DILI between male and female populations. TCM is the most common causative drugs for DILI. The hepatocellular type is the most common clinical type. The cured and improved rate is as high as 90. 34%, and most patients have good prognosis.
Objective To investigate the clinical effect and safety of enhanced recovery after surgery ( ERAS) in laparoscopic hepatectomy.Methods A total of 55 patients who underwent laparoscopic hepatectomy in Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, from January 2014 to December 2016 were enrolled and randomly divided into ERAS group with 27 patients and control group with 28 patients ( conventional perioperative treatment) . The two groups were compared in terms of recovery of liver function after surgery, C-reactive protein ( CRP) , incidence of postoperative complications, postoperative recovery, postoperative physical recovery score, and quality of life. The independent samples t-test was used for comparison of continuous data between groups, an analysis of variance with repeated measures was used for comparison of change trends of indices between the two groups, and the chi-square test was used for comparison of categorical data between groups. Results There were no significant differences in related indices before and during surgery between the two groups ( all P > 0. 05) . Compared with the control group, the ERAS group had significantly lower aspartate aminotransferase and CRP on day 5 after surgery ( t = 2. 168 and 2. 291, both P < 0. 05) , and there were no significant differences in other liver function parameters between the two groups ( all P > 0. 05) . The ERAS group had significantly lower incidence rates of postoperative non-surgical site complications than the control group ( χ2= 4. 15, P < 0. 05) , and there were no significant differences in the overall incidence of complications, incidence rates of surgical site complications, and the Clavien-Dindo classification of complications between the two groups ( all P > 0. 05) . As for postoperative recovery scores, the ERAS group had significantly better comprehensive score, pain score, and activity score than the control group ( t = 1. 297, 2. 777, and 3. 009, all P < 0. 05) . Compared with the control group, the ERAS group had significantly shorter time to first flatus, time to first defecation, and length of postoperative hospital stay ( t =6. 291, 2. 577, and 4. 229, all P < 0. 05) . Conclusion When applied in patients undergoing laparoscopic hepatectomy, ERAS can reduce surgical stress and incidence of non-surgical site complications and accelerate postoperative recovery.
Objective To systematically review the value of enhanced recovery after surgery ( ERAS) in the perioperative period of hepatectomy. Methods A literature search was conducted in Pub Med, Embase, Cochrane Library, Sinomed, Wanfang Data, VIP, and CNKI to identify the articles on the application of ERAS in the perioperative period of hepatectomy published up to July 2017. Quality evaluation and data extraction were performed for the included articles. A Meta-analysis was performed using Revman 5. 3 software. Results A total of 17 articles were included, with 14 randomized controlled trials and 3 controlled clinical trials. A total of 2220 patients were involved and divided into ERAS group ( n = 1002) and control group ( n = 1218) . Compared with the control group, the ERAS group had significantly shortened length of postoperative hospital stay ( weighted mean difference [WMD]=-2. 58, 95% confidence interval [CI]:-3. 47 to-1. 70, P<0. 05) , functional rehabilitation time ( WMD =-3. 39, 95% CI:-4. 32 to-2. 45, P < 0. 05) , and time to first flatus ( standardized mean difference [SMD]=-1. 56, 95% CI:-2. 15 to-0. 97, P < 0. 05) , as well as reduced complication rate ( odds ratio [OR]= 0. 64, 95%CI: 0. 52-0. 78, P < 0. 05) and hospital costs ( SMD =-0. 85, 95% CI:-1. 23 to-0. 47, P < 0. 05) . There were no significant differences between the two groups in readmission rate ( OR = 1. 28, 95% CI: 0. 69-2. 69, P >0. 05) , operation time ( WMD =-11. 36, 95% CI:-23. 25 to 0. 53, P > 0. 05) , and intraoperative blood loss ( WMD =-22. 62, 95% CI:-38. 89 to-6. 34, P > 0. 05) . Conclusion ERAS is safe and effective in the perioperative period of hepatectomy and holds promise for clinical application.
Objective To investigate the clinical effect of Viatorr stent versus double-stent technique in transjugular intrahepatic portosystemic shunt ( TIPS) . Methods A total of 62 patients with portal hypertension who underwent TIPS in Department of Interventional Radiology, The First Affiliated Hospital of Anhui Medical University, from May 2015 to December 2016 were enrolled, among whom 55 had a major symptom of upper gastrointestinal bleeding and 7 had intractable ascites. According to the type of covered stent used in the surgery, the patients were divided into Viatorr stent group with 22 patients and double-stent group with 40 patients ( bare stent + Fluency covered stent) .The patients were followed for 6-17 months after surgery, and the shunt patency rate, incidence rate of hepatic encephalopathy, and mortality rate were determined. The independent samples t-test or the paired samples t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups. Results All patients underwent TIPS successfully, and a total of 22 Viatorr stents, 40 bare stents, and 40 Fluency covered stents, with a diameter of 8 mm, were implanted. Portal venous pressure was significantly reduced from 28. 7 ± 4. 9 mm Hg before surgery to 18. 7 ± 4. 7 mm Hg after surgery in the Viatorr stent group ( t = 9. 9, P < 0. 01) and from 27. 2 ± 4. 3 mm Hg before surgery to 18. 8 ± 3. 9 mm Hg after surgery in the double-stent group ( t = 13. 5, P < 0. 01) . Gastrointestinal bleeding was stopped for all 55 patients with upper gastrointestinal bleeding, and 7 patients with intractable ascites achieved ascites regression. The patency rate was 95. 5% in the Viatorr stent group and 90. 0% in the double-stent group, the incidence rate of hepatic encephalopathy was 9% in the Viatorr stent group and 15% in the double-stent group, and the mortality rate was 4. 5% in the Viatorr stent group and 12. 5% in the double-stent group; there were no significant differences between the two groups ( all P> 0. 05) . Conclusion Both Viatorr stent and double-stent technique have a good clinical effect in TIPS, and the short-term outcome of TIPS shunt established by Viatorr stent is similar to that of TIPS shunt established by double-stent technique. Further studies are needed to investigate the advantages of Viatorr stent over double-stent technique.
Objective To investigate the changes in the diagnostic and therapeutic methods for Lemmel's syndrome over the past 20 years in China, and to provide experience for standardized diagnosis and treatment of this disease. Methods A retrospective analysis was performed for the clinical data of 23 patients with Lemmel's syndrome who were diagnosed and treated in Tongji Hospital of Tongji University from January 1998 to June 2017 and 384 patients with Lemmel's syndrome reported in China during the same period of time ( 407 patients in total) .According to the admission time, the patients were divided into groups A ( 139 patients admitted from 1998 to 2007) and B ( 268 patients admitted from 2008 to 2017) . The patients' clinical features, diagnostic and therapeutic methods, and prognosis were recorded. The t-test was used for comparison of normally distributed continuous data between groups, and the Wilcoxon rank sum test was used for comparison of non-normally distributed continuous data between groups; the chi-square test was used for comparison of categorical data between groups.Results Compared with group A, group B had significantly higher age of onset ( 67. 8 ± 17. 8 vs 62. 3 ± 12. 3, t =-13. 238, P = 0. 019) and incidence rate of cholangitis ( 45. 9% vs 32. 4%, χ2= 6. 903, P = 0. 009) . As for diagnostic methods, compared with group A, group B had a significantly higher proportion of patients who used multi-slice spiral CT ( MSCT) ( 26. 9% vs 8. 6%, χ2= 18. 576, P < 0. 001) , endoscopic ultrasonography ( EUS) ( 15. 7% vs 5. 8%, χ2= 8. 352, P = 0. 004) , magnetic resonance cholangiopancreatography ( MRCP) ( 75. 0% vs 33. 1%, χ2= 67. 303, P < 0. 001) , or endoscopic retrograde cholangiopancreatography ( ERCP) ( 63. 4% vs 36. 7%, χ2=26. 377, P < 0. 001) , while the two groups had a similar false positive rate ( 22. 8% vs 28. 1%, χ2= 1. 385, P = 0. 239) . As for therapeutic methods, compared with group A, group B had a significantly higher proportion of patients who underwent ERCP combined with conservative pharmacotherapy and surgical operation ( χ2= 34. 758, P < 0. 001) . There was a significant difference in recurrence rate between endoscopic surgery group and conservative pharmacotherapy group ( χ2= 40. 211, P < 0. 001) , as well as between surgical operation group and conservative pharmacotherapy group ( χ2= 26. 785, P < 0. 001) ; there was no significant difference in recurrence rate between surgical operation group and endoscopic surgery group ( χ2= 0. 055, P = 0. 815) , but endoscopic surgery had the advantages of minimal invasiveness, fast recovery, and low costs. Conclusion Age of onset of Lemmel's syndrome is gradually increasing. MSCT, EUS, MRCP, and ERCP applied alone or in combination are major diagnostic methods, and ERCP is the preferred therapeutic method for Lemmel's syndrome.
Objective To establish a subcutaneous xenograft tumor model of alveolar echinococcosis in nude mice, and to lay a foundation for further research on alveolar echinococcosis. Methods A total of 25 nude mice were given subcutaneous injection of 0. 1 ml 20% Echinococcus multilocularis protoscolex suspension at the back of the neck. The growth of lesions was observed and recorded, and trypan blue staining was performed at 6 months after injection to observe the cell viability of protoscolices. Results Subcutaneous lesions were observed at about 8 days after injection. At 3 months after the establishment of the model, the survival rate of the nude mice was 92% ( 23/25) , and the infection rate of Echinococcus multilocularis was 100% ( 23/23) . A small number of protoscolices died and were blue on trypan blue staining, and the cell viability of protoscolices was 98%. Conclusion Echinococcus multilocularis can be successfully transplanted to the subcutaneous part of nude mice, which provides a reference for further studies on the establishment of animal models of alveolar echinococcosis.
Abstract: Studies have shown that liver fibrosis and some cases of early liver cirrhosis can be reversed, and thus a timely, accurate judgment of fibrosis degree has important clinical significance in prevention/treatment and prognostic evaluation of chronic liver diseases. In recent years, great achievements have been made in the application of serum markers and transient elastography for the evaluation of liver fibrosis. This article introduces the value of serological markers and related models in evaluating liver fibrosis, including CHI3 L1, GP model, Forns, APRI, and FIB-4 index, and reviews the advances in the application of transient elastography in determining fibrosis stage in patients with chronic liver diseases. It is pointed out that a combination of these two methods has a high value in evaluating fibrosis degree.
Abstract: Alcoholic liver fibrosis is a series of pathological changes caused by excessive intrahepatic deposition of fibrous connective tissue due to hepatocyte inflammation and necrosis caused by excessive drinking. Laboratory markers help with the differentiation of alcoholic liver disease, and a combination of these markers and examination of liver fibrosis can be used for the diagnosis of alcoholic liver fibrosis. Liver biopsy remains the gold standard for the diagnosis of liver fibrosis, but its clinical application is limited by its invasiveness. Therefore, more and more new serum molecular markers with a diagnostic value have been identified in recent years, and great breakthroughs have been made. In addition, a noninvasive diagnostic and predictive model based on various biochemical parameters and imaging findings also brings new hope to the diagnosis and treatment of liver fibrosis. This article reviews the recent research advances in the noninvasive diagnosis of alcoholic liver fibrosis by serum markers.
Abstract: Cell senescence is a basic cell response triggered by various stimuli and is a basic characteristic of living organism. Liver fibrosis refers to the pathological process of diffuse excessive deposition of extracellular matrix in the liver caused by abnormal proliferation of connective tissue due to various pathogenic factors and can progress to liver cirrhosis and liver cancer. Studies have shown that cell senescence is closely associated with the progression of liver fibrosis. This article reviews the regulatory effect of different types of cell senescence on liver fibrosis.
Abstract: Portal vein thrombosis ( PVT) refers to the formation of thrombus within the portal vein or its branches, the splenic vein, or the superior mesenteric vein. PVT is a common complication after splenectomy in patients with portal hypertension and may lead to liver injury, upper gastrointestinal bleeding, hepatic coma, and even ischemic intestinal necrosis. Therefore, early identification and effective intervention of PVT play an important role in reducing the mortality of PVT patients. This article reviews the risk factors for PVT after splenectomy in cirrhotic patients and the treatment of PVT and points out that effective intervention should be performed for PVT as early as possible.
Abstract: Pregnant women have a higher incidence rate of liver failure than women who are not pregnant, and liver failure is one of the major causes of death in pregnant women and parturients. Liver failure in pregnancy has complex symptoms and various complications and greatly threatens the safety of mothers and infants. Accurate judgment of the prognosis of patients with liver failure plays an important role in guiding clinical work. This article introduces the influencing factors for the prognosis of patients with liver failure and the application of various models in pregnant women, in order to provide a reference for clinical work.
Abstract: Bacterial liver abscess is a common disease among common infections in the liver system and can even threaten patients' lives in severe cases. There have been great changes in the epidemiology and diagnosis and treatment of bacterial liver abscess in recent years. This article analyzes the main pathogens and routes of infection of liver abscess and summarizes the new problems which should be taken seriously in clinical practice. As for the treatment of liver abscess, this article analyzes the advantages and disadvantages of different treatment modalities for bacterial liver abscess, and the treatment regimen should be selected based on patients' conditions. A certain method alone or in combination with other methods can help to achieve the goal of individualized treatment.
Abstract: Hepatic alveolar echinococcosis ( HAE) is a parasitic disease characterized by invasive growth. Major treatment methods include pharmacotherapy and surgical treatment, and surgical treatment mainly includes radical hepatectomy and palliative surgery. Radical hepatectomy is the first choice, and palliative surgery is mainly used to alleviate disease conditions and complications. Pharmacotherapy also plays an important role in the delay and control of HAE. In recent years, autologous liver transplantation has been used in the treatment of HAE and has become an effective therapy for end-stage HAE patients who cannot be cured by routine surgery. This article introduces the indications and advantages/disadvantages of radical hepatectomy and palliative surgery, as well as the experience in the application of multidisciplinary treatment, the concept of fast-track surgery, and autologous liver transplantation in the treatment of HAE patients, in order to provide a reference for the treatment of HAE.
Abstract: Silent information regulator 1 ( SIRT1) , a member of the Sirtuin family, is a deacetylase depending on nicotinamide adenine dinucleotide and is mainly involved in energy metabolism, cell survival, aging, and apoptosis. Nonalcoholic fatty liver disease ( NAFLD) is a chronic liver disease closely related to insulin resistance, oxidative stress, and lipid peroxidation. This article elaborates on the association of SIRT1 with energy metabolism, oxidative stress, lipid peroxidation, and endoplasmic reticulum stress and points out that SIRT1 is closely associated with the development and progression of NAFLD.
Abstract: Extracellular vesicles ( EVs) are membrane-bound vesicles released by cells into the extracellular environment and can selectively enrich specific proteins and RNA and mediate intercellular communication. Therefore, EVs have the potential of a biomarker for diseases, a therapeutic target, and a delivery vector. This article reviews the research advances in the role of EVs in viral hepatitis, liver fibrosis, and liver cancer and emphasizes the prospects of EVs in liver diseases.
Abstract: Endoscopic retrograde cholangiopancreatography ( ERCP) is an important technique for the diagnosis and treatment of biliary and pancreatic diseases and post-ERCP pancreatitis ( PEP) is the most common complication of ERCP. Since the birth of ERCP, the prevention and treatment of PEP has become the focus of international research. In recent years, much progress has been made in the aspects of risk factors, pharmacological prevention, and prophylactic stent implantation in the pancreatic duct. Since these research findings are not consistent, further clinical studies are needed to demonstrate such findings.
Abstract: Delayed gastric emptying ( DGE) is a common complication after pancreatoduodenectomy. Due to its complex causes and difficulties in treatment, it has been a difficult problem in general surgery. By analyzing the improvement in the surgical procedure of pancreaticoduodenectomy in recent years and the influence of the establishment of predictive scoring model on DGE, this article puts forward new directions for the prevention and treatment of DGE. It is pointed out that effective preoperative assessment and reasonable selection of surgical procedures may help to reduce the incidence rate of DGE after surgery.
Abstract: Mutations and polymorphisms of genes associated with pancreatic function are involved in the development and progression of pancreatitis. In addition, systemic inflammatory response also affects the severity of pancreatitis, while mutations and polymorphisms of genes which encode inflammatory factors and cytokines can regulate the expression of such factors and thus affect the progression of systemic inflammatory response. This article reviews the association between pancreatitis and polymorphisms of genes related to cationic trypsinogen, pancreatic secretory trypsin inhibitor, cystic fibrosis conductance regulator, inflammatory factors, and cytokines.