Factors affecting ampullary access of ERCP after Billroth Ⅱ gastrectomy / 中华消化内镜杂志

Objective To investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy.Methods A retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017.Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access,and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors.Results A total of 345 ERCP sessions were collected.The successful ampullary access and cannulation rate were 82.3％ (284/345) and 89.1％ (253/284),respectively.The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3％,61/92) and failure of selective cannulation (33.7％,31/92).The ERCP-related complication rate was 14.2％ (49/345),with post-ERCP pancreatitis rate was 3.2％ (11/345).Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717,95％CI:2.581-23.068.P＜0.001),with Braun anastomosis (OR =8.737,95％CI:2.479-30.797,P =0.001),and no cap-assisted forward-viewing gastroscope (OR =2.774,95％ CI:1.283-5.997,P=0.009) were independent risk factors for failure of ampullary access.According to the B value of each risk factor in logistic regression analysis,that is,no cap-assisted as 1 point,the first ERCP attempt as 2 points,and Braun anastomosis as 2 points,the area under ROC curve was 0.773.When the cut-off point was 2.5,the sensitivity and specificity were 75.0％ and 70.8％,respectively.Conclusion The first ERCP attempt,with Braun anastomosis,and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients.Early identification of high-risk patients may help to improve the success rate of ampullary access.

Retrospective analysis of endoscopic retrograde cholangiopancreatography in patients with prior Billroth Ⅱ gastrectomy / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography ( ERCP ) in the treatment of patients with biliary and pancreatic diseases after Billroth Ⅱ gastrectomy. Methods Clinical data of 178 patients with biliary and pancreatic diseases undergoing 237 times of ERCP at the digestive endoscopy center in Changhai Hospital from January 2011 to December 2016 were retrospectively collected. The success rate of procedures and related complications were summed up. Results Among 178 patients undergoing 237 times of ERCP, the successful intubation rate of the endoscope to reach the duodenal papilla was 83. 5％ ( 198/237 ) . The success rate of selective cannulation and completing the expected intervention were 91. 4％ ( 181/198 ) and 98. 9％ ( 179/181 ) , respectively. The total success rate of ERCP was 75. 5％ (179/237), which had an increasing trend with time. The total success rate of ERCP in patients with common bile duct stone was 85. 2％ ( 127/149) , and the stone retrieval rate during the first session was 56. 7％ (72/127). The ERCP-related complication rate was 14. 3％ ( 34/237 ) , with 1. 7％ ( 4/237 ) perforation, 1. 3％ ( 3/237 ) bleeding, 3. 4％ ( 8/237 ) pancreatitis, and 8. 0％ ( 19/237 ) asymptomatic hyperamylasemia. One patient with perforation and 2 patients with severe pancreatitis died of septic shock and multiple organ failure ( 1. 3％, 3/237 ) . Most ERCP-related complications were improved by conservative treatment or second endoscopic intervention ( 91. 2％, 31/34 ) . Conclusion ERCP is effective and safe in the treatment of biliary and pancreatic diseases in patients with prior Billroth Ⅱ gastrectomy. With the development of endoscopic techniques and experience accumulation of endoscopists, the success rate of intubation, selective cannulation and therapeutic intervention can be close to those of patients with normal anatomy, and the incidence of related complications is low.

Key issues about the endoscopic treatment for upper gastrointestinal submucosal tumors / 中华消化内镜杂志

Objective To investigate the necessity and selection of endoscopic treatment in patients with upper gastrointestinal submucosal tumors ( SMTs) . Methods Clinical data of 306 patients with upper gastrointestinal SMTs at the Digestive Endoscopy Center of Shanghai Changhai Hospital from January 2012 to October 2013 were reviewed, and distribution characteristics, pathology types, endoscopic operation option of SMTs were analyzed. Results Of all 306 cases, 55 lesions ( 18. 0％) were located in esophagus, 244 (79. 7％) in stomach, 7 ( 2. 3％) in duodenum. Pathological results showed that there were 142 cases ( 46. 4％) of leiomyoma, 114 ( 37. 3％) gastrointestinal stromal tumors ( GIST ) , 15 ( 4. 9％) ectopic pancreas,14 ( 4. 6％) lipomas,7 ( 2. 3％) neuroendocrine tumors ( NETs) , and 14 ( 4. 6％) other types. Of esophageal SMTs, leiomyoma accounted for 85. 4％, GIST 5. 4％. Of cardiac SMTs, leiomyoma was 78. 8％, GIST was 12. 1％. Of gastric fundus SMTs, leiomyoma was 28. 7％, GIST was 69. 0％. Of gastric body SMTs, leiomyoma was 38. 6％, GIST was 45. 5％. Of gastric antrum SMTs, leiomyoma was 25. 7％, GIST was 14. 3％. Of duodenal SMTs, leiomyoma was 14. 3％, GIST was 28. 6％. Of all 306 cases, 242 cases( 79. 1％) received ESE, 28 cases( 9. 2％) received STER, 25 cases( 8. 2％) received EFR. Of esophageal operations, ESE was 54. 5％, STER was 40％. Of gastric operations, ESE was 84. 4％, STER was 2. 5％, EFR was 10. 2％. All duodenal patients received ESE. STER was mainly used in esophagus ( 78. 6％) , and EFR was mainly used at gastric fundus ( 72. 0％) and body ( 24. 0％) . Conclusion Regular endoscopic follow-up could be a good option for SMTs located in esophagus, gastric cardiac and antrum, which are mostly benign lesions, especially when no obvious symptoms develop. Endoscopic therapy should be recommended for SMTs located in gastric fundus and body, which are mostly GISTs. STER may be more safe and effective for esophageal SMTs, but not suitable for giant lesions. ESE is the major operation for gastric SMTs, while EFR is more suitable for deep-origin lesions, especially in fundus and body. ESE is the major mode for duodenal SMTs. However, laparoscopic or surgical treatment should be considered when endoscopic treatment is difficult or risky.

Analysis of submucosal tunneling endoscopic resection on treatment of esophageal submucosal tumors / 中华消化内镜杂志

Objective To investigate the optimal indication of submucosal tunneling endoscopic resection(STER)in patients with esophageal submucosal tumor(SMT). Methods Clinical data of 67 patients with esophageal SMT from May 2013 to August 2014 were summarized in the Digestive Endoscopy Center of Shanghai Changhai Hospital, and relationships between lesion features and success rate or complications of STER were analyzed. Results Of all 67 cases, 60 cases(89.6%)located in the middle and low segment of the esophagus,64 cases(95.6%)were endo-luminal growth. The maximum diameter of lesions were ranged from 1 to 6 cm with mean length of(2.34±1.13)cm. The length of tunnel incision was 1-2 cm with mean length of(1.19±0.37)cm,and the length of submucosal tunnel was 2-7 cm with mean length of(4.09±1.26)cm. The mucosal injury rate and muscularis propria injury rate was 7.5%(5/67) and 4.5%(3/67), respectively. The number of hemostatic clips for tunnel incision closure was 2-17 with mean number of 8.79 ± 3.39. No delayed hemorrhage or severe adverse events occurred in any of the 67 patients following STER. The success rate of STER was 100%. The en bloc resection rate was 91.0% (61/67),while the en bloc removal rate was 83.6%(56/67). When the maximum diameter of lesions was more than 3 cm,the operation time increased significantly,while the en bloc resection or removal rates were declined. Conclusion STER is safe and effective for esophageal SMT, especially for lesions located in the middle and low segment esophagus with less than 3 cm maximum diameter.

Risk factors of refractory esophageal stenosis after large-scale endoscopic submucosal dissection for patients with early esophageal cancer / 中华消化内镜杂志

Objective To analyze the risk factors of refractory postoperative stenosis after large-scale endoscopic submucosal dissection (ESD) for patients with early esophageal cancer.Methods The data of 35 postoperative stenosis patients previously treated by ESD (dissection ≥3/4 circumferential) for early esophageal cancer from January 2011 to September 2016 in Digestive Endoscopy Center, Changhai Hospital were reviewed.According to the number of endoscopic dilation, 35 patients were divided into two groups: refractory stenosis (≥6 endoscopic dilations, n=21) and non-refractory stenosis (≤5 endoscopic dilations, n=14), comparison between the two groups was performed using t test or Fisher exact probability method.Results Muscle layer damage (P=0.018), longitudinal mucosal defect length (P=0.013), tumor infiltrating depth (P=0.031), and the number of hemostatic clips (P=0.031) were significantly different between the two groups.The history of chemotherapy and radiotherapy, the location of tumor, the macroscopic type, and the postoperative administration of oral prednisolone were not significant differences between the two groups (P>0.05).Conclusion Refractory esophageal stenosis commonly occurs in patients undergoing large-scale ESD with tumor depth >M2, muscle layer damage, longitudinal mucosal defect length ≥50 mm and the number of hemostatic clips ≥6.

Physiological effects of rare earth elements and their application in traditional Chinese medicine / 中国中药杂志

The process in the studies on physiological effects of rare earth elements in plants and their action mechanisms were summarized in the aspects of seed germination, photosynthesis, mineral metabolism and stress resistance. And the applications of rare earth elements in traditional Chinese medicine (TCM) in recent years were also overviewed, which will provide reference for further development and application of rare earth elements in TCM.